RESUMO
BACKGROUND: Anorectal stricturing is a particularly morbid manifestation of Crohn's disease resulting in a diminished quality of life related to pain, incontinence, and recurrent operative interventions. OBJECTIVE: To determine the role of medical therapy, endoscopic dilation, and surgical intervention for the treatment of isolated anorectal stricturing. DATA SOURCES: An organized search of MEDLINE, PubMed, EMBASE, Scopus, and the Cochrane Database of Collected Reviews was performed from January 1, 1990 through May 1, 2020. STUDY SELECTION: Full text papers which included management of isolated anorectal strictures in the setting of Crohn's disease. INTERVENTION(S): Medical and surgical management. MAIN OUTCOME MEASURES: Symptomatic relief, need for proctocolectomy. RESULTS: Our search identified a total of 553 papers; after exclusion based on title (n = 430) and abstract (n = 47), 76 underwent full text review with 65 relevant to the management of anorectal strictures. A summary of the retrospective reports suggests that medical therapy can help control luminal inflammation, but fibrosis may ultimately set in resulting in a need for endoscopic or surgical intervention. Surgical options are limited in the anal canal due to inflammation and ulceration and concomitant perianal fistulizing disease. While fecal diversion can provide symptomatic relief, successful restoration of intestinal continuity remains uncommon and most patients ultimately undergo a total proctocolectomy with end ileostomy. LIMITATIONS: Limited literature published, all retrospective in nature. CONCLUSIONS: Despite significant advances in medical and surgical therapy in Crohn's disease over the last decades, there is clearly an unmet need in the management of anorectal strictures in Crohn's disease.
Assuntos
Doenças do Ânus/etiologia , Constrição Patológica/terapia , Doença de Crohn/complicações , Dilatação/métodos , Endoscopia/métodos , Doenças do Ânus/patologia , Terapia Biológica/métodos , Constrição Patológica/classificação , Constrição Patológica/psicologia , Doença de Crohn/cirurgia , Gerenciamento Clínico , Feminino , Humanos , Ileostomia/métodos , Proctocolectomia Restauradora/métodos , Proctocolectomia Restauradora/estatística & dados numéricos , Qualidade de Vida , Estudos Retrospectivos , Resultado do TratamentoRESUMO
PURPOSE OF REVIEW: The aim of this review is to summarize data regarding surgical trends in inflammatory bowel disease in the prebiologic and biologic era, with a focus on population-based studies and randomized controlled trials (RCTs). RECENT FINDINGS: There is paucity of data in RCTs regarding surgical rates, with only a few clinical trials reporting them. From the available data, meta-analyses of RCTs have concluded that antitumor necrosis α agents (anti-TNF) reduce surgical rates in ulcerative colitis and Crohn's disease. A large body of evidence from population-based studies from different regions of the world is available to evaluate surgical trends before and after the introduction of anti-TNF agents. The risk of surgery decreased significantly over the past six decades; these decreasing trends continued in the biologic era, which might indicate a potential beneficial disease-modifying effect of biologics. There is lack of data with nonanti-TNF biologics (i.e. anti-integrins and ustekinumab) regarding the risk of surgery. SUMMARY: Although data from population-based studies and available RCTs suggest a protective effect from surgery of anti-TNF agents, definitive conclusions should be drawn only when more disease-modifying trials with different biologics and treatment strategies become available.