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Salgado-Nesme N, Alvarez-Bautista FE, Mongardini FM, Docimo L, Hoyos-Torres A, Ruiz-Muñoz EA, Vergara-Fernàndez O, Suastegui HOG, Illanes MFR, Reyes NDM. LIFT procedure: postoperative outcomes, risk factors for fistula recurrence and continence impairment. Updates Surg 2024; 76:989-997. [PMID: 38570423 DOI: 10.1007/s13304-024-01818-2] [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: 12/19/2023] [Accepted: 03/04/2024] [Indexed: 04/05/2024]
Abstract
Ligation of the intersphincteric fistula tract has been recently employed as definitive treatment of anal fistulas. However, it carries a potential risk of continence impairment, fistula recurrence, and repeated operations. This study aimed to assess postoperative outcomes related to this procedure and evaluate the potential influence of preoperative and intraoperative features. Patients who underwent LIFT procedure between June 2012 and September 2021 were retrospectively analyzed. Patients were divided according to whether they developed fistula recurrence and on the history of a surgery prior to the LIFT. Preoperative features, postoperative outcomes, and risk factors adverse outcomes were analyzed. Forty-eight patients were included, of which 25 received primary LIFT, being the high transsphincteric fistula pattern the most frequent (62.5%). The median follow-up was 13.3 months, with a recurrence rate of 20.8%, of which the majority presented an intersphincteric fistula pattern (50%); and continence impairment rate of 16.7%. A higher prevalence of diabetes (p = 0.026) and a trend towards a higher prevalence of patients with a history of high transsphincteric fistula (0.052) were observed in the group with fistula recurrence. The history of diabetes and the operation time with a cut-off value ≥ 69 min showed a trend as a risk factors for developing fistula recurrence (0.06) and postoperative continence impairment (0.07), respectively. The LIFT procedure seems to be safe in terms of morbidity, with a reasonable incidence of recurrences, showing better results when it is primarily performed. Preoperative characteristics should be considered as they may impact outcomes.
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Affiliation(s)
- N Salgado-Nesme
- Department of Colorectal Surgery, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - F E Alvarez-Bautista
- Department of Colorectal Surgery, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - F M Mongardini
- Division of General, Oncological, Mini-Invasive and Obesity Surgery, University of Study of Campania "Luigi Vanvitelli", 80131, Naples, Italy
| | - L Docimo
- Division of General, Oncological, Mini-Invasive and Obesity Surgery, University of Study of Campania "Luigi Vanvitelli", 80131, Naples, Italy
| | - A Hoyos-Torres
- Department of Colorectal Surgery, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - E A Ruiz-Muñoz
- Department of Colorectal Surgery, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - O Vergara-Fernàndez
- Department of Colorectal Surgery, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - H O Gómez Suastegui
- Department of Colorectal Surgery, Hospital de Especialidades-Centro Médico Nacional Siglo XXI, Mexico City, Mexico
| | - M F Rojas Illanes
- Department of Colorectal Surgery, Hospital de Especialidades-Centro Médico Nacional Siglo XXI, Mexico City, Mexico
| | - N D Mitre Reyes
- Department of Colorectal Surgery, Hospital de Especialidades-Centro Médico Nacional Siglo XXI, Mexico City, Mexico.
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van Oostendorp JY, Verkade C, Han-Geurts IJM, van der Mijnsbrugge GJH, Wasowicz-Kemps DK, Zimmerman DDE. Ligation of intersphincteric fistula tract (LIFT) for trans-sphincteric cryptoglandular anal fistula: long-term impact on faecal continence. BJS Open 2024; 8:zrae055. [PMID: 38843378 PMCID: PMC11156194 DOI: 10.1093/bjsopen/zrae055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2024] [Revised: 04/08/2024] [Accepted: 04/11/2024] [Indexed: 06/09/2024] Open
Abstract
BACKGROUND The ligation of intersphincteric fistula tract is a surgical technique designed to treat trans-sphincteric anal fistulas aiming to preserve sphincter integrity. Recent studies suggest its efficacy in short-term fistula healing with limited impact on continence. However, comprehensive prospective data on long-term outcomes, including recurrence and bowel continence, are limited. The present study aims to report on the long-term functional outcomes. METHODS Patients who underwent the ligation of intersphincteric fistula tract procedure for trans-sphincteric cryptoglandular anal fistulas between July 2012 and October 2018 at two Dutch referral centres were retrospectively reviewed. The primary outcome of interest was the long-term bowel continence after the ligation of intersphincteric fistula tract procedure, using the faecal incontinence severity index. Short-term data (collected in 2018) and long-term data (collected in 2023) on bowel continence, healing rates and recurrences were obtained through electronic records and Rockwood questionnaires. Sankey diagrams were used to visually represent individual variations in continence status (preoperative versus follow-up). RESULTS Among 110 patients included (50% female, median follow-up 92 months), 101 patients (92%) were treated with previous surgeries (median 2, range 0-6) and 80% had previous seton drainage. Preligation of intersphincteric fistula tract, 16% of the patients reported incontinence (mean(s.d.) faecal incontinence severity index: 2.4(7.5), increasing to 18% after ligation of intersphincteric fistula tract at short-term follow-up, including 11% newly induced cases. Long-term follow-up collected using Rockwood questionnaires (63% response rate) in 69 patients uncovered a 74% incontinency rate (mean(s.d.) faecal incontinence severity index: 9.22(9.5). In those patients without subsequent surgery 49% (17 of 35) reported incontinence at long-term follow-up. Primary fistula healing after ligation of intersphincteric fistula tract was 28%. Preoperative seton drainage significantly improved healing rates (33% versus 9%). Notably, 43% (34 of 79) of unhealed fistulas transitioned into intersphincteric tracts; in these patients, 19 were treated with subsequent fistulotomy achieving cure in 18 cases. CONCLUSIONS Ligation of intersphincteric fistula tract healing rates fell below recent literature standards. Although the immediate impact on postoperative continence appears minimal, long-term incontinence rates are concerning. In recognizing the deterioration of individual continence, we advocate for a patient-centered approach and urge fellow researchers and clinicians to collect comprehensive prospective continence data.
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Affiliation(s)
- Justin Y van Oostendorp
- Department of Surgery, Proctos Kliniek, Bilthoven, The Netherlands
- Department of Surgery, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Carolien Verkade
- Department of Surgery, Elisabeth-TweeSteden Hospital, Tilburg, The Netherlands
| | | | | | | | - David D E Zimmerman
- Department of Surgery, Elisabeth-TweeSteden Hospital, Tilburg, The Netherlands
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Karki C, Athavale A, Abilash V, Hantsbarger G, Geransar P, Lee K, Milicevic S, Perovic M, Raven L, Sajak-Szczerba M, Silber A, Yoon A, Tozer P. Multi-national observational study to assess quality of life and treatment preferences in patients with Crohn's perianal fistulas. World J Gastrointest Surg 2023; 15:2537-2552. [PMID: 38111766 PMCID: PMC10725550 DOI: 10.4240/wjgs.v15.i11.2537] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Revised: 09/27/2023] [Accepted: 10/30/2023] [Indexed: 11/26/2023] Open
Abstract
BACKGROUND Patients with Crohn's disease (CD) are at risk of developing complications such as perianal fistulas. Patients with Crohn's perianal fistulas (CPF) are affected by fecal incontinence (FI), bleeding, pain, swelling, and purulent perianal discharge, and generally face a higher treatment burden than patients with CD without CPF. AIM To gain insights into the burden of illness/quality of life in patients with CPF and their treatment preferences and satisfaction. METHODS This cross-sectional observational study was conducted in patients with CD aged 21-90 years via a web-enabled questionnaire in seven countries (April-August 2021). Patients were recruited into three cohorts: Cohort 1 included patients without perianal fistulas; cohort 2 included patients with perianal fistulas without fistula-related surgery; and cohort 3 included patients with perianal fistulas and fistula-related surgery. Validated patient-reported outcome measures were used to assess quality of life. Drivers of treatment preferences were measured using a discrete choice experiment (DCE). RESULTS In total, 929 patients were recruited (cohort 1, n = 620; cohort 2, n = 174; cohort 3, n = 135). Short Inflammatory Bowel Disease Questionnaire scores were worse for patients with CPF (cohorts 2 and 3) than for those with CD without CPF (cohort 1): Mean score 3.8 and 3.7 vs 4.1, respectively, (P < 0.001). Similarly, mean Revised FI and FI Quality of Life scores were worse for patients with CPF than for those with CD without CPF. Quality of Life with Anal Fistula scores were similar in patients with CPF with or without CPF-related surgery (cohorts 2 and 3): Mean score 41 and 42, respectively. In the DCE, postoperative discomfort and fistula healing rate were the most important treatment attributes influencing treatment choice: Mean relative importance 35.7 and 24.7, respectively. CONCLUSION The burden of illness in CD is significantly higher for patients with CPF and patients rate lower postoperative discomfort and higher healing rates as the most desirable treatment attributes.
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Affiliation(s)
- Chitra Karki
- Global Evidence and Outcomes-Gastroenterology, Takeda Pharmaceuticals United States, Inc, Cambridge, MA 02139, United States
| | - Amod Athavale
- Trinity Partners, LLC, Waltham, MA 02451-7528, United States
| | - Vijay Abilash
- Trinity Partners, LLC, Waltham, MA 02451-7528, United States
| | - Gary Hantsbarger
- Observational Research, Takeda Pharmaceuticals United States, Inc, Cambridge, MA 02139, United States
| | - Parnia Geransar
- Medical Affairs, Takeda Pharmaceuticals International Co., Opfikon 8152, Zurich, Switzerland
| | - Kate Lee
- Research and Patient Programs, Crohn’s and Colitis Canada, 600-60 St. Clair Avenue East, Toronto M4T 1N5, Ontario, Canada
| | - Slobodan Milicevic
- Medical Affairs, Takeda Pharmaceuticals International Co., Opfikon 8152, Zurich, Switzerland
| | - Marko Perovic
- Treasurer, European Federation of Crohn’s & Ulcerative Colitis Associations, Brussels B 1000, Belgium
| | - Leanne Raven
- Crohn’s and Colitis Australia, Camberwell South, VIC 3124, Australia
| | | | - Abigail Silber
- Trinity Partners, LLC, Waltham, MA 02451-7528, United States
| | - Annabelle Yoon
- Japan Medical Office, Takeda Pharmaceutical Company Limited, Tokyo 103-8668, Japan
| | - Phil Tozer
- Department of Colorectal Surgery, St Mark’s Hospital and Academic Institute, London HA1 3UJ, United Kingdom
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Sahara R, Koizumi M, Morimoto K, Kubota I. Subcutaneous incision of the fistula tract and internal sphincterotomy (SIFT-IS): a novel surgical procedure for transsphincteric anal fistula. Colorectal Dis 2022; 24:1576-1583. [PMID: 35946094 PMCID: PMC10087595 DOI: 10.1111/codi.16297] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Revised: 07/28/2022] [Accepted: 07/31/2022] [Indexed: 01/07/2023]
Abstract
AIM The aetiology of anal fistula has not been fully clarified. One of the causes of anal fistulas may be the markedly deep crypts that characterize the primary openings. We developed subcutaneous incision of the fistula tract and internal sphincterotomy (SIFT-IS) to eradicate these deep crypts. The aim of this study was to evaluate outcomes in patients with anal fistula treated with SIFT-IS. METHOD A retrospective study was performed over a 2-year period. Patients with transsphincteric anal fistula who underwent SIFT-IS were enrolled. The primary endpoint was the anal fistula healing rate at 16 weeks postoperatively. The secondary endpoints were healing time, postoperative complications and clinical continence status. RESULTS One hundred and fifty one patients were enrolled. Primary healing was accomplished in 129 patients (85%). There were 17 patients (11%) with a remnant fistula and five (3%) with a recurrence. The remnant fistulas healed spontaneously at more than 16 weeks postoperatively in seven patients. The median healing time was 6 (3-96) weeks. Surgical intervention was required in seven patients with a remnant fistula and four with recurrence. At the final follow-up, the wounds had healed in 148 patients (98%). No significant postoperative complications or incontinence were observed. CONCLUSION Subcutaneous incision of the fistula tract and internal sphincterotomy is a promising surgical option for transsphincteric anal fistulas, with a satisfactory healing rate.
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Affiliation(s)
- Rikisaburo Sahara
- Proctology Center, Makita General Hospital, Tokyo, Japan.,Nishiarai Coloproctology Clinic, Tokyo, Japan
| | - Michihiro Koizumi
- Nishiarai Coloproctology Clinic, Tokyo, Japan.,Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Nippon Medical School, Tokyo, Japan
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Hong Y, Xu Z, Gao Y, Sun M, Chen Y, Wen K, Wang X, Sun X. Sphincter-Preserving Fistulectomy Is an Effective Minimally Invasive Technique for Complex Anal Fistulas. Front Surg 2022; 9:832397. [PMID: 35392057 PMCID: PMC8980274 DOI: 10.3389/fsurg.2022.832397] [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: 12/09/2021] [Accepted: 02/03/2022] [Indexed: 11/13/2022] Open
Abstract
Background The optimal treatment of complex anal fistulas remains unclear, though many different sphincter-preserving procedures have been described. A minimally invasive technique with a better outcome is desired. The purpose of this study was to present a new technique—sphincter-preserving fistulectomy (SPF) and its clinical outcomes. Materials and Methods A retrospective study was performed to compare the efficacy and outcomes of SPF with ligation of the intersphincteric fistula tract (LIFT) in the management of complex anal fistulas in regards to postoperative pain, complications, wound healing time, recurrence, overall success rate, fecal continence function, and quality of life. Continence function was evaluated using the Wexner incontinence scale and anal manometry. The fecal incontinence quality of life (FIQL) scale was used to assess patients' quality of life. Results From June 2020 to July 2021, 41 patients with 43 SPF procedures and 35 patients with 35 LIFT procedures were included. Postoperative pain was comparable between two groups. The morbidity rate and the mean wound healing time in the SPF group were lower than those in the LIFT group (2.3% vs. 48.6%, p < 0.001; 1.4 ± 0.3 vs. 1.7 ± 0.4 months, p = 0.001). At a mean follow-up duration of 11.4 ± 3.5 months in the SPF group and 10.7 ± 4.3 months in the LIFT group, SPF achieved a better overall success rate than LIFT (97.7% vs. 77.1%, p = 0.014). Three patients in the SPF group and 4 patients in the LIFT group who all underwent a simultaneous fistulotomy procedure complained new incontinence of flatus. There was no statistical difference between the two groups in regards to the Wexner scores (p = 0.790), the maximum resting anal canal pressure (p = 0.641), the maximum squeeze pressure (p = 0.289), and the FIQL scores including lifestyle (p = 0.188), coping (p = 0.188), depression (p = 0.850), and embarrassment (p = 0.910). Conclusions SPF is a novel, safe, and effective minimally invasive technique for the management of complex anal fistulas, with a promising success rate and negligible impairment on continence. Future prospective studies are needed to evaluate the long-term outcomes of SPF.
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Affiliation(s)
- Yinwen Hong
- Department of Obstetrics and Gynecology, Suzhou Hospital of Integrated Traditional Chinese and Western Medicine, Suzhou, China
| | - Zhizhong Xu
- Department of Colorectal Surgery, Suzhou TCM Hospital Affiliated to Nanjing University of Chinese Medicine, Suzhou, China
| | - Ying Gao
- Department of Colorectal Surgery, Suzhou TCM Hospital Affiliated to Nanjing University of Chinese Medicine, Suzhou, China
| | - Mingming Sun
- Department of Colorectal Surgery, Suzhou TCM Hospital Affiliated to Nanjing University of Chinese Medicine, Suzhou, China
| | - Yinghui Chen
- Department of Colorectal Surgery, Suzhou TCM Hospital Affiliated to Nanjing University of Chinese Medicine, Suzhou, China
| | - Ke Wen
- Department of Colorectal Surgery, Suzhou TCM Hospital Affiliated to Nanjing University of Chinese Medicine, Suzhou, China
| | - Xiaopeng Wang
- Department of Colorectal Surgery, Suzhou TCM Hospital Affiliated to Nanjing University of Chinese Medicine, Suzhou, China
- *Correspondence: Xiaopeng Wang
| | - Xueliang Sun
- Department of Colorectal Surgery, Suzhou TCM Hospital Affiliated to Nanjing University of Chinese Medicine, Suzhou, China
- Xueliang Sun
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Sturm A, Atreya R, Bettenworth D, Bokemeyer B, Dignaß A, Ehehalt R, Germer C, Grunert PC, Helwig U, Herrlinger K, Kienle P, Kreis ME, Kucharzik T, Langhorst J, Maaser C, Ockenga J, Ott C, Siegmund B, Zeißig S, Stallmach A. Aktualisierte S3-Leitlinie „Diagnostik und Therapie des Morbus Crohn“ der Deutschen Gesellschaft für Gastroenterologie, Verdauungs- und Stoffwechselkrankheiten (DGVS) – August 2021 – AWMF-Registernummer: 021-004. ZEITSCHRIFT FUR GASTROENTEROLOGIE 2022; 60:332-418. [PMID: 35263784 DOI: 10.1055/a-1713-3941] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
- Andreas Sturm
- Klinik für Innere Medizin mit Schwerpunkt Gastroenterologie, DRK Kliniken Berlin Westend, Berlin, Deutschland
| | - Raja Atreya
- Medizinische Klinik 1, Universitätsklinikum Erlangen, Deutschland
| | | | - Bernd Bokemeyer
- Gastroenterologische Gemeinschaftspraxis Minden, Deutschland
| | - Axel Dignaß
- Medizinische Klinik I, Agaplesion Markus Krankenhaus, Frankfurt am Main, Deutschland
| | | | - Christoph Germer
- Chirurgische Klinik I, Universitätsklinikum Würzburg, Deutschland
| | - Philip C Grunert
- Klinik für Innere Medizin IV (Gastroenterologie, Hepatologie und Infektiologie), Universitätsklinikum Jena, Deutschland
| | - Ulf Helwig
- Internistische Praxengemeinschaft, Oldenburg, Deutschland
| | | | - Peter Kienle
- Allgemein- und Viszeralchirurgie, Theresienkrankenhaus und Sankt Hedwig-Klinik GmbH, Mannheim, Deutschland
| | - Martin E Kreis
- Klinik für Allgemein-, Viszeral- und Gefäßchirurgie, Charité Campus Benjamin Franklin - Universitätsmedizin Berlin, Deutschland
| | - Torsten Kucharzik
- Klinik für Allgemeine Innere Medizin und Gastroenterologie, Klinikum Lüneburg, Deutschland
| | - Jost Langhorst
- Klinik für Integrative Medizin und Naturheilkunde, Klinikum am Bruderwald, Bamberg, Deutschland
| | | | - Johann Ockenga
- Medizinische Klinik II, Klinikum Bremen Mitte - Gesundheit Nord, Bremen, Deutschland
| | - Claudia Ott
- Gastroenterologie Facharztzentrum, Regensburg, Deutschland
| | - Britta Siegmund
- Medizinische Klinik I, Charité Universitätsmedizin Berlin, Campus Benjamin Franklin, Deutschland
| | - Sebastian Zeißig
- Medizinische Klinik und Poliklinik I, Universitätsklinikum Dresden, Deutschland
| | - Andreas Stallmach
- Klinik für Innere Medizin IV (Gastroenterologie, Hepatologie und Infektiologie), Universitätsklinikum Jena, Deutschland
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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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Jiang J, Zhang Y, Ding X, Zhang N, Ji L. Efficacy and safety of an innovatively modified cutting seton technique for the treatment of high anal fistula: A protocol for a randomized controlled trial. Medicine (Baltimore) 2021; 100:e24442. [PMID: 33592892 PMCID: PMC7870255 DOI: 10.1097/md.0000000000024442] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Accepted: 01/05/2021] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND Anal fistula is a common anorectal disease. So far, operation is still the optimal method to cure anal fistula. High anal fistula (HAF) is an even more clinically difficult disease to treat. Evidence suggested that seton placement can be a definitive treatment for HAF. However, tightening the seton brings great pain to patients, which affects the clinical application of the therapy. Also, this may lead to difficulty in controlling anal fluids and gas because of the larger scar left and the local defect in the anal after the operation. We propose an innovative seton technique for the treatment of HAF, after long term attempts, the operation of the modified seton cutting technique. The aim of our present study is to compare the difference of anal function, healing time, pain severity, recurrence, and complications between the procedure of the modified seton cutting technique and the conventional cutting seton operation against HAF with a randomized, controlled, prospective study. METHODS 204 participants in this trial will be randomly divided into treatment group (procedure of the modified seton cutting technique) and control group (cutting seton technique) in a 1:1 ratio. The outcomes of continence state, pain severity after tightening, complete healing of fistula, duration to healing, operation time, recurrence rates, and postoperative complications will be recorded at 1, 2, 3, 4 weeks, then every month in the outpatient clinic. Data will be analyzed by SPSS version 22. CONCLUSIONS The findings of the study will help to explore the efficacy and safety of the procedure of the modified seton cutting technique against AF. TRIAL REGISTRATION NUMBER DOI 10.17605/OSF.IO/V6G2S.
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Affiliation(s)
- Jie Jiang
- Changshu Hospital Affiliated to Nanjing University of Chinese Medicine, Changshu, Jiangsu province
| | - Yang Zhang
- Department of Anorectal Surgery, Nanjing Hospital of Chinese Medicine Affiliated to Nanjing University of Chinese Medicine, Nanjing
| | - Xufeng Ding
- Changshu Hospital Affiliated to Nanjing University of Chinese Medicine, Changshu, Jiangsu province
| | - Naijin Zhang
- Tianjin University of Traditional Chinese Medicine, Tianjin, China
| | - Lijiang Ji
- Changshu Hospital Affiliated to Nanjing University of Chinese Medicine, Changshu, Jiangsu province
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Zhang J, Hao X, Zhu Y, Luan R. Efficacy and safety of ligation of intersphincteric fistula tract in the treatment of anal fistula: A protocol for systematic review and meta-analysis. Medicine (Baltimore) 2021; 100:e23700. [PMID: 33530171 PMCID: PMC7850721 DOI: 10.1097/md.0000000000023700] [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: 11/11/2020] [Accepted: 11/16/2020] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND Anal fistula is characterized with perianal cellulitis, anorectal pain, smelly or bloody drainage of pus, and difficulty in controlling bowel movements. Ligation of intersphincteric fistula tract (LIFT) technique is a recently developed approach against anal fistula, and it could alleviate the pain of the patient, with little postoperative trauma, which can greatly shorten the wound healing time and hospitalization stay. We conduct the meta-analysis and systematic review to systematically evaluate the clinical efficacy and safety of LIFT in the treatment of anal fistula. METHODS Randomized controlled trials of LIFT against anal fistula will be searched in several Chinese and English databases. Two reviewers will independently conduct the literature extraction and risk of bias assessment. Statistical analysis will be conducted in RevMan 5.3. RESULTS AND CONCLUSIONS The study will help to systematically evaluate the clinical efficacy and safety of LIFT in the treatment of anal fistula. OSF REGISTRATION NUMBER DOI 10.17605/OSF.IO/T4FUH.
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Placer Galán C, Aguirre I, Pastor T, Etxart A, Enriquez Navascués JM. LIFT procedure for posterior fistula-in-ano. Are outcomes good enough? A systematic review and meta-analysisis of observational studies. Cir Esp 2020; 99:183-189. [PMID: 33303194 DOI: 10.1016/j.ciresp.2020.08.009] [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: 05/30/2020] [Revised: 06/28/2020] [Accepted: 08/23/2020] [Indexed: 12/16/2022]
Abstract
INTRODUCTION Efficacy of the ligation of intersphincteric fistula tract (LIFT) procedure for posterior fistula-in-ano remains under debate. However, there is scarcity of quality evidence analysing this issue. Thus, the aim of this study is to evaluate outcomes of LIFT surgery in patients with posterior anal fistula. MATERIAL AND METHODS Systematic review and meta-analysis to evaluate efficacy of LIFT procedure for posterior anal fistula. MEDLINE (PubMed), EMBASE, Scopus, Web of Science, Cochrane Library and Google Scholar data sources were searched for key-words (MeSH terms): "LIFT" OR "Ligation of the intersphincteric fistula tract" AND "posterior anal fistula" OR "posterior fistula-in-ano". Original, observational and experimental, non-language restriction studies published from January 2000 to March 2020 and reporting outcomes on LIFT procedure for posterior anal fistula were reviewed. Quality and potential biases were assessed using Newcastle-Ottawa scale, following AHRQ recommendations. Additional sensitivity analysis and publication bias evaluation (Beg and Egger's tets) were performed. RESULTS No significant differences were found in recurrence rate among patients undergoing LIFT procedure for posterior fistula-in-ano in contrast to other locations (OR 1.36 [IC 95% 0.60-3.07]; p=.46). I2 test value was 77%, expressing a fair heterogeneity among included studies. The weighed median for overall recurrence was 37.8% (RI 18.3-47.7%); with a weighed median of 47.1% (RI 30.7 - 63.7%) and 36.3% (RI 15.8-51.3%) (p=.436) respectively for recurrence after LIFT for posterior fistula and fistula in other locations. There was not clear evidence about the sample size ("n") of included studies nor the disparities in quality assessment of those, could justify the observed heterogeneity. No significant publication bias was found. CONCLUSION This systematic review and meta-analysis suggests that there are no clear data in the literature for not performing the LIFT procedure in posteriorly located fistulas.
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Affiliation(s)
- Carlos Placer Galán
- Sección de Cirugía Colo-rectal, Servicio de Cirugía General y Digestiva, Hospital Universitario Donostia, Biodonostia, San Sebastián, España.
| | - Ignacio Aguirre
- Sección de Cirugía Colo-rectal, Servicio de Cirugía General y Digestiva, Hospital Universitario Donostia, Biodonostia, San Sebastián, España
| | - Tania Pastor
- Sección de Cirugía Colo-rectal, Servicio de Cirugía General y Digestiva, Hospital Universitario Donostia, Biodonostia, San Sebastián, España
| | - Ane Etxart
- Sección de Cirugía Colo-rectal, Servicio de Cirugía General y Digestiva, Hospital Universitario Donostia, Biodonostia, San Sebastián, España
| | - Jose María Enriquez Navascués
- Sección de Cirugía Colo-rectal, Servicio de Cirugía General y Digestiva, Hospital Universitario Donostia, Biodonostia, San Sebastián, España
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11
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Leenders LAM, Stijns J, van Loon YT, Van Tilborg F, Wasowicz DK, Zimmerman DDE. The complexity of cryptoglandular fistula-in-ano can be predicted by the distance of the external opening to the anal verge; implications for preoperative imaging? Tech Coloproctol 2020; 25:109-115. [PMID: 33180233 DOI: 10.1007/s10151-020-02353-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Accepted: 09/25/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Many surgeons believe that the distance from the external opening to the anal verge (DEOAV) predicts the complexity of a cryptoglandular fistulas-in-ano and, therefore, predicts the need for additional imaging. However, there is no evidence to support this. The primary aim of this study was to determine if DEOAV can predict the complexity of a fistula. Secondary aims were clinical outcome and identification of those patients that might not benefit from preoperative imaging. METHODS All patients having surgery for cryptoglandular fistula-in-ano between January 2014 and December 2016 were evaluated. Preoperative imaging was used to classify fistulas as simple or complex. The DEAOV was measured preoperatively and was divided into categories ≤ 1 cm, 1-2 cm, or > 2 cm. The relationship between the DEOAV and complexity of the fistula was investigated. Clinical outcome was recorded and a group of patients that might not benefit from preoperative imaging was identified. RESULTS A total of 103 patients [m:f = 65:38, median age 47 (range 19-79) years] were included. Magnetic resonance imaging identified 39 simple and 64 complex fistulas. The percentage of simple fistula was 88% in fistulas with DEAOV ≤ 1 cm, 48% in DEAOV 1-2 cm and 38% in > 2 cm. There was a significant difference between the complexity of the fistula and the distance to the anal verge (p < 0.001). The overall healing rate was 88%. CONCLUSIONS The complexity of perianal fistula depends on the DEAOV. We propose that preoperative imaging should be performed in fistulas with external opening > 1 cm from the anal verge.
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Affiliation(s)
- L A M Leenders
- Department of Surgery, ETZ (Elisabeth, TweeSteden Ziekenhuis), Doctor Deelenlaan 5, 5042 AD, Tilburg, The Netherlands
| | - J Stijns
- Department of Surgery, ETZ (Elisabeth, TweeSteden Ziekenhuis), Doctor Deelenlaan 5, 5042 AD, Tilburg, The Netherlands.,Department of Surgery, UZ Brussel, Brussels, Belgium
| | - Y T van Loon
- Department of Surgery, ETZ (Elisabeth, TweeSteden Ziekenhuis), Doctor Deelenlaan 5, 5042 AD, Tilburg, The Netherlands
| | - F Van Tilborg
- Department of Radiology, ETZ Tilburg, Tilburg, The Netherlands
| | - D K Wasowicz
- Department of Surgery, ETZ (Elisabeth, TweeSteden Ziekenhuis), Doctor Deelenlaan 5, 5042 AD, Tilburg, The Netherlands
| | - D D E Zimmerman
- Department of Surgery, ETZ (Elisabeth, TweeSteden Ziekenhuis), Doctor Deelenlaan 5, 5042 AD, Tilburg, The Netherlands.
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12
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Video-Assisted Ligation of Intersphincteric Fistula Tract for Complex Anal Fistula: Technique and Preliminary Outcomes. Dis Colon Rectum 2020; 63:1534-1540. [PMID: 33044294 DOI: 10.1097/dcr.0000000000001691] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Sphincter-preserving operations have been increasingly used for treating anal fistula. However, their success rates remain modest in complex anal fistulas. OBJECTIVE This study aimed to report outcomes of video-assisted ligation of intersphincteric fistula tract (a procedure combining video-assisted anal fistula treatment and ligation of intersphincteric fistula tract) for treating complex anal fistulas and to compare its results with conventional ligation of intersphincteric fistula tract. DESIGN A review of prospectively collected data from October 2014 to December 2017 was performed. SETTINGS The study was conducted at a large tertiary hospital in Thailand. PATIENTS All patients with primary or recurrent complex anal fistulas undergoing video-assisted ligation of intersphincteric fistula tract were included. Patients with anal fistula related to malignancy, Crohn's disease, tuberculosis, or acute abscess were excluded. MAIN OUTCOME MEASURES Healing as defined by an absence of fistula or drainage from an external opening and complete epithelialization of the external opening were measured. RESULTS This study included 103 patients with a median age of 47 years. The primary healing rate was 84.5% at a median follow-up of 28 months (range, 15-38 mo). Primary healing rates of anterior high transsphincteric fistula, semi-horseshoe fistula, and horseshoe fistula were 88% (44 of 50 cases), 77% (30 of 39 cases), and 93% (13 of 14 cases). Median time to healing was 4 weeks (range, 4-8 wk). Accordingly, the overall failure rate was 15.5%. None reported worse fecal incontinence postoperatively. Video-assisted ligation of intersphincteric fistula tract had a higher rate of primary healing for complex anal fistula than ligation of intersphincteric fistula tract (84.5% vs 63.4%; p < 0.001). LIMITATIONS This study is limited by its small sample size. CONCLUSIONS The outcomes of video-assisted ligation of intersphincteric fistula tract for complex anal fistulas are quite good. This technique has the potential to become another viable option of sphincter-preserving operation for complex anal fistulas. See Video Abstract at http://links.lww.com/DCR/B373. LIGADURA ASISTIDA POR VIDEO DEL TRACTO DE LA FÍSTULA INTERESFINTÉRICA PARA LA FÍSTULA ANAL COMPLEJA: TÉCNICA Y RESULTADOS PRELIMINARIES: Las operaciones de preservación del esfínter se han utilizado cada vez más para tratar la fístula anal. Sin embargo, sus tasas de éxito siguen siendo modestas en las fístulas anales complejas.Este estudio tuvo como objetivo informar los resultados de la ligadura asistida por video del tracto de la fístula interesfintérica (un procedimiento que combina el tratamiento de la fístula anal asistida por video y la ligadura del tracto de la fístula interesfintérica) para el tratamiento de las fístulas anales complejas y comparar sus resultados con la ligadura convencional de la fístula interesfintérica tracto.Se realizó una revisión de los datos recolectados prospectivamente desde Octubre de 2014 hasta Diciembre de 2017.El estudio se realizó en un gran hospital terciario en Tailandia.Se incluyeron todos los pacientes con fístulas anales complejas primarias o recurrentes sometidas a ligadura asistida por video del tracto de la fístula interesfintérica. Se excluyeron los pacientes con fístula anal relacionada con malignidad, enfermedad de Crohn, tuberculosis o absceso agudo.Curación definida por la ausencia de fístula o drenaje de la abertura externa y la epitelización completa de la abertura externa.Este estudio incluyó 103 pacientes con una mediana de edad de 47 años. La tasa de curación primaria fue del 84,5% con una mediana de seguimiento de 28 meses (rango 15-38). La tasa de curación primaria de la fístula transesfintérica alta anterior, la fístula semi-herradura y la fístula de herradura fue del 88% (44 de 50 casos), 77% (30 de 39 casos) y 93% (13 de 14 casos), respectivamente. El tiempo mediano hasta la curación fue de 4 semanas (rango 4-8). En consecuencia, la tasa de fracaso general fue del 15,5%. Ninguno informó peor incontinencia fecal después de la operación. La ligadura asistida por video del tracto de la fístula interesfintérica tuvo una mayor tasa de curación primaria para la fístula anal compleja que la ligadura del tracto de la fístula interesfintérica (84.5% vs 63.4%; p <0.001).Este estudio está limitado por su pequeño tamaño de muestra.Los resultados de la ligadura asistida por video del tracto de la fístula interesfintérica para fístulas anales complejas son bastante buenos. Esta técnica tiene el potencial de convertirse en otra opción viable de operación de preservación del esfínter para fístulas anales complejas. Consulte Video Resumen en http://links.lww.com/DCR/B373. (Traducción-Dr Yesenia Rojas-Khalil).
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13
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Longterm outcome of anal fistula - A retrospective study. Sci Rep 2020; 10:6483. [PMID: 32300218 PMCID: PMC7162908 DOI: 10.1038/s41598-020-63541-3] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2019] [Accepted: 03/27/2020] [Indexed: 12/19/2022] Open
Abstract
This retrospective observational study analyses the outcomes of patients undergoing surgery for anal fistula at a single centre in order to assess recurrence and re-operation rates after different surgical techniques. During January 2005 and May 2013, all patients with anal fistula were included. Baseline characteristics, details of presentation, fistula anatomy, type of surgery, post-surgical outcomes and follow-up data were collected. The primary endpoints were long-term closure rate and recurrence rate after 2 years. Secondary endpoints were persistent pain, postoperative complications and continence status. A total of 65 patients were included. From a total amount of 93 operations, 65 were fistulotomies, 13 mucosal advancement flaps, 7 anal fistula plugs and 8 cutting-setons. The mean follow up was 80 months. Healing was achieved in 85%. The highest recurrence rate was seen in anal fistula plug with 42%. On the other hand, no recurrence was observed in the cutting-seton procedures. For all included operation no persistent postoperative pain nor incontinence was observed. In conclusion, despite all existing anal fistula operations up to date, the optimal technique with low recurrence rate and assured safety for the anal sphincter is still lacking. Nonetheless, according to our promising results for the cutting-seton technique, this technique, otherwise considered obsolete, should be further evaluated in a prospective study.
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14
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Chen PC. Small modifications can obtain good results when treating high transsphincteric anal fistula with LIFT. Tech Coloproctol 2020; 24:617-618. [PMID: 32193668 DOI: 10.1007/s10151-020-02191-z] [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: 02/18/2020] [Accepted: 03/10/2020] [Indexed: 10/24/2022]
Affiliation(s)
- P C Chen
- Division of Colorectal Surgery, Department of Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, No.138, Shengli Road, Tainan City, Taiwan.
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15
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Adamina M, Bonovas S, Raine T, Spinelli A, Warusavitarne J, Armuzzi A, Bachmann O, Bager P, Biancone L, Bokemeyer B, Bossuyt P, Burisch J, Collins P, Doherty G, El-Hussuna A, Ellul P, Fiorino G, Frei-Lanter C, Furfaro F, Gingert C, Gionchetti P, Gisbert JP, Gomollon F, González Lorenzo M, Gordon H, Hlavaty T, Juillerat P, Katsanos K, Kopylov U, Krustins E, Kucharzik T, Lytras T, Maaser C, Magro F, Marshall JK, Myrelid P, Pellino G, Rosa I, Sabino J, Savarino E, Stassen L, Torres J, Uzzan M, Vavricka S, Verstockt B, Zmora O. ECCO Guidelines on Therapeutics in Crohn's Disease: Surgical Treatment. J Crohns Colitis 2020; 14:155-168. [PMID: 31742338 DOI: 10.1093/ecco-jcc/jjz187] [Citation(s) in RCA: 273] [Impact Index Per Article: 68.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
This article is the second in a series of two publications relating to the European Crohn's and Colitis Organisation [ECCO] evidence-based consensus on the management of Crohn's disease. The first article covers medical management; the present article addresses surgical management, including preoperative aspects and drug management before surgery. It also provides technical advice for a variety of common clinical situations. Both articles together represent the evidence-based recommendations of the ECCO for Crohn's disease and an update of previous guidelines.
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Affiliation(s)
- Michel Adamina
- Department of Surgery, Cantonal Hospital Winterthur, Winterthur, Switzerland.,University of Basel, Basel, Switzerland
| | - Stefanos Bonovas
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy.,IBD Center, Humanitas Clinical and Research Center, Milan, Italy
| | - Tim Raine
- Department of Gastroenterology, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Antonino Spinelli
- Humanitas Clinical and Research Center, Division of Colon and Rectal Surgery, Humanitas University, Department of Biomedical Sciences, Milan, Italy
| | - Janindra Warusavitarne
- Imperial College London, Department of Surgery and Cancer, St Mark's Hospital, Department of Gastroenterology, London, UK
| | - Alessandro Armuzzi
- IBD Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS - Universita' Cattolica del Sacro Cuore, Rome, Italy
| | - Oliver Bachmann
- Department of Internal Medicine I, Siloah St Trudpert Hospital, Pforzheim, Germany
| | - Palle Bager
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark
| | - Livia Biancone
- Department of Systems Medicine, University 'Tor Vergata' of Rome, Rome, Italy
| | | | - Peter Bossuyt
- Imelda GI Clinical Research Centre, Imelda General Hospital, Bonheiden, Belgium
| | - Johan Burisch
- Gastrounit, Medical Division, Hvidovre Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Paul Collins
- Department of Gastroenterology, Royal Liverpool University Hospital, Liverpool, UK
| | - Glen Doherty
- Department of Gastroenterology and Centre for Colorectal Disease, St Vincent's University Hospital, Dublin, Ireland
| | - Alaa El-Hussuna
- Department of Surgery, Aalborg University Hospital, Aalborg, Denmark
| | - Pierre Ellul
- Department of Medicine, Division of Gastroenterology, Mater Dei Hospital, Msida, Malta
| | - Gionata Fiorino
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy.,IBD Center, Humanitas Clinical and Research Center, Milan, Italy
| | | | - Federica Furfaro
- IBD Center, Humanitas Clinical and Research Center, Milan, Italy
| | - Christian Gingert
- Visceral Surgery, Cantonal Hospital Winterthur, Winterthur, Switzerland; Department of Human Medicine, Faculty of Health, University of Witten/Herdecke, Witten, Germany
| | | | - Javier P Gisbert
- Gastroenterology Unit, Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria Princesa [IIS-IP], Universidad Autónoma de Madrid, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas [CIBEREHD], Madrid, Spain
| | - Fernando Gomollon
- IBD UNIT, Hospital Clíico Universitario 'Lozano Blesa', IIS Aragón, CIBEREHD, Zaragoza, Spain
| | | | - Hannah Gordon
- Department of Gastroenterology, Barts Health NHS Trust, Royal London Hospital, London, UK
| | - Tibor Hlavaty
- Fifth Department of Internal Medicine, Sub-department of Gastroenterology and Hepatology, University Hospital Bratislava and Faculty of Medicine, Comenius University Bratislava, Slovakia
| | - Pascal Juillerat
- Clinic for Visceral Surgery and Medicine, Inselspital, University Hospital of Bern, Bern, Switzerland
| | - Konstantinos Katsanos
- Department of Gastroenterology and Hepatology, University and Medical School of Ioannina, Ioannina, Greece
| | - Uri Kopylov
- Department of Gastroenterology, Tel-HaShomer Sheba Medical Center, Ramat Gan, Israel; and Sackler Medical School, Tel Aviv, Israel
| | - Eduards Krustins
- Department of Gastroenterology, Hepatology and Nutrition, Pauls Stradins Clinical University Hospital, Department of Internal Medicine, Riga Stradiņš University, Riga, Latvia
| | - Torsten Kucharzik
- Department of Internal Medicine and Gastroenterology, Hospital Lüneburg, Lüneburg, Germany
| | | | - Christian Maaser
- Outpatients Department of Gastroenterology, Hospital Lüneburg, Lüneburg, Germany
| | - Fernando Magro
- Department of Pharmacology and Therapeutics; Institute for Molecular and Cell Biology, University of Porto, Faculty of Medicine, Porto, Portugal
| | - John Kenneth Marshall
- Department of Medicine [Division of Gastroenterology] and Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, ON, Canada
| | - Pär Myrelid
- Department of Surgery, and Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
| | - Gianluca Pellino
- Department of Advanced Medical and Surgical Sciences, Universitá degli Studi della Campania 'Luigi Vanvitelli', Naples, Italy
| | - Isadora Rosa
- Department of Gastroenterology, IPOLFG, Lisbon, Portugal
| | - Joao Sabino
- Department of Gastroenterology and Hepatology, University Hospitals, KU Leuven, Leuven, Belgium
| | - Edoardo Savarino
- Department of Surgery, Oncology and Gastroenterology, University of Padova, Padova, Italy
| | - Laurents Stassen
- Department of General Surgery, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - Joana Torres
- Department of Gastroenterology, Hospital Beatriz Ângelo, Loures, Portugal
| | - Mathieu Uzzan
- Department of Gastroenterology, IBD unit, Beaujon Hospital, APHP, Clichy, France
| | - Stephan Vavricka
- Division of Gastroenterology and Hepatology, University Hospital, Zürich, Switzerland
| | - Bram Verstockt
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, KU Leuven, Leuven, Belgium, and Department of Chronic Diseases, Metabolism and Ageing, TARGID - IBD, KU Leuven, Leuven, Belgium
| | - Oded Zmora
- Department of Surgery, Shamir Medical Center [Assaf Harofe], Tel Aviv, Israel
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