Selective use of cystogram following segmental bowel resection in patients with enterovesical fistula.

AIM: Patients undergoing resectional surgery for enterovesical fistulas generally have an indwelling urinary catheter postoperatively to prevent a recurrent fistula. The aim of this study was to assess the role of a cystogram as part of the postoperative follow-up of such surgery, when it should be performed and for how long the bladder should be drained after surgery. METHOD: A retrospective single-centre study of all patients undergoing ileocaecal or sigmoid resection for surgery for enterovesical fistula with the primary end-point of recurrent urinary fistula. RESULTS: Between 1994 and 2015, 46 patients (23 male; mean age 55.4 ± 18.3 years) underwent surgery [23 (50%) for diverticular disease, 16 (34.8%) for Crohn's disease, five (10.9%) for malignancy and two (4.3%) for previous radiotherapy]. Closure of the bladder fistula was by simple suture in 21 (46%) patients and with an omental pedicle in 16 (36%). Overall median duration of urinary drainage was 10.5 [interquartile range (IQR): 7.3-14.0] days. A postoperative cystogram was performed in 26 (57%) patients after a median of 10.0 (IQR: 8.0-13.0) days. This demonstrated persistent leakage in three patients, of whom two had undergone surgical closure of the bladder. This group required prolonged drainage (7, 19 and 40 days). One patient who had undergone surgery following radiotherapy for urothelial cancer developed a recurrent malignant fistula at 9 months, even though the postoperative cystogram had been negative. CONCLUSION: This study suggests that a routine postoperative cystogram after surgery for enterovesical fistula may not be necessary for all patients if the bladder is drained for 1-2 weeks after bowel resection.

Single port laparoscopic ileocaecal resection for Crohn's disease: a multicentre comparison with multi-port laparoscopy.

AIM: Single port (SP) ileocaecal resection (ICR) is an established technique but there are no large studies comparing SP and multi-port (MP) laparoscopic surgery in Crohn's disease (CD). The aim of this study was to compare postoperative pain scores and analgesia requirements after SP and MP laparoscopic ICR for CD. METHOD: This was a retrospective study of patients undergoing SP or MP ICR for CD in three tertiary referral centres from February 1999 to October 2014. Baseline characteristics (age, sex, body mass index and indication for surgery) were compared. Primary end-points were postoperative pain scores, analgesia requirements and short-term postoperative outcomes. RESULTS: SP ICR (n = 101) and MP ICR (n = 156) patients were included in the study. Visual analogue scale scores were significantly lower after SP ICR on postoperative day 1 (P = 0.016) and day 2 (P = 0.04). Analgesia requirements were significantly reduced on postoperative day 2 in the SP group compared with the MP group (P = 0.007). Duration of surgery, conversion to open surgery and stoma rates were comparable between the two groups. Surgery was more complex in terms of additional procedures when MP was adopted (P = 0.001). There were no differences in postoperative complication rates, postoperative food intake, length of stay and readmissions. CONCLUSION: These data suggest that in comparison to standard laparoscopic surgery SP ICR might be less painful and patients might require less opioid analgesia.

The association between intensified medical treatment, time to surgery and ileocolic specimen length in Crohn's disease.

AIM: During the last decade, treatment protocols have changed for patients with ileocolic Crohn's disease. Anti-tumour necrosis factor (anti-TNF) has become part of standard medical treatment, usually in a step-up approach. The aim was to analyse if improved medical treatment has resulted in more limited ileocolic resections and a longer interval between diagnosis and surgery. METHOD: Patients undergoing ileocolic resection for Crohn's disease were included (1999-2014). Patient characteristics were compared to the results of a population-based study (between 2004 and 2010) previously performed in the catchment area of the present tertiary referral centre. Time trends were analysed using the Cochrane-Armitage trend, Spearman's correlation coefficient and linear regression. RESULTS: In total, 195 patients undergoing ileocolic resection were included. Patient characteristics were not significantly different from the background cohort, confirming a representative study group. Sixty-three patients were men (32.3%, median age at surgery 30.0 years, interquartile range 23.0-40.0). Anti-TNF and immunomodulator use prior to surgery increased significantly during the study period (χ2  = 49.1, P < 0.001). Over the years, a significant increase in time from diagnosis to operation was found (median 39.0 months, interquartile range 12.0-86.0, rho 0.175, P = 0.014). The length of the resected ileum did not change significantly (median 20.0 cm, interquartile range 12.0-30.0, rho -0.107, P = 0.143). The number of fistulas or postoperative complications that needed re-intervention was not significantly different between the groups with or without anti-TNF. CONCLUSION: This study demonstrated that over time patients with ileocolic Crohn's disease who eventually underwent ileocolic resection have been treated more intensively medically; however, this did not result in reduced specimen size.

Treatment of perianal fistula in Crohn's disease: a systematic review and meta-analysis comparing seton drainage and anti-tumour necrosis factor treatment.

AIM: The introduction of anti-tumour necrosis factor (anti-TNF; infliximab and adalimumab) has changed the management of Crohn's perianal fistula from almost exclusively surgical treatment to one with a much larger emphasis on medical therapy. The aim of this systematic review was to provide an overview of the success rates of setons and anti-TNF for Crohn's perianal fistula. METHOD: Studies evaluating the effect of setons and anti-TNF on Crohn's perianal fistula were included. Studies assessing perianal fistula in children, rectovaginal and rectourinary fistulae were excluded. The primary end-point was the fistula closure rate. Partial closure and recurrence rates were secondary end-points. RESULTS: Ten studies on seton drainage were included (n = 305). Complete closure varied from 13.6% to 100% and recurrence from 0% to 83.3%. In 34 anti-TNF studies (n = 1449), complete closure varied from 16.7% and 93% (partial closure 8.0-91.2%) and recurrence from 8.0% to 40.9%. Four randomized controlled trials (n = 1028) comparing anti-TNF with placebo showed no significant difference in complete or partial closure in meta-analysis (risk difference 0.12, 95% CI -0.06 to 0.30 and 0.09, 95% CI -0.23 to 0.41, respectively). Subgroup analysis (n = 241) showed a significant advantage for complete fistula closure with anti-TNF in two trials with follow-up > 4 weeks (46% vs 13%, P = 0.003 and 30% vs 13%, P = 0.03). Of four included cohort studies, two revealed a significant difference in response in favour of combined treatment (P = 0.001 and P = 0.014). CONCLUSION: Closure and recurrence rates after seton drainage as well as anti-TNF vary widely. Despite a large number of studies, no conclusions can be drawn regarding the preferred strategy. However, combination therapy with (temporary) seton drainage, immunomodulators and anti-TNF may be beneficial in achieving perianal fistula closure.

Systematic review of evidence and consensus on perianal fistula: an analysis of national and international guidelines.

AIM: Treatment of perianal fistula has evolved with the introduction of new techniques and biologicals in Crohn's disease (CD). Several guidelines are available worldwide, but many recommendations are controversial or lack high-quality evidence. The aim of this work was to provide an overview of the current available national and international guidelines for perianal fistula and to analyse areas of consensus and areas of conflicting recommendations, thereby identifying topics and questions for future research. METHOD: MEDLINE, EMBASE and PubMed were systematically searched for guidelines on perianal fistula. Inclusion was limited to papers in English less than 10 years old. The included topics were classified as having consensus (unanimous recommendations in at least two-thirds of the guidelines) or controversy (fewer than three guidelines commenting on the topic or no consensus) between guidelines. The highest level of evidence was scored as sufficient (level 3a or higher of the Oxford Centre for Evidence-based Medicine Levels of Evidence 2009, http://www.cebm.net/oxford-centre-evidence-based-medicine-levels-evidence-march-2009/) or insufficient. RESULTS: Twelve guidelines were included and topics with recommendations were compared. Overall, consensus was present in 15 topics, whereas six topics were rated as controversial. Evidence levels varied from strong to lack of evidence. CONCLUSION: Evidence on the diagnosis and treatment of perianal fistulae (cryptoglandular or related to CD) ranged from nonexistent to strong, regardless of consensus. The most relevant research questions were identified and proposed as topics for future research.