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Current Research in Pharmacology and... 2022Crohn's disease is a chronic inflammatory bowel disease that affects various intestinal segments and can involve the perianal region. Although anti-tumor necrosis factor... (Review)
Review
Crohn's disease is a chronic inflammatory bowel disease that affects various intestinal segments and can involve the perianal region. Although anti-tumor necrosis factor (TNF) agents have revolutionized the management of Crohn's disease and improved the prognosis for patients with perianal Crohn's disease (pCD), their long-term effectiveness is limited: over 60% of patients relapse after one year of maintenance therapy. In recent years, significant advances have been made in the treatment of complex perianal fistulas after anti-TNF failure. Concomitant treatment with antibiotics and immunosuppressants improves the effectiveness of anti-TNF agents. Therapeutic drug monitoring and dose adjustment of anti-TNF therapy (targeting a higher trough level) might also improve treatment response. Novel therapeutic strategies might provide new opportunities for pCD management; for example, ustekinumab might be effective after anti-TNF treatment failure, although more studies are needed. As suggested in recent international guidelines, mesenchymal stem cell injection might be an effective, safe treatment for complex pCD.
PubMed: 35106477
DOI: 10.1016/j.crphar.2022.100081 -
The Journal of International Medical... Feb 2021Cryptoglandular perianal fistula is a common benign anorectal disorder that is managed mainly with surgery. A fistula is typically defined as a pathological... (Review)
Review
Cryptoglandular perianal fistula is a common benign anorectal disorder that is managed mainly with surgery. A fistula is typically defined as a pathological communication between two epithelialized surfaces. More specifically, perianal fistula manifests as an abnormal tract between the anorectal canal and the perianal skin. Perianal fistulas are often characterized by significantly decreased patient quality of life. The cryptoglandular theory of perianal fistulas suggests their development from the proctodeal glands, which originate from the intersphincteric plane and perforate the internal sphincter with their ducts. Involvement of proctodeal glands in the inflammatory process could play a primary role in the formation of cryptoglandular perianal fistula. The objective of this narrative review was to investigate the current knowledge of the pathogenesis of cryptoglandular perianal fistula with the specific aims of characterizing the potential role of proinflammatory factors responsible for the development of chronic inflammation. Further studies are crucial to improve the therapeutic management of cryptoglandular perianal fistulas.
Topics: Anal Canal; Humans; Quality of Life; Rectal Fistula; Treatment Outcome
PubMed: 33595349
DOI: 10.1177/0300060520986669 -
ANZ Journal of Surgery Jul 2022Perianal abscesses are a common surgical emergency. Due to their perceived ease, drainage is often delegated to junior trainees with varying levels of experience. The...
BACKGROUND
Perianal abscesses are a common surgical emergency. Due to their perceived ease, drainage is often delegated to junior trainees with varying levels of experience. The purpose of this study is to evaluate the current trend in perianal abscesses management at our institution, and identify factors that predict subsequent fistula formation or abscess recurrence.
METHODS
All acute patients admitted to a major teaching hospital who required surgical drainage of a perianal abscess were analysed over a two-year period from January 2019 to December 2020. Patient demographics, clinical and laboratory findings were retrospectively reviewed. Proceduralist experience, operative management strategy and recurrence rates (fistula or abscess) were analysed.
RESULTS
The mean age of patients was 43 years old, and 73% were male. Trainees performed 96% of the procedures. Re-presentation with a fistula or abscess recurrence requiring further surgery was 31%. Comorbidities of IBD, diabetes, or malignancy were present in one-third of patients and significantly increased the risk of recurrence (P = 0.01). Searching for a fistula tract was performed in 41% of cases but did not reduce recurrence (P = 0.9). Seton insertion occurred in 10%, and fistulotomy in 2%.
CONCLUSION
Perianal abscess drainage at our institution is almost exclusively performed by trainees, the majority of which occurs after-hours. Patients who present with a fever, inflammatory bowel disease, diabetes mellitus or malignancy are at an increased risk of recurrent abscess or a subsequent fistula after drainage, and input from an experienced surgeon may be of value when considering seton insertion or fistulotomy.
Topics: Abscess; Adult; Anus Diseases; Drainage; Female; Humans; Male; Rectal Fistula; Recurrence; Retrospective Studies; Skin Diseases; Treatment Outcome
PubMed: 35485429
DOI: 10.1111/ans.17750 -
The Israel Medical Association Journal... Jul 2023Perianal abscesses require immediate incision and drainage (I&D). However, prompt bedside drainage is controversial as it may compromise exposure and thorough anal...
BACKGROUND
Perianal abscesses require immediate incision and drainage (I&D). However, prompt bedside drainage is controversial as it may compromise exposure and thorough anal examination.
OBJECTIVES
To examine outcomes of bedside I&D of perianal abscesses in the emergency department (ED) vs. the operating room (OR).
METHODS
We conducted a retrospective review of all patients presented to the ED with a perianal abscesses between January 2018 and March 2020. Patients with Crohn's disease, horseshoe or recurrent abscesses were excluded.
RESULTS
The study comprised 248 patients; 151 (60.89%) underwent I&D in the OR and 97 (39.11%) in the ED. Patients elected to bedside I&D had smaller abscess sizes (P = 0.01), presented with no fever, and had lower rates of inflammatory markers. The interval time from diagnosis to intervention was significantly shorter among the bedside I&D group 2.13 ± 2.34 hours vs. 10.41 ± 8.48 hours (P < 0.001). Of patients who underwent I&D in the OR, 7.3% had synchronous fistulas, whereas none at bedside had (P = 0.007). At median follow-up of 24 months, recurrence rate of abscess and fistula formation in patients treated in the ED were 11.3% and 6.2%, respectively, vs. 19.9% and 15.23% (P = 0.023, 0.006). Fever (OR 5.71, P = 0.005) and abscess size (OR 1.7, P = 0.026) at initial presentation were risk factors for late fistula formation.
CONCLUSIONS
Bedside I&D significantly shortens waiting time and does not increase the rates of long-term complications in patients with small primary perianal abscesses.
Topics: Humans; Abscess; Rectal Fistula; Anus Diseases; Drainage; Retrospective Studies; Skin Diseases
PubMed: 37461172
DOI: No ID Found -
Cancers Dec 2023Distinction between anal canal and perianal squamous cell carcinomas (pSCCs) is essential, as these two subgroups have different anatomical, histological, and lymphatic... (Review)
Review
Nodal Elective Volume Selection and Definition during Radiation Therapy for Early Stage (T1-T2 N0 M0) Perianal Squamous Cell Carcinoma: A Narrative Clinical Review and Critical Appraisal.
Distinction between anal canal and perianal squamous cell carcinomas (pSCCs) is essential, as these two subgroups have different anatomical, histological, and lymphatic drainage features. Early-stage true perianal tumors are very uncommon and have been rarely included in clinical trials. Perianal skin cancers and aCCs are included in the same tumor classification, even though they have different lymphatic drainage features. Furthermore, pSCCs are treated similarly to carcinomas originating from the anal canal. Radiation therapy (RT) is an essential treatment for anal canal tumors. Guidelines do not differentiate between treatment volumes for perianal tumors and anal cancers. So far, in pSCC, no study has considered modulating treatment volume selection according to the stage of the disease. We conducted a narrative literature review to describe the sites at higher risk for microscopic disease in patients with early-stage perianal cancers (T1-T2 N0 M0) to propose a well-thought selection of RT elective volumes.
PubMed: 38136378
DOI: 10.3390/cancers15245833 -
Abdominal Imaging Oct 2013Perianal fistula is a clinical entity with multiple surgical treatment options. Recently, magnetic resonance imaging (MRI) has emerged as an important imaging modality... (Review)
Review
Perianal fistula is a clinical entity with multiple surgical treatment options. Recently, magnetic resonance imaging (MRI) has emerged as an important imaging modality in the management of perianal fistulas. It provides accurate description of the fistula within the anal canal in relation to the sphincter complex and other pelvic floor structures as well as the associated complications such as abscess. By understanding the surgical viewpoint, the appearance of perianal fistulas, associated complications, and post-treatment findings of commonly used surgical interventions can more accurately be interpreted to aid clinicians. The objective of the article is to review MRI indications and findings, radiological versus surgical classification schemes, and surgical treatment options for perianal fistulas.
Topics: Contrast Media; Fissure in Ano; Humans; Magnetic Resonance Imaging; Rectal Fistula
PubMed: 23242265
DOI: 10.1007/s00261-012-9965-4 -
World Journal of Gastrointestinal... Nov 2019Perianal fistulae are either primary (idiopathic) or secondary [commonly associated with Crohn's disease, (CD)]. It is assumed, although not proven, that the...
BACKGROUND
Perianal fistulae are either primary (idiopathic) or secondary [commonly associated with Crohn's disease, (CD)]. It is assumed, although not proven, that the pathophysiology differs.
AIM
To systematically compare the clinical phenotypes, cytokine and phosphoprotein profiles of idiopathic and CD-related perianal fistulae.
METHODS
Sixty-one patients undergoing surgery for perianal fistula were prospectively recruited (48 idiopathic, 13 CD) into a cohort study. Clinical data, including the Perineal Disease Activity Index (PDAI) and EQ-5D-5L were collected. Biopsies of the fistula tract, granulation tissue, internal opening mucosa and rectal mucosa were obtained at surgery. Concentrations of 30 cytokines and 39 phosphoproteins were measured in each biopsy using a magnetic bead multiplexing instrument and a chemiluminescent antibody array respectively. Over 12000 clinical and 23500 laboratory measurements were made.
RESULTS
The PDAI was significantly higher (indicating more active disease) in the CD group with a mean difference of 2.40 (95%CI: 0.52-4.28, = 0.01). Complex pathoanatomy was more prevalent in the CD group, namely more multiple fistulae, supralevator extensions, collections and rectal thickening. The IL-12p70 concentration at the internal opening specimen site was significantly higher (median difference 19.7 pg/mL, 99%CI: 0.2-40.4, = 0.008) and the IL-1RA/IL-1β ratio was significantly lower in the CD group at the internal opening specimen site (median difference 15.0, 99%CI = 0.4-50.5, = 0.008). However in the remaining 27 cytokines and all 39 of the phosphoproteins across the four biopsy sites, no significant differences were found between the groups.
CONCLUSION
CD-related perianal fistulae are more clinically severe and anatomically complex than idiopathic perianal fistulae. However, overall there are no major differences in cytokine and phosphoprotein profiles.
PubMed: 31750007
DOI: 10.4291/wjgp.v10.i4.42 -
The Turkish Journal of Gastroenterology... Mar 2021Perianal disease is reported more widely in pediatric Crohn patients than in the past, and has been stated as an independent modifier of the disease behavior. In this...
BACKGROUND
Perianal disease is reported more widely in pediatric Crohn patients than in the past, and has been stated as an independent modifier of the disease behavior. In this study, we aimed to analyze the clinical characteristics and outcomes of fistulising perianal Crohn's disease (fpCD) in the pediatric age group.
METHODS
A total number of 149 children with an established diagnosis of inflammatory bowel disease who have been diagnosed before 18 years of age and followed in our tertiary center were revised. Clinical, endoscopic, laboratory, and radiologic data of 50 patients with CD, who had at least 18 months follow-up data, were compiled.
RESULTS
Of 50 patients, 26 (52%) were diagnosed as fpCD (38% at onset). More than half of the patients without any notable external orifices around the perianal area were diagnosed as fpCD by an magnetic resonance imaging (MRI). Pediatric fpCD patients had a higher disease activity score and platelet count, lower serum albumin level, and a higher rate of granuloma in the biopsy samples, compared with non-fistulising patients. A considerably high rate of surgical interventions (i.e., seton placement 46% and abscess drainage 15%) was performed in combination with infliximab.
CONCLUSION
Fistulising perianal Crohn's disease seems to be more common than previously reported in the pediatric age group. A severe course of the disease might serve as a warning for the development of fpCD. A careful physical examination and use of perianal MRI with a high index of suspicion may increase the likelihood of fistula detection, hence may change the treatment strategy.
Topics: Child; Crohn Disease; Humans; Rectal Fistula; Treatment Outcome
PubMed: 34160353
DOI: 10.5152/tjg.2021.191034 -
The Indian Journal of Radiology &... Mar 2022The aim of this study was to evaluate the role of transcutaneous perianal ultrasonography (TPUS) in patients with perianal fistula and to correlate the findings with...
The aim of this study was to evaluate the role of transcutaneous perianal ultrasonography (TPUS) in patients with perianal fistula and to correlate the findings with magnetic resonance imaging (MRI) as gold standard. This prospective study included patients who presented with suspicion of perianal fistula. After clinical examination, TPUS and MRI of perianal region were performed on each of them. Clockwise position of internal opening of the fistula was described. The entire length of the tract was evaluated up to the external opening. Also, any ramifications along the primary tract were described. Parks et al and St James's University Hospital MR Imaging Classification of Perianal Fistulas were used for classifying the fistulas. Out of total 37 patients, the most common age group of presenting individuals was 45 to 60 years with male to female ratio of 6.4:1. There was excellent agreement between TPUS and MRI for detecting primary fistulous tract with kappa correlation coefficient of 1. The kappa correlation coefficient for detecting secondary fistulous tracts and abscess on TPUS and MRI was 0.839 and 0.937 showing excellent agreement. Moderate agreement was seen with kappa correlation coefficient of 0.839 in the detection of internal opening on TPUS and MRI. TPUS showed promising results in diagnosis and classification of perianal fistulae with MRI as gold standard. A wide availability, cost-effectiveness, and better tolerability of TPUS can make it an imaging modality of first choice for evaluating perianal fistulae.
PubMed: 35722645
DOI: 10.1055/s-0042-1743111 -
Animals : An Open Access Journal From... Jan 2023The presence of androgen (AR) and estrogen (ER) receptors has been demonstrated both in normal perianal (hepatoid) glands and in perianal tumors. The aim of this study...
The presence of androgen (AR) and estrogen (ER) receptors has been demonstrated both in normal perianal (hepatoid) glands and in perianal tumors. The aim of this study was to demonstrate the relationship between the expression of AR and ER in perianal gland tumors and the effectiveness of antihormonal treatment. The study was performed on 41 male dogs with neoplastic lesions of the anal region. Histopathological evaluation of the lesions revealed 24 adenomas, 12 epitheliomas, and five carcinomas. Treatment was administered orally with tamoxifen at a dose of 1 mg/kg BW and cyproterone acetate at a dose of 5 mg/kg. Tumor diameters were measured regularly with calipers and recorded in millimeters starting with the measurement before treatment, and then after 1, 2, 3, 6, 12, 18, and 24 months of therapy. The results show that hepatoid adenomas that are characterized by high expression of AR and ER receptors respond positively to antihormonal therapy, resulting in complete tumor regression. For locally malignant hepatoid epitheliomas and carcinomas with low expression of AR and ER receptors, antihormonal therapy makes it possible to reduce the size of the tumor, but does not make it possible to cure it completely.
PubMed: 36766353
DOI: 10.3390/ani13030463