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Danish Medical Bulletin Oct 2011A fistula is defined as a pathological connection between the intestine and an inner (bladder or other intestine) or outer (vagina or skin) epithelial surface. Fistulas... (Review)
Review
A fistula is defined as a pathological connection between the intestine and an inner (bladder or other intestine) or outer (vagina or skin) epithelial surface. Fistulas are discovered in up to 25% of all Crohn's disease patients during long-term follow-up examinations. Most are perianal fistulas, and these may be classified as simple or complex. The initial investigation of perianal fistulas includes imaging (MRI of the pelvis and rectum), examination under anaesthesia (EUA) with digital imaging, endoscopy, probing and anal ultrasound. Non-perianal fistulas require contrast imaging and/or CT/MRI for complete anatomical definition. Any abscess should be drained, and the disease extent throughout the entire gastrointestinal tract should be evaluated. Treatment goals for perianal fistulas include reduced fistula secretion or none, evaluated by clinical examination; the absence of abscesses; and patient satisfaction. MR imaging is required to demonstrate definitive fistula closure. Fistulotomy is considered for simple perianal fistulas. In complex perianal fistulas, antibiotics and azathioprine or 6-mercaptopurine, which are often combined with a loose seton, constitute the first-line medical therapy. In cases with persistent secretion, infliximab at 5 mg/kg is given at weeks 0, 2, and 6 and subsequently every 8 weeks. Adalimumab may improve fistula response in both infliximab-naïve patients and following infliximab treatment failure. Local therapy with fibrin glue or fistula plugs is rarely effective. Definitive surgical closure of perianal fistulas using an advancement flap may be attempted, but this procedure is associated with a high risk of relapse. Colostomy and proctectomy are the ultimate surgical treatment options for fistulas. Intestinal resection is almost always needed for the closure of symptomatic non-perianal fistulas.
Topics: Combined Modality Therapy; Crohn Disease; Digestive System Surgical Procedures; Drainage; Humans; Rectal Fistula; Rectum; Treatment Outcome
PubMed: 21975159
DOI: No ID Found -
Gastroenterologie Clinique Et Biologique Jan 2010
Review
Topics: Anti-Bacterial Agents; Diagnosis, Differential; Digestive System Surgical Procedures; Endosonography; Humans; Magnetic Resonance Imaging; Rectal Fistula
PubMed: 20004071
DOI: 10.1016/j.gcb.2009.10.014 -
World Journal of Gastroenterology Jul 2011Peri-anal fistulae are a worldwide health problem that can affect any person anywhere. Surgical management of these fistulae is not free from risks. Recurrence and fecal...
Peri-anal fistulae are a worldwide health problem that can affect any person anywhere. Surgical management of these fistulae is not free from risks. Recurrence and fecal incontinence are the most common complications after surgery. The cumulative personal surgical experience in managing cases with anal fistulae is significantly considered as necessary for obtaining better results with minimal adverse effects after surgery. The purpose for conducting this survey is to facilitate better outcome after surgical interventions in idiopathic anal fistulae' cases.
Topics: Anal Canal; Disease Management; Humans; Rectal Fistula; Treatment Outcome
PubMed: 21876612
DOI: 10.3748/wjg.v17.i28.3271 -
World Journal of Gastroenterology Jun 2022Tumor necrosis factor-alpha inhibitors, including infliximab and adalimumab, are effective medical treatments for perianal fistulising Crohn's disease (CD), but not all...
BACKGROUND
Tumor necrosis factor-alpha inhibitors, including infliximab and adalimumab, are effective medical treatments for perianal fistulising Crohn's disease (CD), but not all patients achieve fistula healing.
AIM
To determine the correlation between perianal fistula healing and closure with infliximab and adalimumab trough levels.
METHODS
In this multicentre retrospective study conducted across four tertiary inflammatory bowel disease centres in Australia, we identified CD patients with perianal fistulae on maintenance infliximab or adalimumab who had a trough level within twelve weeks of clinical assessment. Data collected included demographics, serum infliximab and adalimumab trough levels (mg/L) within 12 wk before or after their most recent clinical assessment and concomitant medical or surgical therapy. The primary outcome was fistula healing, defined as cessation in fistula drainage. The secondary outcome was fistula closure, defined as healing and closure of all external fistula openings. Differences between patients who did or did not achieve fistula healing were compared using the chi-square test, test or Mann-Whitney test.
RESULTS
One hundred and fourteen patients (66 infliximab, 48 adalimumab) were included. Forty-eight (72.7%) patients on maintenance infliximab achieved fistula healing and 18 (27.3%) achieved fistula closure. Thirty-seven (77%) patients on maintenance adalimumab achieved fistula healing and 17 (35.4%) achieved fistula closure. Patients who achieved fistula healing had significantly higher infliximab and adalimumab trough levels than patients who did not [infliximab: 6.4 (3.8-9.5) 3.0 (0.3-6.2) mg/L, = 0.003; adalimumab: 9.2 (6.5-12.0) 5.4 (2.5-8.3) mg/L, = 0.004]. For patients on infliximab, fistula healing was associated with lower rates of detectable anti-infliximab antibodies and younger age. For patients on adalimumab, fistula healing was associated with higher rates of combination therapy with an immunomodulator. Serum trough levels for patients with and without fistula closure were not significantly different for infliximab [6.9 (4.3-10.2) 5.5 (2.5-8.3) mg/L, = 0.105] or adalimumab [10.0 (6.6-12.0) 7.8 (4.2-10.0) mg/L, = 0.083].
CONCLUSION
Higher maintenance infliximab and adalimumab trough levels are associated with perianal fistula healing in CD.
Topics: Adalimumab; Crohn Disease; Gastrointestinal Agents; Humans; Infliximab; Rectal Fistula; Retrospective Studies; Treatment Outcome; Tumor Necrosis Factor-alpha
PubMed: 35949350
DOI: 10.3748/wjg.v28.i23.2597 -
Praxis Mar 2014During their disease course, the majority of Crohn's disease patients will develop a complicated disease which is characterized by the occurrence of fistulas and/or... (Review)
Review
During their disease course, the majority of Crohn's disease patients will develop a complicated disease which is characterized by the occurrence of fistulas and/or stenosis. Symptomatic, perianal fistulas should be surgically drained before anti-inflammatory therapy will be initiated. Antibiotics, such as metronidazole, improve disease symptomatic however, they are not sufficient to induce continuous fistula closure. For this purpose, azathioprine/6-mercaptopurine as well as anti-TNF antibodies are useful when administered continuously. Surgical options include seton drainage, fistula excision, fistula plugs and mucosa flaps. As ultima ratio, temporary ileostomy and proctectomy are to be discussed. Non-perianal fistulas often require surgical approaches. Symptomatic strictures or stenosis can be treated by anti-inflammatory medications (only if they are cause by inflammation), endoscopic balloon dilatation or surgery.
Topics: Anti-Inflammatory Agents; Combined Modality Therapy; Crohn Disease; Humans; Immunosuppressive Agents; Intestinal Obstruction; Intestines; Rectal Fistula
PubMed: 24618311
DOI: 10.1024/1661-8157/a001592 -
Alimentary Pharmacology & Therapeutics Jan 2011Crohn's anal fistulas are common and cause considerable morbidity. Their management is often difficult; medical and surgical treatments rarely lead to true healing with... (Review)
Review
BACKGROUND
Crohn's anal fistulas are common and cause considerable morbidity. Their management is often difficult; medical and surgical treatments rarely lead to true healing with frequent recurrence and complications.
AIM
To examine medical treatments previously and currently used, surgical techniques and the important role of optimal imaging.
METHODS
We conducted a literature search in the Pub Med database using Crohn's, Anal Fistula, Surgery, Imaging and Medical Treatment as search terms.
RESULTS
Antibiotics and immunosuppressants have a role, but slow initial response, side effects and relatively low remission rates of up to around a third with frequent recurrence limit their value. Long-term infliximab produces clinical remission in 36-58% of patients with combined medical and surgical management achieving optimal outcomes. Traditional and newer surgical procedures often have a high rate of recurrence with a significant risk of temporary or, in up to 10% of cases, permanent stomas, incontinence and unhealed or slowly healing wounds in 30%.
CONCLUSIONS
Management of Crohn's anal fistulas remains challenging. Established principles are to drain infection, use setons as required, aggressively manage active proctitis, give antibiotics, immunosuppressants and employ anti-TNFα therapy, and they demand significant co-operation between gastroenterologists and surgeons.
Topics: Anti-Bacterial Agents; Antibodies, Monoclonal; Combined Modality Therapy; Crohn Disease; Gastrointestinal Agents; Humans; Immunosuppressive Agents; Infliximab; Magnetic Resonance Imaging; Rectal Fistula; Recurrence; Risk Factors; Treatment Outcome; Wound Healing
PubMed: 21083581
DOI: 10.1111/j.1365-2036.2010.04486.x -
World Journal of Gastroenterology Apr 2020Infliximab (IFX), as a drug of first-line therapy, can alter the natural progression of Crohn's disease (CD), promote mucosal healing and reduce complications,... (Review)
Review
Infliximab (IFX), as a drug of first-line therapy, can alter the natural progression of Crohn's disease (CD), promote mucosal healing and reduce complications, hospitalizations, and the incidence of surgery. Perianal fistulas are responsible for the refractoriness of CD and represent a more aggressive disease. IFX has been demonstrated as the most effective drug for the treatment of perianal fistulizing CD. Unfortunately, a significant proportion of patients only partially respond to IFX, and optimization of the therapeutic strategy may increase clinical remission. There is a significant association between serum drug concentrations and the rates of fistula healing. Higher IFX levels during induction are associated with a complete fistula response in these patients. Given the apparent relapse of perianal fistulizing CD, maintenance therapy with IFX over a longer period seems to be more beneficial. It appears that patients without deep remission are at an increased risk of relapse after stopping anti-tumor necrosis factor agents. Thus, only patients in prolonged clinical remission should be considered for withdrawal of IFX treatment when biomarker and endoscopic remission is demonstrated, especially when the hyperintense signals of fistulas on T2-weighed images have disappeared on magnetic resonance imaging. Fundamentally, the optimal timing of IFX use is highly individualized and should be determined by a multidisciplinary team.
Topics: Crohn Disease; Drug Administration Schedule; Humans; Infliximab; Magnetic Resonance Imaging; Proctoscopy; Rectal Fistula; Recurrence; Remission Induction; Secondary Prevention; Time Factors; Treatment Outcome; Wound Healing
PubMed: 32327905
DOI: 10.3748/wjg.v26.i14.1554 -
Asian Journal of Surgery Oct 2023
Topics: Humans; Anus Neoplasms; Rectal Fistula; Anal Canal; Treatment Outcome
PubMed: 37344312
DOI: 10.1016/j.asjsur.2023.05.085 -
European Radiology Dec 2022There are a range of sphincter-preserving procedures available to treat anorectal fistula, some of which can be precluded, or rendered more optimal by specific features... (Review)
Review
There are a range of sphincter-preserving procedures available to treat anorectal fistula, some of which can be precluded, or rendered more optimal by specific features of fistula anatomy. Magnetic resonance imaging (MRI) is the gold standard modality for assessing anorectal fistula. To maximise clinical utility, the MRI report should accurately describe these clinically relevant features. We aimed to develop a minimum dataset for reporting MRI of anorectal fistula, in order to improve the assessment and management of these patients. A longlist of 70 potential items for the minimum dataset was generated through systematic review of the literature. This longlist was presented to radiologists, surgeons and gastroenterologists in an online survey to understand the features that shape current clinical practice. The longlist and survey results were then presented to an expert consensus panel to generate the final minimum dataset through discussion and anonymous voting. The final minimum dataset details the general characteristics, features of the internal and external openings, path of the fistula through the sphincters and any associated extensions and collections that should be described in all MRI reports for anal fistula. Additional surgical and perianal Crohn's disease subsets were developed to indicate the features that aid decision-making for these patients, in addition to a minimum dataset for the clinical request. This study represents a multi-disciplinary approach to developing a minimum dataset for MRI reporting of anal fistula, highlighting the most important features to report that can assist in clinical decision-making. KEY POINTS: • This paper recommends the minimum features that should be included in all MRI reports for the assessment of anal fistula, including Parks classification, number of tracts, features of the internal and external opening, path of the tract through the sphincters, the presence and features of extensions and collections. • Additional features that aid decision-making for surgery or in the presence of Crohn's disease have been identified. • The items that should be included when requesting an MRI are specified.
Topics: Humans; Crohn Disease; Consensus; Rectal Fistula; Magnetic Resonance Imaging; Clinical Decision-Making
PubMed: 35732929
DOI: 10.1007/s00330-022-08931-z -
Journal of Traditional Chinese Medicine... Oct 2023In the study of the mechanism of wound healing after anal fistula surgery, how to scientifically and efficiently promote wound healing is of great significance. At...
In the study of the mechanism of wound healing after anal fistula surgery, how to scientifically and efficiently promote wound healing is of great significance. At present, modern medical treatment of wounds after anal fistula surgery mostly focuses on physical therapy intervention, new wound dressing and packing, and external application of growth factors. However, these therapies have many problems, and there is still no consensus on their clinical use. Traditional Chinese Medicine (TCM) has several methods to promote wound healing, such as oral administration, rubbing, and fumigation, which have a long history and obvious efficacy, but research in this area is relatively scattered and lacks classification and summarizing. Therefore, this paper analyzes and summarizes the existing research on TCM for promotion of wound healing after anal fistula surgery, carries out targeted analyses according to different clinical syndromes and treatment methods, and analyzes the defects in current research and anticipates future research trends in order to provide theoretical support for the advantages of TCM in promoting wound healing after anal fistula surgery.
Topics: Humans; Medicine, Chinese Traditional; Administration, Oral; Wound Healing; Rectal Fistula
PubMed: 37679994
DOI: 10.19852/j.cnki.jtcm.20230630.002