Prevalence, diagnosis, and surgical management of complex ileocolic-duodenal fistulas in Crohn's disease

BACKGROUND

The aim of the present study was to review the prevalence and surgical management of patients with Crohn's disease (CD) complicated by ileocolic-duodenal fistulas (ICDF).

METHODS

We performed a retrospective chart review of CD patients who underwent surgical takedown and repair of ICDF during January 2011-December 2021 at two inflammatory bowel disease referral centers.

RESULTS

We identified 17 patients with ICDF (1.3%) out of 1283 CD patients who underwent abdominal surgery. Median age was 42 (20-71) years, 13 patients were male (76%) and median body mass index was 22.7 (18.4-30.3) kg/m². Four patients (24%) were diagnosed preoperatively and only 2 (12%) were operated on for ICDF-related symptoms. The most common procedure was ileocolic resection (13 patients, 76%) including 4 repeat ileocolic resections (24%). The duodenal defect was primarily repaired in all patients with no re-fistulization or duodenal stenosis, regardless of the repair technique. A laparoscopic approach was attempted in the majority of patients (14 patients, 82%); however, only 5 (30%) were laparoscopically completed. The overall postoperative complication rate was 65% including major complications in 3 patients (18%) and 2 patients (12%) who required surgical re-intervention for abdominal wall dehiscence and postoperative bleeding. Preoperative nutritional optimization was performed in 9 patients (53%) due to malnutrition. These patients had significantly less intra-operative blood loss (485 vs 183 ml, p = 0.05), and a significantly reduced length of stay (18 vs 8 days, p = 0.05).

CONCLUSION

ICDF is a rare manifestation of CD which may go unrecognized despite the implementation of a comprehensive preoperative evaluation. Although laparoscopic management of ICDF may be technically feasible, it is associated with a high conversion rate. Preoperative nutritional optimization may be beneficial in improving surgical outcomes in this select group of patients.

Endorectal advancement flap for complex anal fistula: does flap configuration matter?

AIM

Treatment of complex anal fistula (CAF) is challenging, often requiring multiple operations due to a high failure rate. The plethora of options attests to the lack of a panacea. Endorectal advancement flap (ERAF) carries the advantages of no sphincter division, no contour defect to the anal canal and no perineal wound. The failure rate of this procedure ranges between 15% and 60%. Although the procedure traditionally described a rhomboid (tongue-shaped) flap, an elliptical (curvilinear) flap was introduced to try to improve the results. This study aimed to describe the elliptical-shaped ERAF performed by the senior authors and others and compare failure rates between elliptical and rhomboid ERAFs for CAF.

METHOD

A retrospective review of all patients who underwent ERAF for CAF between 2011 and 2017 was undertaken. Patients were divided into two groups based on the type of flap: rhomboid or elliptical. The main outcomes measures were postoperative persistent or recurrent fistula.

RESULTS

Seventy-six ERAF procedures for CAF were identified in 71 patients; 39 had a classic rhomboid flap and 37 had an elliptical configuration with mean follow-up of 13.8 and 13.9 months, respectively. The groups were similar for demographic parameters and preoperative fistula characteristics. The overall failure rate was 37%, with a success rate of 64% in the rhomboid and 62% in the elliptical group.

CONCLUSION

The shape of the ERAF for treatment of CAF does not appear to influence failure rate.

Empathy during consoling touch is modulated by mu-rhythm: An EEG study

The aim of the present study was to examine the mechanisms of empathy for pain that contribute to consoling touch, a distress-alleviating contact behavior carried out by an observer in response to the suffering of a target. We tested romantic couples in a paradigm that involves consoling touch and examined the attenuation of the mu/alpha rhythm (8-13Hz) in the consoling partner. During the task, the toucher either held the consoled partner's right hand (human touch) or held onto the armrest of the chair (non-human touch), while the consoled partner experienced inflicted pain (pain condition) or did not experience any pain (no-pain condition). In accordance with our hypotheses, the results revealed an interaction between touch and pain at in mu/alpha rhythms in all central sites (C3, C4, Cz). Specifically, we found that the toucher's mu suppression was higher in the consoling touch condition, i.e., while touching the partner who is in pain, compared to the three control conditions. Additionally, we found that in the consoling touch condition, mu suppression at electrode C4 of the toucher correlated with a measure of situational empathy. Our findings suggest that electrophysiological and behavioral measures that have been associated with empathy for pain are modulated during consoling touch.