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Hamel C, Avard B, Belanger C, Chatterjee A, Hartery A, Lim H, Kanagaratnam S, Fung C. Canadian Association of Radiologists Gastrointestinal Imaging Referral Guideline. Can Assoc Radiol J 2024; 75:462-472. [PMID: 38183236 DOI: 10.1177/08465371231217230] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2024] Open
Abstract
The Canadian Association of Radiologists (CAR) Gastrointestinal Expert Panel consists of radiologists, a gastroenterologist, a general surgeon, a family physician, a patient advisor, and an epidemiologist/guideline methodologist. After developing a list of 20 clinical/diagnostic scenarios, a systematic rapid scoping review was undertaken to identify systematically produced referral guidelines that provide recommendations for one or more of these clinical/diagnostic scenarios. Recommendations from 58 guidelines and contextualization criteria in the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) for guidelines framework were used to develop 85 recommendation statements specific to the adult population across the 20 scenarios. This guideline presents the methods of development and the referral recommendations for dysphagia/dyspepsia, acute nonlocalized abdominal pain, chronic abdominal pain, inflammatory bowel disease, acute gastrointestinal bleeding, chronic gastrointestinal bleeding/anemia, abnormal liver biopsy, pancreatitis, anorectal diseases, diarrhea, fecal incontinence, and foreign body ingestion.
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Affiliation(s)
- Candyce Hamel
- Canadian Association of Radiologists, Ottawa, ON, Canada
| | - Barb Avard
- North York General Hospital, Toronto, ON, Canada
| | | | - Avi Chatterjee
- The Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada
| | - Angus Hartery
- Eastern Health, Memorial University, St. Clare's, St. John's, NL, Canada
| | - Howard Lim
- University of British Columbia, BC Cancer, Vancouver Centre, Vancouver, BC, Canada
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Cao D, Wang X, Qian K, Yang N, Xu K, Xu G, Zhu M, Zhang Y, Cui Z. Long-term outcomes of fistula-tract laser closure for complex perianal fistulizing Crohn's disease. Tech Coloproctol 2024; 28:89. [PMID: 39085710 DOI: 10.1007/s10151-024-02949-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2023] [Accepted: 05/25/2024] [Indexed: 08/02/2024]
Abstract
BACKGROUND Fistula-tract laser closure (FiLaC™) has shown promising outcomes in perianal fistulizing Crohn's disease (pfCD). However, most studies assessed a mixed cohort encompassing pfCD and cryptoglandular fistulas during a short follow-up period. This study aimed to evaluate the long-term treatment outcomes of FiLaC™ in patients with complex pfCD. METHODS Data from patients with complex pfCD who underwent FiLaC™ during deep remission of Crohn's disease between January 2019 and December 2020 were retrospectively analyzed. Patient demographics, surgery history, and medication strategy were registered before surgery. Follow-ups were scheduled at 1, 2, and 3 months after FiLaC™, and at 2-month intervals thereafter. The primary endpoint was clinic healing, while clinic remission/unhealed/recurrence were classified as unhealed. Additionally, adverse events and Wexner fecal incontinence score were documented. RESULTS Forty-nine patients (40 men and 9 women) with a median age of 26.0 (19.0-35.5) years were included with a median follow-up of 50.0 (39.5-54.0) months. Of these, 31 (63.3%) patients achieved fistula healing, 3 (6.1%) experienced improvement, 3 (6.1%) remained unhealed, and 12 (24.5%) experienced recurrence. Montreal A category was lower in the healed group (P < 0.001). No major complications, such as bleeding or fecal or urinary incontinence, were observed, and pain was transient. The Wexner incontinence score decreased significantly at the last available follow-up, indicating an intact postoperative continence function (P = 0.014). PCDAI scores were significantly higher in the unhealed group (P = 0.041). CONCLUSION FiLaC™ is an efficient and safe sphincter-saving procedure for patients with complex pfCD.
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Affiliation(s)
- D Cao
- Department of Gastrointestinal Surgery, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, 200127, China
- Department of General Surgery, Baoshan Branch, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, 200444, China
| | - X Wang
- Department of General Surgery, Baoshan Branch, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, 200444, China
| | - K Qian
- Laboratory Medicine, Baoshan Branch, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, No.1058, Huan Zhen Bei Rd, Baoshan District, Shanghai, 200444, China
| | - N Yang
- Department of Gastrointestinal Surgery, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, 200127, China
| | - K Xu
- Institute of Translational Medicine, Shanghai University, Shanghai, 200444, China
- Organoid Research Center, Shanghai University, Shanghai, 200444, China
- Wenzhou Institute of Shanghai University, Wenzhou, 325000, China
| | - G Xu
- Laboratory Medicine, Baoshan Branch, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, No.1058, Huan Zhen Bei Rd, Baoshan District, Shanghai, 200444, China
| | - M Zhu
- Division of Gastroenterology and Hepatology, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, 200127, China
| | - Y Zhang
- Laboratory Medicine, Baoshan Branch, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, No.1058, Huan Zhen Bei Rd, Baoshan District, Shanghai, 200444, China.
| | - Z Cui
- Department of Gastrointestinal Surgery, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, 200127, China.
- Department of General Surgery, Baoshan Branch, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, 200444, China.
- Institute of Translational Medicine, Shanghai University, Shanghai, 200444, China.
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Garg P, Ladukar L, Yagnik VD, Bhattacharya K, Kaur G. Rectovaginal Fistulas Not Involving the Rectovaginal Septum Should Be Treated Like Anal Fistulas: A New Concept and Proposal for a Reclassification of Rectovaginal Fistulas. Clin Exp Gastroenterol 2024; 17:97-108. [PMID: 38646156 PMCID: PMC11032160 DOI: 10.2147/ceg.s456855] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2024] [Accepted: 04/12/2024] [Indexed: 04/23/2024] Open
Abstract
Background Many rectovaginal fistulas(RVF), especially low RVF, do not involve/penetrate the RV-septum, but due to lack of proper nomenclature, such fistulas are also managed like RVF (undertaking repair of RV-septum) and inadvertently lead to the formation of a high RVF (involving RV-septum) in many cases. Therefore, REctovaginal Fistulas, Not Involving the Rectovaginal Septum, should be Treated like Anal fistulas(RENISTA) to prevent any risk of injury to the RV septum. This concept(RENISTA) was tested in this study. Methods RVFs not involving RV-septum were managed like anal fistulas, and the RV-septum was not cut/incised. MRI, objective incontinence scoring, and anal manometry were done preoperatively and postoperatively. High RVF (involving RV-septum) were excluded. Results Twenty-seven patients with low RVF (not involving RV-septum) were operated like anal fistula[age:35.2±9.2 years, median follow-up-15 months (3-36 months)]. 19/27 were low fistula[<1/3 external anal sphincter(EAS) involved] and fistulotomy was performed, whereas 8/27 were high fistula (>1/3 EAS involved) and underwent a sphincter-sparing procedure. Three patients were excluded. The fistula healed well in 22/24 (91.7%) patients and did not heal in 2/24 (8.3%). The healing was confirmed on MRI, and there was no significant change in mean incontinence scores and anal pressures on tonometry. RV-septum injury did not occur in any patient. Conclusions RVF not involving RV-septum were managed like anal fistulas with a high cure rate and no significant change in continence. RV-septum injury or formation of RVF with septum involvement did not occur in any patient. The RENISTA concept was validated in the present study. A new classification was developed to prevent any inadvertent injury to the RV-septum.
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Affiliation(s)
- Pankaj Garg
- Department of Colorectal Surgery, Garg Fistula Research Institute (GFRI), Panchkula, Haryana, India
| | - Laxmikant Ladukar
- Department of Surgery, Ladukar Surgical Hospital, Bramhapuri, Maharashtra, India
| | - Vipul D Yagnik
- Department of Surgery, Banas Medical College and Research Institute, Palanpur, Gujarat, India
| | - Kaushik Bhattacharya
- Department of Surgery, MGM Medical College and LSK Hospital, Kishanganj, Bihar, India
| | - Gurleen Kaur
- Department of Pharmacology, Adesh Medical College and Hospital, Shahbad, Haryana, India
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Aggarwal P, Malik R, Sarawagi R, Kumar A, Sharma J. Diffusion-Weighted MRI in Perianal Abscess: Role and Comparison With Contrast-Enhanced MRI. Cureus 2024; 16:e59035. [PMID: 38800169 PMCID: PMC11128151 DOI: 10.7759/cureus.59035] [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] [Accepted: 04/25/2024] [Indexed: 05/29/2024] Open
Abstract
BACKGROUND Perianal abscess is a clinical infective and/or inflammatory collection in the perianal region, one entity of a large group of anal and perianal disorders. Perianal abscesses are often seen as a complication of grade 2 and grade 4 perianal fistulas from St. James's University Hospital classification. Several imaging modalities have been tried in the past for adequate assessment of perianal abscess with contrast-enhanced magnetic resonance imaging (CE-MRI) providing the most accurate results. Diffusion-weighted imaging (DWI) is an emerging sequence that can provide comparable results to CE-MRI in diagnosing and characterizing perianal abscess. The main objective of this study is to assess the role of DWI in adequate identification and assessment of perianal abscess and compare the final results with contrast-enhanced images. METHODS Twenty patients with complicated perianal fistula with clinically suspected perianal abscess were evaluated with DWI and CE-MRI. This study was a comparative cross-sectional study conducted in the Department of Radiodiagnosis and Imaging, All India Institute of Medical Sciences, Bhopal, India. Chi-square test was done to find the association between categorical variables. Kappa test was used to find the agreement between two different tests. Receiver operating characteristics (ROC) analysis was done to estimate the area under the curve in predicting the outcome. Sensitivity, specificity, positive predictive value, negative predictive value and accuracy were used to measure the validity of the tests. RESULTS DWI is a very sensitive MRI sequence and is equivalent to CE-MRI to detect the location and analyzing the loco-regional extent of abscess in complicated perianal fistula cases. DWI is also very sensitive and superior to T2 short tau inversion recovery (STIR) in differentiating perianal abscess from perianal inflammation without abscess. CONCLUSION DWI can be used as an alternative to post-contrast fat-suppressed MRI in precisely defining the location and extent of anal and perianal abscesses and disease activity in complicated fistula cases.
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Affiliation(s)
- Pooja Aggarwal
- Radiology, All India Institute of Medical Sciences, Bhopal, IND
| | - Rajesh Malik
- Radiology, All India Institute of Medical Sciences, Bhopal, IND
| | - Radha Sarawagi
- Radiology, All India Institute of Medical Sciences, Bhopal, IND
| | - Aman Kumar
- Radiology, All India Institute of Medical Sciences, Bhopal, IND
| | - Jitendra Sharma
- Radiology, All India Institute of Medical Sciences, Bhopal, IND
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Ye S, Huang Z, Zheng L, Shi Y, Zhi C, Liu N, Cheng Y. Restricted cubic spline model analysis of the association between anal fistula and anorectal abscess incidence and body mass index. Front Surg 2024; 10:1329557. [PMID: 38259976 PMCID: PMC10800495 DOI: 10.3389/fsurg.2023.1329557] [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: 10/29/2023] [Accepted: 12/18/2023] [Indexed: 01/24/2024] Open
Abstract
Objective The epidemiological profile of anal fistula and anorectal abscess has not been well studied. Based on the results of a retrospective cross-sectional survey, we aimed to investigate the potential influential factors associated with anal fistula and anorectal abscess. Methods We conducted a retrospective analysis of outpatients who visited the proctology department at China-Japan Friendship Hospital between January 2017 and May 2022. A comprehensive questionnaire was designed to collect potential influential factors, and according to formal anorectal examination and the corresponding diagnostic criteria, all the participants were divided into patients with anal fistula or perianal abscess and healthy control group. Multiple logistic regression was used to identify factors in significant association with anal fistula and perianal abscess. Additionally, we combined restricted cubic spline regression to examine the dose-response relationship between factors and the risk of developing anal fistula or anorectal abscess. Results The present study included 1,223 participants, including 1,018 males and 206 females, with 275 anal fistulas, 184 anorectal abscesses, and 765 healthy controls. We found no statistically significant differences between patients and controls in basic information and preoperative assessment of life factors, except for body mass index. It was indicated that people with overweight or obesity were more prone to anal fistula (OR overweight = 1.35, 95% CI: 1.00-1.82, P = 0.047; OR obesity = 3.44, 95% CI: 2.26-5.26, P < 0.001) or anorectal abscess (OR overweight = 1.41, 95% CI: 1.00-1.99, P = 0.05; OR obesity: 2.24, 95% CI: 1.37-3.67, P = 0.001) than normal-weight individuals. The dose-response research indicated the J-shaped trend between the ascending BMI levels and the higher risk of suffering from anal fistula and anorectal abscess. Conclusions Our findings indicate that overweight and obesity are risk factors for anal fistula and anorectal abscess, which plays a role in the prevention of anorectal diseases. This provides some theoretical basis for clinicians to provide health education to their patients.
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Affiliation(s)
- Sangyu Ye
- Graduate School, Beijing University of Chinese Medicine, Beijing, China
- Proctology Department, China-Japan Friendship Hospital, Beijing, China
| | - Zichen Huang
- Graduate School, Beijing University of Chinese Medicine, Beijing, China
- Proctology Department, China-Japan Friendship Hospital, Beijing, China
| | - Lihua Zheng
- Proctology Department, China-Japan Friendship Hospital, Beijing, China
| | - Yuying Shi
- Proctology Department, China-Japan Friendship Hospital, Beijing, China
| | - Congcong Zhi
- Proctology Department, China-Japan Friendship Hospital, Beijing, China
| | - Ningyuan Liu
- Proctology Department, China-Japan Friendship Hospital, Beijing, China
| | - Yicheng Cheng
- Proctology Department, China-Japan Friendship Hospital, Beijing, China
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Verkade C, van Tilborg GFAJB, Stijns J, Wasowicz DK, Zimmerman DDE. Distalization of perianal fistulas after loose silicone seton drainage is a myth. Tech Coloproctol 2023; 28:16. [PMID: 38097914 PMCID: PMC10721694 DOI: 10.1007/s10151-023-02882-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Accepted: 10/25/2023] [Indexed: 12/18/2023]
Abstract
BACKGROUND It is often stated that loose seton drainage results in distal migration of a fistula tract in perianal fistula. The aim of the present study was to assess this distalization of trans- and suprasphincteric perianal fistulas after a silicone seton has been inserted. METHODS Consecutive patients who underwent loose seton placement for the management of a transsphincteric or suprasphincteric fistula between January 2016 and December 2021 with a pre- and postoperative magnetic resonance imaging (MRI) were included in the present retrospective study. The height of the external anal sphincter (EAS) and the level of penetration of perianal fistula through the EAS or puborectal muscle (PRM) were determined on MRI. Primary outcome was migration of the fistula tract through the EAS and PRM. RESULTS Thirty-eight patients with perianal fistulas were included. Median height of the EAS was 28 (IQR 25-34) mm before seton placement and 27 (IQR 24-33) mm afterward. Median level of perforation was 32 (IQR 17-40) mm before seton placement and 28 (IQR 17-40) mm afterward (p = 0.37). One fistula (3%) was downgraded from mid to low transsphincteric and was laid open after 14.9 months of loose seton drainage. CONCLUSIONS No statistically significant distalization of complex fistula tracts after loose silicone seton drainage was found. Some complex fistulas may downgrade to a less complex fistula after long-term seton drainage. However, loose silicone seton drainage should not be offered to patients as a treatment option to downgrade a complex fistula to a simple one or even have the hope to heal it.
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Affiliation(s)
- Carolien Verkade
- Colorectal Research Group, Department of Surgery, Elisabeth-TweeSteden Hospital, Tilburg, The Netherlands
| | - G Fiek A J B van Tilborg
- Colorectal Research Group, Department of Surgery, Elisabeth-TweeSteden Hospital, Tilburg, The Netherlands
- Department of Radiology, Elisabeth-TweeSteden Hospital, Tilburg, The Netherlands
| | - Jasper Stijns
- Colorectal Research Group, Department of Surgery, Elisabeth-TweeSteden Hospital, Tilburg, The Netherlands
- Department of Surgery, University Hospital Brussels, Brussels, Belgium
| | - Daria K Wasowicz
- Colorectal Research Group, Department of Surgery, Elisabeth-TweeSteden Hospital, Tilburg, The Netherlands
| | - David D E Zimmerman
- Colorectal Research Group, Department of Surgery, Elisabeth-TweeSteden Hospital, Tilburg, The Netherlands.
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Skovgaards DM, Perregaard H, Dibbern CB, Nordholm-Carstensen A. Fistula development after anal abscess drainage-a multicentre retrospective cohort study. Int J Colorectal Dis 2023; 39:4. [PMID: 38093036 PMCID: PMC10719138 DOI: 10.1007/s00384-023-04576-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/29/2023] [Indexed: 12/17/2023]
Abstract
PURPOSE Anal abscesses are common and, despite correct treatment with surgical drainage, carry the risk of developing fistulas. Studies identifying risk factors for the development of anal fistulas are sparse. This study aimed to identify the risk factors for anal fistulas after anal abscess surgery. METHODS This was a multicentre, retrospective cohort study of patients undergoing acute surgery for anal abscesses in the Capital Region of Denmark between 2018 and 2019. The patients were identified using ICD-10 codes for anal abscesses. Predefined clinicopathological factors and postoperative courses were extracted from patient records. RESULTS A total of 475 patients were included. At a median follow-up time of 1108 days (IQR 946-1320 days) following surgery, 164 (33.7%) patients were diagnosed with an anal fistula. Risk factors for developing fistulas were low intersphincteric (OR 2.77, 95CI 1.50-5.06) and ischioanal (OR 2.48, 95CI 1.36-4.47) abscesses, Crohn's disease (OR 5.96, 95CI 2.33-17.2), a history of recurrent anal abscesses (OR 4.14, 95CI 2.47-7.01) or repeat surgery (OR 5.96, 95CI 2.33-17.2), E. coli-positive pus cultures (OR 4.06, 1.56-11.4) or preoperative C-reactive protein (CRP) of more than 100 mg/L (OR 3.21, 95CI 1.57-6.71). CONCLUSION Several significant clinical risk factors were associated with fistula development following anal abscess surgery. These findings are clinically relevant and could influence the selection of patients for specialised follow-up, facilitate expedited diagnosis, and potentially prevent unnecessarily long treatment courses.
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Affiliation(s)
- Daniel Mark Skovgaards
- Digestive Disease Center, Bispebjerg Hospital, University of Copenhagen, Copenhagen, Denmark.
| | - Helene Perregaard
- Surgical Department, Nordsjællands Hospital, University of Copenhagen, Hillerød, Denmark
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Gnanadev R, Malkoc A, Nguyen A, Weaver T, Lebedevskiy O, Hussain F, Kim E. The Impact of Computed Tomography Scans on the Management and Wait Times in Perianal Abscess Diagnoses. Cureus 2023; 15:e49417. [PMID: 38149138 PMCID: PMC10750221 DOI: 10.7759/cureus.49417] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/26/2023] [Indexed: 12/28/2023] Open
Abstract
Background Diagnosis and management of perianal abscesses (PAA) are based on history and clinical examination. Imaging is not indicated except in complicated cases, as determined by the surgical team. The monetary, ionizing radiation, and resource utilization costs of a computed tomography (CT) scan in the emergency room must be considered when used for diagnostic purposes of PAAs. Methods A retrospective analysis of 129 patients diagnosed with a diagnosis of PAA between 2015-2020 was performed. The primary endpoints included length of stay, CT performed, time from patient presentation to CT, and CT scan completion prior to surgical consultation. Data is reported as n (%) or median (IQR). Results Of the 129 patients diagnosed with PAA, 81 underwent CT, and 48 did not. General surgery was consulted in 88% of cases. There were no statistically significant differences in age (p=0.562), sex (p=0.531), or ethnicity (p=0.356). The median hospitalization time was two days when CT was performed (p=0.001). The median time elapsed from presentation to the emergency department and CT scan performed was 16 hours (p=0.001). CT scans were ordered before the surgical consultation in 65% of cases (p=0.001) and 17% after a surgical consultation was placed (p=0.009). Conclusion Performing CT scans prior to surgical evaluation for the diagnosis of PAA is not a responsible practice. The cost, resources, and radiation exposure must be considered. This study demonstrated that more CT scans are ordered prior to surgical consultation for PAA, resulting in a prolonged wait time in the emergency department.
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Affiliation(s)
- Raja Gnanadev
- General Surgery, Arrowhead Regional Medical Center, Colton, USA
| | - Aldin Malkoc
- General Surgery, Arrowhead Regional Medical Center, Colton, USA
| | | | - Tara Weaver
- General Surgery, Arrowhead Regional Medical Center, Colton, USA
| | | | - Farabi Hussain
- General Surgery, Arrowhead Regional Medical Center, Colton, USA
| | - Edwin Kim
- General Surgery, Arrowhead Regional Medical Center, Colton, USA
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Hannes S, Kochergin M, Al-Haidary J, Götze T, Habbe N. OTSC Proctology clip as appropriate treatment for complicated anorectal fistula. Int J Colorectal Dis 2023; 38:222. [PMID: 37646885 DOI: 10.1007/s00384-023-04516-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/19/2023] [Indexed: 09/01/2023]
Abstract
PURPOSE Evaluation of the effectiveness and tolerability of the application of an OTSC (Ovesco Endoscopy AG Tuebingen, Germany) Proctology clip as an innovative strategy of anorectal fistulae closure when established treatment strategies had already failed or were not feasible. METHODS Retrospective single-center study including consecutive patients treated between March 2014 and March 2016 with the OTSC Proctology system for anorectal fistula closure, including one rectovaginal and one rectourethral fistula. The primary outcome was the healing rate with a minimum follow up of 6 months. Healing was defined as closure of the internal fistula ostium and absence of secretion or local inflammation during follow up. RESULTS A total of 66 fistula closures by the OTSC Proctology clip were investigated, including cryptoglandular fistulas (45/66 patients, 68%), fistulas associated with CED (19/66 patients, 29%), and other non-cryptoglandular fistulas (2/66 patients, 4%). 47% (31/66 patients) had a failed previous therapy. In that selected collective, a successful fistula closure was achieved in 29/66 cases (44%) after a median follow up time of 40 months (6-61 months). Suprasphincteric and high transsphincteric fistulas showed healing in 63% and 42% in CD associated fistulas. CONCLUSION Fistula closure by the OTSC Proctology clip is an innovative, sphincter protecting treatment strategy in anorectal fistulas that can achieve long-term cure in complex anorecta.
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Affiliation(s)
- Sabine Hannes
- Department of Surgery and Coloproctology, DKD Helios Klinik Wiesbaden, Aukammallee 33, 65191, Wiesbaden, Germany
| | - Maxim Kochergin
- Department of Surgery and Coloproctology, DKD Helios Klinik Wiesbaden, Aukammallee 33, 65191, Wiesbaden, Germany
| | - Jasmin Al-Haidary
- Department of Surgery and Coloproctology, DKD Helios Klinik Wiesbaden, Aukammallee 33, 65191, Wiesbaden, Germany
| | - Thorsten Götze
- Institute for Clinical Oncological Research, North West Hospital, Frankfurt, Germany
| | - Nils Habbe
- Department of Surgery and Coloproctology, DKD Helios Klinik Wiesbaden, Aukammallee 33, 65191, Wiesbaden, Germany.
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Reichert M, Eckerth L, Fritzenwanker M, Imirzalioglu C, Amati AL, Askevold I, Padberg W, Hecker A, Liese J, Bender F. New Perianal Sepsis Risk Score Predicts Outcome of Elderly Patients with Perianal Abscesses. J Clin Med 2023; 12:5219. [PMID: 37629259 PMCID: PMC10455731 DOI: 10.3390/jcm12165219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2023] [Revised: 07/29/2023] [Accepted: 08/07/2023] [Indexed: 08/27/2023] Open
Abstract
Antibiotic therapy following surgical perianal abscess drainage is debated, but may be necessary for high-risk patients. Frailty has been shown to increase the risk of unfavorable outcomes in elderly surgical patients. This study aims to identify high-risk patients by retrospectively analyzing a single-center cohort and using a pretherapeutic score to predict the need for postoperative antibiotics and extended nursing care following perianal abscess drainage surgery. The perianal sepsis risk score was developed through univariable and multivariable analysis. Internal validation was assessed using the area under receiver-operating characteristic curve. Elderly, especially frail patients exhibited more severe perianal disease, higher frequency of antibiotic therapy, longer hospitalization, poorer clinical outcomes. Multivariable analysis revealed that scores in the 5-item modified frailty index, severity of local infection, and preoperative laboratory markers of infection independently predicted the need for prolonged hospitalization and anti-infective therapy after abscess drainage surgery. These factors were combined into the perianal sepsis risk score, which demonstrated better predictive accuracy for prolonged hospitalization and antibiotic therapy compared with chronological age or frailty status alone. Geriatric assessments are becoming increasingly important in clinical practice. The perianal sepsis risk score identifies high-risk patients before surgery, enabling early initiation of antibiotic therapy and allocation of additional nursing resources.
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Affiliation(s)
- Martin Reichert
- Department of General, Visceral, Thoracic, Transplant and Pediatric Surgery, University Hospital of Giessen, Rudolf-Buchheim Strasse 7, 35390 Giessen, Germany; (L.E.); (A.-L.A.); (I.A.); (W.P.); (A.H.); (J.L.); (F.B.)
- German Center for Infection Research (DZIF), Site Giessen-Marburg-Langen, Justus-Liebig-University of Giessen, Schubertstrasse 81, 35392 Giessen, Germany; (M.F.); (C.I.)
| | - Lukas Eckerth
- Department of General, Visceral, Thoracic, Transplant and Pediatric Surgery, University Hospital of Giessen, Rudolf-Buchheim Strasse 7, 35390 Giessen, Germany; (L.E.); (A.-L.A.); (I.A.); (W.P.); (A.H.); (J.L.); (F.B.)
| | - Moritz Fritzenwanker
- German Center for Infection Research (DZIF), Site Giessen-Marburg-Langen, Justus-Liebig-University of Giessen, Schubertstrasse 81, 35392 Giessen, Germany; (M.F.); (C.I.)
- Institute of Medical Microbiology, Justus-Liebig-University of Giessen, Schubertstrasse 81, 35392 Giessen, Germany
| | - Can Imirzalioglu
- German Center for Infection Research (DZIF), Site Giessen-Marburg-Langen, Justus-Liebig-University of Giessen, Schubertstrasse 81, 35392 Giessen, Germany; (M.F.); (C.I.)
- Institute of Medical Microbiology, Justus-Liebig-University of Giessen, Schubertstrasse 81, 35392 Giessen, Germany
| | - Anca-Laura Amati
- Department of General, Visceral, Thoracic, Transplant and Pediatric Surgery, University Hospital of Giessen, Rudolf-Buchheim Strasse 7, 35390 Giessen, Germany; (L.E.); (A.-L.A.); (I.A.); (W.P.); (A.H.); (J.L.); (F.B.)
- German Center for Infection Research (DZIF), Site Giessen-Marburg-Langen, Justus-Liebig-University of Giessen, Schubertstrasse 81, 35392 Giessen, Germany; (M.F.); (C.I.)
| | - Ingolf Askevold
- Department of General, Visceral, Thoracic, Transplant and Pediatric Surgery, University Hospital of Giessen, Rudolf-Buchheim Strasse 7, 35390 Giessen, Germany; (L.E.); (A.-L.A.); (I.A.); (W.P.); (A.H.); (J.L.); (F.B.)
| | - Winfried Padberg
- Department of General, Visceral, Thoracic, Transplant and Pediatric Surgery, University Hospital of Giessen, Rudolf-Buchheim Strasse 7, 35390 Giessen, Germany; (L.E.); (A.-L.A.); (I.A.); (W.P.); (A.H.); (J.L.); (F.B.)
| | - Andreas Hecker
- Department of General, Visceral, Thoracic, Transplant and Pediatric Surgery, University Hospital of Giessen, Rudolf-Buchheim Strasse 7, 35390 Giessen, Germany; (L.E.); (A.-L.A.); (I.A.); (W.P.); (A.H.); (J.L.); (F.B.)
- German Center for Infection Research (DZIF), Site Giessen-Marburg-Langen, Justus-Liebig-University of Giessen, Schubertstrasse 81, 35392 Giessen, Germany; (M.F.); (C.I.)
| | - Juliane Liese
- Department of General, Visceral, Thoracic, Transplant and Pediatric Surgery, University Hospital of Giessen, Rudolf-Buchheim Strasse 7, 35390 Giessen, Germany; (L.E.); (A.-L.A.); (I.A.); (W.P.); (A.H.); (J.L.); (F.B.)
| | - Fabienne Bender
- Department of General, Visceral, Thoracic, Transplant and Pediatric Surgery, University Hospital of Giessen, Rudolf-Buchheim Strasse 7, 35390 Giessen, Germany; (L.E.); (A.-L.A.); (I.A.); (W.P.); (A.H.); (J.L.); (F.B.)
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11
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Charalampopoulos A, Papakonstantinou D, Bagias G, Nastos K, Perdikaris M, Papagrigoriadis S. Surgery of Simple and Complex Anal Fistulae in Adults: A Review of the Literature for Optimal Surgical Outcomes. Cureus 2023; 15:e35888. [PMID: 36911578 PMCID: PMC9993441 DOI: 10.7759/cureus.35888] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/08/2023] [Indexed: 03/11/2023] Open
Abstract
Anal fistulas are common anorectal conditions, and surgery is the primary treatment option. In the last 20 years of literature, there exist a large number of surgical procedures, especially for the treatment of complex anal fistulas, as they present more recurrences and continence problems than simple anal fistulas. To date, there are no guidelines for choosing the best technique. We conducted a recent literature review, mainly the last 20 years, based on the PubMed and Google Scholar medical databases, with the goal of identifying the surgical procedures with the highest success rates, lowest recurrence rates, and best safety profiles. Clinical trials, retrospective studies, review articles, comparative studies, recent systematic reviews, and meta-analyses for various surgical techniques, as well as the latest guidelines of the American Society of Colon and Rectal Surgeons, the Association of Coloproctology of Great Britain and Ireland, and the German S3 guidelines on simple and complex fistulas were reviewed. According to the literature, there is no recommendation for the optimal surgical technique. The etiology, complexity, and many other factors affect the outcome. In simple intersphincteric anal fistulas, fistulotomy is the procedure of choice. In simple low transsphincteric fistulas, the patient's selection is crucial in order to perform a safe fistulotomy or another sphincter-saving technique. The healing rate in simple anal fistulas is higher than 95% with low recurrence and without significant postoperative complications. In complex anal fistulas, only sphincter-saving techniques should be used; the optimal outcomes are obtained by the ligation of the intersphincteric fistulous tract (LIFT) and rectal advancement flaps. Those techniques assure high healing rates of 60-90%. The novel technique of the transanal opening of the intersphincteric space (TROPIS) is under evaluation. The novel sphincter-saving techniques of fistula laser closure (FiLac) and video-assisted anal fistula treatment (VAAFT) are safe, with reported healing rates ranging from 65% to 90%. Surgeons should be familiar with all sphincter-saving techniques in order to face the variability of the fistulas-in-ano. Currently, there is no universally superior technique that can treat all fistulas.
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Affiliation(s)
- Anestis Charalampopoulos
- Third Department of Surgery, "Attikon" University General Hospital/National and Kapodistrian University of Athens, School of Medicine, Athens, GRC
| | - Dimitrios Papakonstantinou
- Third Department of Surgery, "Attikon" University General Hospital/National and Kapodistrian University of Athens, School of Medicine, Athens, GRC
| | - George Bagias
- Third Department of Surgery, "Attikon" University General Hospital/National and Kapodistrian University of Athens, School of Medicine, Athens, GRC
| | - Konstantinos Nastos
- Third Department of Surgery, "Attikon" University General Hospital/National and Kapodistrian University of Athens, School of Medicine, Athens, GRC
| | - Markos Perdikaris
- Third Department of Surgery, "Attikon" University General Hospital/National and Kapodistrian University of Athens, School of Medicine, Athens, GRC
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12
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Sautereau M, Bouchard D, Brochard C, Pigot F, Siproudhis L, Fayette JM, Train C, Laurain A, Favreau C, Abramowitz L. Prospective and multicentre study of radiofrequency treatment in anal fistula. Colorectal Dis 2023; 25:289-297. [PMID: 36128714 DOI: 10.1111/codi.16344] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Revised: 09/04/2022] [Accepted: 09/06/2022] [Indexed: 02/08/2023]
Abstract
BACKGROUND The most effective treatment for anal fistula is fistulotomy, but it involves a risk of anal incontinence. To reduce this morbidity, sphincter-sparing treatments have been developed, but their success in real life is often less than 50%. The aim is to determine the clinical healing rate 6 months after radiofrequency treatment. METHODS We planned to evaluate 50 patients from three French proctology centres. Treatment efficacy was evaluated at 6 and 12 months by means of clinical and magnetic resonance imaging examination. We evaluated morbidity and healing prognostic factors. RESULTS Fifty patients with a mean age of 51 years (22-82) were included. Eleven patients had a low trans-sphincteric fistula (LTS), 21 patients had a high trans-sphincteric fistula (HTS), eight had a complex fistula and nine had Crohn's disease fistula. After 6 months, 17 patients (34.7%) had a clinically healed fistula, including five (45.5%) with LTS fistula, seven (33.3%) with HTS fistula, one (12.5%) with complex fistula, four (44.4%) with Crohn's disease, with no significant difference between these fistula types (p: 0.142). At 12 months, the healing rate was identical. MRI in 15 out of 17 clinically healed patients showed a deep remission of 73.3% at 12 months. Energy power was associated with the success of the treatment. There was an 8.2% incidence of post-surgical complications with 4.1% being abscesses (one required surgical management). Postoperative pain was minor. No new cases or deterioration of continence have been shown. CONCLUSION Radiofrequency is effective in 34.7% of the cases as an anal fistula treatment in this first prospective study, with low morbidity and no effect on continence. Clinical healing was deep (MRI) in three-quarters at 1 year. The increase in energy power during the procedure seems to be a key point to be analysed to optimise results.
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Affiliation(s)
- Marie Sautereau
- Department of Gastroenterology and Proctology, APHP, CHU Bichat, Paris, France
| | | | - Charlène Brochard
- Digestive Physiology Unit, Rennes Pontchaillou University Hospital, University of Rennes 1, Rennes, France
| | - François Pigot
- Department of Proctology, Bagatelle Hospital, Talence, France
| | - Laurent Siproudhis
- Digestive Physiology Unit, Rennes Pontchaillou University Hospital, University of Rennes 1, Rennes, France
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13
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Schoene MI, Schatz S, Brunner M, Fuerst A. Gracilis muscle transposition in complex anorectal fistulas of diverse types and etiologies: long-term results of 60 cases. Int J Colorectal Dis 2023; 38:16. [PMID: 36652018 PMCID: PMC9849283 DOI: 10.1007/s00384-022-04293-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/22/2022] [Indexed: 01/19/2023]
Abstract
PURPOSE Complex fistulas often require several attempts at repair and continue to be a challenging task for the surgeon, but above all, a major burden for the affected patient. This study is aimed at evaluating the potential of gracilis muscle transposition (GMT) as a therapeutic option for complex fistulas of diverse etiologies. METHODS A retrospective study was conducted over a period of 16 years with a total of 60 patients (mean age 50 years). All were treated for complex fistula with GMT at St. Josef's Hospital in Regensburg, Germany. Follow-up data were collected and analyzed using a prospective database and telephone interview. Success was defined as the absence of fistula. RESULTS A total of 60 patients (44 women, 16 men; mean age 50 years, range 24-82 years) were reviewed from January 2005 to June 2021. Primary fistula closure after GMT was achieved in 20 patients (33%) and 19 required further interventions for final healing. Overall healing rate was 65%. Fistula type was heterogeneous, with a dominant subgroup of 35 rectovaginal fistulas. Etiologies of the fistulas were irradiation, abscesses, obstetric injury, and iatrogenic/unknown, and 98% of patients had had previous unsuccessful repair attempts (mean 3.6, range 1-15). In 60% of patients with a stoma (all patients had a stoma, 60/60), stoma closure could be performed after successful fistula closure. Mean follow-up after surgery was 35.9 months (range 1-187 months). No severe intraoperative complications occurred. Postoperative complications were observed in 25%: wound healing disorders (n = 6), gracilis necroses (n = 3), incisional hernia (n = 2), scar tissue pain (n = 2), suture granuloma (n = 1), and osteomyelitis (n = 1). In 3 patients, a second gracilis transposition was performed due to fistula recurrence (n = 2) or fecal incontinence (n = 1). CONCLUSION Based on the authors' experience, GMT is an effective therapeutic option for the treatment of complex fistulas when other therapeutic attempts have failed and should therefore be considered earlier in the treatment process. It should be seen as the main but not the only step, as additional procedures may be required for complete closure in some cases.
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Affiliation(s)
- Milla Isabelle Schoene
- Department of Surgery, Caritas Clinic St. Josef, Landshuter Str. 65, 93053, Regensburg, Germany
- University of Regensburg, Regensburg, Germany
| | - Sabine Schatz
- Department of Surgery, Caritas Clinic St. Josef, Landshuter Str. 65, 93053, Regensburg, Germany
| | - Marion Brunner
- Department of Surgery, Caritas Clinic St. Josef, Landshuter Str. 65, 93053, Regensburg, Germany
| | - Alois Fuerst
- Department of Surgery, Caritas Clinic St. Josef, Landshuter Str. 65, 93053, Regensburg, Germany.
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14
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Tang X, He T, Li X, Liu Y, Wu Y, You G, Li J, Yun Y, Wu L, Li L, Kang J. Clinical features and independent predictors of postoperative refractory trauma to anal fistula combined with T2DM: A propensity score-matched analysis-retrospective cohort study. Front Surg 2023; 10:1119113. [PMID: 36911620 PMCID: PMC9998506 DOI: 10.3389/fsurg.2023.1119113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Accepted: 01/31/2023] [Indexed: 02/26/2023] Open
Abstract
Background Refractory wound is a common postoperative complication in anal fistula surgery, when combined with type 2 diabetes mellitus (T2DM) it presents a slower recovery time and more complex wound physiology. The study aims to investigate factors associated with wound healing in patients with T2DM. Materials and methods 365 T2DM patients who underwent anal fistula surgery at our institution were recruited from June 2017 to May 2022. Through propensity score-matched (PSM) analysis, multivariate logistic regression analysis was applied to determine independent risk factors affecting wound healing. Results 122 pairs of patients with no significant differences were successfully established in matched variables. Multivariate logistic regression analysis revealed that uric acid (OR: 1.008, 95% CI: 1.002-1.015, p = 0.012), maximal fasting blood glucose (FBG) (OR: 1.489, 95% CI: 1.028-2.157, p = 0.035) and random intravenous blood glucose (OR: 1.130, 95% CI: 1.008-1.267, p = 0.037) elevation and the incision at 5 o'clock under the lithotomy position (OR: 3.510, 95% CI: 1.214-10.146, p = 0.020) were independent risk factors for impeding wound healing. However, neutrophil percentage fluctuating within the normal range can be considered as an independent protective factor (OR: 0.906, 95% CI: 0.856-0.958, p = 0.001). After executing the receiver operating characteristic (ROC) curve analysis, it was found that the maximum FBG expressed the largest under curve area (AUC), glycosylated hemoglobin (HbA1c) showed the strongest sensitivity at the critical value and maximum postprandial blood glucose (PBG) had the highest specificity at the critical value. To promote high-quality healing of anal wounds in diabetic patients, clinicians should not only pay attention to surgical procedures but also take above-mentioned indicators into consideration.
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Affiliation(s)
- Xiao Tang
- Department of Proctology, Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, China.,School of Clinical Medicine, Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Taohong He
- Department of Proctology, Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Xinyi Li
- Department of Proctology, Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, China.,School of Clinical Medicine, Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Ya Liu
- Department of Endocrinology, Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Yuqi Wu
- Department of Proctology, Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, China.,School of Clinical Medicine, Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Gehang You
- Department of Proctology, Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, China.,School of Clinical Medicine, Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Jie Li
- Department of Proctology, Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, China.,School of Clinical Medicine, Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Yu Yun
- Department of Proctology, Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, China.,School of Clinical Medicine, Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Lei Wu
- Department of Proctology, Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, China.,School of Clinical Medicine, Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Li Li
- Department of Proctology, Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, China.,School of Clinical Medicine, Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Jian Kang
- Department of Proctology, Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, China
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15
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Doerner J, Seiberth R, Jafarov S, Zirngibl H, Boenicke L. Risk factors for therapy failure after surgery for perianal abscess in children. Front Surg 2022; 9:1065466. [PMID: 36589625 PMCID: PMC9797814 DOI: 10.3389/fsurg.2022.1065466] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2022] [Accepted: 11/30/2022] [Indexed: 12/23/2022] Open
Abstract
Purpose The role of surgery in managing perianal abscesses in the pediatric population is debatable, and data on recurrence risk is rare. This study aimed to evaluate the efficiency of surgery for a perianal abscess in children and identify parameters that predict recurrence. Methods We performed a retrospective review of all children younger than age 14 requiring surgery for a perianal abscess from 2000 to 2018. Results Out of 103 enrolled patients, 27 (26%) had recurrent perianal disease. Recurrences appeared after a median of 5 months (range: 1-18 months), in 12 cases as perianal abscess and 15 cases as fistula in ano. Anal fistula probing was performed in 33% of all patients, of which 16 (15%) underwent fistulotomy. In univariate analysis, older age (p = 0.034), fistula probing (p = 0.006) and fistulotomy (p = 0.009) was associated with treatment success. History of perianal abscess, multilocal occurrence, and the presence of enteric flora in wound swabs was associated with treatment failure (p = 0.002, OR = 0.032). In multivariate analysis, anal fistula probing was independently associated with treatment success (p = 0.019, OR = 22.08), while the history of perianal abscess was associated with treatment failure (p = 0.002, OR = 0.032). Conclusion Our study identified probing for fistula as a predictor of therapy success, while the history of perianal abscess was identified as a predictor of treatment failure. Therefore, in all children with perianal abscess, fistula probing and if present, fistulotomy should be performed.
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Affiliation(s)
- Johannes Doerner
- Department of General and Visceral Surgery, Helios University Hospital Wuppertal, Witten/Herdecke University, Wuppertal, Germany,Correspondence: Johannes Doerner
| | - Rose Seiberth
- Department of General and Visceral Surgery, Helios University Hospital Wuppertal, Witten/Herdecke University, Wuppertal, Germany
| | - Sakhavat Jafarov
- Department of General and Visceral Surgery, Helios University Hospital Wuppertal, Witten/Herdecke University, Wuppertal, Germany
| | - Hubert Zirngibl
- Department of General and Visceral Surgery, Helios University Hospital Wuppertal, Witten/Herdecke University, Wuppertal, Germany
| | - Lars Boenicke
- Department of General and Visceral Surgery, Helios University Hospital Wuppertal, Witten/Herdecke University, Wuppertal, Germany
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16
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van Oostendorp JY, Dekker L, van Dieren S, Bemelman WA, Han-Geurts IJM. Antibiotic Treatment foLlowing surgical drAinage of perianal abScess (ATLAS): protocol for a multicentre, double-blind, placebo-controlled, randomised trial. BMJ Open 2022; 12:e067970. [PMID: 36351727 PMCID: PMC9644350 DOI: 10.1136/bmjopen-2022-067970] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
INTRODUCTION Perianal fistula is a burdening disease with an annual incidence of 6-12/100 000 in Western countries. More than 90% of crypto-glandular fistulas originate from perianal abscess. Despite adequate drainage, up to 83% recur or result in an anal fistula, the majority developing within 12 months. There is some evidence that gut-derived bacteria play a role in the development of perianal fistula. Up till now, it is not common practice to routinely administer prophylactic antibiotics to prevent anal fistula development. There is a need for a study to establish whether adding antibiotic treatment to surgical drainage of perianal abscess results in a reduction in perianal fistulas. METHODS AND ANALYSIS This multicentre, double-blind, randomised, placebo-controlled trial investigates whether addition of antibiotics (ciprofloxacin and metronidazole) to surgical drainage of a perianal abscess is beneficial compared with surgical drainage alone. The primary outcome is the development of a perianal fistula within 1 year. Secondary outcomes include quality of life, treatment costs, need for repeated drainage, patient-reported outcomes and other clinical outcomes. Participants are recruited in one academic and seven peripheral Dutch clinics. To demonstrate a reduction of perianal fistula from 30% to 15% when treated with adjuvant antibiotics with a two-sided alpha of 0.05, a power of 80% and taking a 10% loss to follow-up percentage into account, the total sample size will be 298 participants. Data will be analysed according to the intention-to-treat principle. ETHICS AND DISSEMINATION The study protocol has been approved by the Medical Ethics Review Committee of the Amsterdam University Medical Centers (nr. 2021_010). Written consent is obtained from each participant prior to randomisation into the study. The results of this trial will be submitted for publication in international peer-reviewed journals, presented at conferences and spread to coloproctological associations. TRIAL REGISTRATION NUMBERS 2020-004449-35; NCT05385887.
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Affiliation(s)
- Justin Y van Oostendorp
- Department of Surgery, Amsterdam UMC Location AMC, Amsterdam, The Netherlands
- Department of Surgery, Proctos Kliniek, Bilthoven, The Netherlands
| | - Lisette Dekker
- Department of Surgery, Amsterdam UMC Location AMC, Amsterdam, The Netherlands
- Department of Surgery, Proctos Kliniek, Bilthoven, The Netherlands
| | - Susan van Dieren
- Department of Surgery, Amsterdam UMC Location AMC, Amsterdam, The Netherlands
| | - Willem A Bemelman
- Department of Surgery, Amsterdam UMC Location AMC, Amsterdam, The Netherlands
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17
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Kelm M, Kusan S, Surat G, Anger F, Reibetanz J, Germer CT, Schlegel N, Flemming S. Disease- and Medication-Specific Differences of the Microbial Spectrum in Perianal Fistulizing Crohn's Disease-Relevant Aspects for Antibiotic Therapy. Biomedicines 2022; 10:2682. [PMID: 36359202 PMCID: PMC9687552 DOI: 10.3390/biomedicines10112682] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2022] [Revised: 10/14/2022] [Accepted: 10/20/2022] [Indexed: 08/27/2023] Open
Abstract
Perianal fistulizing Crohn's Disease (CD) with abscess formation represents an aggressive phenotype in Inflammatory Bowel Disease (IBD) with increased morbidity. Treatment is multidisciplinary and includes antibiotics, but knowledge about the microbial spectrum is rare often resulting in inadequate antimicrobial therapy. In this single center retrospective study, all patients who were operated due to perianal abscess formation were retrospectively analyzed and the microbial spectrum evaluated. Patients were divided into a CD and non-CD group with further subgroup analysis. 138 patients were finally included in the analysis with 62 patients suffering from CD. Relevant differences were detected for the microbial spectrum with anaerobic bacteria being significantly more often isolated from non-CD patients. In a subgroup-analysis of CD patients only, medical therapy had a relevant effect on the microbial spectrum since Streptococcus groups and Enterobacterales were significantly more often isolated in patients treated with steroids compared to those being treated by antibodies. In conclusion, the microbial spectrum of patients suffering from CD varies significantly from non-CD patients and immunosuppressive medication has a relevant effect on isolated pathogens. Based on that, adaption of antibiotic treatment might be discussed in the future.
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Affiliation(s)
- Matthias Kelm
- Department of General, Visceral, Transplant, Vascular and Pediatric Surgery, University Hospital of Wuerzburg, 97080 Wuerzburg, Germany
| | - Simon Kusan
- Department of General, Visceral, Transplant, Vascular and Pediatric Surgery, University Hospital of Wuerzburg, 97080 Wuerzburg, Germany
| | - Güzin Surat
- Unit for Infection Control and Antimicrobial Stewardship, University Hospital of Wuerzburg, 97080 Wuerzburg, Germany
| | - Friedrich Anger
- Department of General, Visceral, Transplant, Vascular and Pediatric Surgery, University Hospital of Wuerzburg, 97080 Wuerzburg, Germany
| | - Joachim Reibetanz
- Department of General, Visceral, Transplant, Vascular and Pediatric Surgery, University Hospital of Wuerzburg, 97080 Wuerzburg, Germany
| | - Christoph-Thomas Germer
- Department of General, Visceral, Transplant, Vascular and Pediatric Surgery, University Hospital of Wuerzburg, 97080 Wuerzburg, Germany
| | - Nicolas Schlegel
- Department of General, Visceral, Transplant, Vascular and Pediatric Surgery, University Hospital of Wuerzburg, 97080 Wuerzburg, Germany
| | - Sven Flemming
- Department of General, Visceral, Transplant, Vascular and Pediatric Surgery, University Hospital of Wuerzburg, 97080 Wuerzburg, Germany
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18
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Newton K, Dumville J, Briggs M, Law J, Martin J, Pearce L, Kirwan C, Pinkney T, Needham A, Jackson R, Winn S, McCulloch H, Hill J. Postoperative Packing of Perianal Abscess Cavities (PPAC2): randomized clinical trial. Br J Surg 2022; 109:951-957. [PMID: 35929816 PMCID: PMC10364677 DOI: 10.1093/bjs/znac225] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Revised: 05/16/2022] [Accepted: 05/31/2022] [Indexed: 08/02/2023]
Abstract
BACKGROUND Perianal abscess is common. Traditionally, postoperative perianal abscess cavities are managed with internal wound packing, a practice not supported by evidence. The aim of this randomized clinical trial (RCT) was to assess if non-packing is less painful and if it is associated with adverse outcomes. METHODS The Postoperative Packing of Perianal Abscess Cavities (PPAC2) trial was a multicentre, RCT (two-group parallel design) of adult participants admitted to an NHS hospital for incision and drainage of a primary perianal abscess. Participants were randomized 1:1 (via an online system) to receive continued postoperative wound packing or non-packing. Blinded data were collected via symptom diaries, telephone, and clinics over 6 months. The objective was to determine whether non-packing of perianal abscess cavities is less painful than packing, without an increase in perianal fistula or abscess recurrence. The primary outcome was pain (mean maximum pain score on a 100-point visual analogue scale). RESULTS Between February 2018 and March 2020, 433 participants (mean age 42 years) were randomized across 50 sites. Two hundred and thirteen participants allocated to packing reported higher pain scores than 220 allocated to non-packing (38.2 versus 28.2, mean difference 9.9; P < 0.0001). The occurrence of fistula-in-ano was low in both groups: 32/213 (15 per cent) in the packing group and 24/220 (11 per cent) in the non-packing group (OR 0.69, 95 per cent c.i. 0.39 to 1.22; P = 0.20). The proportion of patients with abscess recurrence was also low: 13/223 (6 per cent) in the non-packing group and 7/213 (3 per cent) in the packing group (OR 1.85, 95 per cent c.i. 0.72 to 4.73; P = 0.20). CONCLUSION Avoiding abscess cavity packing is less painful without a negative morbidity risk. REGISTRATION NUMBER ISRCTN93273484 (https://www.isrctn.com/ISRCTN93273484). REGISTRATION NUMBER NCT03315169 (http://clinicaltrials.gov).
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Affiliation(s)
- Katy Newton
- Correspondence to: Katy Newton, Department of Surgery, Manchester Royal Infirmary, Oxford Road, Manchester, M14 9WL, UK (e-mail: )
| | - Jo Dumville
- School of Midwifery, Nursing and Social Work, University of Manchester, UK
| | - Michelle Briggs
- School of Midwifery, Nursing and Social Work, University of Manchester, UK
| | | | | | - Lyndsay Pearce
- Department of General Surgery, Salford Royal NHS Foundation Trust, UK
| | - Cliona Kirwan
- Department of Academic Surgery, Wythenshawe Hospital, Manchester University NHS Foundation Trust, UK
| | - Thomas Pinkney
- Academic Department of Surgery, University of Birmingham, UK
| | | | | | | | | | - James Hill
- Department of General Surgery, Manchester Royal Infirmary, Manchester University NHS Foundation Trust, UK
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19
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Bender F, Eckerth L, Fritzenwanker M, Liese J, Askevold I, Imirzalioglu C, Padberg W, Hecker A, Reichert M. Drug resistant bacteria in perianal abscesses are frequent and relevant. Sci Rep 2022; 12:14866. [PMID: 36050427 PMCID: PMC9436980 DOI: 10.1038/s41598-022-19123-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Accepted: 08/24/2022] [Indexed: 11/29/2022] Open
Abstract
Perianal abscesses are frequent diseases in general surgery. Principles of standard patient care are surgical drainage with exploration and concomitant treatment of fistula. Antiinfective therapy is frequently applied in cases of severe local disease and perianal sepsis. However, the role of microbiologic testing of purulence from perianal abscesses is disputed and the knowledge concerning bacteriology and bacterial resistances is very limited. A retrospective cohort study was performed of consecutive patients (≥ 12 years of age) from a tertiary care hospital, who underwent surgical treatment for perianal abscess from 01/2008 to 12/2019. Subdividing the cohort into three groups regarding microbiological testing results: no microbiological testing of purulence (No_Swab, n = 456), no detection of drug resistant bacteria [DR(−), n = 141] or detection of bacteria with acquired drug resistances from purulence [DR(+), n = 220]. Group comparisons were performed using Kruskall–Wallis test and, if applicable, followed by Dunn´s multiple comparisons test for continuous variables or Fishers exact or Pearson’s X2 test for categorical data. Fistula persistence was estimated by Kaplan Meier and compared between the groups using Log rank test. Corralation analysis between perioperative outcome parameters and bacteriology was performed using Spearman´s rho rank correlation. Higher pretherapeutic C-reactive protein (p < 0.0001) and white blood cell count (p < 0.0001), higher rates of supralevatoric or pararectal abscesses (p = 0.0062) and of complicated fistula-in-ano requiring drainage procedure during index surgery (p < 0.0001) reflect more severe diseases in DR(+) patients. The necessity of antibiotic therapy (p < 0.0001), change of antibiotic regimen upon microbiologic testing results (p = 0.0001) and the rate of re-debridements during short-term follow-up (p = 0.0001) were the highest, the duration until definitive fistula repair was the longest in DR(+) patients (p = 0.0061). Escherichia coli, Bacteroides, Streptococcus and Staphylococcus species with acquired drug resistances were detected frequently. High rates of resistances against everyday antibiotics, including perioperative antibiotic prophylaxis were alarming. In conclusion, the knowledge about individual bacteriology is relevant in cases of complex and severe local disease, including locally advanced infection with extended soft tissue affection and perianal sepsis, signs of systemic inflammatory response as well as the need of re-do surgery for local debridements during short-term and fistula repair during long-term follow-up. Higher rates of acquired antibiotic resistances are to be expected in patients with more severe diseases.
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Affiliation(s)
- Fabienne Bender
- Department of General, Visceral, Thoracic, Transplant and Pediatric Surgery, University Hospital of Giessen, Rudolf-Buchheim Strasse 7, 35390, Giessen, Germany
| | - Lukas Eckerth
- Department of General, Visceral, Thoracic, Transplant and Pediatric Surgery, University Hospital of Giessen, Rudolf-Buchheim Strasse 7, 35390, Giessen, Germany
| | - Moritz Fritzenwanker
- Institute of Medical Microbiology, Justus-Liebig-University of Giessen, Schubertstrasse 81, 35392, Giessen, Germany.,German Center for Infection Research (DZIF), Site Giessen-Marburg-Langen, Justus-Liebig-University of Giessen, Schubertstrasse 81, 35392, Giessen, Germany
| | - Juliane Liese
- Department of General, Visceral, Thoracic, Transplant and Pediatric Surgery, University Hospital of Giessen, Rudolf-Buchheim Strasse 7, 35390, Giessen, Germany
| | - Ingolf Askevold
- Department of General, Visceral, Thoracic, Transplant and Pediatric Surgery, University Hospital of Giessen, Rudolf-Buchheim Strasse 7, 35390, Giessen, Germany
| | - Can Imirzalioglu
- Institute of Medical Microbiology, Justus-Liebig-University of Giessen, Schubertstrasse 81, 35392, Giessen, Germany.,German Center for Infection Research (DZIF), Site Giessen-Marburg-Langen, Justus-Liebig-University of Giessen, Schubertstrasse 81, 35392, Giessen, Germany
| | - Winfried Padberg
- Department of General, Visceral, Thoracic, Transplant and Pediatric Surgery, University Hospital of Giessen, Rudolf-Buchheim Strasse 7, 35390, Giessen, Germany
| | - Andreas Hecker
- Department of General, Visceral, Thoracic, Transplant and Pediatric Surgery, University Hospital of Giessen, Rudolf-Buchheim Strasse 7, 35390, Giessen, Germany
| | - Martin Reichert
- Department of General, Visceral, Thoracic, Transplant and Pediatric Surgery, University Hospital of Giessen, Rudolf-Buchheim Strasse 7, 35390, Giessen, Germany.
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Efficacy and safety of FiLaC™ for perianal fistulizing Crohn's disease: a systematic review and meta-analysis. Tech Coloproctol 2022; 26:775-781. [PMID: 35962294 DOI: 10.1007/s10151-022-02682-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Accepted: 08/05/2022] [Indexed: 10/15/2022]
Abstract
BACKGROUND Most patients with perianal fistulizing Crohn's disease (pfCD) present with complex types of perianal fistulas and need repetitive repair operations, resulting in a high risk of sphincter injury. Fistula-tract Laser Closure (FiLaC™) is a novel sphincter-saving technique that obliterates the fistula tract with a photothermal effect. The aim of the present systematic review and meta-analysis was to evaluate the efficacy and safety of FiLaC in pfCD. METHODS This study was conducted according to Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines. Electronic databases, including PubMed, Embase, Cochrane Library and Wanfang Data were searched for published articles from January 2000 to June 2021. The clinicaltrials.gov website was searched for completed or ongoing trials on pfCD and FiLaC™. The references of each article were also searched for eligible data. The main outcome was the primary healing rate of the FiLaC™ procedure. Additionally, fecal incontinence was analyzed as the secondary outcome to evaluate the safety of FiLaC™. RESULTS Six studies met the eligibility criteria and were included in the final analysis. All studies were published within the past 6 years and came from European countries. There were 50 pfCD patients recruited, and 31 patients' fistulas were healed after FiLaC™. The pooled primary healing rate was 68% (95% CI 53.0-84.0%, I2 = 27%, p = 0.23). There was no major fecal incontinence after surgery. CONCLUSIONS These data suggest that FiLaC™ may be an effective and safe procedure for pfCD patients. However, the evidence is poor and there is a need for more high-quality prospective controlled studies with long-term follow-up before this minimally invasive technique is recommended for surgical treatment of pfCD.
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21
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Hwang SH. Trends in Treatment for Hemorrhoids, Fistula, and Anal Fissure: Go Along the Current Trends. J Anus Rectum Colon 2022; 6:150-158. [PMID: 35979269 PMCID: PMC9328791 DOI: 10.23922/jarc.2022-012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2022] [Accepted: 04/27/2022] [Indexed: 12/31/2022] Open
Abstract
Recent trends in benign anal disease treatment are minimizing surgery to preserve normal anorectal anatomical unit and its functions. However, some surgeons still prefer and are confident with the use of conventional solid surgical methods. In this report, we will investigate the recent trends in the treatment for hemorrhoids, fistula, and anal fissure. The practice guidelines of advanced countries, including UK, Italy, France, USA, Japan, and ESCP, are referred to in this review. Opinions suggested in international meetings were also added. In the management of hemorrhoids, surgical treatments and office procedures were recommended according to a patient's status and preference. For the management of complex anal fistula, novel sphincter-preserving surgical techniques are more widely accepted than a sphincter-dividing procedure of immediate repair following fistulectomy. The treatment of anal fissures is well covered in the guidelines of the ASCRS.
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Affiliation(s)
- Sung Hwan Hwang
- Busan Hangun Hospital & Busan Hangun Hospital Bumcheon Campus
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22
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Chen ZW, Zheng Y, Zhao R, Wang ZJ. Treatment of anal fistula using a decellularized porcine small intestinal submucosa plug: A non-inferiority trial. Medicine (Baltimore) 2022; 101:e29110. [PMID: 35866804 PMCID: PMC9302366 DOI: 10.1097/md.0000000000029110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2021] [Revised: 03/01/2022] [Accepted: 03/01/2022] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Using small intestinal submucosa (SIS) has increasingly become the standard method for the treatment of anal fistula. The porcine SIS manufactured by Biosis Healing is a novel biological material that has several advantages for the safe and effective repair of tissues. Our study aimed to verify the efficacy and safety of the decellularized porcine SIS (VIDASIS) anal fistula plug. METHODS We conducted a non-inferiority multicenter, randomized, controlled clinical trial involving patients with chronic anal fistula. Patients from 3 centers across China were randomized 1:1 to Biosis SIS vs commercial SIS. The primary endpoint was the healing rate and secondary endpoints included recurrence within 6 months, rate of copracrasia, healing time, pain using a visual analog scale, and patient and doctor satisfaction. RESULTS A total of 186 patients were randomized. Of these, 82 patients in the Biosis SIS and 81 in the control (commercial) SIS completed the trial (per-protocol set). The healing rate at the 6-month follow-up (full analysis set) was 92.0% for the Biosis SIS and 89.8% for the control SIS (P = .620). The rate difference of 2.2% (full analysis set; 95% confidence interval: -6.4% and 10.7%, respectively) was within the pre-specified non-inferiority margin of -10%. There were no differences between the 2 groups with regard to the secondary endpoints. No serious adverse event or death occurred. CONCLUSION Our study shows that the VIDASIS anal fistula plug manufactured by the company Biosis Healing is safe and effective and is not inferior to existing commercial SIS materials.
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Affiliation(s)
- Zhao Wen Chen
- Department of General Surgery, Peking University Third Hospital, Beijing, China
| | - Yi Zheng
- Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Rong Zhao
- Tianjin People's Hospital, Tianjin, China
| | - Zhen Jun Wang
- Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
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The Effects of Phellodendron Decoction on Wound Healing of Anal Fistula after Anal Fistulotomy. EVIDENCE-BASED COMPLEMENTARY AND ALTERNATIVE MEDICINE 2022; 2022:7363006. [PMID: 36016687 PMCID: PMC9396417 DOI: 10.1155/2022/7363006] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Revised: 06/26/2022] [Accepted: 07/04/2022] [Indexed: 11/18/2022]
Abstract
Objective To analyze the therapeutic effect of Compound Phellodendron decoction on wounds after anal fistulotomy. Methods 100 patients with anal fistula who underwent anal fistulotomy from April 2019 to April 2021 were included in the study group and control group according to the random number table method. 50 patients in the study group were treated with Compound Phellodendron decoction by fumigation and sitting bath, while warm water replaced Compound Phellodendron decoction in the control group. Perianal pain, wound edema, and exudation were scored on postoperative days 3 and 7, and wound healing time was recorded. Interleukin-2(IL-2), IL-5, IL-6, and IL-12 were measured via a double-antibody sandwich enzyme-linked immunosorbent assay. Hematoxylin-eosin (HE) staining and immunofluorescence were used to quantitatively analyze the capillary number and CD4+ and CD8+ lymphocytes in granulation tissue on postoperative days 7. Results The scores of pain, edema, and exudation in 2 groups on postoperative day 7 were lower than those on the 3rd postoperative day. Compared with the control group, the pain, edema, and exudation scores in the study group were decreased, and the wound healing time was shortened; the expressions of IL-2 and IL-12 in the study group were significantly increased, while the expressions of IL-5 and IL-6 were decreased; the number of capillaries and CD4+ lymphocytes in the study group was increased, while the number of CD8+ lymphocytes was decreased. Conclusion Compound Phellodendron decoction had efficacy in promoting wound healing, reducing complications, and changing lymphocyte aggregation and alleviating local inflammatory response.
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Garg P, R Menon G, Kaur B. Comparison of different methods to manage supralevator rectal opening in anal fistulas: A retrospective cohort study. Cir Esp 2022; 100:295-301. [PMID: 35598957 DOI: 10.1016/j.cireng.2022.05.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Accepted: 03/17/2021] [Indexed: 06/15/2023]
Abstract
INTRODUCTION Supralevator fistula-in-ano are difficult to manage. If these fistulas have an additional supralevator internal-opening in rectum apart from the primary internal-opening at the dentate line, then the management becomes even more difficult. There is no literature/guidelines available on the management of supralevator rectal opening (SRO). METHODS All consecutive supralevator fistula-in-ano patients having a SRO were retrospectively analyzed. The operative management of SRO in these fistulas was reviewed. All the fistulas were managed by the same procedure, transanal opening of intersphincteric space (TROPIS). The latter was a modification of LIFT (ligation of intersphincteric tract) procedure in which the intersphincteric tract was opened-up in the rectum rather than ligated (as is done in LIFT). The SRO was managed in three ways, group-1:SRO was laid-open into the rectum in continuity with the primary opening at dentate line, group-2:the mucosa around SRO was cauterized, group-3:nothing could be done to SRO. RESULTS Out of 836 patients operated between 2015 and 2020, 138 patients (16.5%) had supralevator extension. Amongst these, 23/138 (16.6%) patients had a SRO. 2 patients were excluded (short follow-up) and 21 patients were included in the analysis. 12/13(92%) patients in group-1, 4/5 (80%) patients in group-2 and 2/3(67%) patients in group-3 got healed (p=0.47, Chi-square test). The overall healing rate was 18/21(86%). CONCLUSIONS The supralevator rectal opening (SRO) heals well irrespective of the method utilized. Thus, proper management of the primary opening at the dentate line holds the key to fistula healing and SRO is perhaps not much responsible for persistence of the fistula. However, more studies are needed to corroborate these findings.
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Affiliation(s)
- Pankaj Garg
- Indus International Hospital, Mohali, Punjab, India; Garg Fistula Research Institute, Panchkula, Haryana, India.
| | - Geetha R Menon
- Chief Statistician, Indian Council of Medical Research, New Delhi, India
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25
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USING ULTRASOUND DIAGNOSTICS AND MAGNETIC RESONANCE TOMOGRAPHY IN SURGICAL TREATMENT OF COMPLICATED FORMS OF ACUTE PARAPROCTITIS. WORLD OF MEDICINE AND BIOLOGY 2022. [DOI: 10.26724/2079-8334-2022-2-80-183-188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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26
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Recurrence and incidence of fistula after urgent drainage of an anal abscess. Long-term results. Cir Esp 2021; 100:25-32. [PMID: 34876366 DOI: 10.1016/j.cireng.2021.11.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Accepted: 11/13/2020] [Indexed: 11/20/2022]
Abstract
INTRODUCTION Anal abscess is the most frequent urgent proctological problem. The recurrence rate and reported incidence of fistula after drainage and debridement of an anal abscess is widely variable. The objective of this study is to analyse the long-term recurrence rate and the incidence of fistula after drainage and urgent debridement of an anal abscess. METHODS Retrospective observational study of a prospective cohort with anal abscess of cryptoglandular origin. All patients (n = 303) were evaluated two months and one year after the intervention. At the 5th year, all the medical records were reviewed and a telephone call or appointment was made for an assessment if necessary. Specific antecedents of anal pathology, abscess characteristics, time and type of recurrence, presence of symptoms in the first revision and presence of clinical and/or ultrasound fistula were recorded. RESULTS Mean follow-up 119.7 months. Recurrence rate 48.2% (82.2% in the first year). Two hundred twenty-two ultrasounds performed. Incidence of ultrasound fistula: 70% symptomatic vs. 2.4% asymptomatic (p < 0.001). Global incidence of fistula 40.3%. The history of anal pathology and the presence of symptoms in the postoperative review significantly increase the possibility of recurrence (p < 0.001). The fistula is statistically more frequent if the abscess recurs (p < 0.001). CONCLUSION After drainage and debridement of an anal abscess, half of the patients relapse and 40% develop fistula especially in the first year, so longer follow-ups are not necessary. Endoanal ultrasound for the evaluation of the presence of fistula is highly questionable in the absence of signs or symptoms.
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27
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Roblick MH, Völl M. Die proktologische Untersuchung. COLOPROCTOLOGY 2021. [DOI: 10.1007/s00053-021-00559-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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28
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Marti L. Transanale Abdeckelung des intersphinktären Raums (TROPIS). COLOPROCTOLOGY 2021. [DOI: 10.1007/s00053-021-00563-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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29
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Ohzu M, Takazawa H, Furukawa S, Komeno Y. Anorectal Abscess in a Patient with Neutropenia and Refractory Acute Myeloid Leukemia: To Operate or not to Operate? AMERICAN JOURNAL OF CASE REPORTS 2021; 22:e931589. [PMID: 34218249 PMCID: PMC8274364 DOI: 10.12659/ajcr.931589] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Anorectal infections occur in 5% to 9% of patients with hematological malignancies, including acute myeloid leukemia, and cause febrile neutropenia and sepsis. Surgical treatments of anorectal abscesses tend to be avoided in patients with leukemia owing to persistent neutropenia and bleeding risks. CASE REPORT A 56-year-old man presented with an ischiorectal abscess. Preoperative laboratory test results revealed leukocytopenia and anemia. He was diagnosed with acute myeloid leukemia. He developed septic shock. Antibiotic treatment was ineffective, and fever persisted. One week later, the abscess was treated by incision and drainage. Two days later, induction chemotherapy was initiated. No pus was drained; cellulitis spread to both buttocks. Pain worsened, and oxycodone was administered. Achievement of complete remission failed. Reinduction therapy was started, followed by fistulotomy of the abscess with extensive debridement of cellulitis on day 6. Granulation was observed on day 17. The patient's fever resolved on day 21. Although hematopoietic recovery was observed, bone marrow examination demonstrated partial remission. Two additional courses of chemotherapy were administered. Abscess recurrence was not observed, even during febrile neutropenia. The surgical wound shrank to a skin defect along the gluteal cleft. He achieved complete remission and was transferred to another hospital, where he underwent 3 allogeneic stem cell transplants. He died of leukemia progression. CONCLUSIONS Surgical treatments can prevent fatal progression of anorectal abscess, even during neutropenia. Incision and drainage are suitable for fluctuant abscesses. For a non-fluctuant abscess aggravated by sepsis and cellulitis, it is worth considering more invasive surgical interventions, including debridement and fistulotomy.
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Affiliation(s)
- Masami Ohzu
- Department of Hematology, Japan Community Healthcare Organization (JCHO) Tokyo Yamate Medical Center, Shinjuku City, Tokyo, Japan.,Department of Hematology and Oncology, The University of Tokyo, Bunkyo City, Tokyo, Japan
| | - Hitomi Takazawa
- Department of Hematology, Japan Community Healthcare Organization (JCHO) Tokyo Yamate Medical Center, Shinjuku City, Tokyo, Japan.,Department of Internal Medicine, Japan Community Healthcare Organization (JCHO) Tokyo Yamate Medical Center, Shinjuku City, Tokyo, Japan
| | - Satomi Furukawa
- Department of Coloproctology, Japan Community Healthcare Organization (JCHO) Tokyo Yamate Medical Center, Shinjuku City, Tokyo, Japan
| | - Yukiko Komeno
- Department of Hematology, Japan Community Healthcare Organization (JCHO) Tokyo Yamate Medical Center, Shinjuku City, Tokyo, Japan
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Zhi C, Huang Z, Liu D, Zheng L. Long-term follow-up study of loose combined cutting seton surgery for patients with high anal fistula. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:1160. [PMID: 34430601 PMCID: PMC8350621 DOI: 10.21037/atm-21-3242] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Accepted: 07/14/2021] [Indexed: 11/24/2022]
Abstract
BACKGROUND The treatment of high anal fistula (HAF) is still difficult for clinical surgeons. Our previous study demonstrated the short-term benefit of loose combined cutting seton (LCCS) for patients with HAF. This study aimed to evaluate the long-term effectiveness of LCCS for treating HAF patients. METHODS We retrospectively enrolled consecutive HAF patients who received LCCS therapy in our hospital between March 2014 and July 2017. After enrollment, all patients were followed up by clinical review. The patients' clinical information and most recent follow-up results were collected. Pain was assessed by the visual analog scale (VAS), and the severity of fecal incontinence was assessed by the Wexner Continence Grading Scale. We also assessed the patients' quality of life (QOL) using a the MOS item short from health survey (SF-36) questionnaire. HAF healing was considered the primary outcome, while the fistula recurrence rate, severity of fecal incontinence, and QOL were the secondary outcomes. RESULTS In total, 22 patients (18 male, four female) were enrolled in the final analysis. The mean duration of follow-up was 3.65 years (interquartile range: 3.55-4.22; range, 3.50-5.43). All patients were cured and there was no recurrence during the follow-up period. Eight patients reported a Wexner score of 1, while the remaining patients reported a score of 0 at the final follow-up. Furthermore, one patient had a VAS score of 1, while the remaining patients had a VAS score of 0, which indicated almost no postoperative pain. The QOL of all patients improved significantly. CONCLUSIONS LCCS is an effective method to treat HAF patients. Large, multicenter randomized controlled trials are warranted.
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Affiliation(s)
- Congcong Zhi
- Proctology Department, China-Japan Hospital, Beijing, China
| | - Zichen Huang
- Graduate School of Beijing University of Chinese Medicine (Master and Doctoral Class of 2020 in China-Japan Friendship Hospital), Beijing, China
| | - Dun Liu
- Graduate School of Beijing University of Chinese Medicine (Master and Doctoral Class of 2020 in China-Japan Friendship Hospital), Beijing, China
| | - Lihua Zheng
- Proctology Department, China-Japan Hospital, Beijing, China
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Garg P, R Menon G, Kaur B. Comparison of different methods to manage supralevator rectal opening in anal fistulas: A retrospective cohort study. Cir Esp 2021; 100:S0009-739X(21)00114-7. [PMID: 33875192 DOI: 10.1016/j.ciresp.2021.03.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Revised: 03/17/2021] [Accepted: 03/17/2021] [Indexed: 12/14/2022]
Abstract
INTRODUCTION Supralevator fistula-in-ano are difficult to manage. If these fistulas have an additional supralevator internal-opening in rectum apart from the primary internal-opening at the dentate line, then the management becomes even more difficult. There is no literature/guidelines available on the management of supralevator rectal opening (SRO). METHODS All consecutive supralevator fistula-in-ano patients having a SRO were retrospectively analyzed. The operative management of SRO in these fistulas was reviewed. All the fistulas were managed by the same procedure, transanal opening of intersphincteric space (TROPIS). The latter was a modification of LIFT (ligation of intersphincteric tract) procedure in which the intersphincteric tract was opened-up in the rectum rather than ligated (as is done in LIFT). The SRO was managed in three ways, group-1:SRO was laid-open into the rectum in continuity with the primary opening at dentate line, group-2:the mucosa around SRO was cauterized, group-3:nothing could be done to SRO. RESULTS Out of 836 patients operated between 2015 and 2020, 138 patients (16.5%) had supralevator extension. Amongst these, 23/138 (16.6%) patients had a SRO. 2 patients were excluded (short follow-up) and 21 patients were included in the analysis. 12/13(92%) patients in group-1, 4/5 (80%) patients in group-2 and 2/3(67%) patients in group-3 got healed (p=0.47, Chi-square test). The overall healing rate was 18/21(86%). CONCLUSIONS The supralevator rectal opening (SRO) heals well irrespective of the method utilized. Thus, proper management of the primary opening at the dentate line holds the key to fistula healing and SRO is perhaps not much responsible for persistence of the fistula. However, more studies are needed to corroborate these findings.
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Affiliation(s)
- Pankaj Garg
- Indus International Hospital, Mohali, Punjab, India; Garg Fistula Research Institute, Panchkula, Haryana, India.
| | - Geetha R Menon
- Chief Statistician, Indian Council of Medical Research, New Delhi, India
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Management of cryptoglandular fistula-in-ano among gastrointestinal surgeons in the Netherlands. Tech Coloproctol 2021; 25:709-719. [PMID: 33860363 PMCID: PMC8124037 DOI: 10.1007/s10151-021-02446-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Accepted: 04/01/2021] [Indexed: 02/06/2023]
Abstract
BACKGROUND Management of cryptoglandular fistula-in-ano (FIA) can be challenging. Despite Dutch and international guidelines determining optimal therapy is still quite difficult. The aim of this study was to report current practices in the management of cryptoglandular FIA among gastrointestinal surgeons in the Netherlands. METHODS Dutch surgeons and residents who are treating FIA regularly were sent a survey invitation by email. The survey was available online from September 19 to December 1 2019. The questionnaire consisted of 28 questions concerning diagnostic and surgical techniques in the treatment of intersphincteric and transsphincteric FIA. RESULTS In total, 147 (43%) surgeons responded and completed the survey. Magnetic resonance imaging was the preferred diagnostic imaging modality (97%) followed by the endo-anal ultrasound (12%). In case of a high FIA, 86% used a non-cutting seton. Most respondents removed a seton between 6 weeks and 3 months (n = 84, 58%). Fistulotomy was the procedure of preference in low transsphincteric (86%) and low intersphincteric FIA (92%). Mucosal advancement flap (MAF) and ligation of intersphincteric fistula tract (LIFT), with 78% and 46%, respectively, were the procedures that were applied most often in high transsphincteric FIA. In high intersphincteric FIA 67% performed a MAF and 33% a fistulotomy. Thirty-three percent of all respondents stated that they habitually closed the internal fistula opening, half of them used a Z-plasty. For debridement of the fistula tract the preferred method was curettage (78%). CONCLUSIONS Dutch gastrointestinal surgeons use various techniques in the management of FIA. Novel promising techniques should be investigated adequately in sufficient large trials to increase consensus. A core outcome measurement and a prospective international database would help in comparing results. Until then, treatment should be adjusted to the individual patient, governed by fistula characteristics and patient choice.
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Litta F, Bracchitta S, Naldini G, Mistrangelo M, Tricomi N, La Torre M, Altomare DF, Mozzon M, Testa A, Zigiotto D, Sica G, Tutino R, Lisi G, Marino F, Luglio G, Vergari R, Terrosu G, Cantarella F, Foti N, Giuliani A, Moroni R, Ratto C. FISSIT (Fistula Surgery in Italy) study: A retrospective survey on the surgical management of anal fistulas in Italy over the last 15 years. Surgery 2021; 170:689-695. [PMID: 33846008 DOI: 10.1016/j.surg.2021.02.055] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Revised: 02/21/2021] [Accepted: 02/23/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND Surgical treatment of anal fistulas is still a challenge. The aims of this study were to evaluate the adoption and healing rates for the different surgical techniques used in Italy over the past 15 years. METHODS This was a multicenter retrospective observational study of patients affected by simple and complex anal fistulas of cryptoglandular origin who were surgically treated in the period 2003-2017. Surgical techniques were grouped as sphincter-cutting or sphincter-sparing and as technology-assisted or techno-free. All patients included in the study were followed for at least 12 months. RESULTS A total of 9,536 patients (5,520 simple; 4,016 complex fistulas) entered the study. For simple fistulas, fistulotomy was the most frequently used procedure, although its adoption significantly decreased over the years (P < .0005), with an increase in sphincter-sparing approaches; the overall healing rate in simple fistulas was 81.1%, with a significant difference between sphincter-cutting (91.9%) and sphincter-sparing (65.1%) techniques (P = .001). For complex fistulas, the adoption of sphincter-cutting approaches decreased, while sphincter-sparing techniques were mildly preferred (P < .0005). Moreover, there was a significant trend toward the use of technology-assisted procedures. The overall healing rate for complex fistulas was 69.0%, with a measurable difference between sphincter-cutting (81.1%) and sphincter-sparing (61.4%; P = .001) techniques and between techno-free and technology-assisted techniques (72.5% and 55.0%, respectively; P = .001). CONCLUSION Surgical treatment of anal fistulas has changed, with a trend toward the use of sphincter-sparing techniques. The overall cure rate has remained stable, even if the most innovative procedures have achieved a lower success rate.
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Affiliation(s)
- Francesco Litta
- Proctology Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy.
| | | | - Gabriele Naldini
- Proctology and Pelvic Floor Clinical Centre, University Hospital of Pisa, Italy
| | - Massimiliano Mistrangelo
- Surgical Science Department, University of Turin, Città della Salute e della Scienza Hospital, Turin, Italy
| | | | - Marco La Torre
- Coloproctology Unit, Salvator Mundi International Hospital, UPMC (University of Pittsburgh Medical College), Rome, Italy
| | | | - Marta Mozzon
- Chirurgia Generale, Azienda Ospedaliero Universitaria Friuli Centrale, Udine, Italy
| | | | - Daniele Zigiotto
- Proctological and Perineal Surgical Unit, Ospedale Civile Maggiore, University of Verona, Verona, Italy
| | - Giuseppe Sica
- Department of Surgical Science, University Hospital Tor Vergata, Rome, Italy
| | - Roberta Tutino
- Department of Surgical, Oncological and Stomatological Disciplines (Di. Chir. On. S.), University of Palermo, Italy
| | - Giorgio Lisi
- General Surgery, Sant'Eugenio Hospital, Rome, Italy
| | - Fabio Marino
- Unit of Surgery, National Institute of Gastroenterology "Saverio de Bellis", Research Hospital, Castellana Grotte, Bari, Italy
| | - Gaetano Luglio
- Department of Public Health, School of Medicine Federico II of Naples, Naples, Italy
| | - Roberto Vergari
- Clinica Chirurgica, Azienda Ospedaliero Universitaria Ospedali Riuniti di Ancona, Italy
| | | | | | - Nicola Foti
- UOC Chirurgia Generale e Week Surgery, Ospedale "Andosilla" di Civita Castellana (VT), Italy
| | - Antonio Giuliani
- U.O.C. Chirurgia Generale Universitaria, San Salvatore Hospital. Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, Italy
| | - Rossana Moroni
- Direzione Scientifica, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Carlo Ratto
- Proctology Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy; Catholic University of Rome, Italy
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Attaallah W, Uprak TK, Kara B, Sen A, Tuney D, Yegen C. Chemical Ablation for Treating Anal Fistulas without Surgical Intervention: Long-Term Results. Surg Innov 2021; 28:731-737. [PMID: 33787391 DOI: 10.1177/15533506211006080] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Purposes. This study aimed to evaluate long-term outcomes after the application of a corrosive chemical agent for ablation of epithelial tissue as a non-surgical treatment of anal fistulas. Methods. Adult patients with symptomatic perianal fistula were prospectively included in the study. The fistula tract was irrigated with a 5% silver nitrate solution. The primary outcome measured in this study was the rate of clinical healing after long-term follow-up. Factors that may affect healing were also analysed. Results. A total of 186 patients with anal fistula were analysed. After irrigation with silver nitrate, 82 (44%) patients had complete clinical healing during a median follow-up time of 50 (7-64) months. Patients with intermittent discharge had a significantly higher rate of complete clinical healing than those with continuous discharge (P < .04). Fistulas without abscesses or secondary tracts had a significantly higher rate of complete clinical healing than the other types (P = .007). Conclusion. Chemical ablation of the epithelium of the anal fistula yields promising long-term outcomes in the management of anal fistulas without surgical intervention.
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Affiliation(s)
- Wafi Attaallah
- Department of General Surgery, 64050Marmara University School of Medicine, Istanbul, TURKEY
| | - Tevfik K Uprak
- Department of General Surgery, 64050Marmara University School of Medicine, Istanbul, TURKEY
| | - Burak Kara
- Department of General Surgery, 64050Marmara University School of Medicine, Istanbul, TURKEY
| | - Aliosman Sen
- Department of Radiology, 64050Marmara University School of Medicine, Istanbul, Turkey
| | - Davut Tuney
- Department of Radiology, 64050Marmara University School of Medicine, Istanbul, Turkey
| | - Cumhur Yegen
- Department of General Surgery, 64050Marmara University School of Medicine, Istanbul, TURKEY
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Grott M, Rickert A, Hetjens S, Kienle P. Clinical outcome and quality of life after gracilis muscle transposition for fistula closure over a 10-year period. Int J Colorectal Dis 2021; 36:569-580. [PMID: 33386945 DOI: 10.1007/s00384-020-03825-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/16/2020] [Indexed: 02/04/2023]
Abstract
PURPOSE Gracilis muscle transposition (GMT) is an established surgical technique in the treatment of anorectal fistulas and fistulas to the vagina and the urinary system when previous closure options have failed. There is little evidence on the success rate of this procedure in the long term. METHODS This is a follow-up study on all patients undergoing GMT over a 10-year period at a tertiary referral center for complex fistulas. Postoperative function and quality of life were evaluated by standardized questionnaires (Wexner score, Fecal Incontinence Quality of Life Score (FIQL), SF-12 and a brief questionnaire designed for this study). Sexual function was evaluated by the Female Sexual Function Index (FSFI) and the International Index of Erectile Function. RESULTS Forty-seven gracilis muscle transpositions (GMT) in 46 patients were performed. Most treated patients had (neo-)-rectovaginal fistulas (n = 29). An overall fistula closure was achieved in 34 of 46 patients (74%): in 25 cases primarily by GMT (53%) and in nine patients with persistent or recurrent fistula by additional surgical procedures. A clinically apparent relapse occurred on average 276 days (median: 180 days) after GMT (mean follow-up 73.4 months). CONCLUSION GMT in our hands has a primary closure rate of 53%, and after further procedures, this rises to 74%. Fecal continence is impaired in patients having undergone GMT. The overall quality of life in patients after GMT is only slightly impaired, and sexual function is severely impaired in female patients.
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Affiliation(s)
- M Grott
- Department of Thoracic Surgery, Thoraxklinik Heidelberg University, Röntgenstraße 1, 69126, Heidelberg, Germany
| | - A Rickert
- Department of Surgery, St. Josefskrankenhaus Heidelberg, Akademisches Lehrkrankenhaus der Medizinischen Fakultät Mannheim der Universität Heidelberg, Landhausstraße 25, 69115, Heidelberg, Germany
| | - S Hetjens
- Department for Medical Statistics and Biomathematics, Universitätsmedizin Mannheim, Medical Faculty Mannheim, Heidelberg University, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - P Kienle
- Department of Surgery, Theresienkrankenhaus Mannheim, Akademisches Lehrkrankenhaus der Universität Heidelberg, Heidelberg University, Bassermannstraße 1, 68165, Mannheim, Germany.
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Miller AS, Boyce K, Box B, Clarke MD, Duff SE, Foley NM, Guy RJ, Massey LH, Ramsay G, Slade DAJ, Stephenson JA, Tozer PJ, Wright D. The Association of Coloproctology of Great Britain and Ireland consensus guidelines in emergency colorectal surgery. Colorectal Dis 2021; 23:476-547. [PMID: 33470518 PMCID: PMC9291558 DOI: 10.1111/codi.15503] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2020] [Revised: 12/08/2020] [Accepted: 12/12/2020] [Indexed: 12/15/2022]
Abstract
AIM There is a requirement for an expansive and up to date review of the management of emergency colorectal conditions seen in adults. The primary objective is to provide detailed evidence-based guidelines for the target audience of general and colorectal surgeons who are responsible for an adult population and who practise in Great Britain and Ireland. METHODS Surgeons who are elected members of the Association of Coloproctology of Great Britain and Ireland Emergency Surgery Subcommittee were invited to contribute various sections to the guidelines. They were directed to produce a pathology-based document using literature searches that were systematic, comprehensible, transparent and reproducible. Levels of evidence were graded. Each author was asked to provide a set of recommendations which were evidence-based and unambiguous. These recommendations were submitted to the whole guideline group and scored. They were then refined and submitted to a second vote. Only those that achieved >80% consensus at level 5 (strongly agree) or level 4 (agree) after two votes were included in the guidelines. RESULTS All aspects of care (excluding abdominal trauma) for emergency colorectal conditions have been included along with 122 recommendations for management. CONCLUSION These guidelines provide an up to date and evidence-based summary of the current surgical knowledge in the management of emergency colorectal conditions and should serve as practical text for clinicians managing colorectal conditions in the emergency setting.
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Affiliation(s)
- Andrew S. Miller
- Leicester Royal InfirmaryUniversity Hospitals of Leicester NHS TrustLeicesterUK
| | | | - Benjamin Box
- Northumbria Healthcare Foundation NHS TrustNorth ShieldsUK
| | | | - Sarah E. Duff
- Manchester University NHS Foundation TrustManchesterUK
| | | | | | | | | | | | | | - Phil J. Tozer
- St Mark’s Hospital and Imperial College LondonHarrowUK
| | - Danette Wright
- Western Sydney Local Health DistrictSydneyNew South WalesAustralia
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Chaveli Díaz C, Esquiroz Lizaur I, Eguaras Córdoba I, González Álvarez G, Calvo Benito A, Oteiza Martínez F, de Miguel Velasco M, Ciga Lozano MÁ. Recurrence and incidence of fistula after urgent drainage of an anal abscess. Long-term results. Cir Esp 2020; 100:S0009-739X(20)30384-5. [PMID: 33358408 DOI: 10.1016/j.ciresp.2020.11.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Revised: 11/05/2020] [Accepted: 11/13/2020] [Indexed: 01/06/2023]
Abstract
INTRODUCTION Anal abscess is the most frequent urgent proctological problem. The recurrence rate and reported incidence of fistula after drainage and debridement of an anal abscess is widely variable. The objective of this study is to analyse the long-term recurrence rate and the incidence of fistula after drainage and urgent debridement of an anal abscess. METHODS Retrospective observational study of a prospective cohort with anal abscess of cryptoglandular origin. All patients (n = 303) were evaluated two months and one year after the intervention. At the 5th year, all the medical records were reviewed and a telephone call or appointment was made for an assessment if necessary. Specific antecedents of anal pathology, abscess characteristics, time and type of recurrence, presence of symptoms in the first revision and presence of clinical and/or ultrasound fistula were recorded. RESULTS Mean follow-up 119.7 months. Recurrence rate 48.2% (82.2% in the first year). Two hundred twenty-two ultrasounds performed. Incidence of ultrasound fistula: 70% symptomatic vs. 2.4% asymptomatic (p < 0.001). Global incidence of fistula 40.3%. The history of anal pathology and the presence of symptoms in the postoperative review significantly increase the possibility of recurrence (p < 0.001). The fistula is statistically more frequent if the abscess recurs (p < 0.001) CONCLUSION: After drainage and debridement of an anal abscess, half of the patients relapse and 40% develop fistula especially in the first year, so longer follow-ups are not necessary. Endoanal ultrasound for the evaluation of the presence of fistula is highly questionable in the absence of signs or symptoms.
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Affiliation(s)
- Carlos Chaveli Díaz
- Unidad de Cirugía Colorrectal, Área de Cirugía, Complejo Hospitalario de Navarra, Pamplona, España.
| | - Irene Esquiroz Lizaur
- Unidad de Cirugía Colorrectal, Área de Cirugía, Complejo Hospitalario de Navarra, Pamplona, España
| | - Inés Eguaras Córdoba
- Unidad de Cirugía Colorrectal, Área de Cirugía, Complejo Hospitalario de Navarra, Pamplona, España
| | | | - Ana Calvo Benito
- Unidad de Cirugía Colorrectal, Área de Cirugía, Complejo Hospitalario de Navarra, Pamplona, España
| | - Fabiola Oteiza Martínez
- Unidad de Cirugía Colorrectal, Área de Cirugía, Complejo Hospitalario de Navarra, Pamplona, España
| | - Mario de Miguel Velasco
- Unidad de Cirugía Colorrectal, Área de Cirugía, Complejo Hospitalario de Navarra, Pamplona, España
| | - Miguel Ángel Ciga Lozano
- Unidad de Cirugía Colorrectal, Área de Cirugía, Complejo Hospitalario de Navarra, Pamplona, España
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Garg P, Sodhi SS, Garg N. Management of Complex Cryptoglandular Anal Fistula: Challenges and Solutions. Clin Exp Gastroenterol 2020; 13:555-567. [PMID: 33204136 PMCID: PMC7667587 DOI: 10.2147/ceg.s198796] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2020] [Accepted: 10/15/2020] [Indexed: 12/16/2022] Open
Abstract
Anal fistulae can be a very difficult disease to manage. The management of complex fistulae is even more challenging. The risk to the fecal continence mechanism due to damage to the anal sphincters and refractoriness to the treatment (high recurrence rate) pose the two biggest challenges in the management of this disease. Apart from these, there are several other challenges in the treatment of complex fistulae. The intriguing and uphill task is that satisfactory solutions to most of these challenges are still not known, and there is hardly any consensus on whatever treatment solutions are available. To summarize, there is no gold-standard treatment available for treating complex anal fistulae, and the search for a satisfactory treatment option is still on. In this review, the endeavor has been to discuss and highlight recent path-breaking updates in the management of complex anal fistulae.
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Affiliation(s)
- Pankaj Garg
- Department of Colorectal Surgery, Garg Fistula Research Institute, Panchkula, Haryana, India
| | - Sohail Singh Sodhi
- Department of General Surgery, Dayanand Medical College and Hospital, Ludhiana, Punjab, India
| | - Navdeep Garg
- Department of General Surgery, Government Medical College and Hospital, Chandigarh, India
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Abstract
Perianal abscess (PA) and fistula-in-ano (FIA) are common entities in infancy. Although several hypotheses have been suggested, the pathogenesis of PA/FIA remains elusive. The natural course of these diseases in infancy is self-limiting in the majority of cases whereas older children show similarities to PA/FIA in adults. It is important to rule out rare differential diagnoses of PA/FIA such as inflammatory bowel disease (IBD), surgical complications after colorectal surgery, and immunodeficiencies. Treatment remains empiric, comprises conservative, as well as surgical approaches, and is dependent on the age of the patient. This review summarizes anatomical aspects, current evidence on disease pathogenesis, clinical presentation, and management of pediatric patients with PA and FIA.
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Affiliation(s)
| | - Martin Lacher
- Department of Pediatric Surgery, University of Leipzig, Leipzig, Germany
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Gokce FS, Gokce AH. Can the risk of anal fistula development after perianal abscess drainage be reduced? Rev Assoc Med Bras (1992) 2020; 66:1082-1086. [DOI: 10.1590/1806-9282.66.8.1082] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2020] [Accepted: 03/15/2020] [Indexed: 01/08/2023] Open
Abstract
SUMMARY OBJECTIVE Perianal abscesses are frequently seen in clinical practice, and perianal fistulas develop in 30%–50% of cases after treatment. This study investigated whether the type of dressing applied after abscess drainage is correlated with fistula development. Prevention of fistula formation would reduce both the loss of work and healthcare costs. METHODS The records of patients who underwent drainage of perianal abscesses between January 2015 and January 2018 were retrospectively reviewed. Patients with postoperative dressings changed with washing of the area in the hospital were included as Group 1. Patients with dressings changed at home and the area bathed in 10% povidone-iodine sitz bath were included as Group 2. The frequency and time of fistula formation, age, sex, cost, and workdays lost in the two groups were compared. RESULTS Between-group differences in age, sex, body mass index, and type of fistula that developed after months and 1 year of the abscess drainage were not statistically significant (p > 0.05). During follow-up, fistula development was significantly lower in Group 1 than in Group 2 (p < 0.001). The risk of perianal fistula development was significantly increased in those with a body mass index (BMI) > 30 (p = 0.004). CONCLUSIONS After perianal abscess drainage, in-hospital washing and dressing of the abscess area until abscess closure reduced the risk of perianal fistula, lost work time, and cost. The risk of perianal fistula development appeared to increase with BMI. A large, prospective study is needed for confirmation.
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Boenicke L, Doerner J, Wirth S, Zirngibl H, Langenbach MR. Efficacy of conservative treatment of perianal abscesses in children and predictors for therapeutic failure. Clin Exp Pediatr 2020; 63:272-277. [PMID: 32408417 PMCID: PMC7374001 DOI: 10.3345/cep.2019.00969] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2019] [Accepted: 12/31/2019] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND The optimal management of perianal abscess in children is controversial. PURPOSE To evaluate the efficiency of conservative treatment of perianal abscess in children and identify parameters that predict therapy failure. METHODS All cases of children younger than 14 years of age with perianal abscesses between 2001-2016 were evaluated. RESULTS Of the 113 enrolled patients, 64 underwent subsequent surgery for advanced disease (primary surgery group). Conservative treatment was initiated in 49 patients (primary conservative group) but was stopped because of inefficiency in 25 patients, who were referred for surgery after a median 7.03 days (range, 2 to 16 days). The other 24 patients (48%) initially achieved complete remission after conservative treatment, but 10 were readmitted after a median 34 months (range, 3 to 145 months) with recurrent disease. There were no significant differences in permanent success after conservative treatment between infants (10 of 29, 34%) and older children (4 of 20 [20%], P=0.122). Overall, conservative treatment alone was effective in only 14 of 113 patients. Recurrence after surgery occurred in 16 patients (25%) in the primary surgery group and 11 patients (22%) in the primary conservative group (P=0.75). Univariate analysis of predictors for conservative treatment failure revealed inflammatory values (C-reactive protein and white blood count, P=0.017) and abscess size (P=0.001) as significant parameters, whereas multivariate analysis demonstrated that only abscess size (odds ratio, 3.37; P=0.023) was significant. CONCLUSION Conservative treatment of perianal abscess is permanently efficient in only a minority of children but is not associated with a higher recurrence rate after subsequent surgery. Abscess size is a predictor for therapy failure.
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Affiliation(s)
- Lars Boenicke
- Department of General and Visceral Surgery, Helios University Hospital Wuppertal, University Witten-Herdecke, Wuppertal, Germany
| | - Johannes Doerner
- Department of General and Visceral Surgery, Helios University Hospital Wuppertal, University Witten-Herdecke, Wuppertal, Germany
| | - Stefan Wirth
- Department of Pediatrics, Helios University Hospital Wuppertal, University Witten-Herdecke, Wuppertal, Germany
| | - Hubert Zirngibl
- Department of General and Visceral Surgery, Helios University Hospital Wuppertal, University Witten-Herdecke, Wuppertal, Germany
| | - Mike Ralf Langenbach
- Department of General and Visceral Surgery, Helios University Hospital Wuppertal, University Witten-Herdecke, Wuppertal, Germany.,Department of General and Visceral Surgery and Coloproctology, Helios Clinic Oberhausen, Oberhausen, Germany
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He Z, Du J, Wu K, Chen J, Wu B, Yang J, Xu Z, Fu Z, Pan L, Wen K, Wang X. Formation rate of secondary anal fistula after incision and drainage of perianal Sepsis and analysis of risk factors. BMC Surg 2020; 20:94. [PMID: 32375721 PMCID: PMC7204285 DOI: 10.1186/s12893-020-00762-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2020] [Accepted: 04/28/2020] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND The choice of surgery for perianal sepsis is currently controversial. Some people advocate one-time radical surgery for perianal sepsis, while others advocate incision and drainage. The objective of this study is to observe the formation probability of secondary anal fistula after incision and drainage in patients with perianal sepsis and determine factors that contribute to secondary anal fistula after incision and drainage. METHODS A retrospective descriptive analysis was conducted in 288 patients with perianal sepsis who were treated with anorectal surgery in the Suzhou Hospital of Traditional Chinese Medicine from January 2016 to June 2018. The patients were followed by telephone, physical examination, and pelvic MRI examination for at least 1 year after surgery. RESULTS Three patients were not followed, 98 patients did not receive surgical treatment or one-time radical surgery for perianal sepsis, and 187 patients were ultimately identified for the study. Anal fistula was present in 105 patients, and the rate of formation of secondary anal fistula was 56.15%. There was no statistically significant difference in the fistula formation rate between different types of sepsis (P>0.05). And, in patients with secondary anal fistula, there was no significant correlation between the location of sepsis and the type of secondary anal fistula (P>0.05). CONCLUSIONS The incidence of secondary anal fistula after incision and drainage of perianal sepsis is 56.15%, which is lower than the incidence found in previous study. Young is a risk factor for secondary anal fistula after incision and drainage of perianal sepsis. There is no significant correlation between the location of sepsis and the type of secondary anal fistula. Simple incision and drainage is a suitable choice for patients with acute perianal sepsis.
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Affiliation(s)
- Zongqi He
- Department of Anorectal Surgery, Suzhou Hospital of Traditional Chinese Medicine Affiliated to Nanjing University of Chinese Medicine, No. 18, Yangsu Road, Suzhou, Jiangsu, China
| | - Jun Du
- Department of Anorectal Surgery, Suzhou Hospital of Traditional Chinese Medicine Affiliated to Nanjing University of Chinese Medicine, No. 18, Yangsu Road, Suzhou, Jiangsu, China
| | - Kaiwen Wu
- Department of Anorectal Surgery, Kunshan Fourth Peoples Hospital, No. 21, Zhenbei Road, Kunshan, Jiangsu, China
| | - Jiajia Chen
- Department of Radiology, Suzhou Hospital of Traditional Chinese Medicine Affiliated to Nanjing University of Chinese Medicine, No. 18, Yangsu Road, Suzhou, Jiangsu, China
| | - Bensheng Wu
- Department of Anorectal Surgery, Suzhou Hospital of Traditional Chinese Medicine Affiliated to Nanjing University of Chinese Medicine, No. 18, Yangsu Road, Suzhou, Jiangsu, China
| | - Jianhua Yang
- Department of Anorectal Surgery, Suzhou Hospital of Traditional Chinese Medicine Affiliated to Nanjing University of Chinese Medicine, No. 18, Yangsu Road, Suzhou, Jiangsu, China
| | - Zhizhong Xu
- Department of Anorectal Surgery, Suzhou Hospital of Traditional Chinese Medicine Affiliated to Nanjing University of Chinese Medicine, No. 18, Yangsu Road, Suzhou, Jiangsu, China
| | - Zhihui Fu
- Department of Radiology, Suzhou Hospital of Traditional Chinese Medicine Affiliated to Nanjing University of Chinese Medicine, No. 18, Yangsu Road, Suzhou, Jiangsu, China
| | - Li Pan
- Department of Anorectal Surgery, Suzhou Hospital of Traditional Chinese Medicine Affiliated to Nanjing University of Chinese Medicine, No. 18, Yangsu Road, Suzhou, Jiangsu, China
| | - Ke Wen
- Department of Anorectal Surgery, Suzhou Hospital of Traditional Chinese Medicine Affiliated to Nanjing University of Chinese Medicine, No. 18, Yangsu Road, Suzhou, Jiangsu, China.
| | - Xiaopeng Wang
- Department of Anorectal Surgery, Suzhou Hospital of Traditional Chinese Medicine Affiliated to Nanjing University of Chinese Medicine, No. 18, Yangsu Road, Suzhou, Jiangsu, China.
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Amato A, Bottini C, De Nardi P, Giamundo P, Lauretta A, Realis Luc A, Piloni V. Evaluation and management of perianal abscess and anal fistula: SICCR position statement. Tech Coloproctol 2020; 24:127-143. [DOI: 14) evaluation and management of perianal abscess and anal fistula: siccr position statement.a.amato, c.bottini, p.de nardi, p.giamundo, a.lauretta, a.realis luc & v.piloni.tech coloproctol 2020 24:127-143 doi 10.1007/s10151-019-02144-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2019] [Accepted: 12/23/2019] [Indexed: 09/10/2023]
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Evaluation and management of perianal abscess and anal fistula: SICCR position statement. Tech Coloproctol 2020; 24:127-143. [PMID: 31974827 DOI: 10.1007/s10151-019-02144-1] [Citation(s) in RCA: 47] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2019] [Accepted: 12/23/2019] [Indexed: 02/07/2023]
Abstract
Perianal sepsis is a common condition ranging from acute abscess to chronic anal fistula. In most cases, the source is considered to be a non-specific cryptoglandular infection starting from the intersphincteric space. Surgery is the main treatment and several procedures have been developed, but the risks of recurrence and of impairment of continence still seem to be an unresolved issue. This statement reviews the pertinent literature and provides evidence-based recommendations to improve individualized management of patients.
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Sammut M, Skaife P. The management of cryptoglandular fistula-in-ano. Br J Hosp Med (Lond) 2020; 81:1-9. [PMID: 32003630 DOI: 10.12968/hmed.2019.0353] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Idiopathic cryptoglandular fistula-in-ano is a common pathological condition. Fistula-in-ano has been managed by a number of surgical techniques, and there is still no consensus regarding the management of this condition. Surgical techniques aim to treat and cure the fistula-in-ano with minimal risk of recurrence or complications, and to maintain patient continence. This article discusses the evidence available to inform the management of idiopathic cryptoglandular fistula-in-ano, and problems that surgeons face because of the lack of high-quality evidence.
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Affiliation(s)
- Matthew Sammut
- Colorectal Department, Aintree University Hospital NHS Foundation Trust, Liverpool, UK
| | - Paul Skaife
- Colorectal Department, Aintree University Hospital NHS Foundation Trust, Liverpool, UK
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Ommer A. Analfisteln. COLOPROCTOLOGY 2019. [DOI: 10.1007/s00053-019-00394-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Lu D, Lu L, Cao B, Li Y, Cao Y, Li Z, Wang Z, Lu J. Relationship Between Body Mass Index and Recurrence/Anal Fistula Formation Following Initial Operation for Anorectal Abscess. Med Sci Monit 2019; 25:7942-7950. [PMID: 31642447 PMCID: PMC6822332 DOI: 10.12659/msm.917836] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND The association between body mass index (BMI) and recurrence of anorectal abscess remains controversial. This study investigated the exact relationship between BMI and anorectal abscess recurrence or anal fistula formation following initial surgery. MATERIAL AND METHODS This was a retrospective registry-based study conducted at the First Affiliated Hospital of Guizhou University of Chinese Medicine. Patients treated for anorectal abscess from 01/2015 to 03/2016 were included. Clinical data and time to recurrence were recorded. The Cox regression model was used to estimate the association between BMI and recurrence. RESULTS A total of 790 patients were operated on during the study period. The average age of the participants was 38.3±11.6 years, and 83.2% were male. Median follow-up was 27 (range, 1-38) months. Compared with the low BMI (range, 15.7-22.8 kg/m²) patients, the high BMI (range, 26.0-40.6 kg/m²) patients showed higher risk of recurrence (HR=1.75, 95% CI: 1.15-2.67). In the non-adjusted model, high BMI was found to be positively correlated with recurrence (HR=1.62, 95% CI: 1.10-2.40, P=0.02), and a stronger association was found in the fully adjusted model (HR=1.75, 95% CI: 1.15-2.67, P=0.01). BMI was also used as a continuous variable for sensitivity analysis, and a similar trend was observed (P=0.01 for trend). CONCLUSIONS Elevated BMI is an independent risk factor of anorectal abscess recurrence and for increased risk of abscess recurrence or anal fistula formation.
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Affiliation(s)
- Dan Lu
- Department of Anorectal Surgery, Longhua Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, China (mainland).,Department of Surgery Nursing, Guizhou University of Traditional Chinese Medicine, Guiyang, Guizhou, China (mainland)
| | - Linyuan Lu
- Department of Anorectal Surgery, Longhua Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, China (mainland)
| | - Bo Cao
- Department of Colorectal and Anal Surgery, The First Affiliated Hospital of Guizhou University of Traditional Chinese Medicine, Guiyang, Guizhou, China (mainland)
| | - Yunfei Li
- Department of Surgical Nursing, Guizhou Nursing Vocational Institute, Guiyang, Guizhou, China (mainland)
| | - Yongqing Cao
- Department of Anorectal Surgery, Longhua Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, China (mainland)
| | - Zhi Li
- Department of Colorectal and Anal Surgery, The First Affiliated Hospital of Guizhou University of Traditional Chinese Medicine, Guiyang, Guizhou, China (mainland)
| | - Ziming Wang
- Department of Colorectal and Anal Surgery, The First Affiliated Hospital of Guizhou University of Traditional Chinese Medicine, Guiyang, Guizhou, China (mainland)
| | - Jingen Lu
- Department of Anorectal Surgery, Longhua Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, China (mainland)
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Zhang XY, Jin HY, Wang C, Wang J, Zhang CX, Ye XR, Yang Y, Liu JL, Zhu Y. A prospective cohort study of safety and efficacy of three-cavity clearance in treatment of perianal cryptoglandular abscess. Shijie Huaren Xiaohua Zazhi 2019; 27:948-953. [DOI: 10.11569/wcjd.v27.i15.948] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Perianal abscess is a common anorectal disease, mainly caused by anal gland infection. Abscess, once formed, should be timely treated. At present, there are many methods available to treat perianal abscess, but each of them has some shortcomings. According to the physiological and pathological mechanism of perianal abscess, we designed a new surgical method named three-cavity clearance (TCC) to maximize the protection of anal sphincter function and reduce the pain of patients.
AIM To evaluate the safety and efficacy of TCC in perianal cryptoglandular abscess.
Methods From January 2017 to January 2018, perianal abscess patients who underwent TCC at the Center for Anorectal Diagnosis and Treatment of the Second Affiliated Hospital of Nanjing University of Traditional Chinese Medicine were selected as a study group. Patients who underwent simple incision and drainage for perianal abscess during the same period were selected into a control group. The two groups were 1:1 paired with comparable age, sex, and abscess site. Hospitalization time, wound healing time, anal fistula formation rate, and anal incontinence were compared between the two groups.
RESULTS There were 32 patients in each group and a total of 64 patients were included in this study. The formation rate of anal fistula in the TCC group was 6%, significantly lower than that in the control group (34.0%, P < 0.01). There was no anal incontinence in either group. The hospitalization time and wound healing time of the two groups showed no statistical difference (P > 0.05).
CONCLUSION TCC for perianal abscess is a safe and complete anal sphincter preserving technique, which can effectively reduce the rate of postoperative anal fistula formation.
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Affiliation(s)
- Xin-Yi Zhang
- Graduate School of Nanjing University of Chinese Medicine, Nanjing 210023, Jiangsu Province, China
| | - Hei-Ying Jin
- Department of colorectal surgery, The Second Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing 210017, Jiangsu Province, China
| | - Can Wang
- Graduate School of Nanjing University of Chinese Medicine, Nanjing 210023, Jiangsu Province, China
| | - Jun Wang
- Department of colorectal surgery, The Second Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing 210017, Jiangsu Province, China
| | - Chun-Xia Zhang
- Department of colorectal surgery, The Second Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing 210017, Jiangsu Province, China
| | - Xiao-Rui Ye
- Department of colorectal surgery, The Second Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing 210017, Jiangsu Province, China
| | - Yang Yang
- Department of colorectal surgery, The Second Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing 210017, Jiangsu Province, China
| | - Jian-Lei Liu
- Department of colorectal surgery, The Second Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing 210017, Jiangsu Province, China
| | - Ya Zhu
- Department of colorectal surgery, The Second Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing 210017, Jiangsu Province, China
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EXPERIMENTAL APPROVAL OF THE EFFICACY OF THE COMBINED COMPOSITION RECTAL CREAM NEW TEST-SAMPLES IN THE CONDITIONS OF ACUTE COMPLICATED ANAL FISSURE IN RATS. EUREKA: HEALTH SCIENCES 2019. [DOI: 10.21303/2504-5679.2019.00955] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Anal fissure (AF) is one of the most common anorectal problems. The severity of the disease, the chronicity of the pathological process and frequent complications lead to a sharp deterioration in the quality of life of patients. An important place in the treatment of anal fissure is occupied by drugs that affect its key mechanism of pathogenesis, namely, reduce the muscle tone of the internal anal sphincter and have anti-inflammatory, analgesic, and reparative properties.
Aim: conducting of screening studies of the effectiveness of new test samples of rectal cream of the combined composition (RCCC) on the model of acute complicated anal fissure in rats and determining the optimal composition of the potential drug.
Materials and methods. The research was conducted on the basis of the Central Scientific Research Laboratory of the National Pharmaceutical University (CSRL NUPH) in the spring (April) season of 2015 on the female rats.
A study of test specimens of the rectal cream of the combined composition was performed on a modified model of acute anal fissure. The effectiveness of the treatment was evaluated in terms of (0 to 2) severity of edema, hyperaemia, local bleeding, purulent necrotic processes, scapular formation, anatomical defect, and a general indicator of the severity of the pathological process (by the sum of the points for all the criteria that were analyzed). The level of proinflammatory PGE2 in serum was determined by the immune enzyme method.
Results. The RCCC sample No. 4 showed the most expressive therapeutic effect among the four samples under study, and had credible benefits to the inhibitory effect on purulent-necrotic processes, as expressed by the differences in the overall rate of the pathological process (6 days: 5.83±0.47 points against 7.00±0.37; 7.83±0.31 under the influence of RCCC No. 2, No. 3, respectively, and for 11 days 5.00±1.03 versus 6.83±1.28 points (p=0.08 ) under the influence of RCCC No. 1). The ability of RCCCs No.1 and No.4 to reduce the level of pro-inflammatory PGE2 in blood serum of rats compared with CP in 1.8 and 2.0 times, respectively, contributed to accelerating epithelization and scar formation. The advantages of RCCC No. 4 on the comparison of the ointment "Proctozan" with the reduction of the period of epithelization of the defect of the mucous membrane of the anal canal for 3 days (for 7 days – RCCC No. 4, for 10 days - ointment "Proctozan").
Conclusions. The rectal cream of the combined composition No. 4 showed the greatest efficacy, had advantages over the comparison ointment "Proctozan", and is promising for the creation on its basis a new drug for the treatment of anal fissures.
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Ratto C, Grossi U, Litta F, Di Tanna GL, Parello A, De Simone V, Tozer P, DE Zimmerman D, Maeda Y. Contemporary surgical practice in the management of anal fistula: results from an international survey. Tech Coloproctol 2019; 23:729-741. [PMID: 31368010 PMCID: PMC6736896 DOI: 10.1007/s10151-019-02051-5] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Accepted: 07/19/2019] [Indexed: 12/22/2022]
Abstract
Background Management of anal fistula (AF) remains challenging with many controversies. The purpose of this study was to explore current surgical practice in the management of AF with a focus on technical variations among surgeons. Methods An online survey was conducted by inviting all surgeons and physicians on the membership directory of European Society of Coloproctology and American Society of Colon and Rectal Surgeons. An invitation was extended to others via social media. The survey had 74 questions exploring diagnostic and surgical techniques. Results In March 2018, 3572 physicians on membership directory were invited to take part in the study 510 of whom (14%) responded to the survey. Of these respondents, 492 (96%) were surgeons. Respondents were mostly colorectal surgeons (84%) at consultant level (84%), age ≥ 40 years (64%), practicing in academic (53%) or teaching (30%) hospitals, from the USA (36%) and Europe (34%). About 80% considered fistulotomy as the gold standard treatment for simple fistulas. Endorectal advancement flap was performed using partial- (42%) or full-thickness (44%) flaps. Up to 38% of surgeons performed ligation of the intersphincteric fistula tract (LIFT) sometimes with technical variations. Geographic and demographic differences were found in both the diagnostic and therapeutic approaches to AF. Declared rates of recurrence and fecal incontinence with these techniques were variable and did not correlate with surgeons’ experience. Only 1–4% of surgeons were confident in performing the most novel sphincter-preserving techniques in patients with Crohn’s disease. Conclusions Profound technical variations exist in surgical management of AF, making it difficult to reproduce and compare treatment outcomes among different centers. Electronic supplementary material The online version of this article (10.1007/s10151-019-02051-5) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- C Ratto
- Proctology Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Largo A. Gemelli, 8, 00168, Rome, Italy.,Università Cattolica del Sacro Cuore, Rome, Italy
| | - U Grossi
- Proctology Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Largo A. Gemelli, 8, 00168, Rome, Italy. .,National Bowel Research Centre, Queen Mary University of London, London, UK.
| | - F Litta
- Proctology Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Largo A. Gemelli, 8, 00168, Rome, Italy
| | - G L Di Tanna
- Statistics Division, The George Institute for Global Health, UNSW, Sydney, Australia
| | - A Parello
- Proctology Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Largo A. Gemelli, 8, 00168, Rome, Italy
| | - V De Simone
- Proctology Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Largo A. Gemelli, 8, 00168, Rome, Italy
| | - P Tozer
- Fistula Research Unit, St Mark's Hospital and Academic Institute, London, UK.,Imperial College London, London, UK
| | - D DE Zimmerman
- Department of Surgery, ETZ (Elisabeth-TweeSteden Hospital), Tilburg, The Netherlands
| | - Y Maeda
- Department of Colorectal Surgery, Western General Hospital, Edinburgh, UK
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