-
International Journal of Gynecological... Dec 2023To evaluate the feasibility of uterine transposition as a method of preserving fertility and ovarian function after pelvic radiation. (Observational Study)
Observational Study
OBJECTIVE
To evaluate the feasibility of uterine transposition as a method of preserving fertility and ovarian function after pelvic radiation.
METHODS
This prospective multicenter observational study included patients with non-gynecologic pelvic cancers who underwent pelvic radiation as part of their cancer treatment between June 2017 and June 2019. For inclusion in the study, patients were required to have normal menstrual cycles and hormone levels (follicle-stimulating hormone, luteinizing hormone, and estrogen) before treatment. Uterine transposition to the upper abdomen was performed prior to irradiation. Clinical examinations and Doppler ultrasonography were used to evaluate the gonadal vasculature post-surgery. The uterus was repositioned into the pelvis 2-4 weeks after radiation therapy or at the time of rectosigmoid resection in patients with rectal cancer who had undergone neoadjuvant treatment. Cancer treatment and follow-up were performed according to standard guidelines.
RESULTS
Eight patients (seven with rectal cancer and one with pelvic liposarcoma) underwent uterine transposition at a median age of 30.5 years (range 19-37). The uterus was successfully preserved in six patients, accompanied by normal menses, hormonal levels, and vaginal intercourse after treatment. One patient with rectal cancer died of carcinomatosis 4 months after uterine transposition. One patient presented with uterine necrosis 4 days after uterine transposition, and the uterus was removed; however, one ovary was preserved. Cervical ischemia was the most common post-surgical complication in three (37.5%) patients. Three patients attempted to conceive, and two (66%) were spontaneously successful and delivered healthy babies at 36 and 38 weeks by cesarean section without complications.
CONCLUSIONS
Uterine transposition is a feasible procedure for preserving gonadal and uterine function in patients requiring pelvic radiotherapy for non-gynecological cancer, with the potential for achieving spontaneous pregnancy and successful delivery.
Topics: Adult; Female; Humans; Pregnancy; Young Adult; Cesarean Section; Fertility; Fertility Preservation; Prospective Studies; Rectal Neoplasms; Uterine Cervical Neoplasms; Uterus
PubMed: 37898483
DOI: 10.1136/ijgc-2023-004723 -
Digestive Diseases and Sciences Oct 2023Crohn's disease perianal fistulae (CD-PAF) occur in 25% of patients and are notoriously challenging to manage. Tumor necrosis factor inhibitors are first line agents.
BACKGROUND
Crohn's disease perianal fistulae (CD-PAF) occur in 25% of patients and are notoriously challenging to manage. Tumor necrosis factor inhibitors are first line agents.
AIMS
The aim of this study was to compare infliximab (IFX) versus adalimumab (ADA) efficacy in CD-PAF healing over time.
METHODS
A retrospective study at two large-tertiary medical centers was performed. Inclusion criteria were actively draining CD-PAF and initial treatment with IFX or ADA following CD-PAF diagnosis. The primary endpoints were perianal fistula response and remission at 6 and 12 months. Secondary endpoints included biologic persistence over time and dose escalation at 6 and 12 months.
RESULTS
Among 151 patients included in the study, 92 received IFX and 59 received ADA as first line agents after CD-PAF diagnosis. At 6 months, the 64.9% of the IFX group and 34.8% of the ADA group demonstrated CD-PAF clinical improvement (p < 0.01). Univariate and multivariate analyses demonstrated significant differences among the IFX and ADA groups for clinical response at 6-months and 12-months (p = 0.002 and p = 0.042, respectively). There were no factors that predicted response, with the exception of concomitant immunomodulator affecting the 6-month clinical response (p = 0.021). Biologic persistence, characterized by Kaplan Meier methods, was significantly longer in the IFX group compared to the ADA group (Log-rank p = 0.01).
CONCLUSION
IFX induction and maintenance is associated with higher rates of response and remission in CD-PAF healing as well as higher treatment persistence compared to ADA. Additionally, our study supports the use of concomitant immunomodulator therapy for CD-PAF healing and remission.
Topics: Humans; Infliximab; Adalimumab; Crohn Disease; Retrospective Studies; Treatment Outcome; Immunologic Factors; Rectal Fistula; Biological Products; Tumor Necrosis Factor-alpha
PubMed: 37540392
DOI: 10.1007/s10620-023-08060-7 -
Digestive and Liver Disease : Official... Apr 2021Ulcerative colitis, a chronic inflammatory condition that affects the colon from rectum to caecum, is characterized by periods of increased bowel movements, blood in... (Comparative Study)
Comparative Study Review
Ulcerative colitis, a chronic inflammatory condition that affects the colon from rectum to caecum, is characterized by periods of increased bowel movements, blood in feces, rectal urgency, tenesmus, and abdominal pain, with periods of remission and flares of disease, which negatively impact quality of life. A number of therapeutic options are available for patients with moderate-to-severe ulcerative colitis, however, no clear treatment algorithm exists. Therapeutic goals include short-term benefits for patients (i.e., the reduction/absence of symptoms, essentially stool frequency and rectal bleeding) and long-term benefits (i.e., sustained clinical remission, steroid-free remission, and mucosal healing). Therapies currently approved and available for the treatment of moderate-to-severe ulcerative colitis include monoclonal antibodies such as those targeting anti-tumor necrosis factor α (i.e., infliximab, adalimumab, golimumab), anti-adhesion molecules (i.e., vedolizumab), anti-interleukin 12/23 agents (i.e., ustekinumab), and Janus Kinase inhibitors (i.e., tofacitinib). Surgical approaches should also be considered in patients refractory to medical therapy or with complications (including toxic megacolon or colonic dysplasia/cancer). This review provides an overview of currently available treatment options for patients with moderate-to-severe ulcerative colitis and summarizes factors that should be considered during the therapeutic decision.
Topics: Anastomosis, Surgical; Cell Adhesion Molecules; Colitis, Ulcerative; Humans; Interleukin-12; Interleukin-23; Janus Kinase Inhibitors; Proctocolectomy, Restorative; Randomized Controlled Trials as Topic; Severity of Illness Index; Treatment Outcome; Tumor Necrosis Factor Inhibitors
PubMed: 33051163
DOI: 10.1016/j.dld.2020.09.022 -
Minerva Ginecologica Oct 2017Based on a review of the current literature, we will discuss early and late (more than three months postoperative) complications associated with surgery for colorectal... (Review)
Review
Based on a review of the current literature, we will discuss early and late (more than three months postoperative) complications associated with surgery for colorectal endometriosis resection. The most common surgical complications are: rectovaginal fistulae, anastomotic leakages and abscesses. Postoperative bleeding occurs rarely but has also been reported; and usually requires blood transfusion without surgical interventions. The selection of patients for surgery requires a multidisciplinary approach and complete preoperative imaging work-up by an experienced physician. The surgical procedure is challenging, including resection of all extrarectal DIE lesions, often in a context of patients who already underwent operations. Considering the major complications that may occur, there are three frequently observed risk factors. First is the opening of the vagina at the time of the bowel surgical procedure. However, this is a matter of debate, and experts commonly open the vagina during the procedure, as appropriate, without increasing the rate of complications. Second is excessive use of electrocoagulation, which increases the risk of rectovaginal fistulae and abscesses, due to the risk of necrosis of the posterior vaginal cuff. Third is surgical treatment of low rectal lesions (5-8 cm from the anal verge), which increases the risk of anastomotic leaks. In addition, we refuse to consider functional postoperative complications that affect gastrointestinal and sexual function, as minor complications. These can have a severe impact on the quality of life of young women. Further research is needed to prevent and treat such complications.
Topics: Colonic Diseases; Endometriosis; Female; Humans; Patient Selection; Postoperative Complications; Postoperative Hemorrhage; Quality of Life; Rectal Diseases; Risk Factors
PubMed: 28381079
DOI: 10.23736/S0026-4784.17.04052-7 -
The American Surgeon Apr 2024Idiopathic acute rectal necrosis (IARN) is a rare condition due to a robust rectal blood supply. This report describes an 83-year-old man presenting with septic shock...
Idiopathic acute rectal necrosis (IARN) is a rare condition due to a robust rectal blood supply. This report describes an 83-year-old man presenting with septic shock due to distal sigmoid and complete rectal necrosis with perforation. He underwent emergent exploratory laparotomy, sigmoid and proximal rectum resection, and end sigmoid colostomy creation with delayed distal rectal evaluation. Bedside proctoscopy revealed pale, viable-appearing distal rectal mucosa on postoperative day 3. The patient had a protracted, complicated hospital stay but required no further operative intervention. Subsequent colostomy reversal was done 8 months postoperatively, and the patient did well and has been discharged with normal gastrointestinal function. Our successful conservative operative management of IARN deviates from previously described management in the literature which is emergent abdominoperineal resection. This conservative surgical strategy appears to have contributed to the patient's positive outcomes, highlighting the importance of considering a similar approach for future IARN cases.
PubMed: 38569206
DOI: 10.1177/00031348241241690 -
The American Journal of Case Reports Feb 2020BACKGROUND A 70-year-old African American man presented with fatigue, dizziness, generalized weakness, and considerable weight loss of over 20 pounds in 3 weeks....
BACKGROUND A 70-year-old African American man presented with fatigue, dizziness, generalized weakness, and considerable weight loss of over 20 pounds in 3 weeks. History-taking revealed he was positive for HIV, hepatitis C, and severe chronic condyloma acuminatum, which had been progressing for 16 years. Treatment and surgical intervention had been continuously postponed due to the patient's long-standing history of heroin abuse. CASE REPORT Physical exam and diagnostics showed evidence of sepsis. He was hypotensive, with lactic acidosis and significant leucocytosis, and had acute-on-chronic kidney disease. Urinalysis was positive for nitrites and leukocyte esterase; therefore, broad-spectrum antibiotics were initiated. Additional sources of sepsis were considered due to persistent leucocytosis despite appropriate antibiotic coverage. An MRI of the pelvis was done to evaluate for necrosis of fistulization from potential internal warts as a source of sepsis. The lesions extended from the inguinal areas bilaterally, covering the medial thighs, lower scrotal wall, and wall junction. It had infiltrated the perineum and the entire rectal area, including the gluteal cleft and anus. The patient was consulted by colorectal surgery, urology, and infectious disease services. CONCLUSIONS Surgical biopsies found that he had both low- and high-grade squamous intraepithelial neoplasia. There was no evidence of invasive carcinoma, which was a concern given his weight loss. Surgery devised a plan that included a diverting colostomy (allowing the infected anal area to heal), followed by resection of his giant condyloma, and re-anastomosing of the bowels to return him to a normal baseline anatomy. A favorable prognosis was expected.
Topics: Aged; Buschke-Lowenstein Tumor; Colostomy; Condylomata Acuminata; HIV; Hepatitis C; Heroin Dependence; Humans; Immunocompromised Host; Male; Rectal Neoplasms; Squamous Intraepithelial Lesions
PubMed: 32088723
DOI: 10.12659/AJCR.920516 -
Brazilian Journal of Medical and... 2022Roflumilast, a highly selective oral phosphodiesterase IV inhibitor, exerts anti-inflammatory and anti-fibrotic effects. Oral roflumilast causes gastrointestinal side...
Roflumilast, a highly selective oral phosphodiesterase IV inhibitor, exerts anti-inflammatory and anti-fibrotic effects. Oral roflumilast causes gastrointestinal side effects, especially vomiting, which could be reduced by administering roflumilast via off-label routes. Inhaled roflumilast reportedly improved inflammatory and histopathological changes in asthmatic mice. The current study investigated the effects of oral and rectal roflumilast on trinitrobenzenesulfonic acid (TNBS)-induced chronic colitis in rats, an experimental model resembling human Crohn's disease. Five groups of rats (n=8) were used: normal control, TNBS-induced colitis, and three TNBS-treated colitic groups, which received oral sulfasalazine (500 mg·kg-1·day-1), oral roflumilast (5 mg·kg-1·day-1), or rectal roflumilast (5 mg·kg-1·day-1) for 15 days after colitis induction. Then, the following were assessed: the colitis activity score, tumor necrosis factor (TNF)-α, interleukin (IL)-2, and IL-6 serum levels, colonic length, and myeloperoxidase, malonaldehyde, and glutathione levels. Histological examinations employed H&E, Masson trichrome, and PAS stains in addition to immunostaining for KI-67 and TNF-α. The TNBS-induced colitis rats showed significant increases in disease activity scores, serum TNF-α, IL-2, and IL-6 levels, and colonic myeloperoxidase and malonaldehyde content. They also showed significant decreases in colonic length and glutathione levels in addition to histopathological and immunohistochemical changes. All the treatments significantly improved all these changes. Sulfasalazine provided the greatest improvement, followed by oral roflumilast, and then rectal roflumilast. In conclusion, both oral and rectal roflumilast partially improved TNBS-induced chronic colitis, suggesting the potential of roflumilast as an additional treatment for Crohn's disease.
Topics: Aminopyridines; Animals; Benzamides; Colitis; Cyclopropanes; Disease Models, Animal; Mice; Peroxidase; Rats; Trinitrobenzenesulfonic Acid; Tumor Necrosis Factor-alpha
PubMed: 35239781
DOI: 10.1590/1414-431X2021e11877 -
Postgraduate Medicine Apr 2015Perianal involvement in Crohn's disease (CD), which encompasses fistulas, ulcers, abscesses, strictures and cancer, can lead to significant impairment in quality of... (Review)
Review
Perianal involvement in Crohn's disease (CD), which encompasses fistulas, ulcers, abscesses, strictures and cancer, can lead to significant impairment in quality of life. The objective of this article is to review the major perianal complications of CD and the current medical and surgical modalities used to treat them. Antibiotics are commonly used despite a lack of controlled trials to validate their use and should be used as a bridge to maintenance therapy. The anti-metabolites azathioprine and 6-MP have shown a positive response in terms of fistula closure, although these data are mostly from trials looking at this as a secondary endpoint. Infliximab is an effective agent for induction and maintenance of treatment of fistulizing CD. Further studies to evaluate the use of subcutaneous anti-tumor necrosis factors are needed to convincingly prove their efficacy for perianal fistulizing disease. In CD, clinicians should avoid surgery as a first-line approach for skin tags, hemorrhoids or fissures in the setting of proctitis. Surgery, particularly lateral internal sphincterotomy, in combination with medical therapy is associated with higher fissure healing rates in the absence of proctitis. Fistulotomy is curative for most simple low perianal fistulae, but complex fistulas often require sphincter-sparing surgical procedures. Less invasive approaches such as a chemical sphincterotomy should be used first, with therapy escalated only if this fails.
Topics: Anus Diseases; Crohn Disease; Humans; Rectal Fistula
PubMed: 25746229
DOI: 10.1080/00325481.2015.1023160 -
Trauma Case Reports Oct 2023The rectum is an anatomically protected and well vascularized structure. Injury to the rectum is usually the result of penetrating perineal mechanisms or reported...
The rectum is an anatomically protected and well vascularized structure. Injury to the rectum is usually the result of penetrating perineal mechanisms or reported scalding enemas. Here, we report a case of isolated rectal necrosis following a 72 % total body surface area burn that resulted from a motor vehicle crash. The patient's rectal injury was managed with open resection, left in discontinuity and ultimately expired. In presenting this case, we hope to share an unusual development in a patient with critical illness and guide future care.
PubMed: 37654702
DOI: 10.1016/j.tcr.2023.100886 -
Journal of Acquired Immune Deficiency... Apr 2023Methamphetamine (MA) use is associated with sexual risk behavior as well as systemic and mucosal inflammation, suggesting parallel biological and behavioral mechanisms...
BACKGROUND
Methamphetamine (MA) use is associated with sexual risk behavior as well as systemic and mucosal inflammation, suggesting parallel biological and behavioral mechanisms of HIV transmission among men who have sex with men (MSM) who use MA. Data evaluating the combined biological effects of MA use with concomitant rectal gonococcal and/or chlamydial (GC/CT) infection on inflammation are limited.
SETTING
Secondary analysis of stored rectal and plasma specimens from 100 MSM participating in an NIDA-funded longitudinal cohort in Los Angeles, CA.
METHODS
This cross-sectional analysis evaluated systemic and rectal inflammatory markers under 2 conditions: (1) recent MA use (by urine drug screen) and (2) rectal GC/CT infection. We evaluated 50 participants with recent MA use (25 with and 25 without rectal GC/CT) and 50 MSM without MA use (25 with and 25 without rectal GC/CT). Log-transformed plasma and rectal immune markers were regressed on MA exposure and rectal GC/CT, controlling for HIV status and age.
RESULTS
Median age was 32 (range 19-45) years, and 58% of participants were living with HIV. Plasma tumor necrosis factor (TNF)-α, interleukin (IL)-6, IL-8, IL-1ß, and rectal IL-6 were associated with rectal GC/CT and MA use, independent of HIV status. Higher levels of rectal TNF-α, IL-1ß, and IL-17a were associated with rectal GC/CT.
CONCLUSIONS
Systemic and rectal inflammation was positively associated with rectal GC/CT and MA use. Condomless sex in the setting of GC/CT- and MA-induced immune activation may provide a basis for synergistic biobehavioral mechanisms that promote HIV/STI transmission among MSM who use MA.
Topics: Male; Humans; Young Adult; Adult; Middle Aged; Sexually Transmitted Diseases; Homosexuality, Male; HIV Infections; Methamphetamine; Cross-Sectional Studies; Chlamydia Infections; Sexual and Gender Minorities; Chlamydia trachomatis; Sexual Behavior; Gonorrhea; Inflammation; Interleukin-6; Tumor Necrosis Factor-alpha
PubMed: 36515912
DOI: 10.1097/QAI.0000000000003143