Management of Perianal Fistulas Associated with Crohn Disease: A Nurse's Perspective.

Crohn disease perianal fistulas are associated with considerable morbidity and impaired quality of life. Nurses who specialize in inflammatory bowel disease (IBD) play a vital role in the management of Crohn disease perianal fistulas from diagnosis to long-term care; however, there is little evidence available to inform Crohn associated perianal fistula management strategies for nurses. This narrative review aims to provide IBD nurses with an up-to-date overview of Crohn perianal fistulas. It discusses the vital role IBD nurses play within the multidisciplinary team; the physical, social, and psychological impacts of Crohn perianal fistulas on patients; available treatment options; and how IBD nurses can support patients in their perianal fistula journey to enable optimum outcomes for patients. It also reviews diagnostic techniques and IBD nurses' involvement in Crohn perianal fistula diagnosis. While this article is aimed at IBD nurses, it is relevant to all nurses irrespective of their role (unit, clinic, community, and stoma) who interact with patients with Crohn perianal fistulas because awareness of the signs and symptoms of this condition will enable timely referrals and diagnosis.

The effect of tranexamic acid on blood transfusion in lower gastrointestinal bleeding-A double blind prospective randomised controlled trial.

PURPOSE: Acute gastrointestinal bleeding is a common emergency. Tranexamic acid (TXA) reduces clot breakdown by inhibiting the action of plasmin and has been shown to reduce the need for blood transfusion in trauma, surgical procedures, and upper gastrointestinal bleeding. This study examined the efficiency of intravenous TXA in patients with acute lower gastrointestinal bleeding. METHODS: Eighty-one patients aged >18 years with lower GI hemorrhage, presenting as active rectal bleeding and anemia (hemoglobin lower than 11 g/dL or a decrease of 2 gr/dl from the patient's base level), were enrolled in this single center, double blind prospective research. Patients were randomly assigned to receive intravenous TXA or placebo from admission until colonoscopy took place. The need for transfusion of packed red blood cells (PRBC) and number of units was recorded and compared between the two groups. RESULTS: Eighty-one patients were randomized in this study, thirty-nine in the TXA arm, and forty-two in the placebo arm. Patient characteristics did not differ between the groups. Forty-three out of the 81 patients received blood transfusion; twenty-two were on the placebo arm and twenty-one on the TXA arm (p = 0.89). Twenty-nine patients required 2 or more units, 14 in the TXA arm and 15 in the placebo arm (p = 0.98). CONCLUSIONS: Intravenous TXA has no significant effect on blood requirement in patients with lower GI bleeding. There was no difference in the consumption of PRBC units among the patients in the placebo and TXA groups. It seems that tranexamic acid has no significant effect on transfusion of PRBC units in lower GI bleeding.

Effect of local prolonged-release incisional doxycycline on surgical site infection prophylaxis in abdominal colorectal surgery: The SHIELD 1 randomized clinical trial.

INTRODUCTION: Despite advanced infection control practices including preoperative antibiotic prophylaxis, surgical site infection (SSI) remains a challenge. This study aimed to test whether local administration of a novel prolonged-release Doxycycline-Polymer-Lipid Encapsulation matriX (D-PLEX) before wound closure, concomitantly with standard of care (SOC), reduces the incidence of incisional SSI after elective abdominal colorectal surgery. MATERIALS AND METHODS: This was a phase 3 randomized, controlled, double-blind, multinational study (SHIELD 1) between June 2020 to June 2022. Patients with at least one abdominal incision length >10 cm were randomized 1:1 to the investigational arm (D-PLEX+SOC) or control (SOC) arm . The primary outcome was a composite of incisional SSI, incisional reintervention, and all-cause mortality. RESULTS: A total of 974 patients were analyzed, of whom 579 (59.4%) were male. The mean age (±SD) was 64.2±13.0 years. The primary outcome occurred in 9.3% of D-PLEX patients versus 12.1% (SOC) (risk difference estimate [RDE], -2.8%; 95% CI [-6.7%, 1.0%], P=0.1520). In a pre-specified analysis by incision length, a reduction in the primary outcome was observed in the >20 cm subpopulation: 8% (D-PLEX) versus 17.5% (SOC) (RDE, -9.4%; 95% CI [-15.5%, -3.2%], P=0.0032). In the >10 to ≤20 cm subgroup, no reduction was observed: 9.9% versus 7.9% (RDE, 2.0%; 95% CI [-2.8%, 6.7%], P=0.4133). Exploratory post-hoc analyses of patients with increased SSI risk (≥1 patient-specific comorbidity) indicated a reduction in the incidence of the primary outcome: 9.0% (D-PLEX) versus 13.7% (SOC) (RDE, -4.8%; 95% CI [-9.5%, -0.1%], P=0.0472). The D-PLEX safety profile was good (no difference in treatment-emergent adverse events between the groups). CONCLUSIONS: The SHIELD-1 study did not meet its primary outcome of reduced incisional SSI, incisional reinterventions, or all-cause mortality. Pre-specified and post-hoc analyses suggested that D-PLEX may reduce the incidence of the primary outcome event in patients with increased SSI risk, including lengthy incisions.

Antibiotic Treatment Has No Influence on Anal Fistula Formation and Recurrent Perianal Abscess After Incision and Drainage of Cryptogenic Perianal Abscess: A Randomized Single-Blinded Prospective Study.

BACKGROUND: Anal fistula commonly appears after incision and drainage of a perianal abscess. Theoretically, a fistula develops as a consequence of the infection process. Antibiotic treatment was suggested to decrease the possibility of fistula development. OBJECTIVE: We hypothesized that antibiotic treatment has no influence on the development of anal fistula after surgical treatment of perianal abscess. DESIGN: A single-blinded randomized prospective study. SETTINGS: Patients with primary cryptogenic abscesses were eligible to participate. PATIENTS: Patients were divided into 2 groups. Patients in group I received amoxicillin 875 mg/clavulanic acid 125 mg during 7 days after surgery, and patients in group II received no antibiotics. The study database included demographics and clinical and laboratory data. MAIN OUTCOME MEASURES: Patients were examined in our outpatient clinic 2 weeks, 4 months, and 1 year after surgery, and a telephone questionnaire was performed 6 months after surgery. The primary outcome was the formation of anal fistula. The secondary outcome was recurrent perianal abscess. RESULTS: Overall, 98 patients completed the study. Groups were not different in inclusion. Anal fistula was diagnosed in 16 patients (16.3%) in group I (treatment group) and 10 patients (10.2%) in group II (control group; p = 0.67). Nine patients (9.2%) developed recurrent perianal abscess, 4 in the treatment group and 5 in the control group ( p = 0.73). LIMITATIONS: A relatively small number of patients were treated in a single medical center. CONCLUSION: Antibiotic therapy has no influence on anal fistula or recurrent perianal abscess formation after incision and drainage of perianal abscess. See Video Abstract . EL TRATAMIENTO CON ANTIBITICOS NO TIENE INFLUENCIA EN LA FORMACIN DE FSTULA ANAL Y EN EL ABSCESO PERIANAL RECURRENTE DESPUS DE LA INCISIN Y DRENAJE DE UN ABSCESO PERIANAL CRIPTOGNICO UN ESTUDIO PROSPECTIVO ALEATORIZADO, SIMPLE CIEGO: ANTECEDENTES:La fístula anal comúnmente aparece después de la incisión y drenaje de un absceso perianal. Teóricamente, la fístula se desarrolla como consecuencia del proceso infeccioso. Se sugirió tratamiento antibiótico para disminuir la posibilidad de desarrollo de fístula.OBJETIVO:Hipotetizamos que el tratamiento con antibióticos no tiene influencia en el desarrollo de fístula anal después del tratamiento quirúrgico del absceso perianal.DISEÑO:Estudio prospectivo, aleatorio, simple ciego.AJUSTE Y PACIENTES:Los pacientes con absceso criptogénico primario fueron elegibles para participar. Los pacientes se dividieron en dos grupos. Los pacientes del Grupo I recibieron amoxicilina 875 mg/ácido clavulánico 125 mg durante los 7 días posteriores a la cirugía y los pacientes del Grupo II no recibieron antibióticos. La base de datos del estudio incluyó datos demográficos, clínicos y de laboratorio.PRINCIPALES MEDIDAS DE RESULTADO:Los pacientes fueron examinados en nuestra clínica ambulatoria 2 semanas, cuatro meses y 1 año después de la cirugía y se realizó un cuestionario telefónico 6 meses después de la cirugía. El resultado primario fue la formación de una fístula anal. El resultado secundario fue el absceso perianal recurrente.RESULTADOS:En total, 98 pacientes completaron el estudio. Los grupos no fueron diferentes en cuanto a la inclusión. Se diagnosticó fístula anal en 16 (16,3%) pacientes del Grupo I (grupo de tratamiento) y 10 (10,2%) pacientes del Grupo II (grupo control) (p = 0,67). Nueve pacientes (9,2%) desarrollaron absceso perianal recurrente, 4 en el grupo de tratamiento y 5 en el grupo control (p = 0,73).LIMITACIONES:Número relativamente pequeño de pacientes tratados en un solo centro médico.CONCLUSIÓN:La terapia con antibióticos no tuvo influencia sobre la fístula anal o la formación de absceso perianal recurrente después de la incisión y drenaje del absceso perianal. (Traducción - Dr. Fidel Ruiz Healy ).

The multi-societal European consensus on the terminology, diagnosis and management of patients with synchronous colorectal cancer and liver metastases: an E-AHPBA consensus in partnership with ESSO, ESCP, ESGAR, and CIRSE.

BACKGROUND: Contemporary management of patients with synchronous colorectal cancer and liver metastases is complex. The aim of this project was to provide a practical framework for care of patients with synchronous colorectal cancer and liver metastases with a focus on terminology, diagnosis and management. METHODS: This project was a multi-organisational, multidisciplinary consensus. The consensus group produced statements which focused on terminology, diagnosis and management. Statements were refined during an online Delphi process and those with 70% agreement or above were reviewed at a final meeting. Iterations of the report were shared by electronic mail to arrive at a final agreed document comprising twelve key statements. RESULTS: Synchronous liver metastases are those detected at the time of presentation of the primary tumour. The term "early metachronous metastases" applies to those absent at presentation but detected within 12 months of diagnosis of the primary tumour with "late metachronous metastases" applied to those detected after 12 months. Disappearing metastases applies to lesions which are no longer detectable on MR scan after systemic chemotherapy. Guidance was provided on the recommended composition of tumour boards and clinical assessment in emergency and elective settings. The consensus focused on treatment pathways including systemic chemotherapy, synchronous surgery and the staged approach with either colorectal or liver-directed surgery as first step. Management of pulmonary metastases and the role of minimally invasive surgery was discussed. CONCLUSIONS: The recommendations of this contemporary consensus provide information of practical value to clinicians managing patients with synchronous colorectal cancer and liver metastases.

Multisocietal European consensus on the terminology, diagnosis, and management of patients with synchronous colorectal cancer and liver metastases: an E-AHPBA consensus in partnership with ESSO, ESCP, ESGAR, and CIRSE.

BACKGROUND: Contemporary management of patients with synchronous colorectal cancer and liver metastases is complex. The aim of this project was to provide a practical framework for care of patients with synchronous colorectal cancer and liver metastases, with a focus on terminology, diagnosis, and management. METHODS: This project was a multiorganizational, multidisciplinary consensus. The consensus group produced statements which focused on terminology, diagnosis, and management. Statements were refined during an online Delphi process, and those with 70 per cent agreement or above were reviewed at a final meeting. Iterations of the report were shared by electronic mail to arrive at a final agreed document comprising 12 key statements. RESULTS: Synchronous liver metastases are those detected at the time of presentation of the primary tumour. The term 'early metachronous metastases' applies to those absent at presentation but detected within 12 months of diagnosis of the primary tumour, the term 'late metachronous metastases' applies to those detected after 12 months. 'Disappearing metastases' applies to lesions that are no longer detectable on MRI after systemic chemotherapy. Guidance was provided on the recommended composition of tumour boards, and clinical assessment in emergency and elective settings. The consensus focused on treatment pathways, including systemic chemotherapy, synchronous surgery, and the staged approach with either colorectal or liver-directed surgery as first step. Management of pulmonary metastases and the role of minimally invasive surgery was discussed. CONCLUSION: The recommendations of this contemporary consensus provide information of practical value to clinicians managing patients with synchronous colorectal cancer and liver metastases.

Chronic pain following totally extra-peritoneal inguinal hernia repair: a randomized clinical trial comparing glue and absorbable tackers.

PURPOSE: Chronic pain following inguinal hernia repair occurs in up to 20% of patients. The underlying mechanism probably involves sensory nerve damage and abnormal healing that might be influenced by the materials chosen for mesh fixation. The main objective of this study was to compare glue and absorbable tackers on the rate of chronic pain after surgery in patients undergoing totally extraperitoneal inguinal hernia repair (TEP). METHODS: Patients undergoing (TEP) inguinal hernia repair were enrolled in a single-blind randomized clinical trial and were randomized for mesh fixation with glue (LIQUIBAND FIX 8 Neopharm) or absorbable tackers (SECURE STRAP Johnson & Johnson). Pain was assessed using a validated 4-point verbal-rank scale (none, mild, moderate, and severe) at 1 week, 1 month, 6 months, and 1 year postoperatively. Chronic pain was defined as pain persisting beyond 3 months. RESULTS: Two hundred and eight patients were analyzed. The groups were similar in age, gender, and hernia side. Chronic pain of any intensity was reported in 31.7% (66/208) after 6 months and in 13% (29/208) after 12 months. No differences in postoperative pain were observed between the two forms of mesh fixation. Still, when only those with severe pain were considered, mesh fixation with glue resulted in less pain compared to fixation by tackers (log-rank p = 0.025). At 1 year, 4 symptomatic recurrent hernias were identified in patients whose mesh was fixated with absorbable tackers. CONCLUSIONS: Patients who underwent TEP inguinal hernia repair with mesh fixated by glue suffered from less pain.

Reduction in surgical site infections by localized administration with D-PLEX100 in patients with multiple risk factors undergoing colorectal surgery.

BACKGROUND: D-PLEX100 is a novel drug-eluting lipid polymer matrix that supplies a high, local concentration of doxycycline for approximately 30 days. The objective of this post-hoc analysis was to assess the efficacy of D-PLEX100 in preventing superficial and deep SSIs in patients with ≥2 risk factors. PATIENTS AND METHODS: A post-hoc analysis of a previously reported prospective randomized trial assessing D-PLEX100 plus Standard of Care (SOC) versus SOC alone in colorectal surgery was performed to assess SSI rate in patients with ≥2 risk factors. RESULTS: The overall incidence of SSI was significantly lower for the D-PLEX100 arm (9.9%) versus SOC (21%), p = 0.033. Patients with ≥2 risk factors, SSI incidence was 37.5% for SOC and 15.8% in D-PLEX100 treated patients. CONCLUSIONS: D-PLEX100 reduces the incidence of SSIs beyond benefits associated with SOC treatment alone and including patients with ≥2 risk factors. D-PLEX100 may be a promising addition to established SSI prophylaxis bundles.

Use of fluorescence imaging and indocyanine green during colorectal surgery: Results of an intercontinental Delphi survey.

BACKGROUND: Fluorescence imaging with indocyanine green is increasingly being used in colorectal surgery to assess anastomotic perfusion, and to detect sentinel lymph nodes. METHODS: In this 2-round, online, Delphi survey, 35 international experts were asked to vote on 69 statements pertaining to patient preparation and contraindications to fluorescence imaging during colorectal surgery, indications, technical aspects, potential advantages/disadvantages, and effectiveness versus limitations, and training and research. Methodological steps were adopted during survey design to minimize risk of bias. RESULTS: More than 70% consensus was reached on 60 of 69 statements, including moderate-strong consensus regarding fluorescence imaging's value assessing anastomotic perfusion and leak risk, but not on its value mapping sentinel nodes. Similarly, although consensus was reached regarding most technical aspects of its use assessing anastomoses, little consensus was achieved for lymph-node assessments. Evaluating anastomoses, experts agreed that the optimum total indocyanine green dose and timing are 5 to 10 mg and 30 to 60 seconds pre-evaluation, indocyanine green should be dosed milligram/kilogram, lines should be flushed with saline, and indocyanine green can be readministered if bright perfusion is not achieved, although how long surgeons should wait remains unknown. The only consensus achieved for lymph-node assessments was that 2 to 4 injection points are needed. Ninety-six percent and 100% consensus were reached that fluorescence imaging will increase in practice and research over the next decade, respectively. CONCLUSION: Although further research remains necessary, fluorescence imaging appears to have value assessing anastomotic perfusion, but its value for lymph-node mapping remains questionable.

Clinical Presentation of Acute Cholecystitis during the COVID-19 Outbreak.

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic has had a significant impact on healthcare systems worldwide. The fear of seeking medical attention to avoid the possibility of being infected may have altered the course of some diseases. OBJECTIVES: To describe our experience with the management of patients with acute cholecystitis during the pandemic at our medical center. METHODS: We compared patients treated for acute cholecystitis between 1 March and 31 August 2020 (Group I) to patients admitted with the same diagnosis during the same months in 2019 (Group II). We evaluated demographics, presenting symptoms, laboratory and imaging findings at presentation, the disease's clinical course, management, and outcome. RESULTS: Group I consisted of 101 patients and group II included 94 patients. No differences were noted for age (66 years, IQR 48-78 vs. 66 years, IQR 47-76; P = 0.50) and sex (57.4% vs. 51.1% females; P = 0.39) between the two groups. The delay between symptom onset and hospital admission was longer for Group I patients (3 days, IQR 2-7 vs. 2 days, IQR 1-3; P = 0.002). Moderate to severe disease was more commonly encountered in Group I (59.4% vs. 37.2%, P = 0.003). Group I patients more often failed conservative management (36% vs. 6%, P = 0.001) and had a higher conversion rate to open surgery (15.4% vs. 0%, P = 0.025). CONCLUSIONS: Patients presenting with acute cholecystitis during the COVID-19 pandemic more often presented late to the emergency department and more showed adverse outcomes.