Anal Monkeypox Disease: Description of 65 Cases.

BACKGROUND: Monkeypox is a zoonosis endemic in Africa caused by 3 orthopoxvirus clades. Knowledge of the disease is limited, but a worldwide outbreak involving a new route of transmission was declared in April 2022. OBJECTIVE: This study aimed to describe anal symptoms and outcomes in patients infected with Monkeypox virus presenting to an emergency proctology unit in Paris. DESIGN: This was an observational study. SETTING: We reported anal symptoms of all consecutive patients with monkeypox anal infection in a single proctology center between June 16, 2022, and July 26, 2022. Association with sexually transmitted infections and outcomes were also recorded. PATIENTS: Sixty-five men with a mean age of 39.6 (19.9-64.6) years with confirmed monkeypox anal infection were included in the study. MAIN OUTCOME MEASURES: Anal symptoms and their severity were clinically assessed. A favorable outcome consisted of a complete resolution of clinical manifestation. RESULTS: Sexual transmission was reported in 51 patients (78.4%), among whom 63 (97%) were men who have sex with men. Twenty-eight (43%) were living with HIV, and 24 (36.9%) were taking tenofovir/emtricitabine for HIV preexposure prophylaxis. Anal symptoms appeared first in 36 patients (55.4%) and skin rash or other general symptoms in 22 patients (33.8%). Incubation time was 6.9 (1-26) days. Symptoms included painful perianal (n = 42 patients; 64.6%), anal (n = 28, 43%), and rectal (n = 25; 38.4%) ulcerations and perianal vesicles (n = 24; 36.9%). Proctitis was observed in 49 patients (75.4%). It was mild in 20 (40.8%) and intense in 29 (59.2%), and severe proctitis mimicking high intersphincteric suppuration was found in 4 (8.2%). Fifteen patients (23.1%) had concurrent sexually transmitted infection and 3 were hospitalized. Complete symptom resolution occurred within 12 days. LIMITATIONS: We performed a single-center study during a short period of time. CONCLUSIONS: Proctological symptoms are frequent in the current outbreak of monkeypox disease, probably linked to the route of transmission. Rectal ulcerations mimicking high intersphincteric suppuration should be recognized to avoid unnecessary surgery. See Video Abstract . ENFERMEDAD ANAL DE LA VIRUELA DEL MONO DESCRIPCIN DE CASOS: ANTECEDENTES:La viruela del simio mono es una zoonosis endémica en África causada por tres clados de orthopoxvirus. El conocimiento de la enfermedad es limitado, pero en abril de 2022 se declaró un brote mundial que implica una nueva vía de transmisión.OBJETIVO:Describir los síntomas anales y los resultados en pacientes que sufren de infección por Monkeypox que asistieron a una unidad de proctología de emergencia en París.DISEÑO:Un estudio observacional.ESCENARIO:Informamos los síntomas anales de todos los pacientes consecutivos con infección anal por viruela del mono en un solo centro de proctología entre el 16/6/2022 y el 26/7/2022. También se registró la asociación con infecciones de transmisión sexual (ITS) y el resultado.PACIENTES:Sesenta y cinco hombres de 39,6 [19,9-64,6] años con infección anal confirmada.PRINCIPALES MEDIDAS DE RESULTADO:Los síntomas anales y su gravedad se evaluaron clínicamente. Un resultado favorable consistió en una resolución completa de la manifestación clínica.RESULTADOS:La transmisión sexual se informó en 51 (78,4%) pacientes, de los cuales 63 (97%) eran hombres que tuvieron sexo con hombres. Veintiocho (43%) vivían con el VIH y 24 (36,9%) tomaban Emtricitabina/Tenofovir para profilaxis previa por exposición al VIH. Los síntomas anales aparecieron primero en 36 (55,4%) pacientes y la erupción cutánea u otros síntomas generales en 22 (33,8%). El tiempo de incubación fue de 6,9 [1-26] días. Los síntomas incluyeron ulceraciones perianales dolorosas (n = 42 pacientes, 64,6%), anales (n = 28, 43%), rectales (n = 25, 38,4%) y vesículas perianales (n = 24, 36,9%). Se observó proctitis en 49 (75,4%) pacientes. Fue leve en 20 (40,8%) e intensa en 29 (59,2%) y proctitis severa simulando supuración interesfinteriana alta en 4 (8,2%). Quince (23,1%) pacientes presentaban ITS concurrentes y 3 fueron hospitalizados. La resolución completa de los síntomas ocurrió dentro de los 12 días.LIMITACIONES:Estudio de un solo centro y durante corto período de tiempo.CONCLUSIÓN:Los síntomas proctológicos son frecuentes en el brote actual de la enfermedad de la viruela del mono, probablemente relacionados con la vía de transmisión. Las ulceraciones rectales que simulan una supuración interesfinteriana alta deben reconocerse para evitar una cirugía innecesaria. (Traducción-Dr. Fidel Ruiz Healy ).

Prevalence of Chlamydia infection detected by immunohistochemistry in patients with anorectal ulcer and granulation tissue.

Anorectal ulcer with granulation tissue is typically associated with left-sided inflammatory bowel disease or infection. Due to emerging cases of Chlamydia proctitis, we aim to investigate the prevalence of Chlamydia infection using immunohistochemistry (IHC) in anorectal biopsies showing ulcer and granulation tissue. Seventy-seven patients including 60 males and 17 females with mean age of 51 years old were retrospectively identified in surgical pathology archives. Chlamydia IHC was validated with a monoclonal antibody on an index who was positive for Chlamydia by rectal swab nucleic acid amplification test (NAAT), then performed on formalin fixed and paraffin embedded (FFPE) tissue sections. Confirmative molecular test using real-time PCR was performed on DNA extractions of 14 IHC-positive and 14 IHC-negative FFPEs, 18 NAAT-positive, and 5 NAAT-negative cytology specimens. Chlamydia IHC showed strong intracytoplasmic or extracellular sphere morphology in 14 of 77 (18.2 %) FFPEs, including 11 of 60 (18.3 %) males and 3 of 17 (17.6 %) females (age 11-84 years). Eight of 14 (57.1 %) Chlamydia-IHC positive patients had known history of STDs, high-risk behavior, or immunosuppressive conditions. One of 14 (7.1 %) IHC-positive FFEP and 15 of 18 (83.3 %) NAAT-positive cytology cases were confirmed by real-time PCR. Chlamydia inclusions were detected in all 4 randomly selected NAAT and PCR-positive cytology specimens by IHC. Our data suggested that Chlamydia infection is more prevalent than we thought in patients with active proctitis and ulceration. Chlamydia IHC may be performed as a screening test in biopsies to facilitate early detection of this treatable proctitis in high-risk population.

Infective anoproctitis in men having sex with men: Don't forget Mycoplasma genitalium.

OBJECTIVES: The aim was to describe the clinical characteristics of symptomatic anoproctitis and the occurrence of Chlamydia trachomatis (CT), Neisseria gonorrhoeae (NG) and Mycoplasma genitalium (MG) infections in a prospective cohort of MSM patients. METHODS: From February 2018 to January 2020, all consecutive patients presenting at the Leopold Bellan Proctology Institute of Saint-Joseph Hospital, Paris, France with symptoms of anoproctitis were tested on rectal samples for C. trachomatis (CT), N. gonorrhoeae (NG), M. genitalium (MG). Clinical, microbiological, biological data, STI risk factors, medical history and treatments were collected. RESULTS: Three hundred and sixty-five patients were included for suspected infective anoproctitis. CT was detected in 84/365 (23%) patients, NG in 45/365 (12%) and MG in 46/315 patients (15%), associated with macrolide resistance in 28/46 MG strains (61%). The most frequent symptoms were rectal pains, rectal bleeding, purulent discharge in 253 (79%), 191 (60%), and 164 (51%) of cases respectively. In comparison with MG infections, ulcerations, erythematous proctitis, rectorragia and false needs were more frequently described in CT infections, while purulent proctitis, functional pain and purulent discharge were more often observed in NG and CT anoproctitis. CONCLUSION: We found a high prevalence rate of STIs due to CT, NG, while MG detection was associated with a high rate of macrolide resistance in a cohort of MSM patients. Our results confirm that in cases of symptomatic anoproctitis, MG should be tested in association with other STI pathogens.

Characteristics of rectal chlamydia among men who have sex with men in southern Taiwan, 2020-2022: An emerging threat of rectal lymphogranuloma venereum L2b.

BACKGROUND: The prevalence of rectal chlamydia among men who have sex with men (MSM) without human deficiency virus infection (non-HIV) remains uncertain in Taiwan, and rectal lymphogranuloma venereum (LGV) among MSM has never been reported in the Far East. MATERIAL AND METHODS: From January 2020 to April 2022, MSM coming for anonymous voluntary counseling and testing, for pre-exposure prophylaxis, and for antiretroviral therapy were enrolled. All participants submitted his fecal samples and completed a QR-code questionnaire. Medical records of those who took regular medical visits for HIV were recorded. Multiplex polymerase chain reaction (PCR) was performed for all fecal samples, and ompA gene sequencing was therefore performed for each Chlamydia-positive fecal sample. RESULTS: Among 341 MSM during 2020-2022 in southern Taiwan, 21 (6.2%) had rectal chlamydia infection. Risk factors of rectal chlamydia included co-infection with rectal gonorrhea (adjusted odds ratio [AOR] 6.78, 95% confidence interval [CI] 1.44-31.91, P = 0.015) and multiple sexual partners (AOR 1.373, 95% CI 1.002-1.882, P = 0.048). Further ompA gene sequencing from 19 Chlamydia-positive fecal samples revealed that the prevalent genotypes or genovariants were Da (26.3%) and L2b (26.3%), followed by B (21.1%), J (14.3%), and G (9.5%). All cases of rectal LGV genovariant L2b presented as acute proctitis with diarrhea, anal pain, or discharge and were treated successfully with prolonged treatment of doxycycline. CONCLUSIONS: Rectal gonorrhea and multiple sexual partners are risk factors for rectal chlamydia. Clinicians in Taiwan should be aware of the emerging threat of rectal LGV among MSM with acute proctitis.

Overlooked monkeypox cases among men having sex with men during the 2022 outbreak - a retrospective study.

OBJECTIVES: The aim of this study was to characterize overlooked cases of patients with monkeypox infection in the 2022 outbreak. METHODS: Clinical characteristics of 26 patients who were misdiagnosed with other diseases were described. RESULTS: Of the 26 patients who were misdiagnosed, six (23%) were given a diagnosis of bacterial tonsillitis, six (23%) were diagnosed with primary syphilis, five (19.2%) with oral or genital herpes, and four (15.3%) with bacterial proctitis or anal abscess. The average time interval between missed and right diagnosis was 4.4 days. There was no difference in the missed cases between the early and the later month of the outbreak. CONCLUSION: Monkeypox might still be commonly overlooked, especially in patients presenting with fever and sore throat or solitary ulcer as sole manifestations.

Imaging features of anorectal proctitis in monkeypox infection.

The monkeypox outbreak of 2022 saw the first community-sustained transmission of the monkeypox virus outside of Africa, and rapidly developed into multi-country spread. A common presenting sign of monkeypox infection during this outbreak has been rectal pain due to proctitis. Proctitis with large hypoattenuated anorectal ulcers on CT scan should invoke consideration for monkeypox infection in young homosexual or bisexual men with associated skin eruptions.

Monkeypox outbreak in Spain: clinical and epidemiological findings in a prospective cross-sectional study of 185 cases.

BACKGROUND: Since May 2022, a new outbreak of monkeypox has been reported in several countries, including Spain. The clinical and epidemiological characteristics of the cases in this outbreak may differ from those in earlier reports. OBJECTIVES: To document the clinical and epidemiological characteristics of cases of monkeypox in the current outbreak. METHODS: We conducted a prospective cross-sectional study in multiple medical facilities in Spain to describe the cases of monkeypox in the 2022 outbreak. RESULTS: In total, 185 patients were included. Most cases started with primarily localized homogeneous papules, not pustules, in the probable area of inoculation, which could be cutaneous or mucous, including single lesions. Generalized small pustules appeared later in some of them. Heterogeneous lesions occurred during this generalized phase. All patients had systemic symptoms. Less common lesions included mucosal ulcers (including pharyngeal ulcers and proctitis) and monkeypox whitlows. Four patients were hospitalized, none died. Smallpox vaccination and well-controlled HIV disease were not associated with markers of severity. Contact during sex is the most likely mechanism of transmission. In this outbreak, cases have been described in men who have sex with men and are strongly associated with high-risk sexual behaviours. Seventy-six per cent of the patients had other sexually transmitted diseases upon screening. CONCLUSIONS: The clinical findings in this outbreak differ from previous findings and highly suggest contact transmission and initiation at the entry site. The characterization of the epidemiology of this outbreak has implications for control. What is already known about this topic? Monkeypox eruption is described as consisting of pustules. The roles of HIV and previous smallpox vaccination in the prognosis are unknown. The transmission route was initially described as respiratory droplets and was later suggested to be via sexual contact. What does this study add? Initial lesions at the probable inoculation area were homogeneous and papular (pseudopustules). Generalized small pustules appeared later in some of them. Heterogeneous lesions occurred during this generalized phase. All patients had systemic symptoms. Less common signs included mucosal ulcers (including pharyngeal ulcers and proctitis) and monkeypox whitlows. Well-controlled HIV and previous smallpox vaccination were not associated with severity. No patient died. The data support the hypothesis of transmission via contact during sex. Although this might change, the outbreak is currently limited mostly to men who have sex with men, with high-risk factors for sexually transmitted diseases.

First reported lymphogranuloma venereum cases in Russia discovered in men who have sex with men attending proctologists.

BACKGROUND: Several lymphogranuloma venereum (LGV) outbreaks among men who have sex with men (MSM) have been reported throughout the world since 2003. Nevertheless, no LGV cases have been internationally reported from Russia. We evaluated the prevalence of LGV among MSM attending proctologists in Moscow, Russia, and compared the LGV and non-LGV rectal Chlamydia trachomatis (CT) infections. METHODS: MSM (n = 534) attending for proctologic care were included. Rectal specimens were sampled for CT and Neisseria gonorrhoeae (NG) by nucleic acid amplification tests (NAATs). All CT-positive patients were tested with an LGV-specific NAAT. RESULTS: In total, 37.3% (95% CI 33.3-41.5; 199/534) of MSM were CT positive. Of these, 68.8% (95% CI 62.1-74.9; 137/199) had LGV and 31.2% (95% CI 25.1-37.9; 62/199) a non-LGV rectal CT infection. Older age (34 years vs. 31 years, p = 0.035) and group-sex practices (67.2% (92/137) vs. 33.9% (21/62), p < 0.0001) were associated with LGV. The LGV-positive MSM were also more likely to be HIV-positive (67.2% (92/137) vs. 41.9% (26/62), p = 0.001). Proctoscopy revealed ulcerative proctitis/proctocolitis in 99.3% (136/137) of LGV-positive MSM. No ulcerative or erosive proctitis was found in the MSM with non-LGV CT infection, but 58.1% (36/62) of them had anorectal disorders. Finally, mild catarrhal or hemorrhagic proctitis was diagnosed in only 21.6% (8/37) of MSM with non-LGV CT infection lacking concomitant NG or syphilis (p < 0.0001). CONCLUSIONS: LGV is widely spread among MSM attending proctologists in Moscow. Clinically, acute LGV proctitis/proctocolitis can be difficult to distinguish from inflammatory bowel disease that leads to mismanaged LGV infections. LGV diagnostic laboratory testing is essential, however, currently mainly lacking for MSM in Russia. All MSM with CT-positive rectal specimens should be subsequently tested for LGV.

[Chlamydial infection still a common and sometimes serious infection]. / Klamydia fortfarande vanlig och ibland allvarlig infektion.

Chlamydial infection is the most common bacterial sexually transmitted infection in Sweden and worldwide, despite extensive testing, efficient treatment and partner notification. The incidence of Lymphogranuloma venereum, currently occurring among men who have sex with men and most often in the rectum, shows no tendency to decline. This infection is usually symptomatic but still evading diagnosis due to similarities to other causes of proctitis. There is evidence that rectal chlamydia is common also in women not practicing anal sex.

The Potential Link between Episodes of Diverticulitis or Hemorrhoidal Proctitis and Diets with Selected Plant Foods: A Case-Control Study.

Diverticulitis and hemorrhoidal proctitis in the population are significant public health problems. We studied the potential association between the intake of certain plant foods and diverticulitis or hemorrhoidal episodes through a case-control study including 410 cases and 401 controls. We used a semiquantitative food frequency questionnaire. The intake was additionally quantified according to a 24 h recall. The plant foods or derived food products were categorized by their main chemical components into ethanol, caffeine/theine/theobromine, capsaicin, alliin, acids, eugenol, and miscellaneous foods such as curcumin. The mean score for overall intake of plant foods under consideration was 6.3 points, and this was significantly higher in cases (8.5) than in controls (4.1). Overall intake was similar in cases presenting with diverticulitis or hemorrhoidal proctitis. Cases had 13 times the odds of being in the upper quartile for overall intake (>7 points), compared to controls. Explanatory logistic regression models showed that the strongest association with diverticulitis and hemorrhoidal proctitis was shown by the chemical food group of capsaicin, followed by ethanol, eugenol, caffeine/theine/theobromine, and acids. Neither alliin nor miscellaneous food groups showed any association. High, frequent consumption of capsaicin, followed by ethanol, eugenol, caffeine/theine/theobromine, and acids increase the risk of diverticulitis and hemorrhoidal proctitis.

Management of Long-Term Toxicity From Pelvic Radiation Therapy.

Pelvic radiation therapy is an integral component in the treatment of various gastrointestinal, gynecologic, and genitourinary cancers. As survival rates from these malignancies improve, the prevalence of toxicity secondary to pelvic radiation has increased. Gastrointestinal toxicities are the most common complications and greatly impact quality of life. Toxicities can present in acute or late stages; although symptoms may be similar during both, the management may differ. Acute toxicities represent an inflammatory reaction in response to the radiation exposure, whereas late toxicities may arise as a result of small vessel disease, ischemia, and fibrosis. Currently, there are no large clinical trials and only limited guidelines on the management of late gastrointestinal radiation toxicities. Therapy is generally approached in a stepwise manner from medical to endoscopic to surgical methods. Several endoscopic therapies, such as the treatment of radiation proctitis with argon plasma coagulation and dilation of radiation bowel strictures, may prevent the need for surgical intervention, which may be associated with high morbidity and mortality. Given that late toxicities can occur years after radiation therapy, they are often difficult to recognize and diagnose. Successful management of late toxicities requires recognition, an understanding of the underlying pathophysiology, and a multidisciplinary approach. More dedicated research could clarify the prevalence of gastrointestinal pelvic radiation toxicities, permit a better understanding of the efficacy and safety profile of current therapies, and allow for the development of novel therapeutic approaches.

Características epidemiológicas y manifestaciones clínicas de pacientes con proctitis infecciosa / Epidemiologic characteristics and clinical manifestations in patients with infectious proctitis

Resumen Objetivo: Describir y caracterizar los aspectos epidemiológicos y clínicos de los pacientes con proctitis infecciosa en nuestro hospital. Materiales y Método: Se trata de un estudio de tipo transversal de pacientes con sintomatología perianal y del canal anal, concordante con proctitis, que consultaron en el policlínico de coloproctología entre enero de 2017 y diciembre de 2018, a quienes se les realizó estudio de secreción anal para confirmar infección de transmisión sexual. Resultados: Son 46 pacientes hombres, 26 años promedio de edad, un 6% heterosexuales. Un 65% había consultado previamente (ninguno a un coloproctólogo). El síntoma más frecuente: ano húmedo (97,8%) y el signo: dermitis perianal (100%). De este grupo, 20 nunca se habían realizado estudio de VIH y 50% resultó ser seropositivo. Presentaban infecciones de transmisión sexual más comunes: Gonorrea (43,4%) y sífilis (31,2%) y en un 32% hubo presencia de más de un germen. Discusión: Los resultados sugieren que la proctitis infecciosa es una patología de pacientes jóvenes quienes tienen relaciones sexuales sin protección, más del 50% no utiliza condón. La mayoría de los pacientes presentan consultas previas con médicos no proctólogos. Los gérmenes con mayor frecuencia que provocan proctitis infecciosa: Neisseria gonorrhoeae, Chlamydia trachomatis, Treponema pallidum. Conclusión: La presencia de una dermitis perianal sin respuesta a tratamiento habitual, muy severa y/o en pacientes de riesgo, debe hacer sospechar proctitis infecciosa.

Objective: Describe and characterize epidemiological and clinical aspects of patients with infectious proctitis at our hospital. Materials and Method: This is a cross-sectional study of patients with perianal and anal canal symptoms consistent with proctitis, who consulted at the Clinical Hospital of The University of Chile coloproctology outpatient clinic between January 2017 and December 2018, with perianal and anal canal symptoms, consistent with proctitis, and with confirmed sexually transmitted disease by anal secretion study. Results: Total of 46 patients, all male with average age of 26 years old. 6% heterosexuals. 65% had previous medical consults (none with a proctologist). The most common symptom was wet anus (97.8%), and the most common physical finding was perianal dermatitis (100%). 20 patients had never been tested for HIV, and 50% were positive for this disease. The most common sexually transmitted diseases were gonorrhea (43.4%) and syphilis (31.2%). In 32% of the patients, the culture informed more than one pathogen. Discussion: The results suggest that infectious proctitis is a disease of young patients who have unprotected sex. More than 50% do not use a condom. Most patients have prior consults, but none with a proctologist. The most frequent pathogen that causes infectious proctitis: Neisseria gonorrhoeae, Chlamydia trachomatis, and Treponema pallidum. Conclusion: The presence of severe perianal dermatitis, lack of response to common treatment, and/or in patients with risk factors, infectious proctitis should be suspected.

Clinicopathological characteristics and outcomes of metachronous rectal cancer in patients with a history of cervical cancer with and without remote radiotherapy: Reports of 45 cases.

The purpose of this study was to report the clinicopathological characteristics and treatment outcomes of 45 rectal cancer patients who have a history of cervical cancer with or without remote radiotherapy. Twenty-nine patients (64.4%) with a history of cervical cancer treated with pelvic radiotherapy were classified as group A, 16 (35.6%) patients with a history of cervical cancer not treated with radiotherapy were classified as group B. The median duration between radiotherapy for cervical cancer and rectal adenocarcinoma diagnosis was 18 years. At the time of rectal cancer diagnosis, 5 (17.2%) patients presented stage I disease, 15 (51.7%) had stage II, 1 (3.4%) had stage III, and 8 (27.6%) had stage IV. The patients in group A had older age, higher rates of gross ulcerative lesions, low hemoglobin levels, and a lower rate of lymph node metastases. The patients with secondary rectal cancer developed after radiotherapy for cervical cancer usually presented with abnormal abdominal symptoms, such as proctitis, cystitis, or rectal fistula. Higher colostomy rate was found in this group of patients due to severe pelvic fibrosis or proctitis.

Adjuvant electronic brachytherapy for endometrial carcinoma: A 4-year outcomes report.

PURPOSE: The purpose of the study was to report the outcomes of a single-center adjuvant electronic brachytherapy (e-BT) experience for patients with endometrial carcinoma. METHODS AND MATERIALS: Patients were retrospectively assessed. Intracavitary e-BT was applied through a cylindrical applicator (diameters 2.5-3.5 cm). e-BT single doses ranged between 4 and 7 Gy (EQD2 ∼ 6-12, α/ß of 10 Gy and an relative biological effectiveness of 1.3) at 5-mm depth. Adverse events are reported at first week, 1-3 months, 3-12 months, 12-24 months, and >24 months. The overall survival, disease-free survival, distant disease control rate, and local control rate were estimated using the Kaplan-Meier method. RESULTS: Twenty-nine patients were assessed. The median age was 68 [48-86] years. External beam radiotherapy was added in n = 8 (27.6%) patients. Staging was 13.8% for T1a, 51.7% for T1b, 24.1% for T2, 6.9% for T3a, and 3.4% for T3b. Grading was G3 in 51.7% (n = 15), G2 in 20.7% (n = 6), and G1 in 27.6% (n = 8). Median followup was 47 months [5-88]. Overall Grade 1, 2, and 3 toxicity was 89.7% (n = 26), 17.2% (n = 5), and 6.9% (n = 2), respectively. No Grade 3 cystitis or proctitis or any Grade 4 or 5 toxicity occurred during followup. No local recurrences were detected. Estimated distant disease control rate was 92.1% (n = 2, distant metastasis at 7 and 11 months). Estimated 4-year overall survival was 84.8% (n = 4 events, two unrelated to disease) and disease-free survival was 84.6%. CONCLUSIONS: Our data suggest that e-BT resembles a very-low-toxicity profile and a high local control rate in the adjuvant scenario for patients with endometrial carcinoma.

Ileorectal Anastomosis Versus IPAA for the Surgical Treatment of Ulcerative Colitis: A Markov Decision Analysis.

BACKGROUND: Ileorectal anastomosis in patients with ulcerative colitis results in decreased postoperative morbidity and better functional outcome but leads to increased risk for rectal cancer compared with IPAA. OBJECTIVE: This study aims to compare ileorectal anastomosis with IPAA in ulcerative colitis by using a decision model. DESIGN: A Markov simulation model was designed to simulate clinical events of ileorectal anastomosis and IPAA over a time horizon of 40 years with time cycles of 1 year. All probabilities and utilities were derived from observational studies, identified after a systematic literature search using MEDLINE. Primary outcomes were life-years and quality-adjusted life-years. Deterministic and probabilistic sensitivity analyses were performed. SETTINGS: A decision model using Markov simulation was designed. PATIENTS: The base case was a 35-year-old patient with ulcerative colitis and a relatively preserved rectum. MAIN OUTCOMES MEASURES: The primary outcome measures were (quality-adjusted) life-years. RESULTS: The model resulted in lower life-years (36.22 vs 37.02) and higher quality-adjusted life-years (33.42 vs 31.57) for ileorectal anastomosis. This was confirmed after probabilistic sensitivity analysis. The model was sensitive to the utility of ileorectal anastomosis, IPAA, and end-ileostomy. A higher proportion of patients with ileorectal anastomosis will develop rectal cancer (7.6% vs 3.2%) and 43.5% of all patients with ileorectal anastomosis will end with an ileostomy as opposed to 23.0% of all patients with IPAA. LIMITATIONS: The study was limited by characteristics inherent to modeling studies, including assumptions necessary to build the model, data input based on best available but often limited evidence, and unavoidable extra- and interpolation of data. CONCLUSIONS: Ileorectal anastomosis was the preferred treatment option when quality-adjusted life-years were the outcome, with higher life-years for IPAA. This model highlights that both surgical strategies are useful in patients who have ulcerative colitis with a relatively spared rectum. See Video Abstract at http://links.lww.com/DCR/B249. ANASTOMOSIS ILEORRECTAL VERSUS ANASTOMOSIS ANAL CON RESERVORIO ILEAL EN EL TRATAMIENTO QUIRÚRGICO DE LA COLITIS ULCEROSA: ANÁLISIS DE DECISIÓN DE MARKOV: Las anastomosis ileorrectales en pacientes con colitis ulcerosa se encuentran asociadas con la disminución de la morbilidad postoperatoria y un mejor resultado funcional, pero conducen a un mayor riesgo de cáncer de recto cuando se las compara con casos de confección de un reservorio íleo-anal.Comparar las anastomosis ileorrectales con la anastomosis de un reservorio íleo-anal en casos de colitis ulcerosa, utilizando un modelo de procesos de decisión.Se diseñó un modelo de proceso de Markov para simular eventos clínicos en casos de anastomosis ileorrectales y anastomosis de reservorios íleo-anales en un horizonte temporal de 40 años comprendiendo ciclos temporales de 1 año. Todas las probabilidades y utilidades se derivaron de estudios observacionales, identificados después de una búsqueda sistemática de literatura usando MEDLINE. Los resultados primarios fueron años de vida y los años ajustados a la calidad de vida. Se realizaron los análisis de sensibilidad determinada y de probabilística.Se diseñó un modelo de decisión utilizando el proceso de simulación de Markov.El caso base fue el de un paciente de 35 años con colitis ulcerosa y con un recto relativamente sano.El resultado principal fué la medida de los años de vida (con ajuste en la calidad de vida).El modelo resultó en menos años de vida (36.22 frente a 37.02) y años de vida de menor calidad (33.42 frente a 31.57) para los casos de anastomosis ileorrectales. Esto se confirmó después del análisis de sensibilidad probabilística. El modelo era sensible a la utilidad de la anastomosis ileorrectal, la anastomosis del reservorio íleo-anal y la ileostomía terminal. Una mayor proporción de pacientes con anastomosis ileorectales desarrollarán cáncer de recto (7,6% frente a 3,2%) y el 43,5% de todos los pacientes con anastomosis ileorrectales terminarán con una ileostomía en comparación con el 23,0% de todos los pacientes con un reservorio íleo-anal.El analisis estuvo limitado por las características inherentes a los estudios de modelado, incluidas las suposiciones necesarias para construir el modelo, la entrada de datos basada en la mejor evidencia disponible pero a menudo limitada y la extrapolación e interpolación inevitable de datos.Las anastomosis ileorrectales fueron la opción de tratamiento preferida cuando el resultado fue ajustado en años con calidad de vida, con años de vida más larga para la anastomosis de reservorios íleo-anales. Este modelo destaca que ambas estrategias quirúrgicas son útiles en pacientes con colitis ulcerosa con rectos relativamente sanos. Consulte Video Resumen en http://links.lww.com/DCR/B249.

Association between acute histopathological changes of rectal walls and late radiation proctitis following radiotherapy for prostate cancer.

PURPOSE: The impact of acute histopathological changes (HC) of the rectum on development of late clinical proctitis (LCP) after external radiotherapy (RT) for prostate cancer is poorly explored and was the primary end point of this prospective study. METHODS: In 70 patients, 15 HC of early rectal biopsies after RT were identified, whereby RT was conventional 2D RT in 41 cases and conformational 3D RT in 29. Associations of HC in anterior and posterior rectal walls (ARW, PRW) with LCP, acute endoscopic (AEP) and acute clinical proctitis (ACP) were statistically evaluated considering as explicative variables the patient general characteristics and the HC. RESULTS: The mean patients' follow-up was 123.5 months (24-209). The median prostatic dose was 72 Gy (2 Gy/fraction). For the 41 and 29 patients the ARW and PRW doses were 64 and 49 Gy vs. 63 and 50 Gy, respectively. The incidence of LCP ≥ grade 2 at 10 years was 12.9%. The univariate (p = 0.02) and Kaplan-Meyer methods (p = 0.007) showed that the gland (or crypts) loss in the ARW was significantly associated with LCP. AEP and ACP occurred in 14.3 and 55.7% of cases. At multivariate level AEP significantly correlated with hemorrhoids (p = 0.014) and neutrophilia in ARW (p = 0.042). CONCLUSIONS: Early after RT, substantial gland loss in ARW is predictive of LCP. To reduce this complication with conventional fractionation, we suggest keeping the mean dose to ARW ≤48-52 Gy.

Proctitis in gay and bisexual men. Are microscopy and proctoscopy worthwhile?

OBJECTIVES: We explored the association between nucleic acid amplification testing (NAAT) and rectal microscopy/proctoscopy findings and correlates of rectal STIs among 150 gay and bisexual men (GBM) diagnosed with proctitis at the Sydney Sexual Health Centre from March 2016 to October 2017. METHODS: From case files, we analysed risk behaviours, microscopy, proctoscopy and NAAT results for rectal STIs (Chlamydia trachomatis, Neisseria gonorrhoeae, Mycoplasma genitalium, herpes simplex virus type 1/2, lymphogranuloma venereum and syphilis). χ2 test assessed the association between microscopy/proctoscopy findings and NAAT results. Linear regression assessed the association between NAAT positivity and correlates of rectal STIs. RESULTS: The mean age was 32.5 (9.8) years, 43% (65/150) were taking pre-exposure prophylaxis, 17% (26/150) were HIV positive and 24% (36/147) had multiple rectal STIs.Among GBM with documented proctoscopy findings (n=113), 58% (65/113) had discharge, 36% (41/113) had anorectal erythema and 25% (28/113) had bleeding. A quarter of GBM (28/113) had negative proctoscopy findings.Discharge found on proctoscopy (p=0.001), positive HIV status (p=0.030) and time since last receptive anal intercourse (p=0.028) were independently associated with NAAT positivity for any rectal STI. Discharge had a positive likelihood ratio of 1.6 (95% CI 1.0 to 2.4).Among those with documented microscopy findings (n=69), 59% (41/69) and 41% (28/69) were NAAT positive and negative, respectively. Among NAAT-positive GBM, 27 (66%) had polymorphonuclear cells (PMNs) (mean number of PMNs, 10 (SD 9) cells per oil immersion field), 1 (2%) had Gram-negative intracellular diplococci and 11 (27%) had negative findings. There was no significant association between microscopy findings and NAAT results (p=0.651) or the number of rectal STI (p=0.279). CONCLUSION: Microscopy does not reliably provide information necessary to tailor the management of GBM diagnosed with proctitis. Discharge found during proctoscopy may identify GBM with rectal STI. Services should consider recommendations to perform these investigations.

Substantial underdiagnosis of lymphogranuloma venereum in men who have sex with men in Europe: preliminary findings from a multicentre surveillance pilot.

OBJECTIVES: Understanding the public health impact of lymphogranuloma venereum (LGV) in Europe is hampered by inadequate diagnostics and surveillance systems in many European countries. We developed and piloted LGV surveillance in three European countries without existing systems and performed a preliminary investigation of LGV epidemiology, where little evidence currently exists. METHODS: We recruited STI or dermatovenereology clinics and associated laboratories serving men who have sex with men (MSM) in Austria, Croatia and Slovenia, using the UK for comparison. We undertook centralised LGV testing of Chlamydia trachomatis (CT)-positive rectal swabs collected between October 2016 and May 2017 from MSM attending these clinics. Stored specimens from Austria (2015-2016) and Croatia (2014) were also tested. Clinical and sociodemographic data were collected using a standardised proforma. The ompA gene of LGV-positive specimens was sequenced. RESULTS: In total, 500 specimens from CT-positive MSM were tested, and LGV positivity was 25.6% (128/500; 95% CI 22.0% to 29.6%) overall, and 47.6% (79/166; 40.1% to 55.2%) in Austria, 20.0% (3/15; 7.1% to 45.2%) in Croatia, 16.7% (1/6; 3.0% to 56.4%) in Slovenia and 14.4% (45/313; 10.9% to 18.7 %) in the UK. Proformas were completed for cases in Croatia, Slovenia and in the UK; proformas could not be completed for Austrian cases, but limited data were available from line listings. Where recorded, 83.9% (78/93) of LGV-CT cases were HIV-positive compared with 65.4% (149/228) of non-LGV-CT cases; MSM with LGV-CT were more likely to have proctitis (Austria, 91.8% vs 40.5%, p<0.001; Croatia, 100% vs 25%, p=0.04; UK, 52.4% vs 11.7%, p<0.001) than those with non-LGV-CT. Six different ompA sequences were identified, including three new variants; the L2 ompA sequence predominated (58.6%, 51/87). CONCLUSIONS: LGV is substantially underdiagnosed in MSM across Europe. Unified efforts are needed to overcome barriers to testing, establish effective surveillance, and optimise diagnosis, treatment and prevention.

Effect of interval between preoperative radiotherapy and surgery on clinical outcome and radiation proctitis in rectal cancer from FOWARC trial.

OBJECTIVE: The aim of this study was to evaluate the effect of the interval between CRT and surgery on radiation proctitis, the pathologic response, and postoperative morbidity. METHODS: This was a cohort study from a phase III, randomized controlled trial (FOWARC study, NCT01211210). Data were retrieved from the leading center of the trial. Patients were divided into the short-interval (≤7 weeks) group and the long-interval (>7 weeks) group. The rate of radiation proctitis, pathologic complete regression (pCR) and morbidities were calculated for each group. Multivariate analysis was used to verify the impact of interval on radiation proctitis. RESULTS: Surgery was performed in 60 patients after an interval of ≤7 weeks and in 97 patients after an interval of >7 weeks. The two groups according to interval were comparable in terms of baseline demographic and clinicotherapeutic characteristics. Radiation proctitis was identified by imaging in 9 (15.0%) patients in short-interval group and in 31 (32.0%) patients in long-interval group (P = .018). Multivariate analysis confirmed the correlation between long interval and radiation proctitis (P = .018). The long interval was significantly associated with longer median operation time compared to the short interval (P = .022). The rates of pCR and postoperative complications were not different between two groups. CONCLUSIONS: A longer interval after CRT may be associated with higher rate of radiation proctitis and longer operation time. Moreover it did not increase the rate of pCR.