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1
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Dawes AJ, Lightner AL. Perianal Fistulizing Crohn's Disease: Outcomes of Surgical Repairs and Current State of Stem Cell-Based Therapies. Clin Colon Rectal Surg 2025; 38:126-140. [PMID: 39944301 PMCID: PMC11813615 DOI: 10.1055/s-0044-1786543] [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] [Indexed: 05/17/2025]
Abstract
Perianal fistulizing Crohn's disease is one of the most disabling phenotypes of Crohn's disease, due to the severe impairment in quality of life including social and personal wellbeing. A multimodal approach with patient-tailored care is the key to optimal management of this condition. Medical therapy is needed to optimize the luminal disease, and surgical intervention is required to control any associated perianal sepsis and attempt palliative or definitive fistula repair. While several medical and surgical options are available, the majority of patients continue to have symptomatic disease. Fortunately, this continues to drive novel innovations which are revolutionizing the treatment and outcomes of perianal fistulizing Crohn's disease. However, there continues to be a need for randomized trials and consistent metrics utilized for classification and treatment outcomes in order to accurately describe optimal treatment outcomes.
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Affiliation(s)
- Aaron J. Dawes
- Section of Colon & Rectal Surgery, Department of Surgery, Stanford University School of Medicine, Stanford, California
- Stanford-Surgery Policy Improvement Research and Education Center, Department of Surgery, Stanford University School of Medicine, Stanford, California
| | - Amy L. Lightner
- Department of General Surgery, Scripps Clinic, La Jolla, California
- Department of Molecular Medicine, Scripps Research Institute, La Jolla, California
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2
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Sharma R, Lonare SB, Nagar S, Badhal S, Anand S. Efficacy and Efficiency of Cyanoacrylate Glue in Fistula-in-Ano. Cureus 2024; 16:e72701. [PMID: 39478771 PMCID: PMC11524060 DOI: 10.7759/cureus.72701] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/30/2024] [Indexed: 11/02/2024] Open
Abstract
AIMS AND OBJECTIVE Most research on fistula-in-ano (FIA) is being done to improve surgical outcomes and reduce complications. Cyanoacrylate glue (CAG) is one of the promising options. We evaluated the efficacy and efficiency of CAG in the treatment of FIA. MATERIALS AND METHODS A cohort of 30 patients were included who underwent treatment using CAG. Each patient followed up at one, three, and six months to evaluate improvement in pain, discomfort, and recurrence. Patients with recurrence were treated with fistulectomy. RESULT The mean age of the cohort was 48.2±14.5 years, with a male-to-female ratio of 6:1, having four diabetic patients. Inter-sphincteric (16.54%) and trans-sphincteric (13.43%) fistulae were more common than extra-sphincteric (1.4%) fistula. The efficacy of CAG was 73%, and the procedure was found efficient with significant improvement in discomfort (p-value: 0.017). The recurrence rate was 27%, which occurred more in diabetic patients (p-value: 0.001) and trans-sphincteric fistula (p-value: 0.035). Conclusion: The CAG application is a simple and safe daycare procedure. However, the incidence of discharge and relief in pain was significantly less, but it cannot be advised to every patient of FIA. A young patient without comorbidities and with inter-sphincteric low fistula can best be treated by this method.
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Affiliation(s)
- Rajat Sharma
- General Surgery, Maharishi Markandeshwar Medical College and Hospital, Solan, IND
| | - Siddharth B Lonare
- General Surgery, B. J. Government Medical College and Sassoon General Hospital, Pune, IND
| | - Saurabh Nagar
- General Surgery, Maharishi Markandeshwar Medical College and Hospital, Solan, IND
| | - Sushant Badhal
- General Surgery, Maharishi Markandeshwar Medical College and Hospital, Solan, IND
| | - Samir Anand
- General Surgery, Maharishi Markandeshwar Medical College and Hospital, Solan, IND
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3
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Chahal JK, Sriranganathan D, Poo S, Lo SW, Kashkooli S, Garg M, Segal JP. Network meta-analysis: efficacy and safety of treatments for fistulising Crohn's disease. Eur J Gastroenterol Hepatol 2023; 35:702-710. [PMID: 37115969 DOI: 10.1097/meg.0000000000002552] [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: 04/30/2023]
Abstract
INTRODUCTION Fistulas are a debilitating complication of Crohn's disease and treatment options remain limited. There is a lack of head-to-head comparisons between treatments. To our knowledge, this is the first network meta-analysis on the efficacy of medical therapies in achieving fistula remission and maintenance of fistula closure in Crohn's disease. METHODS Biomedical databases and the Cochrane Central Registry were searched between 1978 and 2022 for randomized controlled trials (RCTs) reporting on treatments. A network meta-analysis was performed using the frequentist model with pooled relative risks (RRs) and P -scores used to rank treatments. RESULTS Twenty-five RCTs were included for analysis with 2239 patients included. At the 16-24 week time point, infliximab produced the only statistically significant result with the 5 mg/kg dose proving the most effective [RR, 2.30; 95% confidence interval (CI), 1.40-3.77]. At 44 weeks, ustekinumab was found to be most superior with it being 2.38 times (RR, 2.38; 95% CI, 1.24-4.56) more superior to placebo, with adalimumab (RR, 2.06; 95% CI, 1.06-3.99) and infliximab 5 mg/kg (RR, 1.68; 95% CI, 1.03-2.75) also producing a statistically significant result. CONCLUSION Despite infliximab being favoured in international guidelines for the treatment of perianal fistulising Crohn's disease, biologics such as ustekinumab, vedolizumab and adalimumab show promising results.
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Affiliation(s)
- Jacinder K Chahal
- Department of Surgery, Queen Elizabeth Hospital, Lewisham and Greenwich NHS Trust
| | - Danujan Sriranganathan
- Department of Gastroenterology, Whipps Cross University Hospital, Barts Health NHS Trust, London
| | - Stephanie Poo
- Department of Gastroenterology, The Hillingdon Hospitals NHS Foundation Trust, Middlesex, UK
| | - Sheng Wei Lo
- Department of Gastroenterology, Northern Hospital, Epping
| | - Soleiman Kashkooli
- Department of Gastroenterology, Northern Hospital, Epping
- Department of Medicine, University of Melbourne, Parkville, Melbourne, Australia
| | - Mayur Garg
- Department of Gastroenterology, Northern Hospital, Epping
- Department of Medicine, University of Melbourne, Parkville, Melbourne, Australia
| | - Jonathan P Segal
- Department of Gastroenterology, Northern Hospital, Epping
- Department of Medicine, University of Melbourne, Parkville, Melbourne, Australia
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Abstract
PURPOSE OF REVIEW The management of hospitalized patients with inflammatory bowel disease (IBD) is complex. Despite considerable therapeutic advancements in outpatient ulcerative colitis and Crohn's disease management, the in-hospital management continues to lag with suboptimal outcomes. The purpose of this review is to provide a brief overview of our approach to managing patients hospitalized with acute severe ulcerative colitis (ASUC) and Crohn's disease-related complications, followed by a summary of emerging evidence for new management approaches. RECENT FINDINGS ASUC has seen the emergence of well validated prognostic models for colectomy as well as the development of novel treatment strategies such as accelerated infliximab dosing, Janus kinase inhibitor therapy, and sequential therapy, yet the rate of colectomy for steroid-refractory ASUC has not meaningfully improved. Crohn's disease has seen the development of better diagnostic tools, early Crohn's disease-related complication stratification and identification, as well as better surgical techniques, yet the rates of hospitalization and development of Crohn's disease-related complications remain high. SUMMARY Significant progress has been made in the in-hospital IBD management; however, both the management of ASUC and hospitalized Crohn's disease remain a challenge with suboptimal outcomes. Critical knowledge gaps still exist, and dedicated studies in hospitalized patients with IBD are needed to address them.
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Affiliation(s)
- Jeffrey A. Berinstein
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Michigan Medicine, Ann Arbor, MI, USA
| | - Daniel Aintabi
- Department of Medicine, St. Joseph Mercy Ann Arbor Hospital, Ypsilanti, MI, USA
| | - Peter D.R. Higgins
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Michigan Medicine, Ann Arbor, MI, USA
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Pokala A, Shen B. Endoscopic Treatment of Acute and Chronic Anastomotic Leaks from Inflammatory Bowel Disease Surgery. Gastrointest Endosc Clin N Am 2022; 32:801-815. [PMID: 36202517 DOI: 10.1016/j.giec.2022.05.007] [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: 02/04/2023]
Abstract
Acute or chronic anastomotic leak is a common complication after any gastrointestinal surgery in inflammatory bowel disease (IBD). The underlying disease of the bowel, comorbidities, malnutrition, anemia, and concurrent use of corticosteroids increase the risk for the development of anastomotic leaks. Anastomotic leak is traditionally managed with surgery. However, recent innovation has allowed the use of endoscopic methods in the management of some anastomotic leaks and their consequences. This article discusses a variety of endoscopic techniques that have either been established or are under current evaluation, for the management of anastomotic leaks in patients with IBD.
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Affiliation(s)
- Aditya Pokala
- Center for Inflammatory Bowel Disease, Columbia University Irving Medical Center/NewYork Presbyterian Hospital, Herbert Irving Pavilion Suite 843, 161 Ft Washington Avenue, New York, NY 10032, USA
| | - Bo Shen
- Center for Inflammatory Bowel Disease, Columbia University Irving Medical Center/NewYork Presbyterian Hospital, Herbert Irving Pavilion Suite 843, 161 Ft Washington Avenue, New York, NY 10032, USA.
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6
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Gaertner WB, Burgess PL, Davids JS, Lightner AL, Shogan BD, Sun MY, Steele SR, Paquette IM, Feingold DL. The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Management of Anorectal Abscess, Fistula-in-Ano, and Rectovaginal Fistula. Dis Colon Rectum 2022; 65:964-985. [PMID: 35732009 DOI: 10.1097/dcr.0000000000002473] [Citation(s) in RCA: 81] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Affiliation(s)
- Wolfgang B Gaertner
- Division of Colon and Rectal Surgery, University of Minnesota, Minneapolis, Minnesota
| | - Pamela L Burgess
- Department of Surgery, Uniformed Services University of the Health Sciences, Eisenhower Army Medical Center, Fort Gordon, Georgia
| | - Jennifer S Davids
- Department of Surgery, University of Massachusetts, Worcester, Massachusetts
| | - Amy L Lightner
- Department of Colon and Rectal Surgery, Cleveland Clinic, Cleveland, Ohio
| | | | - Mark Y Sun
- Department of Surgery, University of Cincinnati, Cincinnati, Ohio
| | - Scott R Steele
- Department of Colon and Rectal Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Ian M Paquette
- Department of Surgery, University of Cincinnati, Cincinnati, Ohio
| | - Daniel L Feingold
- Division of Colorectal Surgery, Rutgers University, New Brunswick, New Jersey
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7
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Wetwittayakhlang P, Al Khoury A, Hahn GD, Lakatos PL. The Optimal Management of Fistulizing Crohn's Disease: Evidence beyond Randomized Clinical Trials. J Clin Med 2022; 11:3045. [PMID: 35683433 PMCID: PMC9181669 DOI: 10.3390/jcm11113045] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Revised: 05/21/2022] [Accepted: 05/25/2022] [Indexed: 02/04/2023] Open
Abstract
Fistulizing Crohn's disease (FCD) remains the most challenging aspect of treating patients with CD. FCD can occur in up to 30% of patients with CD and may lead to significant disability and impaired quality of life. The optimal treatment strategies for FCD require a multidisciplinary approach, including a combined medical and surgical approach. The therapeutic options for FCD are limited due to sparse evidence from randomized clinical trials (RCTs). The current recommendations are mainly based on post hoc analysis from RCTs, real-world clinical studies and expert opinion. There is variation in everyday clinical practice amongst gastroenterologists and surgeons. The evidence for anti-tumor necrosis factor therapy is the strongest in the treatment of FCD. However, long-term fistula healing can be achieved in only 30-50% of patients. In recent years, emerging data in the advent of therapeutic modalities, including the use of new biologic agents, therapeutic drug monitoring, novel surgical methods and mesenchymal stem cell therapy, have been shown to improve outcomes in achieving fistula healing. This review summarizes the existing literature on current and emerging therapies to provide guidance beyond RCTs in managing FCD.
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Affiliation(s)
- Panu Wetwittayakhlang
- Division of Gastroenterology, McGill University Health Center, Montreal, QC H3G 1A4, Canada or (P.W.); (G.D.H.)
- Gastroenterology and Hepatology Unit, Division of Internal Medicine, Faculty of Medicine, Prince of Songkla University, Songkhla 90110, Thailand
| | - Alex Al Khoury
- Division of Gastroenterology, University of Florida, Jacksonville, FL 32209, USA;
| | - Gustavo Drügg Hahn
- Division of Gastroenterology, McGill University Health Center, Montreal, QC H3G 1A4, Canada or (P.W.); (G.D.H.)
- Graduate Course Sciences in Gastroenterology and Hepatology, School of Medicine, Universidade Federal do Rio Grande do Sul, Porto Alegre 90035-002, Brazil
| | - Peter Laszlo Lakatos
- Division of Gastroenterology, McGill University Health Center, Montreal, QC H3G 1A4, Canada or (P.W.); (G.D.H.)
- First Department of Medicine, Semmelweis University, 1085 Budapest, Hungary
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8
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Choshen S, Turner D, Pratt LT, Precel R, Greer ML, Castro DA, Assa A, Martínez-León MI, Herman-Sucharska I, Coppenrath E, Konen O, Davila J, Bekhit E, Alsabban Z, Focht G, Gavish M, Griffiths A, Cytter-Kuint R. Development and Validation of a Pediatric MRI-Based Perianal Crohn Disease (PEMPAC) Index-A Report from the ImageKids Study. Inflamm Bowel Dis 2022; 28:700-709. [PMID: 34151950 DOI: 10.1093/ibd/izab147] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2021] [Indexed: 12/15/2022]
Abstract
BACKGROUND As part of the prospective multicenter ImageKids study, we aimed to develop and validate the pediatric MRI-based perianal Crohn disease (PEMPAC) index. METHODS Children with Crohn disease with any clinical perianal findings underwent pelvic magnetic resonance imaging at 21 sites globally. The site radiologist and 2 central radiologists provided a radiologist global assessment (RGA) on a 100 mm visual analog scale and scored the items selected by a Delphi group of 35 international radiologists and a review of the literature. Two weighted multivariable statistical models were constructed against the RGA. RESULTS Eighty children underwent 95 pelvic magnetic resonance imaging scans; 64 were used for derivation and 31 for validation. The following items were included: fistula number, location, length and T2 hyperintensity; abscesses; rectal wall involvement; and fistula branching. The last 2 items had negative beta scores and thus were excluded in a contending basic model. In the validation cohort, the full and the basic models had the same strong correlation with the RGA (r = 0.75; P < 0.01) and with the adult Van Assche index (VAI; r = 0.93 and 0.92; P < 0.001). The correlation of the VAI with the RGA was similar (r = 0.77; P < 0.01). The 2 models and the VAI had a similar ability to differentiate remission from active disease (area under the receiver operating characteristic curve, 0.91-0.94). The PEMPAC index had good responsiveness to change (area under the receiver operating characteristic curve, 0.89; 95% confidence interval, 0.69-1.00). CONCLUSIONS Using a blended judgmental and mathematical approach, we developed and validated an index for quantifying the severity of perianal disease in children with CD. The adult VAI may also be used with confidence in children.
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Affiliation(s)
- Sapir Choshen
- Pediatric Department, Shaare Zedek Medical Center, Jerusalem, Israel
| | - Dan Turner
- The Juliet Keidan Institute of Pediatric Gastroenterology, Shaare Zedek Medical Center, Jerusalem, Israel.,Faculty of Medicine, The Hebrew University of Jerusalem, Jerusalem, Israel
| | - Li-Tal Pratt
- Pediatric Imaging Unit, Imaging Division, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ronit Precel
- Pediatric Imaging Unit, Imaging Division, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Mary-Louise Greer
- Department of Diagnostic Imaging, Hospital for Sick Children, Toronto, Canada.,Department of Medical Imaging, University of Toronto, Toronto, Canada
| | - Denise A Castro
- Department of Diagnostic Imaging, Hospital for Sick Children, Toronto, Canada.,Department of Diagnostic Radiology, Kingston Health Science Centre, Queen's University, Kingston, Canada
| | - Amit Assa
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Department of Diagnostic Imaging, Schneider Children's Hospital, Petach-Tikva, Israel
| | | | | | | | - Osnat Konen
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Department of Diagnostic Imaging, Schneider Children's Hospital, Petach-Tikva, Israel
| | - Jorge Davila
- Department of Medical Imaging, Children's Hospital of Eastern Ontario, Ottawa, Canada
| | - Elhamy Bekhit
- Department of Medicine and Radiology, The Royal Children's Hospital, Melbourne, Australia
| | - Zehour Alsabban
- Department of Radiology, King Faisal Specialist Hospital and Research Centre, Jeddah, Saudi Arabia
| | - Gili Focht
- The Juliet Keidan Institute of Pediatric Gastroenterology, Shaare Zedek Medical Center, Jerusalem, Israel
| | - Matan Gavish
- School of Computer Science and Engineering, The Hebrew University, Jerusalem, Israel
| | - Anne Griffiths
- Department of Gastroenterology, Hospital for Sick Children, University of Toronto, Canada
| | - Ruth Cytter-Kuint
- Radiology Department, Shaare Zedek Medical Center, Jerusalem, Israel
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9
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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: 21] [Impact Index Per Article: 7.0] [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.
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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
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10
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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]
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11
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ACG Clinical Guidelines: Management of Benign Anorectal Disorders. Am J Gastroenterol 2021; 116:1987-2008. [PMID: 34618700 DOI: 10.14309/ajg.0000000000001507] [Citation(s) in RCA: 62] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Accepted: 08/09/2021] [Indexed: 12/11/2022]
Abstract
Benign anorectal disorders of structure and function are common in clinical practice. These guidelines summarize the preferred approach to the evaluation and management of defecation disorders, proctalgia syndromes, hemorrhoids, anal fissures, and fecal incontinence in adults and represent the official practice recommendations of the American College of Gastroenterology. The scientific evidence for these guidelines was assessed using the Grading of Recommendations Assessment, Development and Evaluation process. When the evidence was not appropriate for Grading of Recommendations Assessment, Development and Evaluation, we used expert consensus to develop key concept statements. These guidelines should be considered as preferred but are not the only approaches to these conditions.
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12
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Hermann J, Cwaliński J, Banasiewicz T. Application of platelet-rich plasma in rectovaginal fistulas in the patients with ulcerative colitis. Langenbecks Arch Surg 2021; 407:429-433. [PMID: 34155543 PMCID: PMC8847300 DOI: 10.1007/s00423-021-02232-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Accepted: 06/06/2021] [Indexed: 10/28/2022]
Abstract
BACKGROUND There is a need for other than surgical methods of therapy for small and low rectovaginal fistulas (RVF) in the course of inflammatory bowel diseases (IBD), such as application of fibrin sealants, stem cells, biological therapy, or platelet-rich plasma. The aim of this study was to evaluate the results of the treatment after local application of PRP in aforementioned fistulas, exclusively in the patients with ulcerative colitis (UC). PATIENTS AND METHODS Medical records of 13 patients with small and low-lying, active RVF in the course of UC, and after restorative proctocolectomy for UC were evaluated. Curettage of fistulous tracts was performed with the following application of PRP in all patients. RESULTS Complete closure of RVF was achieved after the first injection in 4 patients, 3 women healed their fistulas following the second application, and two of them closed RVF after 3 injections. To sum up, the complete closure of RVF was achieved in 9 (69%) patients. Fistulas remained closed from 6 to 12 months. CONCLUSIONS The application of PRP in small, low, and recurrent IBD anal fistulas is effective, simple, and safe with an acceptable rate of healing. This therapy might also precede any further, surgical methods of treatment.
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Affiliation(s)
- Jacek Hermann
- Department of General, and Endocrynologic Surgery, and Gastroenterologic Oncology, Poznań University of Medical Sciences, 49 Przybyszewski Str., 60-355, Poznań, Poland.
| | - Jarosław Cwaliński
- Department of General, and Endocrynologic Surgery, and Gastroenterologic Oncology, Poznań University of Medical Sciences, 49 Przybyszewski Str., 60-355, Poznań, Poland
| | - Tomasz Banasiewicz
- Department of General, and Endocrynologic Surgery, and Gastroenterologic Oncology, Poznań University of Medical Sciences, 49 Przybyszewski Str., 60-355, Poznań, Poland
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13
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Markaryan DR, Garmanova TN, Kazachenko EA, Agapov MA. SURGICAL TREATMENT OF IATROGENIC COMPLEX RECURRENT EXTRASPHINCTER ANORECTAL FISTULA: A CLINICAL CASE. SURGICAL PRACTICE 2021. [DOI: 10.38181/2223-2427-2021-1-13-19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Background: Anorectal fistula is a benign disease with an average prevalence of 1.69/10,000 population. The disease significantly reduces the life quality and has a tendency to relapse. Repeated surgical treatment can lead to anal sphincter impairment. Paraproctitis is the main anorectal fistulas cause. However, there are also iatrogenic traumatic fistulas that occur after various anorectal surgical interventions.Clinical case: A 44-year old female patient applied to the MSU University clinic in March 2020 with perineal wound with permanent purulent discharge. During examination perianal soft tissue defect was determined, the external fistula opening (40x25x25cm) was visualized at the wound bottom, the internal fistula opening (2x3mm) was visualized at 12h of the clock dial. The perianal area is deformed due to scarring. In 2016 the patient underwent surgical «rectocele elimination, posterior colporaphy, levatoroplasty, plastic surgery of the anterior rectal wall». Obstructive defecation syndrome developed during postoperative period, and repeated surgical treatment was performed – anterior anosfincterolevatoroplasty, Milligan-Morgan hemorrhoidectomy.On the 9th day, there was a «perianal soft tissue rupture» with bleeding and «local anterior rectal wall damage in the suprasphincter zone». Then «the rectal defect suturing» was performed. The perineal wound was left open. The patient was reoperated in 3 months due to a rectovaginal fistula with no effect. A fistulectomy was performed at the Moscow State University Medical Center with the removal of the anal canal defect by mucosal-submucosal flap. The surgical wound heals by secondary tension.Conclusion: The current studies describe a small number of cases of anorectal fistulas secondary to anorectal surgery. At the same time, there is no data on the further surgical management of such patients. It is important to present the iatrogenic anorectal fistulas cases, not only to analyze the fistula cause, but also to describe the surgical treatment method and its efficacy.
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Affiliation(s)
- D. R. Markaryan
- Federal State Budget Educational Institution of Higher Education M.V. Lomonosov Moscow State University (Lomonosov MSU)
| | - T. N. Garmanova
- Federal State Budget Educational Institution of Higher Education M.V. Lomonosov Moscow State University (Lomonosov MSU)
| | - E. A. Kazachenko
- Federal State Autonomous Educational Institution of Higher Education I.M. Sechenov First Moscow State Medical University (Sechenov University)
| | - M. A. Agapov
- Federal State Budget Educational Institution of Higher Education M.V. Lomonosov Moscow State University (Lomonosov MSU)
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14
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Vidon M, Munoz-Bongrand N, Lambert J, Maggiori L, Zeitoun JD, Corte H, Panis Y, Seksik P, Treton X, Abramowitz L, Allez M, Gornet JM. Long-term efficacy of fibrin glue injection for perianal fistulas in patients with Crohn's disease. Colorectal Dis 2021; 23:894-900. [PMID: 33278859 DOI: 10.1111/codi.15477] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Revised: 11/16/2020] [Accepted: 11/26/2020] [Indexed: 12/13/2022]
Abstract
AIM The treatment of perianal fistulas in Crohn's disease remains challenging. Fibrin glue injection has previously shown short-term efficacy in a randomized controlled trial. No long-term data are available to assess the benefit of this treatment. METHODS This retrospective multicentre study included all patients with drained fistulas treated by at least one fibrin glue injection between January 2004 and June 2015 in three tertiary French centres. The primary end-point was the rate of complete clinical remission at 1 year after injection defined by the closure of all fistula tracts with no need for iterative anal surgery or for optimization of immunosuppressants and/or biologics. RESULTS In all, 119 patients (median age 33 years, complex fistulas 65%, median previous anal surgery two, median Harvey Bradshaw score 3, immunosuppressants exposure 50%, anti-tumor necrosis factor exposure 60% with median time of administration of 1.1 year) were analysed with a median follow-up of 18.3 months. The complete clinical remission rate at 1 year was 45.4%. The primary end-point was achieved in 63% of the cases in the combination therapy group and 37% in other patients. The only predictor of complete clinical remission at 1 year was combination therapy at the time of injection (P = 0.01). The rate of early reintervention after glue injection was 2.5%. The cumulative incidence of iterative anal surgery and ostomy in the whole population was 54% and 5.6% respectively at 5 years. CONCLUSION An adjunct of fibrin glue to conventional medical therapy may be an effective and safe treatment for perianal fistulas in patients with Crohn's disease.
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Affiliation(s)
- Mathias Vidon
- Service de Gastroentérologie, Hôpital Saint-Louis, Paris, France
| | | | - Jérôme Lambert
- Université Paris-Denis Diderot, Paris, France.,Service de Biostatistiques, Hôpital Saint-Louis, Paris, France
| | - Léon Maggiori
- Université Paris-Denis Diderot, Paris, France.,Service de Chirurgie Digestive, Hôpital Beaujon, Clichy, France
| | - Jean-David Zeitoun
- Service de Proctologie, Groupe Hospitalier Diaconesses-Croix Saint-Simon, Paris, France
| | - Hélène Corte
- Service de Chirurgie Digestive, Hôpital Saint-Louis, Paris, France
| | - Yves Panis
- Université Paris-Denis Diderot, Paris, France.,Service de Chirurgie Digestive, Hôpital Beaujon, Clichy, France
| | - Philippe Seksik
- Service de Gastroentérologie et Nutrition, APHP, Hôpital Saint-Antoine, Sorbonne Université, Paris, France.,Université Sorbonne-UPMC Paris VI, Paris, France
| | - Xavier Treton
- Université Paris-Denis Diderot, Paris, France.,Service de Gastroentérologie, Hôpital Beaujon, Clichy, France
| | - Laurent Abramowitz
- Proctologie du service de Gastroentérologie, Hôpital Bichat, Clinique Blomet, Groupe Ramsay générale de santé, Paris, France
| | - Matthieu Allez
- Service de Gastroentérologie, Hôpital Saint-Louis, Paris, France.,Université Paris-Denis Diderot, Paris, France
| | - Jean-Marc Gornet
- Service de Gastroentérologie, Hôpital Saint-Louis, Paris, France
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Litta F, Parello A, Ferri L, Torrecilla NO, Marra AA, Orefice R, De Simone V, Campennì P, Goglia M, Ratto C. Simple fistula-in-ano: is it all simple? A systematic review. Tech Coloproctol 2021; 25:385-399. [PMID: 33387100 PMCID: PMC8016761 DOI: 10.1007/s10151-020-02385-5] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Accepted: 11/24/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND Simple anal fistula is one of the most common causes of proctological surgery and fistulotomy is considered the gold standard. This procedure, however, may cause complications. The aim of this systematic review was to assess the surgical treatment of simple anal fistula with traditional and sphincter-sparing techniques. METHODS A literature research was performed using PubMed, Cochrane, and Google Scholar to identify studies on the surgical treatment of simple anal fistulas. Observational studies and randomized clinical trials were included. We assessed the risk of bias of included studies using the Jadad scale for randomized controlled trials, and the MINORS Scale for the remaining studies. RESULTS The search returned 456 records, and 66 studies were found to be eligible. The quality of the studies was generally low. A total of 4883 patients with a simple anal fistula underwent a sphincter-cutting procedure, mainly fistulotomy, with a weighted average healing rate of 93.7%, while any postoperative continence impairment was reported in 12.7% of patients. Sphincter-sparing techniques were adopted to treat 602 patients affected by simple anal fistula, reaching a weighted average success rate of 77.7%, with no study reporting a significant postoperative incontinence rate. The postoperative onset of fecal incontinence and the recurrence of the disease reduced patients' quality of life and satisfaction. CONCLUSIONS Surgical treatment of simple anal fistulas with sphincter-cutting procedures provides excellent cure rates, even if postoperative fecal incontinence is not a negligible risk. A sphincter-sparing procedure could be useful in selected patients.
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Affiliation(s)
- F Litta
- Proctology Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Largo A. Gemelli, 8, 00168, Rome, Italy
| | - A Parello
- Proctology Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Largo A. Gemelli, 8, 00168, Rome, Italy
| | - L Ferri
- Proctology Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Largo A. Gemelli, 8, 00168, Rome, Italy
| | - N O Torrecilla
- Colorectal Unit, University Hospital Josep Trueta, Girona, Spain
| | - A A Marra
- Proctology Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Largo A. Gemelli, 8, 00168, Rome, Italy
| | - R Orefice
- Proctology Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Largo A. Gemelli, 8, 00168, Rome, Italy
| | - V De Simone
- Proctology Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Largo A. Gemelli, 8, 00168, Rome, Italy
| | - P Campennì
- Proctology Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Largo A. Gemelli, 8, 00168, Rome, Italy
| | - M Goglia
- Proctology Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Largo A. Gemelli, 8, 00168, Rome, Italy
| | - C Ratto
- Proctology Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Largo A. Gemelli, 8, 00168, Rome, Italy.
- Università Cattolica del Sacro Cuore, Rome, Italy.
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Long-term results of ligation of intersphincteric fistula tract (LIFT) for management of anal fistula. JOURNAL OF COLOPROCTOLOGY 2021. [DOI: 10.1016/j.jcol.2016.04.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Abstract
Background Ligation of intersphincteric fistula tract technique is a new sphincter saving method with good results in management of anal fistula, but few studies report long-term follow-up data.
Material and methods This study investigated the use of ligation of intersphincteric fistula tract as a sphincter saving method based on long term results. This was a retrospective review of prospectively collected data. The study was conducted at two tertiary care university medical centers. 36 patients with complex fistula from January 2010 to January 2014 treated with classic ligation of intersphincteric fistula tract were retrospectively followed. Demographic data, previous repair attempts, the type of the fistula and score of fecal continence were collected. The procedure was performed by colorectal surgeons. Primary healing rate, failures and fecal incontinence score of patients were followed for 6–48 months.
Results A total of 36 patients underwent ligation of intersphincteric fistula tract during 24 months. The mean age of the patients was 35 years and 50% had two previous attempts at surgery. A total of 25 patients (69/5%) had high transsphincteric fistula. The mean follow up was 27 months. Successful fistula closure was achieved in 63/8% of the patients (23 of 36). The mean time of recurrence was 4.5 weeks. Only one (2/77%) patient reported gas incontinence (score: 3) after the procedure.
Conclusion The recurrence rate and fecal incontinence were measured. The ligation of intersphincteric fistula is a promising sphincter-preserving procedure that is simple and safe. Our study demonstrates favorable long-term results of ligation of intersphincteric fistula tract for management of complex anal fistulas.
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Cestaro G, Gentile M. Anal fistulas treatment with bulking agents: an observational study. Chirurgia (Bucur) 2020. [DOI: 10.23736/s0394-9508.19.05022-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Abstract
BACKGROUND The number of citations a scientific paper has received indicates its impact within any medical field. We performed a bibliometric analysis to highlight the key topics of the most frequently cited 100 articles on perianal fistula to determine the advances in this field. METHODS The Scopus database was searched from 1960 to 2018 using the search terms "perianal fistula" or "anal fistula" or "fistula in ano" or "anal fistulae" or "anorectal fistulae" including full articles. The topic, year of publication, publishing journal, country of origin, institution, and department of the first author were analyzed. RESULTS The median number of citations for the top 100 of 3431 eligible papers, ranked in order of the number of citations, was 100 (range: 65-811), and the number of citations per year was 7.5 (range: 3.8-40.1). The most-cited paper (by Parks et al in 1976; 811citations) focused on the classification of perianal fistula. The institution with the highest number of publications was St Mark's Hospital, London, UK. The most-studied topic was surgical management (n = 47). The country and the decade with the greatest number of publications in this field were the USA (n = 34) and the 2000s (n = 50), respectively. CONCLUSION The 100 most frequently cited manuscripts showed that surgical management had the greatest impact on the study of perianal fistula. This citation analysis provides a reference of what could be considered the most classic papers on perianal fistula, and may serve as a reference for researchers and clinicians as to what constitutes a citable paper in this field.
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19
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Zhou C, Li M, Zhang Y, Ni M, Wang Y, Xu D, Shi Y, Zhang B, Chen Y, Huang Y, Zhang S, Shi H, Jiang B. Autologous adipose-derived stem cells for the treatment of Crohn's fistula-in-ano: an open-label, controlled trial. Stem Cell Res Ther 2020; 11:124. [PMID: 32183875 PMCID: PMC7079384 DOI: 10.1186/s13287-020-01636-4] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Revised: 02/13/2020] [Accepted: 03/05/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Crohn's fistula-in-ano is a refractory disease in colorectal and anal surgery. Although autologous adipose-derived stem cell (ADSC) has been used in the treatment of Crohn's fistula-in-ano because of its convenience, non-incision of normal tissue, good tolerance, repeatability, quick recovery, less pain, less damage to anal function, and high quality of life during the perioperative period, there are no reports of its use in China. This is the first clinical trial in China on the treatment of Crohn's fistula-in-ano with ADSC to evaluate its efficacy and safety. METHODS A total of 22 patients with Crohn's fistula-in-ano were enrolled in this study from January 2018 to October 2018 in the Colorectal Disease Center of Nanjing Hospital of Chinese Medicine Affiliated to Nanjing University of Chinese Medicine. Patients were divided (1:1) into an observation group (ADSC) and a control group (incision-thread-drawing procedure). Primary efficacy endpoint evaluated at months 3, 6, and 12 was the closure of fistulas (closure of all treated fistulas at baseline, confirmed by doctor's clinical assessment and magnetic resonance imaging or transrectal ultrasonography). The patients additionally completed some scoring scales at each follow-up including simplified Crohn's Disease Activity Index (CDAI), Perianal Disease Activity Index (PDAI), Inflammatory Bowel Disease Questionnaire (IBDQ), pain scores with visual analog score (VAS), and Wexner score. The data of inflammatory indexes were also collected. RESULTS The healing rates of the observation group and the control group at months 3, 6, and 12 were as follows: 10/11(90.9%) vs 5/11(45.5%), 8/11(72.7%) vs 6/11(54.5%), and 7/11(63.6%) vs 6/11(54.5%), respectively. There was no statistical difference between the two groups. In addition, the improvement in simplified CDAI, PDAI, IBDQ, VAS, and Wexner score of the observation group were better than that of the control group at each follow-up. The inflammatory indexes decreased in both the observation group and the control group at 3 months follow-up. And there were no significant differences in the changes of inflammatory indexes between two groups at month 3 compared with the baseline. Safety was maintained throughout month 12, and adverse events occurred in 63.6% of patients in the observation group and 100% patients in the control group. And no adverse event associated with ADSC injection was observed in the study. CONCLUSION ADSC is a feasible and effective treatment for Crohn's fistula-in-ano, compared with traditional incision and thread-drawing. It can protect anal function of patients, relieve pain, allow quick recovery, be well-tolerated, and improve the quality of life during perioperative period. TRIAL REGISTRATION China Clinical Trials Registry, No. ChiCTR1800014599. Registered 23 January 2018.
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Affiliation(s)
- Chungen Zhou
- Graduate School of Nanjing University of Chinese Medicine, Nanjing, 210029, Jiangsu Province, China
| | - Meng Li
- Colorectal Disease Center of Nanjing Hospital of Chinese Medicine Affiliated to Nanjing University of Chinese Medicine, Nanjing, 210022, Jiangsu Province, China
| | - Yang Zhang
- Colorectal Disease Center of Nanjing Hospital of Chinese Medicine Affiliated to Nanjing University of Chinese Medicine, Nanjing, 210022, Jiangsu Province, China
| | - Min Ni
- Colorectal Disease Center of Nanjing Hospital of Chinese Medicine Affiliated to Nanjing University of Chinese Medicine, Nanjing, 210022, Jiangsu Province, China
| | - Yehuang Wang
- Colorectal Disease Center of Nanjing Hospital of Chinese Medicine Affiliated to Nanjing University of Chinese Medicine, Nanjing, 210022, Jiangsu Province, China
| | - Dachao Xu
- Colorectal Disease Center of Nanjing Hospital of Chinese Medicine Affiliated to Nanjing University of Chinese Medicine, Nanjing, 210022, Jiangsu Province, China
| | - Yang Shi
- Reaserch Institute of Jiangsu Decon Bio-science Technologies Company Ltd., Nanjing, 210000, Jiangsu Province, China
| | - Bo Zhang
- Zhongda Hospital Southeast University, Nanjing, 210009, Jiangsu Province, China
| | - Yanni Chen
- Zhongda Hospital Southeast University, Nanjing, 210009, Jiangsu Province, China
| | - Yan Huang
- Yale School of Engineering & Applied Science, New Haven, 06520-8292, Connecticut, USA.
| | - Sumin Zhang
- Colorectal Disease Center of Nanjing Hospital of Chinese Medicine Affiliated to Nanjing University of Chinese Medicine, Nanjing, 210022, Jiangsu Province, China.
| | - Hongzhen Shi
- Reaserch Institute of Jiangsu Decon Bio-science Technologies Company Ltd., Nanjing, 210000, Jiangsu Province, China.
| | - Bin Jiang
- Colorectal Disease Center of Nanjing Hospital of Chinese Medicine Affiliated to Nanjing University of Chinese Medicine, Nanjing, 210022, Jiangsu Province, China.
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21
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Boscá MM, Alós R, Maroto N, Gisbert JP, Beltrán B, Chaparro M, Nos P, Mínguez M, Hinojosa J. Recommendations of the Crohn's Disease and Ulcerative Colitis Spanish Working Group (GETECCU) for the treatment of perianal fistulas of Crohn's disease. GASTROENTEROLOGIA Y HEPATOLOGIA 2020; 43:155-168. [PMID: 31870681 DOI: 10.1016/j.gastrohep.2019.09.012] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/26/2019] [Revised: 09/12/2019] [Accepted: 09/21/2019] [Indexed: 02/06/2023]
Abstract
Recommendations are advice that is given and considered to be beneficial; however, they are still suggestions and are therefore open to different interpretations. In this sense, the final objective of the review has been to try to homogenize, with the evidence available, the approach to the diagnosis and medical/surgical treatment of one of the most complex manifestations of Crohn's disease, such as simple and complex perianal fistulas.
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Affiliation(s)
- Marta M Boscá
- Servicio de Medicina Digestiva, Hospital Clínico Universitario, Valencia, España
| | - Rafael Alós
- Servicio de Cirugía General y Digestiva, Hospital Universitario La Fe, Valencia, España
| | - Nuria Maroto
- Servicio de Medicina Digestiva, Hospital Universitario de Manises, Manises, Valencia, España
| | - Javier P Gisbert
- Servicio de Medicina Digestiva, Hospital Universitario de La Princesa, Madrid, España
| | - Belén Beltrán
- Servicio de Medicina Digestiva, Hospital Universitario La Fe, Valencia, España
| | - María Chaparro
- Servicio de Medicina Digestiva, Hospital Universitario de La Princesa, Madrid, España
| | - Pilar Nos
- Servicio de Medicina Digestiva, Hospital Universitario La Fe, Valencia, España
| | - Miguel Mínguez
- Servicio de Medicina Digestiva, Hospital Clínico Universitario, Valencia, España
| | - Joaquín Hinojosa
- Servicio de Medicina Digestiva, Hospital Universitario de Manises, Manises, Valencia, España.
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22
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Recommendations of the Crohn’s Disease and Ulcerative Colitis Spanish Working Group (GETECCU) for the treatment of perianal fistulas of Crohn’s disease. ACTA ACUST UNITED AC 2020. [DOI: 10.1016/j.gastre.2019.09.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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Amato A, Bottini C, De Nardi P, Giamundo P, Lauretta A, Realis Luc A, Piloni V. Evaluation and management of perianal abscess and anal fistula: SICCR position statement. Tech Coloproctol 2020; 24:127-143. [PMID: 31974827 DOI: 10.1007/s10151-019-02144-1] [Citation(s) in RCA: 54] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2019] [Accepted: 12/23/2019] [Indexed: 02/07/2023]
Abstract
Perianal sepsis is a common condition ranging from acute abscess to chronic anal fistula. In most cases, the source is considered to be a non-specific cryptoglandular infection starting from the intersphincteric space. Surgery is the main treatment and several procedures have been developed, but the risks of recurrence and of impairment of continence still seem to be an unresolved issue. This statement reviews the pertinent literature and provides evidence-based recommendations to improve individualized management of patients.
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Affiliation(s)
- A Amato
- Coloproctology Unit, Department of Surgery, Borea Hospital, Sanremo, Italy.
| | - C Bottini
- Unit of Surgery, Hospital S. Antonio Abate, Gallarate, VA, Italy
| | - P De Nardi
- Gastrointestinal Surgery, San Raffaele Scientific Institute, Milan, Italy
| | - P Giamundo
- Department of Colorectal Surgery, Policlinico di Monza, Monza, Italy
| | - A Lauretta
- Unit of General Oncologic Surgery, Centro di Riferimento Oncologico di Aviano (CRO), IRCCS Aviano, Aviano, Italy
| | - A Realis Luc
- Coloproctology Unit, Hospital S. Rita, Vercelli, Italy
| | - V Piloni
- Diagnostic Imaging Centre "Diagnostica Marche", Osimo Stazione, Ancona, Italy
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Amato A, Bottini C, De Nardi P, Giamundo P, Lauretta A, Realis Luc A, Piloni V. Evaluation and management of perianal abscess and anal fistula: SICCR position statement. Tech Coloproctol 2020; 24:127-143. [DOI: 14) evaluation and management of perianal abscess and anal fistula: siccr position statement.a.amato, c.bottini, p.de nardi, p.giamundo, a.lauretta, a.realis luc & v.piloni.tech coloproctol 2020 24:127-143 doi 10.1007/s10151-019-02144-1] [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: 09/05/2019] [Accepted: 12/23/2019] [Indexed: 09/10/2023]
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Advances in Perianal Disease Associated with Crohn's Disease-Evolving Approaches. Gastrointest Endosc Clin N Am 2019; 29:515-530. [PMID: 31078250 DOI: 10.1016/j.giec.2019.02.011] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Perianal diseases, common complications of Crohn's disease, are difficult to diagnose/manage. Patients with perianal Crohn's disease suffer from persistent pain and drainage, recurrent perianal sepsis, impaired quality of life, and financial burden. Conventional medical and surgical therapies carry risk of infection, myelosuppression, incontinence, disease recurrence. Although the phenotype of Crohn's disease has been extensively studied, reported outcomes are inconsistent. Endoanal ultrasonography is also becoming popular because of low cost and ability to acquire images in real time. Emerging management strategies for treatment including laser therapy, local injection of agents, use of hyperbaric oxygen, and stem cell therapy, have demonstrated efficacy.
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Lopez N, Ramamoorthy S, Sandborn WJ. Recent advances in the management of perianal fistulizing Crohn's disease: lessons for the clinic. Expert Rev Gastroenterol Hepatol 2019; 13:563-577. [PMID: 31023087 PMCID: PMC6545251 DOI: 10.1080/17474124.2019.1608818] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Managing fistulizing perianal disease is among the most challenging aspects of treating patients with Crohn's disease. Perianal fistulas are indicative of poor long-term prognosis. They are commonly associated with significant morbidities and can have detrimental effects on quality of life. While durable fistula closure is ideal, it is uncommon. In optimal circumstances, reported long-term fistula healing rates are only slightly higher than 50% and recurrence is common. Achieving these results requires a combined medical and surgical approach, highlighting the importance of a highly skilled and collaborative multidisciplinary team. In recent years, advances in imaging, biologic therapies and surgical techniques have lent to growing enthusiasm amongst treatment teams, however the most advantageous approach is yet to be determined. Areas covered: Here we review current management approaches, incorporating recent guidelines and novel therapies. Additionally, we discuss recently published and ongoing studies that will likely impact practice in the coming years. Expert opinion: Investing in concerted collaborative multi-institutional efforts will be necessary to better define optimal timing and dosing of medical therapy, as well as to identify ideal timing and approach of surgical interventions. Standardizing outcome measures can facilitate these efforts. Clearly, experienced multidisciplinary teams will be paramount in this process.
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Affiliation(s)
- Nicole Lopez
- Division of Colon and Rectal Surgery, University of California San Diego, California, USA
| | - Sonia Ramamoorthy
- Division of Colon and Rectal Surgery, University of California San Diego, California, USA
| | - Willam J. Sandborn
- Inflammatory Bowel Disease Center, University of California San Diego, California, USA,Division of Gastroenterology, University of California San Diego, California, USA
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Mesh fixation using novel bio-adhesive coating compared to tack fixation for IPOM hernia repair: in vivo evaluation in a porcine model. Surg Endosc 2019; 33:2364-2375. [PMID: 31069501 DOI: 10.1007/s00464-019-06806-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2018] [Accepted: 04/29/2019] [Indexed: 12/31/2022]
Abstract
BACKGROUND Mesh fixation in hernia repair is currently based on penetrating sutures or anchors, with proven early and late complications such as pain, adhesions, erosions, and anchor migration. In an attempt to reduce these complications, a bio-adhesive-based self-fixation system was developed. The purpose of this study was to assess the performance and safety of this novel self-adhesive mesh (LifeMesh™) by comparing it with standard tack fixation. METHODS A full-thickness abdominal wall defect was created bilaterally in 24 pigs. The defects were measured 14 days later, and laparoscopic intraperitoneal onlay mesh (IPOM) repairs were performed. In each animal, both LifeMesh and a titanium tack-fixed control, either uncoated polypropylene mesh (PP) or composite mesh (Symbotex™), were used. After 28 and 90 days, we performed macroscopic evaluation and analyzed the fixation strength, shrinkage, adhesion scores, and histopathology in all samples. RESULTS Measurements at both time points revealed that LifeMesh had fully conformed to the abdominal wall, and that its fixation strength was superior to that of the tack-fixated Symbotex and comparable to that of the tack-fixated PP. Shrinkage in all groups was similar. Adhesion scores with LifeMesh were lower than with PP and comparable with Symbotex at both time points. Histology demonstrated similar tissue responses in LifeMesh and Symbotex. Lack of necrosis, mineralization, or exuberant inflammatory reaction in all three groups pointed to their good progressive integration of the mesh to the abdominal wall. By 28 days the bio-adhesive layer in LifeMesh was substantially degraded, allowing a gradual tissue ingrowth that became the main fixation mode of this mesh to the abdominal wall. CONCLUSIONS The excellent incorporation of LifeMesh to the abdominal wall and its superior fixation strength, together with its low adhesion score, suggest that LifeMesh may become a preferred alternative for abdominal wall repair.
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Role of interventional inflammatory bowel disease in the era of biologic therapy: a position statement from the Global Interventional IBD Group. Gastrointest Endosc 2019; 89:215-237. [PMID: 30365985 DOI: 10.1016/j.gie.2018.09.045] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2018] [Accepted: 09/29/2018] [Indexed: 02/08/2023]
Abstract
Interventional (or therapeutic) inflammatory bowel disease (IBD) endoscopy has an expanding role in the treatment of disease and surgical adverse events. Endoscopic therapy has been explored and used in the management of strictures, fistulas/abscesses, colitis-associated neoplasia, postsurgical acute or chronic leaks, and obstructions. The endoscopic therapeutic modalities include balloon dilation, stricturotomy, stent placement, fistulotomy, fistula injection and clipping, sinusotomy, EMR, and endoscopic submucosal dissection. With a better understanding of the disease course of IBD, improved long-term impact of medical therapy, and advances in endoscopic technology, we can foresee interventional IBD becoming an integrated part of the multidisciplinary approach to patients with complex IBD.
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Al-Janabi M, Al-Jasmawi H, Al-Mhanaa AR. Video-assisted anal fistula treatment in the management of fistula-in-ano: A 3-year experience. MEDICAL JOURNAL OF BABYLON 2019. [DOI: 10.4103/mjbl.mjbl_79_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Williams G, Williams A, Tozer P, Phillips R, Ahmad A, Jayne D, Maxwell-Armstrong C. The treatment of anal fistula: second ACPGBI Position Statement - 2018. Colorectal Dis 2018; 20 Suppl 3:5-31. [PMID: 30178915 DOI: 10.1111/codi.14054] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2017] [Accepted: 02/16/2018] [Indexed: 02/08/2023]
Abstract
It is over 10 years since the first ACPGBI Position Statement on the management of anal fistula was published in 2007. This second edition is the result of scrutiny of the literature published during this time; it updates the original Position Statement and reviews the published evidence surrounding treatments for anal fistula that have been developed since the original publication.
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Affiliation(s)
- G Williams
- Royal Wolverhampton NHS Trust, Wolverhampton, UK
| | - A Williams
- Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - P Tozer
- St Mark's Hospital, Harrow, London, UK
| | | | - A Ahmad
- Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - D Jayne
- University of Leeds, Leeds, UK
| | - C Maxwell-Armstrong
- National Institute for Health Research Nottingham Digestive Diseases Biomedical Research Unit, Nottingham University Hospitals NHS Trust and University of Nottingham, Nottingham, UK
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Masaki T, Kishiki T, Kojima K, Asou N, Beniya A, Matsuoka H. Recent trends (2016-2017) in the treatment of inflammatory bowel disease. Ann Gastroenterol Surg 2018; 2:282-288. [PMID: 30003191 PMCID: PMC6036397 DOI: 10.1002/ags3.12177] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2017] [Accepted: 05/08/2018] [Indexed: 12/17/2022] Open
Abstract
Prevalence of inflammatory bowel disease (IBD), ulcerative colitis and Crohn's disease has dramatically increased in Asian countries in the last three decades. In this period, many new medical therapies were introduced for the treatment of IBD, such as immunosuppressants, anti-tumor necrosis factor agents, leukocyte apheresis, anti-integrin antibody, and so on, which have contributed to induce remission and to reduce complications in IBD. As for surgical techniques for Crohn's disease, a stapled functional end-to-end anastomosis and conventional end-to-end anastomosis have similar perianastomotic recurrence rate and reoperation rate. Prospective randomized controlled studies which compare Kono-S anastomosis and stapled side-to-side anastomosis are ongoing. Variant two-stage ileal pouch anal anastomosis (IPAA) and transanal IPAA are new concepts for surgical treatment of ulcerative colitis. Various endoscopic procedures, such as balloon dilation for stenosis or stricture, endoscopic fistulotomy, injection of filling agents, and clipping for fistulas or perforations will be new options in the treatment of Crohn's disease. Adverse effects of preoperative treatments on postoperative complications should also be taken into account to improve surgical outcomes in IBD patients.
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Affiliation(s)
| | | | | | | | - Ayumi Beniya
- Department of SurgeryKyorin UniversityTokyoJapan
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Abstract
Pediatric anal fistulae commonly result from recurrent perianal abscesses, of which nearly 50 per cent develop an anal fistula. The purpose of this study was to report the results of using fibrin glue to treat anal fistula in pediatric patients. Infants and children with recurrent perianal abscesses and anal fistulae were treated with either fistulectomy or fibrin glue. Demographic and clinical characteristics and outcomes were compared between the groups. A total of 34 children were included; 27 received fistulectomy (median age eight months) and seven received fibrin glue treatment (median age 14 months). No significant differences in demographic or clinical characteristics were found between the two groups (all, P > 0.05). Median follow-up duration was significantly higher in the fibrin glue group compared with that in the fistulectomy group (five months vs one month, P = 0.003). There was one recurrence in the fistulectomy group, and no recurrences in the fibrin glue group (P = 1.0). No complications occurred in either group. Fibrin glue treatment is a simple and effective treatment alternative in the management of anal fistula in children, offering the advantage of sphincter muscle-sparing and reduced risk of fecal incontinence.
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Affiliation(s)
- Fan-Ting Liao
- School of Medicine, Fu-Jen Catholic University, New Taipei City, Taiwan
| | - Chi-Jen Chang
- School of Medicine, Fu-Jen Catholic University, New Taipei City, Taiwan
- Division of Pediatric Surgery, Department of Surgery, Shin-Kong Wu Ho-Su Memorial Hospital, Taipei City, Taiwan
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Giordano P, Sileri P, Buntzen S, Nunoo-Mensah J, Lenisa L, Singh B, Thorlacius-Ussing O, Griffiths B, Vujovic Z, Stuto A. Final results of a European, multicentre, prospective, observational study of Permacol™ collagen paste injection for the treatment of anal fistula. Colorectal Dis 2018; 20:243-251. [PMID: 28493393 DOI: 10.1111/codi.13715] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2016] [Accepted: 12/07/2016] [Indexed: 12/22/2022]
Abstract
AIM Permacol™ collagen paste (Permacol™ paste) is an acellular cross-linked porcine dermal collagen matrix suspension for use in soft-tissue repair. The use of Permacol™ paste in the filling of anorectal fistula tract is a new sphincter-preserving method for fistula repair. The MASERATI100 study was a prospective, observational clinical study with the objective to assess the efficacy of Permacol™ collagen paste for anal fistula repair in 100 patients. METHOD Patients (n = 100) with anal fistula were treated, at 10 European surgical sites, with a sphincter-preserving technique using Permacol™ paste. Fistula healing was assessed at 1, 3, 6 and 12 months post-treatment, with the primary end-point being healing at 6 months. Faecal continence and patient satisfaction were surveyed at each follow-up; adverse events (AEs) were monitored throughout the follow-up. RESULTS At 6 months postsurgery, 56.7% of patients were healed and the percentage healed was largely maintained, with 53.5% healed at 12 months. Regarding AEs, 29.0% of patients had at least one AE, and 16.0% of patients had one or more procedure-related AE. Most AEs reported were minor and similar to those commonly observed after fistula treatment, and the incidence of serious adverse events was low (4.0% of patients). Regardless of treatment outcome, 73.0% of patients were satisfied or very satisfied with the procedure. CONCLUSION Permacol™ paste is a promising sphincter-preserving treatment for anal fistulae and has minimal adverse side-effects.
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Affiliation(s)
- P Giordano
- Colorectal Department, Whipps Cross University Hospital, Barts Health, London, UK
| | - P Sileri
- Surgery, University of Rome Tor Vergata, Rome, Italy
| | - S Buntzen
- Colorectal Surgery, Department of Surgery, Aarhus University Hospital, Aarhus, Denmark
| | - J Nunoo-Mensah
- Department of Colorectal Surgery, King's College Hospital, London, UK
| | - L Lenisa
- General Surgery Unit, Casa di Cura Humanitas San Pio X, Milan, Italy
| | - B Singh
- Leicester General Hospital, Leicester, UK
| | - O Thorlacius-Ussing
- Department of Gastrointestinal Surgery, Aalborg University Hospital, Aalborg, Denmark
| | | | - Z Vujovic
- Ninewells Hospital & Medical School, Dundee, Scotland, UK
| | - A Stuto
- Coloproctology and Pelvic Floor Surgery, Policlinico Abano Terme, Padova, Italy
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Edwards SJ, Crawford F, van Velthoven MH, Berardi A, Osei-Assibey G, Bacelar M, Salih F, Wakefield V. The use of fibrin sealant during non-emergency surgery: a systematic review of evidence of benefits and harms. Health Technol Assess 2018; 20:1-224. [PMID: 28051764 DOI: 10.3310/hta20940] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Fibrin sealants are used in different types of surgery to prevent the accumulation of post-operative fluid (seroma) or blood (haematoma) or to arrest haemorrhage (bleeding). However, there is uncertainty around the benefits and harms of fibrin sealant use. OBJECTIVES To systematically review the evidence on the benefits and harms of fibrin sealants in non-emergency surgery in adults. DATA SOURCES Electronic databases [MEDLINE, EMBASE and The Cochrane Library (including the Cochrane Database of Systematic Reviews, the Database of Abstracts of Reviews of Effects, the Health Technology Assessment database and the Cochrane Central Register of Controlled Trials)] were searched from inception to May 2015. The websites of regulatory bodies (the Medicines and Healthcare products Regulatory Agency, the European Medicines Agency and the Food and Drug Administration) were also searched to identify evidence of harms. REVIEW METHODS This review included randomised controlled trials (RCTs) and observational studies using any type of fibrin sealant compared with standard care in non-emergency surgery in adults. The primary outcome was risk of developing seroma and haematoma. Only RCTs were used to inform clinical effectiveness and both RCTs and observational studies were used for the assessment of harms related to the use of fibrin sealant. Two reviewers independently screened all titles and abstracts to identify potentially relevant studies. Data extraction was undertaken by one reviewer and validated by a second. The quality of included studies was assessed independently by two reviewers using the Cochrane Collaboration risk-of-bias tool for RCTs and the Centre for Reviews and Dissemination guidance for adverse events for observational studies. A fixed-effects model was used for meta-analysis. RESULTS We included 186 RCTs and eight observational studies across 14 surgical specialties and five reports from the regulatory bodies. Most RCTs were judged to be at an unclear risk of bias. Adverse events were inappropriately reported in observational studies. Meta-analysis across non-emergency surgical specialties did not show a statistically significant difference in the risk of seroma for fibrin sealants versus standard care in 32 RCTs analysed [n = 3472, odds ratio (OR) 0.84, 95% confidence interval (CI) 0.68 to 1.04; p = 0.13; I2 = 12.7%], but a statistically significant benefit was found on haematoma development in 24 RCTs (n = 2403, OR 0.62, 95% CI 0.44 to 0.86; p = 0.01; I2 = 0%). Adverse events related to fibrin sealant use were reported in 10 RCTs and eight observational studies across surgical specialties, and 22 RCTs explicitly stated that there were no adverse events. One RCT reported a single death but no other study reported mortality or any serious adverse events. Five regulatory body reports noted death from air emboli associated with fibrin sprays. LIMITATIONS It was not possible to provide a detailed evaluation of individual RCTs in their specific contexts because of the limited resources that were available for this research. In addition, the number of RCTs that were identified made it impractical to conduct independent data extraction by two reviewers in the time available. CONCLUSIONS The effectiveness of fibrin sealants does not appear to vary according to surgical procedures with regard to reducing the risk of seroma or haematoma. Surgeons should note the potential risk of gas embolism if spray application of fibrin sealants is used and not to exceed the recommended pressure and spraying distance. Future research should be carried out in surgery specialties for which only limited data were found, including neurological, gynaecological, oral and maxillofacial, urology, colorectal and orthopaedics surgery (for any outcome); breast surgery and upper gastrointestinal (development of haematoma); and cardiothoracic heart or lung surgery (reoperation rates). In addition, studies need to use adequate sample sizes, to blind participants and outcome assessors, and to follow reporting guidelines. STUDY REGISTRATION This study is registered as PROSPERO CRD42015020710. FUNDING The National Institute for Health Research Health Technology Assessment programme.
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Abstract
Perianal fistulizing Crohn's disease has a major negative effect on patient quality of life and is a predictor of poor long-term outcomes. Factors involved in the pathogenesis of perianal fistulizing Crohn's disease include an increased production of transforming growth factor β, TNF and IL-13 in the inflammatory infiltrate that induce epithelial-to-mesenchymal transition and upregulation of matrix metalloproteinases, leading to tissue remodelling and fistula formation. Care of patients with perianal Crohn's disease requires a multidisciplinary approach. A complete assessment of fistula characteristics is the basis for optimal management and must include the clinical evaluation of fistula openings, endoscopic assessment of the presence of proctitis, and MRI to determine the anatomy of fistula tracts and presence of abscesses. Local injection of mesenchymal stem cells can induce remission in patients not responding to medical therapies, or to avoid the exposure to systemic immunosuppression in patients naive to biologics in the absence of active luminal disease. Surgery is still required in a high proportion of patients and should not be delayed when criteria for drug failure is met. In this Review, we provide an up-to-date overview on the pathogenesis and diagnosis of fistulizing Crohn's disease, as well as therapeutic strategies.
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Abstract
Fistulas still represent one of the most important complications in patients with Crohn’s disease (CD). At least one third of CD patients suffer from fistulas during their disease course and amongst them longstanding remission of complex fistulas occurs only in about one third. So far, fistula pathogenesis is only partially understood. From a histopathological view, a fistula is a tube covered by flat epithelial cells. Current research suggests that the driving force for fistula development is epithelial-to-mesenchymal transition (EMT). Around the fistula, high levels of tumor necrosis factor (TNF), IL-13, and TGFβ can be detected and recent studies indicated an involvement of the intestinal microbiota. Fistula diagnosis requires clinical and surgical assessment, radiologic investigations, e.g., magnet resonance imaging and endoscopy. Routine medical treatment of fistulas includes antibiotics, immunosuppressives, and anti-TNF antibodies. There is no well-established role for calcineurin inhibitors in fistula treatment, corticosteroids appear to be even contra-productive. A promising novel approach might be the application of adipose tissue-derived or bone marrow-derived mesenchymal stem cells that have been studied recently. Due to insufficient efficacy of medical treatment and recurrence of fistulas, surgical interventions are frequently necessary. Further research is needed to better understand fistula pathogenesis aiming to develop novel treatment option for our patients.
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38
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Shen B. Exploring endoscopic therapy for the treatment of Crohn's disease-related fistula and abscess. Gastrointest Endosc 2017; 85:1133-1143. [PMID: 28153572 DOI: 10.1016/j.gie.2017.01.025] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2016] [Accepted: 01/14/2017] [Indexed: 02/07/2023]
Abstract
Fistula and abscess represent penetrating disease phenotypes of Crohn's disease (CD) and can develop in patients with or without prior history of CD-related surgery. While CD fistula and abscess have been traditionally treated with medical and surgical therapy, the role of endoscopic therapy in this particular phenotype of CD is expanding recently, thanks to advanced endoscopic techniques and a better understanding of pathogenesis and natural history of the disease and principle of treatment. The success of endoscopic treatment for inflammatory bowel disease depends on comprehension and appreciation of principles, then techniques, followed by instrument and device. Attempts should be made to temporarily or permanently close the feeding side (or the primary) orifice at the gut, by various forms of clipping. Endoscopic fistulotomy is feasible, particularly for perianal fistula and surgery-associated distal bowel fistula. Perianal abscess can be treated with endoscopic incision and drainage and even seton placement. Endoscopic treatment for fistula and abscess as well as for stricture has become an important part of the multidisciplinary approach to complex CD.
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Affiliation(s)
- Bo Shen
- The Interventional IBD Unit, the Cleveland Clinic Foundation, Cleveland, Ohio, USA
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Fabiani B, Menconi C, Martellucci J, Giani I, Toniolo G, Naldini G. Permacol™ collagen paste injection for the treatment of complex anal fistula: 1-year follow-up. Tech Coloproctol 2017; 21:211-215. [PMID: 28210857 DOI: 10.1007/s10151-017-1590-3] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2016] [Accepted: 01/31/2017] [Indexed: 02/06/2023]
Abstract
BACKGROUND Optimal surgical treatment for anal fistula should result in healing of the fistula track and preserve anal continence. The aim of this study was to evaluate Permacol™ collagen paste (Covidien plc, Gosport, Hampshire, UK) injection for the treatment of complex anal fistulas, reporting feasibility, safety, outcome and functional results. METHODS Between May 2013 and December 2014, 21 consecutive patients underwent Permacol paste injection for complex anal fistula at our institutions. All patients underwent fistulectomy and seton placement 6-8 weeks before Permacol™ paste injection. Follow-up duration was 12 months. RESULTS Eighteen patients (85.7%) had a high transsphincteric anal fistula, and three female patients (14.3%) had an anterior transsphincteric fistula. Fistulas were recurrent in three patients (14.3%). Seven patients (33%) had a fistula with multiple tracts. After a follow-up of 12 months, ten patients were considered healed (overall success rate 47.6%). The mean preoperative FISI score was 0.33 ± 0.57 and 0.61 ± 1.02 after 12 months. CONCLUSIONS Permacol™ paste injection was safe and effective in some patients with complex anal fistula without compromising continence.
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Affiliation(s)
- B Fabiani
- Proctological and Perineal Surgical Unit, Department of Gastroenterology, Cisanello University Hospital, Pisa, Italy
| | - C Menconi
- Proctological and Perineal Surgical Unit, Department of Gastroenterology, Cisanello University Hospital, Pisa, Italy
| | - J Martellucci
- General, Emergency and Minimaly Invasive Surgery, Careggi University Hospital, largo Brambilla 3, 50134, Florence, Italy.
| | - I Giani
- Proctological and Perineal Surgical Unit, Department of Gastroenterology, Cisanello University Hospital, Pisa, Italy
| | - G Toniolo
- Proctological and Perineal Surgical Unit, Department of Gastroenterology, Cisanello University Hospital, Pisa, Italy
| | - G Naldini
- Proctological and Perineal Surgical Unit, Department of Gastroenterology, Cisanello University Hospital, Pisa, Italy
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40
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Lightner AL, Pemberton JH, Dozois EJ, Larson DW, Cima RR, Mathis KL, Pardi DS, Andrew RE, Koltun WA, Sagar P, Hahnloser D. The surgical management of inflammatory bowel disease. Curr Probl Surg 2017; 54:172-250. [PMID: 28576304 DOI: 10.1067/j.cpsurg.2017.02.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- Amy L Lightner
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN.
| | - John H Pemberton
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN
| | - Eric J Dozois
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN
| | - David W Larson
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN
| | - Robert R Cima
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN
| | - Kellie L Mathis
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN
| | - Darrell S Pardi
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN
| | - Rachel E Andrew
- Division of Colorectal Surgery, Penn State Health Milton S. Hershey Medical Center, Penn State College of Medicine, Hershey, PA
| | - Walter A Koltun
- Division of Colorectal Surgery, Penn State Health Milton S. Hershey Medical Center, Penn State College of Medicine, Hershey, PA
| | - Peter Sagar
- Division of Colorecal surgery, St. James University Hospital, Leeds, England
| | - Dieter Hahnloser
- Division of Colorecal surgery, Lausanne University Hospital, Lausanne, Switzerland
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Abstract
Perianal Crohn’s disease affects a significant number of patients with Crohn’s disease and is associated with poor quality of life. The nature of the disease, compounded by presentation of various disease severities, has made the treatment of perianal Crohn’s disease difficult. The field continues to evolve with the use of both historical and contemporary solutions to address the challenges associated with it. The goal of this article is to review current literature regarding medical and surgical treatment, as well as the future directions of therapy.
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Affiliation(s)
- Katherine A Kelley
- Department of General Surgery, Division of Gastrointestinal and General Surgery, Oregon Health and Sciences University, Portland, OR, USA
| | - Taranjeet Kaur
- Department of General Surgery, Division of Gastrointestinal and General Surgery, Oregon Health and Sciences University, Portland, OR, USA
| | - Vassiliki L Tsikitis
- Department of General Surgery, Division of Gastrointestinal and General Surgery, Oregon Health and Sciences University, Portland, OR, USA
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Ommer A, Herold A, Berg E, Farke S, Fürst A, Hetzer F, Köhler A, Post S, Ruppert R, Sailer M, Schiedeck T, Schwandner O, Strittmatter B, Lenhard BH, Bader W, Krege S, Krammer H, Stange E. S3-Leitlinie: Kryptoglanduläre Analfisteln. COLOPROCTOLOGY 2016. [DOI: 10.1007/s00053-016-0110-7] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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Clinical Practice Guideline for the Management of Anorectal Abscess, Fistula-in-Ano, and Rectovaginal Fistula. Dis Colon Rectum 2016; 59:1117-1133. [PMID: 27824697 DOI: 10.1097/dcr.0000000000000733] [Citation(s) in RCA: 222] [Impact Index Per Article: 24.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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Oldfield F, Gilbert T, Skaife P. Is modern management of fistula-in-ano acceptable? Br J Hosp Med (Lond) 2016; 77:388-93. [PMID: 27388377 DOI: 10.12968/hmed.2016.77.7.388] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Fistula-in-ano has been managed by a number of techniques and there remains no consensus on the most appropriate management for all patients. The mainstay of any treatment balances the need to control sepsis vs the risk of potential incontinence post-intervention. Management should focus on the primary source of sepsis.
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Affiliation(s)
- Frances Oldfield
- General Surgical Registrar in the Department of Surgery, University Hospital Aintree, Liverpool
| | - Timothy Gilbert
- Core Surgical Trainee in the Department of Surgery, University Hospital Aintree, Liverpool
| | - Paul Skaife
- Consultant Colorectal Surgeon in the Department of Surgery, University Hospital Aintree, Liverpool L9 7AL
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45
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Gecse KB, Sebastian S, Hertogh GD, Yassin NA, Kotze PG, Reinisch W, Spinelli A, Koutroubakis IE, Katsanos KH, Hart A, van den Brink GR, Rogler G, Bemelman WA. Results of the Fifth Scientific Workshop of the ECCO [II]: Clinical Aspects of Perianal Fistulising Crohn's Disease-the Unmet Needs. J Crohns Colitis 2016; 10:758-765. [PMID: 26826183 DOI: 10.1093/ecco-jcc/jjw039] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2016] [Accepted: 01/26/2016] [Indexed: 12/18/2022]
Abstract
BACKGROUND AND AIMS Perianal fistulas affect up to one-third of Crohn's patients during the course of their disease. Despite the considerable disease burden, current treatment options remain unsatisfactory. The Fifth Scientific Workshop [SWS5] of the European Crohn's and Colitis Organisation [ECCO] focused on the pathophysiology and clinical impact of fistulas in the disease course of patients with Crohn's disease [CD]. METHODS The ECCO SWS5 Working Group on clinical aspects of perianal fistulising Crohn's disease [pCD] consisted of 13 participants, gastroenterologists, colorectal surgeons, and a histopathologist, with expertise in the field of inflammatory bowel diseases. A systematic review of literature was performed. RESULTS Four main areas of interest were identified: natural history of pCD, morphological description of fistula tracts, outcome measures [including clinical and patient-reported outcome measures, as well as magnetic resonance imaging] and randomised controlled trials on pCD. CONCLUSIONS The treatment of perianal fistulising Crohn's disease remains a multidisciplinary challenge. To optimise management, a reliable classification and proper trial endpoints are needed. This could lead to standardised diagnosis, treatment, and follow-up of Crohn's perianal fistulas and the execution of well-designed trials that provide clear answers. The prevalence and the natural history of pCD need further evaluation.
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Affiliation(s)
- Krisztina B Gecse
- First Department of Medicine, Semmelweis University, Budapest, Hungary
| | - Shaji Sebastian
- Inflammatory Bowel Disease Unit, Hull & East Yorkshire NHS Trust, Hull, UK
| | - Gert de Hertogh
- Department of Pathology, University of Leuven, Leuven, Belgium
| | - Nuha A Yassin
- Department of Colorectal Surgery, St Mark's Hospital and Academic Institute, London, UK
| | - Paulo G Kotze
- Colorectal Surgery Unit, Catholic University of Paraná, Curitiba, PR, Brazil
| | - Walter Reinisch
- Division of Gastroenterology, Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Antonino Spinelli
- Colorectal Surgery Unit, Humanitas Research Hospital, Humanitas University, Milan, Italy
| | | | - Konstantinos H Katsanos
- Division of Gastroenterology, Department of Medicine, School of Health Sciences, Ioannina, Greece
| | - Ailsa Hart
- Inflammatory Bowel Disease Unit, St Mark's Hospital, London, UK
| | - Gijs R van den Brink
- Department of Gastroenterology, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
| | - Gerhard Rogler
- Division of Gastroenterology and Hepatology, University Hospital Zürich, Zürich, Switzerland
| | - Willem A Bemelman
- Department of Surgery, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
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Rosen DR, Kaiser AM. Definitive seton management for transsphincteric fistula-in-ano: harm or charm? Colorectal Dis 2016; 18:488-495. [PMID: 26382283 DOI: 10.1111/codi.13120] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2015] [Accepted: 07/15/2015] [Indexed: 02/08/2023]
Abstract
AIM The treatment of transsphincteric anal fistula requires a balance between eradication of the disease and preservation of faecal control. A cutting seton is an old tool that is now out of vogue for many surgeons. We hypothesized that the concept remains reliable and safe with results that exceed those reported for many of the more recently described methods. METHOD A retrospective review was conducted of real-time electronic health records (single institution, single surgeon) of patients presenting during the 14 years between 2001 and 2014 with a transsphincteric anal fistula who were treated with a cutting seton. Excluded were patients with Crohn's disease, fistulae related to malignancy or a previous anastomosis and patients whose fistula was treated by another method including a loose draining seton. Data collection included demographics, duration of the disease, duration of the treatment, outcome and continence. RESULTS In all, 121 patients (80 men) of mean age 40.2 ± 12.2 years (range 18-76) with a mean follow-up of 5.1 ± 3.3 (1-24) months were included in the analysis. The median duration of symptoms was 6 (1-84) months; 36% had failed other fistula surgery, 12% had a complex fistula with more than one track and 35% had some form of comorbidity. The median time to healing was 3 (1-18) months; 7.4% required further surgery, but eventually 98% had complete fistula healing. The incontinence rate decreased postoperatively to 11.6% from 19% before treatment with 17/121 with pre-existing incontinence resolved and 8/107 new cases developing. CONCLUSION Despite its retrospective non-comparative design, the study has demonstrated that a cutting seton is a safe, well tolerated and highly successful treatment for transsphincteric anal fistula and is followed overall by improved continence. The results compare very favourably with other techniques.
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Affiliation(s)
- D R Rosen
- Department of Colorectal Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - A M Kaiser
- Department of Colorectal Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
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47
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Kontovounisios C, Tekkis P, Tan E, Rasheed S, Darzi A, Wexner SD. Adoption and success rates of perineal procedures for fistula-in-ano: a systematic review. Colorectal Dis 2016; 18:441-58. [PMID: 26990602 DOI: 10.1111/codi.13330] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2015] [Accepted: 01/04/2016] [Indexed: 12/11/2022]
Abstract
AIM Several sphincter-preserving techniques have been described with extremely encouraging initial reports. However, more recent studies have failed to confirm the positive early results. We evaluate the adoption and success rates of advancement flap procedures (AFP), fibrin glue sealant (FGS), anal collagen plug (ACP) and ligation of intersphincteric fistula tract (LIFT) procedures based on their evolution in time for the management of anal fistula. METHOD A PubMed search from 1992 to 2015. An assessment of adoption, duration of study and success rate was undertaken. RESULTS We found 133 studies (5604 patients): AFP (40 studies, 2333 patients), FGS (31 studies, 871 patients), LIFT (19 studies, 759 patients), ACP (43 studies, 1641 patients). Success rates ranged from 0% to 100%. Study duration was significantly associated with success rates in AFP (P = 0.01) and FGS (P = 0.02) but not in LIFT or ACP. The duration of use of individual procedures since first publication was associated with success rate only in AFP (P = 0.027). There were no statistically significant differences in success rates relative to the number of the patients included in each study. CONCLUSION Success and adoption rates tend to decrease with time. Differences in patient selection, duration of follow-up, length of availability of the individual procedure and heterogeneity of treatment protocols contribute to the diverse results in the literature. Differences in success rates over time were evident, suggesting that both international trials and global best practice consensus are desirable. Further prospective randomized controlled trials with homogeneity and clear objective parameters would be needed to substantiate these findings.
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Affiliation(s)
- C Kontovounisios
- Department of Colorectal Surgery, The Royal Marsden Hospital, London, UK.,Department of Colorectal Surgery, Chelsea and Westminster Hospital, London, UK
| | - P Tekkis
- Department of Colorectal Surgery, The Royal Marsden Hospital, London, UK.,Department of Colorectal Surgery, Chelsea and Westminster Hospital, London, UK
| | - E Tan
- Department of Colorectal Surgery, Chelsea and Westminster Hospital, London, UK
| | - S Rasheed
- Department of Colorectal Surgery, The Royal Marsden Hospital, London, UK
| | - A Darzi
- Department of Colorectal Surgery, The Royal Marsden Hospital, London, UK
| | - S D Wexner
- Department of Colorectal Surgery in the Digestive Disease Center, Cleveland Clinic, Weston, FL, USA
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48
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Esposito F, Angileri FF, Kruse P, Cavallo LM, Solari D, Esposito V, Tomasello F, Cappabianca P. Fibrin Sealants in Dura Sealing: A Systematic Literature Review. PLoS One 2016; 11:e0151533. [PMID: 27119993 PMCID: PMC4847933 DOI: 10.1371/journal.pone.0151533] [Citation(s) in RCA: 64] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2015] [Accepted: 02/28/2016] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND Fibrin sealants are widely used in neurosurgery to seal the suture line, provide watertight closure, and prevent cerebrospinal fluid leaks. The aim of this systematic review is to summarize the current efficacy and safety literature of fibrin sealants in dura sealing and the prevention/treatment of cerebrospinal fluid leaks. METHODS A comprehensive electronic literature search was run in the following databases: Cochrane Database of Systematic Reviews, Cochrane Central Resister of Controlled Trials, clinicaltrials.gov, MEDLINE/PubMed, and EMBASE. Titles and abstracts of potential articles of interest were reviewed independently by 3 of the authors. RESULTS A total of 1006 database records and additional records were identified. After screening for duplicates and relevance, a total of 78 articles were assessed by the investigators for eligibility. Thirty-eight were excluded and the full-text of 40 articles were included in the qualitative synthesis. Seven of these included only safety data and were included in the safety assessment. The remaining 33 articles included findings from 32 studies that enrolled a total of 2935 patients who were exposed to fibrin sealant. Among these 33 studies there were only 3 randomized controlled trials, with the remaining being prospective cohort analysis, case controlled studies, prospective or retrospective case series. One randomized controlled trial, with 89 patients exposed to fibrin sealant, found a greater rate of intraoperative watertight dura closure in the fibrin sealant group than the control group (92.1% versus 38.0%, p<0.001); however, post-operative cerebrospinal fluid leakage occurred in more fibrin sealant than control patients (6.7% versus 2.0%, p>0.05). Other clinical trials evaluated the effect of fibrin sealant in the postoperative prevention of cerebrospinal fluid leaks. These were generally lower level evidence studies (ie, not prospective, randomized, controlled trials) that were not designed or powered to demonstrate a significant advantage to fibrin sealant use. Two small case series studies evaluated the effect of fibrin sealants in persistent cerebrospinal fluid leak treatment, but did not establish firm efficacy conclusions. Specific adverse reports where fibrin sealants were used for dura sealing were limited, with only 8 cases reported in neurosurgical procedures since 1987 and most reporting only a speculative relationship/association with fibrin sealant exposure. CONCLUSIONS A major finding of this systematic literature review is that there is a paucity of randomized studies that have evaluated the effectiveness and safety of fibrin sealants in providing intraoperative watertight dura closure and post-operative cerebrospinal fluid leakage. Among the limited studies available, evidence from a single randomized, controlled trial indicates that fibrin sealants provide a higher rate of intraoperative watertight closure of the dura suture line than control, albeit with a higher rate of postoperative cerebrospinal fluid leakage. Evidence from non-randomized, controlled trials suggests that fibrin sealants may be effective in preventing cerebrospinal fluid leaks with an acceptable safety profile. There is a substantial need for randomized, controlled clinical trials or well-designed prospective observational trials where the conduct of a randomized trial is not feasible to fully assess the impact of fibrin sealant utilization on the rates of intraoperative dura closure, postoperative cerebrospinal leakage, and safety.
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Affiliation(s)
- Felice Esposito
- Department of Biomedical and Dental Sciences and Morpho-Functional Imaging, Division of Neurosurgery, Università degli Studi di Messina, Messina, Italy
| | - Filippo Flavio Angileri
- Department of Biomedical and Dental Sciences and Morpho-Functional Imaging, Division of Neurosurgery, Università degli Studi di Messina, Messina, Italy
| | - Peter Kruse
- Independent medical advisor, Cervignano del Friuli, Italy
| | - Luigi Maria Cavallo
- Department of Neurosciences and Odontostomatological and Reproductive Sciences, Division of Neurosurgery, Università degli Studi di Napoli Federico II, Naples, Italy
| | - Domenico Solari
- Department of Neurosciences and Odontostomatological and Reproductive Sciences, Division of Neurosurgery, Università degli Studi di Napoli Federico II, Naples, Italy
| | - Vincenzo Esposito
- Division of Neurosurgery, Università degli Studi di Roma Sapienza, Rome, Italy
| | - Francesco Tomasello
- Department of Biomedical and Dental Sciences and Morpho-Functional Imaging, Division of Neurosurgery, Università degli Studi di Messina, Messina, Italy
| | - Paolo Cappabianca
- Department of Neurosciences and Odontostomatological and Reproductive Sciences, Division of Neurosurgery, Università degli Studi di Napoli Federico II, Naples, Italy
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49
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de Groof EJ, Cabral VN, Buskens CJ, Morton DG, Hahnloser D, Bemelman WA. Systematic review of evidence and consensus on perianal fistula: an analysis of national and international guidelines. Colorectal Dis 2016; 18:O119-34. [PMID: 26847796 DOI: 10.1111/codi.13286] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2015] [Accepted: 01/04/2016] [Indexed: 12/29/2022]
Abstract
AIM Treatment of perianal fistula has evolved with the introduction of new techniques and biologicals in Crohn's disease (CD). Several guidelines are available worldwide, but many recommendations are controversial or lack high-quality evidence. The aim of this work was to provide an overview of the current available national and international guidelines for perianal fistula and to analyse areas of consensus and areas of conflicting recommendations, thereby identifying topics and questions for future research. METHOD MEDLINE, EMBASE and PubMed were systematically searched for guidelines on perianal fistula. Inclusion was limited to papers in English less than 10 years old. The included topics were classified as having consensus (unanimous recommendations in at least two-thirds of the guidelines) or controversy (fewer than three guidelines commenting on the topic or no consensus) between guidelines. The highest level of evidence was scored as sufficient (level 3a or higher of the Oxford Centre for Evidence-based Medicine Levels of Evidence 2009, http://www.cebm.net/oxford-centre-evidence-based-medicine-levels-evidence-march-2009/) or insufficient. RESULTS Twelve guidelines were included and topics with recommendations were compared. Overall, consensus was present in 15 topics, whereas six topics were rated as controversial. Evidence levels varied from strong to lack of evidence. CONCLUSION Evidence on the diagnosis and treatment of perianal fistulae (cryptoglandular or related to CD) ranged from nonexistent to strong, regardless of consensus. The most relevant research questions were identified and proposed as topics for future research.
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Affiliation(s)
- E J de Groof
- Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands
| | - V N Cabral
- Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands
| | - C J Buskens
- Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands
| | - D G Morton
- Academic Department of Surgery, University of Birmingham, Birmingham, UK
| | - D Hahnloser
- Department of Visceral Surgery, University Hospital CHUV, Lausanne, Switzerland
| | - W A Bemelman
- Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands
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50
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Giordano P, Sileri P, Buntzen S, Stuto A, Nunoo-Mensah J, Lenisa L, Singh B, Thorlacius-Ussing O, Griffiths B, Ziyaie D. A prospective multicentre observational study of Permacol collagen paste for anorectal fistula: preliminary results. Colorectal Dis 2016; 18:286-94. [PMID: 26355641 DOI: 10.1111/codi.13112] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2015] [Accepted: 07/03/2015] [Indexed: 02/08/2023]
Abstract
AIM Permacol collagen paste (Permacol paste) is a new option for the treatment of anorectal fistula. It functions by filling the fistula tract with an acellular crosslinked porcine dermal collagen matrix suspension. The MASERATI 100 study group was set up to evaluate the clinical outcome of Permacol paste in the treatment of anorectal fistula. This paper reports the results from the initial 30 patients enrolled in the MASERATI 100 prospective, observational clinical trial. METHOD Patients (N = 30) with anal fistula presenting to 10 European academic surgical units were treated with a sphincter-preserving technique using Permacol paste. Fistula healing was assessed at 1, 3, 6 and 12 months after treatment, with the primary end-point of fistula healing at 6 months post-surgery. Faecal continence and patient satisfaction were recorded at each follow-up visit and adverse events were monitored throughout the follow-up. RESULTS Of the 28 patients with data at 6 months post-surgery, 15 (54%) were healed, and the healing rate was maintained at 12 months. Healing after treatment with Permacol paste was similar for intersphincteric to transsphincteric fistulae and primary or recurrent fistulae. Only one patient exhibited an adverse event (perianal abscess) that was possibly related to the treatment. At the last outpatient visit, over 60% of patients were satisfied or very satisfied with the operation. CONCLUSION Permacol paste is shown to be effective in treating primary and recurrent cryptoglandular anorectal fistula with minimal unwanted side effects.
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Affiliation(s)
- P Giordano
- Colorectal Department, Whipps Cross University Hospital, Barts Health, London, UK
| | - P Sileri
- University of Rome Tor Vergata, Rome, Italy
| | - S Buntzen
- Department of Surgery, Aarhus University Hospital, Aarhus, Denmark
| | - A Stuto
- General Surgery Department, Ospedale Santa Maria degli Angeli, Pordenone, Italy
| | - J Nunoo-Mensah
- Department of Colorectal Surgery, King's College Hospital, London, UK
| | - L Lenisa
- Surgery Unit, San Pio X Hospital, Milan, Italy
| | - B Singh
- Leicester General Hospital, Leicester, UK
| | - O Thorlacius-Ussing
- Department of Gastrointestinal Surgery, Aalborg University Hospital, Aalborg, Denmark
| | | | - D Ziyaie
- Ninewells Hospital and Medical School, Dundee, Scotland, UK
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