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Digestive Diseases (Basel, Switzerland) 2014Complex perianal disease is associated with poor outcome and requires early effective therapy. Corticosteroids are not effective in perianal fistulising Crohn's disease,... (Review)
Review
Complex perianal disease is associated with poor outcome and requires early effective therapy. Corticosteroids are not effective in perianal fistulising Crohn's disease, and antibiotics, immunosuppressants and anti-TNF therapy are required. It is important to consider combined medical surgical therapy after accurate imaging using an MRI scan of the pelvis. Drainage of any abscess at examination under anaesthesia and seton insertion are important before introduction of immunosuppressants and anti-TNF therapy. Long-term follow up of patients in a single centre reported responders to azathioprine having a reduced risk of perianal surgery (OR = 0.36; 95% CI: 0.27-0.46), but complex perianal fistulising Crohn's disease generally requires combination therapy with anti-TNF and azathioprine. Patients with recent perianal disease without fistulae and aged 40 years or older respond better to azathioprine monotherapy. Response to monotherapy with azathioprine is often slow and incomplete. In the recent GETAID study of early administration of azathioprine versus conventional management in patients at high risk of disabling disease, a higher cumulative proportion of patients in the azathioprine group were free of perianal surgery. In patients not responding to anti-TNF therapy, thalidomide or tacrolimus may be considered. Hyperbaric oxygen may be used as adjunctive therapy where available. The role of adipose-derived stem cell injection requires further long-term studies. In prevention of post-operative recurrence of Crohn's disease, azathioprine or 6-mercaptopurine had a favourable incremental cost-effectiveness ratio compared with no prophylactic therapy up to 1 year. In a Cochrane systematic review, azathioprine/6-mercaptopurine was associated with a significantly reduced risk of clinical recurrence [RR = 0.59, 95% CI: 0.38-0.92, number needed to treat (NNT) = 7] and severe endoscopic recurrence (RR = 0.6, 95% CI: 0.44-0.92, NNT = 4). Individual studies of prevention of post-operative recurrence using azathioprine/6-mercaptopurine have shown only modest benefit. In patients at high risk of relapse after surgical resection, anti-TNF therapy may be beneficial, but more data is required from ongoing studies. Strategies to prevent post-operative recurrence in Crohn's disease are evolving but need further refinement.
Topics: Anus Diseases; Crohn Disease; Humans; Immunosuppressive Agents; Postoperative Period; Recurrence
PubMed: 25531359
DOI: 10.1159/000367835 -
The Cochrane Database of Systematic... Aug 2016A perianal abscess is a collection of pus under the skin, around the anus. It usually occurs due to an infection of an anal gland. In the UK, the annual incidence is 40... (Review)
Review
BACKGROUND
A perianal abscess is a collection of pus under the skin, around the anus. It usually occurs due to an infection of an anal gland. In the UK, the annual incidence is 40 per 100,000 of the adult population, and the standard treatment is admission to hospital for incision and drainage under general anaesthetic. Following drainage of the pus, an internal dressing (pack) is placed into the cavity to stop bleeding. Common practice is for community nursing teams to change the pack regularly until the cavity heals. Some practitioners in the USA and Australia make a small stab incision under local anaesthetic and place a catheter into the cavity which drains into an external dressing. It is removed when it stops draining. Elsewhere in the USA, simple drainage is performed in an outpatient setting under local anaesthetic.
OBJECTIVES
To assess the effects of internal dressings in healing wound cavities resulting from drainage of perianal abscesses.
SEARCH METHODS
In May 2016 we searched: The Cochrane Wounds Specialised Register; The Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library); Ovid MEDLINE; Ovid MEDLINE (In-Process & Other Non-Indexed Citations); Ovid EMBASE and EBSCO CINAHL Plus. We also searched clinical trial registries to identify ongoing and unpublished studies, and searched reference lists of relevant reports to identify additional studies. We did not restrict studies with respect to language, date of publication, or study setting.
SELECTION CRITERIA
Published or unpublished randomised controlled trials (RCTs) comparing any type of internal dressing (packing) used in the post-operative management of perianal abscess cavities with alternative treatments or different types of internal dressing.
DATA COLLECTION AND ANALYSIS
Two review authors independently performed study selection, risk of bias assessment, and data extraction.
MAIN RESULTS
We included two studies, with a total of 64 randomised participants (50 and 14 participants) aged 18 years or over, with a perianal abscess. In both studies, participants were enrolled on the first post-operative day and randomised to continued packing by community district nursing teams or to no packing. Participants in the non-packing group managed their own wounds in the community and used absorbant dressings to cover the area. Fortnightly follow-up was undertaken until the cavity closed and the skin re-epithelialised, which constituted healing. For non-attenders, telephone follow-up was conducted.Both studies were at high risk of bias due to risk of attrition, performance and detection bias.It was not possible to pool the two studies for the outcome of time to healing. It is unclear whether continued post-operative packing of the cavity of perianal abscesses affects time to complete healing. One study reported a mean time to wound healing of 26.8 days (95% confidence interval (CI) 22.7 to 30.7) in the packing group and 19.5 days (95% CI 13.6 to 25.4) in the non-packing group (it was not clear if all participants healed). We re-analysed the data and found no clear difference in the time to healing (7.30 days longer in the packing group, 95% CI -2.24 to 16.84; 14 participants). This was assessed as very low quality evidence (downgraded three levels for very serious imprecision and serious risk of bias). The second study reported a median time to complete wound healing of 24.5 days (range 10 to 150 days) in the packing group and 21 days (range 8 to 90 days) in the non-packed group. There was insufficient information to be able to recreate the analysis and the original analysis was inappropriate (did not account for censoring). This second study also provided very low quality evidence (downgraded four levels for serious risk of bias, serious indirectness and very serious imprecision).There was very low quality evidence (downgraded for risk of bias, indirectness and imprecision) of no difference in wound pain scores at the initial dressing change. Both studies also reported patients' retrospective judgement of wound pain over the preceding two weeks (visual analogue scale, VAS) as lower for the non-packed group (2; both studies) compared with the packed group (0; both studies); (very low quality evidence) but we have been unable to reproduce these analyses as no variance data were published.There was no clear evidence of a difference in the number of post-operative fistulae detected between the packed and non-packed groups (risk ratio (RR) 2.31, 95% CIs 0.56 to 9.45, I(2) = 0%) (very low quality evidence downgraded three levels for very serious imprecision and serious risk of bias).There was no clear evidence of a difference in the number of abscess recurrences between the packed and non-packed groups over the variable follow-up periods (RR 0.72, 95% CI 0.22 to 2.37, I(2) = 0%) (very low quality evidence downgraded three levels for serious risk of bias and very serious imprecision).No study reported participant health-related quality of life/health status, incontinence rates, time to return to work or normal function, resource use in terms of number of dressing changes or visits to a nurse, or change in wound size.
AUTHORS' CONCLUSIONS
It is unclear whether using internal dressings (packing) for the healing of perianal abscess cavities influences time to healing, wound pain, development of fistulae, abscess recurrence or other outcomes. Despite this absence of evidence, the practice of packing abscess cavities is commonplace. Given the lack of high quality evidence, decisions to pack may be based on local practices or patient preferences. Further clinical research is needed to assess the effects and patient experience of packing.
Topics: Abscess; Anus Diseases; Bandages; Drainage; Humans; Postoperative Complications; Randomized Controlled Trials as Topic; Rectal Fistula; Self Care; Time Factors; Wound Healing
PubMed: 27562822
DOI: 10.1002/14651858.CD011193.pub2 -
Postepy Dermatologii I Alergologii Jun 2023Hidradenitis suppurativa (HS) is a chronic disease which is often recurrent and occurs as abscesses of the apocrine gland. The most common locations of HS are... (Review)
Review
Hidradenitis suppurativa (HS) is a chronic disease which is often recurrent and occurs as abscesses of the apocrine gland. The most common locations of HS are gluteal/perianal, axillary or inguinal. It is reasonable to assume that squamous cell carcinoma may arise from HS. As researchers in the field of dermatology, HS surgery and conventional surgical oncology, we studied whether there is any correlation between HS and neoplasms. Evidence shows a correlation between HS and squamous cell carcinoma. The aim of the study was to find literature about HS and SCC and analyse potential risk factors. This is a systemic review concerning squamous cell carcinoma and hidradenitis suppurativa.
PubMed: 37545826
DOI: 10.5114/ada.2023.126563 -
Acta Chirurgica Belgica Mar 2024We conducted a systematic review to assess the safety and efficacy of Aluminum potassium sulfate and tannic acid (ALTA) sclerotherapy for the treatment of hemorrhoidal... (Review)
Review
BACKGROUND
We conducted a systematic review to assess the safety and efficacy of Aluminum potassium sulfate and tannic acid (ALTA) sclerotherapy for the treatment of hemorrhoidal disease.
METHODS
Our study was conducted in accordance with the PRISMA statement (Preferred Reporting Items for Systematic Reviews and Meta-analyses) 2020. Primary endpoints included overall recurrence and type of recurrence while secondary endpoints included postoperative complications, reintervention, presence of rectal ulcer, rectal stricture, defecation abnormalities and perianal abscess. Α regression analysis, where the percentage of patients with grade II, III and IV hemorrhoidal disease was used as a covariate, was also performed.
RESULTS
Twelve studies with 4249 patients met all the inclusion criteria and were eventually included. The crude and pooled estimates of the overall recurrence and complications by the end of follow-up were 10% (95% CI, 6.52%-14.08%) and 5.20% (95% CI, 2.59%-8.52%), respectively. Regression analysis displayed no correlation between recurrence and the grade of hemorrhoid disease II, β= -0.0012 (95% CI, -0.0074 to 0.0049) ( = .64), grade III β= -0.0006 (95% CI, -0.0056 to 0.0045) ( = .79) and grade IV β = 0.0025 (95% CI, -0.0075 to 0.0124). However, a trend suggestive of increased recurrence was observed in patient populations with a higher proportion of grade IV disease.
CONCLUSION
ALTA sclerotherapy may be a safe and viable alternative for patients with hemorrhoidal disease. Long-term follow-up and high-quality randomized controlled trials will help define the place of ALTA sclerotherapy in the armamentarium of treatment of hemorrhoids.
PubMed: 38428446
DOI: 10.1080/00015458.2024.2326273 -
Health Technology Assessment... 2001Most surgically sutured wounds heal without any complication. However, in some cases wound healing can be delayed due to the presence of infection or wound breakdown.... (Review)
Review
BACKGROUND
Most surgically sutured wounds heal without any complication. However, in some cases wound healing can be delayed due to the presence of infection or wound breakdown. This can result in the wounds becoming cavity wounds and thus necessitate healing by secondary intention. Other surgical wounds that are not sutured but left to heal by secondary intention include abscess cavities such as perianal abscesses or breast abscesses. Surgical wounds healing by secondary intention are thought to heal more slowly than wounds healing by primary intention, especially if infection is present or healing is compromised by factors such as decreased blood supply, poor nutritional status or a general suppression of the immune response. Such wounds may contain dead tissue and have a moderate or high level of exudate. Debridement involves the removal of devitalised, necrotic tissue or fibrin from a wound. There are many different methods that can be used to debride a wound, which are broadly classified as surgical/sharp, biosurgical, mechanical, chemical, enzymatic and autolytic. Although it is generally agreed that the management of surgical wounds which contain devitalised tissue and are healing by secondary intention requires debridement, it is not always clear as to what is the best method or agent to use. There is currently a large selection of products with debriding properties available on the market, which vary considerably in cost. It is important that the choice of both debriding method and product is based on the best scientific evidence available, taking into account both cost and effectiveness data.
OBJECTIVES
The review had two main objectives: (1) To determine the clinical effectiveness and cost-effectiveness of debriding agents in treating surgical wounds healing by secondary intention. (2) To evaluate the clinical effectiveness and cost-effectiveness of treating patients with surgical wounds healing by secondary intention at specialised wound care clinics as compared to conventional care. The review incorporated all debriding methods and any agent that is considered to have a debriding property. METHODS The following databases were searched using strategies designed specifically for each database: MEDLINE, EMBASE, CINAHL, HMIC (Health Management Information Consortium), CCTR via the Cochrane Library, the National Research Register (NRR), the NHS Economic Evaluation Database (NHS EED), and the Health Economic Evaluations Database (HEED). Additional references were identified through reviewing manufacturer and sponsor submissions made to NICE, the bibliographies of retrieved articles, and conferences proceedings on the Internet. Only randomised controlled trials (RCTs) or non-randomised controlled trials with concurrent controls and full economic evaluations were considered for inclusion. Only studies that evaluated some sort of debriding method or a specialised wound care clinic (a nurse with specialist training in wound care; care being provided by a multidisciplinary team; a fast-track referral system to other professions (e.g. dermatologist); or access to the latest health technology) were included in the review. Studies had to include participants with surgical wounds healing by secondary intention (e.g. cavity wounds, the consequences of wound dehiscence and abscesses) and report an objective measure of wound healing. Data were extracted by one reviewer and checked by a second. Quality assessment was conducted independently by two reviewers. Disagreements were resolved by consensus and, when necessary, by recourse to a third reviewer. The primary outcomes of interest were wound healing and cost. Results of data extraction and quality assessment were presented in structured tables and also as a narrative summary. In addition, where feasible, the results of individual studies were presented as forest plots. Studies were grouped according to the type of wound, debriding method and outcome measure used. RESULTS - CLINICAL EFFECTIVENESS: Seventeen trials met the inclusion criteria, all of which used the autolytic method of debridement. No studies were found that investigated sharp/surgical, biosurgical, mechanical, chemical or enzymatic debridement in the treatment of surgical wounds healing by secondary intention. No studies were found which investigated specialised wound care clinics that included the provision of care within a clinical setting (based in either primary or secondary care). The type of surgical wounds investigated by studies included in the review were those that had broken down postoperatively, perineal wounds resulting from proctolectomy or rectal excision, and those left open after pilonidal sinus excision or abscess incision, or wounds following a laparotomy. Four additional studies investigated treatment of postoperative wounds from toenail avulsions. (ABSTRACT TRUNCATED)
Topics: Clinical Trials as Topic; Cost-Benefit Analysis; Debridement; Delivery of Health Care; Humans; Postoperative Complications; Technology Assessment, Biomedical; Treatment Outcome; United Kingdom; Wound Healing
PubMed: 11399237
DOI: 10.3310/hta5140 -
Surgical Innovation Jun 2023Mesenchymal stem cells (MSCs)-based therapy for perianal fistulizing Crohn's disease (pfCD) has been extensively studies in the past decade. Its efficacy and safety had... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Mesenchymal stem cells (MSCs)-based therapy for perianal fistulizing Crohn's disease (pfCD) has been extensively studies in the past decade. Its efficacy and safety had been preliminarily confirmed in some phase 2 or phase 3 clinical trials. This meta-analysis is performed to evaluate the efficacy and safety of MSCs-based therapy for pfCD.
METHODS
Electronic databases (Pubmed, Cochrane Library, Embase) were searched for studies that reported the efficacy and safety of MSCs. And RevMan were used to assess the efficacy and safety.
RESULTS
After screening, 5 randomized controlled trials (RCTs) were included in this meta-analysis. RevMan 5.4 for meta-analysis showed that: [Efficacy] Patients had definite remission after MSCs treatment, with an odds ratio (OR) of 2.06 ( < .0001, 95%CI 1.46, 2.89) vs controls. [Safety] The incidence of the most frequently reported TEAEs (treatment-emergent adverse events, TEAEs), perianal abscess and proctalgia, did not significantly increase due to the use of MSCs, with an OR of 1.07 in perianal abscess ( = .87, 95%CI 0.67, 1.72) vs controls, and an OR of 1.10 in proctalgia ( = .47, 95%CI 0.63, 1.92) vs controls.
CONCLUSIONS
MSCs seem to be an effective and safe therapy for pfCD. MSCs based therapy has the potential to be used in combination with traditional therapies.
Topics: Humans; Abscess; Crohn Disease; Mesenchymal Stem Cells
PubMed: 36794974
DOI: 10.1177/15533506231157167 -
Pediatric Surgery International Nov 2020Perianal abscesses are a common surgical presentation in infants. Historically, general anaesthesia (GA) has been used to facilitate incision and drainage, with or...
Perianal abscesses are a common surgical presentation in infants. Historically, general anaesthesia (GA) has been used to facilitate incision and drainage, with or without exploration for a fistula-in-ano (FIA). This review aims to assess outcomes following management of perianal abscesses without GA in infants less than 24 months old. We aim to identify the success of management without GA. Using PRISMA guidelines, studies were identified from MEDLINE, EMBASE and PubMed. Studies including infants less than 24 months with perianal abscesses managed without GA were reviewed. The primary outcome was the number of patients requiring GA following initial management without GA. Secondary outcomes included rates of recurrent perianal abscesses, rates of progression to FIA and time to cure. Nine studies, involving 1049 infants less than 24 months old met inclusion criteria. A total of 1039 (99.0%) were males. Study design consisted of one prospective case series of 18 patients, and eight retrospective cohort studies. There were no randomized control trials. A total of 1037 (98.9%) patients were initially managed without GA. Of these, 59 (5.6%) were documented to subsequently require a general anaesthetic. Treatment modalities included antibiotics, regular baths, needle aspiration, incision and drainage under local anaesthesia, hainosankyuto and fibroblast growth factor. A total of 790 (75.3%) healed primarily without further intervention. A total of 243 (23.2%) were documented to have a recurrence or progression to FIA. All patients who required a subsequent general anaesthetic had progressed to FIA. Despite the lack of well-designed prospective studies, existing evidence supports management of perianal abscesses without initial GA in infants, with more than 75% healing completely. Further research aimed at standardizing care and confirming the safety and efficacy of initial non-operative management are warranted, and may potentially reduce the number of unnecessary initial and subsequent clinical interventions.
Topics: Abscess; Anesthesia, General; Anti-Bacterial Agents; Anus Diseases; Disease Management; Drainage; Humans; Infant; Treatment Outcome
PubMed: 32785778
DOI: 10.1007/s00383-020-04728-7 -
Khirurgiia 2020To analyze efficacy and safety of submucosal laser ablation of internal hemorrhoids (SLT).
OBJECTIVE
To analyze efficacy and safety of submucosal laser ablation of internal hemorrhoids (SLT).
MATERIAL AND METHODS
Systematic review included 10 articles published in electronic databases PubMed, Cochrane Library, Elibrary until January 2019. There were only full-text publications from prospective clinical trials devoted to submucosal laser ablation in the treatment of hemorrhoids. Isolated SLT was used in 4 trials, combination with other minimally invasive procedures was reported in 6 reports.
RESULTS
SLT was predominantly used in the treatment of hemorrhoids grade 2-3. Efficacy of procedure was 91.1-100% after 6 months and 87.5-100% after 12 months. Intra- and postoperative complications included intraoperative bleeding (8.4%), perianal and external piles edema (8.2%), postoperative bleeding (2.7%), urinary retention (1.2%), anal fistula (0.6%), perianal abscess (0.14%).
CONCLUSION
Submucosal laser ablation is quite effective and safe option for treatment of hemorrhoids grade 2-3. However, further researches are required considering the absence of clear recommendations on laser beam parameters, indications for procedure and data on long-term outcomes.
Topics: Hemorrhoidectomy; Hemorrhoids; Humans; Intestinal Mucosa; Laser Therapy
PubMed: 32271744
DOI: 10.17116/hirurgia202003189 -
Inflammatory Bowel Diseases Sep 2022Management of perianal fistulas differs based on fistula type. We aimed to assess the ability of diagnostic strategies to differentiate between Crohn's disease (CD) and... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Management of perianal fistulas differs based on fistula type. We aimed to assess the ability of diagnostic strategies to differentiate between Crohn's disease (CD) and cryptoglandular disease (CGD) in patients with perianal fistulas.
METHODS
We performed a diagnostic accuracy systematic review and meta-analysis. A systematic search of electronic databases was performed from inception through February 2021 for studies assessing a diagnostic test's ability to distinguish fistula types. We calculated weighted summary estimates with 95% confidence intervals for sensitivity and specificity by bivariate analysis, using fixed effects models when data were available from 2 or more studies. The Quality Assessment of Diagnostic Accuracy Studies tool was used to assess study quality.
RESULTS
Twenty-one studies were identified and included clinical symptoms (2 studies; n=154), magnetic resonance imaging (MRI) characteristics (3 studies; n=296), ultrasound characteristics (7 studies; n=1003), video capsule endoscopy (2 studies; n=44), fecal calprotectin (1 study; n=56), and various biomarkers (8 studies; n=440). MRI and ultrasound characteristics had the most robust data. Rectal inflammation, multiple-branched fistula tracts, and abscesses on pelvic MRI and the Crohn's ultrasound fistula sign, fistula debris, and bifurcated fistulas on pelvic ultrasonography had high specificity (range, 80%-95% vs 89%-96%) but poor sensitivity (range, 17%-37% vs 31%-63%), respectively. Fourteen of 21 studies had risk of bias on at least 1 of the Quality Assessment of Diagnostic Accuracy Studies domains.
CONCLUSIONS
Limited high-quality evidence suggest that imaging characteristics may help discriminate CD from CGD in patients with perianal fistulas. Larger, prospective studies are needed to confirm these findings and to evaluate if combining multiple diagnostic tests can improve diagnostic sensitivity.
Topics: Crohn Disease; Cutaneous Fistula; Humans; Leukocyte L1 Antigen Complex; Magnetic Resonance Imaging; Rectal Fistula; Treatment Outcome
PubMed: 34792583
DOI: 10.1093/ibd/izab286 -
American Journal of Surgery May 2019Treatment of anorectal abscesses continues to revolve around early surgical drainage and control of perianal sepsis. Yet even with prompt drainage, abscess recurrence... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Treatment of anorectal abscesses continues to revolve around early surgical drainage and control of perianal sepsis. Yet even with prompt drainage, abscess recurrence and postoperative fistula formation rates are as high as 40% within 12 months. These complications are thought to be associated with inadequate drainage, elevated bacterial load, or a noncryptoglandular etiology of disease. Postoperative antibiotics have been used to account for these limitations, but their use is controversial and only weakly supported by current guidelines due to low-quality evidences. The aim of the present study was to perform a systematic review and meta-analysis of the current literature to determine the role of antibiotics in prevention of anal fistula following incision and drainage of anorectal abscesses.
METHODS
Literature search was conducted using Medline, EMBASE, Scopus, the Cochrane Library, and Web of Science databases from 1946 to April 2018. Search terms were "perianal OR anal OR fistula-in-ano OR ischiorectal OR anorectal AND abscess AND antibiotics" and was limited to human studies in the English language. Literature review and data extraction were completed using PRISMA guidelines. A total of six studies with 817 patients were included for systematic review. The weighted mean age was 37.8 years, 20.4% of patients were female, and the follow up ranged from one to 30 months. Antibiotic courses varied by study, and duration ranged from five to 10 days. Of included patients, 358 (43.8%) underwent management without antibiotics while 459 (56.2%) patients were treated with antibiotics. Fistula rate in subjects receiving antibiotics was 16% versus 24% in those not receiving postoperative antibiotics. Meta-analysis revealed a statistically significant protective effect for antibiotic treatment (3 studies, OR 0.64; CI 0.43-0.96; P = 0.03).
CONCLUSIONS
Antibiotic therapy following incision and drainage of anorectal abscesses is associated with a 36% lower odds of fistula formation. An empiric 5-10-day course of antibiotics following operative drainage may avoid the morbidity of fistula formation in otherwise healthy patients, although quality of evidence is low. Further randomized trials are needed to fully clarify the role, duration, and type of antibiotics best suited for postoperative prevention of fistula following drainage of anorectal abscesses.
Topics: Abscess; Antibiotic Prophylaxis; Drainage; Humans; Postoperative Complications; Rectal Diseases; Rectal Fistula
PubMed: 30773213
DOI: 10.1016/j.amjsurg.2019.01.015