Perianal Fistulas Are Associated with Persistently Higher Direct Health Care Costs in Crohn's Disease: A Population-Based Study.

BACKGROUND: The economic impact of perianal fistulas in Crohn's disease (CD) has not been formally assessed in population-based studies in the biologic era. AIM: To compare direct health care costs in persons with and without perianal fistulas. METHODS: We performed a longitudinal population-based study using administrative data from Ontario, Canada. Adults (> 17 years) with CD were identified between 2007 and 2013 using validated algorithms. Perianal fistula positive "cases" were matched to up to 4 "controls" with CD without perianal fistulas based on age, sex, geographic region, year of CD diagnosis and duration of follow-up. Direct health care costs, excluding drug costs from private payers, were estimated annually beginning 5 years before (lookback) and up to 9 years after perianal fistula diagnosis (study completion) for cases and a standardized date for matched controls. RESULTS: A total of 581 cases were matched to 1902 controls. The annual per capita direct cost for cases was similar at lookback compared to controls ($2458 ± 6770 vs $2502 ± 10,752; p = 0.952), maximally greater in the first year after perianal fistulas diagnosis ($16,032 ± 21,101 vs $6646 ± 13,021; p < 0.001) and remained greater at study completion ($11,358 ± 17,151 vs $5178 ± 9792; p < 0.001). At perianal fistula diagnosis, the cost difference was driven primarily by home care cost (tenfold greater), publicly-covered prescription drugs (threefold greater) and hospitalizations (twofold greater), whereas at study completion, prescription drugs were the dominant driver (threefold greater). CONCLUSION: In our population-based cohort, perianal fistulas were associated with significantly higher direct healthcare costs at the time of perianal fistulas diagnosis and sustained long-term.

Health Care Costs and Resource Utilization Among Patients With Crohn's Disease With and Without Perianal Fistula.

BACKGROUND: Perianal fistula (PAF), a complication of Crohn's disease (CD), is associated with substantial economic costs and poor prognosis. We determined prevalence of PAF CD in the United States and compared costs and health care resource utilization (HRU) of PAF CD patients with matched non-PAF CD patients. METHODS: This was a retrospective cohort study of claims data from the IBM MarketScan Commercial Database from October 1, 2015, to September 30, 2018. Eligible patients were aged 18 to 89 years with ≥2 CD diagnoses. Patients with PAF CD had ≥1 PAF diagnosis or procedure code and were matched with non-PAF CD patients. Cumulative prevalence of PAF CD in the US population was calculated across total patients in MarketScan. All-cause and gastrointestinal (GI)-related costs and HRU were compared between groups using a generalized linear model (GLM). RESULTS: Cumulative 3-year prevalence of PAF was 7.70% of patients with CD (N = 81,862) and 0.01% of the US population. Among PAF CD (n = 1218) and matched non-PAF CD (n = 4095) patients, most all-cause costs and HRU were GI-related. Mean total all-cause and GI-related health care costs per patient and per year for PAF CD were $85,233 and $71,612, respectively, vs $40,526 and $29,458 for non-PAF CD (P < .0001). Among PAF CD vs non-PAF CD patients, GLM-adjusted proportions of patients with GI-related inpatient, outpatient, or pharmacy visits, mean GI-related inpatient length of stay, and mean GI-related surgeries were higher (P < .0001 for all comparisons). CONCLUSIONS: Costs and HRU are significantly higher for patients with PAF CD vs non-PAF CD patients, highlighting the economic burden of the disease.

Burden and outcomes for complex perianal fistulas in Crohn's disease: Systematic review.

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 anti-tumour necrosis factor-α agents, as evidenced by high failure and relapse rates.

Rectal injury during robot-assisted radical prostatectomy: incidence and management.

PURPOSE: Rectal injury during robot-assisted radical prostatectomy is a rare but significant complication. Since the Clavien grading classification of complications does not include intraoperative injury without further sequelae, rectal injury may be underreported in the literature. We present what is to our knowledge the largest retrospective review to date of rectal injury and subsequent management. MATERIALS AND METHODS: We reviewed the records of 6,650 patients who underwent robot-assisted radical prostatectomy at a total of 6 institutions. Patient characteristics, perioperative parameters, pathological findings and rectal injury management were tabulated and analyzed for intraoperative predictors of outcome and subsequent management. RESULTS: A total of 11 rectal injury cases were identified of the 6,650 robot-assisted radical prostatectomies for a combined 0.17% incidence of rectal injury. Of rectal injuries 72.7% were identified intraoperatively and most did well with primary closure. Delayed recognition injury presented as rectourethral fistula without septic complications and required delayed fistula repair after primary diversion. We found no conclusive association of rectal injury with any patient parameter, intraoperative differences, pathological finding or surgeon experience. Posterior prostate plane dissection, including seminal vesicle dissection, is the crucial stage when rectal injury can occur and be identified. CONCLUSIONS: Our review of the records at 6 centers revealed a combined 0.17% incidence of rectal injury. This compares favorably to the incidence in modern open and laparoscopic radical prostatectomy series. No preoperative, intraoperative or pathological differences correlated with injury. Cases in which rectal injury was identified intraoperatively required fewer surgical repeat interventions but ultimately each group had acceptable long-term urinary and bowel function results.

Incidence, clinical symptoms and management of rectourethral fistulas after radical prostatectomy.

PURPOSE: Rectourethral fistula is a rare but severe complication after radical prostatectomy and there is no standardized treatment. We retrospectively evaluated the incidence, symptoms and management of rectourethral fistulas based on our experience. MATERIALS AND METHODS: From 1999 to 2008 we performed 2,447 radical prostatectomies. Patients in whom postoperative rectourethral fistulas developed were identified. Based on the therapeutic approach patients were categorized into group 1-conservative treatment, group 2-colostomy with or without surgical closure and group 3-immediate surgical closure without colostomy. RESULTS: Rectourethral fistulas developed in 13 of 2,447 patients (0.53%) after radical prostatectomy. The risk of rectourethral fistulas was 3.06-fold higher (p = 0.074) for perineal (7 of 675, 1.04%) than for retropubic prostatectomy (6 of 1,772, 0.34%). In 7 of 13 patients (54%) a rectal lesion was primarily closed at radical prostatectomy. Median followup was 59 months. In all patients in group 1 (3) the fistula closed spontaneously with conservative treatment. None of these patients had fecaluria. In group 2 of the 9 patients 3 (33%) experienced spontaneous fistula closure after temporary colostomy and transurethral catheterization. In this group 6 patients (67%) required additional surgical fistula closure, which was successful in all. Surgical fistula closure (1) without colostomy in presence of fecaluria failed (group 3). CONCLUSIONS: The therapeutic concept for rectourethral fistulas should be guided by clinical symptoms. Rectal injury during radical prostatectomy is a major risk factor. In cases with fecaluria colostomy is required for control of infection and may allow spontaneous fistula closure in approximately a third of cases. In the remainder of cases surgical fistula closure was successful in all after protective colostomy.

Persistent perineal sinus: incidence, pathogenesis, risk factors, and management.

This review discusses the incidence, pathogenesis, risk factors, diagnosis, and therapeutic options for persistent perineal sinus (PPS), defined as a perineal wound that remains unhealed more than 6 months after surgery. The incidence of PPS after surgery for inflammatory bowel disease (IBD) ranges from 3% to 70% and after abdominoperineal resection (APR) for low rectal cancer, it can be up to 30%. These unhealed wounds are frequently related to perioperative pelvic or perineal sepsis. Crohn's disease (CD) and neoadjuvant radiation therapy are also important risk factors. The management of PPS is based on an understanding of pathogenesis and clinical grounds. The advantages and disadvantages of the current therapeutic approaches, including the topical administration of various drugs, vacuum-assisted closure, and perineal reconstruction with a muscle flap or a myocutaneous flap are also discussed.

Colonic motility and functional assessment of the patients with anorectal malformations according to Krickenbeck consensus.

BACKGROUND/PURPOSE: In this study, the patients operated on for anorectal malformations (ARM) were evaluated in terms of segmental (SCTT) and total colonic transit times (TCTT) and clinical status according to Krickenbeck consensus before and after treatments. METHODS: Forty-one patients with ARM (28 males/13 females) older than 3 years (median age, 7.7 years; range, 3-25) who had no therapy before were assessed for voluntary bowel movements (VBM), soiling (from 1 to 3), and constipation (from 1 to 3), retrospectively. Distribution of the patients were rectourethral fistula (17), perineal fistula (PF; 8), vestibular fistula (VF; 8), cloaca (3), rectovesical fistula (1), rectovaginal fistula (1), pouch colon with colovestibular fistula (1), no fistula (1), and unknown (1). The patients ingested daily 20 radiopaque markers for 3 days, followed by a single abdominal x-ray on days 4 and 7 if needed. The results were compared with the reference values in the literature. RESULTS: Mean follow-up period was 36 months (range, 1-108.5 months). All patients but 1 had soiling in different degrees. Twenty-one patients who had VBM were divided into group 1, with constipation (n = 9), and group 2, without constipation (n = 12). The other 19 patients who had no VBM were divided into group 3, with constipation (n = 14), and group 4, without constipation (n = 5). The longest TCTT and rectosigmoid SCTT were found in group 3 (69.5 and 35.2 hours, respectively). Group 1 had long SCTT in rectosigmoid but normal TCTT (27.8 and 47.4 hours, respectively). Groups 2 and 4 had normal SCTT and TCTT, and there was no significant difference between them. After the appropriate treatment, of the patients, 45% (18/40) had no soiling, and the soiling score decreased to grade 1 in 27.5% (11/40) and to grade 2 in 10% (4/40). Four had unchanged soiling score, and 3 were excluded from the study because of follow-up problems. Half of the patients in group 3 (4 VF, 2 rectourethral fistula, PF) gained VBM without soiling after laxative treatment. Only four of 23 patients had decreased constipation score (2 cloaca, PF, VF). CONCLUSIONS: In this study, ARM patients complaining of constipation with or without VBM had prolonged SCTT in the rectosigmoid region. Percentage of the improvement in soiling scores was more conspicuous than that of constipation scores. The dismal figure observed at the first examination in the assessment of VBM was not associated with an unfavorable improvement with laxative treatment. So, it is suggested that assessment of VBM initially may be deceptive for clinical status.

An assessment of the incidence of fistula-in-ano in four countries of the European Union.

BACKGROUND AND AIMS: In spite of its long history, fistula-in-ano is generally considered to be relatively uncommon. Nevertheless, no comprehensive analysis of its incidence in developed countries is available. Our goal was to determine the actual incidence of fistula-in-ano based on the study of incidence in four countries of the European Union (EU). MATERIALS AND METHODS: We performed a search of hospital inpatient databases in five different countries. We obtained valid data from four European countries, namely, England (UK; Hospital Episodes Statistics), Germany (German hospitals' databases), Italy (Scheda di Dimissione Ospedaliera), and Spain (Conjunto Mínimo Básico de Datos by Insalud-Spanish National Health Institute). RESULTS: The incidence of fistula-in-ano varied among the different populations in the EU. In the four countries examined, it ranged from 1.04 per 10,000/year in Spain to 2.32 per 10,000/year in Italy. A statistical comparison of rates from the different countries studied gives a confidence interval from 1.20 up to 2.80. The population that we studied represents almost 51% of the total population of the EU. CONCLUSION: This study attempts to determine the actual incidence of fistula-in-ano in the European Community, which was previously uncertain despite its major negative effects on quality of life and the high cost of treatment. Our findings indicate that the incidence of fistula-in-ano in the four countries of the EU studied is significantly higher than that in the only previously published report of the incidence of fistula-in-ano in Europe. Nevertheless, our findings confirm the general perception that fistula-in-ano is a relatively uncommon disease.

Factilidad, riesgo y conveniencia de la cirugía ambulatoria para la patología anorrectal / Factibility, risk and convenience of ambulatory surgery for anorectal pathology

Se analizan y discuten los resultados obtenidos mediante cirugía ambulatoria para el tratamiento de patología anorrectal. De un total de 230 casos tratados en forma electiva entre 1984 y 1989 se recuperaron 160 historias clínicas. En el 92%de los casos, se efectuó el tratamiento ambulatorio. Las complicaciones fueron menos del 2%, registrándose un solo caso(hemorroidectomía) en el que fue necesaria la internación y reintervención antes de las 24 horas. La mortalidad fue nula. No se registraron resultados adversos atinentes a la falta de internación. La aplicación de esta estrategia depende fundamentalmente de la convicción del grupo quirúrgico en cuanto a su utilidad, siempre que la patología y las condiciones propias del paciente lo permitan. Los resultados obtenidos, muestran que en nuestro medio, la cirugía anorrectal ambulatoria puede ser practicada con escaso riesgo y certifican su factibilidad y la convierten en una práctica aconsejable, demostrando su conveniencia frente a la finitud de los medios disponibles