How to manage anal ulcerations and anorectal stenosis in Crohn's disease: algorithm-based decision making : French National Working Group Consensus 2018.

The French National Society of Coloproctology established national recommendations for the treatment of anoperineal lesions associated with Crohn's disease. Treatment strategies for anal ulcerations and anorectal stenosis are suggested. Recommendations have been graded following international recommendations, and when absent professional agreement was established. For each situation, practical algorithms have been drawn.

The incidence of bacteraemia after argon plasma coagulation in patients with chronic radiation proctocolitis.

AIM: Argon plasma coagulation (APC) is considered a safe treatment for haemorrhagic chronic radiation proctocolitis (CRPC), but bacteraemia is a rare complication. The study aimed to evaluate the frequency of bacteraemia after APC. METHOD: A prospective study of 21 patients who underwent APC (30 procedures) for CRPC was carried out. Blood cultures (Bactec(®) ) were obtained before and 30 min after the procedure (60 samples total). Patients were monitored for 48 h after the procedure to detect signs of infection. RESULTS: None of the 21 patients had fever or any sign suggestive of infection after any of the 30 sessions. All baseline blood cultures were negative and two (7%) of the 30-min blood cultures were positive (Staphylococcus hominis n = 1; Streptococcus bovis and Rhodotorula sp n = 1). The first was likely to be a contaminant and the second patient had no evidence of any other colonic disease (neoplasia or polyps) beside CRPC. CONCLUSION: APC is a low-risk procedure regarding bacteraemia and does not warrant prophylactic antibiotic administration.

Laparoscopic reversal of Hartmann's rectosigmoidectomy.

OBJECTIVE: The aim of this study was to analyse the outcome of laparoscopic restoration of bowel continuity post Hartmann's procedure. METHOD: A prospectively electronic database of colorectal laparoscopic procedures between April 2001 and December 2006 has been used to identify surgical outcomes in 28 consecutive patients who have undergone laparoscopic reversal of an open Hartmann's procedure (LRH). RESULTS: Twenty-eight patients (11 males), median age 66 (32-89), median body mass index 26 have undergone an attempted LRH over a 5-year period. Twenty (71%) had undergone surgery for complicated diverticulitis, eight (29%) for cancer; two followed an anastomotic dehiscence post-laparoscopic high anterior resection. The median operation time was 80 min (40-255 min). Twenty-six procedures (93%) were completed laparoscopically. There was one late conversion (to release a small bowel loop from the pelvis). A small, fibrotic rectal stump split whilst attempting a stapled anastomosis - the procedure was abandoned. The median time to normal diet was 18 h and median hospital stay was 3 days (1-63). There were three (11%) readmissions; wound infection (two) and abdominal pain. There were two deaths (7%) - mesenteric emboli and anticoagulant induced upper gastrointestinal haemorrhage. CONCLUSIONS: We believe that in the hands of appropriately trained and experienced surgeons, laparoscopic 'reversal' of a Hartmann's procedure is a feasible, safe and largely predictive operation that allows for early return of gastrointestinal function and very early hospital discharge.

[Predictive factors of recurrence after surgery in severe attacks of hemorrhagic ulcerative proctocolitis]. / Facteurs prédictifs de recours à la chirurgie dans la rectocolite ulcéro hémorragique en poussée grave.

AIM: The purpose of our study was to determine clinical, biological or endoscopic factors that predict surgery after a glucocortico steroid treatment failure in severe attacks of ulcerative colitis. METHODS: Sixty one patients were analyzed. A therapeutic response for glucocorticosteroid was defined as the absence of resort to surgery within the first 30 days after hospitalization. Predictive factors were assessed using univariate and multivariate analysis. RESULTS: Fifteen patients (24.6%) had a medical response. In univariate analysis, predictive factors of surgery were: male sex, tobacco, number of colitis attacks in case history, temperature over 38 degrees C, erythrocyte sedimentation rate over 30 mm, systolic blood pressure below 11, deep and wide ulcers. During the course, bowel movements/day over 7, pulse over 90/mn, temperature over 38 degrees C on day 3 after treatment initiation as well as passage of blood on day 5 were identified as predictors of surgery. In multivariate analysis, bowel movements over 7/day on day 3 of hospitalization was independently predicted a surgery. CONCLUSION: Bowel movements/day over 7 on day 3 of hospitalization was the only independently predictive factor of surgery after glucortico steroid treatment failure

An unusual case of proctosigmoiditis secondary to arteriovenous fistulization.

Refractory chronic colitis presents a medical and surgical challenge, and underlying etiologies are diverse with potential for misclassification as inflammatory bowel disease. We present an unusual case of chronic proctosigmoiditis with rare vascular etiology. A 48-year-old Caucasian male presented with severe diarrhea, weight loss, and abdominal pain. Computed tomography (CT) suggested proctosigmoiditis. Colonoscopy and biopsy findings were non-specific but were suggestive of ischemic etiology and venous congestion. He was initially treated with antibiotics, steroids, and mesalamine, which did not show any improvement. Mesenteric angiography showed a fairly large irregular and bizarre vessel consistent with a large arteriovenous fistula (AVF) associated with one of the branches of the inferior mesenteric artery. AVF was too large to be embolized, and he underwent a laparoscopic low anterior resection with creation of a coloproctostomy and protective diverting loop ileostomy. An AVF was found at the origin of the ascending left colic artery. Inferior mesenteric vein thrombosis and arteriovenous fistulization are rare vascular causes of chronic proctosigmoiditis, but these should be considered in refractory cases. Both initial diagnosis and surgical treatment can be challenging.

Efficacy and safety of Nd:YAG laser for the treatment of bleeding from radiation proctocolitis.

BACKGROUND: Bleeding due to radiation proctocolitis is a frequent and severe complication of radiotherapy in cancers of the pelvis. AIM: The aim of this study was to evaluate the efficacy and safety of endoscopic treatment with Nd:YAG laser in this condition. PATIENTS AND METHODS: A series of 9 patients with radiation-induced damage in the rectum and sigma were treated with endoscopic Nd:YAG laser until significant bleeding stopped and endoscopic features of proctocolitis improved. They received a median of 3 laser treatments (range 1-10) over a maximum time period of 11 months. RESULTS: In 4 cases, bleeding ceased and, in 4, it was reduced to occasional spotting. In the remaining patient, laser therapy led to only a transient improvement, but did not modify the requirement of blood transfusion. In the 5 patients also suffering from urgency, incontinence and/or rectal mucoid discharge, the laser therapy course also relieved these symptoms. No significant treatment-related complications were observed. CONCLUSIONS: Endoscopic Nd: YAG laser is a useful and safe treatment for patients with bleeding due to radiation proctocolitis.

Results of laparoscopically assisted colon resection for carcinoma.

BACKGROUND: Surgical resection is the primary treatment for colorectal carcinoma. Laparoscopically assisted colon resection technically is feasible for both benign and malignant disease. However, the role of laparoscopically assisted colon resection for carcinoma is controversial. METHODS: We prospectively studied our first 100 patients with colorectal carcinoma who successfully underwent laparoscopically assisted colon resection for the carcinoma. RESULTS: The pathologic stages were Dukes' categories A-16, B-52, C-25, and D-7. Operative mortality and morbidity were 2% and 22%, respectively. During a mean follow-up period of 40.3 months, recurrence by stage was zero patients with stage A disease, five patients with stage B disease, nine patients with stage C disease. Thirteen of these patients died as a result of their disease. At this writing, 60 patients are alive without evidence of disease, and 23 have completed the study disease free after more than 60 months. The 5-year survival probabilities by stage were 100% for stage A, 76.8% for stage B, and 51.7% for stage C. CONCLUSIONS: Laparoscopically assisted colectomy for cancer can be performed safely. The recurrence rate after laparoscopically assisted resection appears to be at least as good as after open resection. Results from ongoing prospective, randomized trials are needed to confirm these findings.

Colitis cystica profunda: an unusual surgical problem.

Colitis cystica profunda is a rare, benign, non-neoplastic condition which usually presents as a mass in the rectum associated with bloody, mucoid diarrhea. This clinical presentation associated with the microscopic finding of mucus cysts in the submucosa has led to the mistaken diagnosis of adenocarcinoma of the rectum and unnecessarily radical operative procedures. Attention to the completely normal cellular architecture provides the key to the correct diagnosis. Local excision is curative, and there is no propensity to develop malignancy in these patients. Experience with one case is reported, and the medical literature on the subject is reviewed.

[Ulcerative colitis and Crohn's colitis. Medical or surgical treatment]. / Colite ulcerosa e colite di Crohn. Terapia medica o chirurgica?

Colectomy with ileorectal anastomosis was performed in 47 patients affected by ulcerative colitis and Crohn's colitis. These two forms of "aggressive idiopathic colitis" present the same problems of therapy from both the pharmacological and the surgical point of view. The topical employment of antiphlogistic steroids and sulphasalazine by daily retention enemas caused a regression of proctitis and allowed a safe ileorectal anastomosis. After the surgical procedure a protective treatment of the rectal mucosa was prosecuted with minimal dosages of the same antiphlogistic drug by daily minienemas. Betametasone in aqueous solution have proved, among the antiphlogistic steroids, to be very suitable for a topical action without side-effects in the long time. The association of topical treatment and surgery is particularly indicated for those patients who cannot recover with medical therapy alone, as it enables them to recover and return to a normal life. The opportunity for colectomy is so much greater as it is possible, as a rule, to spare the rectum and protect the ileorectal anastomosis by means of a topical therapy without limitations of time. Therefore the surgical indication should not be delayed whenever the medical treatment by systemic administration of steroids, sulphasalazine and immunosuppressors is unable to prevent the evolution of aggressive idiopathic colitis to a chronic and seriously invalidating disease.

[Clinical characteristics and evolution of permanent digestive ostomies. Results of a nation-wide retrospective survey]. / Caractéristiques cliniques et évolution des stomies digestives définitives. Résultats d'une enquête rétrospective nationale.

Factors influencing the achievement and the evolution of permanent stomas were determined during a National Inquiry including 1,082 stomas (978 colostomies and 104 ileostomies). This study, although not exhaustive, was representative, giving its statistical value. The principal concepts are well known with regard to the indications of colostomies (cancer) and ileostomies (inflammatory bowel diseases), to age (older in patients with colostomies: 63.8 vs 41.7 years, P < 0.001) and to the unequal geographical distribution of ileostomies (most frequent in northern provinces: P = 0.02). Frequency of complications (25%) after definitive stoma have decreased since 1985 (P = 0.01) but reoperation was necessary in 50% of cases. Most patients were informed of their stoma before the operation, but 23% were not. Among the informed patients, one fourth considered themselves insufficiently acquainted with their stoma.

[Sigmoiditis with lower rectal and perirectal development]. / Sigmoïdites à évolution basse rectale et péri-rectale.

Lesions of sigmoiditis do not extend beyond the recto-sigmoid junction and Douglas' pouch. However, in 9 out of 271 patients operated upon for sigmoiditis the lesions invaded the rectum either anteriorly by perforating Douglas' pouch, or around it and posteriorly through the meso-rectum. These cases of "lower" sigmoiditis have several features in common: a long history of infection, frequent haemorrhages and fistulae, pseudo-tumoral lesions, sometimes very large, detectable by rectal palpation. Surgery is indicated only in cases with serious complications, since many technical problems may be encountered. Wide resection of the rectum followed by low-sited anastomosis ensure stable results.

[Surgical treatment in ulcerative rectocolitis . Analysis of a 24 years experience of 50 patients]. / Tratamentul chirurgical în rectocolita ulcerohemoragica. Analiza unei experiente de 50 de pacienti pe o perioada de 24 de ani.

Ulcerative colitis (UC) is an inflammatory bowel disease that may be cured by surgery being indicated for emergency situations resulting from complications of fulminant disease and for elective indications. We analyzed the last 24 years experience regarding 50 patients surgically treated for ulcerative colitis in the Center of General Surgery and Liver Transplantation of Fundeni Clinical Institute. The indications for surgery were: failure of medical treatment in 22 patients, acute disease with complications in 20, chronic complications in 8 cases. We used the following surgical procedures: total proctocolectomy in all 2 cases with associated rectal cancer, total colectomy with ileo-rectal anastomosis (one staged or two staged procedures) in 31, and restorative proctocolectomy in 17 cases (in all cases as a 2 or 3 staged procedure). In acute disease with complications we have performed total colectomy with terminal ileostomy, closure of the rectal stump, or exteriorization of the sigmoid stump in a mucous fistula. The gravity of acute complications does not justify the use of palliative procedures such as ileostomy, colostomy or Hartmann procedure because the mortality rate of these operations is higher than the postoperative mortality rate of total colectomy performed in emergency. Even in the elective surgery, when the patients are in a poor condition, nutritionally depleted, taking large doses of steroids or immunosuppressive drugs, we prefer the staged procedure. Total proctocolectomy is performed only in the cases of ulcerative colitis associated with rectal cancer, severe perianal disease, sphincter incontinence. Total colectomy with ileo-rectal anastomosis is indicated when the rectal stump has minimal inflammatory lesions. Restorative proctocolectomy is the surgery of choice for UC, the functional results being comparable with those of total colectomy with ileo-rectal anastomosis, but having the advantage of curing the disease. The global mortality rate was 12% (6 patients).

[Late results of ileorectal anastomosis in proctocolitis]. / Pozdní výsledky ileorektálních anastomóz pri proktokolitide.

In 1961-1986 at the Surgical Clinic of the Institute for Postgraduate Medicine in Prague 49 colectomies were performed with ileorectal anastomosis. The operations were usually made in several stages. The remote results were evaluated after an interval of 10 to 26 years in 33 patients and were good to satisfactory in 82%. Malignant degeneration in the rectum was not observed. The relatively favourable results can be ascribed to careful selection of patients and frequently also the multi-stage procedure. Ileorectal anastomoses are still justified in the surgical treatment of proctocolitis.