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Hong JC, Chen JS, Jiang ZJ, Chen ZC, Ruan N, Yao XP. Microbiota in adult perianal abscess revealed by metagenomic next-generation sequencing. Microbiol Spectr 2024; 12:e0347423. [PMID: 38385739 PMCID: PMC10986498 DOI: 10.1128/spectrum.03474-23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Accepted: 01/12/2024] [Indexed: 02/23/2024] Open
Abstract
The microbiota of perianal abscesses is scarcely investigated. Identifying causative bacteria is essential to develop antibiotic therapy. However, culture-based methods and molecular diagnostics through 16S PCR technology are often hampered by the polymicrobial nature of perianal abscesses. We sought to characterize the microbiota composition of perianal abscesses via metagenomic next-generation sequencing (mNGS). Fourteen patients suffering from perianal abscesses between March 2023 and August 2023 underwent retrospective assessment. Information from medical records was used, including clinical information, laboratory data, and culture and mNGS results. Forty bacterial taxa were identified from perianal abscesses through mNGS, with Bilophila wadsworthia (71.4%), Bacteroides fragilis (57.1%), and Escherichia coli (50.0%) representing the most prevalent species. mNGS identified an increased number of bacterial taxa, with an average of 6.1 compared to a traditional culture-based method which only detected an average of 1.1 in culture-positive perianal abscess patients, predominantly E. coli (75.0%), revealing the polymicrobial nature of perianal abscesses. Our study demonstrates that a more diverse bacterial profile is detected by mNGS in perianal abscesses, and that Bilophila wadsworthia is the most prevalent microorganism, potentially serving as a potential biomarker for perianal abscess.IMPORTANCEAccurately, identifying the bacteria causing perianal abscesses is crucial for effective antibiotic therapy. However, traditional culture-based methods and 16S PCR technology often struggle with the polymicrobial nature of these abscesses. This study employed metagenomic next-generation sequencing (mNGS) to comprehensively analyze the microbiota composition. Results revealed 40 bacterial taxa, with Bilophila wadsworthia (71.4%), Bacteroides fragilis (57.1%), and Escherichia coli (50.0%) being the most prevalent species. Compared to the culture-based approach, mNGS detected a significantly higher number of bacterial taxa (average 6.1 vs 1.1), highlighting the complex nature of perianal abscesses. Notably, Bilophila wadsworthia emerged as a potential biomarker for these abscesses. This research emphasizes the importance of mNGS in understanding perianal abscesses and suggests its potential for improving diagnostic accuracy and guiding targeted antibiotic therapy in the future.
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Affiliation(s)
- Jian-Chen Hong
- Department of Gastrointestinal Surgery, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China
- Department of Anorectal Surgery, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou, China
| | - Jian-Sheng Chen
- Department of Gastrointestinal Surgery, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China
| | - Zai-Jie Jiang
- Department of Neurology, Institute of Neurology of First Affiliated Hospital, Institute of Neuroscience, Fujian Key Laboratory of Molecular Neurology, Fujian Medical University, Fuzhou, China
| | - Zhi-Chuan Chen
- Department of Gastrointestinal Surgery, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China
| | - Ning Ruan
- Department of Gastrointestinal Surgery, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China
- Department of Anorectal Surgery, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou, China
| | - Xiang-Ping Yao
- Department of Neurology, Institute of Neurology of First Affiliated Hospital, Institute of Neuroscience, Fujian Key Laboratory of Molecular Neurology, Fujian Medical University, Fuzhou, China
- Department of Neurology, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou, China
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Polaino Moreno V, Caballero-Bermejo AF, Artés Caselles M, Serrano González J, Remírez Arriaga X, González Alcolea N, Equisoain Azcona A, Iglesias García E, Lucena de la Poza JL, Sánchez Movilla A, Ruiz-Antorán B. Efficacy of amoxicillin/clavulanic acid after surgical drainage of perianal abscess in the prevention of the development of anal fistula (PERIQxA study): study protocol for a multicenter randomized, double-blind clinical trial. Trials 2024; 25:122. [PMID: 38355562 PMCID: PMC10868096 DOI: 10.1186/s13063-024-07922-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Accepted: 01/10/2024] [Indexed: 02/16/2024] Open
Abstract
BACKGROUND Anorectal fistula, which is a relatively common pathology, is the chronic manifestation of the acute perirectal process that forms an anal abscess. The development of a fistula after incision and drainage of an anal abscess is seen in approximately 26-37%. Its treatment is a relevant topic, and the role of the use of antibiotic therapy in its prevention remains controversial, after the publication of several studies with contradictory results and several methodological limitations. Our hypothesis is that the combination of amoxicillin and clavulanic acid will reduce the incidence of anal fistula. METHOD The aim of this study is to evaluate the efficacy of antibiotherapy after surgical drainage of perianal abscess in the development of perianal fistula. The PERIQxA study is a multicenter, randomized, double-blind controlled trial. The study has been designed to include 286 adult patients who will be randomly (1:1) assigned to either the experimental (amoxicillin/clavulanic acid 875/125 mg TDS for 7 days) or the control arm (placebo). The primary outcome measure is the percentage of patients that develop perianal fistula after surgery and during follow-up (6 months). DISCUSSION This clinical trial is designed to evaluate the efficacy and safety of amoxicillin/clavulanic in the prevention of perianal fistula. The results of this study are expected to contribute to stablish the potential role of antibiotherapy in the therapeutics for anal abscess. TRIAL REGISTRATION EudraCT Number: 2021-003376-14. Registered on November 26, 2021.
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Affiliation(s)
- Verónica Polaino Moreno
- General Surgery Department, Hospital Universitario Puerta de Hierro Majadahonda, Instituto de Investigación Sanitaria Puerta de Hierro Segovia de Arana, Majadahonda, Spain
| | - Antonio F Caballero-Bermejo
- Clinical Pharmacology Department, Hospital Universitario Puerta de Hierro Majadahonda, Instituto de Investigación Sanitaria Puerta de Hierro Segovia de Arana, Majadahonda, Spain.
| | - Mariano Artés Caselles
- General Surgery Department, Hospital Universitario Puerta de Hierro Majadahonda, Instituto de Investigación Sanitaria Puerta de Hierro Segovia de Arana, Majadahonda, Spain
| | | | | | | | - Aritz Equisoain Azcona
- General Surgery Department, Hospital Universitario Puerta de Hierro Majadahonda, Instituto de Investigación Sanitaria Puerta de Hierro Segovia de Arana, Majadahonda, Spain
| | - Eva Iglesias García
- General Surgery Department, Hospital Universitario Puerta de Hierro Majadahonda, Instituto de Investigación Sanitaria Puerta de Hierro Segovia de Arana, Majadahonda, Spain
| | - José Luis Lucena de la Poza
- General Surgery Department, Hospital Universitario Puerta de Hierro Majadahonda, Instituto de Investigación Sanitaria Puerta de Hierro Segovia de Arana, Majadahonda, Spain
| | - Arsenio Sánchez Movilla
- General Surgery Department, Hospital Universitario Puerta de Hierro Majadahonda, Instituto de Investigación Sanitaria Puerta de Hierro Segovia de Arana, Majadahonda, Spain
| | - Belén Ruiz-Antorán
- Clinical Pharmacology Department, Hospital Universitario Puerta de Hierro Majadahonda, Instituto de Investigación Sanitaria Puerta de Hierro Segovia de Arana, Majadahonda, Spain
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Litta F, Papait A, Lucchetti D, Farigu S, Parello A, Tenore CR, Campennì P, Silini AR, Giustiniani MC, Parolini O, Sgambato A, Ratto C. The pathogenesis of cryptoglandular anal fistula: New insight into the immunological profile. Colorectal Dis 2022; 24:1567-1575. [PMID: 35916639 PMCID: PMC10087133 DOI: 10.1111/codi.16290] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2022] [Revised: 07/08/2022] [Accepted: 07/27/2022] [Indexed: 01/07/2023]
Abstract
AIM The aetiology of cryptoglandular anal fistula (AF) is poorly understood. Evidence suggests that persistence and/or recurrence of the disease is more related to inflammatory than infectious factors. The aim of this study was to investigate the immune profile of cryptoglandular AF and to perform a histopathological characterization. METHOD Fistulectomy was performed in all patients; healthy ischioanal fat from the same patients was used as a control. Samples were evaluated by the Luminex xMAP system for the detection of 27 analytes. AF tissues were analysed using immunofluorescence. Staining was performed using primary antibodies to identify M1 inflammatory and M2 anti-inflammatory macrophages. Selective staining of total T lymphocytes and different T lymphocyte subsets was performed. RESULTS Twenty patients with AF underwent a fistulectomy. Specific cytokine pathways differentiated AF from healthy tissue: pro-inflammatory cytokines interleukin (IL)-1β, IL-4, IL-8 and IL-17 and the anti-inflammatory cytokine IL-10 were overexpressed in AF compared with controls. Chemokines involved in macrophage recruitment (CCL2, CCL3, CCL4) were higher in AF than in healthy fatty tissue. Moreover, we showed that Tc17 cells characterize AF patients, thus confirming the enzyme-linked immunosorbent assay data. Furthermore, elevated infiltration of CD68+ myeloid cells and a reduction of the M1/M2 ratio characterize AF patients. CONCLUSION A combination of inflammatory cytokines, chemokines and growth factors reside in the wound microenvironment of AF patients. For the first time an important prevalence of Tc17 cells and a reduction in the M1/M2 ratio was observed, thus suggesting new insights into the immunological characterization of AF patients.
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Affiliation(s)
- Francesco Litta
- Proctology Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Andrea Papait
- Dipartimento di Scienze della Vita e Sanità Pubblica, Università Cattolica del Sacro Cuore, Rome, Italy.,Fondazione Policlinico Universitario 'Agostino Gemelli' IRCCS, Rome, Italy
| | - Donatella Lucchetti
- Dipartimento Universitario di Medicina e Chirurgia Traslazionale, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Serafina Farigu
- Centro di Ricerca E. Menni, Fondazione Poliambulanza, Brescia, Italy
| | - Angelo Parello
- Proctology Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Claudio Ricciardi Tenore
- Dipartimento Universitario di Medicina e Chirurgia Traslazionale, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Paola Campennì
- Proctology Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | | | | | - Ornella Parolini
- Dipartimento di Scienze della Vita e Sanità Pubblica, Università Cattolica del Sacro Cuore, Rome, Italy.,Fondazione Policlinico Universitario 'Agostino Gemelli' IRCCS, Rome, Italy
| | - Alessandro Sgambato
- Dipartimento Universitario di Medicina e Chirurgia Traslazionale, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Carlo Ratto
- Proctology Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
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Sahara R, Koizumi M, Morimoto K, Kubota I. Subcutaneous incision of the fistula tract and internal sphincterotomy (SIFT-IS): a novel surgical procedure for transsphincteric anal fistula. Colorectal Dis 2022; 24:1576-1583. [PMID: 35946094 PMCID: PMC10087595 DOI: 10.1111/codi.16297] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Revised: 07/28/2022] [Accepted: 07/31/2022] [Indexed: 01/07/2023]
Abstract
AIM The aetiology of anal fistula has not been fully clarified. One of the causes of anal fistulas may be the markedly deep crypts that characterize the primary openings. We developed subcutaneous incision of the fistula tract and internal sphincterotomy (SIFT-IS) to eradicate these deep crypts. The aim of this study was to evaluate outcomes in patients with anal fistula treated with SIFT-IS. METHOD A retrospective study was performed over a 2-year period. Patients with transsphincteric anal fistula who underwent SIFT-IS were enrolled. The primary endpoint was the anal fistula healing rate at 16 weeks postoperatively. The secondary endpoints were healing time, postoperative complications and clinical continence status. RESULTS One hundred and fifty one patients were enrolled. Primary healing was accomplished in 129 patients (85%). There were 17 patients (11%) with a remnant fistula and five (3%) with a recurrence. The remnant fistulas healed spontaneously at more than 16 weeks postoperatively in seven patients. The median healing time was 6 (3-96) weeks. Surgical intervention was required in seven patients with a remnant fistula and four with recurrence. At the final follow-up, the wounds had healed in 148 patients (98%). No significant postoperative complications or incontinence were observed. CONCLUSION Subcutaneous incision of the fistula tract and internal sphincterotomy is a promising surgical option for transsphincteric anal fistulas, with a satisfactory healing rate.
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Affiliation(s)
- Rikisaburo Sahara
- Proctology Center, Makita General Hospital, Tokyo, Japan.,Nishiarai Coloproctology Clinic, Tokyo, Japan
| | - Michihiro Koizumi
- Nishiarai Coloproctology Clinic, Tokyo, Japan.,Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Nippon Medical School, Tokyo, Japan
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Perianal fistulas: A review with emphasis on preoperative imaging. Adv Med Sci 2022; 67:114-122. [PMID: 35134600 DOI: 10.1016/j.advms.2022.01.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2021] [Revised: 11/24/2021] [Accepted: 01/14/2022] [Indexed: 02/06/2023]
Abstract
PURPOSE We aim to present a comprehensive literature review which focuses on the preoperative imaging of perianal fistulas. MATERIAL/METHODS Pelvic magnetic resonance imaging (MRI) and endoanal ultrasound (EAUS) are the two first-line imaging modalities for the preoperative evaluation of patients with perianal fistulas. We conducted a search in PubMed, Scopus and Google Scholar concerning articles comparing pelvic MRI with EAUS, which were published from 1994 until 2019. RESULTS In most articles, pelvic MRI is superior to EAUS for the evaluation of perianal fistulas (especially for supralevator and extrasphincteric ones). Preoperative pelvic MRI is associated with statistically significant better results and prognosis after surgical treatment of the disease. Preoperative EAUS poses high sensitivity and specificity in identifying intersphincteric and transsphincteric perianal fistulas, as well as the internal opening of a fistula-in-ano. There is only one meta-analysis which compares the diagnostic accuracy of the two mentioned imaging modalities in preoperative fistula detection. Sensitivity of both - pelvic MRI and EAUS, is acceptably high (0.87). Specificity of pelvic MRI is 0.69 in comparison to EAUS (0.43), but both values are considered low. CONCLUSIONS Future well-designed prospective studies are needed to investigate the diagnostic accuracy of pelvic MRI and EAUS in the preoperative assessment of patients with perianal fistulas. Moreover, the combination of pelvic MRI and EAUS should also be studied, since several published articles suggest that it could lead to improved diagnostic accuracy. A novel treatment algorithm for perianal fistulas could arise from this study.
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Ratto C, Parolini O, Marra AA, Orticelli V, Parello A, Campennì P, De Simone V, Trojan D, Litta F. Human Amniotic Membrane for the Treatment of Cryptoglandular Anal Fistulas. J Clin Med 2022; 11:jcm11051350. [PMID: 35268442 PMCID: PMC8911009 DOI: 10.3390/jcm11051350] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2022] [Revised: 02/25/2022] [Accepted: 02/27/2022] [Indexed: 12/19/2022] Open
Abstract
Background: Implantation of the amniotic membrane and their derivatives can have a beneficial effect on tissue repair and regeneration. We report for the first time the implant of an amniotic membrane in a patient affected by cryptoglandular anal fistula. Methods: A patch of human amniotic membrane was implanted in a female patient affected by an anterior transphincteric fistula. Following an accurate curettage of the anal fistula, the cryopreserved amniotic membrane was thawed and then washed in the operating room; one side of the membrane was transfixed with a resorbable suture thus creating an implantable fusiform patch. The membrane was subsequently implanted into the fistula tract from the external to the internal opening. The inner and outer parts of the membrane were then sutured to the internal and external fistula openings. Results: No intraoperative or postoperative complications occurred. The patient was discharged one day after the procedure after an uneventful hospitalization. At the 1-week, 1- and 3-month follow-up visits no pain (VAS 0) was referred by the patient and no inflammation was evident at the level of the previous external fistula opening. Conclusions: The implant of human amniotic membrane in a patient affected by cryptoglandular anal fistula was safely and easily performed. Moreover, future studies to assess the efficacy in the long-term follow-up are needed.
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Affiliation(s)
- Carlo Ratto
- Proctology Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy; (A.A.M.); (A.P.); (P.C.); (V.D.S.); (F.L.)
- Department of Medicine and Translational Surgery, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
- Correspondence: ; Tel.: +39-3356886968
| | - Ornella Parolini
- Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy; (O.P.); (V.O.)
- Department of Life Science and Public Health, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Angelo Alessandro Marra
- Proctology Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy; (A.A.M.); (A.P.); (P.C.); (V.D.S.); (F.L.)
| | - Valentina Orticelli
- Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy; (O.P.); (V.O.)
| | - Angelo Parello
- Proctology Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy; (A.A.M.); (A.P.); (P.C.); (V.D.S.); (F.L.)
| | - Paola Campennì
- Proctology Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy; (A.A.M.); (A.P.); (P.C.); (V.D.S.); (F.L.)
| | - Veronica De Simone
- Proctology Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy; (A.A.M.); (A.P.); (P.C.); (V.D.S.); (F.L.)
| | - Diletta Trojan
- Tissue Bank, Fondazione Banca Dei Tessuti Di Treviso Onlus, 31100 Treviso, Italy;
| | - Francesco Litta
- Proctology Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy; (A.A.M.); (A.P.); (P.C.); (V.D.S.); (F.L.)
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Flap-Techniken – heute noch „State of the Art“? COLOPROCTOLOGY 2021. [DOI: 10.1007/s00053-021-00573-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Early Results of a Phase I Trial Using an Adipose-Derived Mesenchymal Stem Cell-Coated Fistula Plug for the Treatment of Transsphincteric Cryptoglandular Fistulas. Dis Colon Rectum 2019; 62:615-622. [PMID: 30664554 DOI: 10.1097/dcr.0000000000001333] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Management of transsphincteric cryptoglandular fistulas remains a challenging problem and the optimal surgical approach remains elusive. Mesenchymal stem cells, increasingly being utilized for perianal Crohn's disease, offer a novel therapy to treat cryptoglandular fistulas. OBJECTIVES This study aimed to determine safety and feasibility of using an autologous mesenchymal stem cell-coated fistula plug in patients with transsphincteric cryptoglandular fistulas. DESIGN This study is a phase I clinical trial. SETTING This study was conducted at a tertiary academic medical center. PATIENTS Adult (>18 years) male and female patients with transsphincteric cryptoglandular fistulas were selected. MAIN OUTCOMES MEASURES The primary outcomes measured were the safety, feasibility, and efficacy of a mesenchymal stem cell-coated fistula plug in patients with transsphincteric fistulas. RESULTS Fifteen patients (8 women, mean age 39.8 years) with a single-tract transsphincteric fistula received a mesenchymal stem cell-loaded fistula plug and were followed for 6 months. Duration of disease at the time of study enrollment was a median of 3.0 years (range, 1-13 years) with a median of 3.5 (range, 1-20) prior surgical interventions. Adverse events included 1 plug extrusion, 1 abdominal wall seroma, 3 perianal abscesses requiring drainage, and 1 patient with perianal cellulitis. There were no serious adverse events. At 6 months, 3 patients had complete clinical healing, 8 had partial healing, and 4 patients showed no clinical improvement. Radiographic improvement was seen in 11 of 15 patients. LIMITATIONS This study was limited by the small cohort and short follow-up. CONCLUSIONS Autologous mesenchymal stem cell-coated fistula plug treatment of transsphincteric cryptoglandular fistulas was safe and feasible and resulted in complete or partial healing in a majority of patients. See Video Abstract at http://links.lww.com/DCR/A897.
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Pérez Lara FJ, Hernández González JM, Ferrer Berges A, Navarro Gallego I, Oehling de Los Reyes H, Oliva Muñoz H. Can Perianal Fistula Be Treated Non-surgically with Platelet-Rich Fibrin Sealant? J Gastrointest Surg 2019; 23:1030-1036. [PMID: 30187327 DOI: 10.1007/s11605-018-3932-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2018] [Accepted: 08/16/2018] [Indexed: 01/31/2023]
Abstract
INTRODUCTION In the last 20 years, various procedures have been suggested for the treatment of anal fistula whilst minimising anal sphincter injury and preserving optimal function. Since 2011, patients at our hospital have been treated for anal fistula by means of platelet-rich fibrin plugs. To do so, three different application techniques have been used, the most recent of which is a non-surgical approach. In this paper, we compare and contrast the results obtained by each of these three techniques. MATERIAL AND METHOD This study compares three procedures in which the anal fistula was sealed using platelet-rich fibrin: for the patients in group A, the plug was surgically inserted, under anaesthesia, and traditional methods were used to curette the fistula tract and close the internal orifice; for those in group B, the plug was surgically inserted, under anaesthesia, after curettage of the fistula tract using a graduated set of cylindrical curettes, and the internal orifice was closed as before; and for those in group C, the plug was inserted during outpatient consultation, without anaesthesia, without curettage and without closure of the internal orifice. RESULTS The patients in the three groups were homogeneous in terms of sex, age, ASA classification, location of the fistula and previous insertion of the seton. There were no significant differences in morbidity or postoperative continence. However, there was a statistically significant difference in the outcomes achieved, in favour of group B, while groups A and C obtained similar results. CONCLUSIONS Outpatient treatment of perianal fistula is totally innocuous. It is a very low cost procedure and the results obtained are highly acceptable (similar to those of the surgical insertion of a plug, with traditional curettage). Therefore, we believe this approach should be considered a valid initial treatment for perianal fistula, reserving surgical treatment (curettage and sealing using a cylindrical-curette kit) for cases in which this initial method is unsuccessful. This would avoid many complications and achieve considerable financial savings for the health system.
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Parés D, Abcarian H. Management of Common Benign Anorectal Disease: What All Physicians Need to Know. Am J Med 2018; 131:745-751. [PMID: 29499172 DOI: 10.1016/j.amjmed.2018.01.050] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2017] [Revised: 01/18/2018] [Accepted: 01/19/2018] [Indexed: 12/15/2022]
Abstract
Benign anorectal conditions produce anal pain, rectal bleeding, or discharge from the perianal region, which are highly prevalent symptoms in the general population. Hemorrhoidal disease, anal fissure, perianal abscess, proctalgia syndromes, and pruritus anii are the most common clinical disorders. Well-trained physicians, irrespective of their specialty, can treat most of these disorders and refer them to a specialist in proctology only when necessary. The aim of this review is to provide a practical guide to the management of benign anorectal disorders in terms of their initial management and the criteria for specialist referral.
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Affiliation(s)
- David Parés
- Department of Colon and Rectal Surgery, Hospital Germans Trias i Pujol, School of Medicine, Universitat Autónoma de Barcelona, Badalona, Spain.
| | - Herand Abcarian
- Division of Colon and Rectal Surgery, University of Illinois at Chicago
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Moreno-Serrano A, García-Díaz JJ, Ferrer-Márquez M, Alarcón-Rodríguez R, Álvarez-García A, Reina-Duarte Á. Using autologous platelet-rich plasma for the treatment of complex fistulas. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2017; 108:123-8. [PMID: 26856400 DOI: 10.17235/reed.2016.3946/2015] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVE This study aims to demonstrate the effectiveness and safety of autologous fibrin gel rich in platelet growth factors for the treatment of complex perianal fistulas. MATERIAL AND METHODS Prospective epidemiological study. Patients with complex perianal fistula or perianal fistula mere alteration of continence are included. identification of both holes and the journey, curettage of it and instillation of Vivostat PRF® in the way it is done to observe excess material by OFE. The variables analyzed were: age, sex, use of prior Seton clinic prevalent type of fistula, postoperative complications, fistula closure and impaired quality of life using the SF-36 test (v2). RESULTS From January 2011 to May 2013 have involved 23 patients, 12 men and 11 women, with an average age of 49 years and a minimum follow-up of 12 months. Two dropped out. 17 patients had low transsphincteric fistulas, 2 and 2 high transsphincteric intersphincteric with impaired continence. The most common symptom is the discharge. Twelve patients had a loose seton (62%), of which nine cured. Of all the patients we have operated the success rate is 62%. No patient developed incontinence after treatment. Only two reported a worse quality of life after surgery. CONCLUSION This study demonstrates that there is a clear benefit to the use of Vivostat PRF® as a treatment for complex perianal fistulas. It is a highly reproducible technique with acceptable results and does not produce impairment of continence.
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Ommer A, Herold A, Berg E, Farke S, Fürst A, Hetzer F, Köhler A, Post S, Ruppert R, Sailer M, Schiedeck T, Schwandner O, Strittmatter B, Lenhard BH, Bader W, Krege S, Krammer H, Stange E. S3-Leitlinie: Kryptoglanduläre Analfisteln. COLOPROCTOLOGY 2016. [DOI: 10.1007/s00053-016-0110-7] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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Ratto C, Litta F, Lucchetti D, Parello A, Boninsegna A, Arena V, Donisi L, Calapà F, Sgambato A. Immunopathological characterization of cryptoglandular anal fistula: a pilot study investigating its pathogenesis. Colorectal Dis 2016; 18:O436-O444. [PMID: 27649390 DOI: 10.1111/codi.13527] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2015] [Accepted: 09/05/2016] [Indexed: 12/19/2022]
Abstract
AIM The pathogenesis of cryptoglandular anal fistula (AF) is still under debate. Tissue inflammation could play a primary role. The pathological process of epithelial mesenchymal transition (EMT) might be involved but has never been investigated. METHOD In a prospective pilot study, 12 patients with an AF had a fistulectomy. The excised track was divided into proximal (intrasphincteric) and distal (extrasphincteric) parts which were subjected to standard histopathological examination. The cytokines IL-8 and IL-1beta were analysed as markers of inflammation, while EMT was evaluated by expression of TGF-beta, Vimentin, Zeb-1, Snail and E-cadherin. The mRNA and protein expression of these molecules was investigated by real-time PCR (RT-PCR), Western blot analysis and immunohistochemistry and was compared with that of the normal adjacent tissue. RESULTS Chronic inflammation and granulation tissue and a stratified epithelium were evident on standard histopathological examination. The cytokine IL-8 was more expressed in the proximal than the distal part of the track (fold increase 4.34 vs 3.60), while the reverse was found for IL-1beta (fold increase 1.33 vs 2.01); both were more intensely expressed compared with the normal anal mucosa. EMT was demonstrated, in both proximal and distal parts of the track, with an increase of TGF-beta, Vimentin, Zeb-1 and Snail and a mean decrease of E-cadherin. Western blot analysis and immunohistochemistry confirmed the protein expression. CONCLUSION The study suggests that chronic inflammation is present in cryptoglandular fistulas. The inflammatory pattern might be different in the proximal than in the distal part of the fistula track. The cytokines IL-1beta and IL-8 could play a possible role in fistula formation. The study demonstrates for the first time the potential importance of EMT in the pathogenesis of cryptoglandular AF.
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Affiliation(s)
- C Ratto
- Proctology Unit, Department of Surgical Sciences, Catholic University of Rome, Rome, Italy
| | - F Litta
- Proctology Unit, Department of Surgical Sciences, Catholic University of Rome, Rome, Italy
| | - D Lucchetti
- Institute of General Pathology, Catholic University of Rome, Rome, Italy
| | - A Parello
- Proctology Unit, Department of Surgical Sciences, Catholic University of Rome, Rome, Italy
| | - A Boninsegna
- Institute of General Pathology, Catholic University of Rome, Rome, Italy
| | - V Arena
- Department of Pathology, Catholic University of Rome, Rome, Italy
| | - L Donisi
- Proctology Unit, Department of Surgical Sciences, Catholic University of Rome, Rome, Italy
| | - F Calapà
- Institute of General Pathology, Catholic University of Rome, Rome, Italy
| | - A Sgambato
- Institute of General Pathology, Catholic University of Rome, Rome, Italy
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Romero GT, Santos CHMD, Cassino PC, Odashiro M, Seno GZ, Aléssio GF. Treatment of fistula-in-ano with cyanoacrylate glue with and without prior seton placement in rats. Acta Cir Bras 2016; 31:377-81. [DOI: 10.1590/s0102-865020160060000003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2016] [Accepted: 05/18/2016] [Indexed: 12/19/2022] Open
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Roig JV, García-Armengol J. Tratamiento de las fístulas de ano complejas de causa criptoglandular. ¿Aún se requiere un cirujano con experiencia? Cir Esp 2013; 91:78-89. [DOI: 10.1016/j.ciresp.2011.10.014] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2011] [Revised: 10/09/2011] [Accepted: 10/14/2011] [Indexed: 12/14/2022]
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Ommer A, Herold A, Berg E, Farke S, Fürst A, Hetzer F, Köhler A, Post S, Ruppert R, Sailer M, Schiedeck T, Strittmatter B, Lenhard B, Bader W, Gschwend J, Krammer H, Stange E. S3-Leitlinie: Kryptoglanduläre Analfisteln. COLOPROCTOLOGY 2011. [DOI: 10.1007/s00053-011-0210-3] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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