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Journal of Crohn's & Colitis Jan 2020
Topics: Adrenal Cortex Hormones; Anti-Bacterial Agents; Anti-Inflammatory Agents; Antibodies, Monoclonal; Crohn Disease; Drug Therapy, Combination; Humans; Immunosuppressive Agents; Induction Chemotherapy; Maintenance Chemotherapy; Rectal Fistula; Severity of Illness Index
PubMed: 31711158
DOI: 10.1093/ecco-jcc/jjz180 -
World Journal of Gastroenterology Jan 2015Ideal surgical treatment for anal fistula should aim to eradicate sepsis and promote healing of the tract, whilst preserving the sphincters and the mechanism of... (Review)
Review
Ideal surgical treatment for anal fistula should aim to eradicate sepsis and promote healing of the tract, whilst preserving the sphincters and the mechanism of continence. For the simple and most distal fistulae, conventional surgical options such as laying open of the fistula tract seem to be relatively safe and therefore, well accepted in clinical practise. However, for the more complex fistulae where a significant proportion of the anal sphincter is involved, great concern remains about damaging the sphincter and subsequent poor functional outcome, which is quite inevitable following conventional surgical treatment. For this reason, over the last two decades, many sphincter-preserving procedures for the treatment of anal fistula have been introduced with the common goal of minimising the injury to the anal sphincters and preserving optimal function. Among them, the ligation of intersphincteric fistula tract procedure appears to be safe and effective and may be routinely considered for complex anal fistula. Another technique, the anal fistula plug, derived from porcine small intestinal submucosa, is safe but modestly effective in long-term follow-up, with success rates varying from 24%-88%. The failure rate may be due to its extrusion from the fistula tract. To obviate that, a new designed plug (GORE BioA®) was introduced, but long term data regarding its efficacy are scant. Fibrin glue showed poor and variable healing rate (14%-74%). FiLaC and video-assisted anal fistula treatment procedures, respectively using laser and electrode energy, are expensive and yet to be thoroughly assessed in clinical practise. Recently, a therapy using autologous adipose-derived stem cells has been described. Their properties of regenerating tissues and suppressing inflammatory response must be better investigated on anal fistulae, and studies remain in progress. The aim of this present article is to review the pertinent literature, describing the advantages and limitations of new sphincter-preserving techniques.
Topics: Anal Canal; Digestive System Surgical Procedures; Humans; Postoperative Complications; Rectal Fistula; Risk Factors; Treatment Outcome
PubMed: 25574077
DOI: 10.3748/wjg.v21.i1.12 -
International Journal of Surgery... Sep 2019Despite a burgeoning literature during the last two decades regarding perioperative risk management of anal fistula, little is known about its risk factors that... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Despite a burgeoning literature during the last two decades regarding perioperative risk management of anal fistula, little is known about its risk factors that influence postoperative recurrence. We performed a meta-analysis to summarize and assess the credibility of evidence of potential risk factors for anal fistula recurrence (AFR) after surgery.
METHODS
Pubmed and EMBASE without language restriction were searched from inception to April 2018 that reported risk factors which predisposed recurrence after anal fistula surgery. We excluded studies that involved patients with anal fistula associated with Crohn's disease. MOOSE guidelines were followed when this meta-analysis was performed. We used random-effects models to pool relative risks (RRs) with 95% confidence intervals (CIs). Evidence from observational studies was graded into high-quality (Class I), moderate-quality (Class II/III) and low-quality (Class IV) based on Egger's P value, total sample size and between-study heterogeneity.
RESULTS
Of 3514 citations screened, 20 unique observational studies comprising 6168 patients were involved in data synthesis. High-quality evidence showed that AFR was associated with high transsphincteric fistula (RR, 4.77; 95% CI, 3.83 to 5.95), internal opening unidentified (RR, 8.54; 95% CI, 5.29 to 13.80), and horseshoe extensions (RR, 1.92; 95% CI, 1.43 to 2.59). Moderate-quality evidence suggested an association with prior anal surgery (RR, 1.52; 95% CI, 1.04 to 2.23), seton placement surgery (RR, 2.97; 95% CI, 1.10 to 8.06), and multiple fistula tract (RR, 4.77; 95% CI, 1.46 to 15.51). High-quality evidence demonstrated no significant association with gender or smoking; moderate-quality evidence also suggested no association with age, tertiary referral, alcohol use, diabetes mellitus, obesity, preoperative seton drainage, high internal opening, postoperative drainage, mucosal advancement flap surgery, supralevator extensions, location or type of anal fistula.
CONCLUSION
Several patient, surgery and fistula-related factors are significantly associated with postoperative AFR. These findings strengthen clinical awareness of early warning to identify patients with high-risk disease recurrence for AFR.
Topics: Adult; Female; Humans; Male; Postoperative Complications; Rectal Fistula; Recurrence; Risk Factors
PubMed: 31400504
DOI: 10.1016/j.ijsu.2019.08.003 -
Journal of Crohn's & Colitis Feb 2020This article is the second in a series of two publications relating to the European Crohn's and Colitis Organisation [ECCO] evidence-based consensus on the management of...
This article is the second in a series of two publications relating to the European Crohn's and Colitis Organisation [ECCO] evidence-based consensus on the management of Crohn's disease. The first article covers medical management; the present article addresses surgical management, including preoperative aspects and drug management before surgery. It also provides technical advice for a variety of common clinical situations. Both articles together represent the evidence-based recommendations of the ECCO for Crohn's disease and an update of previous guidelines.
Topics: Abdominal Abscess; Crohn Disease; Humans; Intestinal Obstruction; Intestine, Small; Rectal Fistula
PubMed: 31742338
DOI: 10.1093/ecco-jcc/jjz187 -
World Journal of Gastroenterology Jul 2021Perianal Crohn's disease remains a challenging condition to treat and can have a substantial negative impact on quality of life. It often requires combined surgical and... (Review)
Review
Perianal Crohn's disease remains a challenging condition to treat and can have a substantial negative impact on quality of life. It often requires combined surgical and medical interventions. Anti-tumor necrosis factor (anti-TNF) therapy, including infliximab and adalimumab, remain preferred medical therapies for perianal Crohn's disease. Infliximab has been shown to be efficacious in improving fistula closure rates in randomized controlled trials. Clinicians can be faced with a number of questions relating to the optimal use of anti-TNF therapy in perianal Crohn's disease. Specific issues include evaluation for the presence of perianal sepsis, the treatment target of therapy, the ideal time to commence treatment, whether additional medical therapy should be used in conjunction with anti-TNF therapy, and the duration of treatment. This article will discuss key studies which can assist clinicians in addressing these matters when they are considering or have already commenced anti-TNF therapy for the treatment of perianal Crohn's disease. It will also discuss current evidence regarding the use of vedolizumab and ustekinumab in patients who are failing to achieve a response to anti-TNF therapy for perianal Crohn's disease. Lastly, new therapies such as local injection of mesenchymal stem cell therapy will be discussed.
Topics: Crohn Disease; Humans; Infliximab; Quality of Life; Rectal Fistula; Treatment Outcome; Tumor Necrosis Factor Inhibitors; Tumor Necrosis Factor-alpha
PubMed: 34321838
DOI: 10.3748/wjg.v27.i25.3693 -
Gastroenterology Jun 2021The incidence and prevalence of Crohn's disease (CD) is rising globally. Patients with moderate to severe CD are at high risk for needing surgery and hospitalization and... (Review)
Review
The incidence and prevalence of Crohn's disease (CD) is rising globally. Patients with moderate to severe CD are at high risk for needing surgery and hospitalization and for developing disease-related complications, corticosteroid dependence, and serious infections. Optimal management of outpatients with moderate to severe luminal and/or fistulizing (including perianal) CD often requires the use of immunomodulator (thiopurines, methotrexate) and/or biologic therapies, including tumor necrosis factor-α antagonists, vedolizumab, or ustekinumab, either as monotherapy or in combination (with immunomodulators) to mitigate these risks. Decisions about optimal drug therapy in moderate to severe CD are complex, with limited guidance on comparative efficacy and safety of different treatments, leading to considerable practice variability. Since the last iteration of these guidelines published in 2013, significant advances have been made in the field, including the regulatory approval of 2 new biologic agents, vedolizumab and ustekinumab. Therefore, the American Gastroenterological Association prioritized updating clinical guidelines on this topic. To inform the clinical guidelines, this technical review was completed in accordance with the GRADE (Grading of Recommendations Assessment, Development and Evaluation) framework. The review addressed the following focused questions (in adult outpatients with moderate to severe luminal CD): overall and comparative efficacy of different medications for induction and maintenance of remission in patients with or without prior exposure to tumor necrosis factor-α antagonists, comparative efficacy and safety of biologic monotherapy vs combination therapy with immunomodulators, comparative efficacy of a top-down (upfront use of biologics and/or immunomodulator therapy) vs step-up treatment strategy (acceleration to biologic and/or immunomodulator therapy only after failure of mesalamine), and the role of corticosteroids and mesalamine for induction and/or maintenance of remission. Finally, in adult outpatients with moderate to severe fistulizing CD, this review addressed the efficacy of pharmacologic interventions for achieving fistula and the role of adjunctive antibiotics without clear evidence of active infection.
Topics: Adult; Crohn Disease; Decision Support Systems, Clinical; Disease Management; Female; Gastroenterology; Humans; Male; Practice Guidelines as Topic; Rectal Fistula; Severity of Illness Index; Societies, Medical
PubMed: 34051985
DOI: 10.1053/j.gastro.2021.04.023 -
World Journal of Gastroenterology Sep 2018Endoscopy plays a fundamental role in the diagnosis, management, and treatment of inflammatory bowel disease (IBD). Colonoscopy, flexible sigmoidoscopy, and... (Review)
Review
Endoscopy plays a fundamental role in the diagnosis, management, and treatment of inflammatory bowel disease (IBD). Colonoscopy, flexible sigmoidoscopy, and esophagogastroduodenoscopy have long been used in the care of patients with IBD. As endoscopic technologies have progressed, tools such as endoscopic ultrasound, capsule endoscopy, and balloon-assisted enteroscopy have expanded the role of endoscopy in IBD. Furthermore, chromoendoscopy has enhanced our ability to detect dysplasia in IBD. In this review article, we will focus on the roles, indications, and limitations of these tools in IBD. We will also discuss the most commonly used endoscopic scoring systems, as well as special considerations in post-surgical patients. Lastly, we will discuss the role of endoscopy in the diagnosis and management of fistulae and strictures.
Topics: Capsule Endoscopy; Colitis, Ulcerative; Colon; Colonoscopy; Colorectal Neoplasms; Constriction, Pathologic; Crohn Disease; Diagnosis, Differential; Early Detection of Cancer; Endosonography; Gastrointestinal Agents; Humans; Rectal Fistula
PubMed: 30254405
DOI: 10.3748/wjg.v24.i35.4014 -
International Journal of Colorectal... Jun 2021The aim of this review was to examine current surgical treatments in patients with Crohn's disease (CD) and to discuss currently popular research questions. (Review)
Review
PURPOSE
The aim of this review was to examine current surgical treatments in patients with Crohn's disease (CD) and to discuss currently popular research questions.
METHODS
A literature search of MEDLINE (PubMed) was conducted using the following search terms: 'Surgery' and 'Crohn'. Different current surgical treatment strategies are discussed based on disease location.
RESULTS
Several surgical options are possible in medically refractory or complex Crohn's disease as a last resort therapy. Recent evidence indicated that surgery could also be a good alternative in terms of effectiveness, quality of life and costs as first-line therapy if biologicals are considered, e.g. ileocolic resection for limited disease, or as part of combination therapy with biologicals, e.g. surgery aiming at closure of select perianal fistula in combination with biologicals. The role of the mesentery in ileocolic disease and Crohn's proctitis is an important surgical dilemma. In proctectomy, evidence is directing at removing the mesentery, and in ileocolic disease, it is still under investigation. Other surgical dilemmas are the role of the Kono-S anastomosis as a preventive measure for recurrent Crohn's disease and the importance of (non)conventional stricturoplasties.
CONCLUSION
Surgical management of Crohn's disease remains challenging and is dependent on disease location and severity. Indication and timing of surgery should always be discussed in a multidisciplinary team. It seems that early surgery is gradually going to play a more important role in the multidisciplinary management of Crohn's disease rather than being a last resort therapy.
Topics: Anastomosis, Surgical; Colectomy; Crohn Disease; Humans; Quality of Life; Rectal Fistula
PubMed: 33528750
DOI: 10.1007/s00384-021-03857-2 -
Gastroenterology Jun 2021
Topics: Crohn Disease; Disease Management; Gastroenterology; Humans; Intestinal Mucosa; Minimal Clinically Important Difference; Patient Selection; Rectal Fistula; Societies, Medical
PubMed: 34051983
DOI: 10.1053/j.gastro.2021.04.022 -
The British Journal of Surgery Sep 2022Perianal abscess is common. Traditionally, postoperative perianal abscess cavities are managed with internal wound packing, a practice not supported by evidence. The aim... (Randomized Controlled Trial)
Randomized Controlled Trial
BACKGROUND
Perianal abscess is common. Traditionally, postoperative perianal abscess cavities are managed with internal wound packing, a practice not supported by evidence. The aim of this randomized clinical trial (RCT) was to assess if non-packing is less painful and if it is associated with adverse outcomes.
METHODS
The Postoperative Packing of Perianal Abscess Cavities (PPAC2) trial was a multicentre, RCT (two-group parallel design) of adult participants admitted to an NHS hospital for incision and drainage of a primary perianal abscess. Participants were randomized 1:1 (via an online system) to receive continued postoperative wound packing or non-packing. Blinded data were collected via symptom diaries, telephone, and clinics over 6 months. The objective was to determine whether non-packing of perianal abscess cavities is less painful than packing, without an increase in perianal fistula or abscess recurrence. The primary outcome was pain (mean maximum pain score on a 100-point visual analogue scale).
RESULTS
Between February 2018 and March 2020, 433 participants (mean age 42 years) were randomized across 50 sites. Two hundred and thirteen participants allocated to packing reported higher pain scores than 220 allocated to non-packing (38.2 versus 28.2, mean difference 9.9; P < 0.0001). The occurrence of fistula-in-ano was low in both groups: 32/213 (15 per cent) in the packing group and 24/220 (11 per cent) in the non-packing group (OR 0.69, 95 per cent c.i. 0.39 to 1.22; P = 0.20). The proportion of patients with abscess recurrence was also low: 13/223 (6 per cent) in the non-packing group and 7/213 (3 per cent) in the packing group (OR 1.85, 95 per cent c.i. 0.72 to 4.73; P = 0.20).
CONCLUSION
Avoiding abscess cavity packing is less painful without a negative morbidity risk.
REGISTRATION NUMBER
ISRCTN93273484 (https://www.isrctn.com/ISRCTN93273484).
REGISTRATION NUMBER
NCT03315169 (http://clinicaltrials.gov).
Topics: Abscess; Adult; Anus Diseases; Bandages; Drainage; Humans; Pain; Rectal Fistula; Treatment Outcome
PubMed: 35929816
DOI: 10.1093/bjs/znac225