Laser ablation of fistula tract (LAFT) and complex fistula-in-ano: "the ideal indication" is becoming clearer .

BACKGROUND: An initial study enabled us to achieve 60% healing of high transsphincteric fistula-in-ano with laser ablation of fistula tract (LAFT) The purpose of this new study was to investigate other predictors of the success of this technique in the treatment of complex anoperineal fistulas. METHODS: All patients treated with LAFT in our department between May 2017 and October 2018 were included prospectively. LAFT was used for patients with complex anoperineal fistulas who were at high risk of anal incontinence after fistulotomy. The fistula was considered healed when the internal and external openings were closed and the patient experienced no pain or leakage. RESULTS: A total of 100 consecutive patients (65 males) with a median age of 43 years (range 22-88 years) were included in the study. Eight patients were lost to follow-up. The fistulas were low (8%) or high (79%) transsphincteric, and suprasphincteric (13%). After a median follow-up of 13.6 months (range 6-23 months), fistula healing was observed in 41 patients (44.6%). On univariate analysis, an anterior location, a narrow internal orifice and administration of less than 400 J of energy were significantly associated with healing. On multivariate analysis, a narrow internal orifice and low energy administration remained significant predictive factors of success [OR 5.08 (1.03-25.03), p = 0.046; OR 2.59 (1.08-6.17), p = 0.032]. No new cases of anal incontinence or any worsening of pre-existing anal incontinence was observed during follow up. CONCLUSIONS: This study indicates that complex anoperineal fistulas with a narrow internal orifice can be successfully treated with less than 400 J and are ideal for LAFT.

FiLaC® and Crohn's disease perianal fistulas: a pilot study of 20 consecutive patients.

BACKGROUND: The aim of our study was to evaluate the efficacy of FiLaC®  (Fistula Laser Closure) in the treatment of perianal fistulas in patients with Crohn's disease. METHODS: All adult patients treated in our department between March 3rd 2016 and November 16th 2018 were included in the study. The fistula was considered healed when the internal and external openings were closed and the patient experienced no pain or leakage (spontaneously or under pressure). RESULTS: We included 20 consecutive patients (10 women) with a mean age of 32 years ± 9.61. The main fistula tracks were intersphincteric (n = 1, 5%), low (n = 3, 15%) or high (n = 14, 70%) transsphincteric, suprasphincteric (n = 1, 5%), or extrasphincteric (n = 1, 5%). Secondary extension (intramural, supralevator, or horseshoe) was found in 6 cases (30%). The average number of previous surgeries was 2.45 ± 1.47. Crohn's disease extension was ileal in 2 patients (10%), ileocolonic in 8 patients (40%), and colonic in 10 patients (50%). Two patients were lost to follow up and were considered as failures. After a median follow-up period of 7.1 months (range 2-22.5 months), fistula healing was observed in 11 patients (55%). On univariate analysis, only the disease-modifying therapy for Crohn's disease was a predictive factor of a response to FiLaC® (p = 0.05). The specific analysis of this subgroup showed that FiLaC® was less effective when patients were treated with anti-tumor necrosis factor (TNF) alone with an OR of 13.06 [1.28; 236.66] (p = 0.02). For combination therapy, the results seemed better (5 of 6 healed versus 2 of 9 healed with anti-TNF alone), but the difference was not significant. CONCLUSIONS: This pilot study suggests that FiLaC® may play an important role in the management of perianal fistulas in patients with Crohn's disease.

The optimal indication for FiLaC® is high trans-sphincteric fistula-in-ano: a prospective cohort of 69 consecutive patients.

BACKGROUND: The aim of our study was to prospectively evaluate the effectiveness of the Fistula Laser Closure (FiLaC®) technique in patients at high risk of anal incontinence and to determine the predictors of success and the impact of the procedure on anal continence. METHODS: A prospective study was conducted on all patients treated with FiLaC® in our department in May 2016-April 2017, because they were at high risk of anal incontinence after fistulotomy, The fistula was considered healed when the internal and external openings were closed and the patient experienced was no pain or leakage. RESULTS: A total of 69 consecutive patients (34 males) with a median age of 40 years (33-53 years) were included in the study. One patient was lost to follow up. The fistulas were intersphincteric (3%), low (15%) or high (66%) trans-sphincteric, and suprasphincteric (16%). After a median follow-up period of 6.3 months (4.2-9.3), fistula healing was observed in 31 patients (45.6%). In univariate analysis, high trans-sphincteric fistulas (p = 0.007) and age over 50 years (p = 0.034) were significantly associated with healing. In multivariate analysis, only high trans-sphincteric fistulas were a predictive factor of significant success. No new cases of anal incontinence or any worsening in case of pre-existing anal incontinence were observed during follow-up. CONCLUSIONS: FiLaC® is particularly effective in cases of high trans-sphincteric fistulas (60% cure). This technique seems to be the most promising sphincter-saving technique available for this indication.

Clinical diagnostic and therapeutic aspects of 221 consecutive anorectal Chlamydia trachomatis and Neisseria gonorrhoeae sexually transmitted infections among men who have sex with men.

OBJECTIVES: Proctitis caused by Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG) are known as sexually transmitted infections (STI). This study describes their clinical, diagnostic and therapeutic aspects. METHODS: Between 01/2013-03/2015, all MSM consulting for proctitis at proctology Institute-Saint-Joseph's Hospital, Paris, were included. Demographic, past-medical history, STI status and medical treatment were collected. Detection of CT/NG was performed by Transcription-Mediated Amplification (TMA) and antimicrobial susceptibilities for Ng by agar diffusion method. RESULTS: On 441 rectal samples collected, 221 (50.1%) were positive: 109 Ct (49.3%), 70 Ng (31.7%), 42 positive for both etiologies (19%). Among Ng infections, no resistance was detected to azithromycin and ceftriaxone. However, 84 strains (43.2%) were resistant to fluoroquinolones. More than one episode was diagnosed for 10 (5.1%) and 12 (6.2%) patients with CT and NG infections respectively. Anal abscesses were found for 27 (13.9%) patients, and 14 (7.2%) of them underwent surgery for anal fistula. CONCLUSIONS: The prevalence of CT/NG anorectal infections described is high on symptomatic patients, and a significant level of abscess was reported. These results confirm the interest of the association of recommended antibiotics excluding quinolones. Prospective studies would be relevant on complicated forms of anorectal infections.

Epidermoid anal cancer prognosis comparison among HIV+ and HIV- patients.

BACKGROUND: Previous studies suggest a poor prognosis of epidermoid anal cancer in HIV+ patients. AIM: To investigate the long-term outcome of epidermoid anal cancer in HIV+ and HIV- patients in the highly active antiretroviral treatment (HAART) era. METHODS: We included all patients with epidermoid anal cancer referred to six hospitals from 1998 to 2004. RESULTS: In all, 151 patients (44 HIV+, 107 HIV-) were reviewed retrospectively for 27 (median of 16-44) months. HIV+ patients were male (100% vs. 27%, P < 0.001) and younger (45 vs. 62 years old, P < 0.001) than HIV- patients. No significant differences were observed in the tumour stage, pelvic radiotherapy dose or concomitant chemotherapy, according to the HIV status. After chemoradiotherapy, similar numbers of HIV+ and HIV- patients had grade III-IV toxicity. A complete response was obtained in 82% and 75% (N.S.) of cases, respectively. The disease-free survival rates were 77% and 67% (N.S.) and the overall survival rates were 85% and 84% (N.S.), respectively, after 3 years of follow-up. Duration of HIV infection, viral load and CD4 count had no effect on the survival rate of HIV+ patients with EAC. CONCLUSIONS: The clinical outcome of HIV+ patients with epidermoid anal cancer is similar to that of HIV- patients. Therefore, the same therapeutic guidelines should be applied to both populations.

Rectal lymphogranuloma venereum surveillance in France 2004-2005.

Lymphogranuloma venereum (LGV) is a sexually transmitted infection (STI) caused by Chlamydia trachomatis strains belonging to the L1, L2 or L3 genotype. An alert about an outbreak of LGV among MSM in the Netherlands was published in January 2004. The first cases of rectal LGV in France were retrospectively diagnosed in March 2004 and sentinel surveillance for LGV was implemented in April 2004. Most of the participating centres were located in the cities of Paris and Bordeaux. Only confirmed rectal LGV cases were included in the surveillance. Rectal specimens from men that were found to be positive for C trachomatis by PCR were sent to the National Reference Centre for Chlamydia infection for genotyping. Simple epidemiological data provided by clinicians and genotyping results were sent to the Institut de Veille Sanitaire (InVS) where data were anonymously recorded. A total of 328 C. trachomatis rectal strains isolated in men were genotyped by the end of December 2005. Of these, 244 (74%) were LGV strains belonging to the L2 genotype. No L1 or L3 C. trachomatis genotype was found. Diagnosis was made retrospectively for 46 cases. The median age of patients with LGV was 39 years. HIV status was known for 96 patients: 82/96 (85%) were HIV-infected. Most LGV cases were diagnosed in the Paris area (92%). Among the remaining 26% C. trachomatis strains, genotypes Da and G were the most frequent. As with syphilis in recent years, the emergence of LGV in Europe is mainly affecting HIV-infected MSM. The screening and treatment of STIs should be included in the clinical follow-up of all HIV-infected MSM.

Rectal lymphogranuloma venereum surveillance in France 2004-2005.

Lymphogranuloma venereum (LGV) is a sexually transmitted infection (STI) caused by Chlamydia trachomatis strains belonging to the L1, L2 or L3 genotype. An alert about an outbreak of LGV among MSM in the Netherlands was published in January 2004. The first cases of rectal LGV in France were retrospectively diagnosed in March 2004 and sentinel surveillance for LGV was implemented in April 2004. Most of the participating centres were located in the cities of Paris and Bordeaux. Only confirmed rectal LGV cases were included in the surveillance. Rectal specimens from men that were found to be positive for C trachomatis by PCR were sent to the National Reference Centre for Chlamydia infection for genotyping. Simple epidemiological data provided by clinicians and genotyping results were sent to the Institut de Veille Sanitaire (InVS) where data were anonymously recorded. A total of 328 C. trachomatis rectal strains isolated in men were genotyped by the end of December 2005. Of these, 244 (74%) were LGV strains belonging to the L2 genotype. No L1 or L3 C. trachomatis genotype was found. Diagnosis was made retrospectively for 46 cases. The median age of patients with LGV was 39 years. HIV status was known for 96 patients: 82/96 (85%) were HIV-infected. Most LGV cases were diagnosed in the Paris area (92%). Among the remaining 26% C. trachomatis strains, genotypes Da and G were the most frequent. As with syphilis in recent years, the emergence of LGV in Europe is mainly affecting HIV-infected MSM. The screening and treatment of STIs should be included in the clinical follow-up of all HIV-infected MSM.

Anorectal lesions in human immunodeficiency virus-infected patients.

In a prospective study, we analysed the anorectal lesions observed in 148 human immunodeficiency virus-infected patients and compared the data with those reported in the literature. The majority of the patients (97.3%) were homosexual or bisexual men. The mean age of the population was 34.2 years. A history of previous sexually transmitted diseases was found in 79.7% of the male patients. The stage of HIV-related disease, according to the Centers for Disease Control classification, could be determined in 141 patients: 54.6% were stage II, 3.5% stage III and 41.8% stage IV. Anal condylomata were the most frequent manifestation, affecting 29.7% of the patients, 7.1% of whom showed moderate to severe dysplasia. The types were mainly 6, 11, 16 and 18, but types 31, 35 and 39 were also observed. Ulcerations were the most frequent non-condylomatous lesions, occurring in 41 patients; most (60%) were due to herpes viruses, and a large minority (21%) to cytomegalovirus. The etiology could not be determined in five cases. Anal sepsis was present in 11.4%, haemorrhoidal disease in 16.8% and fissures in 6%. Six patients developed Kaposi's sarcoma and seven, non-Hodgkin's lymphoma. No anal cancers were observed. Finally, wound healing was slowed in the patients operated on for haemorrhoids, fissures and suppuration. No statistical analysis could be performed because of the small number of patients.

Anal ulcerations due to cytomegalovirus in patients with AIDS. Report of six cases.

Lesions due to cytomegalovirus (CMV) are frequent in the immunocompromised patient. This is particularly the case in patients with AIDS, where the colon and rectum are the regions most often involved. The authors report six cases of anal ulcerations due to CMV in patients with AIDS. These lesions, confirmed histologically, were either isolated or associated with other localizations. Treatment is based on specific antiviral agents but resistance and recurrence can occur. The current report underlines the importance of histologic examination of anal lesions in HIV-infected subjects.

Hemorrhoidectomy: Hospital Leopold Bellan procedure.

The authors describe their hemorrhoidectomy technique, a modification of Milligan-Morgan. It differs by the association of a posterior anoplasty (with internal sphincterotomy in the case of a fissure or sphincter hypertonia) and of a sub-mucocutaneous dissection of the security bridges. They report on their experience with 410 operations carried out during the year 1985. Immediate complications are mainly hemorrhage (2.68%) and urinary problems (9%). Average cicatrization time is about six weeks. At one year, there were no relapses nor fissures. A moderate stenosis was observed in 1.45% of the cases, and a hypocontinence to flatus in 2.3%. Use of a CO2 laser does not result in any modification of these results.

[Intramural abscesses of the rectum]. / Les abcés intramuraux de rectum.

Intramural abscesses of the rectum developed in the complex longitudinal layer may be isolated or associated with a transphincteric fistula. They may be acute or subacute and are diagnosed by intrarectal palpation. The only treatment is surgical: the abscess is opened into the rectal cavity, except in case of association with suprasphincteric fistula, when it must be drained through the skin. Postoperative complications are minor ones and relapses are rare (1.75% of cases).