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Gadepalli SK, Adler J. Perianal disease: Updates and controversies in closing the gaps. Semin Pediatr Surg 2024; 33:151402. [PMID: 38603820 DOI: 10.1016/j.sempedsurg.2024.151402] [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: 04/13/2024]
Abstract
Perianal complications are common and morbid in children with Crohn's disease. In this review, we describe the epidemiology, the presentation and diagnosis, evaluation and management. We focus on updates such as the increasing frequency of biologic medications and MRI for evaluation. We also highlight controversies on the timing and approaches to surgical techniques. Finally, perianal disease requires the coordination of multidisciplinary care with nursing, radiology, gastroenterology, and surgery to optimize outcomes - both medical and patient-centered.
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Affiliation(s)
- Samir K Gadepalli
- Section of Pediatric Surgery, Department of Surgery, University of Michigan, Ann Arbor, MI, United States; Susan G. Meister CHEAR Center, University of Michigan, Ann Arbor, MI, United States.
| | - Jeremy Adler
- Susan G. Meister CHEAR Center, University of Michigan, Ann Arbor, MI, United States; Division of Pediatric Gastroenterology, Department of Pediatrics, University of Michigan, Ann Arbor, MI, United States
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The Optimal Management of Fistulizing Crohn’s Disease: Evidence beyond Randomized Clinical Trials. J Clin Med 2022; 11:jcm11113045. [PMID: 35683433 PMCID: PMC9181669 DOI: 10.3390/jcm11113045] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Revised: 05/21/2022] [Accepted: 05/25/2022] [Indexed: 02/04/2023] Open
Abstract
Fistulizing Crohn’s disease (FCD) remains the most challenging aspect of treating patients with CD. FCD can occur in up to 30% of patients with CD and may lead to significant disability and impaired quality of life. The optimal treatment strategies for FCD require a multidisciplinary approach, including a combined medical and surgical approach. The therapeutic options for FCD are limited due to sparse evidence from randomized clinical trials (RCTs). The current recommendations are mainly based on post hoc analysis from RCTs, real-world clinical studies and expert opinion. There is variation in everyday clinical practice amongst gastroenterologists and surgeons. The evidence for anti-tumor necrosis factor therapy is the strongest in the treatment of FCD. However, long-term fistula healing can be achieved in only 30–50% of patients. In recent years, emerging data in the advent of therapeutic modalities, including the use of new biologic agents, therapeutic drug monitoring, novel surgical methods and mesenchymal stem cell therapy, have been shown to improve outcomes in achieving fistula healing. This review summarizes the existing literature on current and emerging therapies to provide guidance beyond RCTs in managing FCD.
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Angriman I, Tomassi M, Ruffolo C, Bordignon G, Saadeh L, Gruppo M, Pucciarelli S, Bardini R, Scarpa M. Impact on Quality of Life of Seton Placing in Perianal Crohn's Disease. Front Surg 2022; 8:806497. [PMID: 35141271 PMCID: PMC8818691 DOI: 10.3389/fsurg.2021.806497] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2021] [Accepted: 12/20/2021] [Indexed: 11/13/2022] Open
Abstract
IntroductionOften, in perineal Crohn's disease (CD), a seton is placed to guarantee a constant drainage and prevent septic complication while biologic therapy is ongoing. This study aimed to assess the long-term quality of life after surgery for perineal CD in relation to seton placing.Patients and MethodsData of 65 consecutive patients with CD and non-CD operated on from 2014 to 2019 for perianal fistula or abscess were retrieved. Forty-three had CD and 14 of them had a seton placed during surgery and they kept it on while they had anti-TNF-alpha therapy. Patients were interviewed with the Cleveland Global Quality of Life (CGQL) and SF-12 quality of life questionnaires. Disease activity was defined as Harvey-Bradshaw Index (HBI) and Perianal Disease Activity Index (PDAI). Comparisons between groups were carried out with the nonparametric tests, and multiple regression models were used to assess predictors of quality of life.ResultsThe total CGQL score and SF-12 mental component score (MCS) were significantly higher (and thus better) in the seton group than in patients treated without seton. On the contrary, SF-12 physical component score (PCS) was not different between the two groups. HBI was significantly better in patients in the seton group. At multivariate analysis, seton placement and HBI were confirmed to be independent predictors of long-term SF-12 MCS whereas only HBI confirmed to be a predictor of total CGQL score.ConclusionsSeton placing during anti-TNF-alpha therapy is independently associated with a better MCS. Unexpectedly, this device, instead of to cause psychological distress, seems to assure patients during their biologic therapy providing psychological benefit beyond the mere medical effect.
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Affiliation(s)
- Imerio Angriman
- Chirurgia Generale III, Department of Surgical Oncological and Gastroenterological Sciences, Azienda Ospedale Università di Padova, Padua, Italy
- General Surgery Unit, Azienda Ospedale Università di Padova, Padua, Italy
- *Correspondence: Imerio Angriman
| | - Monica Tomassi
- Chirurgia Generale III, Department of Surgical Oncological and Gastroenterological Sciences, Azienda Ospedale Università di Padova, Padua, Italy
- General Surgery Unit, Azienda Ospedale Università di Padova, Padua, Italy
| | - Cesare Ruffolo
- Chirurgia Generale III, Department of Surgical Oncological and Gastroenterological Sciences, Azienda Ospedale Università di Padova, Padua, Italy
- General Surgery Unit, Azienda Ospedale Università di Padova, Padua, Italy
| | - Giovanni Bordignon
- General Surgery Unit, Azienda Ospedale Università di Padova, Padua, Italy
| | - Luca Saadeh
- General Surgery Unit, Azienda Ospedale Università di Padova, Padua, Italy
| | - Mario Gruppo
- General Surgery Unit, Azienda Ospedale Università di Padova, Padua, Italy
- Surgical Oncology Unit, Veneto Institute of Oncology IOV Istituto di Ricerca e Cura a Carattere Scientifico (IRCCS), Castelfranco Veneto, Italy
| | - Salvatore Pucciarelli
- Chirurgia Generale III, Department of Surgical Oncological and Gastroenterological Sciences, Azienda Ospedale Università di Padova, Padua, Italy
| | - Romeo Bardini
- General Surgery Unit, Azienda Ospedale Università di Padova, Padua, Italy
| | - Marco Scarpa
- Chirurgia Generale III, Department of Surgical Oncological and Gastroenterological Sciences, Azienda Ospedale Università di Padova, Padua, Italy
- General Surgery Unit, Azienda Ospedale Università di Padova, Padua, Italy
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