Perianal fistula and the ileoanal pouch - different aetiologies require distinct evaluation.

AIM: Restorative proctocolectomy has been widely adopted as the procedure of choice for restoring gastrointestinal continuity following proctocolectomy. It is often associated with improved quality of life and high patient satisfaction; however, the development of a pouch anal fistula can cause significant morbidity. Pouch fistulas are notoriously difficult to treat and there is great heterogeneity in the management reported of these fistulas. A lack of classification, and the assumption that fistulas originating from completely different aetiologies will behave and respond similarly to a particular treatment strategy, precludes meaningful comparison of management outcomes. We aim to introduce consistency in the reporting of pouch fistulas using a novel classification system. METHODS: A consensus process involving clinicians experienced in the management of pouch fistulas from two high volume tertiary centres was performed. RESULTS: We propose that pouch anal fistulas should be classified into four distinct groups according to their aetiology: group 1, anastomotic related; group 2, inflammatory bowel disease related, with sub-classifications Crohn's (type A) and non-Crohn's (type B) in origin; group 3, cryptoglandular related; and group 4, malignancy related. CONCLUSION: Classification of pouch fistulas according to their aetiology will provide consistency in the literature and improve the quality of prospective evidence for the management of pouch fistulas.

Percutaneous Cholecystostomy for Severe Acute Cholecystitis: A Useful Procedure in High-Risk Patients for Surgery.

BACKGROUND: Acute cholecystitis has the potential to cause sepsis and death, particularly in patients with poor physiological reserve. The gold standard treatment of acute cholecystitis (cholecystectomy) is often not safe in high-risk patients and recourse is made to percutaneous cholecystostomy as either definite treatment or temporizing measure. The aim of this study is to evaluate early and late outcomes following percutaneous cholecystostomy in patients with acute cholecystitis treated at our institution. METHODS: All patients who underwent percutaneous cholecystostomy for acute cholecystitis (excluding patients with malignancy) between January 2005 and September 2014 were included in the study. RESULTS: A total of 53 patients (22 female, median age, 74 years; range, 27-95 years) underwent percutaneous cholecystostomy during the study period. In total, 12 patients (22.6%) had acalculous cholecystitis. The main indications for percutaneous cholecystostomy were significant co-morbidities (n = 28, 52.8%) and patients too unstable for surgery (n = 21, 39.6%). The median time to percutaneous cholecystostomy from diagnosis of acute cholecystitis was 3.6 days (range, 0-45 days). The median length of hospital stay was 27 (range, 4-87) days. The overall 90-day mortality was 9.3% with two further deaths at 12-month follow up. The mortality was significantly higher in patients with American Society of Anesthesiology grade 4-5 (18% vs 0% in American Society of Anesthesiology grade 2-3, p = 0.026) and in patients with acalculous cholecystitis (25% vs 4.5%, p = 0.035). The overall readmission rate was 18%. A total of 24 (45.2%) patients had surgery: laparoscopic cholecystectomy, n = 11; laparoscopic converted to open, n = 5; open total cholecystectomy, n = 5; open cholecystectomy, n = 1; laparotomy and washout, n = 1; laparotomy partial cholecystectomy and closure of perforated small intestine and gastrostomy, n = 1. CONCLUSION: Percutaneous cholecystostomy is a useful temporary or permanent procedure in patients with acute cholecystitis of both calculous and acalculous origin, who are unfit for surgery.

Cost-utility analysis of LED fluorescence microscopy in the diagnosis of pulmonary tuberculosis in Indian settings.

BACKGROUND: With support from the Stop TB Partnership's TB REACH Wave 2 Grant, diagnostic microscopy services for tuberculosis (TB) were upgraded from conventional Ziehl-Neelsen (ZN) based sputum microscopy to light emitting diode technology-based fluorescence microscopy (LED FM) in 200 high-workload microscopy centres in India as a pilot intervention. OBJECTIVE: To evaluate the cost-effectiveness of LED-FM over conventional ZN microscopy to inform further scale-up. METHODS: A decision-tree model was constructed to assess the cost utility of LED FM over ZN microscopy. The results were summarised using incremental cost-effectiveness ratio (ICER); one-way and probabilistic sensitivity analyses were also conducted to address uncertainty within the model. Data were analysed from 200 medical colleges in 2011 and 2012, before and after the introduction of LED microscopes. A full costing analysis was carried out from the perspective of a national TB programme. RESULTS: The ICER was calculated at US$14.64 per disability-adjusted life-year, with an 82% probability of being cost-effective at a willingness-to-pay threshold equivalent to Indian gross domestic product per capita. CONCLUSIONS: LED FM is a cost-effective intervention for detecting TB cases in India at high-workload medical college settings.

LED fluorescence microscopy increases the detection of smear-positive pulmonary tuberculosis in medical colleges of India.

In July 2012, light-emitting diode fluorescence microscopy (LED-FM) replaced conventional light microscopy using Ziehl-Neelsen stain in the detection of sputum-positive pulmonary tuberculosis in 190 microscopy centres of medical colleges operating under India's Revised National Tuberculosis Control Programme. We compared the performance of LED-FM (July-December 2012) to that of conventional microscopy (July-December 2011) across 190 sites. Of 222 658 patients examined using conventional microscopy, 28 042 (12.6%) were smear-positive, while of 224 714 examined using LED-FM, 33 552 (14.9%) were smear-positive, an additional yield of 5251 cases after adjusting for the increase in patients examined. We recommend replacing conventional microscopy with LED-FM in high workload microscopy centres in India.

Dans 190 centres de microscopie des collèges médicaux travaillant dans le Programme Révisé de Lutte contre la Tuberculose en Inde, l'examen microscopique par fluorescence à diode émettrice de lumière (LED-FM) a remplacé l'examen microscopique à lumière conventionnelle utilisant la coloration de Ziehl-Neelsen pour la détection de la tuberculose pulmonaire à frottis positif. Nous avons comparé les performances du LED-FM entre juillet et décembre 2012 à celles de l'examen microscopique conventionnel (juillet­décembre 2011) dans l'ensemble des 190 sites. Les frottis ont été positifs chez 28 042 (12.6%) des 222 658 patients examinés par microscopie conventionnelle comparé à 33 552 (14.9%) des 224 714 patients examinés par LED-FM, un rendement supplémentaire de 5251 cas après ajustement pour l'augmentation du nombre de patients examinés. Nous recommandons le remplacement de l'examen microscopique conventionnel par le LED-FM en Inde dans les centres de microscopie dont la charge de travail est élevée.

En julio del 2012 la microscopia de fluorescencia con diodos electroluminescentes (LED-FM) reemplazó el sistema tradicional de microscopia de luz con tinción de Ziehl-Neelsen en la detección de casos de tuberculosis pulmonar con baciloscopia positiva en 190 centros de microscopia de las facultadas de medicina que funcionan en conformidad con el Programa Nacional Revisado de Control de la Tuberculosis de la India. En el presente artículo se comparó el rendimiento diagnóstico de este nuevo sistema de microscopia (entre julio y diciembre del 2012) con el rendimiento de la microscopia de luz (entre julio y diciembre del 2011) en 190 centros. De los 222 658 pacientes investigados mediante la microscopia de luz, 28 042 (12,6 %) presentaron baciloscopia positiva. De los 224 714 pacientes cuyas muestras se examinaron mediante la LED-FM, 33 552 (14,9 %) obtuvieron una baciloscopia positiva, lo cual corresponde a un incremento del rendimiento de 5251 casos, después de corregir con respecto al aumento del número de pacientes examinados. Se recomienda sustituir el sistema tradicional de microscopia de luz por la LED-FM en los centros con un alto volumen de trabajo en la India.