European Society of Coloproctology: Guidelines for diagnosis and treatment of cryptoglandular anal fistula.

AIM: The primary aim of the European Society of Coloproctology (ESCP) Guideline Development Group (GDG) was to produce high-quality, evidence-based guidelines for the management of cryptoglandular anal fistula with input from a multidisciplinary group and using transparent, reproducible methodology. METHODS: Previously published methodology in guideline development by the ESCP has been replicated in this project. The guideline development process followed the requirements of the AGREE-S tool kit. Six phases can be identified in the methodology. Phase one sets the scope of the guideline, which addresses the diagnostic and therapeutic management of perianal abscess and cryptoglandular anal fistula in adult patients presenting to secondary care. The target population for this guideline are healthcare practitioners in secondary care and patients interested in understanding the clinical evidence available for various surgical interventions for anal fistula. Phase two involved formulation of the GDG. The GDG consisted of 21 coloproctologists, three research fellows, a radiologist and a methodologist. Stakeholders were chosen for their clinical and academic involvement in the management of anal fistula as well as being representative of the geographical variation among the ESCP membership. Five patients were recruited from patient groups to review the draft guideline. These patients attended two virtual meetings to discuss the evidence and suggest amendments. In phase three, patient/population, intervention, comparison and outcomes questions were formulated by the GDG. The GDG ratified 250 questions and chose 45 for inclusion in the guideline. In phase four, critical and important outcomes were confirmed for inclusion. Important outcomes were pain and wound healing. Critical outcomes were fistula healing, fistula recurrence and incontinence. These outcomes formed part of the inclusion criteria for the literature search. In phase five, a literature search was performed of MEDLINE (Ovid), PubMed, Embase (Ovid) and the Cochrane Database of Systematic Reviews by eight teams of the GDG. Data were extracted and submitted for review by the GDG in a draft guideline. The most recent systematic reviews were prioritized for inclusion. Studies published since the most recent systematic review were included in our analysis by conducting a new meta-analysis using Review manager. In phase six, recommendations were formulated, using grading of recommendations, assessment, development, and evaluations, in three virtual meetings of the GDG. RESULTS: In seven sections covering the diagnostic and therapeutic management of perianal abscess and cryptoglandular anal fistula, there are 42 recommendations. CONCLUSION: This is an up-to-date international guideline on the management of cryptoglandular anal fistula using methodology prescribed by the AGREE enterprise.

Comparison of Linear versus Circular-Stapled Gastroenterostomy in Roux-en-Y Gastric Bypass: A Nationwide Population-Based Cohort Study.

BACKGROUND: When performing a Roux-en-Y gastric bypass (RYGB), the gastroenterostomy can be constructed with a circular stapled or linear stapled technique. The size of the gastroenterostomy depends on the stapling method and this may affect weight loss outcomes. The aim of this study was to examine the impact of the stapling technique on weight loss outcomes after RYGB. METHODS: This is a nationwide population-based cohort study of patients that received a RYGB. Data were derived from the Dutch Audit of Treatment of Obesity. Primary outcome was the impact of stapling technique on the rate of non-response defined as significant weight regain (≥20% of a patients' lost weight) 2-4 years post-surgery, after initial successful weight loss (≥20% total weight loss, TWL). Secondary outcomes were the rate of response, defined as successful weight loss (≥20% TWL) within 1.5 years post-surgery, the incidence of complications and the progression of comorbidities. RESULTS: In a cohort of 12,468 patients, non-response was equally distributed between both groups (circular 18.0% vs. linear 17.6%). No differences in response rate (circular 97.0% vs. linear 96.5%) or %TWL were observed up to 4 years post-surgery. Patients in the circular stapled group experienced more complications, specifically major bleedings (2.4% vs. 1.2%; p=0.002) within 30 days postoperatively. No differences were found in deteriorated comorbidities, neither in de novo developed comorbidities. CONCLUSION: When comparing stapling technique in RYGB, weight loss outcomes did not differ during a 4-year follow-up period. The linear stapled gastroenterostomy could pose an advantage due to its lower complication rate.

Laparoscopic transdiaphragmatic pericardial fenestration in palliative care: how I do it.

BACKGROUND: The optimal therapeutic strategy for drainage of malignant pericardial effusion is not yet determined. Several techniques are described, with different benefits and disadvantages. The literature suggests that surgical drainage of pericardial effusions has less effusion recurrence; however, randomized controlled trials are not available. Due to the nature of the disease, quality of life should always be considered while making treatment decisions. METHODS: A retrospective analysis of all consecutive patients from November 2016 until June 2019 of our institution in the Netherlands was performed. All patients underwent laparoscopic pericardial fenestration after echocardiography and request for operative treatment by the cardiologist. The same operation technique was performed in every case. RESULTS: Four out of five of our patients needed pericardial fenestration because of oncological diseases. No hemodynamically instability was noted during this fast technique, achieving direct relief of symptoms. No treatment-related morbidity or mortality, nor the need for re-intervention was encountered. We compared the outcome of our five patients with the existing evidence in the literature. CONCLUSIONS: In this article, we highlight the laparoscopic transdiaphragmatic pericardial fenestration as a treatment of preference in a non-acute palliative setting. This laparoscopic approach is safe, and can be a valuable alternative among the other well-known approaches.

Ligation of the Intersphincteric Fistula Tract for High Transsphincteric Fistula Yields Moderate Results at Best: Is the Tide Turning?

BACKGROUND: Ligation of the intersphincteric fistula tract is a well-accepted and often used surgical procedure for perianal fistulas. OBJECTIVE: This study aims to confirm results of the ligation of the intersphincteric fistula tract in a specialized colorectal center. DESIGN: This is a retrospective cohort study. SETTING: This study took place in a large colorectal surgical department with a tertiary referral center for perianal fistulas. PATIENTS: Consecutive patients were operated on with ligation of the intersphincteric fistula tract for a transsphincteric perianal fistula between 2012 and December 2018. INTERVENTIONS: Patients underwent ligation of the intersphincteric fistula tract. MAIN OUTCOME MEASURES: The primary outcome measured was the healing rate. The secondary outcomes measured were conversion into an intersphincteric perianal fistula, risk of recurrence, complications, and postoperative continence status. RESULTS: Forty-six patients were treated with a ligation of intersphincteric fistula tract procedure. All patients (100%) had preoperative imaging in their workup. Forty patients (87%) had a high transsphincteric fistula. The primary healing rate was a disappointing 17 of 46 patients (37%). The median time until failure was 4.2 months (interquartile range, 3.5-6.5). Of the failures, 16 converted to an intersphincteric fistula (55% of failures and 35% of all patients). The mean duration of follow-up in patients without a recurrence was 9.5 months (SD 11.9). Four patients (9%) were lost to follow-up. The mean Fecal Incontinence Severity Index postoperatively was only 2.35 (SD 5.7; range, 0-30). This resulted in 9 patients (20%) having a newly impaired continence status postoperatively. Continence impairment was mild in all these patients. The risk of developing a recurrence 1 year after surgery is 64.2% (95% CI, 49%-80%). LIMITATIONS: This study was limited by its retrospective design and the small numbers with possible selection bias. CONCLUSIONS: Results with the ligation of intersphincteric fistula tract procedure were not as good as hoped. The effect on fecal continence, however, was minimal. The procedure might be more suitable for low transsphincteric fistulas. See Video Abstract at http://links.lww.com/DCR/A992. LA LIGADURA DEL TRACTO DE LA FÍSTULA INTERESFINTÉRICA PARA UNA FÍSTULA TRANSESFINTÉRICA ALTA, PRODUCE RESULTADOS MODERADOS EN EL MEJOR DE LOS CASOS: ¿ESTÁ CAMBIANDO LA MAREA?: La ligadura del tracto de la fístula interesfintérica es un procedimiento quirúrgico bien aceptado y de uso frecuente para las fístulas perianales. OBJETIVO: Confirmar los resultados de la ligadura del tracto de la fístula interesfintérica en un centro colorrectal especializado. DISEÑO:: Estudio de cohorte retrospectivo. AJUSTE: Gran departamento de cirugía colorrectal y con centro de referencia terciaria para fístulas perianales. PACIENTES: Pacientes consecutivos operados con ligadura del tracto de la fístula interesfintérica para una fístula perianal transesfintérica, entre 2012 y diciembre de 2018. INTERVENCIONES: Ligadura del tracto de fístula interesfintérica. PRINCIPALES MEDIDAS DE RESULTADO: Tasa de cicatrización, resultados secundarios: conversión a una fístula perianal interesfintérica, riesgo de recurrencia, complicaciones y estado de continencia postoperatoria. RESULTADOS: Cuarenta y seis pacientes fueron tratados con una ligadura del tracto de la fístula interesfintérica. Todos los pacientes (100 por ciento) tenían imagenología en su preparación preoperatoria. Cuarenta pacientes (87 por ciento) tenían una fístula transesfintérica alta. La tasa de cicatrización primaria fue decepcionante en 17 de 46 pacientes (37 por ciento). El tiempo medio hasta el fracaso fue de 4.2 meses (rango intercuartil 3.5-6.5). De los fracasos, 16 se convirtieron en una fístula interesfintérica (55 por ciento de los fracasos y 35 por ciento de todos los pacientes). La duración media del seguimiento en pacientes sin recurrencia fue de 9.5 meses (desviación estándar de 11.9). Se perdieron durante el seguimiento a cuatro pacientes (9 por ciento). Después de la operación, el promedio del índice de severidad de incontinencia fecal fue de solo 2.35 (desviación estándar de 5.7, rango 0-30). Esto resultó en que 9 pacientes (20 por ciento) tuvieran una continencia deteriorada postoperatoria. El deterioro de la continencia fue leve en todos estos pacientes. El riesgo de desarrollar una recurrencia a un año después de la cirugía es del 64.2 por ciento (intervalo de confianza del 95 por ciento: 49-80 por ciento). LIMITACIONES: Diseño retrospectivo, números pequeños con posible sesgo de selección. CONCLUSIONES: Los resultados del procedimiento con la ligadura del tracto de fístula interesfintérica no fueron tan buenos como se esperaba. El efecto sobre la continencia fecal, sin embargo, fue mínimo. El procedimiento podría ser más adecuado para las fístulas transesfintéricas bajas. Vea el Resumen del video en http://links.lww.com/DCR/A992.

Time trends in the epidemiology and outcome of perianal fistulizing Crohn's disease in a population-based cohort.

OBJECTIVE: Perianal disease is a debilitating condition that frequently occurs in Crohn's disease (CD) patients. It is currently unknown whether its incidence has changed in the era of frequent immunomodulator use and biological availability. We studied the incidence and outcome of perianal and rectovaginal fistulas over the past two decades in our population-based Inflammatory Bowel Disease South-Limburg cohort. PATIENTS AND METHODS: All 1162 CD patients registered in the Inflammatory Bowel Disease South-Limburg registry were included. The cumulative probabilities of developing a perianal and rectovaginal fistula were compared between three eras distinguished by the year of CD diagnosis: 1991-1998, 1999-2005 and 2006-2011. Second, clinical risk factors and the risk of fistula recurrence were determined. RESULTS: The cumulative 5-year perianal fistula rate was 14.1% in the 1991-1998 era, 10.4% in the 1999-2005 era and 10.3% in the 2006-2011 era, P=0.70. Colonic disease was associated with an increased risk of developing perianal disease, whereas older age was associated with a decreased risk (both P<0.01). Over time, more patients were exposed to immunomodulators or biologicals before fistula diagnosis (18.5 vs. 32.1 vs. 52.1%, respectively, P=0.02) and started biological therapy thereafter (18.6 vs. 34.1 vs. 54.0%, respectively, P<0.01). The cumulative 5-year perianal fistula recurrence rate was not significantly different between eras (19.5 vs. 25.5 vs. 33.1%, P=0.28). In contrast, the cumulative 5-year rectovaginal rate attenuated from 5.7% (the 1991-2005 era) to 1.7% (the 2006-2011 era), P=0.01. CONCLUSION: Over the past two decades, the risk of developing a perianal fistula was stable, as well as its recurrence rate, underlining the lasting need for improving treatment strategies for this invalidating condition.

The disappointing quality of published studies on operative techniques for rectovaginal fistulas: a blueprint for a prospective multi-institutional study.

BACKGROUND: Treatment of rectovaginal fistulas is difficult, and many surgical interventions have been developed. The best surgical intervention for the closure of these fistulas is still unclear. OBJECTIVE: A systematic review was performed reporting the outcomes of different surgical techniques for rectovaginal fistulas. DATA SOURCES: Medline (PubMed, Ovid), Embase (Ovid), and The Cochrane Library databases were searched for eligible articles as well as the references of these articles. STUDY SELECTION: Two independent reviewers analyzed the search results for eligible articles based on title, abstract, and described results. INTERVENTION(S): Any surgical intervention for the closure of rectovaginal fistulas was included. MAIN OUTCOME MEASURES: The main outcome was closure rate. Secondary outcomes were quality of life, morbidity, and the effect on sexual functioning. RESULTS: Many articles with different operative techniques were identified and classified in the following categories: advancement flaps (endorectal and endovaginal), transperineal closure, Martius procedure, gracilis muscle transposition, rectal resections, transabdominal closure, mesh repair, plugs, endoscopic repairs, closure with biomaterials, and miscellaneous techniques. Results vary widely with closure rates between 0% and >80%. None of the studies were randomized. Because of the poor quality of the identified studies, the comparison of results and performance of a meta-analysis were not possible.Data regarding the secondary outcomes were mostly unavailable. LIMITATIONS: The major limitation of this review was the limited availability of high-quality prospective studies, making it impossible to perform a meta-analysis. CONCLUSIONS: No conclusion about the best surgical intervention for rectovaginal fistulas could be formulated. More large studies of high quality are needed to find the best treatment for rectovaginal fistulas. A design for these high-quality studies was formulated.

Long-term results of mucosal advancement flap combined with platelet-rich plasma for high cryptoglandular perianal fistulas.

BACKGROUND: The long-term closure rate of high perianal fistulas after surgical treatment remains disappointing. OBJECTIVE: The goal of this study was to improve the long-term closure rate of high cryptoglandular perianal fistulas combining mucosal advancement flap with platelet-rich plasma. DESIGN: This study was retrospective in design. SETTING: This study was conducted at 2 secondary and 1 tertiary referral hospitals. PATIENTS: Patients presenting with high cryptoglandular perianal fistulas involving the middle/upper third of the anal sphincter complex were included. INTERVENTIONS: A staged surgical treatment was performed; After seton placement, a mucosal advancement flap was combined with platelet-rich plasma. MAIN OUTCOME MEASURES: Recurrence was the main outcome. Incontinence was the secondary outcome. RESULTS: We operated on 25 patients between 2006 and 2012. Thirteen (52%) patients had previous fistula surgery. The median follow-up period was 27 months. One patient (4.0%) was lost to follow-up after 4 months. Freedom from recurrence at 2 years was 0.83 (95% CI, 0.62-0.93). Two of the 4 patients with a recurrence (8%) had a repeated treatment and healed. One patient (4.0%) refused another treatment, but agreed to stay in follow-up. One patient (4.0%) requested a colostomy, resulting in closure of the fistula. Complications occurred in 1 patient (4.0%). Incontinence numbers were low with a median Vaizey score of 3.0 out of a maximum of 24. LIMITATIONS: The study was limited by its retrospective design, lack of preoperative incontinence data, selection bias, and phone interview follow-up. CONCLUSION: The long-term outcome results of patients with primary and recurrent high cryptoglandular perianal fistulas treated with a seton followed by mucosal advancement flap and platelet-rich plasma show low recurrence, complication, and incontinence rates. Therefore, this technique seems to be a valid option as treatment. Larger and preferably randomized controlled studies are needed to further explore this surgical technique.

Pulsed Electromagnetic Fields in the treatment of fresh scaphoid fractures. A multicenter, prospective, double blind, placebo controlled, randomized trial.

BACKGROUND: The scaphoid bone is the most commonly fractured of the carpal bones. In the Netherlands 90% of all carpal fractures is a fracture of the scaphoid bone. The scaphoid has an essential role in functionality of the wrist, acting as a pivot. Complications in healing can result in poor functional outcome. The scaphoid fracture is a troublesome fracture and failure of treatment can result in avascular necrosis (up to 40%), non-union (5-21%) and early osteo-arthritis (up to 32%) which may seriously impair wrist function. Impaired consolidation of scaphoid fractures results in longer immobilization and more days lost at work with significant psychosocial and financial consequences.Initially Pulsed Electromagnetic Fields was used in the treatment of tibial pseudoarthrosis and non-union. More recently there is evidence that physical forces can also be used in the treatment of fresh fractures, showing accelerated healing by 30% and 71% reduction in nonunion within 12 weeks after initiation of therapy. Until now no double blind randomized, placebo controlled trial has been conducted to investigate the effect of this treatment on the healing of fresh fractures of the scaphoid. METHODS/DESIGN: This is a multi center, prospective, double blind, placebo controlled, randomized trial. Study population consists of all patients with unilateral acute scaphoid fracture. Pregnant women, patients having a life supporting implanted electronic device, patients with additional fractures of wrist, carpal or metacarpal bones and pre-existing impairment in wrist function are excluded. The scaphoid fracture is diagnosed by a combination of physical and radiographic examination (CT-scanning).Proven scaphoid fractures are treated with cast immobilization and a small Pulsed Electromagnetic Fields bone growth stimulating device placed on the cast. Half of the devices will be disabled at random in the factory.Study parameters are clinical consolidation, radiological consolidation evaluated by CT-scanning, functional status of the wrist, including assessment by means of the patient rated wrist evaluation (PRWE) questionnaire and quality of life using SF-36 health survey questionnaire.Primary endpoint is number of scaphoid unions at six weeks, secondary endpoints are time interval to clinical and radiological consolidation, number of non-unions, functional status at 52 weeks and non-adherence to the treatment protocol. TRIAL REGISTRATION: Netherlands Trial Register (NTR): NTR2064.

Early removal of the chest tube after complete video-assisted thoracoscopic lobectomies.

OBJECTIVE: Chest tubes induce morbidity such as pain, decrease mobility, increase the risk of infection, and prolong the length of hospital stays. This study evaluates a chest-tube protocol containing a high-drainage threshold and a short time period of drainage. METHODS: A retrospective study was performed with data collected from all elective complete video-assisted thoracoscopic (c-VATS) (bi-)lobectomies between March 2006 and December 2009. All patients had one chest-tube, postoperatively. The chest tube was removed if there was no air leakage and there was a drainage volume of 400 ml (24 h)(-1) or less. We aimed to remove the chest tube on postoperative day 1. RESULTS: This series consists of 110 lobectomies and six bilobectomies. The median duration of chest-tube placement was 1.0 day. In 58.8% of patients (confidence interval (CI) 95%: 49.5-68.0), the drain was removed within 24 h of operation and in 82.5% (CI 95%: 74.2-88.7) within 48 h. In six (6.2%) patients, subcutaneous emphysema developed while the drain was still in place, and was treated with removal of the drain. Persistent air leakage was seen in four (3.4%) patients. One (0.9%) persisting pneumothorax was diagnosed. A pneumothorax after removal of the drain was not diagnosed. No major complications developed in 98 patients (84.5%). The median day of discharge was postoperative day 4. CONCLUSIONS: This study shows it is safe, after c-VATS (bi-)lobectomy, to remove the chest tube within 24 h in 58.8%, and within 48 h in 82.5% of patients. As was also shown in other studies, this leads to shorter length of hospital stays, lower costs, and most importantly, reduces patient morbidity without the added risk of complications.