Healing Peristomal Wounds Around Retracted Stomas with Negative-Pressure Wound Therapy: A Case Series.

ABSTRACT: One method for treating a retracted stoma is a vacuum dressing that cleans the wound and protects against intestinal leakage. This case series describes the use of an integrated, single-use negative-pressure wound therapy (NPWT) dressing to treat retracted stomas as an alternative to other noninvasive remedies. The report includes seven patients who were hospitalized in the authors' surgical department from 2019 to 2020. All patients developed severe peristomal infection that failed to respond to local treatment with proper ostomy appliances or specialist dressings. After cleaning each wound and removing necrotic lesions, the authors applied a single-use hydrofiber NPWT dressing to each patient. The dressing was changed every 2 to 5 days, depending on the effects of the therapy. The stoma orifice was covered with a bag with two-piece ostomy systems. The peristomal wound healed in all cases, and leakage was eliminated. The mean time of treatment was 14 days (range, 10-21 days), and the vacuum dressings were changed an average of four times (range, 3-7 times). None of the patients required a stoma translocation or other additional surgery. Three patients received systemic IV antibiotic therapy to treat general infection. Single-use NPWT dressings protect peristomal wounds from bowel leakage and do not hinder the application of stoma bags. This system, similar to standard NPWT devices, effectively protects infected stomas from retraction.

Dehiscence of colorectal anastomosis treated with noninvasive procedures.

Introduction: Most postoperative rectal leakages can be successfully treated with minimally invasive procedures. Endoscopic vacuum therapy supported by tissue adhesives or cellular growth stimulants closes even chronic anastomotic fistulas. Aim: To present a treatment strategy for postoperative leakage of rectal anastomoses with noninvasive procedures. Material and methods: From 2015 to 2020, a group of 25 patients with postoperative rectal leakage was enrolled for minimally invasive treatment. The indication for the therapy was anastomotic dehiscence not exceeding 1/2 of the bowel circuit and the absence of severe septic complications. All patients were healed with endoluminal vacuum therapy (EVT) supported by hemostatic clips, tissue adhesives or cellular growth stimulants. Results: Complete drainage and reduction of leakage were achieved in 23 patients. The fistula was totally closed in 21 patients and in 2 of them it was restricted to a slit sinus. Two patients required revision surgery. Endoscopic treatment attempted within 7 days from leakage detection, as well as the size of the dehiscence less than 1/4 of the bowel circuit, increased the chance of full healing. In contrast, ultra low resection and neoadjuvant radiotherapy impaired the healing process, limiting the effectiveness of noninvasive therapy. Conclusions: The minimally invasive approach successfully restricts anastomotic leakage and reduces the diameter of dehiscence. Early initiation of the therapy and the size of rupture determine the final results. The use of complementary endoscopic solutions, such as clips or tissue adhesives, increases the effectiveness of the noninvasive strategy.

Minimally Invasive Treatment of Recurrent Anal Fistulas with Autologous Platelet-Rich Plasma Combined With Internal Orifice Closure.

AIM: Minimally invasive procedures for the treatment of anal fistulas are gaining more and more popularity. For this purpose, Platelet-Rich Plasma (PRP) are administered to accelerate the healing process of various difficult wounds or lesions. The aim of this study was to evaluate preliminary results of PRP injection into the tissues adjacent to anal fistulas. PATIENTS AND METHODS: A cohort of 42 patients with recurrent anal fistula, who underwent at least one cutting procedure previously, were enrolled into this preliminary and prospective trial. Closure of internal orifice was performed in all investigated patients, however, in 22 patients from group I, that procedure was combined with topical injection of PRP. In the postoperative period, the PRP administration could be repeated in case of incomplete fistula closure. Follow-up consisted of out-patient visits in a fortnight, 1, 2, and 12 months. RESULTS: Complete closure of anal fistulas was achieved in 16 (75%) patients from group I and 10 (45,5%) patients from group II. The fistulas were healed in 9 patients from group I after single application of PRP. In the next 9 patients with incomplete fistula closure, the injection was repeated 2 to 4 times every fortnight leading finally to complete recovery in 6 of them. CONCLUSIONS: Surgical fistula closure with local PRP application spares the anal sphincter and gives the opportunity to repeat the procedure several times if necessary. Treatment of recurrent anal fistulas with PRP can be considered as last resort therapy.

Comparison between application of platelet rich plasma and mucosal advancement flap in patients with high transsphincteric anal fistulas: a randomized control trial.

BACKGROUND: There is still a search for a standard method of therapy for high anal fistulas. The aim of this trial was a comparison between a modified two stage minimally invasive procedure, consisting of loose-seton placement with the subsequent application of platelet rich plasma with mucosal advancement flap for the treatment of high transsphincteric anal fistulas of crypto-glandular origin. METHODS: The study was designed as a prospective, randomized trial including 96 patients. Curettage of fistulous tracts, and loose-seton placement was performed in those patients with active inflammation, and if the diameter of a fistulous tract exceeded 3 mm. Afterwards, the patients were randomly assigned to either the PRP group or MAF group, consisting of 49 patients, and 47 patients, respectively. RESULTS: There was no significant statistical difference (p = 0.152) between both investigated groups of patients regarding closure of fistulas since it was achieved in 35 (71.43%) patients from group I, compared to 27 (57.45%) patients from group II. The diameter of fistulous tracts below 4 mm exerted a significant impact (p < 0.001) on the healing process after PRP application because fistulas with the narrow tracts were closed in 34 (87.18%) patients, whereas a wider fistula was healed in 1 (10%) patient. CONCLUSION: The local application of PRP in high, unbranched, and with narrow tracts trans-sphincteric anal fistulas of crypto-glandular origin, following loose-seton drainage is an effective, simple, and a safe method of therapy with a low rate of morbidity.

Application of platelet-rich plasma in rectovaginal fistulas in the patients with ulcerative colitis.

BACKGROUND: There is a need for other than surgical methods of therapy for small and low rectovaginal fistulas (RVF) in the course of inflammatory bowel diseases (IBD), such as application of fibrin sealants, stem cells, biological therapy, or platelet-rich plasma. The aim of this study was to evaluate the results of the treatment after local application of PRP in aforementioned fistulas, exclusively in the patients with ulcerative colitis (UC). PATIENTS AND METHODS: Medical records of 13 patients with small and low-lying, active RVF in the course of UC, and after restorative proctocolectomy for UC were evaluated. Curettage of fistulous tracts was performed with the following application of PRP in all patients. RESULTS: Complete closure of RVF was achieved after the first injection in 4 patients, 3 women healed their fistulas following the second application, and two of them closed RVF after 3 injections. To sum up, the complete closure of RVF was achieved in 9 (69%) patients. Fistulas remained closed from 6 to 12 months. CONCLUSIONS: The application of PRP in small, low, and recurrent IBD anal fistulas is effective, simple, and safe with an acceptable rate of healing. This therapy might also precede any further, surgical methods of treatment.

The Role of Diagnostic Management in COVID-19 Screening of Asymptomatic Patients Admitted for Elective Surgery.

BACKGROUND: Due to the high risk of COVID-19 transmission by asymptomatic patients, the aim of this study was to evaluate chest computed tomography (CT) and blood differential test as an additional COVID-19 screening tool for patients undergoing elective or urgent surgery. PATIENTS AND METHODS: The preoperative assessment of 118 patients hospitalized from June to July 2020 included real-time reverse transcriptase polymerase chain reaction RNA test before elective surgery or rapid antigen test in emergency patients. The diagnostics were supplemented by chest CT and a complete blood count with a blood smear in all patients. RESULTS: None of the hospitalized patients had molecular, serological or radiographic symptoms of COVID-19 infection. The chest CT revealed non-COVID-19 pathologies in a total of 48 patients. Leukocytosis and lymphopenia were typical of emergency patients. CONCLUSION: Routine chest CT scans have no benefit in screening for potential COVID-19 changes in asymptomatic patients. Blood differential tests are readily available, which makes them more helpful in COVID-19 screening.

ASSESSMENT OF RECURRENT ANAL FISTULAS TREATMENT WITH PLATELET-RICH PLASMA.

BACKGROUND: Surgical treatment of recurrent anal fistulas can lead to numerous complications, including fecal incontinence. Therefore, sphincter preserving techniques are gaining more popularity. OBJECTIVE: The aim of the study was to assess effectiveness of platelet-rich plasma (PRP) therapy in the patients with recurrent cryptoglandular anal fistulas. METHODS: A cohort of 18 patients with anal fistulas was enrolled into a preliminary and prospective trial. They were divided into two groups consisting of eight and ten patients respectively. PRP was injected locally in all patients, however in the group II it was applied after 7 days drainage of fistulas with polyurethane foam or negative pressure wound therapy. On average, three doses of PRP were administered, but with the opportunity to double the number of applications if it was clinically justified. The patients were evaluated in an out-patient department after fortnight and then in 1, 6, and 12 months following the last PRP application. RESULTS: Anal fistulas were closed in 4 (50%) patients from the group I and in 7 (70%) patients form the group II. Although, the difference between both groups was not statistically significant, PRP therapy should be preceded with fistulous tract drainage in all patients. Summarizing, that successful result was achieved in 11 (60%) patients from the entire group of 18 participants. CONCLUSION: The rate of recurrent cryptoglandular anal fistulas closure reaching 60%, after topical treatment with PRP, exceeds the results of other sphincter-saving methods of treatment. Therefore, it might become a novel method of anal fistulas therapy.

Avaliação do tratamento recorrente de fístulas anais com plasma rico em plaquetas / Assessment of recurrent anal fistulas treatment with platelet-rich plasma

ABSTRACT BACKGROUND: Surgical treatment of recurrent anal fistulas can lead to numerous complications, including fecal incontinence. Therefore, sphincter preserving techniques are gaining more popularity. OBJECTIVE: The aim of the study was to assess effectiveness of platelet-rich plasma (PRP) therapy in the patients with recurrent cryptoglandular anal fistulas. METHODS: A cohort of 18 patients with anal fistulas was enrolled into a preliminary and prospective trial. They were divided into two groups consisting of eight and ten patients respectively. PRP was injected locally in all patients, however in the group II it was applied after 7 days drainage of fistulas with polyurethane foam or negative pressure wound therapy. On average, three doses of PRP were administered, but with the opportunity to double the number of applications if it was clinically justified. The patients were evaluated in an out-patient department after fortnight and then in 1, 6, and 12 months following the last PRP application. RESULTS: Anal fistulas were closed in 4 (50%) patients from the group I and in 7 (70%) patients form the group II. Although, the difference between both groups was not statistically significant, PRP therapy should be preceded with fistulous tract drainage in all patients. Summarizing, that successful result was achieved in 11 (60%) patients from the entire group of 18 participants. CONCLUSION: The rate of recurrent cryptoglandular anal fistulas closure reaching 60%, after topical treatment with PRP, exceeds the results of other sphincter-saving methods of treatment. Therefore, it might become a novel method of anal fistulas therapy.

RESUMO CONTEXTO: O tratamento cirúrgico de fístulas anais recorrentes pode levar a inúmeras complicações, incluindo incontinência fecal. Portanto, as técnicas de preservação do esfíncter estão ganhando mais popularidade. OBJETIVO: O objetivo do estudo foi avaliar a eficácia da terapia de plasma rico em plaquetas (PRP) nos pacientes com fístulas anais criptoglandulares recorrentes. MÉTODOS: Uma coorte de 18 pacientes com fístulas anais foi inscrita em ensaio preliminar e prospectivo. Eles foram divididos em dois grupos compostos por 8 e 10 pacientes, respectivamente. PRP foi injetado localmente em todos os pacientes, porém no grupo II foi aplicado espuma de poliuretano ou terapia de feridas por pressão negativa após 7 dias de drenagem de fístulas. Em média, foram administradas três doses de PRP, mas com a oportunidade de dobrar o número de aplicações se fosse clinicamente justificado. Os pacientes foram avaliados em ambulatório após quinze dias e depois em 1, 6 e 12 meses após a última aplicação do PRP. RESULTADOS: As fístulas anais foram fechadas em 4 (50%) pacientes do grupo I e em 7 (70%) pacientes do grupo II. Embora a diferença entre ambos os grupos não tenha sido estatisticamente significante, a terapia PRP deve ser precedida de drenagem do trato fístulo em todos os pacientes. Resumindo, esse resultado bem-sucedido foi alcançado em 11 (60%) pacientes de todo o grupo de 18 participantes. CONCLUSÃO: A taxa de fechamento recorrente de fístulas anais criptoglandulares chegando a 60%, após tratamento tópico com PRP, excede os resultados de outros métodos de tratamento que preservam o esfíncter. Portanto, pode se tornar um novo método de terapia das fístulas anais.

Endoscopic vacuum assisted closure of esophagogastric anastomosis dehiscence: A case report.

BACKGROUND: Esophagogastric leakage is one of the most severe postoperative complications. Partial disruption of the anastomosis, can be successfully treated with an endoscopic vacuum assisted closure (E-VAC). The advantage of that method of treatment is the ability to adjust a vacuum dressing individually to the size of the dehiscence and thus to reduce the risk of a secondary fistula or abscess. The authors present two patients with postoperative gastroesophageal leakage treated successfully with E-VAC. CASE SUMMARY: Two male patients developed a potentially life threatening esophagogastric leakage. Patient A underwent resection of the distal half of the esophagus and upper part of the stomach due to Siewert type II adenocarcinoma of the gastroesophageal junction. Proximal resection of the stomach was performed in the patient B after massive bleeding from Mallory-Weiss tears. Both patients were treated successfully with an individually adapted E-VAC with concomitant correction of fluid and electrolyte disturbances, and treatment of sepsis with appropriate antibiotics. CONCLUSION: Endoscopic vacuum closure is an effective alternative to endoscopic stenting or relaparotomy. Through individual approach it allows a more accurate assessment of healing.

Atypical and Life-threatening Crohn's Disease Following Colectomy: A Case Report.

Although Crohn's Disease (CD) usually occurs between the second and third decade of life, it also may develop in older adults. Treating elderly patients may be challenging due to other comorbidities, including diverticular disease or intestinal ischemia. PURPOSE: The purpose of this case study was to describe successful treatment of atypical and life-threatening CD due to enterocutaneous fistulas with short-bowel syndrome and multiorgan failure after partial colectomy. CASE REPORT: After an urgent colectomy for an inflammatory colon tumor, a 64-year-old woman with a history of CD and multiple comorbidities developed acute small bowel ischemia. Following an extended bowel resection, she developed a severe surgical site infection, entero- and gastrocutaneous fistulas, multiorgan failure, and short bowel syndrome. Her care included intensive medical and nutritional treatment as well as negative pressure wound therapy (NPWT) using continuous negative pressure of -80 mm Hg. She not only survived, but she also achieved complete wound closure and restoration of digestive tract continuity and metabolic control. She was discharged with a central venous catheter on total parenteral nutrition. CONCLUSION: In this case study, a good outcome was observed using intensive medical treatment, nutritional therapy, and conservative surgical treatment that included NPWT for a patient with CD and major comorbidities who developed postoperative complications.

Treatment of Crohn's anal fistulas guided by magnetic resonance imaging.

INTRODUCTION: Clinical evaluation of the Crohn's anal fistulas (CF) closure is inadequate to some extent due to earlier closure of cutaneous openings compared to fistulous tracts. There is a need for a more accurate method of assessment. AIM: To compare clinical signs of CF with radiological findings, before and after treatment, to follow complete closure. MATERIAL AND METHODS: It was a retrospective study of 23 patients suffering from CF admitted to a single specialist centre, who were treated with a combination of surgical and biological therapy. Fistula healing was evaluated with fistula drainage assessment classification (FDA), perianal disease activity index (PDAI), and van Assche magnetic resonance imaging score (MRI) before and 3 months after surgery and induction of the biological treatment. RESULTS: Clinical response occurred in 13 (57%) patients 3 months after induction treatment. Complete clinical response was achieved in 8 (35%) patients, whereas partial response occurred in 5 (22%) patients. Persistence of a fistula tract was visualised on MRI in 4 (50%) patients with clinical closure. CONCLUSIONS: The healing process of CF should be monitored by MRI due to the discrepancy between premature closure of external openings and fistulous tracts. Prolonged biological therapy until complete healing of anal fistulas confirmed on MRI might improve the results of treatment.

Role of Vacuum-Assisted Closure in the Management of Crohn Anal Fistulas.

BACKGROUND: Patients with Crohn disease-related anal fistulas are treated with debridement of fistulous tracts and the placement of noncutting setons (NCSs). However, to reduce the high recurrence rate, there is still a need to develop more effective treatment methods. OBJECTIVE: To compare NCS with vacuum-assisted closure (VAC) treatment. METHODS: Medical records of 47 patients with Crohn anal fistulas were retrospectively evaluated. They were divided into two groups (I, VAC; II, NCS), consisting of 24 and 23 patients, respectively. The fistulas in the former group were applied with VAC, whereas NCSs were placed in the latter group. Fistula healing was evaluated with the Fistula Drainage Assessment classification, Perianal Disease Activity Index, and the van Assche MRI-Based Score. RESULTS: There was a significant difference (P = .006) between the groups; closure of all fistulas at 6 months after treatment was achieved in 18 patients (75%) from group 1, compared with 8 patients (35%) from group 2. Partial response occurred in five patients (21%) from group 1 and in five patients (22%) from group 2. Closure of fistulous tracts was visualized via MRI in nine patients (37.50%) from group 1, more than twice as many patients as from group 2. CONCLUSIONS: Because preliminary results of the study showed a high rate of closure after application of VAC to Crohn anal fistulas, this method might be considered a novel sphincter-saving procedure.

Palliative treatment of anal fistulas in Crohn's disease.

INTRODUCTION: Anal fistula in Crohn's disease is frequently an intractable condition. Methods of treatment are still debated because the results of various procedures are unsatisfactory. Available studies show that results can be improved using a combination of surgical and medical methods. Most patients undergo rather palliative than radical, curative procedures such as incision and drainage of abscesses and prolonged non-cutting seton placement. Surgery is combined today with biological therapy using infliximab, a murine-human chimeric monoclonal antibody against TNF-α or adalimumab a human monoclonal anti-TNF antibody to increase the healing process and in an attempt to prevent fistula recurrence. METHODS: Medical records of 23 patients who were treated for anal fistulas in Crohn's disease between 2012 and 2014 were retrospectively evaluated. RESULTS: There were 10 (43%) males and 13 females. The mean age was 39 years (range 29-60 years). Median duration of CD before present treatment was 6 years (range 1-15 years). Closure of all fistulas in 6 months was achieved in eight (35%) patients, whereas reduction of at least 50% from base line in the number of draining fistulas occurred in four (17%) patients. CONCLUSION: Palliative and combined therapy for anal fistulas in Crohn's disease with surgery and infliximab or adalimumab therapy is an effective treatment for some patients.

Current management of anal fistulas in Crohn's disease.

Anal fistulas occurring in Crohn's disease (CD) comprise a risk factor of severe course of inflammation. They are frequently intractable due to various factors such as penetration of the anal canal or rectal wall, impaired wound healing, and immunosuppression, among others. Anal fistulas typical to CD develop from fissures or ulcers of the anal canal or rectum. Accurate identification of the type of fistula, such as low and simple or high and complex, is crucial for prognosis as well as for the choice of treatment. If fistulotomy remains the gold standard in the surgical treatment of the former, it is contraindicated in high and complex fistulas due to possible risk of damage to the anal sphincter with subsequent faecal incontinence. Therefore, the latter require a conservative and palliative approach, such as an incision and drainage of abscesses accompanying fistulas or prolonged non-cutting seton placement. Currently, conservative, sphincter-preserving, and definitive procedures such as mucosal advancement or dermal island flaps, the use of plugs or glue, video assisted anal fistula treatment, ligation of the intersphincteric track, and vacuum assisted closure are gaining a great deal of interest. Attempting to close the internal opening without injuring the sphincter is a major advantage of those methods. However, both the palliative and the definitive procedures require adjuvant therapy with medical measures.

Endoscopic vacuum-assisted closure system (E-VAC): case report and review of the literature.

Negative pressure wound therapy (NPWT) has become a standard in the treatment of chronic and difficult healing wounds. Negative pressure wound therapy is applied to the wound via a special vacuum-sealed sponge. Nowadays, the endoscopic vacuum-assisted wound closure system (E-VAC) has been proven to be an important alternative in patients with upper and lower intestinal leakage not responding to standard endoscopic and/or surgical treatment procedures. Endoscopic vacuum-assisted wound closure system provides perfect wound drainage and closure of various kinds of defect and promotes tissue granulation. Our experience has shown that E-VAC may significantly improve the morbidity and mortality rate. Moreover, E-VAC may be useful in a multidisciplinary approach - from upper gastrointestinal to rectal surgery complications. On the other hand, major limitations of the E-VAC system are the necessity of repeated endoscopic interventions and constant presence of well-trained staff. Further, large-cohort studies need to be performed to establish the applicability and effectiveness of E-VAC before routine widespread use can be recommended.

Migration of biomaterials used in gastroenterological surgery.

UNLABELLED: Mesh biomaterials have become the standard in the treatment of hernias, regardless the location. In addition to the obvious advantages of the methods based on implantable biomaterials, one should be aware of the possible complications, such as their migration to the abdominal organs. MATERIAL AND METHODS: The study group comprised patients operated at the Department of General, Gastroenterological Oncology, and Plastic Surgery during the period between 2008 and 2011, due to hernia surgery with mesh implantation. We also analysed the number of patients operated, due to complications of mesh migration during the same period. RESULTS: 368 patients were subject to mesh implantation, due to hernias during the period between 2008 and 2011. Three patients underwent surgery because of symptomatic migration of the mesh (ileus, fistula). CONCLUSIONS: The frequency of mesh migration is difficult to determine because of the different criteria of migration, observation period, and other factors. In patients after mesh implantation the potential migration of the biomaterial should be considered in case of unclear or acute abdominal symptoms.

Hamartomatous polyposis syndromes.

Hamartomas are tumour-like malformations, consisting of disorganized normal tissues, typical of the site of tumour manifestation. Familial manifestation of hamartomatous polyps can be noted in juvenile polyposis syndrome (JPS), Peutz-Jeghers' syndrome (PJS), hereditary mixed polyposis syndrome (HMPS) and PTEN hamartoma tumour syndrome (PHTS). All the aforementioned syndromes are inherited in an autosomal dominant manner and form a rather heterogenous group both in respect to the number and localization of polyps and the risk of cancer development in the alimentary tract and other organs. Individual syndromes of hamartomatous polyposis frequently manifest similar symptoms, particularly during the early stage of the diseases when in several cases their clinical pictures do not allow for differential diagnosis. The correct diagnosis of the disease using molecular methods allows treatment to be implemented earlier and therefore more effectively since it is followed by a strict monitoring of organs that manifest a predisposition for neoplastic transformation.

Primary ileo-anal pouch anastomosis in patients with acute ulcerative colitis.

INTRODUCTION: Proctocolectomy with ileal pouch-anal anastomosis (IPAA) was performed in ulcerative colitis (UC) for emergent or urgent indications in three stages. Since the three-step procedure imposes enormous demands on a patient, there was an attempt to introduce primary IPAA for urgent indications. The aim of this study was to compare early complications after Hartmann's colectomy (HC) and IPAA in a selected group of patients. MATERIAL AND METHODS: Medical records of 274 patients who underwent surgery for UC between 1996 and 2010 were retrospectively evaluated. Finally, a group of 77 patients with acute form of UC entered this study. RESULTS: All patients were divided into two groups. Group 1 consisted of 32 (42%) patients who underwent HC, whereas group 2 comprised 45 (58%) patients after IPAA. There was no postoperative mortality. Respiratory failure occurred in 8 (24%) patients after HC and in 6 (14%) patients who underwent IPAA. Intra-abdominal sepsis developed in 4 (12%) patients after HC and in 8 (17%) undergoing IPAA. Fascia dehiscence was present in 3 (8%) patients after HC and in 4 (9%) with IPAA. Bowel obstruction occurred in 1 (4%) patient after the former operation and in 3 (6%) patients after the latter one. Wound infection was diagnosed in 6 (20%) patients after HC and in 9 (20%) after IPAA. The differences between the investigated groups of patients were not statistically significant. CONCLUSIONS: The IPAA could be performed for urgent indications only in the patients with no critical dilatation of the colon or with active UC but without signs of severe malnutrition.