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Wang H, Wang L, Zeng X, Zhang S, Huang Y, Zhang Q. Inflammatory bowel disease and risk for hemorrhoids: a Mendelian randomization analysis. Sci Rep 2024; 14:16677. [PMID: 39030236 PMCID: PMC11271563 DOI: 10.1038/s41598-024-66940-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2024] [Accepted: 07/05/2024] [Indexed: 07/21/2024] Open
Abstract
Observational studies have reported an association between inflammatory bowel disease (IBD), which includes Crohn's disease (CD) and ulcerative colitis (UC), and hemorrhoids (HEM). However, the presence of a causal relationship within this observed association remains to be confirmed. Consequently, we utilized the Mendelian randomization (MR) method to assess the causal effects of IBD on hemorrhoids. We validated the association between IBD and hemorrhoids in humans based on genome-wide association studies (GWAS) data. To investigate the causal relationship between IBD and hemorrhoids, we performed a two-sample Mendelian randomization study using training and validation sets. The genetic variation data for IBD, CD, UC, and hemorrhoids were derived from published genome-wide association studies (GWAS) of individuals of European. Two-sample Mendelian randomization and Multivariable Mendelian randomization (MVMR) were employed to determine the causal relationship between IBD (CD or UC) and hemorrhoids. Genetically predicted overall IBD was positively associated with hemorrhoids risk, with ORs of 1.02 (95% CIs 1.01-1.03, P = 4.39 × 10-4) and 1.02 (95% CIs 1.01-1.03, P = 4.99 × 10-5) in the training and validation sets, respectively. Furthermore, we found that CD was positively associated with hemorrhoids risk, with ORs of 1.02 (95% CIs 1.01-1.03, P = 4.12 × 10-6) and 1.02 (95% CIs 1.01-1.02, P = 3.78 × 10-5) for CD in the training and validation sets, respectively. In addition, we found that UC in the training set was positively associated with hemorrhoids risk (ORs 1.02, 95% CIs 1.01-1.03, P = 4.65 × 10-3), while no significant causal relationship between UC and hemorrhoids was shown in the validation set (P > 0.05). However, after MVMR adjustment, UC in the training set was not associated with an increased risk of hemorrhoids. Our study showed that there is a causal relationship between CD and hemorrhoids, which may suggest that clinicians need to prevent the occurrence of hemorrhoids in CD patients.
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Affiliation(s)
- HanYu Wang
- Clinical Medical College, Chengdu University of Traditional Chinese Medicine, Chengdu, Sichuan, China
| | - Lu Wang
- Clinical Medical College, Chengdu University of Traditional Chinese Medicine, Chengdu, Sichuan, China
| | - XiaoYu Zeng
- Clinical Medical College, Chengdu University of Traditional Chinese Medicine, Chengdu, Sichuan, China
| | - ShiPeng Zhang
- Clinical Medical College, Chengdu University of Traditional Chinese Medicine, Chengdu, Sichuan, China
| | - Yong Huang
- Clinical Medical College, Chengdu University of Traditional Chinese Medicine, Chengdu, Sichuan, China
| | - QinXiu Zhang
- Clinical Medical College, Chengdu University of Traditional Chinese Medicine, Chengdu, Sichuan, China.
- Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, China.
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Akhoundi N, Bozchelouei JK, Abrishami A, Frootan M, Siami A, Alimadadi E, Saba GB, Rezazadeh E, Amerifar M, Eghdami E. Comparison of MRI and Endoanal Ultrasound in Assessing Intersphincteric, Transsphincteric, and Suprasphincteric Perianal Fistula. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2023; 42:2057-2064. [PMID: 37040280 DOI: 10.1002/jum.16225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Revised: 03/07/2023] [Accepted: 03/13/2023] [Indexed: 06/19/2023]
Abstract
OBJECTIVES Perianal fistula is a common disorder characterized by an anomalous perianal track connecting two epithelialized surfaces, most commonly the anal canal and the perianal skin. Although each has its limitations, magnetic resonance imaging (MRI) and endoanal ultrasound are currently two acceptable modalities for assessing perianal fistula. This study aimed to evaluate the accuracy of MRI and endoanal ultrasonography in diagosing perianal fistula, considering the surgical results as the references. METHODS This prospective cohort study was performed on patients with symptomatic perianal fistulas. MRI results of patients reported by the radiologist were collected along with the findings of endoanal ultrasonography performed by a gastroenterologist. These results were compared with surgical findings as the reference standard. RESULTS The study enrolled 126 patients. Exactly 222 definitive fistulas were identified during surgery. Sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of ultrasound for perianal fistula were 87.38, 38.46, 92.38, 26.31, and 82.25% respectively; and for MRI were 76.12, 57.69, 93.88, 22.05, and 74.19% respectively. The accuracy of endoanal ultrasound for detecting transsphincteric and intersphincteric fistulas was higher than MRI. In contrast, the diagnostic value of MRI for detecting suprasphincteric fistulas was higher than endoanal ultrasound. CONCLUSIONS Using endoanal ultrasonography to diagnose perianal fistulas is a relatively accurate method. This method may be more sensitive than MRI in detecting patients with perianal fistulas and abscesses.
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Affiliation(s)
- Neda Akhoundi
- Radiology Department, Hillcrest Hospital, University of California San Diego, San Diego, USA
| | - Javad Komijani Bozchelouei
- Radiology Department, Loghman Hakim Hospital, Shahid Beheshti University of Medical Science, Tehran, Iran
| | - Alireza Abrishami
- Labbafinezhad Hospital, Shahid Beheshti University of Medical Science, Tehran, Iran
| | - Mojgan Frootan
- Gastroenterology Department, Shahid Beheshti University of Medical Science, Tehran, Iran
| | - Alireza Siami
- Biostatistical Analyzer, Amirkabir University of Technology, Tehran, Iran
| | - Elahe Alimadadi
- Taleghani Hospital, Shahid Beheshti University of Medical Sciences, Research Institute For Gastroenterology And Liver Diseases, Tehran, Iran
| | - Gholamreza Bagherzadeh Saba
- Taleghani Hospital, Shahid Beheshti University of Medical Sciences, Research Institute For Gastroenterology And Liver Diseases, Tehran, Iran
| | - Elmira Rezazadeh
- Radiology Department, Loghman Hakim Hospital, Shahid Beheshti University of Medical Science, Tehran, Iran
| | - Maryam Amerifar
- Radiology Department, Loghman Hakim Hospital, Shahid Beheshti University of Medical Science, Tehran, Iran
| | - Ebrahim Eghdami
- Radiology Department, Loghman Hakim Hospital, Shahid Beheshti University of Medical Science, Tehran, Iran
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Moldovan C, Rusu E, Cochior D, Toba ME, Mocanu H, Adam R, Rimbu M, Ghenea A, Savulescu F, Godoroja D, Botea F. Ten-year multicentric retrospective analysis regarding postoperative complications and impact of comorbidities in hemorrhoidal surgery with literature review. World J Clin Cases 2023; 11:366-384. [PMID: 36686344 PMCID: PMC9850966 DOI: 10.12998/wjcc.v11.i2.366] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2022] [Revised: 12/16/2022] [Accepted: 01/03/2023] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Hemorrhoidal disease (HD) is considered a low-severity pathology by both general population and physicians, but the lengthy conservative therapy and postoperative complications suggest otherwise.
AIM To assess the effectiveness of different treatment options, both conservative and surgical, in contrast with some preexisting comorbidities.
METHODS We conducted a retrospective, 10-yearlong study between January 2011 and December 2021 in two surgical centers, a private and a state-owned hospital. We compared the efficacy and safety of several treatment options, such as open hemorrhoidectomy, stapled hemorrhoidopexy, rubber band ligation and infrared coagulation in terms of complication rates and types and their correlation with different preexisting comorbidities such as inflammatory bowel disease (IBD), use of anticoagulant medication (AM) and liver cirrhosis. We also conducted a 20-years long PubMed research (1.263 articles) for relevant comparisons.
RESULTS Our study recorded 10940 patients with HD, 10241 with conservative and 699 with surgical treatment. Out of these, the male-to-female ratio of 1.3, and a peak in age distribution between 59 and 68 years old (32% of patients). For the entire study, we recorded a 90% incidence of immediate pain, immediate bleeding in 1.5% (11 cases), delayed bleeding in 1.0% (7 cases), and 0.6% surgical site infections. Urinary retention was also present, with 0.2% of patients, anal stricture in 1% and fecal incontinence for 0.5% of patients (4 cases). We recorded no severe complications such as Fournier`s gangrene or rectovaginal perforations. IBD accounted for 6% of the patients, with ulcerative colitis in 12% and Chron`s disease in 10.5%. 6.6% of the patients had AM, determining 4% immediate and 2% delayed bleeding, in surgically treated patients.
CONCLUSION Our study determined that most common complications (pain, urinary retention, bleeding, and stricture) are correlated with each surgical technique and pre-existing comorbidities.
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Affiliation(s)
- Cosmin Moldovan
- Department of Medical Surgical Disciplines, Faculty of Medicine, Titu Maiorescu University of Bucharest, Bucharest 031593, Romania
- Department of General Surgery, Witting Clinical Hospital, Bucharest 010243, Romania
| | - Elena Rusu
- Department of Preclinic Disciplines, Faculty of Medicine, Titu Maiorescu University of Bucharest, Bucharest 031593, Romania
| | - Daniel Cochior
- Department of Medical Surgical Disciplines, Faculty of Medicine, Titu Maiorescu University of Bucharest, Bucharest 031593, Romania
- Department of General Surgery, Sanador Clinical Hospital, Bucharest 010991, Romania
- Department of General Surgery, Monza Clinical Hospital, Bucharest 021967, Romania
| | - Madalina Elena Toba
- Department of Medical Surgical Disciplines, Faculty of Medicine, Titu Maiorescu University of Bucharest, Bucharest 031593, Romania
- Department of General Surgery, Witting Clinical Hospital, Bucharest 010243, Romania
| | - Horia Mocanu
- Department of Medical Surgical Disciplines, Faculty of Medicine, Titu Maiorescu University of Bucharest, Bucharest 031593, Romania
- Department of Ear, Nose and Throat, Ilfov County Clinical Emergency Hospital, Bucharest 022104, Romania
| | - Razvan Adam
- Department of Medical Surgical Disciplines, Faculty of Medicine, Titu Maiorescu University of Bucharest, Bucharest 031593, Romania
- Department of Orthopedics and Traumatology, Elias Emergency University Hospital, Bucharest 011461, Romania
| | - Mirela Rimbu
- Medical Doctoral School, Titu Maiorescu University of Bucharest, Bucharest 040317, Romania
| | - Adrian Ghenea
- Department of Coloproctology, MedLife SA Băneasa Hyperclinic, Bucharest 013693, Romania
| | - Florin Savulescu
- Department of Medical Surgical Disciplines, Faculty of Medicine, Titu Maiorescu University of Bucharest, Bucharest 031593, Romania
- 2nd Department of Surgery, Carol Davila Central Military Emergency University Hospital, Bucharest 010242, Romania
| | - Daniela Godoroja
- Department of Anesthesia, Ponderas Academic Hospital, Bucharest 014142, Romania
| | - Florin Botea
- Department of Medical Surgical Disciplines, Faculty of Medicine, Titu Maiorescu University of Bucharest, Bucharest 031593, Romania
- 2nd Department of Surgery, Fundeni Clinical Institute, Bucharest 022328, Romania
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4
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A Novel Modification of the Endorectal Advancement Flap for Complex Anal Fistulas: Surgical Technique and Outcomes. Int Surg 2021. [DOI: 10.9738/intsurg-d-21-00008.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Objective
A modification of the endorectal advancement flap (EAF) procedure is described with outcomes in a single-center, large retrospective cohort study.
Summary of background data
Fistula-in-ano is a common problem encountered by surgeons that can be classified as either simple or complex. Complex fistulas (CFs) cause higher morbidity and are much more challenging to treat. Although numerous treatment options are available for CF, none are proven to be 100% effective. The endorectal advancement flap (EAF) procedure was developed as an alternative to conventional surgical treatments for CF.
Methods
Charts were reviewed of patients with CF who underwent EAF between 2004 and 2019. The conventional EAF procedure was modified by performing transverse imbrication of the internal sphincter over the internal fistula opening. The incidence of new-onset fecal incontinence and recurrence were analyzed at the last available date of in-person follow-up.
Results
With a median follow-up of 6.6 months (range, 3.3–24 months), 99 patients with CFs underwent a modified EAF. Of these, 93% (92 of 99) had resolution of fistula without adverse outcomes, 7% (7 of 99) experienced recurrence, and 1% (1 of 99) experienced new-onset fecal incontinence. Systemic steroid or immunomodulatory therapy use (P = 0.001) and patients with diagnosed inflammatory bowel disease (P < 0.0001) were associated with increased rate of recurrence.
Conclusions
EAF with transverse imbrication of the internal opening using interrupted, absorbable suture is an effective technique to treat complex or recurrent anal fistulas. It is associated with a low risk of recurrence (7%) and fecal incontinence (1%) and is a valid treatment option for CFs.
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van Tol RR, Kleijnen J, Watson AJM, Jongen J, Altomare DF, Qvist N, Higuero T, Muris JWM, Breukink SO. European Society of ColoProctology: guideline for haemorrhoidal disease. Colorectal Dis 2020; 22:650-662. [PMID: 32067353 DOI: 10.1111/codi.14975] [Citation(s) in RCA: 70] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2019] [Accepted: 01/03/2020] [Indexed: 12/15/2022]
Abstract
AIM The goal of this European Society of ColoProctology project was to establish a multidisciplinary, international guideline for haemorrhoidal disease (HD) and to provide guidance on the most effective (surgical) treatment for patients with HD. METHODS The development process consisted of six phases. In phase one we defined the scope of the guideline. The patient population included patients with all stages of haemorrhoids. The target group for the guideline was all practitioners treating patients with haemorrhoids and, in addition, healthcare workers and patients who desired information regarding the treatment management of HD. The guideline needed to address both the diagnosis of and the therapeutic modalities for HD. Phase two consisted of the compilation of the guideline development group (GDG). All clinical members needed to have affinity with the diagnosis and treatment of haemorrhoids. Further, attention was paid to the geographical distribution of the clinicians. Each GDG member identified at least one patient in their country who could read English to comment on the draft guideline. In phase three review questions were formulated, using a reversed process, starting with possible recommendations based on the GDG's knowledge. In phase four a literature search was performed in MEDLINE (Ovid), PubMed, Embase (Ovid) and the Cochrane Database of Systematic Reviews. The search was focused on existing systematic reviews addressing each review question, supplemented by other studies published after the time frame covered by the systematic reviews. In phase five data of the included papers were extracted by the surgical resident (RT) and checked by the methodologist (JK) and the GDG. If needed, meta-analysis of the systematic reviews was updated by the surgical resident and the methodologist using Review Manager. During phase six the GDG members decided what recommendations could be made based on the evidence found in the literature using GRADE. RESULTS There were six sections: (i) symptoms, diagnosis and classification; (ii) basic treatment; (iii) outpatient procedures; (iv) surgical interventions; (v) special situations; (vi) other surgical techniques. Thirty-four recommendations were formulated. CONCLUSION This international, multidisciplinary guideline provides an up to date and evidence based summary of the current knowledge of the management of HD and may serve as a useful guide for patients and clinicians.
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Affiliation(s)
- R R van Tol
- Department of Surgery, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - J Kleijnen
- Care and Public Health Research Institute (CAPHRI), Maastricht University Medical Center+, Maastricht, The Netherlands
| | - A J M Watson
- Department of Surgery, Raigmore Hospital, Inverness, UK
| | - J Jongen
- Department of Surgical Proctology, Proktologische Praxis Kiel,, Kiel, Germany
| | - D F Altomare
- Department of Emergency and Organ Transplantation, University of Aldo Moro of Bari, Bari, Italy
| | - N Qvist
- Surgical Department A, Odense University Hospital, Odense C, Denmark
| | - T Higuero
- Clinique Saint Antoine, Nice, France
| | - J W M Muris
- Department of Family Medicine/General Practice, Research Institute CAPHRI, Maastricht University, Maastricht, The Netherlands
| | - S O Breukink
- Department of Surgery, Maastricht University Medical Centre+, Maastricht, The Netherlands
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6
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Pellino G, Keller DS, Sampietro GM, Angriman I, Carvello M, Celentano V, Colombo F, Di Candido F, Laureti S, Luglio G, Poggioli G, Rottoli M, Scaringi S, Sciaudone G, Sica G, Sofo L, Leone S, Danese S, Spinelli A, Delaini G, Selvaggi F. Inflammatory bowel disease position statement of the Italian Society of Colorectal Surgery (SICCR): Crohn's disease. Tech Coloproctol 2020; 24:421-448. [PMID: 32172396 DOI: 10.1007/s10151-020-02183-z] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Accepted: 02/24/2020] [Indexed: 02/07/2023]
Abstract
The Italian Society of Colorectal Surgery (SICCR) promoted the project reported here, which consists of a position statement of Italian colorectal surgeons to address the surgical aspects of Crohn's disease management. Members of the society were invited to express their opinions on several items proposed by the writing committee, based on evidence available in the literature. The results are presented, focusing on relevant points. The present paper is not an alternative to available guidelines; rather, it offers a snapshot of the attitudes of SICCR surgeons about the surgical treatment of Crohn's disease. The committee was able to identify some points of major disagreement and suggested strategies to improve quality of available data and acceptance of guidelines.
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Affiliation(s)
- G Pellino
- Colorectal Surgery, Department of Advanced Medical and Surgical Sciences, Università degli Studi della Campania "Luigi Vanvitelli", Policlinico CS, Piazza Miraglia 2, 80138, Naples, Italy.
| | - D S Keller
- Division of Colon and Rectal Surgery, Department of Surgery, New York-Presbyterian, Columbia University Medical Center, New York, NY, USA
| | | | - I Angriman
- General Surgery Unit, Azienda Ospedaliera di Padova, Padua, Italy
| | - M Carvello
- Colon and Rectal Surgery Division, Humanitas Clinical and Research Center, Rozzano, Milan, Italy
| | - V Celentano
- Portsmouth Hospitals NHS Trust, University of Portsmouth, Portsmouth, UK
| | - F Colombo
- L. Sacco University Hospital, Milan, Italy
| | - F Di Candido
- Colon and Rectal Surgery Division, Humanitas Clinical and Research Center, Rozzano, Milan, Italy
| | - S Laureti
- Surgery of the Alimentary Tract, Department of Medical and Surgical Sciences, Sant'Orsola Hospital, Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - G Luglio
- Department of Clinical Medicine and Surgery, University of Naples Federico II, Naples, Italy
| | - G Poggioli
- Surgery of the Alimentary Tract, Department of Medical and Surgical Sciences, Sant'Orsola Hospital, Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - M Rottoli
- Surgery of the Alimentary Tract, Department of Medical and Surgical Sciences, Sant'Orsola Hospital, Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - S Scaringi
- Surgical Unit, Department of Surgery and Translational Medicine, University of Firenze, Florence, Italy
| | - G Sciaudone
- Colorectal Surgery, Department of Advanced Medical and Surgical Sciences, Università degli Studi della Campania "Luigi Vanvitelli", Policlinico CS, Piazza Miraglia 2, 80138, Naples, Italy
| | - G Sica
- Minimally Invasive and Gastro-Intestinal Unit, Department of Surgery, Policlinico Tor Vergata, Rome, Italy
| | - L Sofo
- Abdominal Surgery Department, Fondazione Policlinico Universitario A. Gemelli IRCCS, Catholic University of Rome, Rome, Italy
| | - S Leone
- CEO, Associazione nazionale per le Malattie Infiammatorie Croniche dell'Intestino "A.M.I.C.I. Onlus", Milan, Italy
| | - S Danese
- Division of Gastroenterology, IBD Center, Humanitas University, Rozzano, Milan, Italy
| | - A Spinelli
- Colon and Rectal Surgery Division, Humanitas Clinical and Research Center, Rozzano, Milan, Italy
| | - G Delaini
- Department of Surgery, "Pederzoli" Hospital, Peschiera del Garda, Verona, Italy
| | - F Selvaggi
- Colorectal Surgery, Department of Advanced Medical and Surgical Sciences, Università degli Studi della Campania "Luigi Vanvitelli", Policlinico CS, Piazza Miraglia 2, 80138, Naples, Italy
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Abstract
Medical treatment remains the mainstay of perianal disease management for CD; however, aggressive surgical management should be considered for severe or recurrent disease. In all cases of perianal CD, medical and surgical treatments should be used in tandem by a multidisciplinary team. Significant development has been made in the treatment of Crohn's-related fistulas, particularly minimally invasive options with recent clinical trials showing success with mesenchymal stem cell applications. Inevitably, some patients with severe refractory disease may require fecal diversion or proctectomy. When considering reversal of a diverting or end ileostomy, cessation of proctitis is the most important factor.
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Affiliation(s)
- Adam Truong
- Division of Colorectal Surgery, Cedars-Sinai Medical Center, 8737 Beverly Blvd., Suite 101, Los Angeles, CA 90048, USA
| | - Karen Zaghiyan
- Division of Colorectal Surgery, Cedars-Sinai Medical Center, 8737 Beverly Blvd., Suite 101, Los Angeles, CA 90048, USA
| | - Phillip Fleshner
- Division of Colorectal Surgery, Cedars-Sinai Medical Center, 8737 Beverly Blvd., Suite 101, Los Angeles, CA 90048, USA.
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Ho E, Rickard MJFX, Suen M, Keshava A, Kwik C, Ong YY, Yang J. Perianal sepsis: surgical perspective and practical MRI reporting for radiologists. Abdom Radiol (NY) 2019; 44:1744-1755. [PMID: 30770939 DOI: 10.1007/s00261-019-01920-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
This article describes the development of a structured MRI reporting template and diagrammatic worksheet for perianal sepsis through collaboration between radiologists and colorectal surgeons at our institution, and the rationale behind each component of the worksheet. Benefits of this reporting worksheet include optimizing communication of key imaging findings that have a real impact on patient management, less time spent on reporting the study, and easier comparison between studies. We illustrate the utility of the report template with case studies. We summarize the current surgical approaches to perianal sepsis to help radiologists focus on reporting the findings relevant to surgical planning.
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Trends and Attributable Costs of Anorectal Involvement in Pediatric Crohn's Disease. J Surg Res 2018; 232:113-120. [PMID: 30463706 DOI: 10.1016/j.jss.2018.06.013] [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: 03/12/2018] [Revised: 04/30/2018] [Accepted: 06/01/2018] [Indexed: 11/23/2022]
Abstract
BACKGROUND Pediatric Crohn's disease (CD) with anorectal involvement has not been well characterized. We sought to describe trends in the prevalence of pediatric CD with anorectal involvement and its influence on health-care utilization. MATERIALS AND METHODS Patients (<21 y of age) with an International Classification of Diseases, Ninth Revision diagnosis of CD (555.X) were identified in the Kid's Inpatient Database (2003, 2006, 2009, 2012) and stratified by anorectal involvement based on the International Classification of Diseases, Ninth Revision diagnosis and procedural codes. Patient characteristics and resource utilization (length of stay [LOS] and costs) were compared between CD patients with and without anorectal involvement using univariate and multivariable analyses. Propensity score matching was used to estimate attributable LOS and costs. RESULTS There were 26,029 patients with CD identified in the study interval. Of these, 1706 (6.6%) had anorectal involvement. Those with anorectal disease were younger (age 16 versus 17 y old), more likely to be male (59.4% versus 49.9%) and black or Hispanic (24.7% versus 18.2%), and were more commonly treated in urban teaching hospitals compared with rural or nonteaching hospitals (83.2% versus 70.9%) (P < 0.001 for all). The proportion of patients with anorectal involvement increased over time (odds ratio 1.03, 95% confidence interval 1.02-1.05). After propensity score matching, attributable LOS and costs were 0.5 d and approximately $1600, respectively. CONCLUSIONS There has been an increase in the proportion of pediatric CD hospitalizations with anorectal manifestations. This pattern of disease is associated with longer hospitalization and higher costs compared with CD alone. Further research is required to understand the underlying etiology of these observed trends.
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10
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Uzun O, Dinçer M, Senger AS, Değer KC, Duman M. Closure of non-healing perianal Crohn's disease with surgery and vacuum-assisted closure (VAC) system. TURKISH JOURNAL OF GASTROENTEROLOGY 2018; 29:367-369. [PMID: 29755024 DOI: 10.5152/tjg.2018.17138] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Affiliation(s)
- Orhan Uzun
- Department of Gastrointestinal Surgey, Kartal Koşuyolu High Speciality Training and Research Hospital, İstanbul, Turkey
| | - Mürşit Dinçer
- Department of General Surgery, Haseki Training and Research Hospital, İstanbul, Turkey
| | - Aziz Serkan Senger
- Department of Gastrointestinal Surgey, Kartal Koşuyolu High Speciality Training and Research Hospital, İstanbul, Turkey
| | - Kamuran Cumhur Değer
- Department of Gastrointestinal Surgey, Kartal Koşuyolu High Speciality Training and Research Hospital, İstanbul, Turkey
| | - Mustafa Duman
- Department of Gastrointestinal Surgey, Kartal Koşuyolu High Speciality Training and Research Hospital, İstanbul, Turkey
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Comparison of Transperianal Ultrasound With Colonoscopy and Magnetic Resonance Imaging in Perianal Crohn Disease. J Pediatr Gastroenterol Nutr 2018; 66:614-619. [PMID: 28953535 DOI: 10.1097/mpg.0000000000001752] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVE Perianal fistulae and/or abscesses are common complications of Crohn disease (CD), especially in children. Magnetic resonance imaging (MRI) and gross examination under anesthesia are accurate diagnostic modalities for evaluating perianal lesions. Both methods, however, are expensive and have some limitations for use in children. This study aims to assess the accuracy of transperianal ultrasound (TPUS) and colonoscopic examination, compared with MRI, in pediatric patients with perianal CD (PACD). METHODS Thirty-eight children and adolescents with PACD who underwent MRI, TPUS, and gross colonoscopic examination under sedation were included. Fistulae were classified according to Parks' and St. James's University Hospital classifications. Abscesses were identified by their presence and location on each modality. RESULTS Fifty-nine fistulae (26 superficial, 23 intersphincteric, 10 transsphincteric) and 16 abscesses were detected using MRI. Fifty-nine fistulae and 10 abscesses were detected using TPUS. Forty-five fistulae (sensitivity 76.3%, positive predictive value [PPV] 84.2%, and kappa value 0.296] and 9 abscesses (sensitivity 56.3%, PPV 90.0%, and kappa value 0.624) on TPUS corresponded with MRI findings. Forty-six fistulae and fifteen abscesses were detected using colonoscopy. Forty fistulae (sensitivity 67.8%, PPV 89.9%, and kappa value 0.369) and 7 abscesses (sensitivity 43.8%, PPV 48.8%, and kappa value 0.304) on colonoscopy corresponded with MRI findings. With respect to abscess, agreement between TPUS and MRI was superior to that between colonoscopy and MRI (Spearman rho 0.651 vs 0.304, P = 0.007). CONCLUSION TPUS is an appropriate, simple, and real-time method for detecting perianal fistula and/or abscess, in children with PACD.
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12
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Incidence and Risk Factors for Perianal Disease in Pediatric Crohn Disease Patients Followed in CEDATA-GPGE Registry. J Pediatr Gastroenterol Nutr 2018; 66:73-78. [PMID: 28604511 DOI: 10.1097/mpg.0000000000001649] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
OBJECTIVES Perianal disease (PD) with fistula and/or abscess formation is a severe complication in Crohn disease (CD). We examined prevalence, incidence, and risk factors for PD development in a pediatric CD cohort. METHODS Patients with CD from the prospective, multicenter registry for inflammatory bowel disease from Germany and Austria (CEDATA-GPGE) were included if diagnosed at the age of 18 years or younger, registered within 3 months after diagnosis, and having at least 2 follow-up visits within the first year of registration. We examined potential risk factors for PD with Kaplan-Meier analysis and a final Cox model considering sex, family history of inflammatory bowel disease, extraintestinal manifestations, disease location, and induction therapy (corticosteroids or nutritional therapy). RESULTS Of 2406 patients with CD, 742 fulfilled inclusion criteria (59% boys, mean age at diagnosis 12.4 ± 3.4 years). PD was present at diagnosis in 41 patients (5.5%; 80.9% boys), whereas 32 patients (4.3%, 81.3% male) developed PD during follow-up (mean 2.0 ± 1.6 years). The cumulative incidence of PD at 12 and 36 months after diagnosis was 3.5% and 7.5%, respectively. Potential risk factors for PD development during follow-up were male sex (hazard ratio = 3.2, [95%; confidence interval 1.2-7.8]) and induction therapy with corticosteroids (hazard ratio = 2.5 [1.1-5.5]). Diagnostic evaluation at PD diagnosis was incomplete in 40% of affected subjects. PD resolved within 1 year in 50% of cases. CONCLUSIONS Approximately 10% of CD patients in our cohort suffered from PD within the first 3 years of their disease. Male sex and initial corticosteroid therapy were associated with an increased risk to develop PD after diagnosis.
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Primo Romaguera V, Gregorio Hernández A, Andreo Hernández L, de la Morena Valenzuela E. Selective embolization of the superior rectal artery: An alternative to hemorrhoid surgery? Cir Esp 2017; 96:239-241. [PMID: 29042023 DOI: 10.1016/j.ciresp.2017.08.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2017] [Revised: 08/22/2017] [Accepted: 08/31/2017] [Indexed: 10/18/2022]
Affiliation(s)
- Vicent Primo Romaguera
- Servicio de Cirugía General y Digestiva, Hospital de Dénia Marina-Salud, Dénia, Alicante, España.
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Mahmoud NN, Halwani Y, Montbrun SD, Shah PM, Hedrick TL, Rashid F, Schwartz DA, Dalal RL, Kamiński JP, Zaghiyan K, Fleshner PR, Weissler JM, Fischer JP. Current management of perianal Crohn’s disease. Curr Probl Surg 2017; 54:262-298. [DOI: 10.1067/j.cpsurg.2017.02.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2017] [Accepted: 02/04/2017] [Indexed: 12/11/2022]
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15
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Doggweiler R, Whitmore KE, Meijlink JM, Drake MJ, Frawley H, Nordling J, Hanno P, Fraser MO, Homma Y, Garrido G, Gomes MJ, Elneil S, van de Merwe JP, Lin ATL, Tomoe H. A standard for terminology in chronic pelvic pain syndromes: A report from the chronic pelvic pain working group of the international continence society. Neurourol Urodyn 2016; 36:984-1008. [PMID: 27564065 DOI: 10.1002/nau.23072] [Citation(s) in RCA: 108] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2016] [Accepted: 05/23/2016] [Indexed: 12/27/2022]
Abstract
AIMS Terms used in the field of chronic pelvic pain (CPP) are poorly defined and often confusing. An International Continence Society (ICS) Standard for Terminology in chronic pelvic pain syndromes (CPPS) has been developed with the aim of improving diagnosis and treatment of patients affected by chronic pelvic pain syndromes. The standard aims to facilitate research, enhance therapy development and support healthcare delivery, for healthcare providers, and patients. This document looks at the whole person and all the domains (organ systems) in a systematic way. METHODS A dedicated working group (WG) was instituted by the ICS Standardisation Steering Committee according to published procedures. The WG extracted information from existing relevant guidelines, consensus documents, and scientific publications. Medline and other databases were searched in relation to each chronic pelvic pain domain from 1980 to 2014. Existing ICS Standards for terminology were utilized where appropriate to ensure transparency, accessibility, flexibility, and evolution. Consensus was based on majority agreement. RESULTS The multidisciplinary CPPS Standard reports updated consensus terminology in nine domains; lower urinary tract, female genital, male genital, gastrointestinal, musculoskeletal, neurological aspects, psychological aspects, sexual aspects, and comorbidities. Each is described in terms of symptoms, signs and further evaluation. CONCLUSION The document presents preferred terms and definitions for symptoms, signs, and evaluation (diagnostic work-up) of female and male patients with chronic pelvic pain syndromes, serving as a platform for ongoing development in this field. Neurourol. Urodynam. 36:984-1008, 2017. © 2016 Wiley Periodicals, Inc.
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Affiliation(s)
| | - Kristene E Whitmore
- Chair of Urology and Female Pelvic Medicine and Reconstructive Surgery, Drexel University College of Medicine, Philadelphia, Pennsylvania
| | - Jane M Meijlink
- International Painful Bladder Foundation, Naarden, Netherlands
| | - Marcus J Drake
- Department of Urology, School of Clinical Sciences, University of Bristol, Bristol, United Kingdom
| | - Helena Frawley
- Physiotherapy at La Trobe University, Melbourne, Cabrini Health, Melbourne, Australia
| | - Jørgen Nordling
- Department of Urology, University of Copenhagen, Herlev Hospital, Herlev, Denmark
| | - Philip Hanno
- Department of Urology, Division of Urology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Matthew O Fraser
- Department of Urology Surgery, Duke University and Durham Veterans Affairs Medical Centers, Durham, North Carolina
| | - Yukio Homma
- Department of Urology, The University of Tokyo, Tokyo, Japan
| | - Gustavo Garrido
- Head of Voiding Dysfunctions and Urodynamics Section, Urology Division, Hospital de Clínicas, University of Buenos Aires, Argentina
| | - Mario J Gomes
- Department of Urology, St. António Hospital, Oporto, Portugal
| | - Sohier Elneil
- Department of Urogynecology, University College Hospital, National Hospital for Neurology and Neurosurgery, GB
| | | | - Alex T L Lin
- Department of Urology, Taipei Veterans General Hospital, National Yang Ming University, Taipei, Taiwan
| | - Hikaru Tomoe
- Department of Urogynecology, Chair of Pelvic Reconstructive Surgery and Urology, Tokyo Women's Medical University Medical Center East, Japan
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Perianal Crohn’s: Review of endoscopic and cross-sectional imaging. TECHNIQUES IN GASTROINTESTINAL ENDOSCOPY 2016. [DOI: 10.1016/j.tgie.2016.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Abstract
Endoanal ultrasound is a technique that provides imaging of the anal sphincters and its surrounding structures as well as the pelvic floor. However, endoanal magnetic resonance imaging (MRI) is preferred by most physicians, although costs are higher and demand easily outgrows availability. Endoanal ultrasound is an accurate imaging modality delineating anatomy of both cryptoglandular as well as Crohn perianal fistula and abscess. Endoanal ultrasound is comparable with examination under anesthesia and equally sensitive as endoanal MRI in fistula detection. When fistula tracts or abscesses are located above the puborectal muscle, an additional endoanal MRI should be performed. Preoperative imaging is advocated in recurrent cryptoglandular fistula because a more complex pattern can be expected. Endoanal ultrasound can help avoid missing tracts during surgery, lowering the chance for the fistula to persist or recur. It can easily be performed in an outpatient setting and endosonographic skills are quickly incremented. Costs are low and endoanal ultrasound has the potential to improve outcome of patients with both cryptoglandular and fistulizing Crohn disease; therefore, it values more attention.
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Affiliation(s)
- Arjan Paul Visscher
- From the Department of Gastroenterology and Hepatology, VU University Medical Center, Amsterdam, the Netherlands
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Malgras B, Pautrat K, Dray X, Pasquier P, Valleur P, Pocard M, Soyer P. Multidisciplinary management of gastrointestinal fibrotic stenosis in Crohn's disease. Dig Dis Sci 2015; 60:1152-68. [PMID: 25381203 DOI: 10.1007/s10620-014-3421-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2014] [Accepted: 10/30/2014] [Indexed: 12/21/2022]
Abstract
Crohn's disease (CD) is a chronic inflammatory bowel disease that can involve virtually any part of the gastrointestinal tract. CD complications are the main indications for surgery. A large proportion of these interventions are due to stricturing disease. Although immunosuppressive treatments have been used more frequently during the last 25 years, there is no significant decrease in the need for surgery in patients with CD. Unfortunately, surgery is not curative, as the disease ultimately reoccurs in a substantial subset of patients. To best identify the patients who will require a specific treatment and to plane the most appropriate therapeutic approach, it is important to precisely define the type, the size, and the location of CD stenosis. Diagnostic approaches aim to distinguish fibrotic from inflammatory strictures. Medical therapy is required for inflammatory stenosis. Mechanical treatments are required when fibrotic CD strictures are symptomatic. The choice between endoscopic balloon dilation, stricturoplasty, and laparoscopic or open surgery is based on the presence of perforating complications, the remaining length of small bowel, and the number and length of strictures. The non-hierarchical decision-making process for the treatment of fibrotic CD therefore requires multidisciplinary clinical rounds with radiologists, gastroenterologists, interventional endoscopists, and surgeons.
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Affiliation(s)
- Brice Malgras
- Department of Surgery, Laiboisiere Hospital, Paris 7 University and AP-HP, 2 rue Ambroise Paré, 75475, Paris Cedex 10, France,
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Impact of perineal Crohn's disease on utilization of care in the absence of modifiable predictors of treatment failure. Int J Colorectal Dis 2014; 29:1535-9. [PMID: 25269618 DOI: 10.1007/s00384-014-2013-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/16/2014] [Indexed: 02/04/2023]
Abstract
INTRODUCTION The burden of perineal Crohn's disease (PCD) remains poorly characterized, and many patients ultimately require fecal diversion or proctectomy. Our goal was to characterize the clinical course of patients presenting with perineal Crohn's disease, focusing on the cohort of patients ultimately requiring fecal diversion, and identify modifiable predictors for this unfortunate outcome. METHODS We performed a retrospective review of 81 consecutive patients who underwent 172 operations to address complications of PCD. Diverted patients were compared to those who did not require diversion in regard to demographics, surgical procedure, postoperative infliximab, and presence of proctitis (chi square, t tests). Logistic regression was utilized to predict the need for fecal diversion. The number of visits needed to undergo care for this condition was quantified. RESULTS Eight-one patients underwent a total of 172 surgical procedures and had a total of 2713 outpatient visits (range 1-118) to address symptoms of perineal Crohn's disease. Following first intervention, only 57.1 % healed at 3 months. These rates were highest in patients treated with fistulotomies and were not impacted by whether patients received postoperative infliximab (p = 0.703). Patients (23.5 %) underwent three or more surgical procedures to control their PCD and ultimately only 60 % healed without diversion, which was performed in 19 (23.5 %) patients. Patients undergoing more than three operations (OR = 10.9, p = 0.006) and women with rectovaginal fistula (OR = 3.88, p < 0.01) were at a high risk for diversion. Modifiable factors such as infliximab, smoking, proctitis, and surgery aimed at closing the internal anal opening did not alter outcome. CONCLUSIONS In the patients with perineal Crohn's, complex fistulas healing rates appear to be independent of postoperative infliximab or procedures aimed at closing the internal anal opening. Those who do not heal require numerous specialist visits.
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Sica GS, Di Carlo S, Tema G, Montagnese F, Del Vecchio Blanco G, Fiaschetti V, Maggi G, Biancone L. Treatment of peri-anal fistula in Crohn's disease. World J Gastroenterol 2014; 20:13205-13210. [PMID: 25309057 PMCID: PMC4188878 DOI: 10.3748/wjg.v20.i37.13205] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2014] [Revised: 06/03/2014] [Accepted: 07/11/2014] [Indexed: 02/06/2023] Open
Abstract
Anal fistulas are a common manifestation of Crohn’s disease (CD). The first manifestation of the disease is often in the peri-anal region, which can occur years before a diagnosis, particularly in CD affecting the colon and rectum. The treatment of peri-anal fistulas is difficult and always multidisciplinary. The European guidelines recommend combined surgical and medical treatment with biologic drugs to achieve best results. Several different surgical techniques are currently employed. However, at the moment, none of these techniques appear superior to the others in terms of healing rate. Surgery is always indicated to treat symptomatic, simple, low intersphincteric fistulas refractory to medical therapy and those causing disabling symptoms. Utmost attention should be paid to correcting the balance between eradication of the fistula and the preservation of fecal continence.
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Lam TJ, van Bodegraven AA, Felt-Bersma RJF. Anorectal complications and function in patients suffering from inflammatory bowel disease: a series of patients with long-term follow-up. Int J Colorectal Dis 2014; 29:923-9. [PMID: 24965857 DOI: 10.1007/s00384-014-1926-7] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/12/2014] [Indexed: 02/07/2023]
Abstract
AIM The aim of this study is to describe the long-term course of anorectal complains and function in a single centre cohort patients suffering from inflammatory bowel disease (IBD) with perianal lesions. METHODS Between 1993 and 2000, 56 IBD patients (43 Crohn's disease and 13 ulcerative colitis) with perianal complaints underwent anorectal function evaluation (AFE) (baseline). For follow-up, they were approached between 2010 and 2012 by sending questionnaires including Inflammatory Bowel Disease Quality of Life Questionnaire (IBDQ), Perianal Disease Activity Index (PDAI), faecal incontinence scale (Vaizey) and an invitation for AFE. RESULTS At follow-up, 46 patients (82 %) were available, 9 (16 %) were lost and 1 (2 %) had died. Thirty patients returned the questionnaires of which 17 also underwent AFE. The remaining 16 patients were interviewed by phone and were only willing to mention their anorectal complaints. Median follow-up was 14 year. In 25 of the 46 patients (54 %), perianal complaints persisted faecal incontinence (n = 7); soiling (n = 13) and active fistula (n = 5). Eighteen (39 %) patients had an active fistula at baseline and three persisted at follow-up. Two developed a new fistula. Mean IBDQ, Vaizey and PDAI were 178 (SD 29), 7 (SD 5) and 4.2 (SD 3.0), respectively. In 17 patients, who underwent AFE, anal endosonography showed healing in nine of the ten fistulas. Anal pressures as well as rectal capacity remained unaltered in the individual patient, but showed a large range within the group. CONCLUSION After 14 years, 54 % of the IBD patients with perianal lesions still have mild complaints. The quality of life remained moderate over a long period, which is concerning.
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Affiliation(s)
- Tze J Lam
- Department of Gastroenterology and Hepatology, VU University Medical Center, PO Box 7057, 1007 MB, Amsterdam, The Netherlands,
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22
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Cracco N, Zinicola R. Is haemorrhoidectomy in inflammatory bowel disease harmful? An old dogma re-examined. Colorectal Dis 2014; 16:516-9. [PMID: 24422778 DOI: 10.1111/codi.12555] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2013] [Accepted: 11/20/2013] [Indexed: 01/11/2023]
Abstract
AIM Haemorrhoidectomy and removal of anal skin tags in inflammatory bowel disease (IBD) have been considered to be potentially harmful, but the evidence for this is poor. A review of the literature was undertaken to determine the complications rate after haemorrhoidectomy in patients with IBD. METHOD A Medline, PubMed and Cochrane Library search was performed to retrieve studies reporting the surgical treatment of haemorrhoids in patients with IBD. All studies that investigated the complications of haemorrhoidectomy and skin tag removal in patients with IBD were included. Complications included local sepsis, fissure, ulcer, stenosis, faecal incontinence and the direct need for proctectomy or a stoma. RESULTS Eleven retrospective studies including 135 patients were identified. Most series were small and lacked information on the interval between surgery and the onset of complications. The range of complications ranged from 0% to 100%. Taking the studies together, complications occurred more frequently in Crohn's disease (CD) (17.1%) than in ulcerative colitis (UC) (5.5%). The risk of complication was much higher in patients with unknown than in those with known diagnosis of IBD (50% vs 9.8% in CD; 9.1% vs 4% in UC). CONCLUSION There is great variation in the incidence of complications reported after haemorrhoidectomy or removal of skin tags in patients with IBD and it is not possible to draw a firm conclusion. Nevertheless the incidence of complications is high in patients with CD.
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Affiliation(s)
- N Cracco
- Department of General Surgery, Sacro Cuore Don Calabria Hospital, Negrar, Verona
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Abstract
The rectum and anus are two anatomically complex organs with diverse pathologies. This article reviews the basic anatomy of the rectum and anus. In addition, it addresses the current radiographic techniques used to evaluate these structures, specifically ultrasound, magnetic resonance imaging, and defecography.
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Affiliation(s)
- Patrick Solan
- Department of Surgery, University of Cincinnati, 231 Albert Sabin Way, Cincinnati, OH 45267-0558, USA
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Diagnosis and treatment of perianal Crohn disease: NASPGHAN clinical report and consensus statement. J Pediatr Gastroenterol Nutr 2013; 57:401-12. [PMID: 23974063 DOI: 10.1097/mpg.0b013e3182a025ee] [Citation(s) in RCA: 99] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Inflammatory bowel disease is a chronic inflammatory disorder of the gastrointestinal tract that includes both Crohn disease (CD) and ulcerative colitis. Abdominal pain, rectal bleeding, diarrhea, and weight loss characterize both CD and ulcerative colitis. The incidence of IBD in the United States is 70 to 150 cases per 100,000 individuals and, as with other autoimmune diseases, is on the rise. CD can affect any part of the gastrointestinal tract from the mouth to the anus and frequently will include perianal disease. The first description connecting regional enteritis with perianal disease was by Bissell et al in 1934, and since that time perianal disease has become a recognized entity and an important consideration in the diagnosis and treatment of CD. Perianal Crohn disease (PCD) is defined as inflammation at or near the anus, including tags, fissures, fistulae, abscesses, or stenosis. The symptoms of PCD include pain, itching, bleeding, purulent discharge, and incontinence of stool. In this report, we review and discuss the etiology, diagnosis, evaluation, and treatment of PCD.
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25
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Nonneoplastic Diseases of the Small Intestine: Differential Diagnosis and Crohn Disease. AJR Am J Roentgenol 2013; 201:W174-82. [DOI: 10.2214/ajr.12.8495] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
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Saigusa N, Yokoyama T, Shinozaki M, Miyahara R, Konishi T, Nakamura T, Yokoyama Y. Anorectal fistula is an early manifestation of Crohn's disease that occurs before bowel lesions advance: a study of 11 cases. Clin J Gastroenterol 2013; 6:309-14. [PMID: 26181735 DOI: 10.1007/s12328-013-0404-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2013] [Accepted: 06/26/2013] [Indexed: 12/22/2022]
Abstract
The diagnostic significance of single-balloon enteroscopy (SBE) in patients presenting with Crohn's disease (CD)-like anorectal fistula is unknown. We experienced 11 cases undergoing SBE due to CD-like fistulas between December 2007 and April 2013. The mean interval from fistula onset to SBE was 19.2 months with a range of 1.3-44.7. Prior to SBE, all patients underwent anorectal examination under anesthesia (EUA), and 9 patients underwent total colonoscopy with terminal ileal cannulation (TCS-I). One of 7 patients undergoing upper gastrointestinal endoscopy had CD-like gastritis. EUA revealed CD fissures in 7 patients, 1 of whom had no intestinal lesion. Primary TCS-I identified early lesions, such as aphthes and small ulcers, in 4 patients. Among the other 5 patients without any intestinal lesions with TCS-I, SBE indicated early lesions in 3 patients. One of 2 patients who initially underwent SBE without TCS-I showed multiple aphthes. Of the 11 patients, only 4 patients fulfilled the definitive Japanese diagnostic criteria for CD and 7 remained 'suspected CD' cases. Intrinsic anorectal fistulas as a presenting symptom of CD may be an early predictor of bowel lesions. SBE has the potential to reveal incipient disease because an early ileal lesion is not rare for patients with anorectal fistulas.
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Affiliation(s)
- Naoto Saigusa
- Department of Surgery, Yokoyama Hospital for Gastroenterological Diseases, 3-11-20 Chiyoda, Naka-ku, Nagoya, 460-0012, Japan.
| | - Tadashi Yokoyama
- Department of Surgery, Yokoyama Hospital for Gastroenterological Diseases, 3-11-20 Chiyoda, Naka-ku, Nagoya, 460-0012, Japan
| | - Masaru Shinozaki
- Department of Surgery, Research Hospital, Institute of Medical Science, The University of Tokyo, 4-6-1 Shirokanedai, Minato-ku, Tokyo, 108-8639, Japan
| | - Ryoji Miyahara
- Department of Gastroenterology and Hepatology, Nagoya University, Graduate School of Medicine, 65 Tsuruma-cho, Showa-ku, Nagoya, Aichi, 466-8560, Japan
| | - Tsuyoshi Konishi
- Department of Surgery, Gastroenterology Center, The Cancer Institute Hospital of Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan
| | - Toshio Nakamura
- Department of Surgery, Fujieda Municipal General Hospital, 4-1-11 Surugadai, Fujieda, 426-8677, Japan
| | - Yasuhisa Yokoyama
- Department of Surgery, Yokoyama Hospital for Gastroenterological Diseases, 3-11-20 Chiyoda, Naka-ku, Nagoya, 460-0012, Japan
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Kaemmerer E, Westerkamp M, Kasperk R, Niepmann G, Scherer A, Gassler N. Coincidence of active Crohn's disease and florid endometriosis in the terminal ileum: A case report. World J Gastroenterol 2013; 19:4413-4417. [PMID: 23885155 PMCID: PMC3718912 DOI: 10.3748/wjg.v19.i27.4413] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2013] [Revised: 03/15/2013] [Accepted: 04/11/2013] [Indexed: 02/06/2023] Open
Abstract
Crohn’s disease (CD), a variant of chronic inflammatory bowel disease, frequently affects the terminal ileum and coecal region. The clinical symptoms are often subtle and depend on the inflammatory activity of disease. In women of child-bearing age, florid intestinal endometriosis can simulate CD. Moreover, current pathophysiological concepts include intestinal endometriosis as a putative founder lesion for consecutive CD establishment. The report summarizes clinical and histomorphological data of a 35-year-old woman with the rare coincidence of florid intestinal endometriosis and CD both affecting the terminal ileum. The patient was suffering over 10 years from strong abdominal disorders including constipation, diarrhea, weight loss, and diffuse abdominal pain. In magnetic resonance imaging-Sellink, strong inflammation and intestinal obstruction of the terminal ileum were found. The laparoscopy revealed further evidence for existence of an inflammatory disease like CD, but brownish spots on the peritoneum were found indicative for endometriosis. Surgical resection of the terminal ileum and the coecal segment was performed followed by histopathological investigations. In transmural sections of the terminal ileum, histomorphological features of florid endometriosis intermingled with florid CD was found. The diagnostic findings were substantiated with a panel of immunohistological stainings. In conclusion, the findings demonstrate that florid endometriosis persists in florid CD lesions and the putative link between intestinal endometriosis and CD is more complex than previously assumed.
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Zbar AP, Horesh N, Bucholtz V, Zmora O, Beer-Gabel M, Carter D. Are there specific endosonographic features in Crohn's patients with perianal fistulae? J Crohns Colitis 2013; 7:490-6. [PMID: 22921529 DOI: 10.1016/j.crohns.2012.07.024] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2012] [Revised: 07/23/2012] [Accepted: 07/23/2012] [Indexed: 02/08/2023]
Abstract
Both 2-dimensional and 3-dimensional endoanal ultrasounds have been shown to be accurate in the definition of the anatomy of complex fistulae-in-ano in patients with perianal Crohn's disease. Recently, a Crohn's Ultrasound Fistula Sign (CUFS) has been suggested as a discriminating feature of perianal Crohn's disease as has the presence of fistulous debris and fistular bifurcation. We blindly assessed 197 patients (39 Crohn's fistulae and 158 cryptogenic fistulae) to determine if these signs differentiated fistula types. The incidence of CUFS in Crohn's cases was 17/39 (43.6%) and in cryptogenic cases was 4/158 (2.5%) (P<0.0001). The sensitivity, specificity, positive and negative predictive values and accuracy for CUFS were 43.6%, 97.5%, 80.9%, 87.5% and 86.8%, respectively. The presence of debris and fistula bifurcation in evaluable cases had a high specificity (87.2% and 81.8%, respectively) but poor sensitivity. The kappa values for or against CUFS, debris and bifurcation in Crohn's cases between 2 observers blinded to the diagnosis were 0.85, 0.72 and 0.93, respectively and in cryptogenic fistulae were 0.89, 0.85 and 0.80, respectively. The kappa values of an agreed consensus for CUFS in Crohn's disease, cryptogenic fistulae and overall with a third observer with no ultrasound experience were 0.62, 0.85 and 0.77, respectively. The presence of CUFS differentiates Crohn's-related from cryptogenic fistulae-in-ano with a high level of agreement for this sign between experienced and inexperienced observers blinded to the underlying diagnosis.
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Affiliation(s)
- Andrew P Zbar
- Department of Surgery and Transplantation, Chaim Sheba Medical Center Ramat Gan Israel, Israel.
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29
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Abstract
Although Crohn disease (CD) is considered an inflammatory bowel disease, extraintestinal gynecologic manifestations are varied, frequent, and oftentimes difficult to manage. Its predilection for young and reproductive-age women makes it an important disease process for the gynecologist to understand, as its complications can have long-term repercussions on the developmental, sexual, reproductive, and psychological health of affected women. Patients may present with a variety of vulvovaginal, perineal, perianal, and urologic complaints. Perianal involvement from an intestinal fistula is the most common skin manifestation seen in CD. Other gynecologic manifestations include metastatic CD and rectovaginal and urovaginal fistulas. Recognition and accurate diagnosis of extraintestinal gynecologic manifestations, as well as a good understanding of the gynecologic effects of chronic disease, are necessary for optimal management. The article provides an overview of CD and highlights the gynecologic considerations in caring for women affected by this disease.
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D'Ugo S, Franceschilli L, Cadeddu F, Leccesi L, Blanco GDV, Calabrese E, Milito G, Di Lorenzo N, Gaspari AL, Sileri P. Medical and surgical treatment of haemorrhoids and anal fissure in Crohn's disease: a critical appraisal. BMC Gastroenterol 2013; 13:47. [PMID: 23496835 PMCID: PMC3602071 DOI: 10.1186/1471-230x-13-47] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2012] [Accepted: 02/28/2013] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND The principle to avoid surgery for haemorrhoids and/or anal fissure in Crohn's disease (CD) patients is still currently valid despite advances in medical and surgical treatments. In this study we report our prospectively recorded data on medical and surgical treatment of haemorrhoids and anal fissures in CD patients over a period of 8 years. METHODS Clinical data of patients affected by perianal disease were routinely and prospectively inserted in a database between October 2003 and October 2011 at the Department of Surgery, Tor Vergata University Hospital, Rome. We reviewed and divided in two groups records on CD patients treated either medically or surgically according to the diagnosis of haemorrhoids or anal fissures. Moreover, we compared in each group the outcome in patients with prior diagnosis of CD and in patients diagnosed with CD only after perianal main treatment. RESULTS Eighty-six CD patients were included in the study; 45 were treated for haemorrhoids and 41 presented with anal fissure. Conservative approach was initially adopted for all patients; in case of medical treatment failure, the presence of stable intestinal disease made them eligible for surgery. Fifteen patients underwent haemorrhoidectomy (open 11; closed 3; stapled 1), and two rubber band ligation. Fourteen patients required surgery for anal fissure (Botox ± fissurectomy 8; LIS 6). In both groups we observed high complication rate, 41.2% for haemorrhoids and 57.1% for anal fissure. Patients who underwent haemorrhoidectomy without certain diagnosis of CD had significantly higher risk of complications. CONCLUSIONS Conservative treatment of proctologic diseases in CD patients has been advocated given the high risk of complications and the evidence that spontaneous healing may also occur. From these preliminary results a role of surgery is conceivable in high selected patients, but definitve conclusions can't be made. Further randomized trials are needed to establish the efficacy of the surgical approach, giving therapeutic recommendations and guidelines.
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Affiliation(s)
- Stefano D'Ugo
- Department of Surgery, University Hospital Tor Vergata, Viale Oxford 81, Rome 00133, Italy
| | - Luana Franceschilli
- Department of Surgery, University Hospital Tor Vergata, Viale Oxford 81, Rome 00133, Italy
| | - Federica Cadeddu
- Department of Surgery, University Hospital Tor Vergata, Viale Oxford 81, Rome 00133, Italy
| | - Laura Leccesi
- Department of Internal Medicine, Catholic University, Rome, Italy
| | | | - Emma Calabrese
- Department of Gastroenterology, University Hospital Tor Vergata, Rome, Italy
| | - Giovanni Milito
- Department of Surgery, University Hospital Tor Vergata, Viale Oxford 81, Rome 00133, Italy
| | - Nicola Di Lorenzo
- Department of Surgery, University Hospital Tor Vergata, Viale Oxford 81, Rome 00133, Italy
| | - Achille L Gaspari
- Department of Surgery, University Hospital Tor Vergata, Viale Oxford 81, Rome 00133, Italy
| | - Pierpaolo Sileri
- Department of Surgery, University Hospital Tor Vergata, Viale Oxford 81, Rome 00133, Italy
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de la Portilla F, Alba F, García-Olmo D, Herrerías JM, González FX, Galindo A. Expanded allogeneic adipose-derived stem cells (eASCs) for the treatment of complex perianal fistula in Crohn's disease: results from a multicenter phase I/IIa clinical trial. Int J Colorectal Dis 2013; 28:313-23. [PMID: 23053677 DOI: 10.1007/s00384-012-1581-9] [Citation(s) in RCA: 250] [Impact Index Per Article: 22.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/16/2012] [Indexed: 02/04/2023]
Abstract
PURPOSE The management of perianal fistula in patients with Crohn's disease is an extremely challenging medical problem as many fistulas do not respond to available treatments. The objectives were to assess the safety and efficacy of a suspension of expanded adipose-derived allogeneic mesenchymal stem cells (eASCs) for the treatment of complex perianal fistula in Crohn's disease METHODS An open-label, single-arm clinical trial was conducted at six Spanish hospitals. Twenty-four patients were administered intralesionally with 20 million eASCs in one draining fistula tract. A subsequent administration of 40 million eASCs was performed if fistula closure was incomplete at week 12. Subjects were followed until week 24 after the initial administration. RESULTS Treatment-related adverse events did not indicate any clinical safety concerns after 6 months follow-up. The full analysis of efficacy data at week 24 showed 69.2 % of the patients with a reduction in the number of draining fistulas, 56.3 % of the patients achieved complete closure of the treated fistula achieved, and 30 % of the cases presenting complete closure of all existing fistula tracts. Of note, closure was strictly defined as: absence of suppuration through the external orifice and complete re-epithelization, plus absence of collections measured by magnetic resonance image scan (MRI). Furthermore, MRI Score of Severity showed statistically significant differences at week 12 with a marked reduction at week 24. CONCLUSIONS Locally injected eASCs appear to be a simple, safe, and beneficial therapy for perianal fistula in Crohn's disease patients. Additional studies are needed to further confirm the efficacy of the eASCs.
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Affiliation(s)
- F de la Portilla
- Coloproctology Unit, Gastrointestinal Surgery Department, Virgen del Rocio University Hospital, Avda. Manuel Siurot s/n, 41013 Seville, Spain.
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Abstract
Although medical management can control symptoms in a recurring incurable disease, such as Crohn's disease, surgical management is reserved for disease complications or those problems refractory to medical management. In this article, we cover general principles for the surgical management of Crohn's disease, ranging from skin tags, abscesses, fistulae, and stenoses to small bowel and extraintestinal disease.
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Affiliation(s)
- Kim C Lu
- Division of Gastrointestinal and General Surgery, Department of Surgery, Oregon Health & Science University, Portland, OR 97239, USA.
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Paparo F, Bacigalupo L, Garello I, Biscaldi E, Cimmino MA, Marinaro E, Rollandi GA. Crohn's disease: prevalence of intestinal and extraintestinal manifestations detected by computed tomography enterography with water enema. ACTA ACUST UNITED AC 2012; 37:326-37. [PMID: 22160373 DOI: 10.1007/s00261-011-9832-8] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Computed tomography enterography (CTE) may detect the presence, severity, and extent of bowel inflammation in patients with Crohn's disease (CD). The aim of our study was to assess, among a cohort of 22 histologically proven CD patients, the prevalence of disease distribution, behavior, anastomotic recurrence and extraintestinal manifestations detected by an original CTE technique. METHODS Two radiologists reviewed 221 CTEs performed providing both small and large bowel distension by oral administration of neutral contrast material and trans-rectal introduction of a water enema (CTE-WE). RESULTS Ileal CD was detected in 116 CTE-WEs (52.4%), including 71/116 (61.2%) non-stricturing/non-penetrating, 17/116 (14.6%) stricturing, and 28/116 (24.1%) penetrating forms. Colonic CD was appreciable in 35 (15.8%) patients, including 18/35 (51.4%) non-stricturing/non-penetrating, 6/35 (17.1%) stricturing, and 11/35 (31.4%) penetrating forms. Ileocolic CD was present in 52 (23.5%) CTE-WEs, including 30/52 (57.7%) non-stricturing/ non-penetrating; 3/52 (5.7%) stricturing, and 19/52 (36.5%) penetrating forms. In 10/221 patients (4.5%), upper gastrointestinal involvement (UGI) was present. Perianal disease was observed in 17/221 patients (7.7%). Fistulas were present in 52 (23.5%) and abscesses in 24 (10.8%) CTE-WEs, respectively. Among 57/221 (25.8%) patients who had undergone a disease-related intestinal resection, in 30/57 cases (52.6%) CD recurrence at the anastomosis was present. 4/221 patients (1.8%) with a histologically confirmed intestinal neoplastic stenosis were observed. Sacroiliitis (24%) was found to be prevalent over hepatic steatosis (10.8%), cholelithiasis (8.6%), and nephrolithiasis (4%). CONCLUSIONS CTE-WE represents a comprehensive imaging technique which may demonstrate bowel inflammation and CD extraintestinal manifestations. A peculiar prevalence of UGI involvement and neoplastic strictures were observed. In our study the prevalence of sacroiliitis resulted higher than previously reported.
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Affiliation(s)
- F Paparo
- Department of Radiology, E.O. Ospedali Galliera, Genova, Italy.
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Ghazi LJ, Schwartz DA. Perianal Crohn's Disease—A Gastroenterologist's Perspective. SEMINARS IN COLON AND RECTAL SURGERY 2012. [DOI: 10.1053/j.scrs.2012.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Wise PE, Schwartz DA. The evaluation and treatment of Crohn perianal fistulae: EUA, EUS, MRI, and other imaging modalities. Gastroenterol Clin North Am 2012; 41:379-91. [PMID: 22500524 DOI: 10.1016/j.gtc.2012.01.009] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Perianal fistulizing disease is a common complication of CD that requires a multidisciplinary collaboration between gastroenterology, surgery, and radiology professionals for successful assessment and treatment. Optimal success comes from a combined medical and surgical approach to treat the fistulizing disease (see Fig. 1). Unfortunately, even with a variety of surgical options, a subset of patients require permanent fecal diversion and/or proctectomy to successfully treat their disease. Further studies (likely requiring large, multicenter trials) of novel medical and surgical treatments are still warranted to formulate optimal management of this complex condition.
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Affiliation(s)
- Paul E Wise
- Department of Surgery, Section of Surgical Sciences, Vanderbilt University Medical Center, 1211 21st Avenue South, Nashville, TN 37232-0252, USA
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Ratto C, Litta F, Parello A, Donisi L, Zaccone G, De Simone V. Gore Bio-A® Fistula Plug: a new sphincter-sparing procedure for complex anal fistula. Colorectal Dis 2012; 14:e264-9. [PMID: 22288601 DOI: 10.1111/j.1463-1318.2012.02964.x] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
AIM The surgical treatment of a complex anal fistula remains controversial, although 'sphincter-saving' operations are desirable. The Gore Bio-A® Fistula Plug is a new bioprosthetic plug that has been proposed for the treatment of complex anal fistula. This study reports preliminary data following implantation of this plug. METHOD Eleven patients with a complex anal fistula underwent insertion of Gore Bio-A® Fistula Plugs. The disc diameter and number of tubes in the plug were adapted to the fistula to allow accommodation of the disc into a submucosal pocket, and the excess tubes were trimmed. During the follow-up period, patients underwent clinical and physical examinations and three-dimensional endoanal ultrasound. RESULTS Fistulas were high anterior transphincteric in five patients and high posterior transphincteric in six patients. All patients had a loose seton placement before plug insertion. Two, three and four tubes were inserted into the fistula plug in seven, three and one patient, respectively. The median follow-up period was 5 months. No patient reported any faecal incontinence. There was no case of early plug dislodgement. Treatment success was noted for eight (72.7%) of 11 patients at the last follow-up appointment. CONCLUSION Implanting a Gore Bio-A® Fistula Plug is a simple, minimally invasive, safe and potentially effective procedure to treat complex anal fistula. Patient selection is fundamental for success.
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Affiliation(s)
- C Ratto
- Department of Surgical Sciences, Catholic University, Rome, Italy.
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A systematic review of the anal fistula plug for patients with Crohn's and non-Crohn's related fistula-in-ano. Dis Colon Rectum 2012; 55:351-8. [PMID: 22469804 DOI: 10.1097/dcr.0b013e318239d1e4] [Citation(s) in RCA: 119] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND The management of fistula-in-ano is a balance between fistula cure and preservation of continence. OBJECTIVE The aim of this study is to summarize the anal fistula plug literature for Crohn's and non-Crohn's fistula-in-ano in a homogenous patient population. DATA SOURCES PubMed, MEDLINE, Embase, and Cochrane medical databases were searched from 1995 to 2011. Abstracts from The American Society of Colon and Rectal Surgeons, The Society for Surgery of the Alimentary Tract, The European Society of Coloproctology, and the Association of Coloproctology of Great Britain and Ireland meetings between 2007 and 2010 were also evaluated. STUDY SELECTION Studies were included if results for patients with and without Crohn's disease could be differentiated. Patients with rectovaginal, anovaginal, rectourethral, or ileal-pouch vaginal fistulas were excluded as were studies where the mean or median follow-up was less than 3 months. Two researchers independently selected studies matching the inclusion criteria. INTERVENTION Anal fistula plug insertion was performed. MAIN OUTCOME MEASURES The primary outcomes measured were the overall fistula closure rates and length of follow-up. RESULTS Seventy-six articles or abstracts were identified from the title as being of relevance. Twenty studies (2 abstracts, 18 articles) were finally included. Study sample size ranged from 4 to 60 patients; 530 patients were included in all studies (488 non-Crohn's and 42 Crohn's patients). The plug extrusion rate was 8.7% (46 patients). The proportion of patients achieving fistula closure varied widely between studies for non-Crohn's, ranging from 0.2 (95% CI 0.04-0.48) to 0.86 (95% CI 0.64-0.97). The pooled proportion of patients achieving fistula closure in patients with non-Crohn's fistula-in-ano was 0.54 (95% CI 0.50-0.59). The proportion achieving closure in patients with Crohn's disease was similar (0.55, 95% CI 0.39-0.70). LIMITATIONS This study was limited by the variability of operative technique and perioperative care between studies. CONCLUSIONS Fistula closure is achieved by using the anal fistula plug in approximately 54% of patients without Crohn's disease. The anal fistula plug has not been adequately evaluated in the Crohn's population.
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Karin E, Avital S, Dotan I, Skornick Y, Greenberg R. Doppler-guided haemorrhoidal artery ligation in patients with Crohn's disease. Colorectal Dis 2012; 14:111-4. [PMID: 21176064 DOI: 10.1111/j.1463-1318.2010.02541.x] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
AIM The outcome of Doppler-guided haemorrhoidal artery ligation (DGHAL) was assessed in patients with Crohn's disease (CD) suffering from grade III haemorrhoids. METHOD A retrospective study was carried out of patients with CD and symptomatic Grade III haemorrhoids treated by DGHAL. Perioperative and follow-up data were retrieved from our database of patients undergoing DGHAL. RESULTS The study included seven men and six women. The mean age was 34 years old. All had CD without anorectal involvement. The median duration of haemorrhoidal symptoms was 6.3 years. There was no mortality, new incontinence, faecal impaction, urinary retention, abscess formation or persistent pain following the procedure. Mean pain score based on a visual analogue scale (VAS) decreased from 2.4 at 24 h postoperatively to 1.6 on the seventh postoperative day. All patients had completely recovered by the third postoperative day. At 18 months, three (77%) of the patients were asymptomatic and three had recurrent symptoms. CONCLUSION Doppler-guided haemorrhoidal artery ligation is safe and effective in treating Grade III haemorrhoids in patients with CD without rectal involvement.
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Affiliation(s)
- Eliad Karin
- Department of Surgery 'A', Tel-Aviv Medical Center and the Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
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Abstract
PURPOSE OF REVIEW The principles of surgical management of inflammatory bowel disease (IBD) continue to evolve with advances in medical therapy, surgical technique, and minimally invasive operative technology. The purpose of this review is to highlight such advances in colorectal and anorectal surgery for IBD over the last year. RECENT FINDINGS Treatment of ulcerative colitis and Crohn's disease remains challenging and relies on knowledge of both medical and surgical therapies. Recent data support shorter hospitalization prior to surgical intervention in patients with acute severe ulcerative colitis, laparoscopic surgical approaches when feasible, and ciprofloxacin as optimal therapy for pouchitis, when preventive therapy with probiotics is not successful. SUMMARY The management of IBD remains complex and highly individualized. In severe cases, a combination of immunosuppression and surgical therapies may be required. However, the associated risks of complications make judgments about optimal treatment plans challenging.
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Bleier JI, Moloo H. Management of Cryptoglandular Fistula-in-Ano. SEMINARS IN COLON AND RECTAL SURGERY 2011. [DOI: 10.1053/j.scrs.2010.09.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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