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Annals of the Royal College of Surgeons... Nov 2022Acute supralevator abscess (SLA) is an uncommon and complicated form of anorectal sepsis. Its correct management is crucial to avoid complex iatrogenic fistula... (Review)
Review
INTRODUCTION
Acute supralevator abscess (SLA) is an uncommon and complicated form of anorectal sepsis. Its correct management is crucial to avoid complex iatrogenic fistula formation. A comprehensive review of the literature was conducted to determine the incidence of SLA and the surgical outcome with particular reference to the direction of drainage.
METHODS
A search of Medline, PubMed and the Cochrane Library was performed to identify all studies reporting surgical drainage of SLA.
FINDINGS
A total of 19 studies were identified, including 563 patients. The only two prospective studies reported an incidence of SLA of 10% and 3% in 68 and 100 patients, respectively, with anorectal sepsis. In 17 retrospective studies, the incidence ranged from 0% to 28%. Magnetic resonance imaging (MRI) was performed routinely in only one study. The surgical anatomical classification of the abscess was described in six studies diagnosed at surgery. The direction of surgical drainage whether 'inwards' (into the lumen) or 'outwards' (into the ischioanal fossa) was stated in only six studies. In two of these, the direction of drainage was contradictory to the recommendation made by Parks . Recurrent sepsis was reported in eight studies and ranged from 0% to 53%.
CONCLUSIONS
Detailed and prospective data on acute SLA are lacking. Its real incidence is unclear and it is not possible to analyse surgical outcomes conclusively according to different direction of drainage. The routine use of MRI in complicated anorectal sepsis would specify the surgical anatomy of SLA before any drainage is carried out.
Topics: Humans; Abscess; Rectal Fistula; Prospective Studies; Retrospective Studies; Drainage; Sepsis
PubMed: 35133205
DOI: 10.1308/rcsann.2021.0257 -
Cells Jul 2019Perianal fistulizing Crohn's disease (PFCD) is associated with significant morbidity and might negatively impact the quality of life of CD patients. In the last two... (Review)
Review
Perianal fistulizing Crohn's disease (PFCD) is associated with significant morbidity and might negatively impact the quality of life of CD patients. In the last two decades, the management of PFCD has evolved in terms of the multidisciplinary approach involving gastroenterologists and colorectal surgeons. However, the highest fistula healing rates, even combining surgical and anti-TNF agents, reaches 50% of treated patients. More recently, the administration of mesenchymal stem cells (MSCs) have shown notable promising results in the treatment of PFCD. The aim of this review is to describe the rationale and the possible mechanism of action of MSC application for PFCD and the most recent results of randomized clinical trials. Furthermore, the unmet needs of the current administration process and the expected next steps to improve the outcomes will be addressed.
Topics: Animals; Crohn Disease; Humans; Mesenchymal Stem Cell Transplantation; Mesenchymal Stem Cells; Mice; Quality of Life; Randomized Controlled Trials as Topic; Rectal Fistula; Wound Healing
PubMed: 31340546
DOI: 10.3390/cells8070764 -
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 -
Archivos Espanoles de Urologia Nov 2017The aim of this article is to classify and describe the different types of complications of radical prostatectomy, their frequency of appearance, as well as the... (Review)
Review
OBJECTIVES
The aim of this article is to classify and describe the different types of complications of radical prostatectomy, their frequency of appearance, as well as the different factors that may influence their development.
METHODS
A systematic review of the literature was carried out, based on the search of published articles between 2002 and 2015.
RESULTS
Laparoscopic or robotic radical prostatectomy may require conversion into open surgery, and these cases are significantly associated with longer hospital stay and greater rate of complications. Vascular damage comprises from injuries to small and medium caliber vessels (Santorini plexus or epigastric vessels) to possible lesions of large vessels (iliac), although they are infrequent. The most common nerve injury is that of the obturator nerve, which can be treated in the case of a complete section, and in incomplete lesions, damage is usually reversible. Intestinal injury is one of the most serious complications because it could be lifethreatening. Rectal injury is a complication that needs a correct diagnosis and intraoperative treatment, since it may lead to the development of a secondary rectourethral fistula. Such fistulae in most cases require surgical treatment. Lymphocele is a characteristic complication of radical prostatectomy with pelvic lymphadenectomy, requiring treatment only in cases of complication. Anastomotic leakage is a frequent complication, and a prognostic factor for the later development of anastomosis stricture. Some of the factors that seem to influence the development of complications are associated comorbidity, anatomical factors, surgical approach and surgical experience, among others.
CONCLUSIONS
It is crucial to know the potential complications of radical prostatectomy, as well as the associated risk factors, in order to avoid their appearance.
Topics: Humans; Male; Postoperative Complications; Prostatectomy; Rectal Fistula; Rectum; Urethral Diseases; Urinary Fistula
PubMed: 29099379
DOI: No ID Found -
BMC Medical Imaging Sep 2023Accurate preoperative fistula diagnostics in male anorectal malformations (ARM) after colostomy are of great significance. We reviewed our institutional experiences and... (Review)
Review
BACKGROUND
Accurate preoperative fistula diagnostics in male anorectal malformations (ARM) after colostomy are of great significance. We reviewed our institutional experiences and explored methods for improving the preoperative diagnostic accuracy of fistulas in males with ARMs after colostomy.
METHODS
A retrospective analysis was performed on males with ARMs after colostomy admitted to our hospital from January 2015 to June 2022. All patients underwent magnetic resonance imaging (MRI) and high-pressure colostogram (HPC) before anorectal reconstruction. Patients with no fistula as diagnosed by both modalities underwent a voiding cystourethrogram (VCUG). General information, imaging results and surgical results were recorded.
RESULTS
Sixty-nine males with ARMs after colostomy were included. Age at the time of examination was 52 ~ 213 days, and the median age was 89 days. The Krickenbeck classification according to surgical results included rectovesical fistula (n = 19), rectoprostatic fistula (n = 24), rectobulbar fistula (n = 19) and no fistula (n = 7). There was no significant difference in the diagnostic accuracy between MRI and HPC for different types of ARMs. For determining the location of the fistula, compared to surgery, HPC (76.8%, 53/69) performed significantly better than MRI (60.9%, 42/69) (p = 0.043). Sixteen patients diagnosed as having no fistula by MRI or HPC underwent a VCUG, and in 14 patients, the results were comfirmed. However, there were 2 cases of rectoprostatic fistula that were not correctly diagnosed.
CONCLUSION
High-pressure colostogram has greater accuracy than MRI in the diagnosis of fistula type in males with ARMs after colostomy. For patients diagnosed with no fistula by both methods, VCUG reduces the risk of false-negative exclusion, and rectoprostatic fistula should be considered during the operation.
Topics: Humans; Male; Infant; Anorectal Malformations; Retrospective Studies; Colostomy; Rectal Fistula; Magnetic Resonance Imaging
PubMed: 37749545
DOI: 10.1186/s12880-023-01105-3 -
Cellular and Molecular Gastroenterology... 2023Perianal fistula represents one of the most disabling manifestations of Crohn's disease (CD) due to complete destruction of the affected mucosa, which is replaced by...
BACKGROUND AND AIMS
Perianal fistula represents one of the most disabling manifestations of Crohn's disease (CD) due to complete destruction of the affected mucosa, which is replaced by granulation tissue and associated with changes in tissue organization. To date, the molecular mechanisms underlying perianal fistula formation are not well defined. Here, we dissected the tissue changes in the fistula area and addressed whether a dysregulation of extracellular matrix (ECM) homeostasis can support fistula formation.
METHODS
Surgical specimens from perianal fistula tissue and the surrounding region of fistulizing CD were analyzed histologically and by RNA sequencing. Genes significantly modulated were validated by real-time polymerase chain reaction, Western blot, and immunofluorescence assays. The effect of the protein product of TNF-stimulated gene-6 (TSG-6) on cell morphology, phenotype, and ECM organization was investigated with endogenous lentivirus-induced overexpression of TSG-6 in Caco-2 cells and with exogenous addition of recombinant human TSG-6 protein to primary fibroblasts from region surrounding fistula. Proliferative and migratory assays were performed.
RESULTS
A markedly different organization of ECM was found across fistula and surrounding fistula regions with an increased expression of integrins and matrix metalloproteinases and hyaluronan (HA) staining in the fistula, associated with increased newly synthesized collagen fibers and mechanosensitive proteins. Among dysregulated genes associated with ECM, TNFAI6 (gene encoding for TSG-6) was as significantly upregulated in the fistula compared with area surrounding fistula, where it promoted the pathological formation of complexes between heavy chains from inter-alpha-inhibitor and HA responsible for the formation of a crosslinked ECM. There was a positive correlation between TNFAI6 expression and expression of mechanosensitive genes in fistula tissue. The overexpression of TSG-6 in Caco-2 cells promoted migration, epithelial-mesenchymal transition, transcription factor SNAI1, and HA synthase (HAs) levels, while in fibroblasts, isolated from the area surrounding the fistula, it promoted an activated phenotype. Moreover, the enrichment of an HA scaffold with recombinant human TSG-6 protein promoted collagen release and increase of SNAI1, ITGA4, ITGA42B, and PTK2B genes, the latter being involved in the transduction of responses to mechanical stimuli.
CONCLUSIONS
By mediating changes in the ECM organization, TSG-6 triggers the epithelial-mesenchymal transition transcription factor SNAI1 through the activation of mechanosensitive proteins. These data point to regulators of ECM as new potential targets for the treatment of CD perianal fistula.
Topics: Humans; Crohn Disease; Caco-2 Cells; Epithelial-Mesenchymal Transition; Rectal Fistula; Transcription Factors; Extracellular Matrix
PubMed: 36521659
DOI: 10.1016/j.jcmgh.2022.12.006 -
Techniques in Coloproctology Sep 2017Anoperineal lesion (APL) occurrence is a significant event in the evolution of Crohn's disease (CD). Management should involve a multidisciplinary approach combining the... (Review)
Review
BACKGROUND
Anoperineal lesion (APL) occurrence is a significant event in the evolution of Crohn's disease (CD). Management should involve a multidisciplinary approach combining the knowledge of the gastroenterologist, the colorectal surgeon and the radiologist who have appropriate experience in this area. Given the low level of evidence of available medical and surgical strategies, the aim of this work was to establish a French expert consensus on management of anal Crohn's disease. These recommendations were led under the aegis of the Société Nationale Française de Colo-Proctologie (SNFCP). They report a consensus on the management of perianal Crohn's disease lesions, including fistulas, ulceration and anorectal stenosis and propose an appropriate treatment strategy, as well as sphincter-preserving and multidisciplinary management.
METHODOLOGY
A panel of French gastroenterologists and colorectal surgeons with expertise in inflammatory bowel diseases reviewed the literature in order to provide practical management pathways for perianal CD. Analysis of the literature was made according to the recommendations of the Haute Autorité de Santé (HAS) to establish a level of proof for each publication and then to propose a rank of recommendation. When lack of factual data precluded ranking according to the HAS, proposals based on expert opinion were written. Therefore, once all the authors agreed on a consensual statement, it was then submitted to all the members of the SNFCP. As initial literature review stopped in December 2014, more recent European or international guidelines have been published since and were included in the analysis.
RESULTS
MRI is recommended for complex secondary lesions, particularly after failure of previous medical and/or surgical treatments. For severe anal ulceration in Crohn's disease, maximal medical treatment with anti-TNF agent is recommended. After prolonged drainage of simple anal fistula by a flexible elastic loop or loosely tied seton, and after obtaining luminal and perineal remission by immunosuppressive therapy and/or anti-TNF agents, the surgical treatment options to be discussed are simple seton removal or injection of the fistula tract with biological glue. After prolonged loose-seton drainage of the complex anal fistula in Crohn's disease, and after obtaining luminal and perineal remission with anti-TNF ± immunosuppressive therapy, surgical treatment options are simple removal of seton and rectal advancement flap. Colostomy is indicated as a last option for severe APL, possibly associated with a proctectomy if there is refractory rectal involvement after failure of other medical and surgical treatments. The evaluation of anorectal stenosis of Crohn's disease (ARSCD) requires a physical examination, sometimes under anesthesia, plus endoscopy with biopsies and MRI to describe the stenosis itself, to identify associated inflammatory, infectious or dysplastic lesions, and to search for injury or fibrosis of the sphincter. Therapeutic strategy for ARSCD requires medical-surgical cooperation.
Topics: Adult; Anal Canal; Anus Neoplasms; Combined Modality Therapy; Consensus; Crohn Disease; Digestive System Surgical Procedures; Drainage; Female; France; Gastrointestinal Agents; Humans; Male; Perineum; Practice Guidelines as Topic; Rectal Fistula; Treatment Outcome; Tumor Necrosis Factor-alpha
PubMed: 28929282
DOI: 10.1007/s10151-017-1684-y -
World Journal of Gastroenterology Nov 2020One of the most challenging phenotypes of Crohn's disease is perianal fistulizing disease (PFCD). It occurs in up to 50% of the patients who also have symptoms in other... (Review)
Review
One of the most challenging phenotypes of Crohn's disease is perianal fistulizing disease (PFCD). It occurs in up to 50% of the patients who also have symptoms in other parts of the gastrointestinal tract, and in 5% of the cases it occurs as the first manifestation. It is associated with severe symptoms, such as pain, fecal incontinence, and a significant reduction in quality of life. The presence of perianal disease in conjunction with Crohn's disease portends a significantly worse disease course. These patients require close monitoring to identify those at risk of worsening disease, suboptimal biological drug levels, and signs of developing neoplasm. The last 2 decades have seen significant advancements in the management of PFCD. More recently, newer biologics, cell-based therapies, and novel surgical techniques have been introduced in the hope of improved outcomes. However, in refractory cases, many patients face the decision of having a stoma made and/or a proctectomy performed. In this review, we describe modern surgical management and the most recent advances in the management of complex PFCD, which will likely impact clinical practice.
Topics: Crohn Disease; Fecal Incontinence; Humans; Quality of Life; Rectal Fistula; Surgical Stomas
PubMed: 33268947
DOI: 10.3748/wjg.v26.i42.6572 -
Techniques in Coloproctology Oct 2023Currently, the anal fistula treatment which optimises healing and preserves bowel continence remains unclear. The aim of our study was to compare the relative efficacy... (Meta-Analysis)
Meta-Analysis Review
PURPOSE
Currently, the anal fistula treatment which optimises healing and preserves bowel continence remains unclear. The aim of our study was to compare the relative efficacy of different surgical treatments for AF through a network meta-analysis.
METHODS
Systematic searches of MEDLINE, EMBASE and CENTRAL databases up to October 2022 identified randomised controlled trials (RCTs) comparing surgical treatments for anal fistulae. Fistulae were classified as simple (inter-sphincteric or low trans-sphincteric fistulae crossing less than 30% of the external anal sphincter (EAS)) and complex (high trans-sphincteric fistulae involving more than 30% of the EAS). Treatments evaluated in only one trial were excluded from the primary analyses to minimise bias. The primary outcomes were rates of success in achieving AF healing and bowel incontinence.
RESULTS
Fifty-two RCTs were included. Of the 14 treatments considered, there were no significant differences regarding short-term (6 months or less postoperatively) and long-term (more than 6 months postoperatively) success rates between any of the treatments in patients with both simple and complex anal fistula. Ligation of the inter-sphincteric fistula tract (LIFT) ranked best for minimising bowel incontinence in simple (99.1% of comparisons; 3 trials, n = 70 patients) and complex anal fistula (86.2% of comparisons; 3 trials, n = 102 patients).
CONCLUSIONS
There is insufficient evidence in existing RCTs to recommend one treatment over another regarding their short and long-term efficacy in successfully facilitating healing of both simple and complex anal fistulae. However, LIFT appears to be associated with the least impairment of bowel continence, irrespective of AF classification.
Topics: Humans; Fecal Incontinence; Network Meta-Analysis; Wound Healing; Anal Canal; Ligation; Rectal Fistula; Treatment Outcome
PubMed: 37460830
DOI: 10.1007/s10151-023-02845-8 -
World Journal of Gastroenterology Apr 2022Crohn's disease (CD) is a chronic nonspecific intestinal inflammatory disease. The aetiology and pathogenesis of CD are still unclear. Anal fistula is the main...
BACKGROUND
Crohn's disease (CD) is a chronic nonspecific intestinal inflammatory disease. The aetiology and pathogenesis of CD are still unclear. Anal fistula is the main complication of CD and is a difficult problem to solve at present. The main limitation of developing new therapies is bound up with the short of preclinical security and effectiveness data. Therefore, an ideal animal model is needed to establish persistent anal fistula and an inflamed rectal mucosa.
AIM
To improve the induction method of colitis and establish a reliable and reproducible perianal fistulizing Crohn's disease animal model to evaluate new treatment strategies.
METHODS
Twenty male New Zealand rabbits underwent rectal enema with different doses of 2,4,6-trinitrobenzene sulfonic acid to induce proctitis. Group A was treated with an improved equal interval small dose increasing method. The dosage of group B was constant. Seven days later, the rabbits underwent surgical creation of a transsphincteric fistula. Then, three rabbits were randomly selected from each group every 7 d to remove the seton from the fistula. The rabbits were examined by endoscopy every 7 days, and biopsy forceps were used to obtain tissue samples from the obvious colon lesions for histological analysis. The disease activity index (DAI), colonoscopy and histological scores were recorded. Perianal endoscopic ultrasonography (EUS) was used to evaluate the healing of fistulas.
RESULTS
Except for the DAI score, the colonoscopy and histological scores in group A were significantly higher than those in group B ( < 0.05). In the ideal model rabbit group, on the 7 day after the removal of the seton, all animals had persistent lumens on EUS imaging, showing continuous full-thickness high signals. Histological inspection of the fistula showed acute and chronic inflammation, fibrosis, epithelialization and peripheral proctitis of the adjoining rectum.
CONCLUSION
The improved method of CD colitis induction successfully established a rabbit perianal fistula CD preclinical model, which was confirmed by endoscopy and pathology.
Topics: Animals; Colitis; Crohn Disease; Humans; Male; Proctitis; Rabbits; Rectal Fistula; Treatment Outcome
PubMed: 35582134
DOI: 10.3748/wjg.v28.i15.1536