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Posterior compartment prolapse and perineal descent: systematic review of available support devices.International Urogynecology Journal Nov 2023The aim of our study is to systematically review the literature about available devices facilitating perineal support during defecation in patients with obstructive... (Meta-Analysis)
Meta-Analysis Review
OBJECTIVE
The aim of our study is to systematically review the literature about available devices facilitating perineal support during defecation in patients with obstructive defecation syndrome (ODS) and posterior pelvic organ prolapse (POP).
METHODS
We searched for the terms "defecat/ion or ODS" and" pessar/ies or device/aid/tool/perineal/perianal/prolapse and support" in MEDLINE, PubMed and Web of Science. Data abstraction was performed according to PRISMA (Preferred Reporting Items for Systematic reviews and Meta-analysis) guidelines. A two-stage inclusion was performed, selecting first on title and abstract and secondly the full text. For variables with sufficient data, a meta-analysis was performed using a random-effects model. Other variables were descriptively reported.
RESULTS
Ten studies out of 1332 were included for systematic review. The devices could be categorized into three groups: pessaries (n = 8), vaginal stent (n = 1) and external support device (n = 1). Methodology and data reporting is heterogeneous. Meta-analysis could be performed for the Colorectal-Anal Distress Inventory (CRADI-8) and Impact Questionnaire (CRAI-Q-7) in three pessary studies which showed a significant mean change. Significant improvement of stool evacuation was seen in two other pessary studies. The vaginal stent significantly decreases ODS. Subjective perception of constipation improved significantly using the posterior perineal support device.
CONCLUSION
All reviewed devices seem to improve ODS in patients with POP. There are no data on their efficacy with regard to perineal descent-associated ODS. There is a lack of comparative studies between devices. Studies are difficult to compare due to different inclusion criteria and evaluation tools.
Topics: Female; Humans; Pelvic Organ Prolapse; Constipation; Vagina; Anal Canal; Perineum; Pessaries
PubMed: 37074368
DOI: 10.1007/s00192-023-05508-2 -
International Journal of Surgery... Jan 2018Chronic anal fissures (CAF) are common and associated with reduced quality of life. Lateral internal sphincterotomy (LIS) is frequently carried out but carries a... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Chronic anal fissures (CAF) are common and associated with reduced quality of life. Lateral internal sphincterotomy (LIS) is frequently carried out but carries a significant risk of anal incontinence. Anal advancement flap (AAF) has been advocated as an alternative, 'sphincter-preserving' procedure. We aimed to perform a systematic review and meta-analysis to compare the efficacy of both techniques in the treatment of CAF.
METHODS
The online databases of PubMed/Medline, CINAHL, EMBASE and Cochrane Central Register of Controlled Trials were searched from inception to January 2017. All studies that investigated and reported outcomes of LIS and AAF for treatment of CAF were included. The primary outcome measure was anal incontinence while secondary outcomes included unhealed fissure and wound complication rates. Random effects models were used to calculate pooled effect size estimates.
RESULTS
Four studies (2 randomized controlled trials and 2 retrospective studies) describing 300 patients (150 LIS, 150 AAF) fulfilled our inclusion criteria. There was significant clinical heterogeneity among the trials. On random effects analysis, AAF was associated with a significantly lower rate of anal incontinence compared to LIS (OR = 0.06, 95% CI = 0.01 to 0.36, p = .002). However, there were no statistically significant differences in unhealed fissure (OR = 2.21, 95% CI = 0.25 to 19.33, p = .47) or wound complication rates (OR = 1.41, 95% CI = 0.50 to 4.99 p = .51) between AAF and LIS.
CONCLUSIONS
AAF is associated with less incontinence, but similar wound complications as well as a similar rate of unhealed fissures compared to LIS. However, further well-executed, multi-centre randomized trials are required to provide stronger evidence.
Topics: Adult; Anal Canal; Chronic Disease; Fecal Incontinence; Female; Fissure in Ano; Humans; Lateral Internal Sphincterotomy; Male; Postoperative Complications; Quality of Life; Retrospective Studies; Surgical Flaps; Treatment Outcome
PubMed: 29233787
DOI: 10.1016/j.ijsu.2017.12.002 -
Techniques in Coloproctology Apr 2021Simple anal fistula is one of the most common causes of proctological surgery and fistulotomy is considered the gold standard. This procedure, however, may cause... (Review)
Review
BACKGROUND
Simple anal fistula is one of the most common causes of proctological surgery and fistulotomy is considered the gold standard. This procedure, however, may cause complications. The aim of this systematic review was to assess the surgical treatment of simple anal fistula with traditional and sphincter-sparing techniques.
METHODS
A literature research was performed using PubMed, Cochrane, and Google Scholar to identify studies on the surgical treatment of simple anal fistulas. Observational studies and randomized clinical trials were included. We assessed the risk of bias of included studies using the Jadad scale for randomized controlled trials, and the MINORS Scale for the remaining studies.
RESULTS
The search returned 456 records, and 66 studies were found to be eligible. The quality of the studies was generally low. A total of 4883 patients with a simple anal fistula underwent a sphincter-cutting procedure, mainly fistulotomy, with a weighted average healing rate of 93.7%, while any postoperative continence impairment was reported in 12.7% of patients. Sphincter-sparing techniques were adopted to treat 602 patients affected by simple anal fistula, reaching a weighted average success rate of 77.7%, with no study reporting a significant postoperative incontinence rate. The postoperative onset of fecal incontinence and the recurrence of the disease reduced patients' quality of life and satisfaction.
CONCLUSIONS
Surgical treatment of simple anal fistulas with sphincter-cutting procedures provides excellent cure rates, even if postoperative fecal incontinence is not a negligible risk. A sphincter-sparing procedure could be useful in selected patients.
Topics: Anal Canal; Fecal Incontinence; Humans; Organ Sparing Treatments; Quality of Life; Rectal Fistula; Treatment Outcome
PubMed: 33387100
DOI: 10.1007/s10151-020-02385-5 -
Techniques in Coloproctology Oct 2022Video-assisted anal fistula treatment (VAAFT) has gained increasing acceptance as a sphincter-sparing procedure for treating complex anorectal fistulas (CAF), but no... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Video-assisted anal fistula treatment (VAAFT) has gained increasing acceptance as a sphincter-sparing procedure for treating complex anorectal fistulas (CAF), but no unequivocal conclusions can yet be drawn regarding its ultimate effectiveness. We reviewed the literature and performed a meta-analysis to evaluate the efficacy and safety of VAAFT in CAF patients.
METHODS
The study protocol was registered with the PROSPERO database (CRD42021279085). A systematic literature search was performed in the PubMed, Embase, and Cochrane Library databases up to June 2021 with no restriction on language based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We used the keywords video-assisted surgery, video-assisted anal fistula treatment, and complex anorectal fistula to identify relevant studies.
RESULTS
Fourteen trials (7 prospective and 7 retrospective) with a total of 1201 patients (mean age 43.5 years) were included. The median follow-up duration was 16.5(8-48) months. Pooled analysis showed that the rates of success, recurrence and postoperative complication across the studies were 83% (95% CI 81-85%, I = 37.9%), 16% (95% CI 14-18%, I = 4.8%), 11% (95% CI 7-15%, I = 72.1%), respectively. The postoperative Jorge-Wexner score used to assess the level of anal incontinence was 1.09 (95% CI, 0.9-1.27, I = 74.6%). The internal opening detection rate was 97.6% (95% CI 96.1-99.6%, I = 48.2%). Recurrence rates varied according to the closure method of internal opening from 21.4% after using staplers, 18.7% after suturing, to 23.5% after advancement flap. The hospital stay was 3.15 days (95% CI 2.96-3.35, I = 49.7%). Subgroup analysis indicated that the risk of heterogeneity in the urine retention group was higher compared with that of the overall group and that retrospective studies may be the source of heterogeneity for postoperative anal incontinence. r . Sensitivity analysis confirmed the stability of the pooled results. Begg's and Egger's tests showed no evidence of publication bias.
CONCLUSIONS
According to the available evidence, VAAFT may be a valuable alternative to fistulotomy or seton in treating CAF and has the additional long-term benefits of reducing anal incontinence and surgical morbidity, permitting earlier healing and accelerated rehabilitation.
Topics: Adult; Anal Canal; Fecal Incontinence; Humans; Organ Sparing Treatments; Prospective Studies; Rectal Fistula; Retrospective Studies; Treatment Outcome; Video-Assisted Surgery
PubMed: 35347492
DOI: 10.1007/s10151-022-02614-z -
EClinicalMedicine Aug 2023Anal cancer prevention has two critical points: the incidence rate is several fold higher for some groups, such as people living with human immunodeficiency virus (HIV)...
BACKGROUND
Anal cancer prevention has two critical points: the incidence rate is several fold higher for some groups, such as people living with human immunodeficiency virus (HIV) and men who have sex with men (MSM), and there is not a well-defined guideline for its screening. This systematic review evaluates the accuracy of DNA HRHPV (high-risk human papillomavirus), mRNA HPV, DNA HPV16 isolated and p16 staining biomarkers in anal canal smears for identifying anal intraepithelial neoplasia (AIN) 2 or 3, summarised as anal high-grade squamous intraepithelial lesions (aHSIL), and cancer.
METHODS
We searched the MEDLINE, Cochrane Library and Embase electronic databases as well as Grey literature to identify eligible papers published up to 31st July 2022. This systematic review and meta-analysis included observational studies comparing biomarker tests to histopathology after HRA (High-resolution Anoscopy) as a reference standard. We (ACM, TF) analysed studies in which patients of both sexes were screened for anal cancer using DNA HRHPV, mRNA HPV, DNA HPV16 and/or p16 biomarkers. The analysis was performed in pairs, for instance AIN2 or worse (AIN2+) vs. AIN1, HPV infection and normal (AIN1-). PROSPERO CRD42015024201.
FINDINGS
We included 21 studies with 7445 patients. DNA HR HPV showed a higher sensitivity 92.4% (95% CI 84.2-96.5), specificity 41.7% (95% CI 33.9-44.9) and AUC 0.67, followed by the mRNA HPV test, with a sensitivity 77.3% (95% CI 73.2%-80.9%), specificity 61.9% (95% CI 56.6-66.9) and AUC 0.78. DNA HPV16 showed higher specificity 71.7% (95% CI 55.3-83.8), followed by p16 test, 64.1% (95% CI 51.0-75.4); Sensitivity of DNA HPV16 was 53.3% (95% CI 35.4-70.3) and AUC 0.69, while p16 had a sensitivity of 68.8% (95% CI 47.9-84.1) and AUC 0.74. Subgroup analysis of MSM with HIV, with 13 studies and 5123 patients, showed similar accuracy, with a bit higher sensitivities and lower specificities. Considering the measure of the total between-study variability, mRNA HPV tests showed the smallest area of the 95% prediction ellipse, 6.0%, influenced by the low logit sensitivity, 0.011. All other groups of tests exceed 50% prediction ellipse area, which represent a high heterogeneity.
INTERPRETATION
Our findings suggested that DNA HR HPV can be a useful tool for screening for aHSIL and anal cancer if followed by biomarker with a higher specificity. As an isolated test, mRNA HPV had better performance.
FUNDING
There was no funding source for this study.
PubMed: 37588624
DOI: 10.1016/j.eclinm.2023.102128 -
International Urogynecology Journal Jun 2016The objective of this study was to estimate the risk of recurrent obstetric anal sphincter injury (rOASI) in women who have suffered anal sphincter injury in their... (Meta-Analysis)
Meta-Analysis Review
OBJECTIVES
The objective of this study was to estimate the risk of recurrent obstetric anal sphincter injury (rOASI) in women who have suffered anal sphincter injury in their previous pregnancy and analyse risk factors for recurrence through a systematic review and meta-analysis.
DATA SOURCES
A review was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Searches were made in Ovid MEDLINE (1996 to May 2015), PubMed, EMBASE and Google Scholar, including bibliographies and conference proceedings.
METHODS OF STUDY SELECTION
Observational studies (cohort/case-control) evaluating rOASI and risk factors were selected by two reviewers who also analysed methodological quality of those studies. Pooled odds ratios (OR) for rOASI and individual risk factors were calculated using RevMan 5.3.
TABULATION, INTEGRATION AND RESULTS
From the eight studies assessed, overall risk of rOASI was 6.3 % compared with a 5.7 % risk of OASI in the first pregnancy. The risk in parous women with no previous OASI was 1.5 %. Factors that increased the risk in a future pregnancy were instrumental delivery with forceps [OR 3.12, 95 % confidence interval (CI) 2.42-4.01) or ventouse (OR 2.44, 95 % CI 1.83-3.25), previous fourth-degree tear (OR 1.7, 95 % CI 1.24-2.36) and birth weight ≥4 kg (OR 2.29, 95 % CI 2.06-2.54). Maternal age ≥35 years marginally increased the risk (OR 1.16, 95 % CI 1-1.35).
CONCLUSION
The overall rate of rOASI and associated risk factors for recurrence are similar to the rate and risk factors of primary OASI. Antenatal decisions could be based on assessment of foetal weight and intrapartum decisions based upon the requirement for an instrumental delivery.
Topics: Anal Canal; Anus Diseases; Delivery, Obstetric; Female; Humans; Pregnancy; Recurrence; Risk Factors
PubMed: 26676912
DOI: 10.1007/s00192-015-2893-4 -
International Urogynecology Journal Oct 2016There is conflicting evidence on whether mediolateral episiotomy (MLE) reduces the risk of obstetric anal sphincter injuries (OASI) in spontaneous vaginal deliveries... (Meta-Analysis)
Meta-Analysis Review
INTRODUCTION
There is conflicting evidence on whether mediolateral episiotomy (MLE) reduces the risk of obstetric anal sphincter injuries (OASI) in spontaneous vaginal deliveries (SVD).
OBJECTIVES
A systematic review was undertaken to compare rates of OASI amongst women who had undergone mediolateral episiotomy versus those who did not.
SEARCH STRATEGY
Electronic searches were performed in literature databases: CINAHL, Cochrane, EMBASE, Medline and MIDIRS from database inception to July 2015. Studies were eligible if MLE was compared to spontaneous tears and if OASI was the outcome of interest. Two reviewers independently selected and extracted data on study characteristics, quality and results. We computed events of OASI in those who did and did not have an episiotomy from individual studies and pooled these results in a meta-analysis where possible.
MAIN RESULTS
Of the 2090 citations, 16 were included in the review. All were non-randomised, population based or retrospective cohort studies. There was great variation in quality amongst these studies. Data from 7 studies was used for meta-analysis. On collating data from these studies where the majority of women (636755/651114) were nulliparous, MLE reduced the risk of OASI (RR 0.67 95 % CI 0.49-0.92) in vaginal delivery.
CONCLUSION
The pooled analysis of a large number of women undergoing vaginal birth, most of who were nulliparous, indicates that MLE has a beneficial effect in prevention of OASI. An accurately given MLE might have a role in reducing OASI and should not be withheld, especially in nulliparous women. Caution is advised as the data is from non-randomised studies.
Topics: Anal Canal; Case-Control Studies; Delivery, Obstetric; Episiotomy; Female; Humans; Perineum; Pregnancy; Retrospective Studies; Risk; Vagina
PubMed: 26894605
DOI: 10.1007/s00192-016-2956-1 -
Radiotherapy and Oncology : Journal of... Jun 2022To conduct a systematic review evaluating the impact of high dose rate (HDR) brachytherapy (BT) on the clinical outcomes and toxicities of patients with anal cancer. (Review)
Review
PURPOSE
To conduct a systematic review evaluating the impact of high dose rate (HDR) brachytherapy (BT) on the clinical outcomes and toxicities of patients with anal cancer.
METHODS AND MATERIALS
A search of Medline, Embase, and Cochrane Library databases was performed using search terms: "anal", "anal canal", "squamous", "adenocarcinoma", "cancer", "neoplasm", in combination with "brachytherapy", "high dose rate brachytherapy" or "HDR brachytherapy". Additional studies were identified after scanning references. Studies published in English with ≥10 patients were included.
RESULTS
Ten studies (n = 448) were included in this review. 321 patients were treated with curative intent external beam radiotherapy (EBRT), chemotherapy (CT) and HDRBT; of those, 312 and 9 received interstitial and intraluminal BT, respectively. Mean follow up was 39.9 months (range (R): 24-61 months). Complete response was noted between 80%-93% and local control ranged between 81%-88%. Mean rate of local failure was 12.3% (SD 3.6%, R: 8%-18%). Distant failure rate was reported between 2%-3% and metastasis free survival ranged between 82%-88%. Mean disease free survival and overall survival were 77.3% (SD 6.6%, R: 66%-100%) and 82.5% (SD 13.7%, R: 70%-87.7%). Acute toxicity was mostly grade 1/2 dermatitis, proctitis or cystitis; G3 or higher toxicity was reported only in 4 patients in 2 studies (dermatitis n = 3 and sphincter necrosis n = 1). Most common long term toxicities were incontinence (2.5%-9%) and proctitis (2.5%-19%); G3/4 toxicity ranged between 2.2%-7.1%. Mean sphincter preservation rate and colostomy free survival was 88.0% and 80.4%, respectively.
CONCLUSION
Pooled analysis in this review suggests excellent response, local control and survival with HDRBT in combination with EBRT and CT, with limited toxicity. Prospective well conducted trials are needed to further establish role of HDRBT management of anal cancer with future focus on development of international consensus on patient selection, dosimetric parameters, treatment sequencing as well as defining uniform outcome and toxicity assessment.
Topics: Anus Neoplasms; Brachytherapy; Dermatitis; Humans; Proctitis; Prospective Studies; Radiotherapy Dosage; Retrospective Studies
PubMed: 35381275
DOI: 10.1016/j.radonc.2022.03.019 -
Techniques in Coloproctology Nov 2016Fistula-in-ano (FIA) in infants differs, in several ways, from FIA in adults. The current review aims to assess FIA in infants less than 2 years old and to illustrate... (Review)
Review
BACKGROUND
Fistula-in-ano (FIA) in infants differs, in several ways, from FIA in adults. The current review aims to assess FIA in infants less than 2 years old and to illustrate the outcome of different treatment modalities described in the literature.
METHODS
An organized search of the English literature over the past 25 years was conducted according to the preferred reporting items for systematic reviews and meta-analyses guidelines. Electronic databases and Google Scholar were searched for articles focusing on management of FIA in infants.
RESULTS
Fourteen studies were eligible for this review. Variables analyzed comprised patient characteristics, type of FIA, methods of treatment, recurrence, and postoperative complications. The studies included comprised total of 490 infants, 89 % of them less than 1 year old. Most patients (97.5 %) were males with a median age of 7 months. Around 20 % of patients with FIA underwent conservative treatment initially, and 73 % of them achieved complete resolution. Surgery was performed on 86 % of the infants. Fistulotomy accounted for 65 % of the procedures performed and was associated with a higher recurrence rate than fistulectomy (6.6 vs. 1.1 %, respectively). Complications of surgical management occurred in 2.6 % of the patients. FIA typically occurs in male infants, mainly under 1 year of age. Almost all fistulae in this age group are low.
CONCLUSIONS
The majority of the studies reviewed evaluated surgical treatment of FIA. However, the few studies that employed conservative treatment reported complete resolution of FIA in most infants. Fistulotomy was the most commonly performed surgery for FIA and was associated with fewer complications, yet a higher recurrence rate than fistulectomy.
Topics: Anal Canal; Conservative Treatment; Disease Management; Female; Humans; Infant; Male; Postoperative Complications; Rectal Fistula; Recurrence; Sex Factors; Treatment Outcome
PubMed: 27663698
DOI: 10.1007/s10151-016-1536-1 -
Techniques in Coloproctology Apr 2020Fistula laser closure (FiLaC) is a novel sphincter-saving technique for the treatment of fistula-in-ano. The aim of this study was to assess the safety and efficacy of... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Fistula laser closure (FiLaC) is a novel sphincter-saving technique for the treatment of fistula-in-ano. The aim of this study was to assess the safety and efficacy of the FiLaC procedure.
METHODS
Databases including PubMed/Medline, Scopus, Web of Science, and Embase were searched for articles assessing FiLaC. All studies including case series and comparative studies reporting the outcome of FiLaC in the treatment of fistula-in-ano were considered eligible. The main outcomes were healing rates of fistula laser closure, postoperative complications including incontinence, technical aspects of the procedure and failure of healing.
RESULTS
Seven studies were included. There were a total of 454 patients, 69.1% with a transsphincteric fistula-in-ano and 35% with recurrent disease. The median age of the patients was 43 years (range 18-83 years). The median operation time was 18.3 min (range 6-32 min). With a median follow-up of 23.7 months, the weighed mean rate of primary healing was 67.3% and the overall success when FiLaC was reused was 69.7%. The weighted mean rate of complications was 4%, all of them were minor complications and the weighted mean rate of continence affection was 1% in the form of minor soiling.
CONCLUSIONS
FiLaC may be considered an effective and safe sphincter-saving technique for the treatment of fistula-in-ano with an acceptable, low, complication rate. However, well-designed randomized control trials comparing FiLaC with other techniques are required to substantiate the promising outcomes reported in this review.
Topics: Adolescent; Adult; Aged; Aged, 80 and over; Anal Canal; Humans; Lasers; Middle Aged; Operative Time; Postoperative Complications; Rectal Fistula; Treatment Outcome; Wound Healing; Young Adult
PubMed: 32065306
DOI: 10.1007/s10151-020-02165-1