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Surgery Open Science Jan 2024Anorectal fistula is a common, chronic condition, and is primarily managed surgically. Herein, we provide a contemporary review of the relevant etiology and anatomy...
Anorectal fistula is a common, chronic condition, and is primarily managed surgically. Herein, we provide a contemporary review of the relevant etiology and anatomy anorectal fistula, treatment recommendations that summarize relevant outcomes and alternative considerations, in particular when to refer to a fistula expert.
PubMed: 38268776
DOI: 10.1016/j.sopen.2023.12.005 -
American Journal of Surgery Feb 2023Timely incision and drainage (I&D) is first line management for anorectal abscesses. We aimed to define current practices in anorectal abscess management and identify...
BACKGROUND
Timely incision and drainage (I&D) is first line management for anorectal abscesses. We aimed to define current practices in anorectal abscess management and identify factors associated with abscess recurrence and fistula formation.
METHODS
Index episodes of anorectal abscesses treated with I&D in 2014-2018 at a multi-hospital healthcare system were included. Association with one-year abscess recurrence or fistula formation was evaluated using Cox proportional hazard regression. Fistulae were captured only among patients without fistulae at the index operation.
RESULTS
A total of 458 patients met study criteria. One-year rate of abscess recurrence or fistula formation was 20.3%. When compared to bedside procedures, drainage in the operating room was associated with a reduced risk of either recurrence or fistula formation (aHR 0.20 [95%CI 0.114-0.367]).
CONCLUSIONS
Improved exposure and patient comfort in the operating room may allow more complete drainage contributing to decreased rates of abscess recurrence or fistula formation.
Topics: Humans; Abscess; Rectal Fistula; Operating Rooms; Anus Diseases; Drainage; Recurrence
PubMed: 36150906
DOI: 10.1016/j.amjsurg.2022.09.005 -
Clinics in Colon and Rectal Surgery Sep 2022There are many benign anorectal disorders, which can make patients seek care. In low-resource settings, the incidence of those pathologies is not different from the... (Review)
Review
There are many benign anorectal disorders, which can make patients seek care. In low-resource settings, the incidence of those pathologies is not different from the industrialized and western world. However, an interesting difference colorectal surgeons and gastroenterologists can face is the fact that many patients do not seek help or are not aware and have little opportunities to be helped. Latin America population is estimated to be around 8% of the world population, with Brazil having the largest percentage. Infectious diseases, which were previously under control or were steadily declining, have emerged. For example, we have seen resurgence of dengue, malaria, and syphilis in pregnancy, as well as other sexually transmitted diseases that can affect the anorectal region. In this article, we will address the most common benign anorectal disorders.
PubMed: 36111076
DOI: 10.1055/s-0042-1755188 -
Journal of Gastrointestinal Surgery :... Jul 2023Autologous fat grafting (AFG) has shown promise in the treatment of complex wounds, with trials reporting good healing rates and safety profile. We aim to investigate...
BACKGROUND
Autologous fat grafting (AFG) has shown promise in the treatment of complex wounds, with trials reporting good healing rates and safety profile. We aim to investigate the role of AFG in managing complex anorectal fistulas.
METHODS
This was a retrospective review of a prospectively maintained IRB-approved database. We examined the rates of symptom improvement, clinical closure of fistula tracts, recurrence, complications, and worsening fecal incontinence. Perianal disease activity index (PDAI) was obtained for patients undergoing combination of AFG and fistula plug treatment.
RESULTS
In total, 52 unique patients underwent 81 procedures, of which Crohn's was present in 34 (65.4%) patients. The majority of patients previously underwent more common treatments such as endorectal advancement flap or ligation of intersphincteric fistula tract. Fat-harvesting sites and processing technique were selected by the plastic surgeons based on availability of trunk fat deposits. When analyzing patients by their last procedure, 41 (80.4%) experienced symptom improvement, and 29 (64.4%) experienced clinical closure of all fistula tracts. Recurrence rate was 40.4%, and complication rate was 15.4% (7 postoperative abscesses requiring I&D and 1 bleeding episode ligated at bedside). The abdomen was the most common site of lipoaspirate harvest at 63%, but extremities were occasionally used. There were no statistically significant differences in outcomes when comparing single graft treatment to multiple treatments, Crohn's and non-Crohn's, different methods of fat preparation, and diversion.
CONCLUSION
AFG is a versatile procedure that can be done in conjunction with other therapies and does not interfere with future treatments if recurrence occurs. It is a promising and affordable method to safely address complex fistulas.
Topics: Humans; Treatment Outcome; Rectal Fistula; Surgical Flaps; Fecal Incontinence; Ligation; Crohn Disease; Inflammation; Adipose Tissue; Anal Canal; Recurrence
PubMed: 37268827
DOI: 10.1007/s11605-023-05719-4 -
World Journal of Gastroenterology Nov 2020One of the most challenging phenotypes of Crohn's disease is perianal fistulizing disease (PFCD). It occurs in up to 50% of the patients who also have symptoms in other... (Review)
Review
One of the most challenging phenotypes of Crohn's disease is perianal fistulizing disease (PFCD). It occurs in up to 50% of the patients who also have symptoms in other parts of the gastrointestinal tract, and in 5% of the cases it occurs as the first manifestation. It is associated with severe symptoms, such as pain, fecal incontinence, and a significant reduction in quality of life. The presence of perianal disease in conjunction with Crohn's disease portends a significantly worse disease course. These patients require close monitoring to identify those at risk of worsening disease, suboptimal biological drug levels, and signs of developing neoplasm. The last 2 decades have seen significant advancements in the management of PFCD. More recently, newer biologics, cell-based therapies, and novel surgical techniques have been introduced in the hope of improved outcomes. However, in refractory cases, many patients face the decision of having a stoma made and/or a proctectomy performed. In this review, we describe modern surgical management and the most recent advances in the management of complex PFCD, which will likely impact clinical practice.
Topics: Crohn Disease; Fecal Incontinence; Humans; Quality of Life; Rectal Fistula; Surgical Stomas
PubMed: 33268947
DOI: 10.3748/wjg.v26.i42.6572 -
Clinics in Colon and Rectal Surgery Mar 2018Anorectal complaints are not uncommon in pediatric care, but the etiology and management can differ significantly from adults. Age is an important factor when... (Review)
Review
Anorectal complaints are not uncommon in pediatric care, but the etiology and management can differ significantly from adults. Age is an important factor when considering etiology and management, distinguishing between infants, children, and adolescents. For all ages, malignancy is rarely a consideration, but a thorough examination of infants and children typically requires deep sedation or general anesthesia. Very little primary literature or evidence exists to guide care; so there are many opportunities for careful study to enhance our understanding beyond personal experience and historical practice patterns.
PubMed: 29487494
DOI: 10.1055/s-0037-1609026 -
Gastroenterology & Hepatology May 2014Anorectal disorders result in many visits to healthcare specialists. These disorders include benign conditions such as hemorrhoids to more serious conditions such as...
Anorectal disorders result in many visits to healthcare specialists. These disorders include benign conditions such as hemorrhoids to more serious conditions such as malignancy; thus, it is important for the clinician to be familiar with these disorders as well as know how to conduct an appropriate history and physical examination. This article reviews the most common anorectal disorders, including hemorrhoids, anal fissures, fecal incontinence, proctalgia fugax, excessive perineal descent, and pruritus ani, and provides guidelines on comprehensive evaluation and management.
PubMed: 24987313
DOI: No ID Found -
Clinics in Colon and Rectal Surgery Jul 2019Perianal symptoms occur in up to 50% of patients with Crohn's disease in other parts of the gastrointestinal tract, and in 5% of patients it is the first manifestation... (Review)
Review
Perianal symptoms occur in up to 50% of patients with Crohn's disease in other parts of the gastrointestinal tract, and in 5% of patients it is the first manifestation of the disease. The perianal area is often under stress in patients with Crohn's disease, because of the diarrhea, and the fecal urgency, frequency, and incontinence caused by proximal disease. Symptomatic perianal disease can therefore be due to the effects of the stress on an otherwise normal anus, or the result of Crohn's disease in the low rectum and/or perianal tissues themselves. This key distinction should drive the investigation and management of anal and perianal symptoms in patients with Crohn's disease. In this review, the evaluation and management of the various manifestations of Crohn's disease in the perineum and perianal tissues will be described.
PubMed: 31275071
DOI: 10.1055/s-0039-1683907 -
Orphanet Journal of Rare Diseases May 2007Oesophageal atresia (OA) encompasses a group of congenital anomalies comprising of an interruption of the continuity of the oesophagus with or without a persistent... (Review)
Review
Oesophageal atresia (OA) encompasses a group of congenital anomalies comprising of an interruption of the continuity of the oesophagus with or without a persistent communication with the trachea. In 86% of cases there is a distal tracheooesophageal fistula, in 7% there is no fistulous connection, while in 4% there is a tracheooesophageal fistula without atresia. OA occurs in 1 in 2500 live births. Infants with OA are unable to swallow saliva and are noted to have excessive salivation requiring repeated suctioning. Associated anomalies occur in 50% of cases, the majority involving one or more of the VACTERL association (vertebral, anorectal, cardiac, tracheooesophageal, renal and limb defects). The aetiology is largely unknown and is likely to be multifactorial, however, various clues have been uncovered in animal experiments particularly defects in the expression of the gene Sonic hedgehog (Shh). The vast majority of cases are sporadic and the recurrence risk for siblings is 1%. The diagnosis may be suspected prenatally by a small or absent stomach bubble on antenatal ultrasound scan at around 18 weeks gestation. The likelihood of an atresia is increased by the presence of polyhydramnios. A nasogastric tube should be passed at birth in all infants born to a mother with polyhydramnios as well as to infants who are excessively mucusy soon after delivery to establish or refute the diagnosis. In OA the tube will not progress beyond 10 cm from the mouth (confirmation is by plain X-ray of the chest and abdomen). Definitive management comprises disconnection of the tracheooesophageal fistula, closure of the tracheal defect and primary anastomosis of the oesophagus. Where there is a "long gap" between the ends of the oesophagus, delayed primary repair should be attempted. Only very rarely will an oesophageal replacement be required. Survival is directly related to birth weight and to the presence of a major cardiac defect. Infants weighing over 1500 g and having no major cardiac problem should have a near 100% survival, while the presence of one of the risk factors reduces survival to 80% and further to 30-50% in the presence of both risk factors.
Topics: Abnormalities, Multiple; Animals; Digestive System Surgical Procedures; Esophageal Atresia; Genetic Testing; Humans; Infant, Newborn; Patient Selection; Preoperative Care; Prognosis; Risk Assessment; Tracheoesophageal Fistula
PubMed: 17498283
DOI: 10.1186/1750-1172-2-24 -
Annals of the Royal College of Surgeons... Nov 2022Acute supralevator abscess (SLA) is an uncommon and complicated form of anorectal sepsis. Its correct management is crucial to avoid complex iatrogenic fistula... (Review)
Review
INTRODUCTION
Acute supralevator abscess (SLA) is an uncommon and complicated form of anorectal sepsis. Its correct management is crucial to avoid complex iatrogenic fistula formation. A comprehensive review of the literature was conducted to determine the incidence of SLA and the surgical outcome with particular reference to the direction of drainage.
METHODS
A search of Medline, PubMed and the Cochrane Library was performed to identify all studies reporting surgical drainage of SLA.
FINDINGS
A total of 19 studies were identified, including 563 patients. The only two prospective studies reported an incidence of SLA of 10% and 3% in 68 and 100 patients, respectively, with anorectal sepsis. In 17 retrospective studies, the incidence ranged from 0% to 28%. Magnetic resonance imaging (MRI) was performed routinely in only one study. The surgical anatomical classification of the abscess was described in six studies diagnosed at surgery. The direction of surgical drainage whether 'inwards' (into the lumen) or 'outwards' (into the ischioanal fossa) was stated in only six studies. In two of these, the direction of drainage was contradictory to the recommendation made by Parks . Recurrent sepsis was reported in eight studies and ranged from 0% to 53%.
CONCLUSIONS
Detailed and prospective data on acute SLA are lacking. Its real incidence is unclear and it is not possible to analyse surgical outcomes conclusively according to different direction of drainage. The routine use of MRI in complicated anorectal sepsis would specify the surgical anatomy of SLA before any drainage is carried out.
Topics: Humans; Abscess; Rectal Fistula; Prospective Studies; Retrospective Studies; Drainage; Sepsis
PubMed: 35133205
DOI: 10.1308/rcsann.2021.0257