The use of core descriptors from the ENiGMA code study in recent literature: a systematic review.

AIM: The heterogeneity in data quality presented in studies regarding Crohn's anal fistula (CAF) limit extrapolation into clinical practice. The ENiGMA collaborators established a core descriptor set to standardize reporting of CAF. The aim of this work was to quantify the use of these descriptors in recent literature. METHOD: We completed a systematic review of PubMed and the Cochrane Library, extracting publications from the past 10 years specific to the clinical interventions and outcomes of CAF, and reported in line with PRISMA guidance. Each article was assessed for inclusion of ENiGMA descriptors. The median number of descriptors per publication was evaluated along with the overall frequency of each individual descriptor. Use of ENiGMA descriptors was compared between medical and procedural publications. RESULTS: Ninety publications were included. The median number of descriptors was 15 of 37; 16 descriptors were used in over half of the publications while 17 were used in fewer than a third. Descriptors were more frequently used in procedural (n = 16) than medical publications (n = 14) (p = 0.031). In procedural publications, eight descriptors were more frequently used including Faecal incontinence, Number of previous fistula interventions, Presence and severity of anorectal stenosis and Current proctitis. Medical publications were more likely to include Previous response to biological therapy and Duration and type of current course of biological therapy. CONCLUSION: With many descriptors being used infrequently and variations between medical and procedural literature, the colorectal community should assess the need for all 37 descriptors.

Sphincter damage during fistulotomy for perianal fistulae and its relationship with faecal incontinence.

BACKGROUND: The length of sphincter which can be divided during fistulotomy for perianal fistula is unclear. The aim was to quantify sphincter damage during fistulotomy and determine the relationship between such damage with symptoms and severity of faecal incontinence and long-term quality of life (QOL). METHODS: A prospective cohort study was performed over a 2-year period. Patients with intersphincteric and mid to low transsphincteric perianal fistulas without risk factors for faecal incontinence were scheduled for fistulotomy. All patients underwent 3D endoanal ultrasound (3D-EAUS) pre-operatively and 8 weeks postoperatively. Measurements were taken of pre- and postoperative anal sphincter involvement and division. Anal continence was assessed using the Jorge-Wexner scale and QOL scores pre, 6 and 12 months postoperatively. RESULTS: Forty-nine patients were selected. A strong correlation between pre- and postoperative measurements was found p < 0.001. A median length of 41% of the external anal sphincter and 32% of the internal anal sphincter was divided during fistulotomy. Significant differences in mild symptoms of anal continence were found with increasing length of external anal sphincter division. But there was no significant deterioration in continence, soiling, or quality of life scores at the 1-year follow-up. Division of over two-thirds of the external anal sphincter was associated with the highest incontinence rates. CONCLUSIONS: 3D-EAUS is a valuable tool for quantifying the extent of sphincter involvement pre- and postoperatively. Post-fistulotomy faecal incontinence is mild and increases with increasing length of sphincter division but does not affect long-term quality of life.

Role of Diffusion-Weighted Imaging in the Evaluation of Perianal Fistulae.

Background Magnetic resonance imaging (MRI) is the imaging modality of choice for evaluating perianal fistulae, due to its ability to show the relationship of perianal fistulae with anal sphincters, fistula extensions, secondary ramifications and associated complications. Aim To evaluate the role of diffusion-weighted MRI in the evaluation of perianal fistulae. Settings and Design A hospital-based cross-sectional study. Materials and Methods The study group composed of 47 patients of perianal fistula. MRI with diffusion-weighted imaging (DWI) was performed with Philips 0.5 T Ingenia scanner. DWI with different b -values ( b = 50, b = 400, and b = 800 smm 2 ) were obtained. The MRI findings were correlated with local clinical examination and or surgical findings. Statistical Analysis Used Chi-square test, independent samples t -test, and receiver operating characteristic curve analysis. Result Fifty-nine perianal fistulas in 47 patients were included in the study sample. The visibility of perianal fistula on DWI was less than T2-weighted (T2W) and combined DWI-T2W images. Distinctly visualized (visibility score 2) perianal fistulas were observed in 47 fistulas (79.6%) on DWI, 54 (91.5%) on T2W, and 58 (98.3%) on DWI-T2W images. The mean of apparent diffusion coefficient (ADC) values of active fistula was 0.972 ± 0.127 [SD] 10 -3 mm 2 /s and inactive was 1.232 ± 0.185 [SD] 10 -3 mm 2 /s with a significant difference ( p -value < 0.0005). A cut-off mean ADC value of 1.105 × 10 -3 mm 2 /s was used to differentiate active from the inactive fistula with a sensitivity of 87.5% and specificity of 73.3%. Conclusion Combined DWI-T2W evaluation had a better performance in the detection of fistula than DWI or T2W alone. DWI with mean ADC calculation had a good performance in differentiating active from the inactive fistulas.

Endorectal Advancement Flaps for Perianal Fistulae in Crohn's Disease: Careful Patient Selection Leads to Optimal Outcomes.

BACKGROUND: Anorectal fistulae resultant from Crohn's disease (CD) is a clinical challenge. The advent of immune therapy (IT) has altered the way in which fistulae have responded to treatment. Endorectal advancement flap (ERAF) is a surgical procedure that is used to treat complex fistulae. We have employed ERAF as our second stage treatment of choice in this patient population. Our aim was to determine the success of ERAF in treating perianal fistulas in patients with CD in an era of IT. METHODS: Multicenter retrospective review from 2007 to 2017 of all patients with CD and a perianal fistulae who underwent ERAF. RESULTS: Forty-one flaps were performed in 39 patients with perianal CD with an average follow-up of 797 days. There were no significant differences in patient demographics; however, all patients who were diverted at the time of surgery had successful healing. Of patients, 73.2% were on IT at an average of 380 days prior to surgery. The duration of single-agent therapy was associated with better healing rates (p = 0.03). The overall failure rate was 19.5% (n = 8). Six patients underwent secondary techniques for fistulae closure; five were successful. In combination with the patients who did not initially fail, the overall healing rate was 92.6%. CONCLUSIONS: This study demonstrates several factors that may improve fistulae closure for CD patients. Patients who were diverted prior to surgery did not have a fistulae recurrence. Patients who were on IT longer prior to ERAF were more likely to achieve successful closure.

Perianal fistula imaging: a comparison between two-channel superficial Flex coil and eight-channel body coil.

PURPOSE: Perianal fistula is an important health problem with devastating morbidity. For diagnosis and prevention of recurrence, perianal fistula imaging (PFI) is crucial. The aim of this study was to investigate if a Flex-M superficial coil images would provide more information than images obtained with a phased-array body coil in PFI. MATERIAL AND METHODS: Thirty-one fistulas of 29 patients were prospectively evaluated with magnetic resonance imaging. A phased-array body coil was used in all patients as in routine practice, and sequences with Flex-M coil were also obtained. Afterwards, images were evaluated by two experienced radiologists who were blinded to the patients, coil and also to each other. The site of internal and external openings, and presence or absence of abscess and secondary tracts were recorded. RESULTS: The conspicuity of images was better with the Flex-M coil. Both radiologists saw more internal openings with the Flex-M coil. Cohen's κ value was 0.100 (p = 0.201) for Reader 1 and 0.110 (p = 0.361) for Reader 2 between these two coils. Additionally, numerically more internal/external openings and secondary tracts were seen by both readers. Interobserver variability was not statistically significant, and Cohen's κ values signifyied good concordance between readers. CONCLUSIONS: In our study we showed that multichannel superficial phased-array coils improved imaging quality in PFI. We think that Flex-M coil can easily be used in routine clinical practice to gather better images of perianal fistulas.

Prognostic factors affecting outcomes in fistulating perianal Crohn's disease: a systematic review.

BACKGROUND: One in three patients with Crohn's disease will develop a perianal fistulae, and one third of these will achieve long-term healing or closure. A barrier to conducting well-designed clinical trials for these patients is a lack of understanding of prognostic factors. This systematic review sets out to identify factors associated with prognosis of perianal Crohn's fistulae. METHODS: This review was registered on the PROSPERO database (CRD42016050316) and conducted in line with PRISMA guidelines along a predefined protocol. English-language studies assessing baseline factors related to outcomes of fistulae treatment in adult patients were included. Searches were performed on MEDLINE and Embase databases. Screening of abstracts and full texts for eligibility was performed prior to extraction of data into predesigned forms. Bias was assessed using the QUIPS tool. RESULTS: Searches identified 997 papers. Following removal of duplicates and secondary searches, 923 were screened for inclusion. Forty-seven papers were reviewed at full-text level and 13, 2 of which were randomised trials, were included in the final qualitative review. Two studies reported distribution of Crohn's disease as a prognostic factor for healing. Two studies found that CARD15 mutations decreased response of fistulae to antibiotics. Complexity of fistulae anatomy was implicated in prognosis by 4 studies. CONCLUSIONS: This systematic review has identified potential prognostic markers, including genetic factors and disease behaviour. We cannot, however, draw robust conclusions from this heterogeneous group of studies; therefore, we recommend that a prospective cohort study of well-characterised patients with Crohn's perianal fistulae is undertaken.

The comparison of CT fistulography and MR imaging of perianal fistulae with surgical findings: a case-control study.

PURPOSE: The purpose of this study was to evaluate the diagnostic efficacies of CT fistulography and MRI, in the diagnostic work-up of perianal fistula patients. MATERIALS AND METHODS: All 41 patients who were included in the study (36 males and 5 females, with an average age of 41 years) underwent CT fistulography and MRI examinations prior to surgery. The fistula characteristics obtained from these examinations were compared with the surgical findings. The comparative results were evaluated by means of the Kappa analysis method. RESULTS: CT fistulography predicted the correct perianal fistula classification in 30 (73.1%) of the 41 patients, whereas MRI correctly defined fistula classification in 38 (92.7%) of these patients (the K values were 0.621 and 0.896, respectively; with p < 0.001). CT fistulography depicted 29 secondary extensions in 16 patients, whereas MR imaging revealed 28 secondary extensions in 15 patients. A substantial agreement was found between surgical findings and two modalities (K value was 0.789 and 0.793 for CT fistulography and MRI, respectively, with a p value < 0.001). In terms of locations of internal openings, CT fistulography was able to detect the locations in 28 patients (68.2%), whereas MRI was more successful in this aspect, with a number of 35 patients (85.3%). Granulation tissues, inflammation and edema around the fistula, abscesses, and fistular wall fibrosis were also evaluated. CONCLUSION: CT fistulography and MRI have different advantages in the diagnosis of perianal fistulas. A good command of knowledge concerning the issue may be a key factor in modality decision.

Different characteristics of high and low transsphincteric fistulae.

AIM: Transsphincteric fistulae are classified as high or low. The aim of this observational study was to determine whether or not they have different characteristics. METHOD: A consecutive series of 300 patients with a transsphincteric fistula of cryptoglandular origin was studied. Two hundred patients with a high transsphincteric fistula underwent transanal advancement flap repair and 100 patients with a low transsphincteric fistula underwent fistulotomy or ligation of the intersphincteric fistula tract at the Division of Colon and Rectal Surgery, Erasmus MC, Rotterdam. Various patient and fistula characteristics were assessed. Data were analysed by means of logistic regression. RESULTS: Low transsphincteric fistulae occurred more frequently in females (43% low transsphincteric fistulae vs 30% high transsphincteric fistulae; P < 0.05). The internal opening of these fistulae was predominantly located anteriorly (76% vs 18% in high transsphincteric fistulae; P < 0.001). Mean age at surgery was lower in patients with a low transsphincteric fistula (42 vs 47 years; P < 0.001). In these patients an associated abscess was observed in 4% compared with 54% of those patients with a high transsphincteric fistula (P < 0.001). In multivariate analysis, the differences between high and low transsphincteric fistulae regarding location of their internal opening and the presence of associated abscesses remained significant (P < 0.001). CONCLUSION: Although not significant in multivariate analysis, low transsphincteric fistulae occur more frequently in younger patients and more often in females. These fistulae are predominantly located anteriorly and are rarely associated with an abscess. This was significant in univariate and multivariate analysis.

Coring-out fistulectomy with a newly designed 'fistulectome' for complicated perianal fistulae: a retrospective clinical analysis.

AIM: Conventional surgery for complex anal fistula (AF) is associated with continence disturbance and recurrence. In the hope of reducing these we developed a new mechanical device, the 'fistulectome', to excise the entire fistula tract. METHOD: Between March 2001 and April 2011, 136 patients underwent surgery for a complex AF using the fistulectome. All fistulae were cryptoglandular in origin. Five patients were lost to follow up and were excluded from the analysis. RESULTS: Of the 131 fistulae, 76 were trans-sphincteric, 14 were suprasphincteric and 16 were extrasphincteric. Seven had a horseshoe extension and 18 were unclassified. Of the 131, 108 had recurred after conventional fistulotomy performed at another centre and 23 were primary. The mean duration of follow up was 34.6 months, the mean hospital stay was 5 days and the healing time was 14 days. Recurrence, flatus incontinence and soiling occurred in 17 (12.9%), four (3.5%) and two (1.52%) patients. CONCLUSION: The results of this series suggest that coring-out of a fistula using a fistulectome may be a valid treatment for complicated anal fistula.

Diagnóstico diferencial entre doença de crohn e hidradenite supurativa: relato de caso / Differential diagnosis between crohn's disease and hidradenitis supurativa: case report

A doença de Crohn é uma doença inflamatória intestinal crônica com inflamação transmural segmentar, que pode complicar com formação de fístulas e abscessos. A hidradenite supurativa (HS) é caracterizada por abscessos recorrentes e dolorosos, com predileção por áreas ricas em glândulas apócrinas como as regiões axilares, inguinais e perineal. O diagnóstico diferencial entre estas doenças é difícil e pode comprometer o tratamento. Relatamos o caso de C.R.M.A., 40 anos, feminina, branca, com doença de Crohn íleocolônica com fístula perianal e retovaginal há 12 anos, em terapia biológica desde maio 2010. Em setembro de 2010 apresentou abscesso em glúteo direito com saída de secreção purulenta refratária ao uso de ciprofloxacino e metronidazol. Ultrassonografia apresentando coleção de 30 cm3 em região glútea direita. A hipótese diagnóstica foi HS e a paciente foi submetida à ressecção cirúrgica em bloco (10 x 2 cm), com cicatrização por segunda intenção. Realizou enxerto de pele em dezembro de 2010 sem sucesso. Retornou em janeiro de 2011 com nova fístula no local da ressecção, compatível com doença de Crohn. Em fevereiro de 2011 foi submetida à drenagem dos abscessos e colocação de setons nas fístulas perianais. Atualmente em terapia biológica, com boa evolução das fístulas. A prevalência da HS varia de 0,3 a 4% da população em geral. A axila é a região mais afetada e as lesões perianais estão associadas com maior debilidade. Há relatos na literatura de associação entre a HS e a doença de Crohn de forma esporádica, e novos estudos são necessários para avaliar uma patogênese em comum. O diagnóstico diferencial deve ser realizado em todos os casos para tratamento imediato, evitando-se, assim, as complicações e a piora da qualidade de vida do doente.

Crohn?s disease is a chronic inflammatory bowel disease with segmental transmural inflammation, which complicate with formation of fistulas and abscesses. The hidradenitis suppurativa (HS) is characterized by recurrent abscesses, with a predilection for areas rich in apocrine glands such as the axillary, inguinal and perineal. The differential diagnosis between these diseases is difficult and may compromise treatment. Report case: C.R.M.A., 40 year-old, female, white, ileal and colonic Crohn?s disease complicated with perianal and rectovaginal fistula for 12 years, treated with biological therapy since May 2010. In Sep/2010 presented with an abscess in the buttock D with purulent discharge refractory to the use of ciprofloxacin and metronidazole. USG: collection of 30 cm3 in buttock D. The diagnosis was HS and the patient underwent extensive surgical removal of the affected areas (10 x 2 cm) with healing by secondary intention. Skin graft performed unsuccessfully in Dec/2010. The patient returned in jan/2011 with a new fistula at the site of resection, consistent with Crohn?s disease. In fev/2011 underwent drainage of abscesses and placement of setons in perianal fistulas. Currently in therapy with good biological evolution of fistulas. The prevalence of HS varies from 0.3 to 4% of the population in general. The axilla is the region most affected and perianal lesions are associated with greater weakness. There are published reports of association between HS and Crohn?s disease sporadically and further studies are needed to assess a common pathogenesis. The differential diagnosis should be performed in all cases planning immediate treatment, avoiding complications and worsening of the patient?s quality of life.

Tratamento não operatório de hemobilia por ferimento de arma branca: relato de caso / Non-operative management of hemobilia for penetrating abdominal trauma: case report

A hemobilia ocorre quando doenças ou injúrias causam comunicação entre o sangue de vasos intra-hepáticos com o trato biliar. O diagnóstico de hemobilia foi apresentado pela primeira vez por Francis Glisson em 1654, porém o primeiro caso documentado data de 1777 por Antoni Portal. O objetivo do presente relato é apresentar um caso de hemobilia em paciente atendido no Hospital Universitário de Maringá por ferimento de arma branca que apresentou tardiamente hemorragia digestiva alta e diagnosticado hemobilia submetido a tratamento não operatório.

Hemobilia occurs when injury or disease cause comunication between intrahepatic blood vessel and the biliary tract. Francis Glisson introduced the diagnosis of hemobilia in 1654, but Antoine Portal documented the first case in 1777. The aim of this report is to present a case of late presentation of hepatic pseudoaneurysm with hemobilia for penetrating abdominal trauma submeted a non-operative management of hemobilia at the Hospital of Maringá State University.

MRI in perianal fistulae.

MRI has become the method of choice for evaluating perianal fistulae due to its ability to display the anatomy of the sphincter muscles orthogonally, with good contrast resolution. In this article we give an outline of the classification of perianal fistulae and present a pictorial assay of sphincter anatomy and the MRI findings in perianal fistulae. This study is based on a retrospective analysis of 43 patients with a clinical diagnosis of perianal fistula. MRI revealed a total of 44 fistulae in 35 patients; eight patients had only perianal sinuses.

MRI in evaluation of perianal fistulae.

BACKGROUND: Fistula is considered to be any abnormal passage which connects two epithelial surfaces. Parks' fistulae classification demonstrates the biggest practical significance and divides fistulae into: intersphincteric, transsphincteric, suprasphincteric and extrasphincteric. Etiology of perianal fistulae is most commonly linked with the inflammation of anal glands in Crohn's disease, tuberculosis, pelvic infections, pelvic malignant tumours, and with the radiotherapy. Diagnostic method options are: RTG fistulography, CT fistulography and magnetic resonance imaging (MRI) of pelvic organs. PATIENTS AND METHODS: We have included 24 patients with perirectal fistulae in the prospective study. X-rays fistulography, CT fistulography, and then MRI of the pelvic cavity have been performed on all patients. Accuracy of each procedure in regards to the patients and the etiologic cause have been statistically determined. RESULTS: 29.16% of transphincteric fistulae have been found, followed by 25% of intersphincteric, 25% of recto-vaginal, 12.5% of extrasphincteric, and 8.33% of suprasphincteric. Abscess collections have been found in 16.6% patients. The most frequent etiologic cause of perianal fistulae was Crohn's disease in 37.5%, where the accuracy of classification of MRI was 100%, CT was 11% and X-rays 0%. Ulcerous colitis was the second cause, with 20.9% where the accuracy of MRI was 100%, while CT was 80% and X-rays was 0%. All other etiologic causes of fistulae were found in 41.6% patients. CONCLUSIONS: MRI is a reliable diagnostic modality in the classification of perirectal fistulae and can be an excellent diagnostic guide for successful surgical interventions with the aim to reduce the number of recurrences. Its advantage is that fistulae and abscess are visible without the need to apply any contrast medium.