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1.
Purpose
Rectovaginal fistulas are difficult to treat completely, especially when patients present with a history of multiple surgeries and radiation therapy. We aimed to evaluate the efficacy of gracilis muscle flap transposition to treat rectovaginal fistula.Methods
We performed a retrospective chart review of all gracilis muscle transposition cases and other procedures between January 2009 and July 2016.Results
Total 53 cases were reviewed. A total of 11 patients underwent gracilis muscle flap transposition for rectovaginal fistula repair, with 8 patients showing good results without recurrence (total success rate, 72.7%). Comparison of this patient group with patients who had undergone other surgical procedures for rectovaginal fistula repair showed that those who received a gracilis transposition flap had significantly higher average number of previous surgeries (2.18 ± 1.17 vs. 1.1 ± 1.25) and had previously undergone radiotherapy at a significantly higher rate (63.6 vs. 26.2%). Furthermore, none of our patients complained of donor site discomfort.Conclusions
Based on these results, we recommend using the gracilis muscle flap for rectovaginal fistula repair in cases where there is a history of radiotherapy and had surgical failure more than twice.2.
Background
There are limited data available concerning endofistular therapies for fistula-in-ano, with our group reporting the first preliminary outcomes of the use of the radial fibre Fistula laser Closing (FiLaC ?) device.Methods
The aim of this study was to assess a cohort of anal fistulae managed with laser ablation plus definitive flap closure of the internal fistula opening over a long-term follow-up. Factors governing primary healing success and secondary healing success (i.e. success after one or two operations) were determined.Results
The study analysed 117 patients over a median follow-up period of 25.4 months (range 6–60 months) with 13 patients (11.1%) having Crohn’s-related fistulae. No incontinence to solid and liquid stool was reported. Minor incontinence to mucus and gas was observed in two cases (1.7%), and a late abscess treated in one case (0.8%). The primary healing rate was 75/117 (64.1%) overall, and 63.5% for cryptoglandular fistulae versus 69.2% for Crohn’s fistulae, respectively. Of the 42 patients who failed FiLaC? 31 underwent a second operation (“Re-FiLaC?”, fistulectomy with sphincter reconstruction or fistulotomy). The secondary healing rate, defined as healing of the fistula at the end of the study period, was 103/117 (88.0%) overall and 85.5% for cryptoglandular fistulae versus 92.3% for Crohn’s fistulae. A significantly higher primary success rate was observed for intersphincteric-type fistulae with primary and secondary outcome unaffected by age, gender, presence of Crohn’s disease, number of prior surgeries and the type of flap designed to close the internal fistula opening.Conclusions
There is a moderate primary success rate using first-up FiLaC? treatment. If FiLaC? fails, secondary success with repeat FiLaC? or other approaches was high. The minimally invasive FiLaC? approach may therefore represent a sensible first-line treatment option for anal fistula repair.3.
Purpose
Histopathology is commonly used to diagnose tuberculosis in fistula-in-ano. The aim was to compare the sensitivity of polymerase chain reaction and histopathology in detecting tuberculosis in fistula-in-ano.Methods
The histopathology and polymerase chain-reaction of tissue (fistula tract) was done in all the consecutive operated cases. When pus sample was also available, polymerase chain reaction-pus was also doneResults
Three hundred forty seven samples (179 patients) were tested over 2 years (median 6.5 months). The mean age was 38.8 ± 10.7 years, and male/female was 170/9. Histopathology and polymerase chain reaction of tissue (fistula tract) was done in 152 and 165 patients, respectively. Polymerase chain reaction (pus) could be done in 30 patients. Overall, tuberculosis was detected in 20/179 (11.2%) patients. Of these, tuberculosis was detected by histopathology (tissue) in 1/152 (0.7%) and by polymerase chain reaction (tissue) in 14/165 (8.5%) patients. In pus, polymerase chain reaction detected tuberculosis in 6/30 (20%) patients. Both polymerase chain reaction of tissue and pus were positive in one patient. Polymerase chain reaction (tissue) and polymerase chain reaction (pus) were significantly more sensitive than histopathology (tissue) for detecting tuberculosis [histopathology 1/152 vs. polymerase chain reaction (tissue) 14/165, p = 0.0009] [histopathology 1/152 vs. polymerase chain reaction (pus) 6/30, p < 0.0001]. In 20 patients detected to have tuberculosis, four drug anti-tubercular therapy was recommended for 6 months. The therapy was completed in 13 patients and 12/13 (92.3%) were cured. The therapy is continuing in 3/20 patients. Four patients did not take the therapy. None of them was cured.Conclusions
Polymerase chain reaction was significantly more sensitive than histopathology in detecting tuberculosis in fistula-in-ano. Histopathology might be missing out tuberculosis in many patients leading to recurrence of the fistula.4.
Nobutsugu Abe Masanori Sugiyama Yutaka Suzuki Takashi Yamaguchi Toshiyuki Mori Yutaka Atomi 《Journal of hepato-biliary-pancreatic sciences》2008,15(4):373-376
Background/Purpose
The prevention of pancreatic fistula is still a major problem in distal pancreatectomy (DP). We have recently adopted preoperative endoscopic pancreatic stenting with the aim of preventing the leakage of pancreatic juice from the resection plane of the remnant pancreas after DP. We reviewed ten patients who underwent this intervention.Methods
One to 6 days before surgery, the patients underwent an endoscopic transpapillary pancreatic stent (7 Fr., 3 cm) placement. The perioperative short-term outcomes were assessed.Results
Preoperative endoscopic pancreatic stenting was successfully performed in all ten patients. Two (20%) patients, both with intraductal papillary mucinous tumor, developed mild acute pancreatitis after the stent placement. None of the ten patients developed pancreatic fistula. The pancreatic stent was removed 8–28 days (mean, 11 days) postoperatively.Conclusions
Preoperative endoscopic pancreatic stenting may be an effective prophylactic measure against pancreatic fistula development following DP.5.
Operative Verfahren bei hohen kryptoglandulären Analfisteln: Systematische Übersicht und Metaanalyse
K. W. A. Göttgens R. R. Smeets L. P. S. Stassen G. Beets S. O. Breukink 《coloproctology》2016,38(2):93-105
Purpose
Perianal fistulas, and specifically high perianal fistulas, remain a challenge for surgical treatment. Many techniques have been and are still being developed to improve the outcome after surgery. A systematic review and meta-analysis was performed for surgical treatment of high cryptoglandular perianal fistulas.Methods
Medline (Pubmed, Ovid), Embase and The Cochrane Library databases were searched for relevant randomized controlled trials on surgical treatments for high cryptoglandular perianal fistulas. Two independent reviewers selected articles for inclusion based on title, abstract and outcomes described. The main outcome measurement was the recurrence/healing rate. Secondary outcomes were continence status, quality of life and complications.Results
The number of randomized trials available was low. Fourteen studies could be included in the review. A meta-analysis could only be performed for the mucosal advancement flap versus the fistula plug, and did not show a result in favour of either technique in recurrence or complication rate. The mucosal advancement flap was the most investigated technique but did not show any advantage over any other technique. Other techniques identified in randomized studies were seton treatment, medicated seton treatment, fibrin glue, autologous stem cells, island flap anoplasty, rectal wall advancement flap, ligation of the intersphincteric fistula tract, sphincter reconstruction, sphincter-preserving seton and techniques combined with antibiotics. None of these techniques seemed superior to each other.Conclusions
The best surgical treatment for high cryptoglandular perianal fistulas could not be identified. More randomized controlled trials are needed to find the best treatment. The mucosal advancement flap is the most investigated technique available.6.
A. Herold A. Ommer A. Fürst F. Pakravan D. Hahnloser B. Strittmatter T. Schiedeck F. Hetzer F. Aigner E. Berg M. Roblick D. Bussen A. Joos S. Vershenya 《Techniques in coloproctology》2016,20(8):585-590
Background
The aim of this prospective study was to determine the efficiency of the Gore Bio-A synthetic plug in the treatment of anal fistulas.Methods
A synthetic bioabsorbable anal fistula plug was implanted in 60 patients. All fistulas were transsphincteric and cryptoglandular in origin.Results
The healing rate after 1 year of follow-up was 52 % (31 out of 60 patients). No patient was lost to follow-up. The treatment had no effect on the incontinence score. The plug dislodgement rate was 10 % (6 out of 60 patients). Thirty-four per cent of the patients (16 out of 47) required reoperation. The average operating time was 32 ± 10.2 min, and the average length of hospital stay was 3.3 ± 1.8 days.Conclusions
Synthetic plugs may be an alternative to bioprosthetic fistula plugs in the treatment of transsphincteric anal fistulas. This method might have better success rates than treatment with bioprosthetic fistula plugs.7.
Purpose
The aim of this paper is to evaluate to the safety, feasibility and efficacy of a novel treatment for transsphincteric cryptoglandular fistula: injection of autologous plasma rich in growth factors (PRGF) into the fistula tract accompanied by sealing using a fibrin plug created from the activated platelet-poor fraction of the same plasma.Method
This article is a prospective, phase II clinical trial. The procedure was externally audited. Thirty-six patients diagnosed with transsphincteric fistula-in-ano were included. All patients underwent follow-up examinations at 1 week and again at 3, 6 and 12 months after discharge. Main outcome measures safety (number of adverse events), feasibility and effectiveness of the treatment.Results
A total of 36 patients received the study treatment, with the procedure found to be feasible in all patients. A total of seven adverse events (AE) related to the injected product or surgical procedure were identified in 4 of 36 patients. At the end of the follow-up period (12 months), 33.3% of patients (12/36) had achieved complete fistula healing and 11.1% of patients (4/36) had achieved partial healing. In total, this amounted to 44.4% of patients (16/36) being asymptomatic at final follow-up. In successfully healed patients, a gradual reduction in pain was observed, as measured using a Visual Analog Scale (VAS) (p = 0.0278). Compared to baseline, a significant improvement in Wexner score was seen in patients achieving total or partial healing of the fistula (p = 0.0195).Conclusions
The study treatment was safe and feasible, with apparently modest efficacy rates. Continence and pain improvement following treatment may be considered predictive factors for healing.8.
Michelle T. Graham Sandra Andorf Jonathan M. Spergel Talal A. Chatila Kari C. Nadeau 《Current allergy and asthma reports》2016,16(10):75
Purpose of Review
Food allergies (FAs) are a growing epidemic in western countries with poorly defined etiology. Defined as an adverse immune response to common food allergens, FAs present heterogeneously as a single- or multi-organ response that ranges in severity from localized hives and angioedema to systemic anaphylaxis.Recent Findings
Current research focusing on epithelial-derived cytokines contends that temporal regulation by these factors impact initial sensitization and persistence of FA responses upon repeated food allergen exposure. Mechanistic understanding of FA draws insight from a myriad of atopic conditions studied in humans and modeled in mice.Summary
In this review, we will highlight how epithelial-derived cytokines initiate and then potentiate FAs. We will also review existing evidence of the contribution of other atopic diseases to FA pathogenesis and whether FA symptoms overlap with other atopic diseases.9.
Mukesh Nasa Zubin Dev Sharma Narendra S. Choudhary Gaurav Patil Rajesh Puri Randhir Sud 《Indian journal of gastroenterology》2016,35(5):361-365
Introduction
The over-the-scope clip (OTSC) has been successfully used in the closure of fistula, perforation, dehiscence, and endoscopic hemostasis. We describe our experience with the OTSC application.Methods
Between April 2014 and April 2015, seven patients underwent OTSC application. In four patients, OTSC was applied for the closure of esophageal fistula, one had OTSC closure of persistent gastrocutaneous fistula after percutaneous endoscopic gastrostomy removal, and OTSC was applied in duodenum in two patients, for duodenal Dieulafoy’s lesion after failed conventional endotherapy and massive rebleed in one and duodenal perforation in another.Results
All procedures had technical success with no immediate complication related to OTSC application. Patients were followed up for every month with mean duration of follow up 10.2 months. One patient with bronchoesophageal fistula had development of another fistulous opening above the site of OTSC placement, which was successfully closed with another OTSC. One patient had superficial esophageal wall ulcer opposite the OTSC but it healed spontaneously.Conclusion
OTSC provided safe and successful closure in a number of settings.10.
Purpose
Rectal advancement flap is an accepted approach for treating complex fistula-in-ano. However, a diversity of technical modifications have been described. The aim of this study was to evaluate recurrence and fecal continence rates after performing rectal advancement flaps depending upon flap thickness (full-thickness, partial-thickness, or mucosal flaps) and treatment of the fistulous tract (core-out or curettage).Methods
Medline (PubMed, Ovid), the Cochrane Library database, and ClinicalTrials.gov were searched. Studies that involved patients with complex cryptoglandular fistulas who had been treated with rectal advancement flaps were included. The outcomes measured were recurrence and fecal continence. All of the statistical analyses were performed using Comprehensive Meta-Analysis software. A fixed model was used if there was no evidence of heterogeneity; otherwise, a random effects model was used.Results
Twenty-six studies were included (1655 patients). The pooled rate of recurrence was 21%. Full-thickness flaps showed the best results concerning recurrence (7.4%), partial flaps revealed 19% and mucosal flaps 30.1%. Core-out and curettage had a similar recurrence (19 vs 21%). Regarding anal incontinence, the pooled rate was 13.3%. Mucosal- and partial-thickness flaps showed similar rates (9.3 vs 10.2%), while full-thickness flaps disturbed it in 20.4%. Most of these alterations were minor symptoms. Otherwise, core-out and curettage showed similar rates (14.3 vs 12%).Conclusions
1. Full-thickness rectal advancement flaps offer better results regarding the recurrence than mucosal or partial flaps. 2. All flaps cause some incontinence, which increases with the thickness of the flap. 3. The results did not suggest differences in recurrence and incontinence between core-out and curettage.11.
A. Arroyo P. Moya M. A. Rodríguez-Prieto M. J. Alcaide M. M. Aguilar M. Bellón M. T. Pérez-Vázquez F. Candela R. Calpena 《Techniques in coloproctology》2017,21(2):149-153
Background
Photodynamic therapy (PDT) is a new procedure for the treatment of anal fistula. This preliminary study was designed to investigate the safety and effectiveness of this new technique in the treatment of anal fistula.Methods
Ten patients were treated with PDT. Intralesional 5-aminolevulinic acid (ALA) 2% was directly injected into the fistula. The internal and external orifices were closed. After an incubation period of 2 h, the fistula was irradiated using an optical fibre connected to a red laser (MULTIDIODE 630 PDT, INTERmedic, Spain) operating at 1 W/cm for 3 min (180 Joules). Patient demographics, operation notes and complications were recorded.Results
There were no complications. The average length of patient follow-up was 14.9 months (range 12–20 months). We could observe primary healing in eight patients (80%). Two patients (20%) showed persistence of suppuration after the operation. No patient reported incontinence postoperatively.Conclusions
PDT is a potential sphincter-saving procedure that is safe, simple and minimally invasive and has a high success rate.12.
B. Fabiani C. Menconi J. Martellucci I. Giani G. Toniolo G. Naldini 《Techniques in coloproctology》2017,21(3):211-215
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.13.
Jonas F. Schiemer Lennart Zimniak Edin Hadzijusufovic Hauke Lang Werner Kneist 《Techniques in coloproctology》2018,22(6):445-448
Background
Pelvic intraoperative neuromonitoring during nerve-sparing robot-assisted total mesorectal excision (RTME) is feasible. However, visual separation of the neuromonitoring process from the surgeon console interrupts the workflow and limits the usefulness of available information as the procedure progresses. Since the robotic surgical system provides multi-image views in the surgeon console, the aim of this study was to integrate cystomanometry and internal anal sphincter electromyography signals to aid the robotic surgeon in his/her nerve-sparing technique.Methods
We prospectively investigated 5 consecutive patients (1 male, 4 females) who underwent RTME for rectal cancer at our institution in 2017. The robotic surgery was performed using the da Vinci Xi combined with pelvic intraoperative neuromapping with real-time electromyography and cystomanometry signal transmission by multi-image view during RTME.Results
The adapted two-dimensional pelvic intraoperative neuromonitoring imaging successfully simulcasted to the surgeon console view in all 5 cases. The technical note is complemented by an intraoperative video.Conclusions
This report demonstrates the technical feasibility of an improved neuromonitoring process during nerve-sparing RTME. Robotic neuromapping can be fully visualized from the surgeon console.14.
Background
Little is known about self-help associations and their possibilities. Obstacles often prevent early contacts between affected people.Objectives
The psychosocial support given by self-help associations in different phases is evaluated.Materials and methods
Based on the experience of the Deutsche ILCO and from cooperation with other organizations and institutions, various dimensions of self-help groups are investigated.Results
On the professional side, there is a lack of knowledge and of attitude. Suitable structures are rare.Conclusions
The removal of barriers and development of effective structures are overdue.15.
Background
Bouveret's syndrome is an unusual presentation of duodenal obstruction caused by the passage of a large gallstone through a cholecystoduodenal fistula. Endoscopic therapy has been used as first-line treatment, especially in patients with high surgical risk.Case presentation
We report a 67-year-old woman who underwent an endoscopic attempt to fragment and retrieve a duodenal stone using a Holmium: Yttrium-Aluminum-Garnet Laser (Ho:YAG) which resulted in small bowel obstruction. The patient successfully underwent enterolithotomy without cholecystectomy or closure of the fistula.Conclusion
We conclude that, distal gallstone obstruction, due to migration of partially fragmented stones, can occur as a possible complication of laser lithotripsy treatment of Bouveret's syndrome and might require urgent enterolithotomy.16.
Giovanni B. Gaeta Massimo Puoti Nicola Coppola Teresa Santantonio Raffaele Bruno Antonio Chirianni Massimo Galli 《Infection》2018,46(2):183-188
Aim
This paper is aimed at providing practical recommendations for the management of acute hepatitis C (AHC).Methods
This is an expert position paper based on the literature revision. Final recommendations were graded by level of evidence and strength of the recommendations.Results
Treatment of AHC with direct-acting antivirals (DAA) is safe and effective; it overcomes the limitations of INF-based treatments.Conclusions
Early treatment with DAA should be offered when available.17.
J. Daryl Thornton Catherine Sullivan Jeffrey M. Albert Maria Cedeño Bridget Patrick Julie Pencak Kristine A. Wong Margaret D. Allen Linda Kimble Heather Mekesa Gordon Bowen Ashwini R. Sehgal 《Journal of general internal medicine》2016,31(8):832-839
BACKGROUND
Low organ donation rates remain a major barrier to organ transplantation.OBJECTIVE
We aimed to determine the effect of a video and patient cueing on organ donation consent among patients meeting with their primary care provider.DESIGN
This was a randomized controlled trial between February 2013 and May 2014.SETTING
The waiting rooms of 18 primary care clinics of a medical system in Cuyahoga County, Ohio.PATIENTS
The study included 915 patients over 15.5 years of age who had not previously consented to organ donation.INTERVENTIONS
Just prior to their clinical encounter, intervention patients (n?=?456) watched a 5-minute organ donation video on iPads and then choose a question regarding organ donation to ask their provider. Control patients (n?=?459) visited their provider per usual routine.MAIN MEASURES
The primary outcome was the proportion of patients who consented for organ donation. Secondary outcomes included the proportion of patients who discussed organ donation with their provider and the proportion who were satisfied with the time spent with their provider during the clinical encounter.KEY RESULTS
Intervention patients were more likely than control patients to consent to donate organs (22 % vs. 15 %, OR 1.50, 95%CI 1.10–2.13). Intervention patients were also more likely to have donation discussions with their provider (77 % vs. 18 %, OR 15.1, 95%CI 11.1–20.6). Intervention and control patients were similarly satisfied with the time they spent with their provider (83 % vs. 86 %, OR 0.87, 95%CI 0.61–1.25).LIMITATION
How the observed increases in organ donation consent might translate into a greater organ supply is unclear.CONCLUSION
Watching a brief video regarding organ donation and being cued to ask a primary care provider a question about donation resulted in more organ donation discussions and an increase in organ donation consent. Satisfaction with the time spent during the clinical encounter was not affected.TRIAL REGISTRATION
clinicaltrials.gov Identifier: NCT0169713718.
Christoforidis D Etzioni DA Goldberg SM Madoff RD Mellgren A 《Diseases of the colon and rectum》2008,51(10):1482-1487
Purpose
Anal fistulas that involve a significant amount of sphincter may be difficult to treat without compromising continence function. In this study, we evaluated our experience with the Surgisis® anal fistula plug, which was recently reported to be successful in >80 percent of patients with complex fistulas.Methods
We retrospectively collected patient and fistula characteristics, procedure details, and follow-up information for all patients treated with the anal fistula plug at our institution from January 2006 through April 2007. The outcome was considered successful if the external opening was closed and if the patient had no drainage at the last follow-up. Using multivariate statistics, we analyzed the relationship between anal fistula plug success and several key variables.Results
From January 2006 through April 2007, 47 patients with 49 complex anal fistulas underwent 64 anal fistula plug procedures. The median follow-up time for patients who were considered healed was 6.5 (range, 3–11) months. The success rate was 31 percent per procedure and 43 percent per patient. An increased amount of external sphincter involvement was associated with a higher failure rate (P?Conclusions
In our early experience with the anal fistula plug, 43 percent of patients with complex anal fistulas were successfully treated. Patients with less external sphincter involvement were more likely to heal.19.
Zoe E. Parr Francis R. Sutherland Oliver F. Bathe Elijah Dixon 《Journal of hepato-biliary-pancreatic sciences》2008,15(6):563-569
Background/Purpose
Pancreatic fistulae constitute a morbid outcome of pancreatic surgery. Yet, a definition of a pancreatic fistula does not exist that can be reliably used to report on and study this outcome. We compare reported fistula, morbidity, and mortality rates with fistula parameters in order to identify high-risk fistulae predictive of morbid outcomes.Methods
A systematic literature review was performed; of 1426 articles identified, 43 articles ultimately met inclusion and exclusion criteria and were reviewed. Fistula, morbidity, and mortality rates as well as fistula definitions were extracted and then compared and graphically reported.Results
Thirty-two different definitions of pancreatic fistulae were found in 43 articles; only 24 articles defined fistulae according to all three parameters examined in this study. The data trends suggest that fistula, morbidity, and mortality rates have remained relatively stable since 1980. Further, drainage volumes, amylase levels, and length of drainage do not appear to correlate with reported morbidity or mortality rates.Conclusions
This study suggests that pancreatic fistulae may not correlate with morbidity and mortality. Further, the parameters historically used to define fistulae do not appear to correlate with morbidity and mortality. A different system is needed to identify this outcome and determine its clinical significance.20.
