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Karki C, Athavale A, Abilash V, Hantsbarger G, Geransar P, Lee K, Milicevic S, Perovic M, Raven L, Sajak-Szczerba M, Silber A, Yoon A, Tozer P. Multi-national observational study to assess quality of life and treatment preferences in patients with Crohn's perianal fistulas. World J Gastrointest Surg 2023; 15:2537-2552. [PMID: 38111766 PMCID: PMC10725550 DOI: 10.4240/wjgs.v15.i11.2537] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Revised: 09/27/2023] [Accepted: 10/30/2023] [Indexed: 11/26/2023] Open
Abstract
BACKGROUND Patients with Crohn's disease (CD) are at risk of developing complications such as perianal fistulas. Patients with Crohn's perianal fistulas (CPF) are affected by fecal incontinence (FI), bleeding, pain, swelling, and purulent perianal discharge, and generally face a higher treatment burden than patients with CD without CPF. AIM To gain insights into the burden of illness/quality of life in patients with CPF and their treatment preferences and satisfaction. METHODS This cross-sectional observational study was conducted in patients with CD aged 21-90 years via a web-enabled questionnaire in seven countries (April-August 2021). Patients were recruited into three cohorts: Cohort 1 included patients without perianal fistulas; cohort 2 included patients with perianal fistulas without fistula-related surgery; and cohort 3 included patients with perianal fistulas and fistula-related surgery. Validated patient-reported outcome measures were used to assess quality of life. Drivers of treatment preferences were measured using a discrete choice experiment (DCE). RESULTS In total, 929 patients were recruited (cohort 1, n = 620; cohort 2, n = 174; cohort 3, n = 135). Short Inflammatory Bowel Disease Questionnaire scores were worse for patients with CPF (cohorts 2 and 3) than for those with CD without CPF (cohort 1): Mean score 3.8 and 3.7 vs 4.1, respectively, (P < 0.001). Similarly, mean Revised FI and FI Quality of Life scores were worse for patients with CPF than for those with CD without CPF. Quality of Life with Anal Fistula scores were similar in patients with CPF with or without CPF-related surgery (cohorts 2 and 3): Mean score 41 and 42, respectively. In the DCE, postoperative discomfort and fistula healing rate were the most important treatment attributes influencing treatment choice: Mean relative importance 35.7 and 24.7, respectively. CONCLUSION The burden of illness in CD is significantly higher for patients with CPF and patients rate lower postoperative discomfort and higher healing rates as the most desirable treatment attributes.
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Affiliation(s)
- Chitra Karki
- Global Evidence and Outcomes-Gastroenterology, Takeda Pharmaceuticals United States, Inc, Cambridge, MA 02139, United States
| | - Amod Athavale
- Trinity Partners, LLC, Waltham, MA 02451-7528, United States
| | - Vijay Abilash
- Trinity Partners, LLC, Waltham, MA 02451-7528, United States
| | - Gary Hantsbarger
- Observational Research, Takeda Pharmaceuticals United States, Inc, Cambridge, MA 02139, United States
| | - Parnia Geransar
- Medical Affairs, Takeda Pharmaceuticals International Co., Opfikon 8152, Zurich, Switzerland
| | - Kate Lee
- Research and Patient Programs, Crohn’s and Colitis Canada, 600-60 St. Clair Avenue East, Toronto M4T 1N5, Ontario, Canada
| | - Slobodan Milicevic
- Medical Affairs, Takeda Pharmaceuticals International Co., Opfikon 8152, Zurich, Switzerland
| | - Marko Perovic
- Treasurer, European Federation of Crohn’s & Ulcerative Colitis Associations, Brussels B 1000, Belgium
| | - Leanne Raven
- Crohn’s and Colitis Australia, Camberwell South, VIC 3124, Australia
| | | | - Abigail Silber
- Trinity Partners, LLC, Waltham, MA 02451-7528, United States
| | - Annabelle Yoon
- Japan Medical Office, Takeda Pharmaceutical Company Limited, Tokyo 103-8668, Japan
| | - Phil Tozer
- Department of Colorectal Surgery, St Mark’s Hospital and Academic Institute, London HA1 3UJ, United Kingdom
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Maternini M, Guttadauro A, Avella P, Buondonno A, Mascagni D, Milito G, Stuto A, Renzi A, Rennis M, Bottini C, Quarto G, Nudo R, Del Re L, Amato B, Gabrielli F. Collagen treatment of complex anorectal fistula: 3 years follow-up. Open Med (Wars) 2023; 18:20220553. [PMID: 37465352 PMCID: PMC10350888 DOI: 10.1515/med-2022-0553] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 05/16/2022] [Accepted: 08/12/2022] [Indexed: 07/20/2023] Open
Abstract
Fistula in ano is a common anorectal disease in adults. Currently, surgery remains the definitive therapeutic approach, but in some cases, it can lead to serious complications as faecal or gas incontinence. Therefore, sphincter sparing treatments should be considered for complex fistulas. One of the sphincteric preserving treatment is the filling with a dermal extract commonly called "collagen glue" as Salvecoll-E® gel. This is a multicentric, prospective, observational study on the use of Salvecoll-E® gel in treatment of complex anal fistulas. We treated 70 patients from May 2016 to May 2017. In the first phase, we debrided the fistula tract using a loose seton kept for 4-6 weeks. In the second phase, the seton was removed and the fistula tract was filled with Salvecoll-E® gel. In this article, we report results at 36 months of follow-up. Fifty patients (71.4%) had completely healed fistula within 36 months of follow-up. Twenty-eight patients (28.2%) had recurrences. Among these failures, 65% were within 6 months. All low transphincteric fistulas healed. Recurrences occurred only in median and high transphincteric fistulas. No patient had a worsening of continence status measured with Cleveland Clinic Florida Incontinence Severity score. Salvecoll-E® gel is a recent finding among sphincter-sparing treatments. In this study, we demonstrate that it is a safe option in the treatment of complex fistulas. Final results are satisfactory and in line with the best results published in literature among mini-invasive treatments.
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Affiliation(s)
- Matteo Maternini
- General Surgery Department, Istituti clinici Zucchi of Monza, University of Milano-Bicocca, 20126, Milan, Italy
| | - Angelo Guttadauro
- General Surgery Department, Istituti clinici Zucchi of Monza, University of Milano-Bicocca, 20126, Milan, Italy
| | - Pasquale Avella
- Department of Medicine and Health Sciences “V. Tiberio,” University of Molise, Via Francesco De Sanctis 1, 86100, Campobasso, Italy
| | - Antonio Buondonno
- Department of Medicine and Health Sciences “V. Tiberio,” University of Molise, Via Francesco De Sanctis 1, 86100, Campobasso, Italy
| | - Domenico Mascagni
- General Surgery Department, Policlinico Umberto I, University La Sapienza of Rome, 00161, Rome, Italy
| | - Giovanni Milito
- General Surgery Department, University Hospital of Roma “Tor Vergata,”00133, Rome, Italy
| | - Angelo Stuto
- General Surgery Department, IRCCS Policlinico San Donato of Milano, 20097, Milan, Italy
| | - Adolfo Renzi
- General Surgery Department, Clinica Villa Delle Querce, 80136, Naples, Italy
| | - Maria Rennis
- General Surgery Department, Ospedale San Gerardo di Monza, University of Milano-Bicocca, 20900, Milan, Italy
| | - Corrado Bottini
- General Surgery Department, Hospital of Gallarate, 21013, Varese, Italy
| | - Gennaro Quarto
- Department of Clinical Medicine and Surgery, University of Naples “Federico II,”Via S. Pansini, 5, 80131Naples, Italy
| | - Raffaele Nudo
- General Surgery Department, Casa di Cura Fabia Mater, 00171, Rome, Italy
| | - Luca Del Re
- General Surgery Department, Ospedale Multimedica San Giuseppe of Milano, 20123, MilanItaly
| | - Bruno Amato
- Department of Public Health, University of Naples “Federico II,”Via S. Pansini, 5, 80131Naples, Italy
| | - Francesco Gabrielli
- General Surgery Department, Istituti clinici Zucchi of Monza, University of Milano-Bicocca, 20126, Milan, Italy
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García-Olmo D, Gómez-Barrera M, de la Portilla F. Surgical management of complex perianal fistula revisited in a systematic review: a critical view of available scientific evidence. BMC Surg 2023; 23:29. [PMID: 36740680 PMCID: PMC9901165 DOI: 10.1186/s12893-023-01912-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Accepted: 01/10/2023] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Treating complex perianal fistulas in Crohn's disease patients remains a challenge. Classical surgical treatments for Crohn's disease fistulas have been extrapolated from cryptoglandular fistulas treatment, which have different etiology, and this might interfere with its effectiveness, in addition, they increase fecal incontinence risk. Recently, new surgical techniques with support from biological approaches, like stem cells, have been developed to preserve the function of the sphincter. We have performed a systematic literature review to compare the results of these different techniques in the treatment of Crohn's or Cryptoglandular fistula. METHODS PubMed, EMBASE, Database of Abstracts of Reviews of Effectiveness, Cochrane Central Register of Controlled Trials were searched systematically for relevant articles. We included randomized controlled trials and observational studies that referred to humans, were written in English, included adults 18+ years old, and were published during the 10-year period from 2/01/2010 to 2/29/2020. Evidence level was assigned as designated by the Scottish Intercollegiate Guidelines Network. RESULTS Of the 577 citations screened, a total of 79 were ultimately included in our review. In Crohn's disease patients, classical techniques such as primarily seton, Ligation of Intersphincteric Fistula Tracks, or lay open, healing rates were approximately 50-60%, while in cryptoglandular fistula were around, 70-80% for setons or flaps. In Crohn's disease patients, new surgical techniques using derivatives of adipose tissue reported healing rates exceeding 70%, stem cells-treated patients achieved higher combined remission versus controls (56.3% vs 38.6%, p = 0.010), mesenchymal cells reported a healing rate of 80% at week 12. In patients with cryptoglandular fistulas, a healing rate of 70% using derivatives of adipose tissue or platelets was achieved, and a healing rate of 80% was achieved using laser technology. Fecal incontinence was improved after the use of autologous platelet growth factors and Nitinol Clips. CONCLUSION New surgical techniques showed better healing rates in Crohn's disease patients than classical techniques, which have better results in cryptoglandular fistula than in Crohn's disease. Healing rates for complex cryptoglandular fistulas were similar between the classic and new techniques, being the new techniques less invasive; the incontinence rate improved with the current techniques.
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Affiliation(s)
- D. García-Olmo
- grid.419651.e0000 0000 9538 1950New Therapies Laboratory, Health Research Institute-Fundación Jiménez Díaz University Hospital (IIS-FJD/UAM), Department of Surgery, Fundación Jiménez Díaz University Hospital (UAM), Avda. Reyes Católicos, 2, 28040 Madrid, Spain
| | - M. Gómez-Barrera
- grid.512746.3Pharmacoeconomics & Outcomes Research Iberia (PORIB), Paseo Joaquín Rodrigo, 4 i, 28224 Pozuelo de Alarcón, Madrid Spain
| | - F. de la Portilla
- grid.9224.d0000 0001 2168 1229Coloproctology Unit, Clinical Management Unit of General and Gastrointestinal Surgery, Division Seville, Biomedical Research Institute (IBIS), University Hospital Virgen del Rocio/CSIC University of Seville, Seville, Spain
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de la Portilla F, Dios-Barbeito S, Maestre-Sánchez MV, Vázquez-Monchul JM, García-Cabrera AM, Ramallo I, Reyes-Díaz ML. Feasibility and safety of calcium alginate hydrogel sealant for the treatment of cryptoglandular fistula-in-ano: phase I/IIa clinical trial. Colorectal Dis 2021; 23:1499-1506. [PMID: 33655675 DOI: 10.1111/codi.15608] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Revised: 02/09/2021] [Accepted: 02/24/2021] [Indexed: 12/14/2022]
Abstract
AIM Complex perianal fistulas pose a challenge to the surgeon since the fistulous tract must be eliminated without impairing continence. Although without strong scientific evidence, some bibliography has demonstrated the efficacy of some sealants in the treatment of anal fistulas. We aimed to assess the feasibility and safety of calcium alginate hydrogel injections into the fistulous tract as treatment for trans-sphincteric cryptoglandular fistulas. METHODS A prospective, single-centre, case series of this novel technique was conducted in a level 3 Spanish hospital, including patients diagnosed with trans-sphincteric perianal fistulas and treated with a calcium alginate hydrogel sealant. A strict follow-up was performed by an independent surgeon at 1, 3, 6 and 12 months. The main outcome measures were feasibility, safety (number of adverse events) and efficacy of the treatment. RESULTS Twenty patients were treated. The treatment was performed for all patients. Seven adverse events related to the injection product or the surgical procedure were identified. After a 12-month follow-up, 12 patients were completely cured and eight were not cured, with a greater response in the first 6 months. These findings were confirmed by endoanal ultrasound, with a Cohen's kappa concordance rate of 0.89. No statistically significant differences were observed in pain measured using the visual analogue scale, faecal incontinence measured using the Wexner scoring system, and quality of life analysed by the SF-36 Health Survey. CONCLUSION The treatment was feasible, safe and with discrete satisfactory healing results. It also demonstrated an acceptable safety profile, without worsening of faecal incontinence, quality of life and pain following treatment.
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Affiliation(s)
- Fernando de la Portilla
- Colorectal Surgery Unit, Department of General and Digestive Surgery, 'Virgen del Rocío' University Hospital, Seville, Spain.,Department of Surgery, University of Seville, Avda Manuel Siurot s/n, Sevilla, España, 41013, Spain
| | - Sandra Dios-Barbeito
- Colorectal Surgery Unit, Department of General and Digestive Surgery, 'Virgen del Rocío' University Hospital, Seville, Spain
| | - María Victoria Maestre-Sánchez
- Colorectal Surgery Unit, Department of General and Digestive Surgery, 'Virgen del Rocío' University Hospital, Seville, Spain
| | - Jorge Manuel Vázquez-Monchul
- Colorectal Surgery Unit, Department of General and Digestive Surgery, 'Virgen del Rocío' University Hospital, Seville, Spain.,Department of Surgery, University of Seville, Avda Manuel Siurot s/n, Sevilla, España, 41013, Spain
| | - Ana María García-Cabrera
- Colorectal Surgery Unit, Department of General and Digestive Surgery, 'Virgen del Rocío' University Hospital, Seville, Spain
| | - Irene Ramallo
- Colorectal Surgery Unit, Department of General and Digestive Surgery, 'Virgen del Rocío' University Hospital, Seville, Spain
| | - María Luisa Reyes-Díaz
- Colorectal Surgery Unit, Department of General and Digestive Surgery, 'Virgen del Rocío' University Hospital, Seville, Spain
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Abstract
Anal fistulas are a common anorectal disease and are frequently associated with a perianal abscess. The etiology is based on a cryptoglandular infection in the intersphincteric space. Surgery remains the only definitive therapy. The primary goal of definitive fistula surgery is healing; however, success of fistula surgery is influenced by a variety of factors including the surgeon's experience, type of fistula, involvement of sphincter muscles, type of surgical procedure and patient-related factors. For the surgical treatment of a complex anal fistula, a variety of operative procedures have been described including fistulectomy with sphincterotomy, different flap procedures (e.g. mucosal flap and advancement flap) and finally so-called sphincter-preserving techniques, such as LIFT (ligation of intersphincteric fistula tract), VAAFT (video-assisted anal fistula treatment), the use of plugs of collagen or fibrin glue sealants as well as laser procedures or the clip. In the search for suitable quality indicators in anal fistula surgery there is a conflict between healing and preservation of continence. If potential quality indicators are identified the principles of anal fistula surgery must be adhered to and the appropriate selection of patients and procedures is of crucial importance to achieve high healing rates without compromising continence or inducing surgical revision due to abscesses or recurrence. Based on the available literature and guidelines, in the assessment of quality indicators considerable differences exist with respect to patient selection, etiology of anal fistulas and length of follow-up. Heterogeneity of treatment protocols lead to difficulties in a definitive assessment of which surgical treatment is the best option for complex anal fistulas.
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Affiliation(s)
- O Schwandner
- Abteilung für Proktologie, Krankenhaus Barmherzige Brüder Regensburg, Prüfeninger Str. 86, 93049, Regensburg, Deutschland.
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Schiano di Visconte M, Piccoli G, Brusciano L, Docimo L, Veronese M. A mini-invasive procedure for the treatment of supralevator abscess of cryptoglandular origin by extrasphincteric extension: preliminary results at 1-year follow-up. Int J Colorectal Dis 2019; 34:763-767. [PMID: 30645671 DOI: 10.1007/s00384-019-03243-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/10/2019] [Indexed: 02/04/2023]
Abstract
AIM The aim of this retrospective study is to evaluate the preliminary results of a mini-invasive procedure for the treatment of supralevator abscesses (SLA) of cryptoglandular origin by extrasphincteric extension. METHOD In this clinical study, an innovative two-stage procedure was tested for the surgical treatment of SLA. As first step and as a preparation for surgery, the interventional radiologist positioned a CT-guided percutaneous perianal guidewire inside the abscess cavity under local anesthesia. As second step, the surgeon performed an abscess incision and drainage around the guidewire, with a complete debridement of all the necrotic tissue. If a complex anal fistula was identified, a loose seton was placed in situ. RESULTS Nine patients, comprising 5 men (55%) and 4 women (45%), underwent the above-mentioned two-stage procedure to treat SLA of cryptoglandular origin. Median age was 32 years (range, 25-42 years). A silicone draining seton was placed during the surgical procedure in 5 patients (55%), since a coexisting fistula was also revealed by surgery. A repeat surgery, along with a new drainage procedure, was required in one patient out of nine (11.1%) for a complete wound healing. The complete wound healing was achieved after a median of 30 days (range, 26-38). At the 1-year follow-up, the healing rate was 89%. CONCLUSIONS The treatment of SLA of cryptoglandular origin by using this innovative two-stage procedure may be a safe and convenient surgical option to effectively decrease the risk of recurrence and anal sphincteric injuries.
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Affiliation(s)
- Michele Schiano di Visconte
- Colorectal and Pelvic Floor Diseases Center, Department of General Surgery, "S. Maria dei Battuti" Hospital, Via Brigata Bisagno 4, 31015, Conegliano, TV, Italy.
| | - Gianluca Piccoli
- Department of Radiology, "S. Maria dei Battuti" Hospital, Via Brigata Bisagno 4, 31015, Conegliano, TV, Italy
| | - Luigi Brusciano
- Division of General, Mininvasive and Obesity Surgery, University of Study of Campania "Vanvitelli", Naples, Italy
| | - Ludovico Docimo
- Division of General, Mininvasive and Obesity Surgery, University of Study of Campania "Vanvitelli", Naples, Italy
| | - Marta Veronese
- Department of Radiology, "S. Maria dei Battuti" Hospital, Via Brigata Bisagno 4, 31015, Conegliano, TV, Italy
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