This article examines the complex relationship between disease perception,negative emotions,and their impact on postoperative recovery in patients with perianal diseases.These conditions not only cause physical discom...This article examines the complex relationship between disease perception,negative emotions,and their impact on postoperative recovery in patients with perianal diseases.These conditions not only cause physical discomfort,but also carry a significant emotional burden,often exacerbated by social stigma.Psycho-logical factors,including stress,anxiety,and depression,activate neuroendocrine pathways,such as the hypothalamic–pituitary–adrenal axis,disrupting the gut microbiota and leading to dysbiosis.This disruption can delay wound healing,prolong hospital stay,and intensify pain.Drawing on the findings of Hou et al,our article highlights the critical role of illness perception and negative emotions in shaping recovery outcomes.It advocates for a holistic approach that integrates psychological support and gut microbiota modulation,to enhance healing and improve overall patient outcomes.展开更多
Perianal fistulising Crohn’s disease is a challenging complication that can affect up to 20%of patients with Crohn’s disease and is associated with significant morbidity.Despite advances in medical therapies,particu...Perianal fistulising Crohn’s disease is a challenging complication that can affect up to 20%of patients with Crohn’s disease and is associated with significant morbidity.Despite advances in medical therapies,particularly anti-tumor necrosis factor agents,the majority of patients still require surgical intervention.Accurate diagnosis and monitoring are essential to optimise outcomes and guide multidisciplinary management.Although clinical scoring systems such as the perianal disease activity index are widely used,their subjective application limits their reproducibility and reliability,underscoring the need for more objective methods of evaluating perianal fistulising Crohn’s disease activity.Imaging has thus become central to the objective assessment of perianal fistulising Crohn’s disease,with magnetic resonance imaging(MRI)recognised as the gold standard in view of its ability to provide clear,detailed images of the perianal region in a radiation-free manner.Guidelines also endorse the use of imaging modalities such as endoanal ultrasound and transperineal ultrasound as viable alternatives to MRI for the assessment of perianal fistulising Crohn’s disease in centres with appropriate expertise.This article aims to evaluate and compare the diagnostic accuracy and clinical utility of MRI,endoanal ultrasound,and transperineal ultrasound in the assessment of perianal fistulising Crohn’s disease,highlighting their respective strengths,limitations,and roles in clinical practice.展开更多
This article provides a comprehensive analysis of the study by Hou et al,focusing on the complex interplay between psychological and physical factors in the postoperative recovery(POR)of patients with perianal disease...This article provides a comprehensive analysis of the study by Hou et al,focusing on the complex interplay between psychological and physical factors in the postoperative recovery(POR)of patients with perianal diseases.The study sheds light on how illness perception,anxiety,and depression significantly influence recovery outcomes.Hou et al developed a predictive model that demonstrated high accuracy in identifying patients at risk of poor recovery.The article explores the critical role of pre-operative psychological assessment,highlighting the need for mental health support and personalized recovery plans in enhancing POR quality.A multidisciplinary approach,integrating mental health professionals with surgeons,anesthesiologists,and other specialists,is emphasized to ensure comprehensive care for patients.The study’s findings serve as a call to integrate psychological care into surgical practice to optimize outcomes for patients with perianal diseases.展开更多
BACKGROUND Both the etiology and treatment of perianal fistulas present challenges,and there is no standard surgical approach.AIM To present the results of a modified fistulotomy technique that was implemented in a te...BACKGROUND Both the etiology and treatment of perianal fistulas present challenges,and there is no standard surgical approach.AIM To present the results of a modified fistulotomy technique that was implemented in a tertiary coloproctology reference center.METHODS Seventy-two patients who underwent surgical intervention for perianal fistula between August 2019 and January 2023 were treated using a modified fistulotomy technique.In this approach,the fistula tract was excised from the external opening up to the external sphincter fibers.The internal orifice was widened,and the septic focus within the inter sphincteric space was curetted.Partial internal sphincterotomy was performed up to the inter sphincteric plane.The anoderm from the internal orifice to the inter sphincteric space was closed with absorbable suture material,and a loose seton was placed at the level of the external sphincter.RESULTS The 72 patients who underwent modified fistulotomy were 77.8%male and 22.2%female,with a mean age of 42.2±11.5 years.The median follow-up period was 19 months.Preoperatively,93.1%of patients had high trans sphincteric fistulas,and 6.9%were females with anterior low trans sphincteric fistulas.In all cases,setons were placed during surgery using vascular tape.A total of 12.5%of patients experienced incontinence,involving gas(6.9%)or soiling(5.6%).There were no reports of solid or liquid incontinences.Complete healing was achieved in 83.3%of the patients,with a recurrence rate of 4.2%and a non-healing rate of 12.5%.CONCLUSION Our preliminary analysis suggests that this modified fistulotomy technique that targets distalization of the internal orifice is a promising alternative management strategy for perianal fistulas.展开更多
[Objectives]To investigate the use of the classical Chinese medicine formula Sihu Powder modified decoction for postoperative fumigation and sitz bath in patients with perianal abscess,aiming to promote wound healing ...[Objectives]To investigate the use of the classical Chinese medicine formula Sihu Powder modified decoction for postoperative fumigation and sitz bath in patients with perianal abscess,aiming to promote wound healing and reduce medical burden.[Methods]An observational cohort study was conducted,selecting 200 patients with perianal abscess who underwent surgery in Shenzhen Guangming District People's Hospital.They were randomly divided into a treatment group and an observation group,with 100 cases in each group.Both groups followed the same surgical and antibiotic treatment principles.Starting from the first postoperative day,the treatment group received fumigation and sitz bath with modified Sihu Powder for decoction twice daily;the observation group used Compound Huangbai Liquid for fumigation and sitz bath twice daily.Indicators including pain score,wound secretion score,wound granulation tissue growth score,multidrug-resistant bacterial infection clearance rate,antibiotic usage days,and wound healing rate were observed in both groups 7,14 and 21 d after operation.[Results]On postoperative day 7,the differences in postoperative pain score,wound secretions,and multidrug-resistant bacterial clearance rate between the treatment group and the observation group were statistically significant.On postoperative day 14,the differences between the two groups were significant in indicators including pain score,wound secretions,wound granulation tissue growth,multidrug-resistant bacterial clearance rate,and wound healing rate.On postoperative day 21,the difference in wound healing rate between the two groups was significant;furthermore,the antibiotic usage days in the treatment group were significantly fewer than those in the observation group.[Conclusions]Modified Sihu Powder for fumigation and washing can effectively alleviate postoperative pain in perianal abscess patients,inhibit the colonization and infection of multidrug-resistant bacteria at the wound site,accelerate wound healing,reduce antibiotic usage intensity and medical burden.It possesses advantages such as being economical,effective,safe,and easy to operate,making it worthy of clinical promotion.展开更多
Perianal fistulizing Crohn’s disease(PFCD)is a common presentation of CD,which affects the patients’quality of life,including social and sexual function.The management of PFCD remains a critical challenge in inflamm...Perianal fistulizing Crohn’s disease(PFCD)is a common presentation of CD,which affects the patients’quality of life,including social and sexual function.The management of PFCD remains a critical challenge in inflammatory bowel disease,primarily due to limited understanding of the mechanisms involved in its pathogenesis,complicating medical treatment.Increased production of inflammatory cytokines such as tumor necrosis factor and interleukin-13 by infiltrating macrophages and other inflammatory cells stimulate the epithelial-to-mesenchymal transition,resulting in activation of myofibroblasts and elevation of matrix metalloproteinases,leading to fistula formation.Given the potential for malignant transformation,PFCD screening is critical.Cytokine and inflammationtargeted therapies can help control this disease,but recurrence is a common complication.Surgical interventions such as fistulotomy represent viable therapeutic options,with magnetic resonance imaging serving as an important diagnostic tool for delineating fistula tract anatomy.Animal models and clinical trials demonstrate that injection of mesenchymal stem cells(MSCs)into the fistula results in suppression of the inflammatory cells and cytokines and complete resolution of PFCD.Recently,MSC-derived extracellular vesicles were found to stimulate fistula healing,with encouraging results.In this article,we comment on the review article by Pacheco et al,summarizing the various lines of PFCD treatment and highlighting the role of screening for this disease.Importantly,we focus on the various mechanisms involved in the pathogenesis of PFCD,the therapeutic roles of MSCs and related extracellular vesicles,and explore the potential role of autophagy in enhancing the therapeutic efficacy of these cells,which may help in the treatment of this disease.展开更多
BACKGROUND Data regarding complex Crohn’s perianal fistulas(CPF)epidemiology are limited,and optimal treatment strategies are elusive.An improved understanding of how CPF treatment options are used in the real-world ...BACKGROUND Data regarding complex Crohn’s perianal fistulas(CPF)epidemiology are limited,and optimal treatment strategies are elusive.An improved understanding of how CPF treatment options are used in the real-world setting and factors associated with CPF development,treatment failure,and reasons for undergoing multiple surgeries may help to inform optimal patient management strategies,reduce treatment burden,and improve outcomes in patients with CPF.AIM To describe the epidemiology,treatments,outcomes,and associated risk/protective factors for complex CPF.METHODS Electronic databases(MEDLINE,EMBASE,EBM Reviews,EconLit)were searched.Two reviewers independently used populations,interventions,comparators,outcomes,study designs,and time criteria to identify relevant studies.Observational studies published in English from January 1,2015 to February 17,2022 with>50 patients were included,even if complex CPF was not defined.Items of interest included complex CPF definitions,epidemiology,treatment patterns,morbidity,mortality,and risk factors associated with complex CPF development,treatment failure,and undergoing multiple surgeries.Data were reported using descriptive statistics.RESULTS Overall,140 studies were included.Complex CPF definitions were heterogeneous and rarely reported(24 studies).Hence,data mostly related to CPF in general.CPF prevalence was variable(range:1.5%-81.0%).Incidence was wide-ranging and mostly reported cumulatively at 1-year post-Crohn’s disease diagnosis(range:3.5%-50.1%).Overall healing and failure rates after treatment were in the range of 10.5%-80.2%and 3.6%-83.0%,respectively.Abscesses were the most frequently reported morbidity(n=18).No CPF-related deaths were reported.No consistent risk or protective factors were identified.CONCLUSION Epidemiology,treatment patterns,and risk factors for CPF vary,likely due to inconsistent CPF and clinical outcome definitions.Standardization would facilitate comparability,which may inform optimal complex CPF treatment strategies.展开更多
Perianal fistulizing Crohn’s disease(PFCD)is a complication of CD that signi-ficantly impacts patients’quality of life,particularly their social and sexual well-being.Despite advances in therapy,its treatment remain...Perianal fistulizing Crohn’s disease(PFCD)is a complication of CD that signi-ficantly impacts patients’quality of life,particularly their social and sexual well-being.Despite advances in therapy,its treatment remains a major challenge in the field of inflammatory bowel disease.The pathogenesis of PFCD involves in-creased production of inflammatory cytokines by infiltrating macrophages and lymphocytes,stimulation of the epithelial-to-mesenchymal transition,activation of myofibroblasts,and elevated levels of matrix metalloproteinases.Mesenchymal stem cells(MSCs)are multipotent stromal cells with self-renewal and differen-tiation capabilities.Evidence from animal models and clinical trials indicates that MSC injection into PFCD lesions suppresses the infiltration of inflammatory cells and cytokines,resulting in complete fistula healing.More recently,MSC-derived extracellular vesicles(EVs)have shown promising results in promoting fistula healing,particularly in cases of refractory or relapsing fistulas.Notably,the activation of macroautophagy(hereafter referred to as autophagy)in MSCs has been shown to accelerate the healing process.This narrative review discusses the mechanisms underlying PFCD pathogenesis,the therapeutic roles of MSCs and their EVs,and the potential role of autophagy upregulation in enhancing MSC function and EV production.展开更多
BACKGROUND Anal canal adenocarcinoma with secondary perianal Paget’s disease(PPD)is clinically rare and exhibits atypical symptoms,often misdiagnosed as benign conditions such as hemorrhoids or perianal eczema,leadin...BACKGROUND Anal canal adenocarcinoma with secondary perianal Paget’s disease(PPD)is clinically rare and exhibits atypical symptoms,often misdiagnosed as benign conditions such as hemorrhoids or perianal eczema,leading to delayed treatment.Further summarization of diagnostic and therapeutic key points,as well as reasons for misdiagnosis,is necessary to enhance clinical awareness.CASE SUMMARY A retrospective analysis was conducted on a 72-year-old female patient with a 2-year history of perianal moisture,pruritus,and hematochezia,who was repeatedly misdiagnosed with mixed hemorrhoids.The diagnosis of anal canal adenocarcinoma with secondary PPD was confirmed through colonoscopy,perianal skin biopsy,and immunohistochemical staining(CK7,CK20,etc.).The patient underwent 3D laparoscopic-assisted abdominoperineal resection(APR)with extended perianal skin excision,achieving negative margins and primary wound healing.No recurrence or metastasis was observed during the 12-month follow-up.CONCLUSION Secondary PPD has a high misdiagnosis rate.Clinicians should maintain a high index of suspicion for elderly patients with prolonged perianal symptoms(e.g.,pruritus,hematochezia>6 months)and promptly perform colonoscopy and immunohistochemical testing for definitive diagnosis.APR combined with extended perianal resection is an effective treatment,and standardized long-term follow-up is crucial for prognosis.展开更多
BACKGROUND About 90%of perianal infection is caused by cryptoglandular infection.Only a few cases of peritonitis or intra-abdominal abscesses secondary to perforation of the digestive tract by an ingested foreign body...BACKGROUND About 90%of perianal infection is caused by cryptoglandular infection.Only a few cases of peritonitis or intra-abdominal abscesses secondary to perforation of the digestive tract by an ingested foreign body have been reported.The most common sites of impaction and perforation include the appendix,cecum and the terminal ileum.The rectum is an unusual site of foreign body impaction.This report intends to highlight that ingested foreign body impacted in the rectum is an extremely rare cause of perianal abscess and subsequent fistula in infants.CASE SUMMARY Two cases of perianal abscess and fistula due to ingested jujube pit impacted in the rectum are reported.Both cases are infants with free previous medical history suffered from recurrent perianal infection.The caregivers of the two patients denied ingestion of a foreign body or any history of trauma.Physical examination combined with ultrasound or computed tomography scan established the diagnosis.Both of the patients underwent operation under general anesthesia.In case 1,a jujube pit with sharp ends was discovered embedded within a subcutaneous fistula.The jujube pit was then removed intact along with fistula resection.The wound was successfully laid open to allow healing by secondary intention.In case 2,a jujube pit was found with its sharp end puncturing the rectum,surrounded by pus and necrotic tissue.Subsequent incision and adequate drainage were performed.The whole jujube pit was then removed from the abscess cavity at the same time.Both patients received colonoscopy to rule out inflammatory bowel disease or other potential damages by the ingested jujube pit.The postoperative period was uneventful.At 1.5 year follow-up,no recurrent abscess or fistula were found in either patient.CONCLUSION An impacted foreign body must not be overlooked as an unusual cause of perianal abscess and fistula,especially in young children.展开更多
BACKGROUND Perianal fistulas pose dual challenges to Crohn's disease(CD)patients.Low patient compliance due to the complexity of existing examination methods plagues the treatment and follow-up management of peria...BACKGROUND Perianal fistulas pose dual challenges to Crohn's disease(CD)patients.Low patient compliance due to the complexity of existing examination methods plagues the treatment and follow-up management of perianal CD.AIM To determine the accuracy of endoanal ultrasound(EUS)and shear wave elastography(SWE)for evaluating perianal fistulizing CD(PFCD)activity.METHODS This was a retrospective cohort study.A total of 67 patients from August 2022 to December 2023 diagnosed with CD were divided into three groups:Non-anal fistula group(n=23),low-activity perianal fistulas[n=19,perianal disease activity index(PDAI)≤4],high-activity perianal fistulas(n=25,PDAI>4)based on the PDAI.All patients underwent assessments including EUS+SWE,pelvic magnetic resonance[pelvic magnetic resonance imaging(MRI)],C-reactive protein,fecal calprotectin,CD activity index,PDAI.RESULTS The percentage of fistulas indicated by pelvic MRI and EUS was consistent at 82%,and there was good consistency in the classification of perianal fistulas(Kappa=0.752,P<0.001).Significant differences were observed in the blood flow Limberg score(χ^(2)=8.903,P<0.05)and shear wave velocity(t=2.467,P<0.05)between group 2 and 3.Shear wave velocity showed a strong negative correlation with magnetic resonance novel index for fistula imaging in CD(Magnifi-CD)score(r=-0.676,P<0.001),a weak negative correlation with the PDAI score(r=-0.386,P<0.05),and a weak correlation between the Limberg score and the PDAI score(r=0.368,P<0.05).CONCLUSION EUS combined with SWE offers a superior method for detecting and quantitating the activity of perianal fistulas in CD patients.It may be the ideal tool to assess PFCD activity objectively for management strategies.展开更多
BACKGROUND Tailgut cyst is a congenital enterogenous cyst that rarely undergoes malignant transformation.Its clinical manifestations mainly correlate to the mass effect caused by the development of cysts and the infec...BACKGROUND Tailgut cyst is a congenital enterogenous cyst that rarely undergoes malignant transformation.Its clinical manifestations mainly correlate to the mass effect caused by the development of cysts and the infections that originate from these.Furthermore,the complete resection of this cyst is curative.We report our diagnostic and treatment experience with one case of malignant transformation of a perianal tailgut cyst,which was initially misdiagnosed as perianal abscess.CASE SUMMARY A 72-year-old woman visited our institution with complaints of a refractory nonhealing lesion on the right hip,which repeatedly broke and suppurated for more than 70 years,and aggravated in 4 mo.The patient was given a diagnosis of refractory perianal abscess with repeated incision and drainage procedures.Computed tomography of the pelvic cavity revealed a giant perianal cyst.Subsequent biopsy revealed a tumor with moderate-to-severe glandular epithelial dysplasia,and suggested that this was derived from the developmental cysts in the posterior rectal space.After further clarifying the nature and extent of the tumor by magnetic resonance imaging,total cystic resection was performed.Postoperative histopathological examination confirmed the malignancy,dictating the investigators to add postoperative chemotherapy to the treatment regimen.CONCLUSION The malignant transformation of perianal tailgut cysts is very uncommon,and this should be differentiated from perianal abscess.Complete surgical removal is curative,and postoperative pathology may determine the necessity of additional postoperative chemotherapy or radiotherapy,which may be beneficial for preventing local recurrence and metastasis.展开更多
Despite advancements in medical therapy of Crohn's disease(CD), majority of patients with CD will eventually require surgical intervention, with at least a third of patients requiring multiple surgeries. It is imp...Despite advancements in medical therapy of Crohn's disease(CD), majority of patients with CD will eventually require surgical intervention, with at least a third of patients requiring multiple surgeries. It is important to understand the role and timing of surgery, with the goals of therapy to reduce the need for surgery without increasing the odds of emergency surgery and its associated morbidity, as well as to limit surgical recurrence and avoid intestinal failure. The profile of CD patients requiring surgical intervention has changed over the decades with improvements in medical therapy with immunomodulators and biological agents. The most common indication for surgery is obstruction from stricturing disease, followed by abscesses and fistulae. The risk of gastrointestinal bleeding in CD is high but the likelihood of needing surgery for bleeding is low. Most major gastrointestinal bleeding episodes resolve spontaneously, albeit the risk of re-bleeding is high. The risk of colorectal cancer associated with CD is low. While current surgical guidelines recommend a total proctocolectomy for colorectal cancer associated with CD, subtotal colectomy or segmental colectomy with endoscopic surveillance may be a reasonable option. Approximately 20%-40% of CD patients will need perianal surgery during their lifetime. This review assesses the practice parameters and guidelines in the surgical management of CD, with a focus on the indications for surgery in CD(and when not to operate), and a critical evaluation of the timing and surgical options available to improve outcomes and reduce recurrence rates.展开更多
AIM To systematically review the literature on epidemiology,disease burden, and treatment outcomes for Crohn's disease(CD) patients with complex perianal fistulas.METHODS PubMed, Embase, and Cochrane were searched...AIM To systematically review the literature on epidemiology,disease burden, and treatment outcomes for Crohn's disease(CD) patients with complex perianal fistulas.METHODS PubMed, Embase, and Cochrane were searched for relevant articles(published 2000-November 2016) and congress abstracts(published 2011-November 2016).RESULTS Of 535 records reviewed, 62 relevant sources were identified(mostly small observational studies). The cumulative incidence of complex perianal fistulas in CD from two referral-centre studies was 12%-14%(follow-up time, 12 years in one study; not reported in the second study). Complex perianal fistulas result in greatly diminished quality of life; up to 59% of patients are at risk of faecal incontinence. Treatments include combinations of medical and surgical interventions and expanded allogeneic adipose-derived stem cells. High proportions of patients experience lack of or inadequate response to treatment(failure and relapse rates,respectively: medical, 12%-73% and 0%-41%; surgical:0%-100% and 11%.20%; combined medical/surgical:0%-80% and 0%-50%; stem cells: 29%-47% and not reported). Few studies(1 of infliximab; 3 of surgical interventions)have been conducted in treatment-refractory patients, a population with high unmet needs. Limited data exist on the clinical value of anti-tumour necrosis factor-α dose escalation in patients with complex perianal fistulas in CD.CONCLUSION Complex perianal fistulas in CD pose substantial clinical and humanistic burden. There is a need for effective treatments, especially for patients refractory to antitumour necrosis factor-α agents, as evidenced by high failure and relapse rates.展开更多
Perianal disease is one of the most disabling manifestations of Crohn's disease.A multidisciplinary approach of gastroenterologist,colorectal surgeon and radiologist is necessary for its management.A correct diagn...Perianal disease is one of the most disabling manifestations of Crohn's disease.A multidisciplinary approach of gastroenterologist,colorectal surgeon and radiologist is necessary for its management.A correct diagnosis,based on endoscopy,magnetic resonance imaging,endoanal ultrasound and examination under anesthesia,is crucial for perianal fistula treatment.Available medical and surgical therapies are discussedin this review,including new local treatment modalities that are under investigation.展开更多
AIM:To analyze clinical and pathological characteristics of an aggressive subtype of perianal Paget's disease(PPD) and explore its rational treatment modalities.METHODS:PPD patients were retrospectively collected ...AIM:To analyze clinical and pathological characteristics of an aggressive subtype of perianal Paget's disease(PPD) and explore its rational treatment modalities.METHODS:PPD patients were retrospectively collected in the institutional colorectal database of the Fudan University Shanghai Cancer Center.Detailed patient histories of past medical condition,diagnosis,treatment,and pathological findings were reviewed.Surgical specimen from diagnosis and surgery were reviewed by two independent pathologists for confirmation of diagnoses.Follow up was accomplished by clinical interview by cellphone.RESULTS:In total,eight cases of PPD were analyzed.All patients had underlying anorectal adenocarcinoma,including seven with synchronous lesions and one with metachronous lesions.Moreover,all anorectal lesions had a mucin-producing component.The median age at diagnosis was 65(range 29-81 years),and the male/female ratio was 7:1.The Median follow-up time of all patients was 61.5 mo(range 10-204 mo).One patient treated with abdominoperineal resection(APR) died from lung metastases 10 mo after the APR operation.The other patients are still free of disease at the time of this analysis.CONCLUSION:PPD is a rare malignancy and is easily misdiagnosed.Underlying anorectal cancer was not unusual and was a significant prognostic factor.Rational treatment of both anorectal cancer and PPD lesion is essential for long-term survival.展开更多
AIM:To investigate the role of capsule endoscopy in patients with persistent perianal disease and negative conventional work up for Crohn's disease(CD).METHODS:Patients with perianal disease(abscesses,fistulas,rec...AIM:To investigate the role of capsule endoscopy in patients with persistent perianal disease and negative conventional work up for Crohn's disease(CD).METHODS:Patients with perianal disease(abscesses,fistulas,recurrent fissures) were evaluated for underlying CD.Patients who had a negative work up,defined as a negative colonoscopy with a normal ileoscopy or a normal small bowel series or a normal CT/MR enterography,underwent a Pillcam study of the small bowel after signing informed consent.Patients using nonsteroidal anti-inflammatory drugs or who had a history of inflammatory bowel disease or rheumatic disease were excluded.RESULTS:We recruited 26 patients aged 21-61 years(average 35.6 years),17 males and 9 females.One case could not be evaluated since the capsule did not leave the stomach.In 6 of 25(24%) patients with a negative standard work up for Crohn's disease,capsuleendoscopy(CE) findings were consistent with Crohn's disease of the small bowel.Family history of CD,white blood cell,hemoglobin,erythrocyte sedimentation rate or C-reactive protein did not predict a diagnosis of CD.Capsule endoscopy findings led to a change in treatment.CONCLUSION:In patients with perianal disease and a negative conventional work up to exclude CD,CE leads to incremental diagnostic yield of 24%.展开更多
Perianal symptoms are common in patients with Crohn's disease and cause considerable morbidity. The etiology of these symptoms include skin tags, ulcers, fissures, abscesses, fistulas or stenoses. Fistula is the m...Perianal symptoms are common in patients with Crohn's disease and cause considerable morbidity. The etiology of these symptoms include skin tags, ulcers, fissures, abscesses, fistulas or stenoses. Fistula is the most common perianal manifestation. Multiple treatment options exist although very few are evidence-based. The phases of treatment include: drainage of infection, assessment of Crohn's disease status and fistula tracts, medical therapy, and selective operative management. The impact of biological therapy on perianal Crohn's disease is uncertain given that outcomes are conflicting. Operative treatment to eradicate the fistula tract can be attempted once infection has resolved and Crohn's disease activity is controlled. The operative approach should be tailored according to the anatomy of the fistula tract. Definitive treatment is challenging with medical and operative treatment rarely leading to true healing with frequent complications and recurrence. Treatment success must be weighed against the risk of complications, specially anal sphincter injury. A full understanding of the etiology and all potential therapeutic options is critical for success. Multidisciplinary management of fistulizing perianal Crohn's disease is crucial toimprove outcomes.展开更多
AIM:To evaluate accuracy of three-dimensional endoanal ultrasound(3D-EAUS)as compared to 2D-EAUS and physical examination(PE)in diagnosis of perianal fistulas and correlate with intraoperative findings.METHODS:A prosp...AIM:To evaluate accuracy of three-dimensional endoanal ultrasound(3D-EAUS)as compared to 2D-EAUS and physical examination(PE)in diagnosis of perianal fistulas and correlate with intraoperative findings.METHODS:A prospective observational consecutive study was performed with patients included over a two years period.All patients were studied and operated on by the Colorectal Unit surgeons.The inclusion criteria were patients over 18,diagnosed with a criptoglandular perianal fistula.The PE,2D-EAUS and 3D-EAUS was performed preoperatively by the same colorectal surgeon at the outpatient clinic prior to surgery and the fistula anatomy was defined and they were classified in intersphincteric,high or low transsphincteric,suprasphincteric and extrasphincteric.Special attention was paid to the presence of a secondary tract,the location of the internal opening(IO)and the site of external opening.The results of these different examinations were compared to the intraoperative findings.Data regarding location of the IO,primary tract,secondary tract,and the presence of abscesses or cavities wasanalysed.RESULTS:Seventy patients with a mean age of 47years(range 21-77),51 male were included.Low transsphincteric fistulas were the most frequent type found(33,47.1%)followed by high transsphincteric(24,34.3%)and intersphincteric fistulas(13,18.6%).There are no significant differences between the number of IO diagnosed by the different techniques employed and surgery(P>0.05)and,there is a good concordance between intraoperative findings and the 2D-EAUS(k=0.67)and 3D-EAUS(k=0.75)for the diagnosis of the primary tract.The ROC curves for the diagnosis of transsphincteric fistulas show that both ultrasound techniques are adequate for the diagnosis of low transsphincteric fistulas,3D-EAUS is superior for the diagnosis of high transsphincteric fistulas and PE is weak for the diagnosis of both types.CONCLUSION:3D-EAUS shows a higher accuracy than 2D-EAUS for assessing height of primary tract in transsphincteric fistulas.Both techniques show a good concordance with intraoperative finding for diagnosis of primary tracts.展开更多
Complex perianal fistulas have a negative impact on the quality of life of sufferers and should be treated.Correct diagnosis,characterization and classification of the fistulas are essential to optimize treatment.Neve...Complex perianal fistulas have a negative impact on the quality of life of sufferers and should be treated.Correct diagnosis,characterization and classification of the fistulas are essential to optimize treatment.Nevertheless, in the case of patients whose fistulas are associated with Crohn's disease,complete closure is particularly difficult to achieve.Systemic medical treatments(antibiotics, thiopurines and other immunomodulatory agents,and, more recently,anti-tumor necrosis factor-αagents such as infliximab)have been tried with varying degrees of success.Combined medical(including infliximab)and less aggressive surgical therapy(drainage and seton placement)offer the best outcomes in complex Crohn's fistulas while more aggressive surgical procedures such as fistulotomy or fistulectomy may increase the risk of incontinence.This review will focus on emerging novel treatments for perianal disease in Crohn's patients. These include locally applied infliximab or tacrolimus, fistula plugs,instillation of fibrin glue and the use of adult expanded adipose-derived stem cell injection.More welldesigned controlled studies are required to confirm the effectiveness of these emerging treatments.展开更多
文摘This article examines the complex relationship between disease perception,negative emotions,and their impact on postoperative recovery in patients with perianal diseases.These conditions not only cause physical discomfort,but also carry a significant emotional burden,often exacerbated by social stigma.Psycho-logical factors,including stress,anxiety,and depression,activate neuroendocrine pathways,such as the hypothalamic–pituitary–adrenal axis,disrupting the gut microbiota and leading to dysbiosis.This disruption can delay wound healing,prolong hospital stay,and intensify pain.Drawing on the findings of Hou et al,our article highlights the critical role of illness perception and negative emotions in shaping recovery outcomes.It advocates for a holistic approach that integrates psychological support and gut microbiota modulation,to enhance healing and improve overall patient outcomes.
文摘Perianal fistulising Crohn’s disease is a challenging complication that can affect up to 20%of patients with Crohn’s disease and is associated with significant morbidity.Despite advances in medical therapies,particularly anti-tumor necrosis factor agents,the majority of patients still require surgical intervention.Accurate diagnosis and monitoring are essential to optimise outcomes and guide multidisciplinary management.Although clinical scoring systems such as the perianal disease activity index are widely used,their subjective application limits their reproducibility and reliability,underscoring the need for more objective methods of evaluating perianal fistulising Crohn’s disease activity.Imaging has thus become central to the objective assessment of perianal fistulising Crohn’s disease,with magnetic resonance imaging(MRI)recognised as the gold standard in view of its ability to provide clear,detailed images of the perianal region in a radiation-free manner.Guidelines also endorse the use of imaging modalities such as endoanal ultrasound and transperineal ultrasound as viable alternatives to MRI for the assessment of perianal fistulising Crohn’s disease in centres with appropriate expertise.This article aims to evaluate and compare the diagnostic accuracy and clinical utility of MRI,endoanal ultrasound,and transperineal ultrasound in the assessment of perianal fistulising Crohn’s disease,highlighting their respective strengths,limitations,and roles in clinical practice.
基金Supported by National Research Foundation of Korea,No.NRF-2021S1A5A8062526.
文摘This article provides a comprehensive analysis of the study by Hou et al,focusing on the complex interplay between psychological and physical factors in the postoperative recovery(POR)of patients with perianal diseases.The study sheds light on how illness perception,anxiety,and depression significantly influence recovery outcomes.Hou et al developed a predictive model that demonstrated high accuracy in identifying patients at risk of poor recovery.The article explores the critical role of pre-operative psychological assessment,highlighting the need for mental health support and personalized recovery plans in enhancing POR quality.A multidisciplinary approach,integrating mental health professionals with surgeons,anesthesiologists,and other specialists,is emphasized to ensure comprehensive care for patients.The study’s findings serve as a call to integrate psychological care into surgical practice to optimize outcomes for patients with perianal diseases.
文摘BACKGROUND Both the etiology and treatment of perianal fistulas present challenges,and there is no standard surgical approach.AIM To present the results of a modified fistulotomy technique that was implemented in a tertiary coloproctology reference center.METHODS Seventy-two patients who underwent surgical intervention for perianal fistula between August 2019 and January 2023 were treated using a modified fistulotomy technique.In this approach,the fistula tract was excised from the external opening up to the external sphincter fibers.The internal orifice was widened,and the septic focus within the inter sphincteric space was curetted.Partial internal sphincterotomy was performed up to the inter sphincteric plane.The anoderm from the internal orifice to the inter sphincteric space was closed with absorbable suture material,and a loose seton was placed at the level of the external sphincter.RESULTS The 72 patients who underwent modified fistulotomy were 77.8%male and 22.2%female,with a mean age of 42.2±11.5 years.The median follow-up period was 19 months.Preoperatively,93.1%of patients had high trans sphincteric fistulas,and 6.9%were females with anterior low trans sphincteric fistulas.In all cases,setons were placed during surgery using vascular tape.A total of 12.5%of patients experienced incontinence,involving gas(6.9%)or soiling(5.6%).There were no reports of solid or liquid incontinences.Complete healing was achieved in 83.3%of the patients,with a recurrence rate of 4.2%and a non-healing rate of 12.5%.CONCLUSION Our preliminary analysis suggests that this modified fistulotomy technique that targets distalization of the internal orifice is a promising alternative management strategy for perianal fistulas.
基金Supported by Shenzhen Guangming District Health System Scientific Research Project(2020R01120).
文摘[Objectives]To investigate the use of the classical Chinese medicine formula Sihu Powder modified decoction for postoperative fumigation and sitz bath in patients with perianal abscess,aiming to promote wound healing and reduce medical burden.[Methods]An observational cohort study was conducted,selecting 200 patients with perianal abscess who underwent surgery in Shenzhen Guangming District People's Hospital.They were randomly divided into a treatment group and an observation group,with 100 cases in each group.Both groups followed the same surgical and antibiotic treatment principles.Starting from the first postoperative day,the treatment group received fumigation and sitz bath with modified Sihu Powder for decoction twice daily;the observation group used Compound Huangbai Liquid for fumigation and sitz bath twice daily.Indicators including pain score,wound secretion score,wound granulation tissue growth score,multidrug-resistant bacterial infection clearance rate,antibiotic usage days,and wound healing rate were observed in both groups 7,14 and 21 d after operation.[Results]On postoperative day 7,the differences in postoperative pain score,wound secretions,and multidrug-resistant bacterial clearance rate between the treatment group and the observation group were statistically significant.On postoperative day 14,the differences between the two groups were significant in indicators including pain score,wound secretions,wound granulation tissue growth,multidrug-resistant bacterial clearance rate,and wound healing rate.On postoperative day 21,the difference in wound healing rate between the two groups was significant;furthermore,the antibiotic usage days in the treatment group were significantly fewer than those in the observation group.[Conclusions]Modified Sihu Powder for fumigation and washing can effectively alleviate postoperative pain in perianal abscess patients,inhibit the colonization and infection of multidrug-resistant bacteria at the wound site,accelerate wound healing,reduce antibiotic usage intensity and medical burden.It possesses advantages such as being economical,effective,safe,and easy to operate,making it worthy of clinical promotion.
文摘Perianal fistulizing Crohn’s disease(PFCD)is a common presentation of CD,which affects the patients’quality of life,including social and sexual function.The management of PFCD remains a critical challenge in inflammatory bowel disease,primarily due to limited understanding of the mechanisms involved in its pathogenesis,complicating medical treatment.Increased production of inflammatory cytokines such as tumor necrosis factor and interleukin-13 by infiltrating macrophages and other inflammatory cells stimulate the epithelial-to-mesenchymal transition,resulting in activation of myofibroblasts and elevation of matrix metalloproteinases,leading to fistula formation.Given the potential for malignant transformation,PFCD screening is critical.Cytokine and inflammationtargeted therapies can help control this disease,but recurrence is a common complication.Surgical interventions such as fistulotomy represent viable therapeutic options,with magnetic resonance imaging serving as an important diagnostic tool for delineating fistula tract anatomy.Animal models and clinical trials demonstrate that injection of mesenchymal stem cells(MSCs)into the fistula results in suppression of the inflammatory cells and cytokines and complete resolution of PFCD.Recently,MSC-derived extracellular vesicles were found to stimulate fistula healing,with encouraging results.In this article,we comment on the review article by Pacheco et al,summarizing the various lines of PFCD treatment and highlighting the role of screening for this disease.Importantly,we focus on the various mechanisms involved in the pathogenesis of PFCD,the therapeutic roles of MSCs and related extracellular vesicles,and explore the potential role of autophagy in enhancing the therapeutic efficacy of these cells,which may help in the treatment of this disease.
基金Supported by Takeda Pharmaceuticals USA,Inc.Medical writing support was provided by Luke Humphreys,PhD,of Oxford PharmaGenesis,Oxford,UK and was funded by Takeda Development Center Americas,Inc.
文摘BACKGROUND Data regarding complex Crohn’s perianal fistulas(CPF)epidemiology are limited,and optimal treatment strategies are elusive.An improved understanding of how CPF treatment options are used in the real-world setting and factors associated with CPF development,treatment failure,and reasons for undergoing multiple surgeries may help to inform optimal patient management strategies,reduce treatment burden,and improve outcomes in patients with CPF.AIM To describe the epidemiology,treatments,outcomes,and associated risk/protective factors for complex CPF.METHODS Electronic databases(MEDLINE,EMBASE,EBM Reviews,EconLit)were searched.Two reviewers independently used populations,interventions,comparators,outcomes,study designs,and time criteria to identify relevant studies.Observational studies published in English from January 1,2015 to February 17,2022 with>50 patients were included,even if complex CPF was not defined.Items of interest included complex CPF definitions,epidemiology,treatment patterns,morbidity,mortality,and risk factors associated with complex CPF development,treatment failure,and undergoing multiple surgeries.Data were reported using descriptive statistics.RESULTS Overall,140 studies were included.Complex CPF definitions were heterogeneous and rarely reported(24 studies).Hence,data mostly related to CPF in general.CPF prevalence was variable(range:1.5%-81.0%).Incidence was wide-ranging and mostly reported cumulatively at 1-year post-Crohn’s disease diagnosis(range:3.5%-50.1%).Overall healing and failure rates after treatment were in the range of 10.5%-80.2%and 3.6%-83.0%,respectively.Abscesses were the most frequently reported morbidity(n=18).No CPF-related deaths were reported.No consistent risk or protective factors were identified.CONCLUSION Epidemiology,treatment patterns,and risk factors for CPF vary,likely due to inconsistent CPF and clinical outcome definitions.Standardization would facilitate comparability,which may inform optimal complex CPF treatment strategies.
文摘Perianal fistulizing Crohn’s disease(PFCD)is a complication of CD that signi-ficantly impacts patients’quality of life,particularly their social and sexual well-being.Despite advances in therapy,its treatment remains a major challenge in the field of inflammatory bowel disease.The pathogenesis of PFCD involves in-creased production of inflammatory cytokines by infiltrating macrophages and lymphocytes,stimulation of the epithelial-to-mesenchymal transition,activation of myofibroblasts,and elevated levels of matrix metalloproteinases.Mesenchymal stem cells(MSCs)are multipotent stromal cells with self-renewal and differen-tiation capabilities.Evidence from animal models and clinical trials indicates that MSC injection into PFCD lesions suppresses the infiltration of inflammatory cells and cytokines,resulting in complete fistula healing.More recently,MSC-derived extracellular vesicles(EVs)have shown promising results in promoting fistula healing,particularly in cases of refractory or relapsing fistulas.Notably,the activation of macroautophagy(hereafter referred to as autophagy)in MSCs has been shown to accelerate the healing process.This narrative review discusses the mechanisms underlying PFCD pathogenesis,the therapeutic roles of MSCs and their EVs,and the potential role of autophagy upregulation in enhancing MSC function and EV production.
基金Supported by Guangdong Provincial Medical Research Fund General Program,No.B2025209。
文摘BACKGROUND Anal canal adenocarcinoma with secondary perianal Paget’s disease(PPD)is clinically rare and exhibits atypical symptoms,often misdiagnosed as benign conditions such as hemorrhoids or perianal eczema,leading to delayed treatment.Further summarization of diagnostic and therapeutic key points,as well as reasons for misdiagnosis,is necessary to enhance clinical awareness.CASE SUMMARY A retrospective analysis was conducted on a 72-year-old female patient with a 2-year history of perianal moisture,pruritus,and hematochezia,who was repeatedly misdiagnosed with mixed hemorrhoids.The diagnosis of anal canal adenocarcinoma with secondary PPD was confirmed through colonoscopy,perianal skin biopsy,and immunohistochemical staining(CK7,CK20,etc.).The patient underwent 3D laparoscopic-assisted abdominoperineal resection(APR)with extended perianal skin excision,achieving negative margins and primary wound healing.No recurrence or metastasis was observed during the 12-month follow-up.CONCLUSION Secondary PPD has a high misdiagnosis rate.Clinicians should maintain a high index of suspicion for elderly patients with prolonged perianal symptoms(e.g.,pruritus,hematochezia>6 months)and promptly perform colonoscopy and immunohistochemical testing for definitive diagnosis.APR combined with extended perianal resection is an effective treatment,and standardized long-term follow-up is crucial for prognosis.
文摘BACKGROUND About 90%of perianal infection is caused by cryptoglandular infection.Only a few cases of peritonitis or intra-abdominal abscesses secondary to perforation of the digestive tract by an ingested foreign body have been reported.The most common sites of impaction and perforation include the appendix,cecum and the terminal ileum.The rectum is an unusual site of foreign body impaction.This report intends to highlight that ingested foreign body impacted in the rectum is an extremely rare cause of perianal abscess and subsequent fistula in infants.CASE SUMMARY Two cases of perianal abscess and fistula due to ingested jujube pit impacted in the rectum are reported.Both cases are infants with free previous medical history suffered from recurrent perianal infection.The caregivers of the two patients denied ingestion of a foreign body or any history of trauma.Physical examination combined with ultrasound or computed tomography scan established the diagnosis.Both of the patients underwent operation under general anesthesia.In case 1,a jujube pit with sharp ends was discovered embedded within a subcutaneous fistula.The jujube pit was then removed intact along with fistula resection.The wound was successfully laid open to allow healing by secondary intention.In case 2,a jujube pit was found with its sharp end puncturing the rectum,surrounded by pus and necrotic tissue.Subsequent incision and adequate drainage were performed.The whole jujube pit was then removed from the abscess cavity at the same time.Both patients received colonoscopy to rule out inflammatory bowel disease or other potential damages by the ingested jujube pit.The postoperative period was uneventful.At 1.5 year follow-up,no recurrent abscess or fistula were found in either patient.CONCLUSION An impacted foreign body must not be overlooked as an unusual cause of perianal abscess and fistula,especially in young children.
基金the Major Project of Department of Education of Anhui Province of China,No.2023AH040396.
文摘BACKGROUND Perianal fistulas pose dual challenges to Crohn's disease(CD)patients.Low patient compliance due to the complexity of existing examination methods plagues the treatment and follow-up management of perianal CD.AIM To determine the accuracy of endoanal ultrasound(EUS)and shear wave elastography(SWE)for evaluating perianal fistulizing CD(PFCD)activity.METHODS This was a retrospective cohort study.A total of 67 patients from August 2022 to December 2023 diagnosed with CD were divided into three groups:Non-anal fistula group(n=23),low-activity perianal fistulas[n=19,perianal disease activity index(PDAI)≤4],high-activity perianal fistulas(n=25,PDAI>4)based on the PDAI.All patients underwent assessments including EUS+SWE,pelvic magnetic resonance[pelvic magnetic resonance imaging(MRI)],C-reactive protein,fecal calprotectin,CD activity index,PDAI.RESULTS The percentage of fistulas indicated by pelvic MRI and EUS was consistent at 82%,and there was good consistency in the classification of perianal fistulas(Kappa=0.752,P<0.001).Significant differences were observed in the blood flow Limberg score(χ^(2)=8.903,P<0.05)and shear wave velocity(t=2.467,P<0.05)between group 2 and 3.Shear wave velocity showed a strong negative correlation with magnetic resonance novel index for fistula imaging in CD(Magnifi-CD)score(r=-0.676,P<0.001),a weak negative correlation with the PDAI score(r=-0.386,P<0.05),and a weak correlation between the Limberg score and the PDAI score(r=0.368,P<0.05).CONCLUSION EUS combined with SWE offers a superior method for detecting and quantitating the activity of perianal fistulas in CD patients.It may be the ideal tool to assess PFCD activity objectively for management strategies.
文摘BACKGROUND Tailgut cyst is a congenital enterogenous cyst that rarely undergoes malignant transformation.Its clinical manifestations mainly correlate to the mass effect caused by the development of cysts and the infections that originate from these.Furthermore,the complete resection of this cyst is curative.We report our diagnostic and treatment experience with one case of malignant transformation of a perianal tailgut cyst,which was initially misdiagnosed as perianal abscess.CASE SUMMARY A 72-year-old woman visited our institution with complaints of a refractory nonhealing lesion on the right hip,which repeatedly broke and suppurated for more than 70 years,and aggravated in 4 mo.The patient was given a diagnosis of refractory perianal abscess with repeated incision and drainage procedures.Computed tomography of the pelvic cavity revealed a giant perianal cyst.Subsequent biopsy revealed a tumor with moderate-to-severe glandular epithelial dysplasia,and suggested that this was derived from the developmental cysts in the posterior rectal space.After further clarifying the nature and extent of the tumor by magnetic resonance imaging,total cystic resection was performed.Postoperative histopathological examination confirmed the malignancy,dictating the investigators to add postoperative chemotherapy to the treatment regimen.CONCLUSION The malignant transformation of perianal tailgut cysts is very uncommon,and this should be differentiated from perianal abscess.Complete surgical removal is curative,and postoperative pathology may determine the necessity of additional postoperative chemotherapy or radiotherapy,which may be beneficial for preventing local recurrence and metastasis.
文摘Despite advancements in medical therapy of Crohn's disease(CD), majority of patients with CD will eventually require surgical intervention, with at least a third of patients requiring multiple surgeries. It is important to understand the role and timing of surgery, with the goals of therapy to reduce the need for surgery without increasing the odds of emergency surgery and its associated morbidity, as well as to limit surgical recurrence and avoid intestinal failure. The profile of CD patients requiring surgical intervention has changed over the decades with improvements in medical therapy with immunomodulators and biological agents. The most common indication for surgery is obstruction from stricturing disease, followed by abscesses and fistulae. The risk of gastrointestinal bleeding in CD is high but the likelihood of needing surgery for bleeding is low. Most major gastrointestinal bleeding episodes resolve spontaneously, albeit the risk of re-bleeding is high. The risk of colorectal cancer associated with CD is low. While current surgical guidelines recommend a total proctocolectomy for colorectal cancer associated with CD, subtotal colectomy or segmental colectomy with endoscopic surveillance may be a reasonable option. Approximately 20%-40% of CD patients will need perianal surgery during their lifetime. This review assesses the practice parameters and guidelines in the surgical management of CD, with a focus on the indications for surgery in CD(and when not to operate), and a critical evaluation of the timing and surgical options available to improve outcomes and reduce recurrence rates.
基金Kate Lothman of RTI Health Solutions provided medical writing services,which were funded by Takeda
文摘AIM To systematically review the literature on epidemiology,disease burden, and treatment outcomes for Crohn's disease(CD) patients with complex perianal fistulas.METHODS PubMed, Embase, and Cochrane were searched for relevant articles(published 2000-November 2016) and congress abstracts(published 2011-November 2016).RESULTS Of 535 records reviewed, 62 relevant sources were identified(mostly small observational studies). The cumulative incidence of complex perianal fistulas in CD from two referral-centre studies was 12%-14%(follow-up time, 12 years in one study; not reported in the second study). Complex perianal fistulas result in greatly diminished quality of life; up to 59% of patients are at risk of faecal incontinence. Treatments include combinations of medical and surgical interventions and expanded allogeneic adipose-derived stem cells. High proportions of patients experience lack of or inadequate response to treatment(failure and relapse rates,respectively: medical, 12%-73% and 0%-41%; surgical:0%-100% and 11%.20%; combined medical/surgical:0%-80% and 0%-50%; stem cells: 29%-47% and not reported). Few studies(1 of infliximab; 3 of surgical interventions)have been conducted in treatment-refractory patients, a population with high unmet needs. Limited data exist on the clinical value of anti-tumour necrosis factor-α dose escalation in patients with complex perianal fistulas in CD.CONCLUSION Complex perianal fistulas in CD pose substantial clinical and humanistic burden. There is a need for effective treatments, especially for patients refractory to antitumour necrosis factor-α agents, as evidenced by high failure and relapse rates.
文摘Perianal disease is one of the most disabling manifestations of Crohn's disease.A multidisciplinary approach of gastroenterologist,colorectal surgeon and radiologist is necessary for its management.A correct diagnosis,based on endoscopy,magnetic resonance imaging,endoanal ultrasound and examination under anesthesia,is crucial for perianal fistula treatment.Available medical and surgical therapies are discussedin this review,including new local treatment modalities that are under investigation.
基金Supported by Key Project of Science and technology commission of Shanghai Municipality, Shanghai, China, No 07DZ19505
文摘AIM:To analyze clinical and pathological characteristics of an aggressive subtype of perianal Paget's disease(PPD) and explore its rational treatment modalities.METHODS:PPD patients were retrospectively collected in the institutional colorectal database of the Fudan University Shanghai Cancer Center.Detailed patient histories of past medical condition,diagnosis,treatment,and pathological findings were reviewed.Surgical specimen from diagnosis and surgery were reviewed by two independent pathologists for confirmation of diagnoses.Follow up was accomplished by clinical interview by cellphone.RESULTS:In total,eight cases of PPD were analyzed.All patients had underlying anorectal adenocarcinoma,including seven with synchronous lesions and one with metachronous lesions.Moreover,all anorectal lesions had a mucin-producing component.The median age at diagnosis was 65(range 29-81 years),and the male/female ratio was 7:1.The Median follow-up time of all patients was 61.5 mo(range 10-204 mo).One patient treated with abdominoperineal resection(APR) died from lung metastases 10 mo after the APR operation.The other patients are still free of disease at the time of this analysis.CONCLUSION:PPD is a rare malignancy and is easily misdiagnosed.Underlying anorectal cancer was not unusual and was a significant prognostic factor.Rational treatment of both anorectal cancer and PPD lesion is essential for long-term survival.
文摘AIM:To investigate the role of capsule endoscopy in patients with persistent perianal disease and negative conventional work up for Crohn's disease(CD).METHODS:Patients with perianal disease(abscesses,fistulas,recurrent fissures) were evaluated for underlying CD.Patients who had a negative work up,defined as a negative colonoscopy with a normal ileoscopy or a normal small bowel series or a normal CT/MR enterography,underwent a Pillcam study of the small bowel after signing informed consent.Patients using nonsteroidal anti-inflammatory drugs or who had a history of inflammatory bowel disease or rheumatic disease were excluded.RESULTS:We recruited 26 patients aged 21-61 years(average 35.6 years),17 males and 9 females.One case could not be evaluated since the capsule did not leave the stomach.In 6 of 25(24%) patients with a negative standard work up for Crohn's disease,capsuleendoscopy(CE) findings were consistent with Crohn's disease of the small bowel.Family history of CD,white blood cell,hemoglobin,erythrocyte sedimentation rate or C-reactive protein did not predict a diagnosis of CD.Capsule endoscopy findings led to a change in treatment.CONCLUSION:In patients with perianal disease and a negative conventional work up to exclude CD,CE leads to incremental diagnostic yield of 24%.
文摘Perianal symptoms are common in patients with Crohn's disease and cause considerable morbidity. The etiology of these symptoms include skin tags, ulcers, fissures, abscesses, fistulas or stenoses. Fistula is the most common perianal manifestation. Multiple treatment options exist although very few are evidence-based. The phases of treatment include: drainage of infection, assessment of Crohn's disease status and fistula tracts, medical therapy, and selective operative management. The impact of biological therapy on perianal Crohn's disease is uncertain given that outcomes are conflicting. Operative treatment to eradicate the fistula tract can be attempted once infection has resolved and Crohn's disease activity is controlled. The operative approach should be tailored according to the anatomy of the fistula tract. Definitive treatment is challenging with medical and operative treatment rarely leading to true healing with frequent complications and recurrence. Treatment success must be weighed against the risk of complications, specially anal sphincter injury. A full understanding of the etiology and all potential therapeutic options is critical for success. Multidisciplinary management of fistulizing perianal Crohn's disease is crucial toimprove outcomes.
文摘AIM:To evaluate accuracy of three-dimensional endoanal ultrasound(3D-EAUS)as compared to 2D-EAUS and physical examination(PE)in diagnosis of perianal fistulas and correlate with intraoperative findings.METHODS:A prospective observational consecutive study was performed with patients included over a two years period.All patients were studied and operated on by the Colorectal Unit surgeons.The inclusion criteria were patients over 18,diagnosed with a criptoglandular perianal fistula.The PE,2D-EAUS and 3D-EAUS was performed preoperatively by the same colorectal surgeon at the outpatient clinic prior to surgery and the fistula anatomy was defined and they were classified in intersphincteric,high or low transsphincteric,suprasphincteric and extrasphincteric.Special attention was paid to the presence of a secondary tract,the location of the internal opening(IO)and the site of external opening.The results of these different examinations were compared to the intraoperative findings.Data regarding location of the IO,primary tract,secondary tract,and the presence of abscesses or cavities wasanalysed.RESULTS:Seventy patients with a mean age of 47years(range 21-77),51 male were included.Low transsphincteric fistulas were the most frequent type found(33,47.1%)followed by high transsphincteric(24,34.3%)and intersphincteric fistulas(13,18.6%).There are no significant differences between the number of IO diagnosed by the different techniques employed and surgery(P>0.05)and,there is a good concordance between intraoperative findings and the 2D-EAUS(k=0.67)and 3D-EAUS(k=0.75)for the diagnosis of the primary tract.The ROC curves for the diagnosis of transsphincteric fistulas show that both ultrasound techniques are adequate for the diagnosis of low transsphincteric fistulas,3D-EAUS is superior for the diagnosis of high transsphincteric fistulas and PE is weak for the diagnosis of both types.CONCLUSION:3D-EAUS shows a higher accuracy than 2D-EAUS for assessing height of primary tract in transsphincteric fistulas.Both techniques show a good concordance with intraoperative finding for diagnosis of primary tracts.
文摘Complex perianal fistulas have a negative impact on the quality of life of sufferers and should be treated.Correct diagnosis,characterization and classification of the fistulas are essential to optimize treatment.Nevertheless, in the case of patients whose fistulas are associated with Crohn's disease,complete closure is particularly difficult to achieve.Systemic medical treatments(antibiotics, thiopurines and other immunomodulatory agents,and, more recently,anti-tumor necrosis factor-αagents such as infliximab)have been tried with varying degrees of success.Combined medical(including infliximab)and less aggressive surgical therapy(drainage and seton placement)offer the best outcomes in complex Crohn's fistulas while more aggressive surgical procedures such as fistulotomy or fistulectomy may increase the risk of incontinence.This review will focus on emerging novel treatments for perianal disease in Crohn's patients. These include locally applied infliximab or tacrolimus, fistula plugs,instillation of fibrin glue and the use of adult expanded adipose-derived stem cell injection.More welldesigned controlled studies are required to confirm the effectiveness of these emerging treatments.
