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Stem Cell Research & Therapy Apr 2023Perianal fistulas, characterised as granulomatous inflammation of fistulas around the anal canal, are associated with significant morbidity resulting in a negative... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Perianal fistulas, characterised as granulomatous inflammation of fistulas around the anal canal, are associated with significant morbidity resulting in a negative impact on quality of life and a tremendous burden to the healthcare system. Treatment of anal fistulas usually consists of anal surgery; however, results of closure rates are not satisfactory especially with complex perianal fistulas, after which many patients may suffer from anal incontinence. Recently, the administration of mesenchymal stem cells (MSCs) has shown promising efficacy. Herein, we aim to explore whether MSCs are effective for complex perianal fistulas and if they have either short-term, medium-term, long-term or over-long-term efficacy. Additionally, we want to elucidate whether factors such as drug dosage, MSC source, cell type, and disease aetiology influence treatment efficacy. We searched four online databases and analysed data based on information within the clinical trials registry. The outcomes of eligible trials were analysed with Review Manager 5.4.1. Relative risk and related 95% confidence interval were calculated to compare the effect between the MSCs and control groups. In addition, the Cochrane risk of bias tool was applied to evaluate the bias risk of eligible studies. Meta-analyses showed that therapy with MSCs was superior to conventional treatment for complex perianal fistulas in short-, long- and over-long-term follow-up phases. However, there was no statistical difference in treatment efficacy in the medium term between the two methods. Subgroup meta-analyses showed factors including cell type, cell source and cell dosage were superior compared to the control, but there was no significant difference between different experimental groups of those factors. Besides, local MSCs therapy has shown more promising results for fistulas as a result of Crohn's Disease (CD). Although we tend to maintain that MSCs therapy is effective for cryptoglandular fistulas equally, more studies are needed to confirm this conclusion in the future.
SHORT CONCLUSION
MSCs Transplantation could be a new therapeutic method for complex perianal fistulas of both cryptoglandular and CD origin showing high efficacy in the short-term to over-long-term phases, as well as high efficacy in sustained healing. The difference in cell types, cell sources and cell dosages did not influence MSCs' efficacy.
Topics: Humans; Quality of Life; Mesenchymal Stem Cell Transplantation; Treatment Outcome; Mesenchymal Stem Cells; Rectal Fistula; Crohn Disease
PubMed: 37101285
DOI: 10.1186/s13287-023-03331-6 -
Surgical Outcomes after Colorectal Surgery for Endometriosis: A Systematic Review and Meta-analysis.Journal of Minimally Invasive Gynecology Mar 2021To assess the impact of type of surgery for colorectal endometriosis-rectal shaving or discoid resection or segmental colorectal resection-on complications and surgical... (Meta-Analysis)
Meta-Analysis
OBJECTIVE
To assess the impact of type of surgery for colorectal endometriosis-rectal shaving or discoid resection or segmental colorectal resection-on complications and surgical outcomes.
DATA SOURCES
We performed a systematic review of all English- and French-language full-text articles addressing the surgical management of colorectal endometriosis, and compared the postoperative complications according to surgical technique by meta-analysis. The PubMed, Clinical Trials.gov, Cochrane Library, and Web of Science databases were searched for relevant studies published before March 27, 2020. The search strategy used the following Medical Subject Headings terms: ("bowel endometriosis" or "colorectal endometriosis") AND ("surgery for endometriosis" or "conservative management" or "radical management" or "colorectal resection" or "shaving" or "full thickness resection" or "disc excision") AND ("treatment", "outcomes", "long term results" and "complications").
METHODS OF STUDY SELECTION
Two authors conducted the literature search and independently screened abstracts for inclusion, with resolution of any difference by 3 other authors. Studies were included if data on surgical management (shaving, disc excision, and/or segmental resection) were provided and if postoperative outcomes were detailed with at least the number of complications. The risk of bias was assessed according to the Cochrane recommendations.
TABULATION, INTEGRATION, AND RESULTS
Of the 168 full-text articles assessed for eligibility, 60 were included in the qualitative synthesis. Seventeen of these were included in the meta-analysis on rectovaginal fistula, 10 on anastomotic leakage, 5 on anastomotic stenosis, and 9 on voiding dysfunction <30 days. The mean complication rate according to shaving, disc excision, and segmental resection were 2.2%, 9.7%, and 9.9%, respectively. Rectal shaving was less associated with rectovaginal fistula than disc excision (odds ratio [OR] = 0.19; 95% confidence interval [CI], 0.10-0.36; p <.001; I = 33%) and segmental colorectal resection (OR = 0.26; 95% CI, 0.15-0.44; p <.001; I = 0%). No difference was found in the occurrence of rectovaginal fistula between disc excision and segmental colorectal resection (OR = 1.07; 95% CI, 0.70-1.63; p = .76; I = 0%). Rectal shaving was less associated with leakage than disc excision (OR = 0.22; 95% CI, 0.06-0.73; p = .01; I = 86%). No difference was found in the occurrence of leakage between rectal shaving and segmental colorectal resection (OR = 0.32; 95% CI, 0.10-1.01; p = .05; I = 71%) or between disc excision and segmental colorectal resection (OR = 0.32; 95% CI, 0.30-1.58; p = .38; I = 0%). Disc excision was less associated with anastomotic stenosis than segmental resection (OR = 0.15; 95% CI, 0.05-0.48; p = .001; I = 59%). Disc excision was associated with more voiding dysfunction <30 days than rectal shaving (OR = 12.9; 95% CI, 1.40-119.34; p = .02; I = 0%). No difference was found in the occurrence of voiding dysfunction <30 days between segmental resection and rectal shaving (OR = 3.05; 95% CI, 0.55-16.87; p = .20; I = 0%) or between segmental colorectal and discoid resections (OR = 0.99; 95% CI, 0.54-1.85; p = .99; I = 71%).
CONCLUSION
Colorectal surgery for endometriosis exposes patients to a risk of severe complications such as rectovaginal fistula, anastomotic leakage, anastomotic stenosis, and voiding dysfunction. Rectal shaving seems to be less associated with postoperative complications than disc excision and segmental colorectal resection. However, this technique is not suitable for all patients with large bowel infiltration. Compared with segmental colorectal resection, disc excision has several advantages, including shorter operating time, shorter hospital stay, and lower risk of postoperative bowel stenosis.
Topics: Adult; Colon, Sigmoid; Databases, Factual; Digestive System Surgical Procedures; Endometriosis; Female; Humans; Laparoscopy; Middle Aged; Postoperative Complications; Prognosis; Rectal Diseases; Rectovaginal Fistula; Rectum; Treatment Outcome
PubMed: 32841755
DOI: 10.1016/j.jmig.2020.08.015 -
European Urology Open Science Jun 2023Rectal injury (RI) is a dreaded complication after radical prostatectomy (RP), increasing the risk of early postoperative complications, such as bleeding and severe... (Review)
Review
CONTEXT
Rectal injury (RI) is a dreaded complication after radical prostatectomy (RP), increasing the risk of early postoperative complications, such as bleeding and severe infection/sepsis, and late sequelae, such as a rectourethral fistula (RUF). Considering its traditionally low incidence, uncertainty remains as to predisposing risk factors and management.
OBJECTIVE
To examine the incidence of RI after RP in contemporary series and to propose a pragmatic algorithm for its management.
EVIDENCE ACQUISITION
A systematic literature search was performed using the Medline and Scopus databases. Studies reporting data on RI incidence were selected. Subgroup analyses were conducted to assess the differential incidence by age, surgical approach, salvage RP after radiation therapy, and previous benign prostatic hyperplasia (BPH)-related surgery.
EVIDENCE SYNTHESIS
Eighty-eight, mostly retrospective noncomparative, studies were selected. The meta-analysis obtained a pooled RI incidence of 0.58% (95% confidence interval [CI] 0.46-0.73) in contemporary series with significant across-study heterogeneity (I = 100%, < 0.00001). The highest RI incidence was found in patients undergoing open RP (1.25%; 95% CI 0.66-2.38) and laparoscopic RP (1.25%; 95% CI 0.75-2.08) followed by perineal RP (0.19%; 95% CI 0-276.95) and robotic RP (0.08%; 95% CI 0.02-0.31). Age ≥60 yr (0.56%; 95% CI 0.37-06) and salvage RP after radiation therapy (6.01%; 95% CI 3.99-9.05), but not previous BPH-related surgery (4.08%, 95% CI 0.92-18.20), were also associated with an increased RI incidence. Intraoperative versus postoperative RI detection was associated with a significantly decreased risk of severe postoperative complications (such as sepsis and bleeding) and subsequent formation of a RUF.
CONCLUSIONS
RI is a rare, but potentially devastating, complication following RP. RI incidence was higher in patients ≥60 yr of age, and in those who underwent open/laparoscopic approach or salvage RP after radiation therapy. Intraoperative RI detection and repair apparently constitute the single most critical step to significantly decrease the risk of major postoperative complications and subsequent RUF formation. Conversely, intraoperatively undetected RI can lead more often to severe infective complications and RUF, the management of which remains poorly standardised and requires complex procedures.
PATIENT SUMMARY
Accidental rectum tear is a rare, but potentially devastating, complication in men undergoing prostate removal for cancer. It occurs more often in patients aged 60 yr or older as well as in those who underwent prostate removal via an open/laparoscopic approach and/or prostate removal after radiation therapy for recurrent disease. Prompt identification and repair of this condition during the initial operation are the key to reduce further complications such as the formation of an abnormal opening between the rectum and the urinary tract.
PubMed: 37213241
DOI: 10.1016/j.euros.2023.03.017 -
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 -
Systematic Reviews Aug 2023Chronic radiation proctitis (CRP) is a long-term complication of pelvic radiotherapy that manifests as rectal bleeding, diarrhoea, fistula formation and obstruction.... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Chronic radiation proctitis (CRP) is a long-term complication of pelvic radiotherapy that manifests as rectal bleeding, diarrhoea, fistula formation and obstruction. Treatments such as endoscopic argon plasma coagulation, hyperbaric oxygen therapy and rectal topical formalin have imposed a significant medical burden on CRP patients. In contrast, oral therapies offer a more accessible and acceptable option for managing CRP. Here, we conducted a systematic review of the efficacy of oral treatments for CRP to assess their potential as an effective and convenient treatment option for this condition.
METHODS
We searched the Cochrane Central Register of Controlled Trials, PubMed, Web of Science, China National Knowledge Infrastructure and Chinese VIP in February 2021. We included post-radiotherapy participants with CRP that compared oral medicine alone or in combination with other treatments versus control treatments. The primary outcomes were bleeding, diarrhoea and symptom score. Heterogeneity between studies was checked using Cochrane Q test statistics and I test statistics. The Cochrane risk-of-bias tool was used to assess the quality of the included studies.
RESULTS
We included 10 randomised controlled trials (RCTs) and 1 retrospective study with 898 participants. Three placebo-controlled trials evaluated the effects of oral sucralfate on CRP, with meta-analysis showing no significant different with placebo arm. Four trials on TCM demonstrated significant improvement of symptoms, especially for the 3 trials on oral TCM drinks. Retinyl palmitate and high-fibre diet were found to reduce rectal bleeding. The combination of oral pentoxifylline and tocopherol did not significantly change the process of CRP.
CONCLUSIONS
Our study implies that oral TCM drinks, retinyl palmitate and a high-fiber diet showed significant improvement in CRP symptoms, but not with the combination of oral pentoxifylline and tocopherol. Further multicentre, larger-scale RCTs are needed to confirm the efficacy and safety of these treatments and optimize treatment strategies, ultimately improving the quality of life for patients with CRP.
Topics: Humans; Pentoxifylline; Tocopherols; Diarrhea; Proctitis
PubMed: 37608385
DOI: 10.1186/s13643-023-02294-2 -
Inflammatory Bowel Diseases Oct 2022Perianal Crohn's disease (pCD) is a potentially severe phenotype of CD. We conducted a systematic review with meta-analysis to estimate cumulative incidence, risk... (Meta-Analysis)
Meta-Analysis
BACKGROUND AND AIMS
Perianal Crohn's disease (pCD) is a potentially severe phenotype of CD. We conducted a systematic review with meta-analysis to estimate cumulative incidence, risk factors, and outcomes of pCD in population-based cohort studies.
METHODS
Through a systematic literature review through March 1, 2021, we identified population-based inception cohort studies reporting cumulative incidence of perianal disease (primarily abscess and/or fistula) in patients with CD. We estimated the cumulative incidence of pCD at presentation and 1-, 5-, and 10-year follow-up, and risk factors for perianal disease and outcomes including risk of major (bowel resection, proctectomy, ostomy) and minor perianal (incision and drainage, seton placement, etc.) surgery.
RESULTS
In 12 population-based studies, prevalence of pCD was 18.7% (95% confidence interval [CI], 12.5%-27.0%) with 1-, 5-, and 10-year risk of perianal disease being 14.3% (95% CI, 7.9%-24.6%), 17.6% (95% CI, 11.3%-26.5%), and 18.9% (95% CI, 15.0%-23.4%), respectively. Approximately 11.5% of patients (95% CI, 6.7%-19.0%) had perianal disease at or before CD diagnosis. Colonic disease location and rectal involvement were associated with higher risk of pCD. Overall, 63.3% of patients (95% CI, 53.3-72.3) required minor perianal surgery and 6.4% of patients (95% CI, 1.8%-20.6%) required major abdominal surgery for pCD. Use of biologic therapy for pCD is common and has steadily increased throughout the years.
CONCLUSIONS
Approximately 1 in 5 patients with CD develops perianal disease within 10 years of CD diagnosis, including 11.5% who have perianal disease at presentation. Approximately two-thirds of patients require perianal surgery, with a smaller fraction requiring major abdominal surgery.
Topics: Cohort Studies; Crohn Disease; Humans; Incidence; Proctectomy; Rectal Fistula; Treatment Outcome
PubMed: 34792604
DOI: 10.1093/ibd/izab287 -
Techniques in Coloproctology Apr 2021Crohn's anal fistula is a challenging condition, and may require multiple surgical procedures. To replicate successful procedures, these must be adequately reported in... (Review)
Review
A systematic review of the quality of reporting of interventions in the surgical treatment of Crohn's anal fistula: an assessment using the TIDiER and Blencowe frameworks.
BACKGROUND
Crohn's anal fistula is a challenging condition, and may require multiple surgical procedures. To replicate successful procedures, these must be adequately reported in the literature. The aim of this study was to review the quality of reporting of components of surgical interventions for Crohn's anal fistula.
METHODS
A systematic review was conducted. It was registered with PROSPERO (CRD:42019135157). The Medline and EMBASE databases were searched for studies reporting interventions intended to close fistula in patients with Crohn's disease, published between 1999 and August 2019. Abstracts and full texts were screened for inclusion by two reviewers. Dual extraction of data was performed to compare reporting to the TIDiER and Blencowe frameworks for reporting of interventions.
RESULTS
Initial searches identified 207 unique studies; 38 full texts were screened for inclusion and 33 were included. The most common study design was retrospective cohort (17/33), and the most frequently reported interventions were anal fistula plug (n = 8) and fibrin glue (n = 6). No studies showed coverage of all domains of TIDieR. Reporting was poor among domains related to who provided an intervention, where it was provided, and how it was tailored. Reporting of domains in the Blencowe framework was poor; the majority of studies did not report the component steps of procedures or efforts to standardise them.
CONCLUSIONS
This study demonstrates that reporting on technical aspects of interventions for Crohn's anal fistula is poor. Surgeons should aim to improve reporting to allow accurate reproduction of techniques both in clinical practice and in clinical trials.
Topics: Crohn Disease; Digestive System Surgical Procedures; Humans; Rectal Fistula; Retrospective Studies; Treatment Outcome
PubMed: 33599902
DOI: 10.1007/s10151-020-02359-7 -
Cureus Aug 2022Fistula-in-ano is a common proctological condition that primarily affects younger people and leads to chronic morbidity. An anal fistula is divided into simple and... (Review)
Review
Fistula-in-ano is a common proctological condition that primarily affects younger people and leads to chronic morbidity. An anal fistula is divided into simple and complex fistulas. A complex fistula is a challenging problem due to higher recurrence rates and incontinence associated with surgery. Many new methods have been developed for the closure of complex fistula-in-ano, but there is no single best method. The aim of this study is to identify a superior surgical technique for treating complex/high cryptoglandular perianal fistulas (HCPFs). A literature search was done using PubMed and Google Scholar for the period of 2012-2021. Articles that contain surgical treatment for complex anal fistula in the English language published in the last 10 years were included. The types of studies included were randomized controlled trials (RCTs), meta-analyses, systematic reviews, cohort studies, and traditional reviews. Articles excluded were those done more than 10 years ago, in other languages, and containing simple fistula management only. Nine studies were included in the review; a systematic review and meta-analysis concluded that no single method is effective. The ligation of the intersphincteric fistula tract (LIFT) procedure seems to be a promising and effective technique as it has a low rate of fecal incontinence as compared to other methods. Biological techniques give variable success rates so does fistula plug (FP). Mucosal advancement flap (MAF) and rerouting seton give good results according to one study. Fistula plug gives variable results and is not a preferred method. Ligation of the intersphincteric fistula tract (LIFT) seems to be a promising new technique for complex anal fistulas, but the data available is not enough to determine the best method. More randomized trials are required to compare traditional techniques and emerging new biological methods to see the best technique available.
PubMed: 36176822
DOI: 10.7759/cureus.28289 -
Asian Journal of Surgery Jan 2024Radical resection of rectal cancer is a safe and effective treatment, but there remain several complications related to anastomosis. We aimed to assess the risk factors... (Meta-Analysis)
Meta-Analysis Review
Radical resection of rectal cancer is a safe and effective treatment, but there remain several complications related to anastomosis. We aimed to assess the risk factors and incidence of rectal anastomotic stenosis (AS) after rectal cancer resection. We conducted a systematic review and meta-analysis after searching PubMed, Embase, Web of Science, and Medline databases from inception until May 2023. Data are reported as the combined odds ratio (OR) for categorical variables and the weighted mean difference (WMD) for continuous variables. Six hundred and fifty-nine studies were retrieved, nine (3031 patients) of which were included in the meta-analysis. Young age (WMD = -3.09, P = 0.0002), male sex (OR = 1.53, P = 0.0002), smoking (OR = 1.54, P = 0.009), radiotherapy (OR = 2.34, P = 0.0002), protective stoma (OR = 2.88, P = 0.007), intersphincteric resection surgery (OR = 6.28, P = 0.05), anastomotic fistula (OR = 3.72, P = 0.003), and anastomotic distance (WMD = -3.11, P = 0.0006) were identified as factors that increased the risk of AS, while staple (OR = 0.39, P < 0.001) was a protective factor. The incidence of AS after rectal cancer resection was approximately 17% (95% CI: 13%-21%). We identified eight risk factors and one protective factor associated with AS after rectal cancer resection. These factors may be combined in future studies to develop a more comprehensive and accurate prediction model related to AS after rectal cancer resection.
Topics: Humans; Anastomosis, Surgical; Anastomotic Leak; Constriction, Pathologic; Rectal Neoplasms; Rectum; Retrospective Studies; Risk Factors
PubMed: 37704476
DOI: 10.1016/j.asjsur.2023.08.209 -
Journal of Personalized Medicine Oct 2022Fournier's gangrene (FG) is a Necrotizing Soft Tissue Infection (NSTI) of the perineal region characterized by high morbidity and mortality even if appropriately... (Review)
Review
Fournier's gangrene (FG) is a Necrotizing Soft Tissue Infection (NSTI) of the perineal region characterized by high morbidity and mortality even if appropriately treated. The main treatment strategies are surgical debridement, broad-spectrum antibiotics, hyperbaric oxygen therapy, NPWT (Negative Pressure Wound Therapy), and plastic surgery reconstruction. We present the case of a 50-year-old woman with an NSTI of the abdomen, pelvis, and perineal region associated with a rectal fistula referred to our department. After surgical debridement and a diverting blow-out colostomy, an NPWT system composed of two sponges connected by a bridge through a rectal fistula was performed. Our target was to obtain healing in a lateral-to-medial direction instead of depth-to-surface to prevent the enlargement of the rectal fistula, promoting granulation tissue growth towards the rectum. This eso-endo-NPWT technique allowed for the primary suture of the perineal wounds bilaterally, simultaneously treating the rectal fistula and the perineum lesions. A systematic review of the literature underlines the spreading of NPWT and its effects.
PubMed: 36294834
DOI: 10.3390/jpm12101695