1
|
Chen B, Liu Y, Wang Y, Wang Q. Causal relationship between body mass index and anal fistula: a two-sample Mendelian randomization study. Front Genet 2024; 15:1406231. [PMID: 39119578 PMCID: PMC11306059 DOI: 10.3389/fgene.2024.1406231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2024] [Accepted: 07/10/2024] [Indexed: 08/10/2024] Open
Abstract
Background Significant evidence has been documented regarding the intricate connection between the development of anal fistula (AF) and the composition of Body Mass Index (BMI). Nevertheless, due to the inherent limitations of reverse causality and confounders inherent in observational studies, this relationship remains unclarified. Our study aims to reveal the causal impact between BMI and AF, as well as identify its associated risk factors, thereby providing a more comprehensive understanding of this complex interaction. Methods Single nucleotide polymorphisms (SNPs) identified through genome-wide association study (GWAS) databases were used as instrumental variables for analysis. BMI served as the exposure variable, with six pooled GWAS datasets included. AF was the outcome variable. The Inverse Variance Weighted (IVW) method was used as the primary analytical technique, with MR-Egger regression, Weighted Median (WME) estimation, and Multiplicity Residual Sum and Outlier (MR-PRESSO) tests serving as secondary validations of the IVW results. Odds ratios (OR) were utilized as indicators to evaluate the causal relationship between BMI and AF. Results A total of 738 SNPs strongly associated with the exposure were identified as instrumental variables. The IVW results demonstrated a positive correlation between BMI and the risk of AF. The MR-Egger analysis yielded p-values greater than 0.05, indicating no pleiotropic effects among the selected SNPs. Cochran's Q test also resulted in p-values greater than 0.05, suggesting no significant heterogeneity among the instrumental variables. The MR-PRESSO analysis revealed no horizontal pleiotropy or outliers potentially violating the causal assumption (p > 0.05). Conclusion High BMI is positively associated with the risk of AF, and correcting BMI levels may have a preventive effect on the incidence of AF.
Collapse
Affiliation(s)
- Bo Chen
- Department of Anorectal Surgery, Baoshan District Integrated Traditional Chinese and Western Medicine Hospital, Shanghai, China
| | - Yicheng Liu
- Department of Anorectal Surgery, Baoshan District Integrated Traditional Chinese and Western Medicine Hospital, Shanghai, China
| | - Yueting Wang
- Department of Traditional Chinese Medicine, Juquan Xincheng Community Health Service Center, Shanghai, China
| | - Qingming Wang
- Department of Anorectal Surgery, Shuguang Hospital Affiliated to Shanghai University of Traditional Chinese Medicine, Shanghai, China
| |
Collapse
|
2
|
Tang XL, Xu ZY, Yang J, Yang Z, Wang ZG, Zhang ZY, Yao J. Assessing the suitability of video-assisted anal fistula treatment for obese patients compared to conventional surgery: a question worth investigating. Int J Colorectal Dis 2024; 39:108. [PMID: 39008124 PMCID: PMC11249763 DOI: 10.1007/s00384-024-04683-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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/05/2024] [Indexed: 07/16/2024]
Abstract
BACKGROUND AND AIMS Video-assisted anal fistula treatment (VAAFT) is an innovative surgical approach enabling the direct visualization of the fistula tract structure. This study aims to assess the efficacy of VAAFT in comparison with that of traditional surgical methods and explore potential risk factors contributing to fistula recurrence to provide new recommendations for surgical selection. MATERIALS AND METHODS Information was collected from 100 patients with complex anal fistula (CAF) in our hospital who underwent surgical treatment from January 2021 to January 2023. We compared the baseline information and surgical outcomes of two groups, analyzed the risk factors for fistula recurrence by using logistic regression analysis, and conducted further exploration by using the body mass index. RESULTS Equal numbers of patients underwent VAAFT and traditional surgeries, and no significant differences in baseline information were observed. Patients who received VAAFT experienced less intraoperative bleeding (15.5 (14.0-20.0) vs. 32.0 (25.0-36.0)), shorter hospital stays (2.0 (2.0-2.5) vs. 3.0 (3.0-3.5)), reduced postoperative pain and wound discharge, but longer operative times (43.3 ± 6.9 vs. 35.0 (31.5-40.0)) compared with patients who underwent traditional surgeries. No significant differences in recurrence rates were found three and six months after operation (the p-values were 0.790 and 0.806, respectively). However, the Wexner scores of the VAAFT group were significantly low in the first follow-up (0 (0-1.0) vs. 2.0 (1.0-2.0)). Postoperative recurrence of fistulas may be associated with obesity (p-value = 0.040), especially in patients undergoing traditional surgeries (p-value = 0.036). CONCLUSION VAAFT offers advantages, such as less pain, less trauma, and faster recovery, compared with traditional surgical treatment. Obese patients with CAF are prone to recurrence, and we recommend that they undergo VAAFT treatment rather than traditional surgeries.
Collapse
Affiliation(s)
- Xiao-Li Tang
- Department of Surgery, Shanghai Sixth Peoples Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, 200233, China
| | - Zi-Yang Xu
- Department of Surgery, Shanghai Sixth Peoples Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, 200233, China
| | - Jun Yang
- Department of Surgery, Shanghai Sixth Peoples Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, 200233, China
| | - Zhe Yang
- Department of Surgery, Shanghai Sixth Peoples Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, 200233, China
| | - Zhi-Gang Wang
- Department of Surgery, Shanghai Sixth Peoples Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, 200233, China.
| | - Zheng-Yun Zhang
- Department of Surgery, Shanghai Sixth Peoples Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, 200233, China.
| | - Jing Yao
- Department of Surgery, Shanghai Sixth Peoples Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, 200233, China.
| |
Collapse
|
3
|
Herreros MD, Ramirez JM, Otero-Piñeiro AM, Martí-Gallostra M, Badiola I, Enríquez-Navascues JM, Millan M, Barreiro EM, De La Portilla F, Suárez Alecha J, García-Olmo D. Use of Darvadstrocel (Allogenic Stem Cell Therapy) for Crohn's Fistulas in Real Clinical Practice: The National Project to Implement Mesenchymal Stem Cell for the Treatment of Perianal Crohn's Fistula (the PRIME Study). Dis Colon Rectum 2024; 67:960-967. [PMID: 38603800 DOI: 10.1097/dcr.0000000000003216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/13/2024]
Abstract
BACKGROUND Perianal fistulas may affect 15% to 50% of patients with Crohn's disease. Treatment is complex, requiring a multidisciplinary approach. Darvadstrocel (allogenic mesenchymal cells obtained from lipoaspirates) was approved in 2018 by the European and Spanish Agencies of Medicines and Medical Products as a treatment for fistulas in Crohn's disease. Recent guidelines from the European Crohn's and Colitis Organisation and Spanish Working Group on Crohn's Disease and Ulcerative Colitis state that darvadstrocel is effective with a favorable safety profile and a strong level of evidence (n = 2). OBJECTIVE Presenting real-world effectiveness data for darvadstrocel in a Spanish population. DESIGN Observational retrospective cohort study with prospective data gathering. SETTINGS The study was conducted at 14 institutions in Spain. PATIENTS From November 2019 to April 2022, all patients (n = 73) treated with darvadstrocel in these institutions were included, fulfilling the following criteria: 1) complex fistula/s in a patient with Crohn's disease; 2) failure of conventional and antitumor necrosis factor treatment; and 3) the absence of collections of >2 cm confirmed by pelvic MRI at the time of surgery. INTERVENTIONS Darvadstrocel treatment. MAIN OUTCOME MEASURES Clinical response (closure of 50% or more of external openings), complete clinical closure (100% of external openings), and radiological closure (no fluid collection >2 cm, edema, or inflammation) evaluated 6 months after treatment. RESULTS Clinical response was observed in 63 patients (86.3%), complete clinical closure in 50 patients (68.5%), and radiological closure in 45 patients (69.2%). Combined clinical and radiological response was observed in 41 patients (63.1%). Not all clinically healed patients had radiological closure, and vice versa. No serious adverse events were reported. LIMITATIONS Retrospective nature of the study. CONCLUSIONS Study results were consistent with those reported in previous clinical trials, real-world efficacy findings from the INSPIRE study (assessing darvadstrocel effectiveness in Europe, Israel, Switzerland, United Kingdom, and Japan), and previously published literature. Darvadstrocel was effective and demonstrated a favorable safety profile when used in normal clinical practice for the treatment of fistulas in Crohn's disease. See Video Abstract . USO DE DARVADSTROCEL TERAPIA CON CLULAS MADRE ALOGNICAS PARA FSTULA EN ENFERMEDAD DE CROHN EN LA PRCTICA CLNICA REAL EL PROYECTO NACIONAL PARA IMPLEMENTAR DE CLULAS MADRE MESENQUIMALES PARA EL TRATAMIENTO DE LA FSTULA DE CROHN PERIANAL EL ESTUDIO PRIME ANTECEDENTES:Las fístulas perianales pueden afectar entre el 15 y el 50% de los pacientes con enfermedad de Crohn. El tratamiento es complejo y requiere un enfoque multidisciplinario. El darvadstrocel (células mesenquimales alogénicas obtenidas a partir de lipoaspirados) fue aprobado en 2018 por las Agencias Europea y Española de Medicamentos y Productos Sanitarios como tratamiento de las fístulas en la EC. Las recientes directrices de la Organización Europea de Crohn y Colitis y del Grupo de Trabajo Español sobre la Enfermedad de Crohn y Colitis Ulcerosa afirman que darvadstrocel es eficaz con un perfil de seguridad favorable y un sólido nivel de evidencia (2).OBJETIVO:Presentar datos de eficacia real de darvadstrocel en población española.DISEÑO:Estudio de cohorte retrospectivo observacional con recopilación prospectiva de datos.ESCENARIO:14 instituciones.PACIENTES:Desde noviembre de 2019 hasta abril de 2022, se incluyeron todos los pacientes (73) tratados con darvadstrocel en estas instituciones, que cumplieron los siguientes criterios: 1) fístula/s compleja/s en un paciente con enfermedad de Crohn; 2) fracaso del tratamiento convencional y anti factor de necrosis tumoral; 3) ausencia de colecciones > 2 cm confirmada por resonancia magnética pélvica en el momento de la cirugía.INTERVENCIONES:Tratamiento con Darvadstrocel.PRINCIPALES MEDIDAS DE RESULTADO:Respuesta clínica (cierre de ≥50% de las aberturas externas), cierre clínico completo (100% de las aberturas externas) y cierre radiológico (sin acumulación de líquido >2 cm, sin edema ni inflamación) evaluados 6 meses después del tratamiento.RESULTADOS:Se observó respuesta clínica en 63 pacientes (86.3%), cierre clínico completo en 50 pacientes (68.5%) y cierre radiológico en 45 pacientes (69.2%). Se observó respuesta clínica y radiológica combinada en 41 pacientes (63.1%). No todos los pacientes clínicamente curados tuvieron cierre radiológico y viceversa. No hubo eventos adversos graves reportados.LIMITACIONES:Estudio retrospectivoCONCLUSIONES:Los resultados del estudio fueron consistentes con los informados en ensayos clínicos anteriores, los hallazgos de eficacia en el mundo real del estudio INSPIRE (que evalúa la efectividad de darvadstrocel en Europa, Israel, Suiza, el Reino Unido y Japón) y la literatura publicada anteriormente. Darvadstrocel fue eficaz y demostró un perfil de seguridad favorable cuando se utiliza en la práctica clínica habitual para el tratamiento de fístulas en la enfermedad de Crohn. (Traducción-Dr. Jorge Silva Velazco ).
Collapse
Affiliation(s)
- Maria Dolores Herreros
- Department of Surgery, University Hospital Fundación Jiménez Díaz, Madrid, Spain
- New Therapy Laboratory, Instituto de Investigación Sanitaria Fundación Jiménez Díaz, Madrid, Spain
| | - Jose-Manuel Ramirez
- Department of Surgery, University of Zaragoza, Zaragoza, Spain
- Spanish Multimodal Rehabilitation Group (GERM), Zaragoza, Spain
| | | | | | - Izaskun Badiola
- Department of Surgery University Hospital Galdakao-Usansolo, Vizcaya, Pais Vasco, Spain
| | | | - Monica Millan
- Department of Surgery, University Hospital la Fe, Valencia, Spain
| | - Erica M Barreiro
- Department of Surgery, University Hospital of Pontevedra, Galicia, Spain
| | | | | | - Damian García-Olmo
- Department of Surgery, University Hospital Fundación Jiménez Díaz, Madrid, Spain
- New Therapy Laboratory, Instituto de Investigación Sanitaria Fundación Jiménez Díaz, Madrid, Spain
- Surgery Department, Universidad Autonoma de Madrid, Madrid, Spain
| |
Collapse
|
4
|
Zhang D, Gu J, Xu Y, Yu X, Jin H. Exploring the mechanism of Huanglian ointment in alleviating wound healing after anal fistula surgery through metabolomics and proteomics. Heliyon 2024; 10:e29809. [PMID: 38699024 PMCID: PMC11064137 DOI: 10.1016/j.heliyon.2024.e29809] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2023] [Revised: 03/23/2024] [Accepted: 04/15/2024] [Indexed: 05/05/2024] Open
Abstract
Anal fistula is a common anal and intestinal disease. The wound of anal fistula surgery is open and polluting, which is the most difficult to heal among all surgical incisions. To investigate the mechanism of Huanglian ointment (HLO) on wound healing after anal fistula incision. The S. aureus infected wound in SD rats were used to imitate poor healing wound after anal fistula surgery. SD rats with wound sites (n = 24) were randomly divided into four groups (Control group, Model group, Potassium permanganate (PP) treatment group, and HLO treatment group). The wound healing rate was evaluated, HE staining was used to evaluate the pathological changes of each group, ELISA was used to detect the secretion of inflammatory factors in each group, and the mechanism was explored through metabolomics and proteomics in plasma rat. Compared to other groups, the rate of wound healing in the HLO group was higher on days 7 and 14. Histological analysis showed that collagen and fibroblast in HLO rats were significantly increased, inflammatory cells were reduced, and vascular endothelial permeability was increased. ELISA results showed that the secretion of inflammatory factors in HLO rats was significantly lower. Significant proteins and metabolites were identified in the wound tissues of the infected rats and HLO-treated rats, which were mainly attributed to Cdc42, Ctnnb1, Actr2, Actr3, Arpc1b, Itgam, Itgb2, Cttn, Linoleic acid metabolism, d-Glutamine and d-glutamate metabolism, Phenylalanine, tyrosine and tryptophan biosynthesis, Phenylalanine metabolism, alpha-Linolenic acid metabolism, and Ascorbate and aldarate metabolism. In conclusion, this study showed that HLO can promote S. aureus infected wound healing, and the data provide a theoretical basis for the treatment of wounds after anal fistula surgery with HLO.
Collapse
Affiliation(s)
- Dongliang Zhang
- Nanjing University of Chinese Medicine, Nanjing, 210023, China
- Department of Colorectal and Anal Surgery, Zhenjiang Hospital Affiliated to Nanjing University of Chinese Medicine (Zhenjiang Hospital of Traditional Chinese Medicine), Zhenjiang, 212001, China
| | - Jiabo Gu
- Nanjing University of Chinese Medicine, Nanjing, 210023, China
- Department of Colorectal and Anal Surgery, The Second Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing, 210011, China
| | - Yanyan Xu
- Department of Colorectal and Anal Surgery, The Second Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing, 210011, China
| | - Xiaowen Yu
- Department of Colorectal and Anal Surgery, Zhenjiang Hospital Affiliated to Nanjing University of Chinese Medicine (Zhenjiang Hospital of Traditional Chinese Medicine), Zhenjiang, 212001, China
| | - Heiying Jin
- Department of Colorectal and Anal Surgery, The Second Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing, 210011, China
| |
Collapse
|
5
|
Gaillard M, Van den Broeck S, Op de Beeck B, Wouters K, Stijns J, Van de Putte D, Gys B, Houben B, Van Dessel E, Bislenghi G, Komen N. Protocol of the LATFIA trial (Laser Assisted Treatment of Fistula in Ano): a multicentre, prospective, randomized controlled trial comparing fistula-tract laser closure (FiLaC™) with rectal advancement flap for high trans-sphincteric fistulas. Colorectal Dis 2024; 26:1038-1046. [PMID: 38499516 DOI: 10.1111/codi.16951] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2023] [Revised: 02/11/2024] [Accepted: 02/23/2024] [Indexed: 03/20/2024]
Abstract
AIM Anal fistula is one of the most common anal diseases, affecting between 1 and 3 per 10 000 people per year. Symptoms have a potentially severe effect on a patient's quality of life. Surgery is the mainstay of treatment, aiming to cure the fistula and preserve anal sphincter function. Rectal advancement flap (RAF) is currently the gold standard treatment but has recurrence rates varying between 20% and 50% and might lead to disturbance of continence. The aim of the trial described in this work is to discover if the minimally invasive fistula tract laser closure (FiLaC™) technique could achieve higher healing rates and a better functional outcome than RAF. METHOD We will perform a randomized prospective multicentre noninferiority study of the treatment of high trans-sphincteric perianal fistulas, comparing FiLaC™ with RAF in terms of fistula healing, recurrence rate, functional outcome and quality of life. Primary and secondary fistula healing will be evaluated at 26 and 52 weeks' follow-up. Quality of life will be evaluated using the SF-36 questionnaire, the Faecal Incontinence Quality of Life Scale questionnaire and the Vaizey score at 3, 6, 12 and 26 weeks postoperatively. CONCLUSION High trans-sphincteric fistulas have a potentially severe effect on a patient's quality of life. Classical treatment with RAF is a time-consuming invasive procedure. The LATFIA trial aims to compare FiLaC™ with the gold standard treatment with RAF. In case of noninferiority, FiLaC™ treatment could be standardized as a first line treatment for high trans-sphincteric fistulas. Better conservation of the patient's anal sphincter function could possibly be obtained. Likewise, we will report on the postoperative quality of life when applying these two techniques.
Collapse
Affiliation(s)
- Marie Gaillard
- Department of Abdominal Surgery, Antwerp University Hospital, Edegem, Belgium
- Antwerp ReSURG, Antwerp Surgical Training, Anatomy and Research Centre (ASTARC), Faculty of Medicine and Health Sciences, University of Antwerp, Wilrijk, Belgium
| | - Sylvie Van den Broeck
- Department of Abdominal Surgery, Antwerp University Hospital, Edegem, Belgium
- Antwerp ReSURG, Antwerp Surgical Training, Anatomy and Research Centre (ASTARC), Faculty of Medicine and Health Sciences, University of Antwerp, Wilrijk, Belgium
| | - Bart Op de Beeck
- Department of Radiology, Antwerp University Hospital, Edegem, Belgium
| | - Kristien Wouters
- Clinical Trial Center, Antwerp University Hospital, Edegem, Belgium
| | - Jasper Stijns
- Department of Abdominal Surgery, University Hospital Brussels, Jette, Belgium
| | - Dirk Van de Putte
- Department of Abdominal Surgery, University Hospital Ghent, Ghent, Belgium
| | - Ben Gys
- Department of Abdominal Surgery, Hospital St. Dimpna, Geel, Belgium
| | - Bert Houben
- Department of Abdominal Surgery, Jessa Hospital, Hasselt, Belgium
| | - Els Van Dessel
- Department of Abdominal Surgery, GasthuisZusters Hospital, Antwerp, Belgium
| | - Gabriele Bislenghi
- Department of Abdominal Surgery, University Hospital Leuven, Leuven, Belgium
| | - Niels Komen
- Department of Abdominal Surgery, Antwerp University Hospital, Edegem, Belgium
- Antwerp ReSURG, Antwerp Surgical Training, Anatomy and Research Centre (ASTARC), Faculty of Medicine and Health Sciences, University of Antwerp, Wilrijk, Belgium
| |
Collapse
|
6
|
Sohrabi M, Bahrami S, Mosalli M, Khaleghian M, Obaidinia M. Perianal Fistula; from Etiology to Treatment - A Review. Middle East J Dig Dis 2024; 16:76-85. [PMID: 39131109 PMCID: PMC11316198 DOI: 10.34172/mejdd.2024.373] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2023] [Accepted: 01/18/2024] [Indexed: 08/13/2024] Open
Abstract
Anal fistula has been a challenging clinical issue for years due to its complex pathogenesis. The risk of frequent recurrence and incontinence complicates long-term treatment. Recent scientific literature has reviewed new techniques used for anal fistula treatment in recent years, assessing the advantages and disadvantages of each based on clinical outcomes. Although surgery is the main method used to treat anal fistula, there is no simple technique that can completely heal complex anal fistula. The surgical treatment should consider the healing outcome and the protection of anal function comprehensively. Several innovative techniques have emerged in recent years, such as combined techniques based on drainage seton and LIFT-plug, which appear to be relatively effective therapies. However, more multi-center prospective trials with long-term follow-up are needed to validate their effectiveness. In some situations, medical treatment may also be considered.
Collapse
Affiliation(s)
- Masoudreza Sohrabi
- Gastrointestinal and liver Diseases Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Somayeh Bahrami
- Gastrointestinal and liver Diseases Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Mozhdeh Mosalli
- Gastrointestinal and liver Diseases Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Mohsen Khaleghian
- Gastrointestinal and liver Diseases Research Center, Iran University of Medical Sciences, Tehran, Iran
- Department of General Surgery, School of Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Mobin Obaidinia
- Gastrointestinal and liver Diseases Research Center, Iran University of Medical Sciences, Tehran, Iran
| |
Collapse
|
7
|
Wang C, Zhao S, Tu L, Zeng X. Perianal abscess complicating a high complex-type anal fistula. Asian J Surg 2024; 47:1644-1645. [PMID: 38143172 DOI: 10.1016/j.asjsur.2023.12.071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Accepted: 12/08/2023] [Indexed: 12/26/2023] Open
Affiliation(s)
- ChangXin Wang
- First Clinical Medical College, The Gannan Medical University, Ganzhou, China
| | - ShuFeng Zhao
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Gannan Medical University, Ganzhou, China
| | - LiWen Tu
- First Clinical Medical College, The Gannan Medical University, Ganzhou, China
| | - XiangFu Zeng
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Gannan Medical University, Ganzhou, China.
| |
Collapse
|
8
|
Fousekis FS, Mpakogiannis K, Lianos GD, Koukoudis A, Christodoulou DK, Papaconstantinou I, Katsanos KH. Effectiveness and safety of darvadstrocel in patients with complex perianal fistulizing Crohn's disease: a systematic review. Ann Gastroenterol 2024; 37:46-53. [PMID: 38223244 PMCID: PMC10785025 DOI: 10.20524/aog.2023.0850] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2023] [Accepted: 11/21/2023] [Indexed: 01/16/2024] Open
Abstract
Background Managing complex perianal fistulizing Crohn's disease (CD) remains challenging, despite current medical and surgical treatment approaches. Darvadstrocel, a therapy utilizing adipose-derived stem cells, shows promise in promoting tissue regeneration and healing, offering a novel and effective treatment for fistula management. Method A systematic literature search was conducted on PubMed and Scopus to identify studies involving patients with complex perianal fistulizing CD treated with darvadstrocel. Results In total, 2 randomized controlled trials (RCT), 5 observational studies with retrospective data collection and 2 observational studies with prospective design were included in the final review. Data from the European ADMIRE-CD RCT demonstrated that darvadstrocel is superior to placebo in terms of clinical and imaging improvement over both the short and long term. These findings align with the prospective studies analyzed in this systematic review. The rate of treatment-emergent adverse events in the ADMIRE-CD trial's RCTs was similar in both the darvadstrocel and control groups, with perianal abscess being the most common adverse event up to 52 weeks after drug administration. Retrospective studies indicated no side-effects beyond 52 weeks. Conclusions Darvadstrocel appears to be a new, potentially effective and safe treatment option for the management of complex perianal fistulas. However, more randomized clinical trials are needed to evaluate the efficacy and safety profile of the drug.
Collapse
Affiliation(s)
- Fotios S. Fousekis
- Division of Gastroenterology, Department of Internal Medicine, Faculty of Medicine, School of Health Sciences, University of Ioannina, Greece (Fotios S. Fousekis, Konstantinos Mpakogiannis, Anastasios Koukoudis, Dimitrios K. Christodoulou, Konstantinos H. Katsanos)
| | - Konstantinos Mpakogiannis
- Division of Gastroenterology, Department of Internal Medicine, Faculty of Medicine, School of Health Sciences, University of Ioannina, Greece (Fotios S. Fousekis, Konstantinos Mpakogiannis, Anastasios Koukoudis, Dimitrios K. Christodoulou, Konstantinos H. Katsanos)
| | - Georgios D. Lianos
- Department of Surgery, School of Health Sciences, University Hospital of Ioannina and Faculty of Medicine, University of Ioannina, Greece (Georgios D. Lianos)
| | - Anastasios Koukoudis
- Division of Gastroenterology, Department of Internal Medicine, Faculty of Medicine, School of Health Sciences, University of Ioannina, Greece (Fotios S. Fousekis, Konstantinos Mpakogiannis, Anastasios Koukoudis, Dimitrios K. Christodoulou, Konstantinos H. Katsanos)
| | - Dimitrios K. Christodoulou
- Division of Gastroenterology, Department of Internal Medicine, Faculty of Medicine, School of Health Sciences, University of Ioannina, Greece (Fotios S. Fousekis, Konstantinos Mpakogiannis, Anastasios Koukoudis, Dimitrios K. Christodoulou, Konstantinos H. Katsanos)
| | - Ioannis Papaconstantinou
- Second Department of Surgery, Aretaieion University Hospital, Medical School, National and Kapodistrian University of Athens, Greece (Ioannis Papaconstantinou)
| | - Konstantinos H. Katsanos
- Division of Gastroenterology, Department of Internal Medicine, Faculty of Medicine, School of Health Sciences, University of Ioannina, Greece (Fotios S. Fousekis, Konstantinos Mpakogiannis, Anastasios Koukoudis, Dimitrios K. Christodoulou, Konstantinos H. Katsanos)
| |
Collapse
|
9
|
Bertucci Zoccali M, Moallem DH, Park H, Uhlemann AC, Church JM, Kiran RP. Role of Microbiome in the Outcomes Following Surgical Repair of Perianal Fistula: Prospective Cohort Study Design and Preliminary Results. World J Surg 2023; 47:3373-3379. [PMID: 37821648 DOI: 10.1007/s00268-023-07212-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/18/2023] [Indexed: 10/13/2023]
Abstract
BACKGROUND Anal fistulae are common, predominantly cryptoglandular, and almost invariably require surgical treatment. Recurrences are common for procedures other than fistulotomy regardless of technique and adequacy of repair. Growing evidence supports the pivotal role of specific intestinal bacteria in anastomotic failures after bowel resection. Anal crypts harbor colonic microbiota suggesting that similar mechanisms to anastomotic healing might prevail after anal fistula repair and hence influence healing. This study aims at assessing the potential role of the intestinal microbiome in the clinical outcomes after surgical repair of cryptoglandular anal fistula. METHODS This is a pilot prospective cohort study enrolling patients with anal fistula undergoing endoanal advancement flap. For microbiome analysis, stool samples are taken via rectal swab before the procedure; additionally, a portion of the fistula is collected intraoperatively after fistulectomy. Samples from groups with treatment failure are compared to samples from patients who healed after surgical repair. Alpha and beta diversities and differential abundance of microbial taxa are determined and compared between groups with DADA2 analytical pipeline. RESULTS Five patients have been enrolled to date (one female, four male). At median follow-up of 6 months (2-11), one patient experienced disease recurrence at 3 months. DNA from the 5 rectal swab and tissue samples was extracted, showing increased relative abundance of Enterococcus faecalis in samples from the patient who developed a recurrent fistula but not in those without recurrence. CONCLUSION These very preliminary data suggest that intestinal microbiome may represent a crucial determinant of the surgical outcomes after anal fistula surgery.
Collapse
Affiliation(s)
- Marco Bertucci Zoccali
- Division of Colorectal Surgery, Department of Surgery, New York Presbyterian/Columbia University Medical Center, New York, USA.
| | - Dalia H Moallem
- Division of Infectious Diseases, Department of Medicine, New York Presbyterian/Columbia University Medical Center, New York, NY, USA
| | - Heekuk Park
- Division of Infectious Diseases, Department of Medicine, New York Presbyterian/Columbia University Medical Center, New York, NY, USA
| | - Anne-Catrin Uhlemann
- Division of Infectious Diseases, Department of Medicine, New York Presbyterian/Columbia University Medical Center, New York, NY, USA
| | - James M Church
- Division of Colorectal Surgery, Department of Surgery, New York Presbyterian/Columbia University Medical Center, New York, USA
| | - Ravi P Kiran
- Division of Colorectal Surgery, Department of Surgery, New York Presbyterian/Columbia University Medical Center, New York, USA
| |
Collapse
|
10
|
Xu H, Xiao GZ, Zheng YH, Fu YJ, Zhong SL, Ren DL, Li WR, Lin HC. A magnetic resonance imaging-based decision-making tool for predicting complex anal fistulas healing in the early postoperative period. BMC Gastroenterol 2023; 23:372. [PMID: 37907854 PMCID: PMC10617037 DOI: 10.1186/s12876-023-02963-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Accepted: 09/18/2023] [Indexed: 11/02/2023] Open
Abstract
BACKGROUND Magnetic resonance imaging (MRI) has excellent accuracy in diagnosing preoperative lesions before anal fistula surgery. However, MRI is not good in identifying early recurrent lesions and effective methods for quantitative assessment of fistula healing are still warranted. This retrospective study aimed to develop and validate a specific MRI-based nomogram model to predict fistula healing during the early postoperative period. METHODS Patients with complex cryptoglandular anal fistulas who underwent surgery between January 2017 and October 2020 were included in this study. MRI features and clinical parameters were analyzed using univariate and multivariate logistic regression analysis. A nomogram for predicting fistula healing was constructed and validated. RESULTS In total, 200 patients were included, of whom 186 (93%) were male, with a median age of 36 (18-65) years. Of the fistulas, 58.5% were classified as transsphincteric and 19.5% as suprasphincteric. The data were randomly divided into the training cohort and testing cohort at a ratio of 7:3. Logistic analysis revealed that CNR, ADC, alcohol intake history, and suprasphincteric fistula were significantly correlated with fistula healing. These four predictors were used to construct a predictive nomogram model in the training cohort. AUC was 0.880 and 0.847 for the training and testing cohorts, respectively. Moreover, the decision and calibration curves showed high coherence between the predicted and actual probabilities of fistula healing. CONCLUSIONS We developed a predictive model and constructed a nomogram to predict fistula healing during the early postoperative period. This model showed good performance and may be clinically utilized for the management of anal fistulas.
Collapse
Affiliation(s)
- Hao Xu
- Department of Anorectal, Shanghai Fourth People's Hospital, School of Medicine, Tongji University, Shanghai, 200434, China
- Department of Anorectal Surgery, Shuguang Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, 201203, China
| | - Guo-Zhong Xiao
- Department of Colorectal Surgery, The Sixth Affiliated Hospital, Sun Yat-sen University, Yuancun Er Heng Lu, No. 26, Guangzhou, 510655, China
- Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, 510655, China
- Guangdong Institute of Gastroenterology, Guangzhou, 510655, China
| | - Yi-Hui Zheng
- Department of Colorectal Surgery, The Sixth Affiliated Hospital, Sun Yat-sen University, Yuancun Er Heng Lu, No. 26, Guangzhou, 510655, China
- Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, 510655, China
- Guangdong Institute of Gastroenterology, Guangzhou, 510655, China
| | - Yuan-Ji Fu
- Department of Colorectal Surgery, The Sixth Affiliated Hospital, Sun Yat-sen University, Yuancun Er Heng Lu, No. 26, Guangzhou, 510655, China
- Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, 510655, China
- Guangdong Institute of Gastroenterology, Guangzhou, 510655, China
| | - Sheng-Lan Zhong
- Department of Anorectal, Shanghai Fourth People's Hospital, School of Medicine, Tongji University, Shanghai, 200434, China
| | - Dong-Lin Ren
- Department of Colorectal Surgery, The Sixth Affiliated Hospital, Sun Yat-sen University, Yuancun Er Heng Lu, No. 26, Guangzhou, 510655, China
- Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, 510655, China
- Guangdong Institute of Gastroenterology, Guangzhou, 510655, China
| | - Wen-Ru Li
- Department of Radiology, The Sixth Affiliated Hospital, Sun Yat-sen University, Yuancun Er Heng Lu, No. 26, Guangzhou, 510655, China.
| | - Hong-Cheng Lin
- Department of Colorectal Surgery, The Sixth Affiliated Hospital, Sun Yat-sen University, Yuancun Er Heng Lu, No. 26, Guangzhou, 510655, China.
- Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, 510655, China.
- Guangdong Institute of Gastroenterology, Guangzhou, 510655, China.
| |
Collapse
|
11
|
Zhao Y, Xie W, Wu X, Li X, Guo J, Cao Q, Liang J, Chen XL, Zhao W, Sun F, Li H, Luo W, Li Y. Anal fistulotomy with one-stage shaped skin grafting for intersphincter anal fistulas: study protocol on a multicentre randomised controlled trial. Trials 2023; 24:470. [PMID: 37481545 PMCID: PMC10363312 DOI: 10.1186/s13063-023-07495-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2022] [Accepted: 07/04/2023] [Indexed: 07/24/2023] Open
Abstract
BACKGROUND Anal fistulas are mainly treated via surgery. They can be difficult to treat without surgical intervention. Numerous procedures, such as fistulectomy and fistulotomy, are performed to treat anal fistulas and achieve good effects. However, the wounds created through fistulectomy and fistulotomy take a long time to heal. Therefore, a multicentre randomised controlled trial (RCT) is proposed to study the efficacy of one-stage shaped skin grafting at the surgical wound to heal low simple intersphincter anal fistulas. METHODS This study is a multicentre, hospital-based RCT. It will be performed at three hospitals. A total of 104 patients with low simple intersphincter anal fistulas who meet the inclusion criteria will be included in this trial and will be allocated randomly to two groups (test and control groups). The patients in the test group will receive one-stage anal fistulotomy surgery combined with shaped skin grafting, and those in the control group will undergo anal fistulotomy only. All the operations will be performed by attending colorectal surgeons or surgeons of a higher level. Effectiveness and safety indicators will be observed, recorded and analysed. DISCUSSION Anal fistulotomy can heal low simple intersphincter anal fistulas effectively and safely with a low recurrence rate. Skin grafts promote wound epithelisation significantly. We believe that skin grafting can treat low simple intersphincter fistulas with a short healing time. TRIAL REGISTRATION Chinese Clinical Trial Register, ChiCTR2000039174. Registered on 28 October 2020.
Collapse
Affiliation(s)
- Yongchang Zhao
- Department of Anorectal Surgery, the First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, 510000, China
| | - Wei Xie
- Department of Gastrointestinal Surgery, Guangzhou Panyu Hexian Memorial Hospital, Guangzhou, 510000, China
| | - Xiaoshuo Wu
- Department of Anorectal Surgery, the First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, 510000, China
| | - Xiaolan Li
- Department of Anorectal Surgery, Dongguan People's Hospital, Dongguan, 523000, China
| | - Jinyan Guo
- Department of Anorectal Surgery, Jiangmen Wuyi Hospital of Chinese Medicine, Jiangmen, 529000, China
| | - Qiurui Cao
- Department of Anorectal Surgery, Jiangmen Wuyi Hospital of Chinese Medicine, Jiangmen, 529000, China
| | - Jiadi Liang
- Department of Anorectal Surgery, Dongguan People's Hospital, Dongguan, 523000, China
| | - Xin-Lin Chen
- School of Basic Medical Science, Guangzhou University of Chinese Medicine, Guangzhou, 510000, China
| | - Wentao Zhao
- Department of Anorectal Surgery, the First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, 510000, China
| | - Feng Sun
- Department of Anorectal Surgery, the First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, 510000, China
| | - Hongjie Li
- Department of Anorectal Surgery, the First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, 510000, China
| | - Weimin Luo
- Department of Anorectal Surgery, the First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, 510000, China
| | - Yuying Li
- Department of Anorectal Surgery, the First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, 510000, China.
| |
Collapse
|
12
|
Olajide TO, Bode CO. Closure of Fistula-in-Ano Using a Radial-Emitting Laser Probe: Initial Experience in Lagos, Nigeria. JOURNAL OF THE WEST AFRICAN COLLEGE OF SURGEONS 2023; 13:101-106. [PMID: 37538211 PMCID: PMC10395862 DOI: 10.4103/jwas.jwas_108_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Accepted: 06/06/2023] [Indexed: 08/05/2023]
Abstract
Background Fistula-in-ano treatment has remained quite challenging with high failure rates and a potential for damage to the anal sphincteric complex leading to flatal or faecal incontinence. The treatment of fistula-in-ano using the fistula laser closure (FiLaC) as a minimally invasive, sphincter-saving procedure for complex disease has recently been documented. Objectives This review aimed to report the outcome of using it at the Lagos University Teaching Hospital. Patients and Methods The procedures were performed with a radially emitting laser fibre from Biolitec AG-CeramOptec (Bonn, Germany). The duration of symptoms, type of fistula, duration of the procedures, and postoperative complications were evaluated. Results Eleven male patients had laser fistula-in-ano closure. The age range was 33-51 years, with a median age of 39 years and an interquartile range (IQR) of 37-47 years. Five patients were noted to have high fistula/e, whereas six had low fistula/e, seven had a single tract each, and three had three tracts each. The duration of surgery ranged, approximately from 3 to 60 min, with a median of 19 min and IQR of 9-33 min. Postoperative pain was mild in all patients and were all discharged as day case. There was no postoperative wound infection, anal incontinence, anal stenosis, and subcutaneous abscess. However, there was a recurrence in two patients. Conclusions FiLaC has been demonstrated to be a reliable and safe sphincter-saving procedure for treating fistula-in-ano even for complex and high fistulae that is feasible in our subregion.
Collapse
Affiliation(s)
- Thomas Olagboyega Olajide
- General Surgery Unit, College of Medicine, University of Lagos/Lagos University Teaching Hospital, Lagos, Nigeria
| | - Christopher O. Bode
- Paediatric Surgery Unit, Department of Surgery, College of Medicine, University of Lagos/Lagos University Teaching Hospital, Lagos, Nigeria
| |
Collapse
|
13
|
Platelet-rich plasma in the treatment of anal fistula: a systematic review and meta-analysis. Int J Colorectal Dis 2023; 38:70. [PMID: 36905475 DOI: 10.1007/s00384-023-04367-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/05/2023] [Indexed: 03/12/2023]
Abstract
OBJECTIVE To analyse the safety and effectiveness of platelet-rich plasma (PRP) in anal fistula patients. METHODS Online databases including PubMed, Embase, Cochrane Library, and Web of Science were searched from inception to December 5, 2022, for eligible studies about evaluating the efficacy of platelet-rich plasma (PRP) in treating anal fistula. Literature search, screening, data extraction, and quality assessment were carried out by two independent investigators. The overall cure rate, the complete cure rate, the recurrence rate, and the adverse event rate with their 95% confidence intervals (95% CI) were the primary calculation indexes. Subgroup analyses were conducted primarily according to whether PRP was combined with other treatments. Softwares of MedCalc 18.2 and Review Manager 5.3 were used for meta-analysis. RESULTS A total of 14 studies with 514 patients were included in the meta-analysis. The overall cure rate of 14 studies was 72.11% (95% CI 0.64-0.79). The cure rate of PRP alone was 62.39% (95% CI 0.55-0.69). The combined cure rate of PRP with other treatments was 83.12% (95% CI 0.77-0.88). The cure rate of interventions involving PRP were superior to the cure rate of surgery methods without using PRP significantly in the 4 randomized controlled studies (RR = 1.30, 95% CI 1.10-1.54, p = 0.002). The complete cure rate of the 8 studies was 66.37% (95% CI 0.52-0.79). The recurrence rate of the 12 studies was 14.84% (95% CI 0.08-0.24). The adverse event rate of the 12 studies was 6.31% (95% CI 0.02-0.12). CONCLUSION PRP showed favorable safety and effectiveness in the treatment of anal fistula, especially combined with other treatment procedures.
Collapse
|
14
|
Non-Healing Perianal Fistulas: A Clinical Model of Tissue Senescence Impairing Both Tissue Fibrosis and Regenerative Potential. Biomedicines 2023; 11:biomedicines11020537. [PMID: 36831073 PMCID: PMC9953590 DOI: 10.3390/biomedicines11020537] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2023] [Revised: 02/09/2023] [Accepted: 02/10/2023] [Indexed: 02/15/2023] Open
Abstract
Senescent cells and fibrosis are important components that impact the regenerative capacity of skin, particularly when considering chronic non-healing wounds. Anoderm and perianal fistulas in the setting of Crohn's disease are clinically pathophysiological extremes with consequently different healing processes which impact treatment modalities. This study describes the implications of potential senescence reversing techniques including autologous fat grafting and pharmacologic and immunomodulating agents. Given these findings, the authors propose a future direction of study involving exosomes loaded with senolytics as a method for potentially improving chronic wound healing. In conclusion, this manuscript explores the diversity of skin healing and healing outcomes which supports the future investigation of senotherapeutic agents promoting regenerative processes for non-healing wounds.
Collapse
|
15
|
Cwaliński J, Hermann J, Paszkowski J, Banasiewicz T. Minimally Invasive Treatment of Recurrent Anal Fistulas with Autologous Platelet-Rich Plasma Combined With Internal Orifice Closure. Surg Innov 2023; 30:28-35. [PMID: 35430904 DOI: 10.1177/15533506221086778] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
AIM Minimally invasive procedures for the treatment of anal fistulas are gaining more and more popularity. For this purpose, Platelet-Rich Plasma (PRP) are administered to accelerate the healing process of various difficult wounds or lesions. The aim of this study was to evaluate preliminary results of PRP injection into the tissues adjacent to anal fistulas. PATIENTS AND METHODS A cohort of 42 patients with recurrent anal fistula, who underwent at least one cutting procedure previously, were enrolled into this preliminary and prospective trial. Closure of internal orifice was performed in all investigated patients, however, in 22 patients from group I, that procedure was combined with topical injection of PRP. In the postoperative period, the PRP administration could be repeated in case of incomplete fistula closure. Follow-up consisted of out-patient visits in a fortnight, 1, 2, and 12 months. RESULTS Complete closure of anal fistulas was achieved in 16 (75%) patients from group I and 10 (45,5%) patients from group II. The fistulas were healed in 9 patients from group I after single application of PRP. In the next 9 patients with incomplete fistula closure, the injection was repeated 2 to 4 times every fortnight leading finally to complete recovery in 6 of them. CONCLUSIONS Surgical fistula closure with local PRP application spares the anal sphincter and gives the opportunity to repeat the procedure several times if necessary. Treatment of recurrent anal fistulas with PRP can be considered as last resort therapy.
Collapse
Affiliation(s)
- Jarosław Cwaliński
- Department of General, Endocrinological Surgery and Gastroenterological Oncology, 37807Poznan University of Medical Sciences, Poznań, Poland
| | - Jacek Hermann
- Department of General, Endocrinological Surgery and Gastroenterological Oncology, 37807Poznan University of Medical Sciences, Poznań, Poland
| | - Jacek Paszkowski
- Department of General, Endocrinological Surgery and Gastroenterological Oncology, 37807Poznan University of Medical Sciences, Poznań, Poland
| | - Tomasz Banasiewicz
- Department of General, Endocrinological Surgery and Gastroenterological Oncology, 37807Poznan University of Medical Sciences, Poznań, Poland
| |
Collapse
|
16
|
Crohn's Disease-Associated and Cryptoglandular Fistulas: Differences and Similarities. J Clin Med 2023; 12:jcm12020466. [PMID: 36675403 PMCID: PMC9860571 DOI: 10.3390/jcm12020466] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Revised: 01/01/2023] [Accepted: 01/04/2023] [Indexed: 01/09/2023] Open
Abstract
Perianal fistulas are defined as pathological connections between the anorectal canal and the perianal skin. Most perianal fistulas are cryptoglandular fistulas, which are thought to originate from infected anal glands. The remainder of the fistulas mainly arises as complications of Crohn's disease (CD), trauma, or as a result of malignancies. Fistulas in CD are considered as a consequence of a chronic and transmural inflammatory process in the distal bowel and can, in some cases, even precede the diagnosis of CD. Although both cryptoglandular and CD-associated fistulas might look similar macroscopically, they differ considerably in their complexity, treatment options, and healing rate. Therefore, it is of crucial importance to differentiate between these two types of fistulas. In this review, the differences between CD-associated and cryptoglandular perianal fistulas in epidemiology, pathogenesis, and clinical management are discussed. Finally, a flow chart is provided for physicians to guide them when dealing with patients displaying their first episode of perianal fistulas.
Collapse
|
17
|
Abdollahi A, Emadi E, Hamidi Alamdari D. Autologous platelet-rich-plasma injection and platelet-rich fibrin glue interposition for treatment of anal fistula resistant to surgery. GASTROENTEROLOGY AND HEPATOLOGY FROM BED TO BENCH 2023; 16:292-296. [PMID: 37767316 PMCID: PMC10520388 DOI: 10.22037/ghfbb.v16i2.2719] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Accepted: 03/12/2023] [Indexed: 09/29/2023]
Abstract
Aim The current study purposed to evaluate the autologous platelet-rich plasma (PRP), and platelet-rich fibrin glue (PRFG) effect on the treatment of complex, and recalcitrant anal fistula (AF) which was not cured by several surgeries. Background AF has remained one of difficult challenges for centuries. Surgery is the common treatment method for it, but the risk of fecal incontinence and recurrence is still a distressing complication for patients and surgeons. New procedures were published in the scientific literature, each with advantages and disadvantages. According to reports, an effective therapy option is the autologous fibrin glue that is rich in platelets. Methods Autologous PRP and PRFG were prepared from 10 patients' own blood. The surgeon curetted the tract of anal fistula for the deepithelialisation till hemorrhage occurred; PRP was injected around the fistula into the tissue, and PRFG was interpositioned in the tract. Age, number of previous surgeries, complications, number of PRP and PRFG administrations, and duration of halting the discharge were among the information gathered. Patients were followed up between 10 months to 84 months after treatment. Results No complications were observed during and after the injection. During the period of follow-up, AF leakage was stopped for 6 patients, but not for 4 patients. Conclusion Since autologous PRP injection, and PRFG interposition is a safe, effective, and minimally invasive procedure for resistant AF to surgeries; it can be used, along with surgery to increase the healing rate of complex anal fistula.
Collapse
Affiliation(s)
- Abbas Abdollahi
- Surgical Oncology Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Elaheh Emadi
- Vascular and Endovascular Surgery Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
| | | |
Collapse
|
18
|
Ligation of Intersphincteric Fistulous Tract vs Endorectal Advancement Flap for High-Type Fistula in Ano: A Randomized Controlled Trial. J Am Coll Surg 2023; 236:27-35. [PMID: 36519904 DOI: 10.1097/xcs.0000000000000441] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND This study aimed to compare the postoperative outcomes and success rate of the endorectal advancement flap and ligation of intersphincteric fistulous tract (LIFT) in high-type fistula in ano. STUDY DESIGN This randomized control trial included patients with high-type fistula in ano of cryptoglandular origin. The primary endpoint was complete fistula healing at the end of 6 months. However, the patients were followed up for 2 years. Other parameters studied were perioperative complications, duration of surgery, postoperative pain, hospital stay in hours, continence, and quality of life at 6 months. RESULTS A total of 84 patients were recruited (42 in each group). The healing rate in the LIFT arm was better than that in the endorectal advancement flap arm (76.2.% vs 54.7%, p = 0.039). Four patients in the endorectal advancement flap group and two in the LIFT group had flatus incontinence at the end of 6 months, but all were continent at 2 years. At the end of the first week, the Visual Analog Scale score and quality of life at 6 months were better in the LIFT arm (3.7 ± 1.16 vs 4.7 ± 0.81 and 0.7 vs 0.6, p < 0.05). The mean duration of surgery was significantly less in the LIFT group (46.43 ± 9.32 vs 89.29 ± 10.90 minutes). None had any postoperative complications, and >80% were discharged within 24 hours. CONCLUSIONS The shorter operative duration, better quality of life at 6 months, and higher healing rate make LIFT a superior treatment option for high fistula in ano. However, studies with a large sample size will be needed to verify these results.
Collapse
|
19
|
Management of Complex Fistula-in-ano by Interception of Fistula Track with Application of Ksharasutra (IFTAK): A Novel Technique. JOURNAL OF COLOPROCTOLOGY 2022. [DOI: 10.1055/s-0042-1756145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Abstract
Objective Despite all the technological advances, successful management of complex fistula-in-ano is still a challenge due to recurrence and incontinence. The present study evaluates the outcomes of a novel technique, Interception of Fistula Track with Application of Ksharasutra (IFTAK) in terms of success rate and degree of incontinence.
Methods In the present prospective study, 300 patients with complex fistula-in-ano were treated by the IFTAK technique, whose surgical steps include: incision at the anterior or posterior midline perianal area, identification and interception of the fistulous track at the level of the external sphincter, rerouting the track (and extensions) at the site of interception, and application of a ksharasutra (medicated seton) in the proximal track (from the site of interception to the internal opening) that is laid open gradually, with the resulting wound healing with minimum scarring. The distal track is allowed to heal spontaneously.
Results There were 227 trans-sphincteric and 73 intersphincteric varieties of fistula with supralevator extension in 23 cases, of which 130 were recurrent fistulas, 29 had horseshoe track, while 25 had blind fistula with no cutaneous opening. The mean duration of the ksharasutra application was 8.11 ± 3.86 weeks with an overall success rate of 93.33% at the 1-year follow-up. A total of 3.67% of the cases reported with a mild impairment of continence on the Wexner incontinence scoring system. Pre- and postoperative anal manometry evaluation showed minimal reduction in median basal and squeeze pressures.
Conclusion The IFTAK technique is a minimally invasive, daycare surgical procedure for the management of complex fistula-in-ano with low recurrence and minimal sphincter damage.
Collapse
|
20
|
He L, Yang Z, Xu J, Wang Q. Evaluation of the Effectiveness of a Combination of Chinese Herbal Fumigation Sitz-Bath and Red Ointment in Managing Postoperative Wound Healing and Pain Control in Anal Fistula Patients. CONTRAST MEDIA & MOLECULAR IMAGING 2022; 2022:1905279. [PMID: 36176927 PMCID: PMC9499773 DOI: 10.1155/2022/1905279] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Revised: 07/25/2022] [Accepted: 07/29/2022] [Indexed: 11/17/2022]
Abstract
Objective To explore the efficacy of Chinese herbal fumigation and sitz-bath combined with red ointment in the treatment of postoperative wound healing and pain control in anal fistula patients. Methods A total of 118 anal fistula patients were selected as the study population, randomly divided into two groups, i.e., the research group (n = 60) and the control group (n = 60). The control group was treated with red ointment therapy for postoperative wound healing and pain while the research group was treated with a combination of ointment and traditional Chinese medicine fumigation sitz-bath, Postoperative wound healing, pain control, and safety evaluation were compared between the two groups. Results. The total effective rate in the research group was 96.67%, which was significantly higher than that in the control group (93.10%), and the difference was statistically significant (P < 0.05). The VAS scores and postoperative wound healing times in the research group were significantly lower than those in the control group. The difference was statistically significant (P < 0.05). A day after postoperative treatment, there was no significant difference (P > 0.05) in TNF-α and IL-6 levels between the two study groups; however, from day 3 to day 14 the levels were statistically different. TNF-α and IL-6 levels in research group were significantly lower than those in the control group. The difference was statistically significant (P < 0.05). The incidence of postoperative complications in the research group at 6.67% was statistically significant (P < 0.05), significantly lower than 13.79% in the control group. Conclusion. Postoperative intervention with Chinese herbal fumigation and sitz-bath combined with red ointment can effectively reduce the wound healing duration and lower the degree of pain experienced by anal fistula patients, thereby improving their quality of life.
Collapse
Affiliation(s)
- Li He
- Department of Traditional Chinese Medicine, Shanghai Tenth People's Hospital, Shanghai 200072, China
| | - ZhiLing Yang
- Department of Traditional Chinese Medicine, Shanghai Tenth People's Hospital, Shanghai 200072, China
| | - Jin Xu
- Department of Anorectal Diseases, Shanghai Baoshan Integrated Traditional Chinese and Western Medicine Hospital, Shanghai 201900, China
| | - QingMing Wang
- Department of Anorectal Diseases, Shuguang Hospital Affiliated to Shanghai University of Traditional Chinese Medicine, Shanghai 201203, China
| |
Collapse
|
21
|
Zahra A, Malla J, Selvaraj R, Dhanoa RK, Venugopal S, Shoukrie SI, Selvamani TY, Hamouda RK, Hamid P. A Comparison of Different Surgical Treatments for Complex Anal Fistula: A Systematic Review. Cureus 2022; 14:e28289. [PMID: 36176822 PMCID: PMC9512314 DOI: 10.7759/cureus.28289] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Accepted: 08/23/2022] [Indexed: 11/05/2022] Open
Abstract
Fistula-in-ano is a common proctological condition that primarily affects younger people and leads to chronic morbidity. An anal fistula is divided into simple and complex fistulas. A complex fistula is a challenging problem due to higher recurrence rates and incontinence associated with surgery. Many new methods have been developed for the closure of complex fistula-in-ano, but there is no single best method. The aim of this study is to identify a superior surgical technique for treating complex/high cryptoglandular perianal fistulas (HCPFs). A literature search was done using PubMed and Google Scholar for the period of 2012-2021. Articles that contain surgical treatment for complex anal fistula in the English language published in the last 10 years were included. The types of studies included were randomized controlled trials (RCTs), meta-analyses, systematic reviews, cohort studies, and traditional reviews. Articles excluded were those done more than 10 years ago, in other languages, and containing simple fistula management only. Nine studies were included in the review; a systematic review and meta-analysis concluded that no single method is effective. The ligation of the intersphincteric fistula tract (LIFT) procedure seems to be a promising and effective technique as it has a low rate of fecal incontinence as compared to other methods. Biological techniques give variable success rates so does fistula plug (FP). Mucosal advancement flap (MAF) and rerouting seton give good results according to one study. Fistula plug gives variable results and is not a preferred method. Ligation of the intersphincteric fistula tract (LIFT) seems to be a promising new technique for complex anal fistulas, but the data available is not enough to determine the best method. More randomized trials are required to compare traditional techniques and emerging new biological methods to see the best technique available.
Collapse
|
22
|
Lalhruaizela S. Endofistula laser ablation of fistula-in-ano: a new minimally invasive technique for the treatment of fistula-in-ano. Ann Coloproctol 2022; 38:301-306. [PMID: 34324802 PMCID: PMC9441541 DOI: 10.3393/ac.2020.00668.0095] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Revised: 12/29/2020] [Accepted: 04/22/2021] [Indexed: 02/07/2023] Open
Abstract
PURPOSE Many techniques are used to treat fistula-in-ano (FIA). The major problems associated with conventional surgical techniques are postoperative complications like sepsis, incontinence, etc. Therefore, several sphincter-saving techniques have been developed in recent years including laser diodes. METHODS This study presents an early experience of the use of diode lasers with a capacity of 360° radial energy emission endofistula laser ablation (EFLA) of FIA to treat patients with primary low anal fistulas. The primary and secondary success rates were assessed and the factors affecting these rates were evaluated in patients (n=31) who presented with primary, uncomplicated, and low anal fistulas. RESULTS Out of 31 patients, 19 (61.3%) were males and 12 (38.7%) were females with a mean age of 38.6±11.5 years. Twenty-one patients (67.7%) had intersphincteric fistula, 9 (29.0%) had transsphincteric fistula, and 1 (3.2%) had suprasphincteric fistula. Thirteen patients (41.9%) had undergone some surgery in the past for FIA. Eleven patients (35.5%) developed postoperative complications. The patients had a low median pain score of 3 on the numeric pain rating scale. The primary success rate was 67.7% (21 of 31) and the secondary success rate was 80.0% (8 of 10) over a median follow-up of 2 years. A significantly higher primary healing rate was observed in patients who did not undergo any prior surgical treatments (P=0.01). CONCLUSION EFLA resulted in moderate primary and high secondary success rates and was not associated with major postoperative complications. Therefore, EFLA can be considered as a preferred noninvasive efficient technique for FIA treatment.
Collapse
|
23
|
Hwang SH. Trends in Treatment for Hemorrhoids, Fistula, and Anal Fissure: Go Along the Current Trends. J Anus Rectum Colon 2022; 6:150-158. [PMID: 35979269 PMCID: PMC9328791 DOI: 10.23922/jarc.2022-012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2022] [Accepted: 04/27/2022] [Indexed: 12/31/2022] Open
Abstract
Recent trends in benign anal disease treatment are minimizing surgery to preserve normal anorectal anatomical unit and its functions. However, some surgeons still prefer and are confident with the use of conventional solid surgical methods. In this report, we will investigate the recent trends in the treatment for hemorrhoids, fistula, and anal fissure. The practice guidelines of advanced countries, including UK, Italy, France, USA, Japan, and ESCP, are referred to in this review. Opinions suggested in international meetings were also added. In the management of hemorrhoids, surgical treatments and office procedures were recommended according to a patient's status and preference. For the management of complex anal fistula, novel sphincter-preserving surgical techniques are more widely accepted than a sphincter-dividing procedure of immediate repair following fistulectomy. The treatment of anal fissures is well covered in the guidelines of the ASCRS.
Collapse
Affiliation(s)
- Sung Hwan Hwang
- Busan Hangun Hospital & Busan Hangun Hospital Bumcheon Campus
| |
Collapse
|
24
|
Sluckin TC, Gispen WH, Jongenotter J, Hazen SJA, Smeets S, van der Bilt JDW, Smeenk RM, Schouten R. Treatment of cryptoglandular fistulas with the fistula tract laser closure (FiLaC™) method in comparison with standard methods: first results of a multicenter retrospective comparative study in the Netherlands. Tech Coloproctol 2022; 26:797-803. [PMID: 35749023 DOI: 10.1007/s10151-022-02644-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Accepted: 05/20/2022] [Indexed: 01/23/2023]
Abstract
BACKGROUND Current surgical closure techniques for sphincter-sparing treatment of high cryptoglandular fistulas in the Netherlands include the mucosal advancement flap procedure (MAF) and ligation of the intersphincteric fistula tract (LIFT). A relatively novel treatment is the fistula tract laser closure (FiLaC™) method. The aim of this study was to investigate the differences in healing and recurrence rates between FiLaC™ and current standard practices. METHODS This multicenter retrospective cohort study included both primary and recurrent high cryptoglandular anorectal fistulas, treated with either FiLaC™ or standard methods (MAF or LIFT) between September 2015 and July 2020. Patients with extrasphincteric fistulas, Crohn's disease, multiple fistulas, age < 18 years or missing data regarding healing time or recurrence were excluded. The primary outcomes were the clinical primary and secondary healing and recurrence rates. Primary healing was defined as a closed external opening without fluid discharge within 6 months of treatment on examination, while secondary healing was the same endpoint after secondary treatment. Secondary outcomes included healing time and complaints. RESULTS A total of 162 high fistulas from 3 Dutch hospitals were included. Ninety-nine high fistulas were treated with FiLaC™ and 63 with either MAF or LIFT. There were no significant differences between FiLaC™ and MAF/LIFT in terms of clinical healing (55.6% versus 58.7%, p = .601), secondary healing (70.0% versus 69.2%, p = .950) or recurrence rates (49.5% versus 54%, p = .420), respectively. Median follow-up duration was 7.1 months in the FiLaC™ group (interquartile range [IQR] 4.1-14.4 months) versus 6 months in the control group (IQR 3.5-8.1 months). CONCLUSIONS FiLaC™ treatment of high anorectal fistulas does not appear to be inferior to MAF or LIFT. Based on these preliminary results, FiLaC™ can be considered as a worthwhile treatment option for high cryptoglandular fistulas. Prospective studies with a longer follow-up period and well-determined postoperative parameters such as complication rates, magnetic resonance imaging for confirmation of fistula healing, incontinence and quality of life are warranted.
Collapse
Affiliation(s)
- T C Sluckin
- Department of Surgery, Flevoziekenhuis, Almere, the Netherlands
| | - W H Gispen
- Department of Surgery, Flevoziekenhuis, Almere, the Netherlands
| | - J Jongenotter
- Department of Surgery, Albert Schweitzer Hospital, Dordrecht, the Netherlands
| | - S J A Hazen
- Department of Surgery, Albert Schweitzer Hospital, Dordrecht, the Netherlands
| | - S Smeets
- Department of Surgery, Flevoziekenhuis, Almere, the Netherlands
| | | | - R M Smeenk
- Department of Surgery, Albert Schweitzer Hospital, Dordrecht, the Netherlands
| | - R Schouten
- Department of Surgery, Flevoziekenhuis, Almere, the Netherlands.
| |
Collapse
|
25
|
Elfallal AH, Fathy M, Elbaz SA, Emile SH. Comprehensive literature review of the applications of surgical laser in benign anal conditions. Lasers Med Sci 2022; 37:2775-2789. [PMID: 35606626 DOI: 10.1007/s10103-022-03577-1] [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: 04/19/2022] [Accepted: 05/14/2022] [Indexed: 10/18/2022]
Abstract
Surgery for benign anal conditions is a common practice and is usually followed by a good outcome. The present review aimed to summarize the emergence and evolution of different laser techniques used for the treatment of benign anal conditions and report their current outcome. PubMed and Scopus were searched for studies that assessed the use of laser in benign anal conditions. Anal conditions reviewed were hemorrhoids, anal fistula, anal warts, anal stenosis, and anal fissure. The full text of the studies retrieved was summarized in a narrative and tabular form. Laser techniques used for the treatment of hemorrhoidal disease were laser open hemorrhoidectomy, laser hemorrhoidoplasty, and Doppler-guided hemorrhoidal laser dearterialization. Resolution of hemorrhoidal symptoms was reported in 72-100% of patients after laser treatment. YAG laser, fistula laser closure, and photodynamic therapy have been used for the treatment of anal fistula with success rates ranging from 20 to 92.6%. Anal warts can be treated with photodynamic therapy with or without YAG or CO2 laser with a success rate up to 88%. A few studies reported the use of laser in the treatment of chronic anal fissure and anal stenosis. The use of laser in the treatment of benign anal conditions is associated with promising outcomes. Laser was most assessed in hemorrhoidal disease and anal fistula and showed more consistent success rates with hemorrhoidal disease than with anal fistula. Preliminary reports assessed the outcome of laser treatment in other conditions as anal fissure and warts with acceptable outcomes.
Collapse
Affiliation(s)
- Ahmed Hossam Elfallal
- General Surgery Department, Colorectal Surgery Unit, Mansoura University Hospitals, Mansoura University, 60 El-Gomhoria Street, Mansoura, 35516, Dakahlia, Egypt
| | - Mohammad Fathy
- General Surgery Department, Colorectal Surgery Unit, Mansoura University Hospitals, Mansoura University, 60 El-Gomhoria Street, Mansoura, 35516, Dakahlia, Egypt
| | - Samy Abbas Elbaz
- General Surgery Department, Colorectal Surgery Unit, Mansoura University Hospitals, Mansoura University, 60 El-Gomhoria Street, Mansoura, 35516, Dakahlia, Egypt
| | - Sameh Hany Emile
- General Surgery Department, Colorectal Surgery Unit, Mansoura University Hospitals, Mansoura University, 60 El-Gomhoria Street, Mansoura, 35516, Dakahlia, Egypt. .,Department of Colorectal Surgery, Cleveland Clinic Florida, Weston, FL, USA.
| |
Collapse
|
26
|
Yu Q, Zhi C, Jia L, Li H. Cutting seton versus decompression and drainage seton in the treatment of high complex anal fistula: a randomized controlled trial. Sci Rep 2022; 12:7838. [PMID: 35551237 PMCID: PMC9098520 DOI: 10.1038/s41598-022-11712-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Accepted: 04/22/2022] [Indexed: 11/21/2022] Open
Abstract
This study aimed to compare the efficacy between decompression and drainage seton (DADS) and cutting seton (CS) in the treatment of high complex anal fistula. Patients were randomly assigned 1:1 to DADS or CS group. The primary outcome was the rate of wound healing. Second outcomes included time taken to return to work, postoperative pain, the severity of fecal incontinence and other complications. A total of 120 patients with a mean age of 39 years were included. There was no significant difference in the rate of complete wound healing at 1 year. The mean time taken to return to work was 5 ± 2 days in DADS group, shorter than CS group (10 ± 3, p < 0.001). Mean vaizey incontinence score and the post-operation pain in DADS group was significantly lower than CS group. No significant difference was found between two groups in the incidence of complications. DADS is as effective as Cutting seton for the treatment of high complex anal fistula but is associated with less postoperative pain and better sphincter function preserving.
Collapse
Affiliation(s)
- Qiuxiang Yu
- Department of Proctology, China-Japan Friendship Hospital, No 2 Yinghua East Street, Chaoyang District, Beijing, 100029, China
| | - Congcong Zhi
- Department of Proctology, China-Japan Friendship Hospital, No 2 Yinghua East Street, Chaoyang District, Beijing, 100029, China
| | - Lansi Jia
- Department of Proctology, China-Japan Friendship Hospital, No 2 Yinghua East Street, Chaoyang District, Beijing, 100029, China
| | - Hui Li
- Department of Proctology, China-Japan Friendship Hospital, No 2 Yinghua East Street, Chaoyang District, Beijing, 100029, China.
| |
Collapse
|
27
|
Tian Z, Li YL, Nan SJ, Xiu WC, Wang YQ. Video-assisted anal fistula treatment for complex anorectal fistulas in adults: a systematic review and meta-analysis. Tech Coloproctol 2022; 26:783-795. [PMID: 35347492 DOI: 10.1007/s10151-022-02614-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Accepted: 03/08/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND Video-assisted anal fistula treatment (VAAFT) has gained increasing acceptance as a sphincter-sparing procedure for treating complex anorectal fistulas (CAF), but no unequivocal conclusions can yet be drawn regarding its ultimate effectiveness. We reviewed the literature and performed a meta-analysis to evaluate the efficacy and safety of VAAFT in CAF patients. METHODS The study protocol was registered with the PROSPERO database (CRD42021279085). A systematic literature search was performed in the PubMed, Embase, and Cochrane Library databases up to June 2021 with no restriction on language based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We used the keywords video-assisted surgery, video-assisted anal fistula treatment, and complex anorectal fistula to identify relevant studies. RESULTS Fourteen trials (7 prospective and 7 retrospective) with a total of 1201 patients (mean age 43.5 years) were included. The median follow-up duration was 16.5(8-48) months. Pooled analysis showed that the rates of success, recurrence and postoperative complication across the studies were 83% (95% CI 81-85%, I2 = 37.9%), 16% (95% CI 14-18%, I2 = 4.8%), 11% (95% CI 7-15%, I2 = 72.1%), respectively. The postoperative Jorge-Wexner score used to assess the level of anal incontinence was 1.09 (95% CI, 0.9-1.27, I2 = 74.6%). The internal opening detection rate was 97.6% (95% CI 96.1-99.6%, I2 = 48.2%). Recurrence rates varied according to the closure method of internal opening from 21.4% after using staplers, 18.7% after suturing, to 23.5% after advancement flap. The hospital stay was 3.15 days (95% CI 2.96-3.35, I2 = 49.7%). Subgroup analysis indicated that the risk of heterogeneity in the urine retention group was higher compared with that of the overall group and that retrospective studies may be the source of heterogeneity for postoperative anal incontinence. r . Sensitivity analysis confirmed the stability of the pooled results. Begg's and Egger's tests showed no evidence of publication bias. CONCLUSIONS According to the available evidence, VAAFT may be a valuable alternative to fistulotomy or seton in treating CAF and has the additional long-term benefits of reducing anal incontinence and surgical morbidity, permitting earlier healing and accelerated rehabilitation.
Collapse
Affiliation(s)
- Z Tian
- Department of Anorectal Center, Qilu Hospital (Qingdao), Cheeloo College of Medicine, Shandong University, Qingdao, Shandong, China
| | - Y L Li
- The Affiliated Hospital of Qingdao University, Qingdao, Shandong, China
| | - S J Nan
- Department of Anorectal Center, Qilu Hospital (Qingdao), Cheeloo College of Medicine, Shandong University, Qingdao, Shandong, China
| | - W C Xiu
- Department of Anorectal Center, Qilu Hospital (Qingdao), Cheeloo College of Medicine, Shandong University, Qingdao, Shandong, China
| | - Y Q Wang
- Department of Anorectal Center, Qilu Hospital (Qingdao), Cheeloo College of Medicine, Shandong University, Qingdao, Shandong, China.
| |
Collapse
|
28
|
Parwez M, Huda T, Yadav MS, Gupta K, Mital K, Pandya B. A PILOT STUDY on the Clinical and Functional Outcomes of an Improvised Technique of Core-cut Fistulectomy for Fistula-in-ano. Surg Innov 2022; 29:426-437. [PMID: 35341401 DOI: 10.1177/15533506221081134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Anal fistulae are difficult to treat entities and minimally invasive procedures are evolving with promises. Our improvised technique is a simple and easy day-care procedure for simple fistulae. AIM To evaluate the outcomes of a technical modification in the procedure of core-cut fistulectomy in simple cryptoglandular fistula-in-ano. METHODS 47 patients of fistula-in-ano presenting to the out-patient of the General Surgery department at All India Institute of Medical Sciences, Bhopal, from November 2018 to March 2020 were selected. A complete history, physical examination followed by relevant investigations were meticulously performed and recorded. They were operated using an improvised core-cut technique, under a pudendal nerve block. Patients were kept on follow-up for a minimum of 6 months period to note the outcome of the surgery. RESULTS The mean age was 37 ± 13.17 years with a male: female ratio of 5.1:1. The most common clinical presentation was perianal discharge in 96% of patients followed by pain and pruritus ani in 45% and 32%, respectively. 93.62% were inter-sphincteric, and 6.38% were trans-sphincteric. Extra-sphincteric and supra-levator fistulae were excluded from the study. The mean operative time was 17 ± 10.19 minutes. The mean healing time was 19.21 ± 5.99 days. The success rate of this novel technique of core-cut was calculated to be 89.37%. The rate of recurrence was calculated to be 10.63% (5 out of 47 patients). None of our patients developed incontinence. CONCLUSION Our pilot study results for simple fistulae-in-ano had less morbidity, postoperative pain, better wound healing, patient satisfaction, and compliance with low risk of recurrence, and no incontinence. It could hence be recommended for larger groups and more complicated fistulae in the future.
Collapse
Affiliation(s)
- Masoom Parwez
- Department of General Surgery, 390706AIIMS Bhopal, Bhopal, India
| | - Tanweerul Huda
- Department of General Surgery, 390706AIIMS Bhopal, Bhopal, India
| | - Moorat S Yadav
- Department of General Surgery, 390706AIIMS Bhopal, Bhopal, India
| | - Kamal Gupta
- Department of General Surgery, Karan Hospital, Jalandhar, India
| | - Kushal Mital
- Department of General Surgery, Rajeev Gandhi Medical College, Thane, India
| | - Bharati Pandya
- Department of General Surgery, 390706AIIMS Bhopal, Bhopal, India
| |
Collapse
|
29
|
Eberspacher C, Mascagni D, Ferent IC, Coletta E, Palma R, Panetta C, Esposito A, Arcieri S, Pontone S. Mesenchymal Stem Cells for Cryptoglandular Anal Fistula: Current State of Art. Front Surg 2022; 9:815504. [PMID: 35252334 PMCID: PMC8889088 DOI: 10.3389/fsurg.2022.815504] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Accepted: 01/24/2022] [Indexed: 11/19/2022] Open
Abstract
Anal fistula is a common disease that needs surgical treatment to be resolved. Despite a variety of surgical options, the major problem is still to cure complex fistulas without any recurrence in the long-term follow-up but, at the same time, to avoid an impairment of continence. In recent years, one solution has been the application of mesenchymal stem cells derived from adipose tissue, especially in association with other treatments, such as the use of fibrin glue or the previous application of a seton. Their initial use in fistulas associated with Crohn's disease has shown encouraging results. In this non-systematic review our aim is to analyze the use in cryptoglandular fistulas: the rate of healing is not so high, and the number of studies is limited. Therefore, further randomized controlled trials are needed to establish their efficacy in the case of complex cryptoglandular anal fistulas and their possible complications.
Collapse
|
30
|
Huang H, Ji L, Gu Y, Li Y, Xu S. Efficacy and Safety of Sphincter-Preserving Surgery in the Treatment of Complex Anal Fistula: A Network Meta-Analysis. Front Surg 2022; 9:825166. [PMID: 35211503 PMCID: PMC8861434 DOI: 10.3389/fsurg.2022.825166] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Accepted: 01/07/2022] [Indexed: 12/23/2022] Open
Abstract
Background There are many surgical methods of sphincter preservation in treating complex anal fistula, but the therapeutic effects of each operation are different. Therefore, this study aimed to compare the impact of other treatment methods through a network meta-analysis to evaluate the best sphincter preservation method for treating complex anal fistula. Methods We searched PubMed, Embase, Cochrane Library, China National Knowledge Infrastructure, Chinese Biomedical Literature Database, VIP Journal Database, and the Wanfang Database to collate randomized controlled trials on sphincter-preserving surgery for complex anal fistula. Results A total of 29 articles were included in this meta-analysis. The cure rates showed no statistically significant differences between any two interventions (P > 0.05). The recurrence rate results showed that the rate of patients after Fistulectomy was higher than others (P < 0.05). The incidence rate of complications showed that the incidence rate after fistulectomy treatment was higher than that of others (P < 0.05). The surface under the cumulative ranking (SUCRA) was used to arrange their advantages and disadvantages, and a larger SUCRA value indicates that the intervention may be more effective. The results showed that TROPIS may have the highest cure rate (SUCRA = 78.6%), stem cell transplantation (SCT) may have the lowest recurrence rate (SUCRA = 85.5%), and imLIFT may have the least complications (SUCRA = 88.2%). Conclusion According to the existing literature data, for patients with complex anal fistula, TROPIS may be the surgical method with the highest cure rate, SCT may be the treatment method with the lowest recurrence rate, and imLIFT may be the surgical method with the lowest incidence of postoperative complications. Systematic Review Registration PROSPERO, identifier: CRD42020221907.
Collapse
Affiliation(s)
- Hua Huang
- Department of Anorectal, Changshu Hospital Affiliated to Nanjing University of Chinese Medicine, Changshu, China
| | - Lijiang Ji
- Department of Anorectal, Changshu Hospital Affiliated to Nanjing University of Chinese Medicine, Changshu, China
- *Correspondence: Lijiang Ji
| | - Yunfei Gu
- Department of Anorectal, Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing, China
| | - Youran Li
- Department of Anorectal, Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing, China
| | - Shanshan Xu
- Nanjing University of Chinese Medicine, Nanjing, China
| |
Collapse
|
31
|
Schneider R, Ommer A. Spaltung von Analfisteln – noch zeitgemäß? COLOPROCTOLOGY 2022. [DOI: 10.1007/s00053-021-00583-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
|
32
|
An Affordable Approach of Mesenchymal Stem Cell Therapy in Treating Perianal Fistula Treatment. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2022; 1401:73-95. [DOI: 10.1007/5584_2022_716] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
|
33
|
Iqbal N, Dilke SM, Geldof J, Sahnan K, Adegbola S, Bassett P, Tozer P. Is fistulotomy with immediate sphincter reconstruction (FISR) a sphincter preserving procedure for high anal fistula? A systematic review and meta-analysis. Colorectal Dis 2021; 23:3073-3089. [PMID: 34623747 DOI: 10.1111/codi.15945] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Revised: 06/22/2021] [Accepted: 07/19/2021] [Indexed: 12/23/2022]
Abstract
AIM This systematic review aimed to assess the outcomes of fistulotomy or fistulectomy and immediate sphincter repair (FISR) in relation to healing, incontinence and sphincter dehiscence both overall and in patients with high anal fistulae. METHODS Medline, Embase and The Cochrane library were searched for studies of patients undergoing FISR for anal fistula. Data regarding healing, continence and sphincter dehiscence were extracted overall and for high anal fistulae. The DerSimonian-Laird random-effects method was used for pooled analysis, heterogeneity between studies was assessed based on the significance of between-study heterogeneity, and on the size of the I2 value. Risk of bias was assessed using the Cochrane risk of bias tool and the Newcastle-Ottawa scale. RESULTS We identified 21 studies evaluating 1700 patients. Pooled analysis of healing reached 93% (95% CI: 91%-95%, I2 = 51% p-value for heterogeneity = 0.004), with continence disturbance and worsening continence reaching 11% (95% CI: 6%-18%, I2 = 87% p < 0.001) and 8% (95% CI: 4%-13%, I2 = 74% p < 0.001), respectively. Subgroup analysis according to fistula height could only be conducted on limited data. Pooled healing in high anal fistulae was 89% (95% CI: 84%-94%, I2 = 76% p < 0.001), 16% suffered disturbance of continence (95% CI: 7%-27%, I2 = 89% p < 0.001), 8% worsening continence from baseline (95% CI: 2%-16%, I2 = 80% p < 0.001) and 2% suffered sphincter dehiscence (95% CI: 0%-10%, I2 = 89% p < 0.001). CONCLUSION The evidence suggests FISR is a safe, effective procedure. However, data are limited by inconsistencies in reporting of continence and definition of fistula height, particularly high anal fistulae. Significant heterogeneity means that outcomes in high fistulae remain uncertain.
Collapse
Affiliation(s)
- Nusrat Iqbal
- Robin Phillips' Fistula Research Unit, St Mark's Hospital and Academic Institute, Harrow, UK
| | - Stella Maye Dilke
- Department of Colorectal Surgery, St Mark's Hospital and Academic Institute, London, UK
| | - Jeroen Geldof
- Department of Gastroenterology and Hepatology, University Hospital, Ghent, Belgium
| | - Kapil Sahnan
- Robin Phillips' Fistula Research Unit, St Mark's Hospital and Academic Institute, Harrow, UK
| | - Samuel Adegbola
- Robin Phillips' Fistula Research Unit, St Mark's Hospital and Academic Institute, Harrow, UK
| | | | - Philip Tozer
- Robin Phillips' Fistula Research Unit, St Mark's Hospital and Academic Institute, Harrow, UK
| |
Collapse
|
34
|
Fitzpatrick DP, Kealey C, Brady D, Gately N. Application of biomaterials for complex anal fistulae. INT J POLYM MATER PO 2021. [DOI: 10.1080/00914037.2021.1999955] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- Daniel P. Fitzpatrick
- Material Research Institute, Athlone Institute of Technology, Athlone, Ireland
- Department of Life and Physical Science, Athlone Institute of Technology, Athlone, Ireland
| | - Carmel Kealey
- Department of Life and Physical Science, Athlone Institute of Technology, Athlone, Ireland
- Bioscience Research Institute, Athlone Institute of Technology, Athlone, Ireland
| | - Damien Brady
- Department of Life and Physical Science, Athlone Institute of Technology, Athlone, Ireland
- Department of Science and Health, Institute of Technology Carlow, Carlow, Ireland
| | - Noel Gately
- Material Research Institute, Athlone Institute of Technology, Athlone, Ireland
- Applied Polymer Technologies Gateway Centre, Athlone Institute of Technology, Athlone, Ireland
| |
Collapse
|
35
|
Hu Q, He L. A commentary on "Risk factors for postoperative recurrence of anal fistula identified by an international, evidence-based Delphi consultation survey of surgical specialists" [Int J Surg 2021 Aug; 92:106038]. Int J Surg 2021; 95:106099. [PMID: 34525416 DOI: 10.1016/j.ijsu.2021.106099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Accepted: 08/26/2021] [Indexed: 11/28/2022]
Affiliation(s)
- Qianhua Hu
- Department of General Surgery, Affiliated Xiaoshan Hospital, Hangzhou Normal University, Zhejiang, 311200, China
| | | |
Collapse
|
36
|
De Hous N, Van den Broeck T, de Gheldere C. Fistulectomy and primary sphincteroplasty (FIPS) to prevent keyhole deformity in simple anal fistula: a single-center retrospective cohort study. Acta Chir Belg 2021; 121:308-313. [PMID: 32253992 DOI: 10.1080/00015458.2020.1753151] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVE Fistulotomy remains the gold standard for the surgical treatment of simple anal fistula, but may cause fecal incontinence and a characteristic anal 'keyhole' deformity. Although seemingly trivial, keyhole deformity may lead to bothersome symptoms such as anal pruritus and fecal soiling. This study aims to evaluate the efficacy of fistulectomy and primary sphincteroplasty (FIPS), a technique with immediate sphincter reconstruction, in the treatment of simple anal fistula and the prevention of keyhole deformity created by simple fistulotomy. METHODS A retrospective study was performed on all consecutive patients who underwent FIPS for a simple anal fistula at our institution between January 2015 and August 2019. The primary outcome of the study was the rate of early postoperative wound dehiscence, which essentially transforms a FIPS into a simple fistulotomy and may lead to keyhole deformity. All patients received follow-up at regular intervals to evaluate fistula healing and the presence of keyhole deformity. RESULTS FIPS was performed in 24 patients (median age: 52.8 years). After a median follow-up time of 3.0 (2.0, 6.3) months, the overall healing rate was 95.8% (23/24 patients). Six (25%) patients experienced early postoperative wound dehiscence resulting in the development of a keyhole deformity. Five of them were symptomatic (mainly soiling). Keyhole deformity was diagnosed at a median time of 6.0 (3.8, 7.5) months postoperatively. The occurrence of early wound dehiscence and subsequent keyhole deformity was associated with a posteriorly located fistula (p = .02). CONCLUSION FIPS avoids the development of keyhole deformity in the majority of patients with simple anal fistula, but is less successful in posterior fistulas. Since FIPS is a very effective, fast and simple procedure, it should be considered a valid alternative for the treatment of every simple anal fistula.
Collapse
Affiliation(s)
- Nicolas De Hous
- Department of General Surgery, Heilig-Hartziekenhuis, Lier, Belgium
| | - Thomas Van den Broeck
- Department of General Surgery, Heilig-Hartziekenhuis, Lier, Belgium
- Department of Urology, University Hospital of Leuven, Leuven, Belgium
| | | |
Collapse
|
37
|
Ascanelli S, Zamboni P, Campioni D, Grazia Sibilla M, Chimisso L, Zollino I, Valpiani G, Carcoforo P. Efficacy and Safety of Treatment of Complex Idiopathic Fistula-in-Ano Using Autologous Centrifuged Adipose Tissue Containing Progenitor Cells: A Randomized Controlled Trial. Dis Colon Rectum 2021; 64:1276-1285. [PMID: 34016825 DOI: 10.1097/dcr.0000000000001924] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Mesenchymal stem cells derived from adipose tissue have been successfully used to promote sphincter-saving anal fistula healing. OBJECTIVE The aim of this study was to evaluate the efficacy and safety of the use of autologous centrifuged adipose tissue in the healing process of cryptoglandular complex anal fistulas. DESIGN This is a randomized controlled trial. SETTINGS This study was conducted at a single center. PATIENTS Patients with complex perianal fistulas not associated with Crohn's disease were included. Rectovaginal fistulas were not included. INTERVENTIONS Patients were randomly allocated to receive treatment with centrifuged adipose tissue injection (experimental group) and without injection (control group) in combination with fistula surgery. MAIN OUTCOME MEASURES The primary outcome was defined as the proportion of patients with complete fistula closure at 4 weeks (short-term outcome) and 6 months after surgery (long-term outcome). Healing was defined as when the external opening was closed with no perianal discharge on clinical assessment. The secondary outcome was safety that was evaluated by the analysis of adverse events up to 3 months after surgery. Pelvic MRI was performed at 3 months to assure safety and the accuracy of the clinical determination of healing. Postoperative pain, return to work/daily activities, persistent closure at 6 months, fecal incontinence, and patient satisfaction were evaluated. RESULTS Fifty-eight patients who received centrifuged adipose tissue injection and 58 patients who did not receive centrifuged adipose tissue injection were included in the safety and efficacy analysis. After 4 weeks, the healing rate was 63.8% in the experimental group compared with 15.5% in the control group (p < 0.001). No major adverse events were recorded. Postoperative anal pain was significantly lower in the injection group. Time taken to return to work/daily activities was significantly shorter in the experimental group (3 days) than in the control group (17 days). At 6 months, persistent closure was similar in the 2 groups (86.2% vs 81%). Fecal Incontinence Score at 6 months after surgery was identical to the preoperative score. Patient satisfaction was high in both groups. LIMITATIONS The absence of blinding, the lack of correlation between stem cell content, and the clinical outcome were limitations of the study. CONCLUSIONS Autologous centrifuged adipose tissue injection may represent a safe, efficacious, and inexpensive option for the treatment of complex fistula-in-ano. See Video Abstract at http://links.lww.com/DCR/B607. CLINICAL TRIALS REGISTRATION URL: https://www.clinicaltrials.gov. Identifier: NCT04326907. EFICACIA Y SEGURIDAD DEL TRATAMIENTO DE LA FSTULA ANAL COMPLEJA IDIOPTICA UTILIZANDO TEJIDO ADIPOSO CENTRIFUGADO AUTLOGO QUE CONTIENE CLULAS PROGENITORAS UN ENSAYO CONTROLADO ALEATORIO ANTECEDENTES:Las células madre mesenquimales derivadas del tejido adiposo se han utilizado con éxito para promover la curación de la fístula anal con preservación de esfínter.OBJETIVO:El objetivo de este estudio fue evaluar la eficacia y seguridad del uso de tejido adiposo autólogo centrifugado en el proceso de cicatrización de fístulas anales complejas de origen criptoglandular.DISEÑO:Ensayo controlado aleatorio.ENTORNO CLÍNICO:Estudio unicéntrico.PACIENTES:Se incluyeron pacientes con fístulas perianales complejas no asociadas a Enfermedad de Crohn. No se incluyeron las fístulas rectovaginales.INTERVENCIONES:Los pacientes fueron asignados aleatoriamente para recibir tratamiento con inyección de tejido adiposo centrifugado (grupo experimental) y sin inyección (grupo de control) en combinación con cirugía de fístula.PRINCIPALES MEDIDAS DE VALORACIÓN:El resultado primario se definió como la proporción de pacientes con cierre completo de la fístula a las 4 semanas (resultado a corto plazo) y 6 meses después de la cirugía (resultado a largo plazo). La curación se definió cuando orificio externo se cerró sin secreción perianal en la valoración clínica. El resultado secundario fue la seguridad que se evaluó mediante el análisis de los eventos adversos (EA) hasta 3 meses después de la cirugía. La resonancia magnética pélvica se realizó a los 3 meses para garantizar la seguridad y la precisión clínica de la curación. Se evaluó el dolor postoperatorio, el regreso al trabajo / actividades diarias, el cierre persistente a los 6 meses, la incontinencia fecal y la satisfacción del paciente.RESULTADOS:Cincuenta y ocho pacientes que recibieron inyección de tejido adiposo centrifugado y 58 pacientes que no recibieron inyección de tejido adiposo centrifugado se incluyeron en el análisis de seguridad y eficacia. Después de 4 semanas, la tasa de curación fue del 63,8% en el grupo experimental en comparación con el 15,5% en el grupo de control (p <0,001). No se registraron eventos adversos importantes. El dolor anal posoperatorio fue significativamente menor en el grupo de inyección. El tiempo necesario para volver al trabajo / actividades diarias fue significativamente menor en el grupo experimental (3 días) con respecto al grupo de control (17 días). A los 6 meses, el cierre persistente fue similar en los dos grupos (86,2% vs 81%). La puntuación de incontinencia fecal a los 6 meses después de la cirugía fue idéntica a la puntuación preoperatoria. La satisfacción del paciente fue muy alta en ambos grupos.LIMITACIONES:Ausencia de cegamiento, falta de correlación entre el contenido de células madre y el resultado clínico.CONCLUSIONES:La inyección de tejido adiposo centrifugado autólogo puede representar una opción segura, eficaz y económica para el tratamiento de la fístula anal compleja.Registro de ensayos clínicos: www.clinicaltrials.gov, identificador NCT04326907; No patrocinado.Consulte Video Resumen en http://links.lww.com/DCR/B607.
Collapse
Affiliation(s)
- Simona Ascanelli
- Department of Morphology, Surgery and Experimental Medicine, Section General Surgery, University of Ferrara, Italy
| | - Paolo Zamboni
- Department of Morphology, Surgery and Experimental Medicine, Section of Translational of Medicine and Surgery, University of Ferrara, Italy
| | - Diana Campioni
- Provincial Unique Laboratory Department, University Hospital Ferrara, Italy
| | - Maria Grazia Sibilla
- Department of Morphology, Surgery and Experimental Medicine, Section General Surgery, University of Ferrara, Italy
| | - Laura Chimisso
- Department of Morphology, Surgery and Experimental Medicine, Section General Surgery, University of Ferrara, Italy
| | - Ilaria Zollino
- Department of Morphology, Surgery and Experimental Medicine, Section of Translational of Medicine and Surgery, University of Ferrara, Italy
| | - Giorgia Valpiani
- Research Innovation Quality and Accreditation Unit, S. Anna University Hospital of Ferrara, Ferrara, Italy
| | - Paolo Carcoforo
- Department of Morphology, Surgery and Experimental Medicine, Section General Surgery, University of Ferrara, Italy
| |
Collapse
|
38
|
Mukherjee S, Sengupta R, Ghosal SR. Seton in high anal fistula. Trop Doct 2021; 52:110-115. [PMID: 34482783 DOI: 10.1177/00494755211042122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The use of seton still remains a reasonably valid option for its simplicity and optimal results in treating high anal fistulae. Ours was a single-centre retrospective study on patients with supra-sphincteric and transsphincteric types of high anal fistula, using the 'kharsutra' as seton. The first group were treated with a seton alone, while the second with a seton and partial fistulotomy. Results were similar and quite acceptable in both groups.
Collapse
Affiliation(s)
- Sreecheta Mukherjee
- Resident Surgeon, Department of General Surgery, M. R. Bangur District Hospital, Kolkata, India
| | - Ritankar Sengupta
- Assistant Professor, Department of General Surgery, Nilratan Sircar Medical College and Hospital, Kolkata, India
| | - Sushil Ranjan Ghosal
- Professor, Department of general Surgery, Nilratan Sircar Medical College and Hospital, Kolkata, India
| |
Collapse
|
39
|
DURAN Y. Anal Fistül Tedavisinde Minimal İnvaziv Seçenek; Fistül traktının Lazer Ablasyonu , İlk Deneyimlerimiz, Retrospektif Çalışma. KAHRAMANMARAŞ SÜTÇÜ İMAM ÜNIVERSITESI TIP FAKÜLTESI DERGISI 2021. [DOI: 10.17517/ksutfd.948192] [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] Open
|
40
|
Jain A, Chinnakkulam Kandhasamy S, Vijayakumar C, Kumar P. Fecalith in Fistula-in-Ano. Indian J Surg 2021. [DOI: 10.1007/s12262-020-02206-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
|
41
|
Cuevas López MJ, Reyes-Diaz M, Vázquez-Monchul JM, Padillo FJ, de la Portilla F. Stem cell therapy for anal fistula treatment - a video vignette. Colorectal Dis 2021; 23:2212-2213. [PMID: 34008310 DOI: 10.1111/codi.15742] [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: 02/18/2021] [Revised: 04/01/2021] [Accepted: 04/05/2021] [Indexed: 02/08/2023]
Affiliation(s)
- María Jose Cuevas López
- Unit of coloproctology, Department of Surgery, Hospital Universitario Virgen del Rocio, Sevilla, Spain
| | - Maria Reyes-Diaz
- Unit of coloproctology, Department of Surgery, Hospital Universitario Virgen del Rocio, Sevilla, Spain
| | | | - Francisco Javier Padillo
- Unit of coloproctology, Department of Surgery, Hospital Universitario Virgen del Rocio, Sevilla, Spain
| | - Fernando de la Portilla
- Unit of coloproctology, Department of Surgery, Hospital Universitario Virgen del Rocio, Sevilla, Spain
| |
Collapse
|
42
|
Ambulatory seton placement followed by fistulotomy: efficacy and safety for perianal fistula treatment. Eur J Gastroenterol Hepatol 2021; 33:956-960. [PMID: 32925500 DOI: 10.1097/meg.0000000000001913] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
PURPOSE To evaluate the efficacy and safety of ambulatory seton placement followed by superficial fistulotomy as treatment of perianal fistula. METHODS Retrospective observational analysis of patients with cryptogenic perianal fistula aged 18-90 years, followed in a central hospital proctology consultation between 2006 and 2017. Data were obtained through clinical record's analysis. Fistula was characterized, using Parks Classification. A probe was passed through the fistula tract, followed by a seton, which remained in situ until superficial fistulotomy was possible. RESULTS Ninety-six patients were included (66.67% males, mean age 56 ± 15 years old). Nineteen patients (19.89%) had previous history of perianal fistula and 14 (14.58%) previous anorectal surgery. Seventy-four patients (78.72%) were submitted to fistulotomy, three (3.19%) had seton fistulotomy and one had no seton progression. Intention-to-treat and per-protocol efficacy analyses were 80.2 and 98.7%, respectively. Among the 74 patients who completed the procedure, type of fistula and time with seton were distributed as followed: 47 (63.51%) intersphincteric fistula (15 ± 31 weeks), 26 (35.14%) transsphincteric fistula (32 ± 47 weeks), one (1.35%) suprasphincteric fistula (11 weeks). Previous fistula was associated with a longer time with seton (P = 0.018). Incontinence was reported in two (2.7%) patients, who had previous perianal fistula or anorectal surgery. Two patients (2.7%) had recurrence after fistulotomy. CONCLUSION Placement of seton followed by superficial fistulotomy in an ambulatory setting is a safe and effective method for simple low perianal fistula treatment. Incontinence rate may be higher in patients with previous perianal fistula or anorectal surgery.
Collapse
|
43
|
Horiuchi Y. Anal and dental fistulae: Proposal for a novel treatment with ozone nanobubble saline washing. Ann Med Surg (Lond) 2021; 65:102344. [PMID: 34007442 PMCID: PMC8111573 DOI: 10.1016/j.amsu.2021.102344] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Accepted: 04/22/2021] [Indexed: 11/20/2022] Open
Affiliation(s)
- Yasuhiro Horiuchi
- Division of Dermatology, Tsuruse Orthopedic Clinic, 201-11 Fujikubo, Miyoshi, 354-0041, Saitama, Japan.
| |
Collapse
|
44
|
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.
Collapse
|
45
|
Conde AL, Santos CHMD, Dourado DM, Tanus OAV, Souza IFD, Costa RL, Giuncanse F, Costa IO. Evaluation of polypropylene and polyglactin sutures in primary sphincteroplasty for the treatment of anal fistula in rats. JOURNAL OF COLOPROCTOLOGY 2021. [DOI: 10.1016/j.jcol.2019.05.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Abstract
Rationale Fistulotomy followed by primary sphincteroplasty is one of the therapeutic options in transsphincteric fistulae; however, it was not known which suture would present a better result.
Objective To compare polypropylene and polyglactin sutures in primary sphincteroplasty in rats subjected to fistulotomy.
Method Thirty Wistar rats were subjected to peritoneal anesthesia with ketamine and xylazine, followed by transfixation of the anal sphincter with steel thread, which remained for 30 days to develop the anal fistula. After this period, the steel thread was removed and four groups were formed: A – Control (n = 5), without treatment; B – Fistulotomy (n = 5), performed fistulotomy only; C – Polypropylene (n = 10), in which fistulotomy was performed followed by primary sphincteroplasty with polypropylene suture; D – Polyglactin (n = 10), in which fistulotomy was performed followed by primary sphincteroplasty with polyglactin suture; after 30 days the animals were anesthetized again and submitted to euthanasia by deepening the anesthetic plane to remove the specimens, analyzing fistula closure, muscle fiber distance, and inflammatory process.
Results The fistula persisted in all animals of the control group and in none of the other groups; the distances between the muscle fibers were 1620 μm, 4665 μm, and 2520 μm, respectively in Groups B, C, and D (p = 0.067); in relation to fibrosis, the means were 2.4, 2.8, and 3.6, respectively in Groups B, C, and D, showing greater fibrosis in the latter group (p = 0.041).
Conclusion There was no persistence of the fistula in any of the treated animals; there was no difference in the distance between the muscle fibers between the groups subjected to primary sphincteroplasty with polypropylene or polyglactin, or between these groups and the one treated only by fistulotomy. There was greater fibrosis in animals treated with primary sphincteroplasty with polyglactin.
Collapse
Affiliation(s)
- Andrea Lima Conde
- Universidade Federal de Mato Grosso do Sul, Hospital Universitário Maria Aparecida Pedrossian, Campo Grande, MS, Brazil
| | - Carlos Henrique Marques dos Santos
- Universidade Federal de Mato Grosso do Sul, Hospital Universitário Maria Aparecida Pedrossian, Campo Grande, MS, Brazil
- Universidade Anhanguera-Uniderp, Campo Grande, MS, Brazil
| | | | - Otávio Augusto Vendas Tanus
- Universidade Federal de Mato Grosso do Sul, Hospital Universitário Maria Aparecida Pedrossian, Campo Grande, MS, Brazil
| | | | | | | | | |
Collapse
|
46
|
Sousa Júnior EC, Nogueira AT, Rocha BA, Eulálio Filho WMN, Meneses AD. Three-dimensional virtual reconstruction as a tool for preoperative planning in the management of complex anorectal fistulas. JOURNAL OF COLOPROCTOLOGY 2021. [DOI: 10.1016/j.jcol.2017.11.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
AbstractThe making of three-dimensional virtual models is a promising technology in preoperative planning, but that is not used in the treatment of anorectal fistulas. The objective of this work is to describe the development and initial experience of the construction of a virtual three-dimensional model of the pelvic anatomy of a patient, allowing the exact identification of the relationships between the fistulous tracts of complex anorectal fistulas and the other pelvic structures. An MRI was performed on this patient, and the images were exported to the Vitrea fX Workstation® software. A radiologist did the analysis and segmentation of the images that were then sent to a three-dimensional image processor (Meshlab v. 1.3.3 – ISTI – CNR Research Center, Pisa University, Italy). The final 3D color image was analyzed by the surgeon and used to guide the catheterization of the fistulous pathways, the internal orifice and to assist in the identification of adjacent structures. The final three-dimensional model presented a high correlation with the intraoperative findings and facilitated the surgical planning.
Collapse
Affiliation(s)
- Edilson Carvalho Sousa Júnior
- Hospital São Marcos – Associação Piauiense de Combate ao Câncer, Departamento de Coloproctologia, Teresina, PI, Brazil
- Universidade Federal do Piauí (UFPI), Departamento de Clínica Cirúrgica, Teresina, PI, Brazil
| | | | - Bruno Aragão Rocha
- Universidade de São Paulo (USP), Departamento de Radiologia, São Paulo, SP, Brazil
| | | | - Aurus Dourado Meneses
- Hospital São Marcos – Associação Piauiense de Combate ao Câncer, Departamento de Urologia, Teresina, PI, Brazil
| |
Collapse
|
47
|
Carvalho ALD, Filho EFA, Alcantara RSMD, Barreto MDS. FILAC – Fistula – Tract Laser Closure: a sphincter-preserving procedure for the treatment of complex anal fistulas. JOURNAL OF COLOPROCTOLOGY 2021. [DOI: 10.1016/j.jcol.2017.03.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
AbstractSeveral surgical options are described for the treatment of anorectal fistulas, particularly in complex cases where recurrence rates and the possibility of postoperative incontinence are still high. The aim of this study is to describe the use of FILAC technique (Fistula – Tract Laser Closure) minimally invasive and preservation sphincter technique. FILAC has been described in the literature as an option in the management of anorectal fistula.
Collapse
|
48
|
Ji L, Zhang Y, Xu L, Wei J, Weng L, Jiang J. Advances in the Treatment of Anal Fistula: A Mini-Review of Recent Five-Year Clinical Studies. Front Surg 2021; 7:586891. [PMID: 33644110 PMCID: PMC7905164 DOI: 10.3389/fsurg.2020.586891] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Accepted: 12/15/2020] [Indexed: 12/16/2022] Open
Abstract
Anal fistula, with its complicated pathogenesis, has been considered as a clinical challenge for centuries. The risk of frequent recurrence and incontinence constitutes a considerable threat in the long-term treatment of anal fistula. In this work, we narratively reviewed the scientific literature of new techniques that have been used for anal fistula treatment over the recent 5 years, objectively evaluated the pros and cons of each technique on the basis of clinical outcomes, and tried to disclose the effective strategies for anal fistula treatment. Up to date, surgery is the main method used for treating anal fistula, but there is no simple technique that can completely heal complex anal fistula. In the course of surgery treatment, the healing outcome, and the protection of anal function should be weighed comprehensively. Among the innovative techniques that have emerged in recent years, combined techniques based on drainage Seton and LIFT-plug seem to be the relatively effective therapies, but their effectiveness requires more multi-center prospective randomized controlled trials with large sample size and long-term follow-up to be validated.
Collapse
Affiliation(s)
- Lijiang Ji
- Department of Anorectal Surgery, Changshu Hospital Affiliated to Nanjing University of Chinese Medicine, Changshu, China
| | - Yang Zhang
- Colorectal Disease Center, Nanjing Hospital of Chinese Medicine Affiliated to Nanjing University of Chinese Medicine, Nanjing, China
| | - Liang Xu
- Department of General Surgery, Changshu Hospital Affiliated to Nanjing University of Chinese Medicine, Changshu, China
| | - Jun Wei
- Department of Anorectal Surgery, Changshu Hospital Affiliated to Nanjing University of Chinese Medicine, Changshu, China
| | - Liping Weng
- Department of Anorectal Surgery, Changshu Hospital Affiliated to Nanjing University of Chinese Medicine, Changshu, China
| | - Jie Jiang
- Department of Anorectal Surgery, Changshu Hospital Affiliated to Nanjing University of Chinese Medicine, Changshu, China
| |
Collapse
|
49
|
Ding W, Sun YR, Wu ZJ. Treatment of Perianal Abscess and Fistula in Infants and Young Children: From Basic Etiology to Clinical Features. Am Surg 2020; 87:927-932. [PMID: 33284051 DOI: 10.1177/0003134820954829] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Perianal abscess and anal fistula are 2 common anorectal diseases in infants and young children. However, their causes, clinical diagnosis, and treatment remain controversial. Compared to adults, infants with these 2 diseases exhibit unique clinical characteristics. Blind pursuit of conservative treatment or surgery may worsen the condition, resulting in increased pain in young patients and greater economic burden and psychological harm to parents. Therefore, it is crucial to select correct and effective treatments. This review summarizes the relevant literature from the past 10 years and systematically explains the pathogenesis, clinical characteristics, and treatment measures of perianal abscess and anal fistula in infants with the goal of providing clinicians a deeper understanding of perianal abscess and anal fistula in infants and summarizing safe and effective treatment methods.
Collapse
Affiliation(s)
- Wei Ding
- North Sichuan Medical College, Nanchong, China
| | - Yao-Ran Sun
- North Sichuan Medical College, Nanchong, China
| | - Zhi-Jiu Wu
- Department of Anorectal, 117913The Affiliated Hospital of North Sichuan Medical College, Nanchong, China
| |
Collapse
|
50
|
Frountzas M, Stergios K, Nikolaou C, Bellos I, Schizas D, Linardoutsos D, Kontzoglou K, Vaos G, Williams AB, Toutouzas K. Could FiLaC™ be effective in the treatment of anal fistulas? A systematic review of observational studies and proportional meta-analysis. Colorectal Dis 2020; 22:1874-1884. [PMID: 32445614 DOI: 10.1111/codi.15148] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2020] [Accepted: 04/30/2020] [Indexed: 02/08/2023]
Abstract
AIM Fistula Laser Closure (FiLaC™) is a novel sphincter-preserving technique that is based on new technologies and shows promising results in repairing anal fistulas whilst maintaining external sphincter function. The aim of the present meta-analysis is to present the efficacy and the safety of FiLaC™ in the management of anal fistula disease. METHOD The present proportional meta-analysis was designed using the PRISMA and AMSTAR guidelines. We searched MEDLINE, Scopus, clinicaltrials.gov, Embase, Cochrane Central Register of Controlled Trials CENTRAL and Google Scholar databases from inception until November 2019. RESULTS Overall, eight studies were included that recruited 476 patients. The pooled success rate of the technique was 63% (95% CI 50%-75%). The pooled complication rate was 8% (95% CI 1%-18%). Sixty-six per cent of patients had a transsphincteric fistula and 60% had undergone a previous surgical intervention, mainly the insertion of a seton (54%). The majority had a cryptoglandular fistula. Operation time and follow-up period were described for each study. CONCLUSION FiLaC™ seems to be an efficient therapeutic option for perianal fistula disease with an adequate level of safety that preserves quality of life. Nevertheless, randomized trials need to be designed to compare FiLaC™ with other procedures for the management of anal fistulas such as ligation of intersphincteric fistula tract, anal advancement flaps, fibrin glue, collagen paste, autologous adipose tissue, fistula plug and video-assisted anal fistula treatment.
Collapse
Affiliation(s)
- M Frountzas
- Laboratory of Experimental Surgery and Surgical Research, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece.,First Propaedeutic Department of Surgery, School of Medicine, Hippocration General Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - K Stergios
- Laboratory of Experimental Surgery and Surgical Research, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - C Nikolaou
- Laboratory of Experimental Surgery and Surgical Research, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - I Bellos
- Laboratory of Experimental Surgery and Surgical Research, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - D Schizas
- First Department of Surgery, School of Medicine, Laikon General Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - D Linardoutsos
- First Propaedeutic Department of Surgery, School of Medicine, Hippocration General Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - K Kontzoglou
- Laboratory of Experimental Surgery and Surgical Research, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - G Vaos
- Department of Paediatric Surgery, School of Medicine, Attikon University General Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - A B Williams
- Department of Colorectal Surgery, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - K Toutouzas
- First Propaedeutic Department of Surgery, School of Medicine, Hippocration General Hospital, National and Kapodistrian University of Athens, Athens, Greece
| |
Collapse
|