Double seton—A new modified approach to high transsphincteric anal fistula

Despite the fact that complicated extrasphincteric anal fistulas have been recognized and treated for many years, there is still a lack of consensus among colorectal surgeons as to the optimum surgical approach. We have devised a modification of the seton technique, which we used in 23 patients without complications or recurrence.     

Do anal fistulas in Crohn's disease behave differently and defy Goodsall's rule more frequently than fistulas that are cryptoglandular in origin?

OBJECTIVES: The complexity of anal fistulas is different in patients with and without Crohn's disease and in men and women. This may affect the localization of the internal orifice. We compared the characteristics of anal fistulas and the accuracy of Goodsall's rule in predicting the position of the internal orifice in male and female Crohn's and non-Crohn's patients. METHODS: A total of 191 fistula tracks in 182 consecutive patients (110 men and 72 women) were analyzed prospectively. Of the patients, 63 were diagnosed with Crohn's disease. The positions of the orifices were recorded and the accuracy of Goodsall's rule determined. RESULTS: The distribution of fistula subtypes among Crohn's and non-Crohn's patients differed significantly (p = 0.0471). Fistulas with an anterior external opening occurred more frequently in Crohn's patients (p = 0.0350) and in women (p = 0.0030). Fistulas with a posterior external orifice were observed more frequently in non-Crohn's patients (p = 0.0350) and in men (p = 0.0028). Overall, Goodsall's rule performed less well in women compared with men (p = 0.0633). The accuracy of Goodsall's rule overall was not affected by Crohn's disease. In female non-Crohn's patients, the positive predictive value of a posterior external orifice was lower than in men (p = 0.0406). CONCLUSIONS: The distribution of fistula subtypes and the ratio of anterior and posterior external openings among Crohn's and non-Crohn's patients differ significantly. Many fistulas defy Goodsall's rule, particularly in women and when applied to fistulas with anterior external orifices. The popular rule, however, falls equally short in Crohn's and non-Crohn's fistulas.     

Combined therapy with infliximab and seton drainage for perianal fistulizing Crohn’s disease with anal endosonographic monitoring: a single-centre experience

During infliximab treatment of perianal Crohn's disease (CD), the healing of the skin opening precedes fistula tract healing and this contributes to abscess formation and fistula recurrence. The aims of this study were to evaluate the efficacy of combined treatment with infliximab and setons for complex perianal fistulas in CD and to define the optimal time for seton removal by anal endosonography (AE). Nine consecutive patients with CD were studied. Perianal sepsis was eradicated when necessary and setons were placed before infliximab therapy. Setons were removed after AE evidence of fistulous tracts healing. Patients received a mean of 10+/-2.3 infliximab infusions. At week 6 all patients showed a reduction in mean CD activity index (p<0.005) and perianal disease activity index (p<0.0001). Complete fistula response was achieved in eight of nine patients. In six patients after a mean of 9.2 infusions, infliximab treatment was discontinued. Clinical and AE response persisted at 19.4+/-8.8 months (range 3-28 months) in five of these patients. One patient had fistula recurrence 20 weeks after infliximab discontinuation and responded rapidly to retreatment. At the time of this report, two patients were still on infliximab and in remission after a mean follow-up of 25+/-5 months. Combined therapy with infliximab and setons with AE monitoring of the response showed high efficacy in the management of patients with CD with complex perianal fistulas.     

Sexual function and quality of life after surgical treatment for anal fistulas in Crohn’s disease

Background

The aim of this study was to assess sexual function and quality of life (QoL) in patients after surgery for perianal Crohn’s disease.

Methods

Eighty-eight consecutive patients with perianal Crohn’s disease, operated on at the Medical University of Vienna, completed a self-administered questionnaire including the International Index of Erectile Function (IIEF), Female Sexual Function Index (FSFI), Short Form-12 Health Survey (SF-12), and the Inflammatory Bowel Disease Questionnaire (IBDQ). Patients with a current stoma were excluded from further analysis. The median follow-up time was 104 months (range 3–186 months). Healthy subjects served as controls for each case and were matched by age (±6 years) and gender. Forty-seven (68 %) female and 22 male patients with a median age of 46.5 years (range 18–64 years) were analyzed. Eleven (16 %) patients had simple and 58 (84 %) complex anal fistulas.

Results

The median SF-12 physical health score of the patients was significantly lower (47.9 (range 25.5–57.2)) than that of the controls (54.3 (range 34.6–61.8); p = 0.03). Not surprisingly, the median total sore of the IBDQ of the controls was significantly better than that of the patients (controls: 188.5 (range 125–206.5), patients: 157 (range 60–199.5); p < 0.0001). Analysis with the multiple logistic regression test showed that type of operation, >1 perianal fistula opening, and active Crohn’s disease were independent risk factors for a worse IBDQ (p = 0.03, p = 0.015 and p < 0.0001). Interestingly, the median FSFI and IIEF score were not found to be significant different in any domain.

Conclusions

QoL but not sexual function is significantly influenced by surgery for perianal Crohn’s disease.     

Is Crohn's disease rare in India?

BACKGROUND: Crohn's disease (CD) is believed to be rare in India. OBJECTIVE: To analyze the data pertaining to patients with CD seen in a tertiary referral center. METHODS: Data on patients with chronic inflammatory bowel disease attending our Unit over a 5-year period were analyzed. The diagnosis of CD was established by the presence of characteristic segmental bowel involvement, consistent histological picture, exclusion of infectious causes, relapsing nature of the disease, response to appropriate drug therapy, and lack of evidence for another etiological factor. RESULTS: Of the 25 patients (age range 12-52, mean 31.7, years) 13 were men. Abdominal pain was present in 21 (84%) patients, diarrhea in 20 (80%), blood per rectum in 11 (44%) and fever in 4 (16%). The ileocecal region was involved in 6 (24%) patients and anal canal in 4 (16%); 19 (76%) had patchy involvement of different segments of the large bowel. Colonoscopic biopsies revealed granulomas in 12 (48%). During a mean follow up of 36.4 (range 6-54) months, 15 (60%) patients had 21 relapses. Despite initial response to 5-aminosalicylic acid in five patients, 23 needed glucocorticoid therapy at least once. CONCLUSIONS: CD may not be rare in India. Because of the high prevalence of intestinal tuberculosis there is a possibility that CD may be under-recognized in India.     

Can we influence fibrosis in Crohn's disease?

Despite recent advances in the therapy of active Crohn's disease (CD) fibrostenosis remains a challenging complication of the disease. Transmural inflammation of CD is associated with phenotypic switch of the mesenchymal cells resulting in proliferation and collagen deposition. Both resident myofibroblasts and smooth muscle are candidate progenitor cells of the fibrogenic cells in CD stenoses. The principal growth factors involved in intestinal fibrosis have not been identified although TGF-beta 1 and 2, PDGF and IL-1 may be involved. Research aimed at elucidating the basic mechanisms underlying fibrosis in the gut has been hindered by the lack of an adequate animal model. Recently, however, new rodent models of chronic inflammation with distinct fibrosis have been described. Cell culture research has provided more information about possible pathways that may limit uncontrolled mesenchymal proliferation in the inflamed intestinal wall. The modulator role of neurotransmitters such as VIP, nitric oxide and prostaglandines is an important target for therapeutic intervention. Interfering with the phenotypic switch of mesenchymal cells may offer new therapeutic perspectives in the prevention of fibrostenosis. Further in vitro and animal studies as well as restenosis prevention studies are needed to develop pharmacological tools in the prevention of Crohn's disease fibrostenosis.     

Is Hartmann's procedure safe in Crohn's disease?

INTRODUCTION: Crohn's disease-associated colorectal cancer may occur in an area of defunctioning bowel. Some patients with Crohn's colitis undergo subtotal colectomy, ileostomy, and low Hartmann's procedure in an effort to preserve the rectum. This procedure has also been advocated for patients with severe anorectal Crohn's disease, in whom nonhealing of the perineal wound after proctectomy occurs with alarming frequency. The authors present a review of the literature and three cases of cancer developing in the defunctioning rectal stump despite surveillance proctoscopy. METHODS: Twenty-five patients underwent low Hartmann's procedure for severe anorectal Crohn's disease. Surveillance proctoscopy was performed as follow-up. Development of cancer in the rectal remnant or anus or recurrence of symptoms was managed by resection and adjuvant therapy. RESULTS: One patient developed squamous-cell carcinoma of the anal canal, underwent resection and adjuvant therapy, and was disease free at the time of this study. Two patients developed adenocarcinoma of the rectum. Both underwent resection and adjuvant therapy. One patient died and the other developed a recurrence. CONCLUSIONS: The authors recommend interval perineal proctectomy in all patients undergoing low Hartmann's procedure for severe anorectal Crohn's disease in whom rectal preservation is not possible. Regularly scheduled interim surveillance proctoscopy performed every two years, with biopsies of macroscopically normal-appearing and abnormal-appearing rectal mucosa and curetting of fistulous tracts, is also recommended to decrease the possibility of missing occult malignancies.     

A role for bacteria in celiac disease?

The finding of rod-shaped bacteria attached to the small intestinal epithelium of some untreated and treated celiac-disease patients, but not to the epithelium of healthy controls, ignites the notion that bacteria may be involved in the pathogenesis of celiac disease. This editorial discusses this possibility in relation to the current understanding of the molecular basis of this disorder.