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Urology Case Reports May 2024We report a patient with history of recurrent invasive rectal adenocarcinoma complicated by obstructive uropathy requiring nephro-ureteral catheter placement. Two years...
We report a patient with history of recurrent invasive rectal adenocarcinoma complicated by obstructive uropathy requiring nephro-ureteral catheter placement. Two years later during a regular catheter exchange, the patient developed unusually bloody urine raising suspicion for possible vascular injury. CT angiogram and conventional angiogram were negative. However, an antegrade nephrostogram revealed a fistulous communication between the right ureter and the right internal iliac artery. Subsequently, the artery was sacrificed using detachable coils. We discuss the rare encounter of a silent arterio-ureteral fistula, the value of antegrade nephrostogram as a diagnostic tool, and the management options in such scenario.
PubMed: 38623493
DOI: 10.1016/j.eucr.2024.102712 -
DEN Open Apr 2024We describe the case of a 66-year-old man with an anastomotic fistula after rectal surgery, which was treated colonoscopically using polyglycolic acid sheets and fibrin...
We describe the case of a 66-year-old man with an anastomotic fistula after rectal surgery, which was treated colonoscopically using polyglycolic acid sheets and fibrin glue. Polyglycolic acid sheets and fibrin glue have been used in thoracic surgery and otolaryngology to reinforce sutures and prevent air leakage. There have been recent reports of their use in endoscopic surgery for the closure of intraoperative perforations after endoscopic submucosal dissection and for fistula closure after upper gastrointestinal tract surgery. However, anastomotic fistulas in colorectal surgery are difficult to visualize endoscopically and may be difficult to suture with clips due to fibrosis. Polyglycolic acid sheets can be easily trimmed, and the fistula can be easily filled using these sheets; moreover, using fibrin glue to fix the sheets may enable fistula closure in areas that are difficult to visualize endoscopically.
PubMed: 38601270
DOI: 10.1002/deo2.364 -
World Journal of Stem Cells Mar 2024Stem cell transplantation is a promising therapeutic option for curing perianal fistula in Crohn's disease (CD). Anti-tumor necrotic factor (TNF) therapy combined with...
BACKGROUND
Stem cell transplantation is a promising therapeutic option for curing perianal fistula in Crohn's disease (CD). Anti-tumor necrotic factor (TNF) therapy combined with drainage procedure is effective as well. However, previous studies are limited to proving whether the combination treatment of biologics and stem cell transplantation improves the effect of fistula closure.
AIM
This study aimed to evaluate the long-term outcomes of stem cell transplantation and compare Crohn's perianal fistula (CPF) closure rates after stem cell transplantation with and without anti-TNF therapy, and to identify the factors affecting CPF closure and recurrence.
METHODS
The patients with CD who underwent stem cell transplantation for treating perianal fistula in our institution between Jun 2014 and December 2022 were enrolled. Clinical data were compared according to anti-TNF therapy and CPF closure.
RESULTS
A total of 65 patients were included. The median age of females was 26 years (range: 21-31) and that of males was 29 (44.6%). The mean follow-up duration was 65.88 ± 32.65 months, and complete closure was observed in 50 (76.9%) patients. The closure rates were similar after stem cell transplantation with and without anti-TNF therapy (66.7% 81.6% at 3 year, = 0.098). The patients with fistula closure had short fistulous tract and infrequent proctitis and anorectal stricture ( = 0.027, 0.002, and 0.008, respectively). Clinical factors such as complexity, number of fistulas, presence of concurrent abscess, and medication were not significant for closure. The cumulative 1-, 2-, and 3-year closure rates were 66.2%, 73.8%, and 75.4%, respectively.
CONCLUSION
Anti-TNF therapy does not increase CPF closure rates in patients with stem cell transplantation. However, both refractory and non-refractory CPF have similar closure rates after additional anti-TNF therapy. Fistulous tract length, proctitis, and anal stricture are risk factors for non-closure in patients with CPF after stem cell transplantation.
PubMed: 38577230
DOI: 10.4252/wjsc.v16.i3.257 -
World Journal of Gastrointestinal... Mar 2024Abdominal wall deficiencies or weakness are a common complication of temporary ostomies, and incisional hernias frequently develop after colostomy or ileostomy takedown....
BACKGROUND
Abdominal wall deficiencies or weakness are a common complication of temporary ostomies, and incisional hernias frequently develop after colostomy or ileostomy takedown. The use of synthetic meshes to reinforce the abdominal wall has reduced hernia occurrence. Biologic meshes have also been used to enhance healing, particularly in contaminated conditions. Reinforced tissue matrices (RTMs), which include a biologic scaffold of native extracellular matrix and a synthetic component for added strength/durability, are designed to take advantage of aspects of both synthetic and biologic materials. To date, RTMs have not been reported to reinforce the abdominal wall following stoma reversal.
AIM
To evaluate the effectiveness of using an RTM to reinforce the abdominal wall at stoma takedown sites.
METHODS
Twenty-eight patients were selected with a parastomal and/or incisional hernia who had received a temporary ileostomy or colostomy for fecal diversion after rectal cancer treatment or trauma. Following hernia repair and proximal stoma closure, RTM (OviTex 1S permanent or OviTex LPR) was placed to reinforce the abdominal wall using a laparoscopic, robotic, or open surgical approach. Post-operative follow-up was performed at 1 month and 1 year. Hernia recurrence was determined by physical examination and, when necessary, computed tomography scan. Secondary endpoints included length of hospital stay, time to return to work, and hospital readmissions. Evaluated complications of the wound/repair site included presence of surgical site infection, seroma, hematoma, wound dehiscence, or fistula formation.
RESULTS
The observational study cohort included 16 male and 12 female patients with average age of 58.5 years ± 16.3 years and average body mass index of 26.2 kg/m ± 4.1 kg/m. Patients presented with a parastomal hernia (75.0%), incisional hernia (14.3%), or combined parastomal/incisional hernia (10.7%). Using a laparoscopic (53.6%), robotic (35.7%), or open (10.7%) technique, RTMs (OviTex LPR: 82.1%, OviTex 1S: 17.9%) were placed using sublay (82.1%) or intraperitoneal onlay (IPOM; 17.9%) mesh positioning. At 1-month and 1-year follow-ups, there were no hernia recurrences (0%). Average hospital stays were 2.1 d ± 1.2 d and return to work occurred at 8.3 post-operative days ± 3.0 post-operative days. Three patients (10.7%) were readmitted before the 1-month follow up due to mesh infection and/or gastrointestinal issues. Fistula and mesh infection were observed in two patients each (7.1%), leading to partial mesh removal in one patient (3.6%). There were no complications between 1 month and 1 year (0%).
CONCLUSION
RTMs were used successfully to treat parastomal and incisional hernias at ileostomy reversal, with no hernia recurrences and favorable outcomes after 1-month and 1-year.
PubMed: 38577081
DOI: 10.4240/wjgs.v16.i3.823 -
The Korean Journal of Internal Medicine May 2024A poor prognostic factor for Crohn's disease (CD) includes perianal fistulizing disease, including perianal fistula and/or perianal abscess. Currently, a tool to assess...
BACKGROUND/AIMS
A poor prognostic factor for Crohn's disease (CD) includes perianal fistulizing disease, including perianal fistula and/or perianal abscess. Currently, a tool to assess perianal symptoms in patients with CD remains nonexistent. This study aimed to develop a perianal fistulizing disease self-screening questionnaire for patients with CD.
METHODS
This prospective pilot study was conducted at three tertiary referral centers between January 2019 and May 2020. We formulated questions on perianal symptoms, including tenesmus, anal discharge, bleeding, pain, and heat. A 4-point Likert scale was used to rate each question. Patients with CD completed a questionnaire and underwent pelvic magnetic resonance imaging (MRI).
RESULTS
Overall, 93 patients were enrolled, with 51 (54.8%) diagnosed with perianal fistulizing disease, as determined by pelvic MRI. The Spearman correlation findings demonstrated that anal pain (p = 0.450, p < 0.001) and anal discharge (p = 0.556, p < 0.001) were the symptoms that most significantly correlated with perianal disease. For anal pain and discharge, the area under the receiver operating characteristic curve of the scores was significantly higher than that of the combined score for all five symptoms (0.855 vs. 0.794, DeLong's test p = 0.04). For the two symptoms combined, the sensitivity, specificity, and positive predictive and negative predictive values were 88.2, 73.8, 80.4, and 83.8%, respectively, with 81.7% accuracy for detecting perianal fistulizing disease.
CONCLUSION
This study indicates that simple questions regarding anal pain and discharge can help accurately identify the presence of perianal fistulizing disease in patients with CD.
Topics: Humans; Crohn Disease; Male; Female; Adult; Rectal Fistula; Prospective Studies; Pilot Projects; Magnetic Resonance Imaging; Middle Aged; Predictive Value of Tests; Surveys and Questionnaires; Young Adult; Reproducibility of Results
PubMed: 38576234
DOI: 10.3904/kjim.2023.410 -
BMC Medical Imaging Apr 2024It is challenging to identify residual or recurrent fistulas from the surgical region, while MR imaging is feasible. The aim was to use dynamic contrast-enhanced MR...
BACKGROUND
It is challenging to identify residual or recurrent fistulas from the surgical region, while MR imaging is feasible. The aim was to use dynamic contrast-enhanced MR imaging (DCE-MRI) technology to distinguish between active anal fistula and postoperative healing (granulation) tissue.
METHODS
Thirty-six patients following idiopathic anal fistula underwent DCE-MRI. Subjects were divided into Group I (active fistula) and Group IV (postoperative healing tissue), with the latter divided into Group II (≤ 75 days) and Group III (> 75 days) according to the 75-day interval from surgery to postoperative MRI reexamination. MRI classification and quantitative analysis were performed. Correlation between postoperative time intervals and parameters was analyzed. The difference of parameters between the four groups was analyzed, and diagnostic efficiency was tested by receiver operating characteristic curve.
RESULTS
Wash-in rate (WI) and peak enhancement intensity (PEI) were significantly higher in Group I than in Group II (p = 0.003, p = 0.040), while wash-out rate (WO), time to peak (TTP), and normalized signal intensity (NSI) were opposite (p = 0.031, p = 0.007, p = 0.010). Area under curves for discriminating active fistula from healing tissue within 75 days were 0.810 in WI, 0.708 in PEI, 0.719 in WO, 0.783 in TTP, 0.779 in NSI. All MRI parameters were significantly different between Group I and Group IV, but not between Group II and Group III, and not related to time intervals.
CONCLUSION
In early postoperative period, DCE-MRI can be used to identify active anal fistula in the surgical area.
TRIAL REGISTRATION
Chinese Clinical Trial Registry: ChiCTR2000033072.
Topics: Humans; Contrast Media; Magnetic Resonance Imaging; ROC Curve; Rectal Fistula; Image Enhancement
PubMed: 38561667
DOI: 10.1186/s12880-024-01257-w -
Surgery Open Science Mar 2024Complex anal fistula has a high recurrence rate and disturbing surgical complications, which are frustrating for patients and challenging for surgeons. Although single...
BACKGROUND
Complex anal fistula has a high recurrence rate and disturbing surgical complications, which are frustrating for patients and challenging for surgeons. Although single or combined management methods have produced positive outcomes, no trials have simultaneously compared these therapies. Therefore, this study aimed to determine the management method for complex anal fistula with the lowest failure and complication rates.
METHODS
This network meta-analysis (NMA) was registered in the international prospective register of systematic reviews (PROSPERO; CRD42023393349). Randomized controlled trials that analyzed complex anal fistula management were obtained from Medline, Scopus, and Cochrane using representative keywords. The primary outcome was the failure of anal fistulas to heal (including recurrences) after 6 to 12 months. The secondary outcome was fecal incontinence. All statistical analysis was conducted within the Bayesian framework using BUGSnet 1.1.0 in R Studio. A forest plot and league table were used to present the results.
RESULTS
A total of 19 studies containing 15 interventions, 1844 subjects, and 104 pairwise comparisons were analyzed quantitatively. The lowest failure rates occurred with ligation of the intersphincteric fistula tract (LIFT) + Plug (RR 0.2; 95 % CI 0.01-2.65), LIFT + platelet-rich plasma (PRP) (RR 0.22; 95 % CI 0.01-2.89), and FSR (RR 0.26; 95 % CI 0.02-2.12) relative to drainage seton. LIFT combined with other management methods showed lower fecal incontinence rates than the other treatments.
CONCLUSION
The combination of LIFT with plug or PRP resulted in lower failure and complication rates in the management of complex anal fistula compared to the other methods tested.
PubMed: 38550268
DOI: 10.1016/j.sopen.2024.03.003 -
Molecular Genetics & Genomic Medicine Mar 2024Wiedemann-Steiner syndrome (WSS) is a rare autosomal-dominant disorder caused by KMT2A variants. The aim of this study was to characterize a novel KMT2A variant in a...
INTRODUCTION
Wiedemann-Steiner syndrome (WSS) is a rare autosomal-dominant disorder caused by KMT2A variants. The aim of this study was to characterize a novel KMT2A variant in a child with WSS and demonstrate integrated diagnostic approaches.
METHODS
A 3-year-old female with developmental delay, distinctive facial features, and anal fistula underwent whole exome sequencing (WES). RNA analysis was performed to assess splicing effects caused by a novel variant.
RESULTS
WES identified novel heterozygous KMT2A c.5664+6T>C variant initially classified as a variant of uncertain significance. RNA analysis provided evidence of aberrant splicing (exon 20 skipping), allowing reclassification to likely pathogenic. The patient exhibited typical WSS features along with a potential novel finding of anal fistula.
CONCLUSION
This report describes a novel non-canonical splice site variant in KMT2A associated with WSS. RNA analysis was critical for variant reclassification. Detailed phenotypic evaluation revealed common and expanded WSS manifestations. This case highlights the importance of combining clinical assessment, DNA testing, and RNA functional assays for the diagnosis of rare genetic disorders.
Topics: Child; Female; Humans; Child, Preschool; Syndrome; Abnormalities, Multiple; RNA; Rectal Fistula; Growth Disorders; Contracture; Intellectual Disability; Facies; Microcephaly
PubMed: 38488438
DOI: 10.1002/mgg3.2415 -
International Wound Journal Mar 2024A meta-analysis was conducted to evaluate the effects of loose combined cutting seton surgery on wound healing and pain in patients with high anal fistula, aiming to... (Meta-Analysis)
Meta-Analysis
A meta-analysis was conducted to evaluate the effects of loose combined cutting seton surgery on wound healing and pain in patients with high anal fistula, aiming to provide evidence-based medical evidence for surgical method selection for these patients. A comprehensive computerized search of PubMed, Cochrane Library, EMBASE, Wanfang and China National Knowledge Infrastructure databases was conducted to collect all relevant studies published up to November 2023, evaluating the effects of loose combined cutting seton surgery in treating patients with high anal fistulas. Two researchers independently screened, extracted data, and assessed the quality of the identified studies. RevMan 5.4 software was employed for data analysis. Overall, 16 articles were included, comprising 1124 patients, with 567 undergoing loose combined cutting seton surgery and 557 undergoing simple cutting seton surgery. The analysis revealed patients undergoing loose combined cutting seton surgery had a higher rate of postoperative wound healing (97.44% vs. 81.69%, odds ratio [OR]: 7.49, 95% confidence interval [CI]: 4.29-13.10, p < 0.00001), shorter wound healing time (standardized mean differences [SMD]: -1.48, 95% CI: -1.89 to -1.08, p < 0.00001), lower postoperative wound pain scores (SMD: -2.51, 95% CI: -3.51 to -1.51, p < 0.00001), and a lower rate of postoperative complications (3.43% vs. 20.83%, OR: 0.13, 95% CI: 0.05-0.31, p < 0.00001). The current evidence suggests that compared to simple cutting seton surgery, loose combined cutting seton surgery in treating high anal fistulas can promote postoperative wound healing, shorten wound healing time, alleviate pain, and reduce the incidence of postoperative complications, making it a worthy clinical practice for widespread application.
Topics: Humans; Postoperative Complications; Pain, Postoperative; Rectal Fistula; Wound Healing; Incidence; Treatment Outcome
PubMed: 38484699
DOI: 10.1111/iwj.14675 -
International Journal of Surgery... Mar 2024A diverting loop ileostomy (DLI) is performed in laparoscopic anterior rectal resection (LAR) surgery at high risk of anastomotic fistula. Minimally invasive surgery...
'Dumpling suture method' versus traditional suture method of protective loop ileostomy in laparoscopic anterior rectal resection with specimen extraction through stoma incision: a retrospective comparative cohort study.
BACKGROUND
A diverting loop ileostomy (DLI) is performed in laparoscopic anterior rectal resection (LAR) surgery at high risk of anastomotic fistula. Minimally invasive surgery promotes postoperative recovery and cosmetics. To reduce abdominal trauma, specimen extraction through stoma incision (EXSI) is usually performed to avoid auxiliary abdominal incision with enlarged stomal incision. The traditional suture method (TSM) reduces the incision size by suturing the ends of the enlarged incision, leading to peristomal incisions and a higher risk of stomal complications. The study aimed to introduce the dumpling suture method (DSM) of PLI and compare this new method with TSM.
MATERIALS AND METHODS
The authors propose a novel stoma suture technique, which utilized a method of skin folding suture to reduce the enlarged incision size. A retrospective analysis was conducted on 71 consecutive patients with rectal cancer who underwent LAR-DLI with EXSI, and the intraoperative details and postoperative outcomes of the two groups were measured.
RESULTS
The DSM group showed a lower stomal complication rate (10.3 vs. 35.7%, P=0.016) than that of the TSM group. The scores of DET (Discoloration, Erosion, Tissue overgrowth), stomal pain, quality of life were all significantly lower in DSM group than in TSM group. In multivariate analysis, DSM was an independent protective factor for stoma-related complications. Operative time, time to first flatus, defecation and eat, nonstomal related postoperative complications were similar in both groups.
CONCLUSION
DSM utilizes a method of skin folding suture to reduce the enlarged incision size, which is safe and effective in reducing the incidence of peristomal skin infections and stomal complications. This procedure offers a novel suturing approach for loop ileostomy with enlarged incision, effectively reducing the postoperative trauma and incidence of stomal complications.
Topics: Humans; Ileostomy; Retrospective Studies; Cohort Studies; Quality of Life; Laparoscopy; Postoperative Complications; Rectal Neoplasms; Anastomosis, Surgical; Surgical Wound; Suture Techniques; Sutures
PubMed: 38484258
DOI: 10.1097/JS9.0000000000000953