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)

Transplantation of adipose-derived mesenchymal stem cells in refractory crohn's disease: systematic review / Transplante de células-tronco mesenquimais derivadas do tecido adiposo na doença de crohn refratária: revisão sistemática

ABSTRACT Background: Crohn's disease is a pathological condition that has different options of treatment, but there are patients who need other therapeutic approach, such as the use of adipose-derived mesenchymal stem cells. Aim: Systematic literature review to determine the different ways of adipose-derived mesenchymal stem cells administration in humans with luminal refractory and perianal fistulizing Crohn's disease. Methods: It was conducted a search for articles (from 2008 to 2018) on PubMed and ScienceDirect databases using the keywords Crohn's disease, fistulizing Crohn's disease, luminal Crohn's disease and transplantation of mesenchymal stem cells or mesenchymal stem cells or stromal cells. Thirteen publications were selected for analysis. Results: Only one study referred to the luminal Crohn´s disease. The number of cells administered was variable, occurring mainly through subcutaneous adipose tissue by liposuction. It could be highlighted the autologous transplant with exclusive infusion of mesenchymal stem cells. The procedures involved in pre-transplant were mainly curettage, setons placement and stitching with absorbable suture, and conducting tests and drug treatment for luminal Crohn´s disease. During transplant, the injection of mesenchymal stem cells across the fistula path during the transplant was mainly on the intestinal tract wall. Conclusion: Although the use of mesenchymal stem cells is promising, the transplant on the luminal region should be more investigated. The injection of mesenchymal stem cells, exclusively, is more explored when compared to treatment with other products. The preparation of the fistulizing tract and the location of cell transplantation involve standardized health care in most studies.

RESUMO Racional: Há diferentes opções de tratamento para a doença de Crohn, porém, em alguns casos, há a necessidade de outras abordagens terapêuticas, como o uso de células-tronco mesenquimais derivadas do tecido adiposo. Objetivo: Revisar sistematicamente a literatura para determinar as diferentes formas de administração das células-tronco mesenquimais derivadas do tecido adiposo em seres humanos com doença de Crohn refratária luminal e fistulizante perianal. Método: Buscaram-se artigos publicados entre 2008 e 2018 nas bases de dados PubMed e ScienceDirect, pelos descritores: Crohn's disease, fistulizing Crohns disease, luminal Crohns disease e transplantation of mesenchymal stem cells ou mesenchymal stem cell ou stromal cells. Treze artigos foram selecionados. Resultados: Somente um trabalho se referiu à doença luminal. A quantidade de células administradas foi variável, obtendo-se principalmente do tecido adiposo subcutâneo por lipoaspiração. Destacou-se o transplante autólogo com a infusão exclusiva de células-tronco mesenquimais. Os procedimentos realizados no pré-transplante foram principalmente o de curetagem, colocação de setons e suturas com fio absorvível, e de exames e tratamento medicamentoso para a doença luminal. No transplante, ocorreu a injeção das células por todo o trajeto fistuloso, principalmente nas paredes do trato. Conclusão: Embora o uso de células-tronco mesenquimais seja promissor, o transplante na região luminal deve ser mais investigado. A injeção exclusiva de células-tronco mesenquimais é mais explorada quando comparada ao tratamento conjunto com outros produtos. A forma de preparo do trato fistuloso e o local de transplante envolvem cuidados médicos padronizados na maioria dos estudos.

Analysis of the clinical characteristics of perianal fistulising crohn's disease in a single center / Análise das características clínicas da doença de crohn fistulizante perianal em um único centro

ABSTRACT Background: Clinical characteristics are keys to improve identification and treatment of Crohn´s disease (CD) so that large sample analysis is of great value. Aim: To explore the clinical characteristics of perianal fistulising CD. Methods: Analysis of 139 cases focused on their clinical data. Results: The proportion of males and females is 3.3:1; the mean age is 28.2 years; 47.5% of patients had anal fistula before CD diagnosis. Patients with prior perianal surgery and medication accounted for 64.7% and 74.1% respectively. The L3 type of lesion was present in 49.6% and the B1 and B2 types for 51.8% and 48.2% respectively; complex anal fistula was diagnosed in 90.6%. Symptoms of diarrhea were found in 46% and perianal lesions alone in 29.5% of patients. Abnormal BMI values was present in 44.6%; active CD activity index in 64.7%; and 94.2% had active perianal disease activity index. A proportion of patients manifest abnormal C-reactive protein, erythrocyte sedimentation rate, platelet, hemoglobin and albumin. Conclusion: We suggest that patients with anal fistula associated to these clinical features should alert the medical team to the possibility of CD, which should be further investigated through endoscopy and imaging examination of alimentary tract to avoid the damage of anal function by routine anal fistula surgery.

RESUMO Racional: As características clínicas são fundamentais para melhorar a identificação e o tratamento da doença de Crohn (DC), de modo que a análise da amostra seja de grande valor. Objetivo: Explorar as características clínicas da DC fistulizante perianal. Métodos: Análise de 139 casos focados em seus dados clínicos. Resultados: A proporção de homens e mulheres foi de 3,3: 1; a média de idade de 28,2 anos; 47,5% dos pacientes tiveram fístula anal antes do diagnóstico de DC. Pacientes com cirurgia perianal prévia e medicação representaram 64,7% e 74,1%, respectivamente. O tipo de lesão L3 estava presente em 49,6% e os tipos B1 e B2, em 51,8% e 48,2%, respectivamente; fístula anal complexa foi diagnosticada em 90,6%. Sintomas de diarréia foram encontrados em 46% e lesões perianais isoladas em 29,5% dos pacientes. Valores anormais de IMC estavam presentes em 44,6%; índice de atividade DC ativa em 64,7%; e 94,2% tinham índice de atividade de doença perianal ativo. Proporção significativa de pacientes tinha proteína-C reativa, taxa de sedimenta do eritrócito, plaquetas hemoglobina e albumina anormais. Conclusão: Sugere-se que pacientes com fístula anal associada às essas características clínicas alertem a equipe médica para a possibilidade de DC, que deve ser investigada por endoscopia e exame de imagem do trato digestivo para evitar dano na função anal pela operação que rotineiramente é realizada no tratamento da fístula anal.

Tuberculosis anal como diagnóstico diferencial de lesión ulcerada anal / Anal tuberculosis as a differential diagnosis of ulcerated anal lesion

La tuberculosis (TBC) es una enfermedad infecciosa crónica, granulomatosa, transmisible, producida por el microorganismo Mycobacterium tuberculosis o bacilo de Koch. Puede presentarse como enfermedad pulmonar, extrapulmonar o ambas. La presentación extrapulmonar, es rara, representando aproximadamente el 11% de todos los casos. El objetivo del presente trabajo es comunicar un caso clínico de tuberculosis de localización extrapulmonarr infrecuente: la región perianal. (AU)

Tuberculosis (TB) is a chronic infectious, granulomatous, transmissible disease produced by the Mycobacterium tuberculosis microorganism or Koch's bacillus.It can present as lung disease, extrapulmonary disease or both.Extrapulmonary presentation is rare, representing approximately 11% of all cases. The objective of the present work is to report a clinical case of tuberculosis of uncommon extrapulmonary location: the perianal region. (AU)

Abscesos y fístulas perianales en enfermedad inflamatoria intestinal: manejo actualizado / Fistulas and perianal abscess in inflammatory bowel disease: current approach

Crohn's disease is an inflammatory bowel disease that affects the intestinal bowel in a transmural way presenting with fistulizing phenotypes with abnormal communication between two epithelial surfaces. In perianal Crohn's disease, there are fistulizing tracts between the anal canal and perianal skin that can complicate with abscess formation. Symptoms include pain, perianal discharge and fluctuating lesions, requiring combined clinical and surgical management. The disease is difficult to treat and is associated with significant reduction in quality of life, requiring a multidisciplinary approach for the management of these patients. The following review describes clinical concepts of perianal Crohn's disease, with emphasis on diagnosis and treatment.

La enfermedad de Crohn es una enfermedad inflamatoria del tubo digestivo con compromiso transmural de la pared que puede manifestarse con fenotipos fistulizantes mediante el desarrollo de comunicaciones anormales entre dos superficies epiteliales. En el caso de la enfermedad de Crohn perianal se establecen trayectos fistulosos entre el epitelio del canal anal y la piel alrededor del ano, que pueden complicarse con la formación de abscesos. Clínicamente se presenta con descarga perianal, dolor y masa fluctuante requiriendo un manejo conjunto médico-quirúrgico para el tratamiento de las complicaciones, el control de las fístulas y el compromiso luminal asociado. Es necesario un enfoque multidisciplinario dado que es una enfermedad de difícil manejo que afecta la calidad de vida de los pacientes. En la siguiente revisión se exponen conceptos acerca de la enfermedad de Crohn fistulizante perianal y sus complicaciones, con énfasis en el diagnóstico y tratamiento.

A prospective study on tubercular fistula in ano and its management / Estudo prospectivo sobre a fístula anal tuberculosa e seu tratamento

Abstract Objective Tuberculosis fistula in ano, though less encountered, is an important clinical entity in developing countries like India. Diagnosis of TB fistula is a challenge despite of advances in diagnostic modalities and it depends upon both local and systemic clinical presentation. This prospective study aimed at to substantiate the importance of clinical diagnosis as well as medical management of tubercular fistula by antitubercular drugs. Methods and results 25 patients of fistula in ano suspected to be of tubercular origin underwent histopathology of fistulous tracks and an 8 week therapeutic trial of antitubercular treatment after getting an informed consent. Though biopsy showed positive evidence of tubercular pathology only in 52% cases, therapeutic trial showed improvement in local and systemic features in 23 (92%) cases. Of these 23 cases, 3 were cured after 18 months of anti tubercular treatment and 18 showed cure after 24 months of anti tubercular treatment while 2 cases withdrew from the study at 12 and 14 months respectively due to adverse drug reactions though their fistulous symptoms were relieved. Conclusion Meticulous clinical evaluation plays a vital role in diagnosis of tubercular fistula in addition to other diagnostic methods. Anti tubercular treatment is the mainstay of treatment in tubercular fistula with a minimum duration of 18-24 months owing to the recurrent and relapsing nature of disease.

Resumo Objetivo A fístula anal da tuberculose (TB), embora menos observada, constitui entidade clínica importante em países em desenvolvimento, como a Índia. O diagnóstico de fístula TB é tarefa desafiadora, apesar dos avanços nas modalidades diagnósticas; seu estabelecimento depende tanto da apresentação clínica local, como da apresentação sistêmica. Esse estudo prospectivo teve por objetivo consubstanciar a importância do diagnóstico clínico e também do tratamento clínico da fístula TB com medicamentos contra tuberculose. Métodos e resultados Foi realizado estudo histopatológico de tratos fistulosos em 25 pacientes com fístula anal com suspeita de origem tuberculosa; depois de obtido o consentimento livre e informado, esses pacientes foram submetidos a tratamento anti-tuberculose (TAT) durante 8 semanas. Embora a biópsia tenha revelado evidência positiva de patologia tuberculosa em apenas 52% dos casos, o curso terapêutico resultou em melhora nos aspectos local e sistêmico em 23 (92%) pacientes. Desses 23 casos, 3 e 18 casos estavam curados após 18 e 24 meses de TAT, respectivamente, enquanto que 2 pacientes desistiram do estudo após 12 e 14 meses, respectivamente, em decorrência de reações farmacológicas adversas, mesmo diante do alívio de seus sintomas fistulosos. Conclusão Juntamente com outros métodos diagnósticos, uma avaliação clínica meticulosa desempenha papel vital no diagnóstico da fístula TB. TAT é o principal procedimento terapêutico em pacientes com fístula TB, com duração mínima de 18-24 meses devido à natureza recorrente e recidivante da doença.

Fístula anal de etiología tuberculosa. A propósito de un caso y breve revisión bibliográfica / Tubercular fistula in-ano. Report of a case and brief review

La fístula anal de etiología tuberculosa es una afección rara. Presentamos un caso en una paciente HIV (-), revisamos datos epidemiológicos y discutimos la fisiopatología, manifestaciones clínicas, nuevos desarrollos diagnósticos y brevemente su tratamiento.

Tubercular fistula in-ano is a rare condition. In addition to presenting a case in a HIV (-) patient, in this paper we review epidemiologic data, pathophysiology, clinical manifestations and new developments in diagnosis and their treatment is discussed briefly.

Enfermedad de Crohn fistulizante perianal, manejo médico-quirúrgico / Fistulizing perianal Crohn’s Disease, medical and surgical management

Crohn’s disease (CD) and ulcerative colitis (UC) are immunologically mediated chronic digestive diseases, with a trend to progressive damage, which generally have an onset at young age and a course characterized by remission and relapse. Its incidence and prevalence present a steady upward trend globally. CD is characterized by transmural inflammation in the digestive tract and it is a complex disease. The perianal involvement –“p”, abscesses or perianal fistulas– is considered a condition that is different from penetrating phenotype, a condition that indicates an aggressive behavior of CD. Early identification and proper treatment of fistulas, including correct diagnosis and classification are essential elements to establish an appropriate treatment plan. A multidisciplinary approach is essential including medical and surgical approach.

La Enfermedad de Crohn (EC) y la colitis ulcerosa (CU) son enfermedades digestivas crónicas, progresivas, mediadas inmunológicamente, que en general, tienen un inicio durante la edad adulta-joven y un curso que se caracteriza por remisión y recaída. Su incidencia y prevalencia ha presentado una tendencia constante de incremento a nivel global. La EC se caracteriza por comprimo transmural del tracto digestivo y por ser una patología compleja. El compromiso perianal –“p”, abscesos o fístulas perianales– se considera una condición diferente al fenotipo penetrante, señalándose en la actualidad como una variable modificadora del comportamiento de la patología y de gravedad. La identificación dirigida y precoz de trayectos fistulosos, su correcto diagnóstico y clasificación son elementos primordiales para poder establecer un plan terapéutico apropiado. Es imprescindible un abordaje multidisciplinario, en el cual exista integración médico-quirúrgica.

Transanal Minimally Invasive Surgery (TAMIS) to Treat Vesicorectal Fistula: A New Approach

ABSTRACT Purpose: Vesicorectal fistula is one of the most devastating postoperative complications after radical prostatectomy. Definitive treatment is difficult due to morbidity and recurrence. Despite many options, there is not an unanimous accepted approach. This article aimed to report a new minimally invasive approach as an option to reconstructive surgery. Materials and Methods: We report on Transanal Minimally Invasive Surgery (TAMIS) with miniLap devices for instrumentation in a 65 year old patient presenting with vesicorectal fistula after radical prostatectomy. We used Alexis® device for transanal access and 3, 5 and 11 mm triangulated ports for the procedure. The surgical steps were as follows: cystoscopy and implant of guide wire through fistula; patient at jack-knife position; transanal access; Identification of the fistula; dissection; vesical wall closure; injection of fibrin glue in defect; rectal wall closure. Results: The operative time was 240 minutes, with 120 minutes for reconstruction. No perioperative complications or conversion were observed. Hospital stay was two days and catheters were removed at four weeks. No recurrence was observed. Conclusions: This approach has low morbidity and is feasible. The main difficulties consisted in maintaining luminal dilation, instrumental manipulation and suturing.

Proposed tuberculosis investigation and management protocol in complex and recurrent fistula-in-ano / Proposta de investigação e tratamento da tuberculose em fístulas anorretais complexas e recorrentes

Background: Tuberculosis (TB) is an ancient disease, endemic in some regions, caused by Mycobacterium tuberculosis. Among 22 countries accounting for 90% of tuberculosis cases worldwide, Brazil occupies the 17th place. The gastrointestinal form ranks sixth (5%) of extrapulmonary cases, while anorectal represents 2-7% of cases of fistula-in-ano, more common in midlife men, from endemic regions. In our country epidemiological data and accumulated clinical evidence strongly suggest the need for a systematic TB research as a responsible co-factor for complex anal fistulas or also those immunosuppression associated, in an attempt to reduce the high rates of recurrence of anal fistula (>30%). Purpose: The course from a complex anal tuberculosis associated fistula, confirmed after initial suspicion of Crohn's disease, is presented in order to emphasize the relevance of suspicion and a diagnosis protocol, as well as healing criteria in fistulas contaminated by the bacilli. Discussion: Sphincter damage risk in repeated fistula-in-ano surgical approaches requires considering tuberculosis infection, an underdiagnosed condition, and a preoperative diagnostic routine should be suggested. In the absence of description in the literature, preliminary clinical protocols must be provided in order to reduce recurrence and sphincter damage rates, when indicating surgical treatment of the disease. (AU)

Introdução: A tuberculose (TB) é uma doença ancestral, endêmica em algumas regiões, e causada pelo Mycobacterium tuberculosis. Entre 22 países responsáveis por 90% dos casos de tuberculose em todo o mundo, o Brasil ocupa o 17° lugar. A forma gastrointestinal está em sexto lugar (5%) dos casos extrapulmonares, enquanto a anorretal representa 2-7% dos casos de fístula anal, sendo mais comum em homens de meia-idade e de regiões endêmicas. Em nosso país, os dados epidemiológicos e evidência clínica acumulada sugerem fortemente a necessidade de uma investigação sistemática TB como um cofator responsável por fístulas anais complexas ou também associada à imunossupressão, na tentativa de reduzir as altas taxas de recorrência de fístula anal (> 30%). Objetivo: O curso de uma fistula anal complexa associada à tuberculose, confirmada após suspeita inicial de doença de Crohn, é apresentada a fim de enfatizar a relevância da suspeita e de um protocolo de diagnóstico, bem como os critérios de cura em fístulas contaminados pelo bacilo. Discussão: O risco de danos no esfíncter nas abordagens cirúrgicas repetidas da fistula anal requer considerar a infecção por tuberculose como uma doença subdiagnosticada. Na ausência de dados da literatura, sugere-se uma rotina de diagnóstico pré-operatório e protocolos clínicos preliminares a fim de reduzir a recorrência da doença e a ocorrência de danos ao esfíncter. (AU)

Duplicación rectal extrofiada asociada a malformación anorrectal y transposición pene-escrotal con hipospadias perineal: Reporte de un caso clínico / Exstrophy of rectal duplication associated with anorectal malformation and penoscrotal transposition with perineal hypospadias: A case report

Se presenta el caso de un paciente masculino quien requirió tratamiento por agenesia anorrectal con fístula rectouretral y transposición pene-escrotal con hipospadias perineal, acompañados de una masa perineal. La tumoración perineal se encontró íntimamente adherida y en continuidad al recto, lo que la hace compatible con una duplicación rectal extrofiada. La reconstrucción quirúrgica de la anomalía se realizó en etapas hasta lograr resultados funcionales y estéticos aceptables.

We present the case of a male patient who required treaatment due to anorectal agenesis with recto urethral fistula and penoscrotal transposition with perineal hypospadias, associated with a perineal tumor. The perineal tumor was found strongly adhered and contiguous to the rectum which makes it compatible with an exstrophy of rectal duplication. Surgical reconstruction of the birth defect was performed in stages until acceptable biological function and esthetic results were obtained.

Tratamiento de la fístula perianal en la enfermedad de Crohn a partir de una experiencia local / Treatment of perianal fistulae in Crohn´s disease: a local experience

Background: Perianal fistula (PF) may be present in 40 percent of patients with Crohn´s Disease (CD). Due to its complexity, its management should be multidisciplinary. Purpose: To describe clinical treatment in patients with CD and PF in our institution. Materials and Methods: This is a descriptive retroprospective study, using a registry of CD patients. We selected patients with PF and further characterized those patients that received their treatment at Clínica las Condes (CLC). Results: From a total of 74 patients with CD in the registry, 23 (31 percent) had PF, 61 percent male, median of 7 years of disease and half with colonic extension. Twelve patients were treated in CLC, from these, seven had concomitant proctitis. Optimal diagnostic study (magnetic resonance imaging/endorectal ultrasound plus examination under anesthetic) was performed in eleven (92 percent) patients. Ten (83 percent) patients received an optimal treatment (drainage and installation of a loose seton + start or optimization of medical therapy). Complete clinical response was achieved in more than half of the patients under optimal treatment within the first 6 months. Six (50 percent) patients had one or more recurrences of PF with similar study and management in a median of 13 months. With a median follow-up of 29 months, eight out of 12 patients had complete clinical response. There was one patient with unfavorable course who required a proctectomy and terminal diversion. Conclusion: Treatment of PF in CD is complex and in our population, the first-line treatment includes the installation of a loose seton and medical therapy to achieve clinical response even though fistulous tracts may persist.

Introducción: La fístula perianal (FP) puede presentarse hasta en 40 por ciento de los pacientes con Enfermedad de Crohn (EC). Dada su complejidad el tratamiento debe ser multidisciplinario. Objetivo: Describir el tratamiento de los pacientes portadores de EC con FP. Métodos: Estudio descriptivo, utilizando un registro de pacientes con EC. Se seleccionaron los pacientes con FP y se caracterizaron aquellos que recibieron el tratamiento en Clínica Las Condes (CLC). Resultados: De un total de 74 pacientes con EC, 23 (31 por ciento) presentaban FP asociada, 61 por ciento de sexo masculino, mediana de duración de enfermedad 7 años y la mitad con extensión colónica. Doce pacientes fueron tratados en CLC, de ellos, siete presentaban proctitis al momento de la FP. En 11 (92 por ciento) pacientes se realizó un estudio diagnóstico óptimo (resonancia magnética/ endosonografía transrrectal y exploración bajo anestesia). Diez (83 por ciento) pacientes recibieron tratamiento óptimo biasociado (drenaje e instalación de sedal no cortante + inicio u optimización de terapia médica). Siete pacientes con tratamiento óptimo presentaron mejoría clínica completa dentro de los primeros 6 meses. Seis (50 por ciento) pacientes presentaron una o más recurrencia de FP con estudio y manejo similar en una mediana de 13 meses. Con una mediana de seguimiento de 29 meses, ocho de los 12 pacientes obtuvieron mejoría clínica completa. Una paciente evolucionó desfavorablemente, requiriendo proctectomía y ostomía terminal. Conclusión: El manejo del FP en EC es complejo, en nuestra población el tratamiento biasociado (sedal + fármacos) fue de elección para lograr una mejoría clínica aun cuando persistieron los trayectos fistulosos.

Enfermedad de Crohn fistulizante: manejo actual y su aplicabilidad en la realidad nacional / Fistulizing Crohn’s disease, current management and its applicability in the national reality

The development of fistulas during the evolution of Crohn’s Disease represents a severe situation that affects quality of life and requires a multidisciplinary care approach that involving gastroenterologists, surgeons and radiologists. Fistulizing Crohn’s disease can be divided in perianal and not perianal disease. Perianal disease can also be divided in simple or complicated disease depending on the fistula’s characteristics that will guide the clinical and therapeutic approach. Fistulizing not perianal disease can be internal when it communicates the bowel with other organs (colovesical, rectovaginal or enteroenteric fistulas), and external when it communicates the bowel with the abdominal wall (enterocutaneous fistula), either as a spontaneous or post-surgical phenomenon. Given the variety of fistula presentation, it is necessary to give an individualized approach, taking into account the fistula’s route, the inflammatory bowel activity, the presence of abscesses, and the nutritional status of the patient. This review is focused on the current management of fistulizing Crohn’s disease in our country.

El desarrollo de fistulas durante la evolución de la enfermedad de Crohn es una situación grave que condiciona una peor calidad de vida, así como mayor complejidad en el enfrentamiento, debiendo involucrar la colaboración multidisciplinar entre gastroenterólogos, cirujanos y radiólogos. La enfermedad fistulizante se divide en aquella que afecta la zona perianal (enfermedad perianal) y en aquella que no afecta la zona perianal. La enfermedad perianal a la vez se dividirá en simple o compleja dependiendo de las características de las fistulas, lo cual condiciona variaciones en el enfrentamiento y tratamiento. La enfermedad fistulizante no perianal se divide en interna cuando comunica al intestino con otros órganos (fistulas entero-vesicales, entero-vaginales, entero-entérico) y externas cuando se comunica al intestino con la pared abdominal (fistulas entero-cutáneas) tanto de forma espontánea como postquirúrgica. Debido a la gran diversidad de presentación de las fistulas es necesario individualizar cada grupo de trayectos fistulosos, valorar la asociación a actividad inflamatoria luminal, descartar la presencia de abscesos y valorar el estado nutricional de los pacientes para definir el manejo integral adecuado. Este artículo se centra en el manejo actual de la enfermedad de Crohn fistulizante en nuestro país.

Association of ano-rectal inflammatory bowel diseases with cases of fistula-in-ano-[a cross sectional hospital based study] at Al Thora Hospital, Al Beida

Incidence of Inflammatory bowel diseases at Libya is 0.9 to 3.6 / 100 000 population as per 2006 study. And extrapolated prevalence of Inflammatory bowel diseases at Libya is 11, 263 / 5.631.585 [1] Inflammatory bowel disease mainly constitute Crohn's disease, Ulcerative colitis, Intermediate colitis, and pouchitis. Perianal pathological problems are fairly frequent manifestation of Inflammatory bowel diseases. A study has been carried out at Al Thora Hospital, Al Beida, in last 5 years, from Jan 2005 to Dec 2009; about the association of ano-rectal Inflammatory bowel diseases with cases of fistula-in-ano

Tratamiento quirúrgico de la fístula anal: análisis de nuestra experiencia / Surgical treatment of anal fistula: analysis of our experience

Introducción: las fistulas perianales tienen una incidencia de 1/10000, son más frecuentes en varones jóvenes. Su tratamiento es complejo debido a la posibilidad de recidiva e incontinencia anal. Objetivo: analizar la morbilidad y los resultados inmediatos y alejados, en pacientes operados por fistula perianal. Diseño: retrospectivo. Serie consecutiva. Período: 2000-2007. Población: 168 casos consecutivos intervenidos quirúrgicamente en forma electiva. Lugar de aplicación: sector coloproctología. Institución Privada Universitaria. Método: variables: edad, sexo, etiología, técnica quirúrgica, patología asociada, morbilidad inmediata y alejada. Incontinencia (SCORE CCF-Cleveland Clinic Florida). Resultado: Edad: 48 años (15-71). Sexo 3/1 (H-M). la etiología fue: criptoglandular 94%, enfermedad de Crohn 1,2 %, cuerpo extraño 2,4 %, posthemorroidectomia 1,2%, postepisiotomía 0,6 %, postesfinterotomía lateral 0,6%. Según tipo, fístulas simples 71,4% y complejas 28,6%. Las técnicas quirúrgicas utilizadas fueron, fistulotomía 71%, sedal 11,3%, descenso mucoso 17%. El 56% presentaron patología anal asociada: hemorroides 45%, fisura 4,7% estenosis anal 5,9%. El seguimiento fue posible en el 80,9%. Recidivaron 9 casos. La incontinencia inmediata fue del 27,9% y alejada en fístulas simples 1,2% y en complejas 11%. Conclusiones: la etiología fue principalmente criptoglandular. Las técnicas más utilizadas fueron la fistulotomía y el descenso mucoso, esta última con menor índice de recidiva. La morbilidad fue baja. El índice de incontinencia fue variable y estuvo relacionado con la complejidad de la fístula y el tratamiento realizado. Se registraron casos de incontinencia alejada únicamente en las fístulas complejas.

Fisura anal, opciones terapéuticas actuales: [revisión] / Anal fissure, actually treatment options: [review]

La fisura anal es una patología frecuente y probablemente la causante de la mayor parte de las proctalgias agudas severas. Esta revisión tiene por objetivo, evaluar los procedimientos actualmente utilizados para el tratamiento de esta enfermedad. En principio se describen algunos aspectos ligados a la etiopatogenia y a la evolución natural con la intención de comprender la utilización de las distintas modalidades terapéuticas. Posteriormente se analizan las características de cada método en particular, como así también sus beneficios, efectos adversos y resultados. Al final del trabajo, se expone el algoritmo de tratamiento seguido por los autores.

The anal fissure is a frequent pathology and probably the cause of most of the severe acute proctalgias. This revision has by objective, to evaluate the procedures at the moment used for the treatment of this disease. In principle some aspects related to etiopatogenia are described and to the natural evolution, with the intention to understand the use of different therapeutic modalities. Later the characteristics of each method in individual are analyzed, like thus also their benefits, adverse effects and results. At the end of the work, the algorithm of treatment followed by the authors is exposed.

Unusual presentation of retrovesical hydatid Cyst: report of three cases

Hydatid disease may occur in any organ of the human body, but an isolated retrovesical hydatid [RVH] cyst is rare. We report two cases of isolated RVH cyst - one mimicking an ovarian cyst, the other presenting as acute urinary retention - and a third case of RVH cyst associated with bladder and rectal fistula and a hepatic hydatid cyst