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)

Effectiveness of the Aloe Vera extract in the treatment of fistula-in-ano / Eficácia do extrato de Aloe Vera no tratamento da fístula anal

Abstract Rationale: Considering that anal fistulae are still challenging regarding their treatment due to the risk of fecal incontinence in the most complex cases and the increasing use of phytotherapeutic drugs such as Aloe Vera in medicine, even with proven healing effectiveness, there is interest in researching this drug in the treatment of anal fistulae. Objective: To evaluate the efficacy of Aloe Vera extract in the treatment of anal fistulae in rats. Method: Thirty male Wistar rats weighing 250-300 g were submitted to anal fistula and after 30 days were divided into three groups: Control Group (GCo) (n = 5), Carbopol Group (GCa) (n = 5), and Aloe Vera Group (GAV) (n = 10). In the GCo no treatment was performed, while in the others a daily infusion of 0.3 mL of solution (Carbopol only in GCa and Carbopol plus Aloe Vera extract in the GAV) was performed through the external orifice of the fistula for 30 days. Afterwards, euthanasia was performed and specimens were removed for histological study. It was evaluated the closure of the fistulous tract, the area of the remaining tract, the inflammatory infiltrate and the degree of vascular congestion. The results were submitted to statistical treatment by Kruskall-Wallis test, considering p<0.05. Results: There was no complete closure of the fistulous tract in any of the animals. The mean area of the remaining tract was 847.2 µm in the GCo, 565.6 µm in the GCa and 377.8 µm in the GAV (p<0.05). The mean of the inflammatory infiltrate score was 2.4 in the GCo, 2.4 in the GCa and 2.3 in the GAV (p<0.05), while in the evaluation of vascular congestion, we observed a mean of 1.6 in the GCo, 1.4 in GCa and 1.1 in GAV (p<0.05). Conclusion: The extract of Aloe vera was able to reduce the lumen of the fistulous tract and reduce the degree of vascular congestion; however, it did not allow the complete closure of the fistulous tract nor diminished the inflammatory process.

Resumo Racional: Considerando que o tratamento das fístulas anais tem risco de incontinência fecal e o crescente uso do Aloe Vera na medicina, há interesse em se pesquisar este fármaco. Objetivo: Avaliar a eficácia do extrato de Aloe vera no tratamento das fístulas anais em ratos. Método: Utilizou-se 30 ratos Wistar, os quais foram submetidos à criação de fístula anal e após 30 dias distribuídos em três grupos: Controle (GCo), Carbopol (GCa) e Aloe Vera (GAV). No GCo nenhum tratamento foi realizado, enquanto nos outros realizou-se infusão diária de 0,3 mL de Carbopol GCa e Carbopol mais extrato de Aloe Vera no GAV por 30 dias. Foram retirados os espécimes para estudo histológico, avaliou-se o fechamento do trajeto fistuloso, a área do trajeto remanescente, o infiltrado inflamatório e o grau de congestão vascular. Resultados: Não houve fechamento completo do trajeto fistuloso em nenhum dos animais. A média da área do trajeto remanescente foi 847,2 µm no GCo; 565,6 µm no GCa e 377,8 µm no GAV (p<0,05). A média do escore de infiltrado inflamatório foi 2,4 no GCo; 2,4 no GCa e 2,3 no GAV (p<0.05), enquanto na avaliação da congestão vascular observou-se média 1,6 no GCo; 1,4 no GCa e 1,1 no GAV (p<0,05). Conclusão: O extrato de Aloe Vera foi capaz de diminuir o lumen dos trajetos fistulosos e reduzir o grau de congestão vascular, porém, não permitiu o fechamento completo dos trajetos fistulosos nem diminuiu o processo inflamatório.

Local irrigation with silver nitrate, a non-surgical approach for persistent anal fistula / Irrigação local com nitrato de prata, uma abordagem não cirúrgica para fístula anal persistente

ABSTRACT Purpose: Treatment of persistent anal fistula implies a major challenge for surgeons, with risk of additional recurrence and potential continence impairment. We present a non-surgical treatment based on irrigation with silver nitrate 1% solution. Methods: This is a prospective study including patients with persistent anal fistula after surgery, who were treated with silver nitrate 1% solution irrigation from May 2015 to March 2017. Patients with evidence of abscess, presence of >1 external opening and those with bowel inflammatory disease were excluded. 3-5 cc of silver nitrate 1% solution were instilled through a catheter. The procedure was repeated on a weekly basis, conducting a maximum of 7 sessions per patient. Results: 18 patients (13 male, 72.2%) with a median age of 48 years old (IQR 41-55) were treated using silver nitrate 1% solution. A median of 5 sessions per patient was performed (IQR 3-6). The median follow-up period was 18 months (IQR 9-25). After the described period 8 patients' (44.4%) presented complete resolution of the fistula, 2 patients' (11.2%) were classified as partial healing and in 8 patients' (44.4%) the treatment was considered to fail. 6 patients' experienced self-limited pain during instillation, with persistence up to 24 h in 2 of them. Conclusions: Treatment with silver nitrate 1% solution is a minimally invasive procedure, with a favourable safety profile, that can be performed in an outpatients' basis achieving a complete healing rate of 44.4%. Therefore, this method should be considered for the treatment of recurrent or persistent anal fistula.

RESUMO Objetivo: O tratamento da fístula anal persistente é um grande desafio para os cirurgiões, com risco de recorrência adicional e potencial comprometimento da continência. Os autores apresentam um tratamento não cirúrgico baseado na irrigação com solução de nitrato de prata a 1%. Métodos: Este foi um estudo prospectivo incluindo pacientes com fístula anal persistente após a cirurgia que foram tratados com irrigação com solução de nitrato de prata a 1% entre maio de 2015 e março de 2017. Pacientes com evidência de abscesso, presença de mais de uma abertura externa e aqueles com doença inflamatória intestinal foram excluídos. Usando um cateter, instilou-se 3 a 5 cc. de solução de nitrato de prata a 1%. O procedimento foi repetido semanalmente, em um máximo de sete sessões por paciente. Resultados: Um total de 18 pacientes (13 homens, 72,2%) com idade mediana de 48 anos (IQR 41-55) foram tratados com solução de nitrato de prata a 1%. Uma mediana de cinco sessões por paciente foi realizada (IQR 3-6). A mediana do período de acompanhamento foi de 18 meses (IQR 9-25). Após o período descrito, oito pacientes (44,4%) apresentaram resolução completa da fístula, dois pacientes (11,2%) foram classificados como cicatrização parcial e em oito pacientes (44,4%) o tratamento falhou. Seis pacientes apresentaram dor autolimitada durante a instilação, que persistiu por até 24 horas em dois deles. Conclusões: O tratamento com solução de nitrato de prata a 1% é um procedimento minimamente invasivo, com perfil de segurança favorável, que pode ser realizado em regime ambulatorial, atingindo taxa de cura completa de 44,4%. Portanto, este método deve ser considerado para o tratamento da fístula anal recorrente ou persistente.

Treatment of fistula-in-ano with cyanoacrylate glue with and without prior seton placement in rats

ABSTRACT PURPOSE: To evaluate the efficacy of ethyl-cyanoacrylate in the treatment of fístula-in-ano in rats with and without prior seton placement. METHODS: Thirty rats Wistar with fístula-in-ano produced surgically, distributed in three groups: group A (ethyl-cyanoacrylate) - treated by application of ethyl-cyanoacrylate into fístula tract; group B (seton + ethyl-cyanoacrylate) - seton placement followed by application of ethyl-cyanoacrylate into fístula tract, 30 days later; group C (control) - no treatment. After 60 days the animals were submited to euthanasia and the specimens were analyzed by pathologist. The results were analyzed by Chi-square test with significant value of p<0.05. RESULTS: One animal of group B died. Were found tracts fully healed: 7, 5 and 2, in groups A, B and C, respectivelly. There was a statistically significant difference between groups A and C (p=0.02). When joined all animals treated with glue (A + B) compared to group C there was also statistically significant difference (p=0.02). CONCLUSIONS: The use of ethyl-cyanoacrylate glue was effective in closing anal fistulae in rats. There was no advantage in the prior application of seton.

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.

Estudo evolutivo de fístulas na doença de crohn / Follow-up study of fistula in Crohn's disease

Foram estudados 16 pacientes portadores de doença de Crohn com fístulas. A evolução de 29 fístulas, nestes casos, 10 tratadas por cirurgia e 19 através de medicamentos, foi acompanhada quanto à cicatrizaçãoe e melhora do processo.