SiLaT: A paradigm shift in the treatment of pilonidal disease?

BACKGROUND: Pilonidal disease (PD) is a common condition for which the global incidence is increasing. Surgery is the currently preferred approach to treatment but there is a growing interest in new minimally invasive techniques, such as sinus laser therapy (SiLaT). AIM: Our primary objective was to assess the efficacy of SiLaT for the treatment of pilonidal disease. The secondary objectives were to evaluate morbidity and patient satisfaction and identify predictive factors of success. METHODS: All adult patients, who underwent SiLaT in our department for a primary or recurrent pilonidal sinus from June 1, 2018, to December 31, 2020, were included in the study. Healing was defined as the closure of cutaneous orifices and the absence of seepage or abscesses. RESULTS: In total, 111 consecutive patients, for whom the male/female sex ratio was 2.1 and the mean age 28.8 (± 9.4) years, were included in this study. Eighteen (16.2%) patients had already undergone prior surgery for PD. The mean follow-up was 339.2 (± 221.4) days. A healing rate of 78.4% was observed, with a median time to healing of 20.0 days (15.0-30.0). The median time to return to usual activities was three days (1-7). The only postoperative complication was bleeding, which occurred for two patients (1.8%). Eighty-two patients (88.2%) reported being "very satisfied" with the treatment. Multivariate analysis showed no predictive factors for healing among the studied variables. CONCLUSION: SiLaT is an efficient and safe procedure for the treatment of PD, with a high level of patient satisfaction. It will now be necessary to position it within the therapeutic algorithm.

Hemorrhoidal disease: Epidemiological study and analysis of predictive factors for surgical management.

INTRODUCTION: There are very few French studies on hemorrhoidal disease and its management. PATIENTS AND METHODS: Prospective single-center study from July to December 2021 including 472 patients. RESULTS: Bleeding, prolapse and pain were the main reasons for consultation. Treatment modalities were medical (44%),±instrumental (72%), and surgical (17%). After treatment, the bleeding score and prolapse score decreased significantly (P=0.002 and P≤0.0001, respectively), but improvement was more marked in the surgery group with a better rate of "very good satisfaction" (73% vs. 54%, P=0.003). Factors associated with likelihood of surgical treatment were: age>44years, hypertrophic perianal skin tags, high scores (Bristol>5, bleeding>5, prolapse>2), severe impact on quality of life, smoking and reading during bowel movements. We have developed an online application, which aims to assess the risk of requiring hemorrhoidal surgery. CONCLUSION: Less than 20% of patients who present with hemorrhoidal disease require surgical treatment, but it is associated with better effectiveness despite more complex postoperative consequences that sometimes motivate patient refusal. We have highlighted factors associated with surgical management, which can guide the practitioner in their therapeutic choices.

Allogenic stem cells for Crohn's anal fistulas: Treating early improves the deep remission rate.

AIM: The aim of this study was to evaluate the real-life clinical and radiological efficacy of darvadstrocel injection into complex perianal fistulas in Crohn's disease. Secondary endpoints were to assess symptomatic efficacy, adverse effects and factors associated with complete combined clinical-radiological response (deep remission). METHODS: After marketing the product in France, all first patients treated consecutively were included. A complete clinical response was defined by a complete closure of all external openings with no discharge on pressure. A complete radiological response (MRI), evaluated at least after six months of follow-up, was defined by a completely fibrotic sequela without abscess. A deep remission was defined as the association of a complete clinical response with a complete radiological response. RESULTS: A total of 43 patients were included (M/F: 22/21, median age 37 [26-45] years). The fistulas were already drained with seton(s) and were on biologic treatment. After a median follow-up of 383 (359-505) days, 28 (65%) patients showed a clinical response (22 complete and 6 partial) and 16 (37%) achieved a deep remission. The Perineal Disease Activity Index decreased significantly after treatment: 39 (91%) patients reported symptomatic improvement in terms of discharge, pain, and induration, and 28 (65%) no longer had any perineal symptoms. No severe adverse events were reported. A short history of Crohn's disease <3 years was significantly associated with deep remission (OD 4.5 [1.0-19.1], p = 0.04). CONCLUSION: Darvadstrocel injection resulted in a clinical response for two thirds of patients and deep remission for one third. A shorter duration of Crohn's disease was associated with deep remission.

[Anal fistulas: Sparing the sphincter]. / Fistules anales, épargner le sphincter.

ANAL FISTULAS: SPARING THE SPHINCTER. Fistulotomy is the most used treatment for anal fistula. It is very effective with a cure rate of over 95% but carries a risk of incontinence. This has led to the development of various sphincter sparing techniques. The injection of biological glue or paste and the insertion of a plug have disappointing results and are expensive. The rectal advancement flap is still practised because of its cure rate of around 75% but it may result in some incontinence. Intersphincteric ligation of the fistula track and laser treatment are widely practised in France with cure rates between 60 and 70%. Video-assisted anal fistula treatment as well as injections of adipose tissue, stromal vascular fraction, platelet-enriched plasma and/or mesenchymal stem cells are emerging techniques for which even better results are expected.

FISTULES ANALES, ÉPARGNER LE SPHINCTER. La fistulotomie est le traitement le plus souvent utilisé dans la fistule anale. Elle est très efficace, avec un taux de guérison supérieur à 95 %, mais expose à un risque d'incontinence. Cela a conduit au développement de diverses techniques d'épargne sphinctérienne. L'injection de colle ou de pâte biologique ainsi que la mise en place d'un plug ont des résultats finalement décevants et un coût élevé. Le lambeau rectal d'avancement est encore pratiqué en raison de son taux de guérison aux alentours de 75 %, mais il peut se solder par quelques troubles séquellaires de la continence. La ligature intersphinctérienne du trajet fistuleux et le laser sont largement pratiqués en France, avec des taux de guérison oscillant entre 60 et 70 %. Le traitement vidéo-assisté du trajet fistuleux ainsi que les injections périfistuleuses de tissu adipeux, de fraction vasculaire stromale, de plasma enrichi en plaquettes et/ou de cellules souches mésenchymateuses sont des techniques émergentes dont on espère de meilleurs résultats encore.

Lessons from the first 70 patients operated by doppler-guided haemorrhoidal artery ligation with mucopexy in a French team specialising in surgical proctology / Lições dos primeiros 70 pacientes operados por ligadura de artéria hemorroidária guiada por doppler com mucopexia por uma equipe francesa especializada em proctologia cirúrgica

ABSTRACT Background: Doppler-guided haemorrhoidal artery ligation with mucopexy is a minimal-invasive surgical technique. It is both effective and less painful than conventional haemorrhoidectomy. Methods: We gathered records on all patients operated on between November 2012 and June 2014. Pre- and postoperative scores were calculated during consultation and then by phone. Unsuccessful surgical treatment was defined by persistent haemorrhoid symptoms within three months following the procedure and relapse defined by recurrent symptoms after the third postoperative month. Results: During the period analysed, 70 patients underwent consecutive surgical procedures for haemorrhoid prolapse (52%), bleeding (29%), or both (17%). Hospitalisation was outpatient or overnight for 87% of patients. There were no complications in 92.7% of cases. The average period away from work was 11 days (± 6.5). The time between the procedure and last postoperative consultation, followed by telephone contact, was respectively 2.7 months (± 5.8) and 16.5 months (± 4.9). At the time of the postoperative telephone call, the Thaha et al. score decreased by 5.6 (p < 0.001), while the quality of life score decreased by 2 (p < 0.001). The Wexner score remained the same or improved for all patients except one. Treatment was unsuccessful for 6/67 patients (9%) and 10/61 patients (16.4%) experienced a subsequent recurrence in haemorrhoid symptoms. Only those over 51 years old were statistically associated with more frequent recurrences (p = 0.044). Conclusion: Doppler-guided haemorrhoidal artery ligation with mucopexy is an effective technique in the medium-term. Good tolerance in makes this treatment an attractive alternative to conventional haemorrhoidectomy.

RESUMO Experiência: A ligação de artéria hemorroidária com mucopexia orientada por Doppler é técnica cirúrgica minimamente invasiva. Esse procedimento é efetivo e menos doloroso do que a hemorroidectomia convencional. Métodos: Reunimos os prontuários de todos os pacientes operados entre novembro de 2012 e junho de 2014. Foram calculados escores pré-operatórios e pós-operatórios durante as consultas e, em seguida, por telefone. Tratamento cirúrgico malsucedido foi definido como a persistência dos sintomas de hemorroidas dentro de três meses após o procedimento, e recidiva foi definida por sintomas recorrentes depois do terceiro mês do pós-operatório. Resultados: Durante o período analisado, 70 pacientes passaram por procedimentos cirúrgicos consecutivos para prolapso de hemorroida (52%), sangramento (29%), ou ambos (17%). Para 87% dos pacientes, a hospitalização foi ambulatorial ou de pernoite. Não ocorreram complicações em 92,7% dos casos. O período médio de absenteísmo foi de 11 ± 6,5 dias. Os tempos transcorridos entre o procedimento e a última consulta no pós-operatório, seguida pelo contato telefônico, foram de respectivamente 2,7 ± 5,8 meses e 16,5 ± 4,9 meses. Por ocasião do contato telefônico no pós-operatório, o escore de Thaha et al. diminuiu em 5,6 pontos (p < 0,001), enquanto o escore de qualidade de vida diminuiu em 2 pontos (p < 0,001). O escore de Wexner permaneceu igual ou melhorou para todos os pacientes, exceto um. O tratamento não obteve sucesso para 6/67 pacientes (9%); e 10/61 pacientes (16,4%) sofreram uma subsequente recorrência nos sintomas hemorroidários. Apenas aqueles participantes com mais de 51 anos demonstraram associação estatística com recorrências mais frequentes (p = 0,044). Conclusão: A ligação de artéria hemorroidária com mucopexia orientada por Doppler é técnica efetiva no meio termo. A boa tolerância faz com que esse tratamento seja uma alternativa efetiva à hemorroidectomia convencional.

[Management of anorectal bleeding]. / Conduite à tenir devant un saignement anorectal

Management of anorectal bleeding. Anorectal bleeding is a common reason for consultation in general medical practice. The ano-rectal origin is suspected on the characteristics of the bleeding which is often scant and bright red color. Medical history and clinical examination alone are often sufficient to make a diagnosis, since the main causes are hemorrhoids and anal fissure. On the other hand, the estimated risk of anorectal tumours in patients with ano-rectal bleeding has been reported in about 10%. Colonoscopy is therefore necessary at the slightest diagnostic doubt and, anyway, in all patients aged over 45 years.

Conduite à tenir devant un saignement anorectal. Les saignements anorectaux sont un motif de consultation fréquent en médecine générale. L'origine anorectale est suspectée sur les caractéristiques du saignement, qui est habituellement de faible abondance et de couleur rouge vif. L'interrogatoire et l'examen clinique seuls suffisent le plus souvent à poser un diagnostic étiologique, puisque les causes sont dominées par la pathologie hémorroïdaire et la fissure anale. D'un autre côté, la pathologie tumorale anorectale, hantise aussi bien des patients que des médecins, en est la cause dans environ 10 %. La coloscopie reste donc indiquée au moindre doute diagnostique et, de principe, chez tous les patients âgés de plus de 45 ans.

Prevalence and risk factors for adenomas in the ileal pouch and the afferent loop after restorative proctocolectomy for patients with familial adenomatous polyposis.

BACKGROUND: Restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA) has become the treatment of choice in familial adenomatous polyposis (FAP) to prevent the risk of colorectal cancer. However, it currently is recognized that adenomas may develop in the ileal pouch. The risk of adenoma occurring in the afferent ileal loop above the pouch is less clearly identified. This study aimed to evaluate the difference in prevalence of adenomas between the ileal pouch and the afferent ileum after IPAA in FAP. METHODS: The study analyzed 442 endoscopies performed between 2003 and 2008 for 139 FAP patients. The patients had undergone an IPAA in 118 cases, an ileorectal anastomosis in 13 cases, or an ileostomy in 8 cases. RESULTS: Among the 118 IPAA patients, 57 (48.3 %) had pouch adenomas a median of 15 years after surgery. The risk factors for pouch adenomas were delay since pouch construction [odds ratio (OR), 1.11; p = 0.016] and presence of advanced duodenal adenomas (OR, 4.35; p = 0.011). Seven patients had pouch adenomas with high-grade dysplasia. Only nine patients had afferent ileal loop adenomas (6.5 %). The only significant risk factor for ileal adenomas was the presence of pouch adenomas (OR, 2.16; p = 0.007). CONCLUSION: After restorative proctocolectomy in FAP, adenoma recurrence is frequent in the pouch, with a higher risk for patients with advanced duodenal adenomas and an increasing risk over time, whereas adenomas are rarely found in the afferent ileal loop. This finding may help to propose redo ileal pouch anal anastomosis if required.

Helpfulness of the combination of acetic acid and FICE in the detection of Barrett's epithelium and Barrett's associated neoplasias.

AIM: To investigate the mucosal morphology in Barrett's oesophagus by chromo and magnifying endoscopy. METHODS: A prospective pilot study at a tertiary medical centre was conducted to evaluate the use of acetic acid pulverisation combined with virtual chromoendoscopy using Fujinon intelligent chromoendoscopy (FICE) for semiological characterization of the mucosal morphology in Barrett's oesophagus and its neoplastic complications. Upper endoscopy using high definition white light, 2% acid acetic pulverisation and FICE with high definition videoendoscopy were performed in 20 patients including 18 patients who presented with aspects of Barrett's oesophagus at endoscopy examination. Two patients used as controls had normal endoscopy and histological results. Prospectively, videos were watched blind from histological results by three trained FICE technique endoscopists. RESULTS: The videos of patients with high-grade dysplasia showed an irregular mucosal pattern in 14% using high definition white light endoscopy and in 100% using acid acetic-FICE combined. Videos did not identify irregular vascular patterns using high definition white light endoscopy, while acid acetic-FICE combined visualised one in 86% of cases. CONCLUSION: Combined acetic acid and FICE is a promising method for screening high-grade dysplasia and early cancer in Barrett's oesophagus.

[Surveillance in Barrett's esophagus]. / Place de la surveillance endoscopique de l'œsophage de Barrett.

Barrett's esophagus (BE) is a consequence of chronic gastroesophageal reflux. Barrett's esophagus is a well-established risk factor for adenocarcinoma. There is no effective method available to prevent the malignant transformation of Barrett's esophagus. Endoscopy is therefore the only means of patients' screening and monitoring. Endoscopic surveillance is recommended to detect precancerous or cancerous lesions at an early stage, where curative treatment can be proposed.