Injection of freshly collected adipose tissue for the treatment complex cryptoglandular anal fistula: case report

Introduction: Perianal fistula is a common colorectal disease which is caused mainly by cryptoglandular disease. Although most cases are treated successfully by surgery, management of complex perianal fistulas (CPAF) remains a challenge with limited results in recurrence and sometimes associated with fecal incontinence. The CPAF treatment with autologous adipose-derived mesenchymal stem cells (ASCs) had become a research hotspot. The technique started to be used in the treatment of Crohn's disease (CD) fistulas, where the studies showed safe and goods result from the procedure. Cultured ASCs have been used but this approach requires the preceding collection of adipose tissue, time for isolation of ASCs and subsequent in vitro expansion, need for laboratory facilities, and expertise in cell culturing. These factors have been getting over by using the commercially available alternative, allogenic ASCs. Treatment with allogeneic ASCs has shown good results in patients with CD fistulas, however with the disadvantage of being expensive. Objective: To show that the injection with freshly collected adipose tissue is an alternative to treatment with autologous or allogenic ASCs with several advantages. Methods: In this case report, we show our first experience in the treatment of CPAF with the application of collected adipose tissue in a tertiary referral hospital from Belo Horizonte, Brazil. Results The patient had a good postoperative recuperation with a complete fistula healing after 8 months without adverse effects. Conclusion: Injection with freshly collected adipose tissue is a promising and apparently safe sphincter-sparing technique in the treatment of CPAF. (AU)

Doença de Crohn perianal fistulizante: o gênero do paciente é relevante? Uma revisão sistemática / Fistulizing perianal crohn's disease: is the patient's sex a burden? a systematic review

ABSTRACT Background: Fistulizing perianal Crohn's disease poses a treatment challenge, and researchers postulate that this phenotype in young male patients could have a worst outcome. Objective: Thus, the aim of this study was to assess whether sex influences the response to treatment for these patients. Methods: This systematic review (PROSPERO CRD42022319629) was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses protocol. We selected articles published in English, Spanish, Portuguese, and Italian between 2010 and 2020 in the PubMed and Science Direct databases. According to the PICO acronym, prospective studies in patients older than 18 years with the objective of treating fistulizing perianal Crohn's disease were selected. Studies in pediatric populations, retrospective, without treatment objectives, and that included only rectovaginal fistulas or a single sex were excluded. Study quality was assessed using the Cochrane risk of bias tool and Newcastle-Ottawa scale. Results: Of the 1887 articles found, 33 were included. Most studies used anti-TNF drugs as treatment (n=11). Ten studies had subgroup analyses; of them, the two studies reporting sex differences used infliximab and adalimumab as treatment and showed that women had a longer fistula closure time than men. Conclusion: This systematic review showed that few data corroborate the difference between sexes in the treatment of fistulizing perianal Crohn's disease, possibly having a greater relationship with the phenotype. However, considering the lack of results, further studies with this objective and with standardization of fistulas and response assessment methods are needed.

RESUMO Contexto: A doença de Crohn perianal fistulizante representa um desafio de tratamento, e postula-se que esse fenótipo em pacientes jovens do sexo masculino poderia ter um pior resultado. Objetivo: O objetivo deste estudo foi avaliar se o sexo influencia a resposta ao tratamento desses pacientes. Métodos: Esta revisão sistemática (PROSPERO CRD42022319629) foi conduzida de acordo com o protocolo Preferred Reporting Items for Systematic Reviews and Meta-Analyses. Foram selecionados artigos publicados em inglês, espanhol, português e italiano entre 2010 e 2020 nas bases de dados PubMed e Science Direct. De acordo com o acrônimo PICO, foram selecionados estudos prospectivos em pacientes maiores de 18 anos com objetivo de tratamento da doença de Crohn perianal fistulizante. Foram excluídos estudos em populações pediátricas, retrospectivos, sem objetivos de tratamento e que incluíssem apenas fístulas retovaginais ou um único sexo. A qualidade dos estudos foi avaliada usando a ferramenta de risco de viés Cochrane e a escala Newcastle-Ottawa. Resultados: Dos 1.887 artigos encontrados, 33 foram incluídos. A maioria dos estudos utilizou medicamentos anti-TNF como tratamento (n=11). Dez estudos tiveram análises de subgrupos; deles, os dois estudos que relataram diferenças entre os sexos usaram infliximabe e adalimumabe como tratamento e mostraram que as mulheres tiveram um tempo de fechamento da fístula maior que os homens. Conclusão: Esta revisão sistemática mostrou que poucos dados corroboram a diferença entre os sexos no tratamento da doença de Crohn perianal fistulizante, possivelmente tendo maior relação com o fenótipo. Porém, dada à falta de resultados, são necessários mais estudos com esse objetivo e com padronização das fístulas e métodos de avaliação da resposta.

Clinical study on Sanhuang Qingre Fuming and Washing Decoction combined with Chinese medical excision in the treatment of horseshoe perianal abscess after high position / 国际中医中药杂志

Objective:To observe the clinical effect of Sanhuang Qingre Fuming and Washing Decoction combined with Chinese medical excision in the treatment of horseshoe-shaped perianal abscess after high position and to explore its mechanism of action.Methods:Randomized controlled trial. Sixty surgical patients in our hospital from April 2020 to February 2021 were selected as observation objects. The patients were divided into two groups according to the random number table, with 30 patients in each group. Both groups were treated with Traditional Chinese Medicine drainage. On the second day after operation, the control group was treated with potassium permanganate sitz bath fumigation and washing, and the observation group was treated with Sanhuang Qingre Fuming and Washing Decoction. The wound healing time was observed in the two groups, serum TNF-α, IL-1β, IL-6, VEGF, bFGF, and EGF levels were detected by ELISA on the 1st and 7th d after operation, respectively. Serum SOD level was detected by the chemiluminescence method, and serum MDA level was detected by thiobarbituric acid method.Results:The wound healing time in the observation group was shorter than that in the control group ( t=3.37, P<0.01). The recovery rate was 93.3% (28/30) in the observation group and 76.7% (23/30) in the control group. The difference was statistically significant between the two groups ( χ2=4.32, P=0.038). Seven days after surgery, the levels of serum TNF-α, IL-1β and IL-6 in the observation group were significantly lower than those in the control group ( t values were 2.01, 2.05 and 4.88, respectively, P<0.05 or P<0.01), the level of SOD was significantly higher than that of the control group ( t=-2.13, P=0.038), the level of MDA water was significantly lower than that of the control group ( t=3.26, P=0.002), and the levels of VEGF, bFGF and EGF were significantly higher than those in the control group ( t values were -2.02, -3.33, -3.77, respectively, P<0.05). Conclusion:Sanhuang Qingre Tuming and Washing Decoction combined with Chinese medical excision in the treatment could shorten the healing time of the wound surface of horseshoe-shaped perianal abscess after high elevation and improve the recovery rate. The Sanhuang Qingre Fuming and Washing Decoction may reduce inflammatory reaction and oxidative stress damage, improve the level of growth factors and facilitate the postoperative tissue repair.

Clinical study on the treatment of chronic perianal eczema with Qufeng Zhiyang Decoction and Fuzhiqing Ointment / 国际中医中药杂志

Objective:To evaluate the efficacy of Qufeng Zhiyang Decoction combined with Fuzhiqing Ointment in the treatment of chronic perianal eczema.Methods:Randomized controlled trial. A total of 122 patients with chronic perianal eczema in Meishan People's Hospital from January 2020 to May 2021 were selected as the observation objects and divided into 2 groups according to random number table method, with 61 cases in each group. The conventional group was treated with Fuzhiqing Ointment. The study group was treated with Qufeng Zhiyang Decoction. The treatment for both groups lasted for two weeks. TCM symptom score was recored before and after treatment; the degree of skin lesions was evaluated by the area and Eczema Area and Severity Index (EASI); the quality of life of patients was evaluated by the quality of life index of dermatosis (DLQI); the number of Treg and Th17 cells was measured by flow cytometry; the ratio of Th17/Treg cells was calculated; the levels of TNF-α, IL-10 and IL-6 were detected by ELISA. The adverse reactions were recorded and the clinical efficacy was evaluated. The patients were followed up for 3 months and the recurrence was recorded.Results:The total effective rate of the study group was 86.89% (53/61) and that of the conventional group was 72.13% (44/61), with statistical significance ( χ2=4.08, P=0.044). After treatment, the scores of pruritus, spurt water, erythema and burning, upset and thirsty, yellow urine and dry urine in the study group were lower than those in the conventional group ( t values were 19.64, 49.13, 19.64, 33.14, 24.61, P<0.01); EASI and DLQI scores were lower than those in the conventional group ( t values were -6.52 and -29.33, P<0.01). After treatment, Treg cells [(6.58±0.78) % vs. (5.49±0.81) %, t=7.57] in the study group was higher than that of the conventional group ( P<0.01), Th17 cells [(1.03±0.28) % vs. (1.27±0.39) %, t=-3.90] and Th17/Treg ratio [(0.15±0.07) vs. (0.23±0.05), t=7.68] were lower than those in the conventional group ( P<0.01). After treatment, the level of IL-10 in the study group was higher than that of the conventional group ( t=-16.97, P<0.01), and the levels of IL-6 and TNF-α were lower than those in the conventional group ( t values were -21.48 and -25.59, P<0.01). During treatment, the incidence of adverse reactions was 6.56% (4/61) in the study group and 9.84% (6/61) in the conventional group, without statistical significance in the incidence of adverse reactions between the two groups ( χ2=0.44, P=0.509). During the follow-up period, the recurrence rate was 15.09% (8/53) in the study group and 50.00% (22/44) in the conventional group, with statistical significance in the recurrence rate between the two groups ( χ2=14.55, P<0.01). Conclusion:Qufeng Zhiyang Decoction combined with Fuzhiqing Ointment can reduce the levels of inflammatory factors in patients with chronic perianal eczema, maintain Th17/Treg cell immune balance, improve clinical efficacy, and have a low recurrence rate.

Approaches in the treatment of perianal fistula in Crohn disease

Perianal fistula is a common complication of Crohn disease, and it is a great burden on the life and psychology of patients, but its treatment is still a difficult problem to face. In recent years, progress in the treatment of Crohn disease has progressed rapidly due to the advent of biological agents, but there has been a lack of research on perianal fistula in Crohn disease, and the direction of research has been scattered; therefore, the author reviews the traditional treatment of perianal fistula in Crohn disease in the context of the available literature and discusses emerging and potential therapeutic approaches. (AU)

Primary extensive perianal cutaneous tuberculosis: A challenging diagnosis. Case report and a review of the literature

Abstract Rationale Perianal tuberculosis is extremely rare without previous or active pulmonary infection. Ulcerative skin lesion is a rare presentation of extrapulmonary tuberculosis in the oral, perianal, or genital mucosa and the adjacent skin. Case report A 71-year-old woman complained of pain during evacuation and fecal incontinence for two years. There was an ulcerated lesion in the perianal and intergluteal region and perianal fistulous tracts. A polymerase chain reaction test on blood and biopsies of perianal ulcers, perianal fistula, and the intergluteal area was positive for Mycobacterium tuberculosis. The pathological examination revealed a chronic epithelioid granulomatous inflammatory process with the presence of multinucleated giant cells. After the end of the tuberculosis drug regimen, there was marked improvement in the patient's clinical condition. Conclusion Even in the absence of an identifiable primary focus, tuberculosis should be considered in the differential diagnosis of ulcerative and fistulous lesions of the perianal area.

Langerhans Cell Histiocytosis in an Adult Female with Multisystem Involvement

Langerhans cell histiocytosis (LCH) also known as histiocytosis X, is a rare systemic disorder arising from the clonal proliferation of myeloid dendritic cells (histiocytes) with a tendency to involve single or multiple organ systems with variable clinical course and prognosis. Clinical presentation usually depends on the site of involvement. The organs commonly affected in adults by order of decreasing frequency include lungs, bone, skin, pituitary glands, lymph nodes, and the liver. Vulval and perianal involvement is extremely rare in adults. We describe the case of a 31-year-old non-smoker adult female with multisystemic LCH involving the vulva, perianal region, and lung. Probable involvement of other sites with LCH included mandibular bone, pituitary gland, skin, lymph nodes, liver, thyroid, and colon. She is undergoing systemic chemotherapy and has completed two cycles of cytarabine and steroids without any complications. Treatment is not standardized due to the very less incidence of the disease and inadequate knowledge regarding its pathophysiology. Langerhans cell histiocytosis remains a major concern for treating physicians because of its rarity with many faces and requires careful consideration for management.

Perianal psoriasis as the first manifestation of the disease

Introduction: Inverse psoriasis affects the skin of flexural areas, such as the groin, axillae, umbilicus, intergluteal fold, and external genitalia. Clinical Case: We herein report the case of a man who presented with anal pruritus and, upon physical examination, a perianal dermatosis was found, which was characterized by erythematous plaques, with fine scaling. The case was initially managed with zinc oxide, and when no improvement was observed, we decided to take an incisional biopsy, which indicated histological changes suggestive of psoriasiform dermatitis. Discussion: Inverse psoriasis affects 3% to 7% of patients with psoriasis, and it manifests with erythematous plaques without the classic scaling appearance. The skin in these areas is susceptible to maceration, irritation, and ulceration, which alter the classic clinical picture. It may present with typical lesions or, less frequently, in isolation in the anogenital region. In the anogenital presentation only, the diagnosis should be made by biopsy, looking for the classic histopathological features of psoriasis. As for the first-line treatment, low- or medium-potency topical steroids are used for short periods of time; the second-line treatment is with emollients and tar-based products; and the third-line treatment uses an immunomodulator. Conclusion: This presentation is infrequent, and it requires a high index of suspicion for the diagnosis, always supported by biopsies, in search of the classic histopathological features of psoriasis. (AU)

Tratamiento de fístulas perianales complejas mediante tapón de colágeno piramidal. ¿En la geometría está la solución?

Introducción: Las fístulas perianales complejas siguen siendo un auténtico desafío terapéutico en nuestros días, dada la ausencia de una terapia universal y los resultados a largo plazo, ya que el porcentaje de complicaciones o recidivas no es desdeñable. Entre las opciones terapéuticas encontramos los tapones biológicos, siendo respetuosos con los esfínteres, pero con resultados dispares. Objetivos: Evaluar los resultados a largo plazo tras la colocación de un tapón de colágeno piramidal en dos pacientes con fístula perianal compleja. Materiales y Método: Se presentan 2 pacientes con fístula perianal compleja intervenidos mediante colocación de tapón biológico cumpliendo estrictos criterios de inclusión. Discusión: Dentro del arsenal terapéutico disponible actualmente, los tapones biológicos prometen una solución definitiva para determinadas fístulas perianales, evitando una posible incontinencia. Con resultados dispares en la bibliografía, en nuestros dos casos los pacientes han evolucionado de forma excelente, con resolución completa de la enfermedad fistulosa sin complicaciones ni recidiva a largo plazo. Conclusiones: Dados los excepcionales resultados obtenidos en nuestros dos primeros casos con este tipo de tapón, nos planteamos si la morfología del mismo puede ser determinante en su éxito.

Introduction: Complex perianal fistulas continue to be a real therapeutic challenge today, given the absence of universal therapy and long-term results, since the percentage of complications or recurrences is not negligible. Among the therapeutic options we find biological plugs, being respectful with the sphincters but with disparate results. Aim: To evaluate the long-term results after the placement of a pyramidal collagen plug in two patients with complex perianal fistula. Materials and Method: We present two patients with complex perianal fistula who were operated on by placing a biological plug, meeting strict inclusion criteria. Discussion: Within the therapeutic arsenal currently available, biological plugs promise a definitive solution for certain perianal fistulas, avoiding possible incontinence. With different results in the literature, in our two cases the patients have evolved excellently, with complete resolution of the fistulous disease without complications or long-term recurrence. Conclusions: Considering the exceptional results obtained in our first two cases with this type of plug, we wonder if its morphology can be a determining factor in its success.

Application of surgical removal and setons abscess drainage management in patients with moderate and severe acne inverse at gluteal and perianal area / 中华医学美学美容杂志

Objective:To investigate the application value and effect of surgical removal and setons abscess drainage in moderate and severe acne inverse.Methods:A retrospective case study of 4 patients (3 males and 1 female with an average of onset of 28 years) with acne inverse at gluteal and perianal area in the Qixia Traditioal Chinese Medical Hospital of Shandong province between June 2016 and August 2020, The operative technique was based on the complete excision of the entire diseased skin and subcutaneous fatty tissue, down to the muscular fascia. The cavity was explored using a probe, two setons were placed in each of the fistula tracts, and the wound were covered with absorptive dressing.Results:All the wounds in 4 patients healed primarily and showed no recurrence after surgery, execpt for one patient who did not take supine position in time after operation which resulted in more bleeding in a short time. The other patients recovered well. The patients were followed up for 6 months without affecting the anal skin function, skin lesions and recurrence.Conclusions:The technique of wide surgical excision and setons abscess drainage is an effective method for moderate and severe acne inverse.

Proctitis y enfermedad perianal de causa infecciosa: una mirada más allá de la enfermedad inflamatoria intestinal / Infectious proctitis and perianal disease: a gaze beyond inflammatory bowel disease

Resumen La proctitis infecciosa secundaria a una enfermedad de transmisión sexual ha aumentado en incidencia y deben ser consideradas especial-mente en varones homosexuales o bisexuales con síntomas rectales. Presentamos un paciente con una proctitis y enfermedad perianal por Chlamydia trachomatis que podría haber sido diagnosticado con otra enfermedad ano-rectal como es la enfermedad inflamatoria intestinal, si la historia clínica no hubiese sido considerada. Un alto nivel de sospecha es necesario para evitar un diagnóstico incorrecto, retrasar el tratamiento antimicrobiano y el desarrollo de complicaciones.

Abstract Infectious proctitis by sexually transmitted diseases are increasing in incidence and should be considered in homosexual patients with rectal symptoms. In this case, we show a patient with proctitis and perianal disease caused by Chlamydia trachomatis that could be diagnosed as another anorectal disease such as inflammatory bowel disease if the clinical history is not taken into account. A high level of suspicion is crucial, in order to avoid an incorrect diagnosis, delayed antibiotic therapy and the development of complications.

Enfermedad de Paget extramamaria perianal, tratada con imiquimod tópico / Atypical presentation of perianal extramammary Paget's disease, treated with topical imiquimod

RESUMEN La enfermedad de Paget extramamaria (EPEM) perianal es un adenocarcinoma intraepitelial del margen anal de muy baja frecuencia. La forma primaria representa una neoplasia de origen apocrino, mientras que la forma secundaria representa una diseminación pagetoide de una neoplasia maligna en general anorectal. Debido a su similitud clínica con otras patologías de presentación frecuente, se requiere de un alto índice de sospecha para diagnosticarla. La resección quirúrgica amplia o la cirugía micrográfica de Mohs se considera comúnmente el pilar del tratamiento con altas tasas de recurrencia. Estudios previos han demostrado buena respuesta en la EPEM vulvar con imiquimod 5% en crema, pero su eficacia no ha sido bien descrita en la afectación perianal. En este artículo presentamos un caso de EPEM perianal primario con sobreinfección con HPV, al que se le indicó tratamiento tópico con imiquimod.

ABSTRACT Perianal extramammary Paget disease is a very low frequency intraepithelial adenocarcinoma of the anal margin. The primary form represents a neoplasm of apocrine origin, while the secondary form represents a pagetoid spread of a generally anorectal malignant neoplasm. Due to its clinical similarity with other pathologies with frequent presentation, a high index of suspicion is required to diagnose it. Wide surgical resection or Mohs micrographic surgery is commonly considered the mainstay of treatment with high recurrence rates. Previous studies have shown a good response in vulvar extramammary Paget disease with imiquimod 5% cream, but its efficacy has not been well described in perianal involvement. In this article we present a case of primary perianal extramammary Paget disease with HPV superinfection, which received topical treatment with imiquimod.

Magnetic resonance imaging of perianal fistulas in clinically symptomatic patients and the correlation among plain, contrast, and post jelly MRI fistulography

Abstract Objectives To evaluate different types of perianal fistulas and their complications on magnetic resonance imaging (MRI) and to compare plain, contrast, and jelly magnetic resonance fistulography findings. Materials and Methods This prospective study was performed in 30 patients who presented with perianal pus discharge or external fistulous opening. Magnetic resonance imaging of the perianal region before and after giving intravenous contrast and after injecting jelly through a percutaneous opening was performed on a 3T scanner and the results were correlated. Results The mean age of the patients was 40.13±13.88 years (range 19-75 years). The male to female ratio was 14:1. The most common type of fistula was St. James classification type I, which was seen in 13 patients (43%), followed by type IV in 30%, type III in 16%, type II in 6.66%, and type V in 3.33% of the patients. Using agreement analysis, we compared the number of primary and secondary tracts, internal openings, and horseshoe tracts and found a significant agreement between plain and post Jelly MRI fistulography (kappa statistic close to 1).When comparing plain and contrast MRI, there was significant agreement in the primary and secondary tracts, while statistically insignificant results were obtained (p>0.05) for the horseshoe tract and internal openings. Contrast injection was helpful in 7 subjects (23.3%) as peripheral enhancement of abscesses were better delineated. Conclusion Magnetic resonance imaging is the one stop diagnostic modality for perianal fistulas. Acquisition of axial (Ax) T2, axial T2 FS, coronal T2 and coronal T2 FS sequences without administering intravenous contrast or jelly is usually sufficient for the diagnosis of fistulas and their complications.

Evaluation of fistulotomy with immediate sphincteric reconstruction in the treatment of high transsphincteric perianal fistula

Background: High perianal fistula treatment remains challenging, mainly due to the variability in success and recurrence rates as well as continence impairment risks. So far, no procedure can be considered the gold standard for surgical treatment. Yet, strong efforts to identify effective and complication-free surgical options are ongoing. Fistulotomy can be considered the best perianal fistula treatment option, providing a perfect surgical field view, allowing direct access to the source of chronic inflammation. Controversy exists concerning the risk of continence impairment associated with fistulotomy. The present study aimed to assess the outcomes of fistulotomy with immediate sphincteric reconstruction regaring fistula recurrence, incontinence, and patient satisfaction. Methods: This interventional study was performed at the General Surgery Department of Zagazig University Hospital during the period from July 2018 to December 2019 on 24 patients with a clinical diagnosis of high transsphincteric fistula-in-ano. The fistulous tract was laid open over the probe placed in the tract. After the fistula tract had been laid open, the tract was curetted and examined for secondary extensions. Then, suturing muscles to muscles, including the internal and external sphincters, by transverse mattress sutures. Results: Our study showed that 2 patients develop incontinence to flatus ~ 8.3%.and only one patient develop incontinence to loose stool, 4.2%. Complete healing was achieved in 83% and recurrence was 16.6%. Conclusion: Fistulotomy with immediate sphincteric reconstruction is considered to be an effective option in the management of high perianal fistula, with low morbidity and high healing rate with acceptable continence state. (AU)

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.

Guía de práctica clínica para el tratamiento de la enfermedad de Crohn en población adulta / Clinical practice guidelines for the treatment of Crohn's disease in the adult population

Resumen Objetivo: La enfermedad de Crohn es un trastorno inflamatorio idiopático de etiología desconocida con características genéticas, inmunológicas e influencias del medio ambiente. La incidencia y la prevalencia de la enfermedad de Crohn han aumentado en Colombia. El tratamiento de estos pacientes no es fácil y ha evolucionado en los últimos años; por lo tanto, es necesario desarrollar una guía de práctica clínica en Colombia, orientada al tratamiento de esta compleja enfermedad, para unificar criterios. Materiales y métodos: Esta guía fue desarrollada por un equipo multidisciplinario con apoyo de la Asociación Colombiana de Gastroenterología, el Grupo Cochrane ITS y el Instituto de Investigaciones Clínicas de la Universidad Nacional de Colombia. Se desarrollaron preguntas clínicas relevantes a la entidad y se realizó la búsqueda de guías nacionales e internacionales en bases de datos especializadas. Las guías existentes fueron evaluadas en términos de calidad y aplicabilidad. El Grupo Cochrane realizó la búsqueda sistemática de la literatura. Las tablas de evidencia y recomendaciones fueron realizadas usando la metodología GRADE. Resultados: Se realizó una guía de práctica clínica basada en la evidencia, para el tratamiento tanto médico como quirúrgico de la enfermedad de Crohn en población adulta en Colombia. Se diseñaron algoritmos de manejo teniendo en cuenta la actividad, el comportamiento y la localización de la enfermedad. Conclusiones: Se estableció que una adecuada evaluación clínica, endoscópica e imagenológica, así como una estratificación de riesgo individual son importantes para el manejo, y se especificaron las indicaciones para el adecuado tratamiento tanto médico como quirúrgico de estos pacientes.

Abstract Objective: Crohn's disease is an idiopathic inflammatory disorder of unknown origin, influenced by genetic, immunological, and environmental factors. The incidence and prevalence of Crohn's disease have increased in Colombia. The treatment of these patients is not easy and has improved in recent years. Therefore, it is necessary to develop the Colombian Clinical Practice Guideline to guide the treatment of this complex disease and unify criteria. Materials and methods: The present guideline was carried out by a multidisciplinary team with support from the Asociación Colombiana de Gastroenterología, the Cochrane ITS Team, and the Clinical Research Institute of the Universidad Nacional de Colombia. Clinical questions regarding this disease were developed, and national and international guidelines were searched in specialized databases. The existing guidelines were evaluated in terms of quality and applicability. The Cochrane Group conducted a systematic search of the existing literature. Evidence tables were elaborated, and recommendations were made using the GRADE methodology. Results: An evidence-based clinical practice guideline was developed for the medical and surgical treatment of Crohn's disease in the adult population in Colombia. Treatment algorithms were designed, taking into account the activity, behavior, and location of the disease. Conclusions: It was established that proper clinical, endoscopic, and imaging assessment, as well as individual risk stratification, are important for treatment. Also, the indications for adequate medical and surgical treatment of these patients were specified.

Comparison of Intrathecal Dexmedetomidine and Nalbuphine as an Adjuvant in Hyperbaric Bupivacaine for Saddle Block and Postoperative Analgesia in Patients Undergoing Perianal Surgeries.

Saddle block is the most commonly used anaesthetic technique for perianal surgeries in adults. Perianal surgeries under saddle block are considered as day care surgeries. Major disadvantage is that the low volume of spinally given drug won’t prolong duration of postoperative analgesia. Inj. Dexmedetomidine (α2-Adrenoceptor agonist) and Inj. Nalbuphine (opioid agonist-antagonist) were studied as an adjuvant as to whether they increase the duration of post-operative analgesia. Secondary objectives of this study were to compare hemodynamic stability and side effects among Inj. Dexmedetomidine and Inj. Nalbuphine. METHODSA total of 60 patients with American Society of Anaesthesiologist physical Status I and II scheduled for elective perianal surgeries were randomly allocated into two equal groups in this randomized prospective comparative study. Group D received 0.5% hyperbaric bupivacaine 0.8 mL + 5 mcg dexmedetomidine and group N received 0.5% hyperbaric bupivacaine 0.8 mL + 0.6 mg nalbuphine. Onset and duration of sensory and motor blockade, and duration of analgesia were recorded. Post-operative analgesic consumption and side effects were studied for 24 hours. Statistical analysis was done by using descriptive and inferential statistics using Chi- square test and Student’s t-test. RESULTSDemographic characteristics, duration of surgery, onset of sensory and motor block were comparable. Duration of analgesia was 320.26 ± 89.52 min for dexmedetomidine (D) whereas it was 222.23 ± 25.43 min for nalbuphine (N) with a P value of <0.05. No side effects were noted. CONCLUSIONA dose of 5 mcg dexmedetomidine as an adjuvant seems to be optimal for providing postoperative analgesia with better hemodynamic stability.

Role of seton versus conventional techniques in the management of anorectal fistulas

Background: This study was conducted to compare the use of different setons with conventional management like fistulotomy and fistulectomy in terms of healing (after 1 and 3 months), recurrence and incontinence.Methods: This was a retrospective non-randomized study conducted at JNMCH, Aligarh from January 2018 to June 2019. Patients included- patients (males and females) of age group 18-70 years, patients giving consent. Patients excluded- fistula secondary to- Crohn’s disease, tuberculosis, malignancy, recurrent fistula, pregnant females, immuno-suppressed patients.Results: After 1 month, 17 out of 24 patients (70.8%) of fistulotomy, 48 out of 68 patients (70.6%) of seton group and 21 out of 32 patients (65.6%) of fistulectomy group had their wounds healed (p=0.8693). After 3 months, 19 out of 24 (79.2%) patients of fistulotomy, 61 out of 68 (89.7%) of seton, and 24 out of 32 patients (75%) with fistulectomy had their wound healed (p=0.1374). Recurrence was observed in 5 out of 24 patients of fistulotomy, 10 out of 68 patients of seton use and 5 out of 32 patients with fistulectomy (p=0.7788). 6 out of 24 patients (25%) had incontinence after fistulotomy, 7 out of 68 (10.3%) of seton group and 8 out of 24 (25%) after fistulectomy (p=0.0944). Healing was higher in patients of non-cutting setons as compared to cutting seton (p=0.0252). After 3 months, no difference was observed (p=0.1245). Recurrence higher in cutting setons as compared to non-cutting setons (p=0.0187).Conclusions: Setons are safe, low-cost, less invasive, precise, and cost-effective option for treating simple and complex fistula-in-ano.

Quiste epidérmico gigante de región perianal: reporte de un caso / Giant epidermal cyst of the perianal region: a case report

Introducción: Quiste epidermoide de inclusión es una lesión dérmica benigna frecuente, predominante en hombres de 30-40 años, originada por secuestro de restos epidérmicos, oclusión pilosebácea o implantación traumática de elementos epiteliales en la dermis.Caso clínico: Paciente femenino de 75 años de edad la cual presenta tumoración perineal de 4 años de evolución, con aumento progresivo en el último año ocasionando disconfort. Resonancia magnética nuclear, muestra lesión quística. Escisión quirúrgica incluyendo capsula en su totalidad. Anatomía patológica, quiste de inclusión epidérmica. Control a los 6 meses sin evidencia de recidiva.Conclusión: El quiste epidérmico gigante de inclusión perineal es raro, por lo cual hay que descartar otras patologías similares. El tratamiento quirúrgico debe evitar la escisión fraccionada e incluir la capsula en forma completa, de lo contrario la recidiva es una constante.

Introduction: The epidermoid inclusion cyst is a frequent benign dermal lesion, predominantly in men aged 30-40, caused by sequestration of epidermal remains, pilosebaceous occlusion or traumatic implantation of epithelial elements in the dermis.Case report: A 75-year-old female patient who has 4 years of evolution perineal tumor with a progressive increase in size in the last year causing discomfort. MRI shows a cyst lesion. Surgical excision including capsule. Pathological anatomy, epidermoid inclusion cyst. Following at 6 months without evidence of recurrence.Conclusion: The giant epidermoid cyst of perineum is rare, therefore we must rule out other similar pathologies. Surgical treatment should avoid fractional excision and include the capsule completely, otherwise recurrence is a constant.

Afecciones perianales no infecciosas, no neoplásicas, del adulto / Noninfectious, non-neoplasic adult perianal affections

Las enfermedades perianales del adulto, de carácter no infeccioso y no neoplásico, son un motivo de consulta poco frecuente. Se caracterizan por la variedad de su etiología y de su sintomatología clínica, y plantean dificultad en el diagnóstico y en la terapéutica. El objetivo del presente trabajo es abordar una patología que plantea la necesidad de una intervención interdisciplinaria. Se incluyen consideraciones anatomopatológicas, clínicas y terapéuticas. (AU)

Noninfectious, non- neoplasic perianal affections are uncommon diseases. They are characterized by the variety of the etiology and clinical symptomatology, posing difficulty in diagnosis and therapeutics. The objective of this paper is to address a pathology that raises the need for interdisciplinary intervention anatomopathological, clinical and therapeutic considerations are included. (AU)