Impact of Internal Anal Sphincter Division on Continence Disturbance in Female Patients.

BACKGROUND: Few studies measured the pre- and postoperative anatomic and functional anal canal using 3-dimensional endoanal ultrasound and anal manometry and correlated sphincter division with fecal incontinence, severity, and function. OBJECTIVE: To assess the incidence of fecal incontinence in patients who underwent internal anal sphincter division for anal fissure or intersphincteric anal fistula and correlate severity of symptoms with percentage of divided muscle, anatomical measurements, and anal pressures. DESIGN: Prospective cohort study. SETTINGS: Colorectal surgery unit, tertiary referral center. PATIENTS: Patients underwent clinical assessment using the Cleveland Clinic Florida Fecal Incontinence score for severity of symptoms, manometry, and ultrasound. MAIN OUTCOMES MEASURES: Ultrasound measurements of length, percentage, and angle of divided internal anal sphincter, anterior external anal sphincter, posterior external anal sphincter plus puborectalis, and gap lengths. RESULTS: Sixty-three women (mean age, 44 years) were divided into 2 groups: 30 (48%) underwent fistulotomy for intersphincteric anal fistula and 33 (52%) underwent sphincterotomy for chronic anal fissure with high anal resting pressure. Forty-six percent experienced some measure of fecal incontinence after internal anal sphincter division. Incidence of fecal incontinence, severity of symptoms, and angle of the divided internal anal sphincter were similar between the groups. Length and percentage of the divided internal anal sphincter were significantly higher in the intersphincteric anal fistula. External anal sphincter and external anal sphincter plus puborectalis lengths were similar in both groups. Gap length was significantly longer in chronic anal fissures with high anal resting pressure. LIMITATIONS: Single-institution, exclusion of males. CONCLUSIONS: Fecal incontinence was reported in half of the patients who underwent internal anal sphincter division. Despite the greater length and percentage of internal anal sphincter division in patients who underwent fistulotomy, incidence and severity of fecal incontinence were similar in both groups. Three-dimensional endoanal ultrasound showed greater gap length in the sphincterotomy group, which may be functionally significant after the division of the shorter internal anal sphincter but with a similar impact on fecal incontinence in both groups. IMPACTO DE LA DIVISIN DEL ESFNTER ANAL INTERNO EN LA ALTERACIN DE LA CONTINENCIA EN PACIENTES DE SEXO FEMENINO: ANTECEDENTES:Pocos estudios han medido el canal anal anatómico y funcional antes y después de la cirugía mediante ecografía endoanal tridimensional y manometría anal, y correlacionado la división del esfínter con la incontinencia fecal, la gravedad y la función.OBJETIVO:Evaluar la incidencia de incontinencia fecal en pacientes sometidos a división del esfínter anal interno por fisura anal o fístula anal interesfinteriana, y correlacionar la gravedad de los síntomas con el porcentaje de músculo dividido, las medidas anatómicas y las presiones anales.DISEÑO:Estudio de cohorte prospectivo.AJUSTE:Unidad de cirugía colorrectal, centro de referencia de tercer nivel.PACIENTES:Pacientes sometidos a una evaluación clínica utilizando la puntuación de incontinencia fecal de Cleveland Clinic Florida para la gravedad de los síntomas, la manometría y la ecografía.PRINCIPALES MEDIDAS DE RESULTADO:Mediciones por ultrasonido de la longitud, el porcentaje y el ángulo del esfínter anal interno dividido y el esfínter anal externo anterior, el esfínter anal externo posterior más el puborrectal y las longitudes del espacio.RESULTADOS:Sesenta y tres mujeres (edad media, 44 años) se dividieron en 2 grupos: 30 (48%) sometidos a fistulotomía por fístula anal interesfinteriana y 33 (52%) sometidos a esfinterotomía por fisura anal crónica con alta presión anal en reposo. El 46% experimentó algún grado de incontinencia fecal después de la división del esfínter anal interno. La incidencia de incontinencia fecal, la gravedad de los síntomas y el ángulo del esfínter anal interno dividido fueron similares entre los grupos. La longitud y el porcentaje del esfínter anal interno dividido fueron significativamente mayores en la fístula anal interesfinteriana. Las longitudes del esfínter anal externo y del esfínter anal externo más el puborrectal fueron similares en ambos grupos. La longitud del espacio fue significativamente mayor en la fisura anal crónica con alta presión anal en reposo.LIMITACIONES:Institución única, exclusión de varones.CONCLUSIÓN:La incontinencia fecal se reportó en la mitad de los pacientes sometidos a división del esfínter anal interno. A pesar de la mayor longitud y porcentaje de división del esfínter anal interno en los pacientes sometidos a fistulotomía, la incidencia y gravedad de la incontinencia fecal fue similar en ambos grupos. La ecografía endoanal tridimensional mostró una mayor longitud del espacio en el grupo de esfinterotomía, lo que puede ser funcionalmente significativo después de la división del esfínter anal interno más corto, pero con un impacto similar en la incontinencia fecal en ambos grupos. (Traducción-Dr. Fidel Ruiz Healy ).

Risk of anorectal cancer in patients with Crohn's disease and perianal fistula: a nationwide Danish cohort study.

AIM: Patients with Crohn's disease (CD) often suffer from perianal fistulizing disease. Their risk of anorectal cancer remains uncertain. We aimed to examine the long-term risk of anorectal cancer in a population-based cohort of CD patients with anorectal fistula. METHOD: Our study population covered all individuals (n = 7 987 520) aged 15+ years living in Denmark from 1978 to 2018. We identified all patients with CD and anorectal fistula in the Danish National Patient Register (NPR) and 50 matched noninflammatory bowel disease (IBD) individuals from the general population. Using Cox regression analyses, we examined the risk of anorectal cancer in CD fistula patients versus non-IBD individuals. All patients with CD were identified using codes from the International Classification of Diseases and their data extracted from the NPR. The main outcome measure was cases of anorectal cancer. RESULTS: A total of 2786 CD patients with anorectal fistula and 139 300 non-IBD individuals were followed for 1 553 917 person-years. During follow-up, anorectal cancer was observed in 19 CD patients (0.68%) and 340 non-IBD individuals (0.24%), corresponding to a 2.9-fold increased hazard ratio (HR) of anorectal cancer in CD fistula patients (95% CI 1.80-4.53), with a particularly high risk of anal cancer (HR 15.13, 95% CI 6.88-33.31) and a mean time from CD fistula diagnosis to anorectal cancer of 6.7 (SD 6.5) years. The risk was slightly higher in women than men and had no apparent relation to treatment with tumour necrosis factor-α inhibitors. Sensitivity analyses using CD nonfistula patients for comparison revealed similar results. Individual data on smoking and infection with human papilloma virus were not available. CONCLUSION: Patients with CD and anorectal fistula have a three-fold increased risk of anorectal cancer compared with the general population. The number needed to surveil to detect one case of anorectal cancer in this patient population was 2160 patients per year in patients with long-standing fistula (>6 years).

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.

Characteristics of Patients with Crohn's Disease With or Without Perianal Fistulae in the CorEvitas Inflammatory Bowel Disease Registry.

BACKGROUND: There are limited real-world data characterizing perianal fistulae in patients with Crohn's disease (CD). AIM: To describe characteristics of patients with CD with and without perianal fistulae. METHODS: In this cross-sectional study, characteristics, treatment history, and health outcomes of patients with CD enrolled in the CorEvitas IBD Registry were described according to perianal fistula status (current/previous or none). RESULTS: Eight hundred and seventy-eight patients were included. Compared with patients with no perianal fistulae (n = 723), patients with current/previous perianal fistulae (n = 155) had longer disease duration since CD diagnosis (mean 16.5 vs 12.3 years; difference 4.3 years; 95% CI, 2.0, 6.6) and fewer had Harvey-Bradshaw Index scores indicative of remission (0-4, 56.8% vs 69.6%; difference - 12.9%; 95% CI, - 21.6, - 4.2). More patients with current/previous fistulae reported a history of IBD-related emergency room visits (67.7% vs 56.1%; difference 11.6%; 95% CI, 3.4, 19.8), hospitalizations (76.1% vs 58.4%; difference 17.7%; 95% CI, 10.1, 25.4), and surgeries (59.4% vs 27.7%; difference 31.7%; 95% CI, 23.3, 40.1), and a history of treatment with tumor necrosis factor inhibitors (81.3% vs 60.7%; difference 20.6%; 95% CI, 13.5, 27.7), immunosuppressants (51.6% vs 31.2%; difference 20.4%; 95% CI, 11.9, 29.0), and antibiotics (50.3% vs 23.7%; difference 26.6%; 95% CI, 18.2, 35.1) than patients without perianal fistulae. CONCLUSIONS: Patients with CD with current/previous perianal fistulae have more symptomatic experiences of disease, higher medication use, hospitalization rates, and emergency room visits than patients without perianal fistulae. Interventions to prevent/reduce risk of developing fistulae may help improve outcomes in CD.

Incidence and diagnostic performance of ultrasound for perianal abscess or fistula-in-ano in pediatric patients with perianal inflammation.

OBJECTIVES: To describe the incidence and diagnostic performance of ultrasound for perianal abscess or fistula-in-ano in pediatric patients with perianal inflammation. METHODS: We included 45 patients with perianal inflammation who underwent ultrasonography. To demonstrate the diagnostic performance of ultrasound for fistula-in-ano, a definite diagnosis of perianal abscess, and fistula-in-ano was determined as that proven through magnetic resonance imaging (MRI) or computed tomography (CT). The absence or presence of perianal abscess and fistula-in-ano on ultrasonography was recorded. RESULTS: Among the 45 patients, on ultrasound, perianal abscess and fistula-in-ano were detected in 22 (48.9%) and 30 (68.2%) patients, respectively. Nine patients had MRI or CT and a definite diagnosis of perianal abscess or fistula-in-ano; accuracy, negative predictive value, and positive predictive value of ultrasound for perianal abscess were 77.8% (7/9; 95% confidence interval [CI]: 40.0%-97.1%), 66.7% (2/3; 95% CI: 9.4%-99.2%), 83.3% (5/6; 95% CI: 35.9%-99.6%), and those of fistula-in-ano were 100% (9/9; 95% CI: 66.4%-100%), 100% (8/8; 95% CI: 63.1%-100%), and 100% (1/1; 95% CI: 2.5%-100%), respectively. CONCLUSIONS: Perianal abscess and fistula-in-ano were detected by ultrasound in half of the patients with perianal inflammation. Accordingly, ultrasound has an acceptable diagnostic performance for perianal abscess and fistula-in-ano.

Natural History of Perianal Crohn's Disease: Long-term Follow-up of a Population-Based Cohort.

BACKGROUND AND AIMS: The natural history of perianal Crohn's disease (PCD) remains poorly described and is mainly based on retrospective studies from referral centers. The aim of this study was to assess the incidence, outcomes and predictors of the onset of PCD. METHODS: All incident cases of patients diagnosed with possible CD were prospectively registered from 1994 to 1997 in Brittany, a limited area in France. At diagnosis, the clinical features of perianal disease were recorded. All patient charts were reviewed from the diagnosis to the last clinic visit in 2015. RESULTS: Among the 272 out of 331 incident CD patients followed up, 51 (18.7%) patients had PCD at diagnosis. After a mean follow-up of 12.8 years, 93 (34%) patients developed PCD. The cumulative probabilities of perianal CD occurrence were 22%, 29%, and 32% after 1 year, 5 years, and 10 years, respectively. The cumulative probabilities of anal ulceration were 14%, and 19% after 1 year and 10 years, respectively. Extraintestinal manifestations were associated with the occurrence of anal ulceration. The cumulative probabilities of fistulizing PCD were 11%, 16%, and 19% after 1 year, 5 years, and 10 years, respectively. Extraintestinal manifestations, rectal involvement and anal ulceration were predictors of fistulizing PCD. The cumulative probability of developing anal stricture was 4% after 10 years. CONCLUSIONS: PCD is frequently observed during CD, in approximately one-third of patients. These data underline the need for targeted therapeutic research on primary perianal lesions (proctitis, anal ulceration) to avoid the onset of fistulizing perianal disease.

Perianal Crohn's Disease Is Associated With Poor Disease Outcome: A Nationwide Study From the epiIIRN Cohort.

BACKGROUND & AIMS: Limited population-based data have explored perianal involvement in Crohn's disease (CD) and compared the disease course between severe and non-severe perianal CD (PCD). We aimed to explore the disease course of these phenotypes in a population-based study of CD. METHODS: Cases were identified from the epi-IIRN cohort and included 2 Israeli health maintenance organizations covering 78% of the population. We validated specific algorithms to identify fistulizing PCD and to differentiate severe from non-severe disease by medication utilization, International Classification of Disease, 9th Revision codes, and perianal procedures. RESULTS: A total of 12,904 CD patients were included in an inception cohort from 2005 (2186 pediatric-onset, 17%) providing 86,119 person-years of follow-up. Fistulizing PCD was diagnosed in 1530 patients (12%) (574 with severe PCD, 4%). The prevalence of PCD was 7.9%, 9.4%, 10.3%, and 11.6% at 1, 3, 5, and 10 years from CD diagnosis, respectively. At 5 years, PCD patients were more likely to be hospitalized (36% in non-PCD vs 64% in PCD; P < .001), undergo inflammatory bowel disease-related surgeries (9% vs 38%, respectively; P < .001), and develop anorectal cancer (1.2/10,000 person-years for non-PCD vs 4.2/10,000 for PCD; P = .01). Severe PCD was associated with poorer outcomes compared with non-severe PCD, as shown for hospitalizations (61% in non-severe PCD vs 73% in severe; P = .004) and surgeries (35% vs 43%; P = .001). CONCLUSIONS: Despite higher utilization of immunomodulators and biologics, PCD is associated with poor disease outcomes, especially in severe PCD.

Perianal Fistula After Ileoanal Pouch in Patients With Ulcerative Colitis: A Review of 475 Patients Operated on at a Major IBD Center.

BACKGROUND: Ileoanal pouch anastomosis is the surgical treatment of choice for patients with intractable ulcerative colitis. Perianal disease is a feature that is often present in Crohn's disease and infrequently in ulcerative colitis. OBJECTIVE: The aim of this study is to identify the incidence and factors associated with the development of postoperative perianal fistula in patients undergoing ileoanal pouch anastomosis for ulcerative colitis. DESIGN: A prospectively collected database at the time of surgery with subsequent follow-up was utilized. SETTING: The study was conducted at a high-volume single institution. PATIENTS: We studied a series of 475 consecutive patients with preoperative diagnosis of ulcerative colitis who underwent ileoanal pouch anastomosis. MAIN OUTCOME MEASURES: The incidence of postoperative perianal fistula and the factors correlating with its development were primary outcome measures of the study. RESULTS: The overall number of patients developing perianal fistulas was 44 of 475 (9%). Eleven patients with perianal fistula (25%) required return to ileostomy, of which 7 had pouch excision. Patients who developed a postoperative perianal fistula had a younger age at the onset of disease, had a lower age at index surgery, and were more likely to be subsequently classified as indeterminate colitis or Crohn's disease. Patients developing perianal fistulas were also more likely to develop partial dehiscence or stricture of the ileoanal anastomosis. LIMITATIONS: This study spans nearly 40 years during which the surgical procedure evolved. CONCLUSIONS: Young age at the onset of disease, lower age at surgery, and postoperative diagnosis of Crohn's disease and indeterminate colitis were the factors correlating with perianal fistulas. Delayed healing of the ileoanal anastomosis with partial separation and/or stricture also correlated with the onset of perianal fistulas. The severity of rectal inflammation at the time of surgery or the presence of stapled versus handsewn anastomosis did not correlate with the development of perianal fistulas. See Video Abstract at http://links.lww.com/DCR/B705. FSTULA PERIANAL POSTERIOR A RESERVORIO ILEOANAL EN PACIENTES CON COLITIS ULCERATIVA UNA REVISIN DE PACIENTES OPERADOS EN UN CENTRO PRINCIPAL DE EII: ANTECEDENTES:El reservorio ileoanal es el tratamiento quirúrgico de elección para los pacientes con colitis ulcerativa intratable. La enfermedad perianal es una característica que a menudo está presente en la enfermedad de Crohn y con poca frecuencia en la colitis ulcerativa.OBJETIVO:El objetivo del estudio es identificar la incidencia y los factores asociados con el desarrollo de fístula perianal posoperatoria en pacientes sometidos a reservorio ileoanal por colitis ulcerativa.DISEÑO:Base de datos recopilada prospectivamente en el momento de la cirugía con seguimiento subsecuente.ENTORNO CLÍNICO:El estudio se llevó a cabo en una única institución de gran volumen.PACIENTES:Estudiamos una serie de 475 pacientes consecutivos con diagnóstico preoperatorio de colitis ulcerativa a los que se les realizó reservorio ileoanal.PRINCIPALES MEDIDAS DE VALORACIÓN:La incidencia de fístula perianal posoperatoria y los factores que se correlacionan con su desarrollo fueron las principales medidas de resultado del estudio.RESULTADOS:El número total de pacientes que desarrollaron fístulas perianales fue 44 de 475 (9%). Once pacientes con fístula perianal (25%) requirieron volver a la ileostomía, de los cuales 7 tuvieron resección del reservorio. Los pacientes que desarrollaron fístula perianal posoperatoria tenían edad más temprana al inicio de la enfermedad, menor edad en el momento de la cirugía inicial y tenían más probabilidades de ser clasificados posteriormente como colitis indeterminada o enfermedad de Crohn. Los pacientes que desarrollaron fístulas perianales también fueron más propensos a desarrollar dehiscencia parcial o estenosis de la anastomosis ileoanal.LIMITACIONES:Este estudio abarca casi 40 años durante los cuales ha evolucionado el procedimiento quirúrgico.CONCLUSIONES:Edad temprana al inicio de la enfermedad, menor edad al momento de la cirugía, diagnóstico postoperatorio de enfermedad de Crohn y colitis indeterminada fueron los factores que se correlacionaron con las fístulas perianales. El retraso en la cicatrización de la anastomosis ileoanal con separación parcial y/o estenosis también se correlacionó con la aparición de fístulas perianales. La gravedad de la inflamación rectal en el momento de la cirugía o la presencia de anastomosis con grapas versus anastomosis manual no se correlacionó con el desarrollo de fístulas perianales. Consulte Video Resumen en http://links.lww.com/DCR/B705.

Clinicopathological determinants of recurrence after surgical treatment of fistula-in-ano in a Ghanaian teaching hospital.

AIM: The aim of this work is to describe the clinicopathological and surgical aspects of fistula-in-ano and assess the risks associated with recurrence of the disease in a Ghanaian teaching hospital. METHOD: This was a retrospective observational study assessing all fistula-in-ano surgeries performed at the Korle Bu Teaching hospital from January 2014 to January 2021 that had completed follow up of at least 3 months after wound healing. Demographic, clinical, pathological and surgical data were extracted from patient records. Logistic regression analysis was used to test for association between these variables and recurrence. RESULTS: A total of 105 patients underwent 124 fistula surgeries. Their median age was 41 years, the male:female ratio was 4:1 and 12 had comorbidities including human immunodeficiency virus infection and diabetes mellitus. Thirty-one per cent (39/124) of fistulas had previously been operated on. At surgery, 51% (64/124) of fistulas followed a single straight tract, 30% (37/124) a single curved tract and 19% (23/124) had multiple curved tracts. More than half (65/124) were trans-sphincteric, 35% (44/124) suprasphincteric, 10% (12/124) subsphincteric and 2% (3/124) were intersphincteric. Sixty per cent of fistulas were treated with a ligation of intersphincteric fistula tract (74/124), 35% (44/124) a fistulectomy and 5% a fistulotomy. Recurrence after surgery was 22.5% (28/124); this was significantly higher for fistulas with multiple curved tracts (OR 4.153, 95% CI 1.431-12.054, p = 0.012) and fistulas with comorbidities (OR 3.222, 95% CI 1.076-9.647, p = 0.037). CONCLUSION: There was high recurrence after fistula surgery with increased risk for fistulas with multiple tracts and the presence of comorbidities.

Intersphincteric Exploration With Ligation of Intersphincteric Fistula Tract or Attempted Closure of Internal Opening for Acute Anorectal Abscesses.

BACKGROUND: Acute anorectal abscesses of cryptoglandular origin are commonly managed by incision and drainage, which results in fistula development in up to 73% of cases, requiring subsequent definitive fistula surgery. However, given that fistula tracts may already be present at the initial presentation, primary closure of the tract as secondary prevention of fistula formation, using ligation of intersphincteric fistula tract, may be useful. OBJECTIVE: This study aims to examine the feasibility and outcomes of performing intersphincteric exploration with ligation of intersphincteric fistula tract or attempted closure of internal opening for acute anorectal abscesses. DESIGN: This is a retrospective study of patients with acute anorectal cryptoglandular abscesses who underwent surgery between January 2014 and December 2016. SETTINGS: The patients were treated at a tertiary referral center in Thailand. PATIENTS: Eighty-six patients with acute anorectal abscesses without previous surgery were included. INTERVENTIONS: Intersphincteric dissection was performed. Further surgical intervention was dependent on the intersphincteric findings. MAIN OUTCOME MEASURE: The main outcome measure was the 90-day healed rate. RESULTS: Of the 86 patients, 3 had low intersphincteric abscesses, 26 had low transsphincteric abscesses, 25 had anterior high transsphincteric abscesses, 27 had posterior high transsphincteric abscesses, and 5 had high intersphincteric abscesses. Ligation of intersphincteric fistula tract was successfully performed in 66 patients with an identifiable intersphincteric tract. Intersphincteric exploration with attempted closure of the internal opening was performed in the remaining 20 patients. The success rates were 86% and 70%. Unidentified internal opening and intersphincteric pathology were risk factors for nonhealing. No patients reported fecal incontinence postoperatively. LIMITATIONS: The limitation of this study is its retrospective nature and that all operations were performed by a single surgeon; therefore, the results may vary according to the individual surgeon's expertise. CONCLUSIONS: Fistula tract formation was found in most cases of acute anorectal abscesses. Definitive surgery using this strategy provides promising results. See Video Abstract at http://links.lww.com/DCR/B451. EXPLORACIN INTERESFINTRICA CON LIGADURA DEL TRAYECTO EN LA FSTULA INTERESFINTRICA O INTENTO DE CIERRE DEL ORIFICIO INTERNO EN ABSCESOS ANORRECTALES AGUDOS: ANTECEDENTES:Los abscesos anorrectales agudos de origen criptoglandular, comúnmente se manejan mediante incisión y drenaje, lo que resulta en el desarrollo de una fístula hasta en un 73% de los casos, requiriendo posteriormente cirugía definitiva de la fístula. Sin embargo, dado que los trayectos de la fístula ya pueden estar inicialmente presentes, puede ser útil el cierre primario del trayecto, como prevención secundaria en la formación de la fístula, mediante la ligadura del trayecto de la fístula interesfintérica.OBJETIVO:El estudio tiene como objetivo, examinar la viabilidad y los resultados en realizar exploración interesfintérica, con ligadura del trayecto de fístula interesfintérica o intento de cierre del orificio interno para abscesos anorrectales agudos.DISEÑO:Se trata de un estudio retrospectivo de pacientes con abscesos criptoglandulares anorrectales agudos, que fueron operados entre enero de 2014 y diciembre de 2016.AJUSTES:Los pacientes fueron tratados en un centro de referencia terciario en Tailandia.PACIENTES:Se incluyeron 86 pacientes con abscesos anorrectales agudos, sin cirugía previa.INTERVENCIONES:Se realizó disección interesfintérica. La intervención quirúrgica adicional dependió de los hallazgos interesfintéricos.PRINCIPALES MEDIDAS DE RESULTADO:La principal medida de resultado, fue la tasa de cicatrización a 90 días.RESULTADOS:De los 86 pacientes, hubo 3 abscesos interesfintéricos bajos, 26 abscesos transesfintéricos bajos, 25 abscesos transesfintéricos anteriores altos, 27 abscesos transesfintéricos posteriores altos y 5 abscesos interesfintéricos altos. La ligadura del tracto de la fístula interesfintérica, con tracto interesfintérico identificable, se realizó con éxito en 66 pacientes. Se realizó exploración interesfintérica, con intento de cierre del orificio interno en los 20 pacientes restantes. Las tasas de éxito fueron 86% y 70% respectivamente. Orificio interno no identificado y patología interesfintérica, fueron factores de riesgo para la falta de cicatrización. Ningún paciente reportó incontinencia fecal posoperatoria.LIMITACIONES:La limitación de este estudio, es su naturaleza retrospectiva y que todas las operaciones fueron realizadas por un solo cirujano, por lo tanto, los resultados pueden variar según la experiencia de cada cirujano.CONCLUSIONES:En la mayoría de los casos de abscesos anorrectales agudos, se encontró formación de trayectos fistulosos. La cirugía definitiva con esta estrategia, proporciona resultados prometedores. Consulte Video Resumen en http://links.lww.com/DCR/B451.

Incidence and Outcomes of Perianal Disease in an Asian Population with Crohn's Disease: A Nationwide Population-Based Study.

BACKGROUND: Little is known about the natural history of perianal fistulas in Asian populations with Crohn's disease (CD). AIMS: We investigated the incidence and outcomes of perianal CD (pCD) in Korean CD patients. METHODS: A nationwide population-based cohort of 6265 CD patients diagnosed in 2010-2014 was analyzed to investigate the incidence and outcomes of pCD. The results were validated in a hospital-based cohort of 2923 CD patients diagnosed in 1981-2015. Factors associated with pCD development were analyzed. The incidence and outcomes of pCD were compared between the prebiologic and biologic eras. RESULTS: pCD occurred in 39.2% of the population-based cohort and 56.1% of the hospital-based cohort during the median follow-up of 4.2 and 8.5 years, respectively. The cumulative incidence of pCD was 40.0% at 5 years after CD diagnosis in the population-based cohort and 62.5% at 20 years in the hospital-based cohort. In multivariate analysis, pCD development was positively associated with male sex, younger age and colonic involvement at diagnosis, early diagnosis, and CD diagnosis in the prebiologic era. The cumulative probability of proctectomy at 10, 20, and 30 years after pCD diagnosis was 2.9%, 12.2%, and 16.2%, respectively. The cumulative incidence of pCD occurring after CD diagnosis and the cumulative probability of proctectomy were significantly lower in the biologic era than in the prebiologic era (p < 0.001 and p = 0.03, respectively). CONCLUSIONS: Compared with Western patients with CD, Korean patients show a high incidence of pCD but have a low probability of proctectomy, suggesting the favorable course of pCD.

Analysis of Risk Factors for Anorectal Stenosis of Perianal Fistulizing Crohn's Disease.

BACKGROUND To analyze the risk factors of anorectal stenosis associated with perianal fistulizing Crohn's disease (PFCD). MATERIAL AND METHODS We retrospectively analyzed 139 cases of PFCD from January 2010 to December 2017 at the Affiliated Hospital of Nanjing University of Chinese Medicine. They were divided into 2 groups according to whether anorectal stenosis occurred. The possible factors associated with anorectal stenosis of PFCD were selected based on the literature review and clinical observations. Univariate analysis was performed to screen the risk factors of anorectal stenosis, and multivariate logistic regression analysis was performed on these risk factors and factors that were clinically considered to be potentially influential, to screen out the independent risk factors of anorectal stenosis. RESULTS We found that 44 cases (31.7%) of PFCD were associated with anorectal stenosis. Univariate analysis showed that CDAI, lesion location, and age at diagnosis were risk factors for anorectal stenosis of PFCD. Logistic regression analysis showed that mild (fair to good) (OR=3.833, 95% CI: 1.123~13.080) to moderate (poor) (OR=7.345, 95% CI: 1.964~27.474) CDAI and age at diagnosis (OR=1.067, 95% CI: 1.013~1.124) were independent risk factors for anorectal stenosis of PFCD. CONCLUSIONS Higher CDAI and older age at diagnosis appear to confer higher risk of anorectal stenosis associated with PFCD.

Formation rate of secondary anal fistula after incision and drainage of perianal Sepsis and analysis of risk factors.

BACKGROUND: The choice of surgery for perianal sepsis is currently controversial. Some people advocate one-time radical surgery for perianal sepsis, while others advocate incision and drainage. The objective of this study is to observe the formation probability of secondary anal fistula after incision and drainage in patients with perianal sepsis and determine factors that contribute to secondary anal fistula after incision and drainage. METHODS: A retrospective descriptive analysis was conducted in 288 patients with perianal sepsis who were treated with anorectal surgery in the Suzhou Hospital of Traditional Chinese Medicine from January 2016 to June 2018. The patients were followed by telephone, physical examination, and pelvic MRI examination for at least 1 year after surgery. RESULTS: Three patients were not followed, 98 patients did not receive surgical treatment or one-time radical surgery for perianal sepsis, and 187 patients were ultimately identified for the study. Anal fistula was present in 105 patients, and the rate of formation of secondary anal fistula was 56.15%. There was no statistically significant difference in the fistula formation rate between different types of sepsis (P>0.05). And, in patients with secondary anal fistula, there was no significant correlation between the location of sepsis and the type of secondary anal fistula (P>0.05). CONCLUSIONS: The incidence of secondary anal fistula after incision and drainage of perianal sepsis is 56.15%, which is lower than the incidence found in previous study. Young is a risk factor for secondary anal fistula after incision and drainage of perianal sepsis. There is no significant correlation between the location of sepsis and the type of secondary anal fistula. Simple incision and drainage is a suitable choice for patients with acute perianal sepsis.

Loss of seton in patients with complex anal fistula: a retrospective comparison of conventional knotted loose seton and knot-free seton.

BACKGROUND: Loose setons are often utilized. Replacements after seton loss are frequent, but the exact incidence of this loss of seton (LOS) in patients is unknown. The aim of the present study was to assess the incidence of LOS in a population with complex anal fistula, comparing the knot-free loose seton with the conventional knotted loose seton. METHODS: All consecutive patients treated with a loose seton for complex anal fistula in two large teaching hospitals in the Netherlands between January 2017 and December 2019 were included in the present study. The incidence of loss of a conventional knotted loose seton was compared with the loss of commercially available knot-free setons. RESULTS: There were 212 patients. Fifty-two patients were included in the knotted loose group and 160 patients were included in the knot-free seton group. Sixteen patients who were treated with both a knotted and a knot-free loose seton were included in both groups. The incidence of LOS was 12% in the knotted seton group and 28% in the knot-free loose seton group (p = 0.02). Median time to LOS was 36 days for the knotted loose seton and 89 days for the knot-free loose seton (p = 0.36). Sex (p = 0.61), age at the time of seton placement (p = 0.60), and presence of inflammatory bowel disease (p = 0.28) were not significantly associated with LOS. CONCLUSIONS: LOS occurs frequently in patients treated for complex anal fistulas. The incidence of LOS is significantly higher in patients treated with a knot-free loose seton. Further developments in seton manufacturing should be focussed on optimisation of the closure mechanism.

Persistent Fistula After Anorectal Abscess Drainage: Local Experience of 11 Years.

BACKGROUND: The characteristics of patients who develop a fistula-in-ano after an anorectal abscess are unclear. OBJECTIVE: Our study explored this relationship and patient factors associated with fistula development. DESIGN: International Classification of Diseases, 10 Revision, and Classification of Interventions and Procedures, version 4, codes were used to identify all of the patients with a primary anorectal abscess. Multivariable analysis was used to identify factors predictive of fistula formation. SETTINGS: The study was conducted in a district general hospital. PATIENTS: Patients with anorectal abscess who were admitted to our institution (2004-2015) were included. MAIN OUTCOMES MEASURES: The rate of subsequent fistula formation was measured. RESULTS: A total of 1970 abscess patients were identified; 70.0% (n = 1379) were men, and 7.3% (n = 144) had Crohn's disease. Fistulas occurred in 16.2% (n = 319) at a median of 7 months (interquartile range, 3-7 mo). Patients with Crohn's disease were more than twice as likely to develop a fistula than patients without Crohn's disease (32.6% vs 14.9%; OR = 2.5 (95% CI, 1.7-3.7); p < 0.001). Patients with Crohn's disease with a fistula were more likely to be women (55.3% vs 34.6%; p = 0.007) and aged <30 years (51.1% vs 24.3%; p< 0.001) versus patients without Crohn's disease with a fistula. At multivariable analysis of the entire cohort, male sex (OR = 0.7 (95% CI, 0.5-0.9); p = 0.005) and diabetes mellitus (OR = 0.5 (95% CI, 0.3-0.9); p = 0.027) were associated with a reduced likelihood of developing a fistula after abscess formation. LIMITATIONS: The study was limited by its single-center scope, retrospective analysis, and lack of a standardized definition for Crohn's disease. CONCLUSIONS: Abscesses are more common in men, but progression to fistula is more likely in women. The rate of fistula progression in Crohn's disease is twice that in patients without Crohn's disease. Identification of patients at risk may help delineate those who will benefit from a more conservative surgical approach, enhanced follow-up, or investigation after abscess drainage. See Video Abstract at http://links.lww.com/DCR/A798.

Perianal Tuberculosis: Lessons Learned in 57 Patients From 743 Samples of Histopathology and Polymerase Chain Reaction and a Systematic Review of Literature.

BACKGROUND: Few data are published on perianal tuberculosis. OBJECTIVE: This study aimed to determine the best method to diagnose tuberculosis in patients with fistula-in-ano and to conduct a systematic review to determine the incidence and characteristics of tuberculosis fistula-in-ano. DATA SOURCES: The prospective study data and existing literature were derived from PubMed, Google scholar, and Scopus STUDY SELECTION:: Prospective analysis of patients with tuberculous fistula-in-ano treated between 2014 and 2018 was conducted, and a systematic review of studies describing ≥3 patients with tuberculosis fistula-in-ano was completed. INTERVENTION: Testing of tuberculosis was performed by histopathology or polymerase chain reaction of tissue or pus from the fistula tract. MAIN OUTCOME MEASURES: The primary outcomes measured were the detection rate of various tests to detect tuberculosis in fistula-in-ano and the prevalence rate of tuberculosis in simple versus complex fistulas. RESULTS: In 637 samples (410 patients) tested, tuberculosis was detected in 49 samples (43 patients). Additional samples (n = 106) sent in patients with a high index of suspicion tested positive in 14 more patients. Thus, overall, 63 samples tested positive in 57 patients (total: 743 samples in 410 patients were tested). Tuberculosis was detected in 2 of 181 patients (1.1%) in tissue (histopathology), in 28 of 341 patients (8.2%) in tissue (polymerase chain reaction), and in 19 of 115 patients (16.5%) in pus (polymerase chain reaction) samples. To detect tuberculosis, tissue (polymerase chain reaction) was significantly better than tissue (histopathology) (28/341 vs 2/181, p < 0.00001) and pus (polymerase chain reaction) was significantly better than tissue (polymerase chain reaction) (19/115 vs 28/341, p < 0.0009). Tuberculosis was significantly more common in complex fistulas than in simple fistulas (20.3% vs 7.2%, p = 0.0002). The systematic review (n = 199) highlighted that tubercular fistulas are more common in recurrent and complex fistulas and in tuberculosis endemic regions. LIMITATIONS: The true sensitivity and specificity of each testing modality could not be determined because not all patients with tuberculosis fistula-in-ano were tested by every diagnostic modality studied. CONCLUSIONS: The tuberculosis detection rate of polymerase chain reaction was significantly higher than histopathology. Among polymerase chain reaction, pus had higher detection rate than tissue. Tuberculosis was associated with more complex and recurrent fistulas.

Anal fistula and pilonidal sinus disease coexisting simultaneously: An audit in a cohort of 1284 patients.

Fistula-in-ano and pilonidal disease are not known to occur together. In a retrospective study, all patients having fistula-pilonidal disease coexisting simultaneously were included. Out of 1284 patients, 933 were operated (fistula-in-ano, 849; pilonidal disease, 77; and coexisting fistula-pilonidal, 7). A total of 351 patients did not undergo any surgery (two patients had coexisting fistula-pilonidal). Thus, a total of nine patients having coexisting fistula-pilonidal sinus were included in the study (mean age 35.8 ± 19.9 years, M/F 7/2). pIn 6/9 patients, the pilonidal tract was communicating with fistula-in-ano, and in 3/9 patients, they were not communicating/connected. The connection could be established preoperatively with the help of MRI. In all patients with communicating fistula-pilonidal sinus (n=6), the fistula was posterior. 6/9 patients had recurrent fistula and all (9/9) had multiple tracts. The fistula was high and complex in 8/9 patients (grade IV-7, grade V-1). 4/9 patients tested positive for tuberculosis while one patient was suffering from hidradenitis suppurativa. The latter improved on medical treatment. One patient did not agree for surgery and seven were operated. The disease healed in four patients, the disease did not heal in one patient, and two patients were in the convalescent stage. Anal fistula and pilonidal disease can coexist in a same patient and can even be connected. Such diseases are more complex and have a higher incidence of associated diseases like tuberculosis. Magnetic resonance imaging plays a pivotal role in diagnosis. If the connection is missed, the disease treatment becomes difficult.

Clinical characteristics and long-term prognosis of elderly-onset Crohn's disease.

OBJECTIVES: This study aimed to evaluate the clinical characteristics and clinical course of Asian elderly-onset Crohn's disease (EOCD) patients in a large well-defined cohort of South Korean IBD patients. MATERIALS AND METHODS: From the Asan inflammatory bowel disease registry, we identified 29 EOCD patients (diagnosed with CD in age of 60 years or over) out of 2989 CD patients (1.0%). After excluding two patients with unclear data, 27 EOCD were matched with 108 young-onset CD (YOCD) and 108 middle age-onset CD (MOCD) for the interval from symptom onset to diagnosis (±3 years) and follow-up duration (±3 years). RESULTS: Females were predominant in the EOCD group (59.3%) compared to MOCD (31.5%) and YOCD (29.6%) groups (p = .012). In EOCD group, terminal ileal location was the most common (63.0%) at diagnosis, whereas ileocolonic location in other groups (57.4% in MOCD and 78.7% in YOCD, respectively) (p < .001). Patients with perianal fistula at CD diagnosis were less common (14.8% in EOCD vs. 28.7% in MOCD vs. 49.1% in YOCD, p < .001). During follow-up, thiopurines were used less frequently in the EOCD group (48.1% in EOCD vs. 87.0% in MOCD vs. 89.8% in YOCD, p < .001), but the risk for intestinal resection was comparable among three groups (p = .583). CONCLUSIONS: EOCD may have a better clinical course than MOCD and YOCD, as demonstrated by the similar risk for intestinal resection despite the less frequent use of thiopurines.

Patients with perianal Crohn's fistulas experience delays in accessing anti-TNF therapy due to slow recognition, diagnosis and integration of specialist services: lessons learned from three referral centres.

AIM: Crohn's anal fistula should be managed by a multidisciplinary team. There is no clearly defined 'patient pathway' from presentation to treatment. The aim of this study was to describe the patient route from presentation with symptomatic Crohn's anal fistula to starting anti-tumour necrosis factor (anti-TNF) therapy. METHOD: Case note review was undertaken at three hospitals with established inflammatory bowel disease services. Patients with Crohn's anal fistula presenting between 2010 and 2015 were identified through clinical coding and local databases. Baseline demographics were captured. Patient records were interrogated to identify route of access, and clinical contacts during the patient pathway. RESULTS: Seventy-nine patients were included in the study, of whom 54 (68%) had an established diagnosis of Crohn's disease (CD). Median time from presentation to anti-TNF therapy was 204 days (174 vs 365 days for existing and new diagnosis of CD, respectively; P = 0.019). The mean number of surgical outpatient attendances, operations and MRI scans per patient was 1.03, 1.71 and 1.03, respectively. Patients attended a mean of 1.49 medical clinics. Seton insertion was the most common procedure, accounting for 48.6% of all operations. Where care episodes ('clinical events per 30 days') were infrequent this correlated with prolongation of the pathway (r = -0.87; P < 0.01). CONCLUSION: This study highlights two key challenges in the treatment pathway: (i) delays in diagnosis of underlying CD in patients with anal fistula and (ii) the pathway to anti-TNF therapy is long, suggesting issues with service design and delivery. These should be addressed to improve patient experience and outcome.

Multiple Nodule Removal by Disc Excision and Segmental Resection in Multifocal Colorectal Endometriosis.

STUDY OBJECTIVE: To report postoperative outcomes after dual digestive resection for deep endometriosis infiltrating the rectum and the colon. DESIGN: A retrospective study using data prospectively recorded in the CIRENDO database (Canadian Task Force classification II-2). SETTING: A university tertiary referral center. PATIENTS: Twenty-one patients managed for multiple colorectal deep endometriosis infiltrating nodules. INTERVENTIONS: Concomitant disc excision and segmental resection of both the rectum and sigmoid colon. MEASUREMENTS AND MAIN RESULTS: The assessment of postoperative outcomes was performed. Rectal nodules were managed by disc excision and segmental resection in 20 patients and 1 patient, respectively. Sigmoid colon nodules were removed by short segmental resection and disc excision in 15 and 6 patients, respectively. The rectal nodule diameter was between 1 and 3 cm and over 3 cm in 33% and 67% of patients, respectively. Associated vaginal infiltration requiring vaginal excision was recorded in 76.2% of patients. The mean diameter of the rectal disc removed averaged 4.6 cm, and the mean height of the rectal suture was 5.8 cm. The length of the sigmoid colon specimen and the height of the anastomosis were 7.3 cm and 18.5 cm, respectively. The mean operative time was 290 minutes, and the mean postoperative follow-up averaged 30 months. Clavien-Dindo 3 complications occurred in 28% of patients, including 4 with rectal fistulae (19%). The pregnancy rate was 67% among patients with pregnancy intention. CONCLUSION: Our data suggest that combining disc excision and segmental resection to remove multiple deep endometriosis nodules infiltrating the rectum and the sigmoid colon can preserve the healthy bowel located between 2 consecutive nodules. However, the rate of postoperative complications is high, particularly in patients with large low rectal nodules.