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Alimentary Pharmacology & Therapeutics Oct 2014The management of perianal Crohn's fistulas represents a significant challenge. A combination of medical and surgical therapy, guided by radiology, is often required. (Review)
Review
BACKGROUND
The management of perianal Crohn's fistulas represents a significant challenge. A combination of medical and surgical therapy, guided by radiology, is often required.
AIM
To review systematically the literature to assess fistula healing rates with medical treatment (anti-TNF-α therapies ± immunomodulators) or surgical treatment alone, compared with combined medical and surgical treatment in fistulising perianal Crohn's disease (CD).
METHODS
The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were used. Two independent reviewers searched the literature.
RESULTS
Twenty-four articles were included. The total population was 1139 patients; 460 (40%) received single treatment with either medical or surgical therapy, and 679 (60%) received combined medical and surgical therapy. Eight studies compared single and combination therapy, with a total population of 797 patients (single therapy: n = 448, combination therapy: n = 349). In the single therapy group, 191/448 were in complete remission (43%). This was lower than the healing rate of the combination therapy group 180/349 (52%). No response to therapy was noted in 34% (153/448) of the single therapy group compared with 23% (80/349) of the combination group.
CONCLUSIONS
Combined surgical and medical (anti-TNF-α ± immunomodulators) therapy may have additional beneficial effects on perianal fistula healing in patients with Crohn's disease, compared with surgery or medical therapy alone. A well-designed Crohn's perianal fistula clinical trial is required in a multidisciplinary medical and surgical setting, with clearly defined end points of clinical (and likely patient reported outcomes) and radiological healing.
Topics: Combined Modality Therapy; Crohn Disease; Humans; Immunologic Factors; Rectal Fistula; Treatment Outcome; Tumor Necrosis Factor-alpha
PubMed: 25115149
DOI: 10.1111/apt.12906 -
The Cochrane Database of Systematic... Jul 2010The perianal abscess is a common surgical problem. A third of perianal abscesses may manifest a fistula-in-ano which increases the risk of abscess recurrence requiring... (Comparative Study)
Comparative Study Meta-Analysis Review
BACKGROUND
The perianal abscess is a common surgical problem. A third of perianal abscesses may manifest a fistula-in-ano which increases the risk of abscess recurrence requiring repeat surgical drainage. Treating the fistula at the same time as incision and drainage of the abscess may reduce the likelihood of recurrent abscess and the need for repeat surgery. However, this could affect sphincter function in some patients who may not have later developed a fistula-in-ano.
OBJECTIVES
We aimed to review the available randomised controlled trial evidence comparing incision and drainage of perianal abscess with or without fistula treatment.
SEARCH STRATEGY
Randomised trials were identified from MEDLINE, EMBASE, the Cochrane Library, and reference lists of published papers and reviews.
SELECTION CRITERIA
Trials comparing outcome after fistula surgery with drainage of perianal abscess compared with drainage alone were included in the review.
DATA COLLECTION AND ANALYSIS
The primary outcomes were recurrent or persistent abscess/fistula which may require repeat surgery and short-term and long-term incontinence. Secondary outcomes were duration of hospitalisation, duration of wound healing, postoperative pain, quality of life scores. For dichotomous variables, relative risks and their confidence intervals were calculated.
MAIN RESULTS
We identified six trials, involving 479 subjects, comparing incision and drainage of perianal abscess alone versus incision and drainage with fistula treatment. Metaanalysis showed a significant reduction in recurrence, persistent abscess/fistula or repeat surgery in favour of fistula surgery at the time of abscess incision and drainage (RR=0.13, 95% Confidence Interval of RR = 0.07-0.24). Transient manometric reduction in anal sphincter pressures, without clinical incontinence, may occur after treatment of low fistulae with abscess drainage. Incontinence at one year following drainage with fistula surgery was not statistically significant (pooled RR 3.06, 95% Confidence Interval 0.7-13.45) with heterogeneity demonstrable between the trials (Chi(2) =5.39,df=3, p=0.14, I(2) =44.4%).
AUTHORS' CONCLUSIONS
The published evidence shows fistula surgery with abscess drainage significantly reduces recurrence or persistence of abscess/fistula, or the need for repeat surgery. There was no statistically significant evidence of incontinence following fistula surgery with abscess drainage. This intervention may be recommended in carefully selected patients.
Topics: Abscess; Anus Diseases; Cutaneous Fistula; Drainage; Humans; Randomized Controlled Trials as Topic; Rectal Fistula; Secondary Prevention
PubMed: 20614450
DOI: 10.1002/14651858.CD006827.pub2 -
Ultraschall in Der Medizin (Stuttgart,... Jun 2017Transperineal ultrasound (TPUS) is a practical tool for assessing perianal inflammatory lesions. We systematically review its accuracy for detecting and classifying... (Comparative Study)
Comparative Study Meta-Analysis Review
Transperineal ultrasound (TPUS) is a practical tool for assessing perianal inflammatory lesions. We systematically review its accuracy for detecting and classifying perianal fistulae and abscesses. The National Library of Medicine and Embase were searched for articles on TPUS for the assessment of idiopathic and Crohn's perianal fistulae and abscesses. Two reviewers independently reviewed eligible studies and rated them for quality using the QUADAS tool. The primary outcome measure was the accuracy of TPUS as measured by its sensitivity and positive predictive value (PPV) in detecting and classifying perianal fistulae, internal openings and perianal abscesses. We included 12 studies (565 patients). Overall, the methodological quality of the studies was suboptimal. 3 studies were retrospective and 4 showed significant risks of bias in the application of the reference standard. The sensitivity of TPUS in detecting perianal fistulae on a per-lesion basis was 98 % (95 % CI 96 - 100 %) and the PPV was 95 % (95 % CI 90 - 98 %). The detection of internal openings had a sensitivity of 91 % (95 % CI 84 - 97 %) with a PPV of 87 % (95 % CI 76 - 95 %). The classification of fistulae yielded a sensitivity of 92 % (95 % CI 85 - 97 %) and a PPV of 92 % (95 % CI 83 - 98 %). TPUS had a sensitivity of 86 % (95 % CI 67 - 99 %) and PPV of 90 % (95 % CI 76 - 99 %) in the detection of perianal abscesses. The current literature on TPUS illustrates good overall accuracy in the assessment of perianal fistulae and abscesses. However, many studies had methodological flaws suggesting that further research is required.
Topics: Abscess; Adolescent; Adult; Aged; Aged, 80 and over; Anus Diseases; Child; Child, Preschool; Endosonography; Female; Humans; Magnetic Resonance Imaging; Male; Middle Aged; Rectal Fistula; Retrospective Studies; Sensitivity and Specificity; Treatment Outcome; Young Adult
PubMed: 28399604
DOI: 10.1055/s-0043-103954 -
Journal of Crohn's & Colitis Apr 2024Fistulas are a debilitating complication of Crohn's disease [CD]. We conducted a systematic review to assess the efficacy of medical therapies for fistulizing CD. (Meta-Analysis)
Meta-Analysis
BACKGROUND
Fistulas are a debilitating complication of Crohn's disease [CD]. We conducted a systematic review to assess the efficacy of medical therapies for fistulizing CD.
METHODS
MEDLINE, Embase, and CENTRAL were searched on May 26, 2022, for randomized controlled trials [RCTs] of pharmacological therapy in adults with fistulizing CD. The primary outcome was induction and maintenance of fistula response. Pooled risk ratios [RRs] and 95% confidence intervals [CIs] were calculated. GRADE was used to assess the certainty of evidence.
RESULTS
Thirty-eight RCTs were included. Nineteen trials [50%] exclusively involved perianal fistula. The remaining studies included some participants with non-perianal fistula. Pooled RRs for anti-tumour necrosis factor [TNF] agents were not statistically significant for induction [RR 1.36, 95% CI 0.97-1.91] or maintenance of fistula response [RR 1.48, 95% CI 0.97-2.27]. However, in a sensitivity analysis of studies with fistula response as the primary outcome, anti-TNFs were superior to placebo for induction [RR 1.94, 95% CI 1.10-3.41] and maintenance [RR 1.88, 95% CI 1.23-2.88] of fistula response. Oral small molecules [RR 2.56, 95% CI 1.18-5.53] and mesenchymal stem cell [MSC] therapy [RR 1.26, 95% CI 1.01-1.57] were effective for induction of fistula response. Ustekinumab was associated with maintenance of fistula response [RR 1.80, 95% CI 1.04-3.11]. Vedolizumab was not superior to placebo. The certainty of evidence ranged from very low to moderate.
CONCLUSION
Very low- to moderate-certainty evidence suggests that anti-TNF therapy, oral small molecules, ustekinumab, and MSCs are effective for perianal fistulizing CD. Dedicated fistula studies evaluating biologics and small molecules are needed.
Topics: Humans; Crohn Disease; Rectal Fistula; Gastrointestinal Agents; Intestinal Fistula; Randomized Controlled Trials as Topic
PubMed: 37933849
DOI: 10.1093/ecco-jcc/jjad185 -
Journal of Crohn's & Colitis Apr 2023The aim of this systematic review was to assess the literature on the incidence and risk factors for colorectal cancer and anal cancer in patients with perianal Crohn's... (Meta-Analysis)
Meta-Analysis
BACKGROUND AND AIMS
The aim of this systematic review was to assess the literature on the incidence and risk factors for colorectal cancer and anal cancer in patients with perianal Crohn's disease.
METHOD
A systematic review of the literature was performed using PubMed, Embase and Google Scholar. A meta-analysis was then conducted using a random-effects model.
RESULTS
Five studies were included in the systematic review. Of the total patients, 26.5% had perianal Crohn's disease. The median follow-up was 6 years. In total, 127 cases of colorectal cancer were found [0.43% of the included Crohn's disease patients]. Perianal involvement was present in 50% of colorectal cancer patients [0.89% of the population]. Three of the studies specified the cancer to be rectal or anal, which were present in 68 and 24 cases [0.3% and 0.1% of patients], respectively. In a subgroup analysis of rectal and anal cancer, perianal involvement was most frequent in anal cancer, accounting for 46% of the cases. In the rectal cancer group, 37% had perianal involvement. The higher incidence of colorectal cancer in patients with perianal Crohn's disease was confirmed in a meta-analysis.
CONCLUSION
Half of the patients with colorectal cancer and anal cancer were found to have perianal Crohn's disease. In patients with perianal involvement, there was a higher percentage of anal cancer compared with rectal cancer. These results support the theory that patients with perianal Crohn's disease are at increased risk for developing colorectal and anal cancer. Studies collecting more detailed data regarding patients and their cancers are needed to further specify the disease course.
Topics: Humans; Crohn Disease; Anus Neoplasms; Rectal Neoplasms; Rectum; Anal Canal; Rectal Fistula
PubMed: 36130090
DOI: 10.1093/ecco-jcc/jjac143 -
The Cochrane Database of Systematic... May 2010Surgery for anorectal fistula may result in recurrence, or impairment of continence. The ideal treatment for anorectal fistulae should be associated with low recurrence... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Surgery for anorectal fistula may result in recurrence, or impairment of continence. The ideal treatment for anorectal fistulae should be associated with low recurrence rates, minimal incontinence and good quality of life.
OBJECTIVES
To assess the efficacy and morbidity of operative procedures for chronic anal fistula, primary outcomes being recurrence and incontinence.
SEARCH STRATEGY
The following databases were searched: EMBASE (Webspirs 5.1, Silver Platter version 2.0, 1950-2009); Medline (Webspirs 5.1, Silver Platter version 2.0, 1950-2009); The Cochrane Central Register of Controlled Trials (2009 issue 4)and the IndMed ( Indian Medline, www.indmed.nic.in) database. We restricted our search to the English literature. The Indian Journal of Surgery was electronically searched (issues between 2003 and vol 71, Oct 2009). We also searched all primary trial registers (Indian, Australian, Chinese, WHO, ISRCTN and American).
SELECTION CRITERIA
Randomised controlled trials comparing operative procedures for anorectal fistulae were considered. Non randomised trials and cohort studies were examined where data on recurrence and function were available.
DATA COLLECTION AND ANALYSIS
Two reviewers (TJ and BP) independently selected the trials for inclusion in the review. Disagreements were solved by discussion. Where disagreement persisted and published results made data extraction difficult, we obtained clarification from the authors. REVMAN 5 was used for statistical analysis. Quality of the trials were assessed and allowances made for subgroup analysis and prevention of publication bias, using funnel plots if needed.
MAIN RESULTS
Ten randomised controlled trials were available for analysis. The quality of included studies was adequate, though in some trials the numbers were small and they were inadequately powered for equivalence or to detect significant differences. Comparisons were made between various modalities of treatments. There were no significant difference in recurrence rates or incontinence rates in any of the studied comparisons except in the case of advancement flaps. There were more recurrences in the glue plus flap group, a significant difference that favoured the flap only technique. It was also noted that Fibrin glue and advancement flap procedures report low incontinence rates.In the review of literature of non-randomised trials, most trials on fibrin glue indicate good healing in simple fistulae with low incontinence rates.
AUTHORS' CONCLUSIONS
There are very few randomized controlled trials comparing the various modalities of surgery for fistula in ano. While post operative pain, time to healing and discharge from hospital affect quality of life, recurrence and incontinence are the most important. As it turns out, there seems to be no major difference between the various techniques used as far as recurrence rates are concerned.The use of Fibrin glue and advancement flaps are associated with low incontinence rates.There is a crying need for well powered, well conducted randomised controlled trials comparing various modes of treatment of fistula in ano. Newer operations like the anal fistula plug and the LIFT procedure need to be evaluated by randomised clinical trials.
Topics: Catheter Ablation; Fecal Incontinence; Fibrin Tissue Adhesive; Humans; Randomized Controlled Trials as Topic; Rectal Fistula; Secondary Prevention; Surgical Flaps; Tissue Adhesives
PubMed: 20464741
DOI: 10.1002/14651858.CD006319.pub2 -
Langenbeck's Archives of Surgery Jun 2021To evaluate comparative outcomes of incision and drainage of cutaneous abscess with and without packing of the abscess cavity. (Meta-Analysis)
Meta-Analysis Review
Incision and drainage of cutaneous abscess with or without cavity packing: a systematic review, meta-analysis, and trial sequential analysis of randomised controlled trials.
AIMS
To evaluate comparative outcomes of incision and drainage of cutaneous abscess with and without packing of the abscess cavity.
METHODS
A systematic search of multiple electronic data sources was conducted, and all randomised controlled trials (RCTs) comparing incision and drainage of cutaneous abscess with and without packing were included. Abscess recurrence at maximum follow-up period, need for second intervention, and development of fistula in-ano were the evaluated outcome parameters for the meta-analysis A Trial Sequential Analysis was conducted to determine the robustness of the findings.
RESULTS
Eight RCTs reporting a total number of 485 patients who underwent incision and drainage of cutaneous abscess with (n = 243) or without (n = 242) packing of the abscess cavity were included. There was no significant difference in the risk of recurrence (risk ratio (RR) 1.31, P = 0.56), fistula-in-ano (RR 0.63, P = 0.28), and need for second intervention (RR 0.70, P = 0.05) between two groups. The results remained unchanged on sub-group analyses for ano-rectal abscess, paediatric patients, adult patients, and the use of antibiotics. The Trial Sequential Analysis demonstrated that the meta-analysis was not conclusive, and the results for recurrence were subject to type 2 error.
CONCLUSION
Incision and drainage of cutaneous abscess with or without packing have comparable outcomes. However, considering the cost and post-operative pain associated with packing, performing the procedure without packing of the abscess cavity may be more favourable. The findings of the better quality ongoing RCTs may provide stronger evidence in favour of packing or non-packing.
Topics: Abscess; Adult; Anus Diseases; Bandages; Child; Drainage; Humans; Randomized Controlled Trials as Topic; Rectal Fistula
PubMed: 32740696
DOI: 10.1007/s00423-020-01941-9 -
Minerva Surgery Aug 2021Transanal endoscopic microsurgery (TEM) is a safe procedure and the rates of intra- and postoperative complications are low. The information in the literature on the...
INTRODUCTION
Transanal endoscopic microsurgery (TEM) is a safe procedure and the rates of intra- and postoperative complications are low. The information in the literature on the management of these complications is limited, and so their importance may be either under- or overestimated (which may in turn lead to under- or overtreatment). The present article reviews the most relevant series of TEM procedures and their complications and describes various approaches to their management.
EVIDENCE ACQUISITION
A systematic review of the literature, including TEM series of more than 150 cases each. We analyzed the population characteristics, surgical variables and intraoperative and postoperative complications.
EVIDENCE SYNTHESIS
A total of 1043 records were found. After review, 1031 were excluded. The review therefore includes 12 independent cohorts of TEM procedures with a total of 4395 patients. The rate of perforation into the peritoneal cavity was 5.1%, and conversion to abdominal approach was required in 0.8% of cases. The most frequent complications were acute urinary retention (AUR, 4.9%) and rectal bleeding (2.2%). Less common complications included abscesses (0.99%) and rectovaginal fistula (0.62%). Mortality rates were low, with a mean value of 0.29%.
CONCLUSIONS
Awareness and knowledge of TEM complications and their management can play an important role in their treatment and patient safety. Here, we present a review of the most important TEM series and their complication rates and describe various approaches to their management.
Topics: Female; Humans; Postoperative Complications; Rectal Neoplasms; Transanal Endoscopic Microsurgery; Transanal Endoscopic Surgery; Treatment Outcome
PubMed: 33433070
DOI: 10.23736/S2724-5691.20.08405-9 -
Colorectal Disease : the Official... Oct 2010To assess the efficacy of anal fistula plug (AFP) procedure for the treatment of fistula-in-ano especially the complex fistulas. (Review)
Review
AIMS
To assess the efficacy of anal fistula plug (AFP) procedure for the treatment of fistula-in-ano especially the complex fistulas.
METHOD
The database of PUBMED, MEDLINE, SCOPUS, EMBASE and COCHRANE LIBRARY for the period 1995-2009 was searched. A systematic analysis was carried to evaluate the success rate of AFP procedure in fistula-in-ano.
RESULTS
A total of 25 studies were extracted and 12 (n = 317) were finally included in the systematic review. The follow-up period ranged from 3.5 to 12 months. The AFP procedure had a success rate (patient cure rate) ranging from 24% to 92%. In complex fistula-in-ano in prospective studies (8/12 studies), the success rate was 35-87%. The success rate in patients with Crohn's disease was 29-86%. The success rate in the patients with single tracts was 44-93% and in patients with multiple tracts, success ranged from 20% to 71%. The abscess formation/sepsis rate was 4-29% (11/108) and the plug extrusion rate was 4-41% (42/232-19%).
CONCLUSION
Anal fistula plug procedure has a success rate ranging from 24% to 92% in different studies. In prospective studies of complex fistula-in-ano, there was a moderate success rate of 35-87%. As AFP is associated with low morbidity and sepsis, it appears to be a safe procedure. Further randomized controlled trials studying objective parameters of fistula healing are needed to substantiate these findings.
Topics: Anal Canal; Clinical Trials as Topic; Digestive System Surgical Procedures; Humans; Prostheses and Implants; Rectal Fistula; Wound Healing
PubMed: 19438881
DOI: 10.1111/j.1463-1318.2009.01933.x -
Journal of Clinical Gastroenterology Oct 2016Rectovaginal and enterovesical fistulae are difficult to treat in patients with Crohn's disease. Currently, there is no consensus regarding their appropriate management. (Review)
Review
BACKGROUND
Rectovaginal and enterovesical fistulae are difficult to treat in patients with Crohn's disease. Currently, there is no consensus regarding their appropriate management.
AIM OF THE STUDY
The aim of the study was to review the literature on the medical management of rectovaginal and enterovesical fistulae in Crohn's disease and to assess their response to treatment.
METHOD
A literature search of MEDLINE, EMBASE, Science Citation Index Expanded, and Cochrane was performed.
RESULTS
Twenty-three studies were identified, reporting on 137 rectovaginal and 44 enterovesical fistulae. The overall response rates of rectovaginal fistulae to medical therapy were: 38.3% complete response (fistula closure), 22.3% partial response, and 39.4% no response. For enterovesical fistulae the response rates to medical therapy were: 65.9% complete response, 20.5% partial response, and 13.6% no response. Specifically, response to anti-tumor necrosis factor therapy of 78 rectovaginal fistulae was: 41.0% complete response, 21.8% partial response, and 37.2% no response. Response of 14 enterovesical fistulae to anti-tumor necrosis factor therapy was: 57.1% complete response, 35.7% partial response, and 7.1% no response. The response to a combination of medical and surgical therapy in 43 rectovaginal fistulae was: 44.2% complete response, 20.9% partial response, and 34.9% no response.
CONCLUSIONS
Medical therapy, alone or in combination with surgery, appears to benefit some patients with rectovaginal or enterovesical fistula. However, given the small size and low quality of the published studies, it is still difficult to draw conclusions regarding treatment. Larger, better quality studies are required to assess response to medical treatment and evaluate indications for surgery.
Topics: Combined Modality Therapy; Crohn Disease; Female; Humans; Intestinal Fistula; Rectovaginal Fistula; Treatment Outcome; Urinary Bladder Fistula
PubMed: 27466166
DOI: 10.1097/MCG.0000000000000607