Diagnostik und Therapie von perianalen Fisteln

Perianale Fisteln können die Lebensqualität eines Patienten deutlich beeinträchtigen. Welche Diagnostik ist in der präoperativen Abklärung sinnvoll und welche Eckpfeiler sind im Behandlungsalgorithmus zu berücksichtigen? Gibt es einen «Goldstandard» für die operative Versorgung? Ein Überblick

Mesenchymale Stammzellen als neue Therapie bei Morbus-Crohn-Patienten mit Fisteln

Die Behandlung komplexer Morbus-Crohn-assoziierter perianaler Fisteln erfordert meist ein interdisziplinäres Vorgehen. Der medikamentösen Therapie wird zur initialen Behandlung sowie zum Remissionserhalt eine essenzielle Rolle zuteil. Bei einem unzureichenden Ansprechen oder bei Therapieversagen ist bei symptomatischen Fisteln ein chirurgisches Vorgehen der nächste Schritt. Aufgrund der Komplexität der Grunderkrankung und der krankheitsassoziierten Anatomie führt die operative Behandlung jedoch häufig zu Fistelrezidiven. Die Behandlung mit mesenchymalen Stammzellen etabliert sich als eine neue innovative Therapieoption bei Patienten mit perianalen Crohn-assoziierten komplexen Fisteln, die auf eine konventionelle Therapie oder auf Biologika nicht oder nur unzureichend angesprochen haben. Die aus dem Fettgewebe eines Spenders gewonnenen Stammzellen werden lokal injiziert und weisen immunmodulatorische und antiinflammatorische Eigenschaften auf, was zu einer besseren Fistelheilung führen soll. Diese ambulant durchführbare Operation stellt zudem eine sphinkterschonende Behandlungsmethode ohne größere Wundfläche dar. In der Literatur finden sich zum jetzigen Zeitpunkt vielversprechende Resultate, die bislang auch im eigenen Patientengut bestätigt werden können. = Le traitement de fistules périanales complexes associées à la maladie de Crohn exige en général une approche interdisciplinaire. Le traitement médicamenteux devient le traitement initial et en partie joue un rôle essentiel pour maintenir la rémission. Lors de réponse insuffisante ou d’échec du traitement de fistules causant des symptômes, la prochaine étape est une intervention chirurgicale. En raison de la complexité de la maladie de base et de l’anatomie impliquée, le traitement chirurgical entraîne souvent toutefois le développement de fistules récidivantes. Le traitement par des cellules souches mésenchymateuses s’établit en tant qu’option thérapeutique novatrice lors de non-réponse ou de réponse insuffisante au traitement conventionnel ou aux biomédicaments chez les patients souffrant de fistules périanales complexes dans le cadre de la maladie de Crohn. Les cellules souches prélevées dans le tissu adipeux d’un donneur sont injectées localement dans le site où leurs propriétés immunomodulatrices et anti-inflammatoires doivent permettre une meilleure guérison des fistules. Cette opération ambulatoire est en outre une méthode de traitement qui ménage le sphincter et ne cause pas une grande surface de plaie. La littérature décrit actuellement des résultats prometteurs que nous pouvons confirmer aussi chez notre propre patientèle jusqu’à présent. = Di solito il trattamento delle fistole perianali complesse associate alla malattia di Crohn richiede un approccio interdisciplinare. La terapia farmacologica svolge un ruolo essenziale nel trattamento iniziale e nel mantenimento della remissione. In caso di risposta inadeguata o di fallimento della terapia, il passo successivo è l’intervento chirurgico per il trattamento delle fistole sintomatiche. Tuttavia, a causa della complessità della malattia sottostante e dell’anatomia associata a questa patologia, il trattamento chirurgico porta spesso alla recidiva della fistola. Il trattamento con cellule staminali mesenchimali si sta affermando come nuova opzione terapeutica innovativa per i pazienti con fistole perianali complesse associate al morbo di Crohn che non hanno risposto, o che hanno risposto in modo inadeguato, alla terapia convenzionale o ai biofarmaci. Le cellule staminali ottenute dal tessuto adiposo di un donatore vengono iniettate localmente e presentano proprietà immunomodulanti e antinfiammatorie, che dovrebbero portare ad una migliore guarigione della fistola. Inoltre, questo intervento, che può essere eseguito in regime ambulatoriale, rappresenta un metodo di trattamento delicato per lo sfintere e limita l’ampiezza della ferita. La letteratura attualmente contiene risultati promettenti, che possono essere confermati dai nostri pazienti

Das Hämorrhoidalleiden – ein Therapiealgorithmus aus chirurgischer Sicht

Zusammenfassung. Der auf Höhe der Linea dentata gelegene Corpus cavernosum recti spielt eine tragende Rolle bei der Regulierung der Feinkontinenz. Kommt es zu einer pathologischen Vergrösserung des Corpus cavernosum verbunden mit Symptomen, spricht man von einem Hämorrhoidalleiden. Das Hämorrhoidalleiden ist eine Volkskrankheit mit einer Inzidenz von ca. 40 %, wobei die Rate an Selbsttherapien hoch ist. Im klinischen Alltag fällt der stadienadaptierten Therapie eine wichtige Rolle zu: Hämorrhoiden Grad I sind die Domäne der konservativen Therapie, Hämorrhoiden Grad II können in Abhängigkeit der Schwere der Symptome konservativ oder operativ angegangen werden. Hämorrhoiden Grad III und Grad IV sollten einer Operation zugeführt werden. </jats:p

Die Quälgeister: Fissuren, Fisteln und Co

Anorektale Beschwerden sind häufig, führen aber aus Angst oder Scham oft zu verzögerten Konsultationen. Die Ursachen anorektaler Beschwerden sind oft benigne und eine rasche Diagnosestellung mittels fundierter Anamnese und klinischer Untersuchung meist möglich. Eine Übersicht zu Diagnostik und Therapie der häufigsten Ursachen analer Schmerzen

Allogeneic expanded adipose-derived mesenchymal stem cell therapy for perianal fistulas in Crohn's disease: A case series

AIM Even with optimal medical and surgical therapy, perianal fistulas in patients with Crohn's disease (CD) have low closure rates. As a new therapeutic option, administration of local mesenchymal stem cells (MSCs) has proved to be an innovative option after failure of treatment with immunosuppressive or immunomodulatory agents. The aim of this work is to share our first experience with MSC administration and demonstrate its efficacy, safety and feasibility outside a clinical trial. METHOD A total of 11 CD patients with complex perianal fistulas with nonactive or mildly active luminal disease were treated with local injection of 120 million allogeneic adipose-derived stem cells at a tertiary hospital between February 2019 and June 2020. RESULTS The mean age of the 11 patients was 38.3 years, 72.7% were men and 27.2% were smokers. The mean duration of fistula manifestation was 7.8 years and, except for one patient (therapy with tacrolimus), all other patients had been treated with an antitumour necrosis factor agent without fistula healing in the last 6 months. After a mean follow-up time of 41.5 weeks, 72.7% (8/11) of patients had complete closure of their fistula and three patients failed MSC treatment. Complete fistula healing could be observed 4-6 weeks postoperatively in half of the patients, while 36.5% (4/11) of patients developed a perianal abscess which had to be drained. One patient experienced cytomegalovirus viraemia 2 weeks after MSC administration and one patient developed a testicular carcinoma 16 weeks after treatment. CONCLUSION This case series demonstrates that the efficacy and safety of darvadstrocel in the ADMIRE trial can be replicated outside a clinical trial. This new modality in the treatment of complex perianal fistulas appears to be a promising therapeutic option for a challenging patient population

Allogeneic expanded adipose‐derived mesenchymal stem cell therapy for perianal fistulas in Crohn’s disease: A case series

AIM Even with optimal medical and surgical therapy, perianal fistulas in patients with Crohn's disease (CD) have low closure rates. As a new therapeutic option, administration of local mesenchymal stem cells (MSCs) has proved to be an innovative option after failure of treatment with immunosuppressive or immunomodulatory agents. The aim of this work is to share our first experience with MSC administration and demonstrate its efficacy, safety and feasibility outside a clinical trial. METHOD A total of 11 CD patients with complex perianal fistulas with nonactive or mildly active luminal disease were treated with local injection of 120 million allogeneic adipose-derived stem cells at a tertiary hospital between February 2019 and June 2020. RESULTS The mean age of the 11 patients was 38.3 years, 72.7% were men and 27.2% were smokers. The mean duration of fistula manifestation was 7.8 years and, except for one patient (therapy with tacrolimus), all other patients had been treated with an antitumour necrosis factor agent without fistula healing in the last 6 months. After a mean follow-up time of 41.5 weeks, 72.7% (8/11) of patients had complete closure of their fistula and three patients failed MSC treatment. Complete fistula healing could be observed 4-6 weeks postoperatively in half of the patients, while 36.5% (4/11) of patients developed a perianal abscess which had to be drained. One patient experienced cytomegalovirus viraemia 2 weeks after MSC administration and one patient developed a testicular carcinoma 16 weeks after treatment. CONCLUSION This case series demonstrates that the efficacy and safety of darvadstrocel in the ADMIRE trial can be replicated outside a clinical trial. This new modality in the treatment of complex perianal fistulas appears to be a promising therapeutic option for a challenging patient population

Outcome of Open Inguinal Hernia Repair Using Sutureless Self-Gripping Mesh – a Retrospective Single Cohort Study

Background: Neurological disturbances after open inguinal hernia repair affect approximately one in ten patients. Sutureless, self-gripping meshes were developed with the aim of reducing postoperative neurological disturbances or neuralgia. This study assessed short- and long-term outcomes after open inguinal hernia repair using a self-gripping light-weight mesh in a peripheral teaching hospital. Methods: Patients with uni- or bilateral inguinal hernia were included in this study. Open inguinal hernia repair was performed according to the Lichtenstein technique with a self-gripping, lightweight macroporous mesh. Postoperative follow-up was at 6 weeks after surgery and any long-term complications or recurrences were recorded up to 5 years postoperatively. Results: The median follow up time for all patients was 5&ndash;6 years and the median operation time was 40.0 minutes (inter quartile range 25.0&ndash;55.8). Of the 162 included patients, the mean numeric rating scale for pain (0 = no pain, 10 = excruciating pain) before hospital discharge was 2.7 (standard deviation [SD] 2.6) and 1.1 (SD 1.1) at 6 weeks postoperatively. The overall incidence of neurological disturbances at 6 weeks postoperatively was 11% when surgery was performed by the chief of surgery and 40% when it was performed by a senior consultant, 49% by chief-residents and 47% by supervised residents (p = 0.005). Patients with neurological disturbances were younger than asymptomatic patients (age 50, SD 15 vs 62, SD 17, p &lt;0.001). The 1-, 3- and 5-year recurrence rates were 1%, 2% and 3%, respectively. Conclusions: This study shows that open inguinal hernia repair using a self-gripping mesh is feasible, with a short operation time and low hernia recurrence rates in a peripheral teaching hospital. However, significant differences in neurological disturbances dependent on the surgeons experience were identified. Especially younger patients should be operated on by an experienced surgeon to reduce neurological disturbances and neuralgia

Colorectal Cancer of the Young Displays Distinct Features of Aggressive Tumor Biology: A Single-Center Cohort Study

Background: In recent years, a decrease in incidence and mortality of colorectal cancer (CRC) has been observed in developed nations, presumably through public disease awareness and increased screening efforts. However, a rising incidence of CRC in young patients below the age of 50 years has been reported in several studies. Aim: To study tumor biology in CRC patients below 50 years of age. Methods: All patients with CRC were prospectively enrolled in our single-center oncologic database from January 2013 to December 2018 and were grouped and analyzed according to age (≥ 50 and < 50 years). Clinical as well as histopathological features were analyzed and compared. The study was approved by the local Ethics Committee. Fisher's exact test or t-test was used to test for differences between the groups, as appropriate. All statistical analysis was performed with IBM SPSS software Version 25 (SPSS Inc, Armonk, NY, United States) and with R-Studio using R Version 3.4.1 (RStudio, Boston, MA, United States). Results: Seventeen percent of the 411 patients were younger than 50 years. Young patients were more often diagnosed with locally advanced T4-tumors and lymph node metastases (36.6% and 62% vs 17.7% and 42%; P < 0.01). In addition, a higher frequency of poorly differentiated (G3) tumors (40% vs 22.4% P < 0.05) was observed. More than every second patient below 40 years of age (51.8%) had distant metastases at diagnosis with a significant higher rate ring of signet cell differentiation compared to patients ≥ 50 years (14.8%, P < 0.05). Mutational status (KRAS, NRAS, BRAF, MSI) as well as selected behavioral risk factors showed no significant differences. Conclusion: Distinct histopathologic features of increased biologic aggressiveness are found in patients with CRC of young-onset. Those patients present more frequently with more advanced tumor stages compared to older patients. Features of aggressive tumor biology underscore the need for earlier uptake of routine screening measures. Keywords: Colorectal cancer; Colorectal cancer screening; Colorectal surgery; Tumor aggressiveness; Tumor biology; Young-onset colorectal cancer

Insurance status does not affect short-term outcomes after oncological colorectal surgery in Europe, but influences the use of minimally invasive techniques: a propensity score-matched analysis

Background and Purpose Controversy exists whether surgical treatment is influenced by insurance status. American studies suggest higher morbidity and decreased survival in uninsured patients with colorectal cancer (CRC). It remains elusive, however, whether these findings apply to European countries with mandatory, government-driven insurance systems. We aimed to analyze whether operative techniques, quality of surgery, and complication rates differ among patients covered by statutory (SI) versus private (PI) healthcare insurance. Methods Based on a prospective national surgical quality database, patients undergoing elective resection for CRC during 2007–2015 were identified. A propensity score match of eligible patients with SI and PI yielded 765 patients per group. Results Hierarchical status of the operating surgeon differed substantially (p = 0.001): junior surgeons operated on > 50% of patients with SI, whereas over 80% of patients with PI were operated by senior surgeons. Minimally invasive techniques were used more frequently in patients with PI (p = 0.001) and patients with SI undergoing colonic resection showed an increased conversion rate (OR 2.44). Median duration of surgery (p = 0.001) and blood loss (p = 0.002) were higher in patients with SI; however, length of hospital stay was equal. Neither the rate of positive resection margins nor the number of resected lymph nodes differed among groups. Complications and mortality occurred with similar frequencies for patients undergoing colon (p = 0.140) and rectal (p = 0.335) resection