Nadia Fathallah

Guidelines for the treatment of hemorrhoids (short report).

Hemorrhoids are a common medical problem that is often considered as benign. The French Society of Colo-Proctology (Société nationale française de colo-proctologie [SNFCP]) recently revised its recommendations for the management of hemorrhoids (last issued in 2001), based on the literature and consensual expert opinion. We present a short report of these recommendations. Briefly, medical treatment, including dietary fiber, should always be proposed in first intention and instrumental treatment only if medical treatment fails, except in grade ≥III prolapse. Surgery should be the last resort, and the patient well informed of the surgical alternatives, including the possibility of elective ambulatory surgery, if appropriate. Postoperative pain should be prevented by the systematic implementation of a pudendal block and multimodal use of analgesics.

Horseshoe tract of anal fistula: bad luck or an avoidable extension? Lessons from 82 cases

Aim  The aim of this study was to analyse the characteristics of horseshoe tract formation in anal fistula.

Comparison of anal cancer screening strategies including standard anoscopy, anal cytology, and HPV genotyping in HIV-positive men who have sex with men

BackgroundThere is no consensus on screening strategy of high-grade intraepithelial neoplasia (HGAIN). Guidelines range from clinical examination with digital anorectal examination followed by standard anoscopy (SA), to anal cytology (Pap)+/− HPV genotyping. We compared screening strategy yields based on Pap, SA, and HPV-16 genotyping alone or in combination in HIV-MSM.MethodsPap, SA, and HPV-16 genotyping were performed in all HIV-MSM attending a first anal cancer screening consultation in Paris, France. High-resolution anoscopy, the gold standard to detect HGAIN, was performed in the case of HPV-16 positivity or abnormal cytology. Yield was defined as the number of patients with HGAIN relative to the total number of patients screened.ResultsOn 212 patients, the complete strategy (SA + Pap + HPV genotyping) yield (12.7%) was significantly higher than that of SA (3.3%, p < 0.001) and HPV-16 alone (6.6%, p < 0.05). Although none of the other strategies were significantly different from the complete strategy, Pap + HPV-16 and Pap + SA had closer yields (about 11%), with OR = 0.83 (95% CI [0.44;1.57]) and 0.87 (95% CI [0.46;1.64]), respectively.ConclusionsPap combined with HPV-16 genotyping or SA tended towards higher yields compared to Pap alone, and closer to that of the complete strategy.

Long-term Outcome of a Fissurectomy: A Prospective Single-Arm Study of 50 Operations out of 349 Initial Patients

Purpose The surgical standard of care for patients with chronic anal fissure is still disputed. We aimed to assess the natural course of idiopathic anal fissure and the long-term outcome of a fissurectomy as a surgical treatment. Methods All consecutive patients referred to a single expert practitioner in a tertiary centre were primarily included. A fissurectomy was proposed in cases of refractory symptoms after 4 to 6 weeks of standard medical management. Only patients with idiopathic and noninfected anal fissures were included in this second subsample to undergo surgery. Conventional postoperative management was prescribed for all patients who had undergone surgery. The main outcome measures were the success rate (defined as a combination of wound healing and relief of pain) and postoperative anal continence. Results Three hundred forty-nine patients were primarily recruited. Fifty patients finally underwent surgery for an idiopathic and noninfected fissure. Among them, 47 (94%) were cured at the end of primary follow-up, and 44 of the 47 (93.6%) could be confirmed as being sustainably cured in the longer-term follow-up. The mean time of complete healing was 10.3 weeks (range, 5.7–36.4 weeks). All patients were free of pain at weeks 42. The continence score after surgery was not statistically different from the preoperative score. Conclusion A fissurectomy for the treatment of patients with an idiopathic noninfected fissure is associated with rapid pain relief and a high success rate even though complete healing may often be delayed. Moreover, it appears to have no adverse effect on continence.

Elaboration and validation of Crohn’s disease anoperineal lesions consensual definitions

AIM To establish consensual definitions of anoperineal lesions of Crohn’s (APLOC) disease and assess interobserver agreement on their diagnosis between experts. METHODS A database of digitally recorded pictures of APLOC was examined by a coordinating group who selected two series of 20 pictures illustrating the various aspects of APLOC. A reading group comprised: eight experts from the Société Nationale Française de Colo Proctologie group of study and research in proctology and one academic dermatologist. All members of the coordinating and reading groups participated in dedicated meetings. The coordinating group initially conducted a literature review to analyse verbatim descriptions used to evaluate APLOC. The study included two phases: establishment of consensual definitions using a formal consensus method and later assessment of interobserver agreement on the diagnosis of APLOC using photos of APLOC, a standardised questionnaire and Fleiss’s kappa test or descriptive statistics. RESULTS Terms used in literature to evaluate visible APLOC did not include precise definitions or reference to definitions. Most of the expert reports on the first set of photos agreed with the main diagnosis but their verbatim reporting contained substantial variation. The definitions of ulceration (entity, depth, extension), anal skin tags (entity, inflammatory activity, ulcerated aspect), fistula (complexity, quality of drainage, inflammatory activity of external openings), perianal skin lesions (abscess, papules, edema, erythema) and anoperineal scars were validated. For fistulae, they decided to follow the American Gastroenterology Association’s guidelines definitions. The diagnosis of ulceration (κ = 0.70), fistulae (κ = 0.75), inflammatory activity of external fistula openings (86.6% agreement), abscesses (84.6% agreement) and erythema (100% agreement) achieved a substantial degree of interobserver reproducibility. CONCLUSION This study constructed consensual definitions of APLOC and their characteristics and showed that experts have a fair level of interobserver agreement when using most of the definitions.

Main Advantages of Dearterialization of Haemorrhoids and Mucopexy

Haemorrhoidal dearterialization with mucopexy is a minimally invasive method of treating haemorrhoidal disease which is effective for reducing the symptoms of haemorrhoids and improving quality of life. Moreover, it has the obvious advantages of preservation of the anatomy and physiology of the anal canal, absence of external wounds, better tolerance, and a less painful postoperative period, especially compared with haemorrhoidectomy, but also probably compared with stapled haemorrhoidopexy. It is therefore usually provided on a day surgery basis and scores better in terms of general activity and ability to return to social and/or work activities. The procedure is also safe, with low postoperative morbidity and few complications, which are usually minor. There is a probable higher long-term risk of recurrence of prolapse and/or bleeding after haemorrhoidal dearterialization with mucopexy, particularly in comparison with haemorrhoidectomy, but it is not a real problem in a time when patients often prefer a risk-free procedure and a short-term benefit to a potential long-term disadvantage.

Reconnaître et traiter une rectite infectieuse

La rectite est un probleme courant en gastroenterologie, elle est frequemment associee aux maladies inflammatoires de l’intestin (rectocolite hemorragique). Cependant, face a une rectite, de nombreuses causes doivent etre cherchees, notamment une origine infectieuse, avant de conclure a une rectite inflammatoire. Les maladies veneriennes sont a evoquer en priorite chez les hommes ayant des rapports sexuels avec les hommes (HSH), infectes par le VIH. Ce d’autant que leur incidence est en augmentation ces deux dernieres decennies. Les autres pathogenes frequemment responsable de colite infectieuse, tels que Clostridium difficile, cytomegalovirus, amibiase, Campylobacter, Shigella, etc., peuvent etre responsable d’une atteinte rectale isolee ou d’une rectocolite.Les symptomes sont le plus souvent non specifiques, avec des presentations cliniques tres variees. Il existe egalement des formes pauci- ou asymptomatiques.L’interrogatoire avec le contexte clinique sont indispensables pour etablir un diagnostic. Ils seront soutenus par l’examen physique, les prelevements infectieux et parfois la realisation d’une endoscopie avec prelevements histologiques.Devant une rectite aigue sans cause evidente, un traitement antibiotique empirique doit etre initie apres la realisation des prelevements infectieux.

Anal manifestation of sarcoidosis

La Presse Medicale - In Press.Proof corrected by the author Available online since samedi 5 decembre 2015

La neuromodulation sacrée dans l’incontinence fécale : le changement, c’est maintenant…

La neuromodulation sacree, tout d’abord evaluee dans les troubles fonctionnels urinaires obstructifs et irritatifs, est remboursee depuis 2009 en France dans la prise en charge de l’incontinence fecale severe en echec des mesures therapeutiques de premiere intention. Elle consiste a stimuler les racines nerveuses sacrees de la region pelvi-perineale via une electrode introduite par voie percutanee dans un trou sacre et reliee a un stimulateur externe implante en sous-cutane. L’indication de la neuromodulation doit etre posee dans le cadre d’un staff multidisciplinaire apres un bilan complet prealable incluant un calendrier des selles, un score d’incontinence anale, une endosonographie, une manometrie ano-rectale, voire un bilan uro-dynamique en cas de troubles urinaires associes et/ou une imagerie pelvienne dynamique en cas de suspicion de trouble de la statique rectale. Les resultats de cette nouvelle technique sont stables depuis les premieres publications et on peut estimer qu’environ 50 % des patients eligibles au depart en beneficieront. Le mode d’action de ce traitement reste obscur, et malgre les nombreuses publications, aucun facteur predictif consensuel d’efficacite n’a pu etre identifie. Son effet ne se limite pas a stimuler un sphincter anatomiquement intact mais fonctionnellement defaillant. Elle agit egalement sur la motricite colique, sur la reponse sensitivo-motrice du rectum a la distension et sur l’integration centrale corticale de la perception ano-rectale. Ceci explique les extensions recentes des indications a l’incontinence fecale avec defect sphincterien et aux suites de resection rectale ou recto-sigmoidienne. Le suivi post-implantation est une etape essentielle et tres specialisee. Elle consiste a verifier le circuit, ajuster si besoin les reglages encore tres empiriques du stimulateur et a depister les complications.

Une fistule anale désespérante

Une patiente de 42 ans consulte au service d’accueil des urgences pour des douleurs anales continues, insomniantes et apparues 48 heures auparavant. Comme principal antecedent, elle est diabetique de type 2 non insulino-dependante. Elle a par ailleurs accouche a trois reprises par voie basse sans complication notable. L’examen proctologique complet est impossible en raison de la douleur. En effet, la marge anale semble normale (figure 1) mais [...]