Search

Aim The study aimed to quantify incontinence before and after laparoscopic rectopexy in patients suffering from rectal prolapse. Method Eighty-five patients underwent laparoscopic rectopexy to treat rectal prolapse between 2003 and 2009. Symptomatic and functional data were collected prospectively before and after surgery by self-administered questionnaires including the Cleveland Clinic Fecal Incontinence Score (CCIS) and constipation, gastrointestinal quality of life and urinary incontinence questionnaires. Incontinence was considered to be present when the CCIS remained at ≥ 5 after surgery. Results After a mean follow-up period of 36 months after surgery, 83% of the patients reported good to excellent results. Continence was improved in 58 (68%), with a significant decrease in the continence score (−3.4 ± 5.8, P = 0.001). However, 50 (58.9%) patients remained incontinent: 47 (55%) reported urge incontinence and 27 (32%) had passive leakage. Incontinence for liquid stool, incontinence for solid stool and the need for protection was seen in 43 (51%), 35 (41%) and 43 (51%) patients. Manometry, defaecography and ultrasonography were not associated with any improvement. In contrast, the patients’ average age (60.2 ± 15.8 vs 46.9 ± 15.5 years; P = 0.003), symptom duration before surgery (58.1 ± 70.1 vs 29.5 ± 33.3 months; P = 0.011), preoperative urinary incontinence score (10.7 ± 10.8 vs 4.2 ± 5.7; P = 0.0131) and faecal incontinence score (12.9 ± 4.9 vs 7.1 ± 6; P

The puborectoplasty in fecal incontinence (FI) has been described through retropubic approach. Here, we describe a puborectal sling placement through transobturator approach with a device used for vaginal vault prolapse and report long-term outcome at 5 years. Six women with FI for whom usual treatments (including sacral nerve stimulation) have failed were enrolled in a pilot study. Cleveland Clinic Incontinence Score (CCIS) and FI quality of life (FIQL) were used to evaluate results. The median CCIS was significantly improved at 12 months (18.5 [15–20] vs 7.5 [4–20] in postoperative assessment; p = 0.037). The median FIQL was improved at 12 months (6.05 [5.6–7] vs 10.2 [5.6–12.5]; p = 0.0542). No adverse event was recorded except the distension of the device in one patient. Finally, at 5 years, 3 patients were improved, 1 had recurrence of FI symptoms (at 24 months) and 2 had no change. This technique is a minimally invasive surgical treatment and constitutes a new therapeutic option for FI in case of failure of conventional treatment.

Patients with inflammatory bowel disease [IBD] may develop, similarly to individuals from general population, rare cases of human papilloma virus [HPV]-related anal canal squamous cell carcinoma [SCC] and intra-epithelial precursor lesions, as well as very rare cases of anal canal adenocarcinoma. Patients with chronic perianal Crohn's disease [CD] are at substantial risk of developing SCC or adenocarcinoma from the fistula-lining epithelium, as well as SCC or adenocarcinoma arising from chronic anorectal ulcerations or strictures. Based on this lesion stratification, we provide in this review tailored incidence estimates and we propose an IBD-specific classification of all types of anal neoplasia that may occur in patients with IBD. After reviewing putative carcinogenesis of all types of neoplasia, we conclude that HPV vaccination could reduce the incidence of HPV-related lesions, although an anal screening programme related to these lesions is not mandatory on the sole basis of IBD. By contrast, we point out that all patients with chronic perianal CD should be explored in depth, including biopsies under anaesthesia and fistula curettage when necessary, in case of any change in anal symptoms ─in particular new, increasing, unexplained pain. Finally, we conclude that there is an urgent need for elaborating and evaluating surveillance algorithms in patients with chronic perianal CD, in order to avoid cancers with late diagnosis and poor prognosis.

Background 3D-high definition anorectal manometry (3DARM) may aid the diagnosis of functional anorectal disorders, but data comparing asymptomatic and symptomatic subjects are scarce. We aimed to describe 3DARM values in asymptomatic volunteers and those with fecal incontinence (FI) or chronic constipation (CC), and identify which variables differentiate best these groups. Methods Asymptomatic subjects were stratified by sex, age, and parity. Those with FI or CC were included according to anorectal symptom questionnaires. Endoanal ultrasound examination and 3DARM were performed the same day. Anal pressures were analyzed at rest, during voluntary squeeze, and during push maneuver, and compared between the 3 groups. Anal pressure defects were defined and compared to ultrasound defects. Key Results A total of 126 subjects (113 female, mean age 52 years, range 18-83) were included; 36 asymptomatic, 38 FI, 42 CC. Anal resting and squeeze pressures, and rectal sensitivity values were lower in FI women than in the other groups. Typical anal sphincter asymmetry during squeezing was less frequently observed in FI women. A dyssynergic pattern during push maneuver was found in 70% of asymptomatic subjects, and with a similar frequency in the 2 symptomatic groups. There was slight concordance between 3D-pressure defects and ultrasound defects. Conclusions & Inferences 3D anal pressures in asymptomatic women were significantly lower than in men, and in FI compared to asymptomatic women. The classical dyssynergic pattern during push maneuver was found as frequently in asymptomatic and symptomatic patients. Further studies should try to identify 3DARM variables that could reliably identify dyssynergic defecation.

International audience; BackgroundObesity is an emerging risk factor for fecal incontinence (FI). The aim of this study was to characterize pathophysiologic mechanisms of FI in obese patients compared with non-obese patients in a prospective case-matched study. MethodsThe general characteristics and data of the anorectal manometry and endosonography of patients who were evaluated for FI at a single institution from 2005 to 2015 were prospectively assessed. Fecal incontinence was defined by a Cleveland Clinic Incontinence Score (CCIS) >4. Obesity was defined by a body mass index 30kg/m(2). Obese patients were case-matched with two age- and sex-matched non-obese patients. Key ResultsA total of 201 patients were included (67 obese matched with 134 non-obese). The CCIS, Knowles-Eccersley-Scott Symptom Constipation Score and quality of life score were comparable between obese and non-obese patients with FI. Factors significantly associated with obesity in FI patients were cholecystectomy (odds ratio [OR]=3.45 [1.19-10.32], P=.0230), irritable bowel syndrome - diarrhea (OR=2.94 [1.22-7.19], P=.0158), upper part of the anal canal resting pressure 22mmHg (OR=3.45 [1.45-8.76], P=.0045), maximum rectal tolerable volume 240mL (OR=3.14 [1.34-7.54], P=.0082), and abdominal pressure 28mmHg (OR=2.75 [1.13-7.33], P=.0248) by multivariate analysis. Conclusions & InferencesObese patients with FI had a comparable severity of FI to that of non-obese patients with FI. Regarding obesity in patients with FI, physicians should focus on stool consistency.

Hemorrhoids are a common medical problem that is often considered as benign. The French Society of Colo-Proctology (Societe nationale francaise 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.

International audience; Background: An association between acid gastro-oesophageal reflux disease (GERD) and Jackhammer oesophagus has been suggested. Aim: To assess the prevalence and characteristics of acid-GERD in Jackhammer oesophagus and the efficacy of proton pump inhibitors. Methods: Data and outcomes of patients with Jackhammer oesophagus were assessed. Two groups were compared: (i) GERD, defined by endoscopic oesophagitis or by an increase in acid exposure time or by an acid-hypersensitive oesophagus and (ii) non-GERD defined by normal oesophageal acid exposure without acid-hypersensitive oesophagus. Results: Among the 1994 high-resolution manometries performed, 44 Jackhammer oesophagus (2.2%) were included (sex ratio M/F: 19/25; median age: 66 [61-75] years). Nineteen patients (43.2%) had GERD, 16 (36.4%) had no GERD and 9 patients (20.4%) were undetermined. Dysphagia was the predominant symptom (37/43 (86%)). After a median follow-up of 25.3 months [9.6-31.4], dysphagia was improved in 22/36 (61.1%) patients. Dysphagia improvement as well as other symptoms improvement was not associated with GERD status or proton-pump inhibitors use. Conclusion: The prevalence of GERD is high among patients with Jackhammer oesophagus. The rates of symptom improvement in Jackhammer oesophagus were high regardless of the use of proton-pump inhibitors treatment or of the presence of GERD. (C) 2016 Editrice Gastroenterologica Italiana S.r.l. Published by Elsevier Ltd. All rights reserved.

International audience; Cronkhite-Canada syndrome (CCS) is a rare, non-familial disorder characterized by multiple gastrointestinal polyps and ectodermal changes. This article presents the first small-bowel video sequences of CCS using video capsule endoscopy (VCE).

International audience; Background: Ileal pouch anal anastomosis (IPAA) may alter sexuality and fertility in women. The laparoscopic approach seems to reduce infertility rates in women after IPAA. However, the impact of hand-sewn versus stapled IPAA on sexuality and fertility has never been assessed in patients with ulcerative colitis (UC). The objective of this study was to analyse the impact of the IPAA technique on sexuality and fertility in UC. Methods: All UC patients who underwent an IPAA between May 1996 and April 2011 were included. The patients answered mailed questionnaires including sexuality validated questionnaires and fertility questionnaires. The risk factors of sexual dysfunction were explored. Results: A total of 135 patients were included. Eighty-eight patients (65%) answered the questionnaires. Their mean age and follow-up were 37.2 ± 13.4 years and 109.7 ± 57.5 months. The rates of female and male sexual dysfunction were 50% and 29%, respectively. Intestinal transit disorders were identified as risk factors in both men and women, and anastomotic stricture in women sexual dysfunction, in univariate analyses. The IPAA technique did not impact sexual function in women but there was a trend for less erectile dysfunction following hand-sewn IPAA (16.7% vs 44.4%). The fertility rate was 47% in women and 75% in men, with a trend for a better fertility in women after hand-sewn IPAA (p=0.07). Conclusion In this preliminary study, the hand-sewn or stapled IPAA technique did not impact the sexuality or fertility outcomes of UC patients, but there was a trend for better female fertility and male erectile function following hand-sewn IPAA. Intestinal transit disorders contributed to male and female sexual dysfunction after IPAA.

International audience; Background:The incidences of high-grade anal intraepithelial neoplasia (HSIL) and superficially invasive squamous cell carcinomas (SISCCA) related to human papillomavirus (HPV) have increased. These lesions can progress to invasive anal cancer. The aim of the study was to assess the clinical outcome with a special focus on the healing rate.Methods: Forty-six consecutive patients (M/F:35/11; HIV+:30) with histologically proven HSIL lesions (N = 41) or SISCCA (N = 5) were enrolled in a follow-up survey.Results Of the 46 patients, 40 were treated by excision (n = 9), electrocoagulation (n = 13), topical treatment (n = 2) or combined strategies (n = 16). After a mean follow-up of 35 (27-43) months, only one patient progressed to an invasive cancer. Regression and healing were observed in 14(30%) and 15(33%) patients. The cumulative probabilities of healing were 14%, 49% and 74% after 1, 3 and 5 years. None of the current smokers healed. Heterosexual patients, sexual abstinence, patients older than 44 years old, non-smokers, patients without any past history of condyloma and those with less than 2 high-risk HPVs at baseline were more likely to heal.Conclusion Progression to invasive cancer is a rare event. Large, prospective cohort studies are needed to plan coherent strategies for both follow-up and treatment

Aim The aim of this study was to assess patient dissatisfaction and functional symptoms following haemorrhoid surgery, aspects of which are seldom covered in other published series. Method A self-administered questionnaire was mailed to 359 consecutive patients (prospective database; 198 men, 161 women; median follow up, 59 [1–120] months) who underwent either Milligan-Morgan haemorrhoidectomy (n = 205) or stapled haemorrhoidopexy (n = 154). Results The response rate was 72%; 2.4% of patients had no opinion, 13.6% were dissatisfied, 33.0% were satisfied, and 51.0% were very satisfied with the treatment. Dissatisfied patients were more likely to be women and more likely to have a long history of constipation and irritable bowel syndrome. The duration of surgery and the rates of pre- and postoperative complications did not differ between groups. Residual bleeding (49%vs 32%), prolapse (67%vs 31%) and pain (91%vs 55%) occurred more frequently in the dissatisfied group compared with the satisfied group (P

Nonfistulizing perianal lesions, including ulcerations, strictures, and anal carcinoma, are frequently observed in Crohn's disease. Their clinical course remains poorly known. The management of these lesions is difficult because none of the treatments used is evidence-based. Ulcerations may be symptomatic in up to 85% of patients. Most ulcerations heal spontaneously but may also progress to anal stenosis or fistula/abscess. Topical treatments only improve symptoms, while complete healing can occur in patients with perianal ulcerations receiving infliximab therapy. Half of all patients with anal strictures will require permanent fecal diversion. Dilatation for symptomatic strictures should be performed on a highly selective basis in the absence of active rectal disease in order to avoid infectious complications. Anorectal strictures associated with rectal lesions should first be managed with medical therapy. Skin tags are usually painless and may hide other perianal lesions. Anal cancer is uncommon. Its treatment is similar to that recommended for anal cancer occurring in non-Crohn's disease patients. After reviewing the classification, clinical features, and epidemiology of each type of nonfistulizing perianal lesion (ulceration, stricture, skin tags, and anal cancer), we discuss the efficacy of medical treatment and surgery. This review article may help physicians in decision-making when managing potentially disabling lesions.

Background & Aims Little is known about the magnitude of the risk of anal and rectal cancer in patients with anal and/or perineal Crohn's disease. We aimed to assess the risk of anal and rectal cancer in patients with Crohn's perianal disease followed up in the Cancers Et Surrisque Associe aux Maladies Inflammatoires Intestinales En France (CESAME) cohort. Methods We collected data from 19,486 patients with inflammatory bowel disease (IBD) enrolled in the observational CESAME study in France, from May 2004 through June 2005; 14.9% of participants had past or current anal and/or perianal Crohn's disease. Subjects were followed up for a median time of 35 months (interquartile range, 29–40 mo). To identify risk factors for anal cancer in the total CESAME population, we performed a case-control study in which participants were matched for age and sex. Results Among the total IBD population, 8 patients developed anal cancer and 14 patients developed rectal cancer. In the subgroup of 2911 patients with past or current anal and/or perianal Crohn's lesions at cohort entry, 2 developed anal squamous-cell carcinoma, 3 developed perianal fistula–related adenocarcinoma, and 6 developed rectal cancer. The corresponding incidence rates were 0.26 per 1000 patient-years for anal squamous-cell carcinoma, 0.38 per 1000 patient-years for perianal fistula–related adenocarcinoma, and 0.77 per 1000 patient-years for rectal cancer. Among the 16,575 patients with ulcerative colitis or Crohn's disease without anal or perianal lesions, the incidence rate of anal cancer was 0.08 per 1000 patient-years and of rectal cancer was 0.21 per 1000 patient-years. Among factors tested by univariate conditional regression (IBD subtype, disease duration, exposure to immune-suppressive therapy, presence of past or current anal and/or perianal lesions), the presence of past or current anal and/or perianal lesions at cohort entry was the only factor significantly associated with development of anal cancer (odds ratio, 11.2; 95% CI, 1.18-551.51; P = .03). Conclusions In an analysis of data from the CESAME cohort in France, patients with anal and/or perianal Crohn's disease have a high risk of anal cancer, including perianal fistula–related cancer, and a high risk of rectal cancer.

Aim Sacral nerve stimulation (SNS) has a place in the treatment algorithm for faecal incontinence (FI). However, after implantation, 15–30% of patients with FI fail to respond for unknown reasons. We investigated the effect of SNS on continence and quality of life (QOL) and tried to identify specific predictive factors of the success of permanent SNS in the treatment of FI. Method Two hundred consecutive patients (six men; median age = 60; range 16–81) underwent permanent implantation for FI. The severity of FI was evaluated by the Cleveland Clinic Score. Quality of life was evaluated by the French version of the American Society of Colon and Rectal Surgeons (ASCRS) quality of life questionnaire (FIQL). All patients underwent a preoperative evaluation. After permanent implantation, severity and QOL scores were reevaluated after six and 12 months and then once a year. Results The severity scores were significantly reduced during SNS (P = 0.001). QOL improved in all domains. At the 6-month follow-up, the clinical outcome of the permanent implant was not affected by age, gender, duration of symptoms, QOL, main causes of FI, anorectal manometry or endoanal ultrasound results. Only loose stool consistency (P = 0.01), persistent FI even though diarrhoea was controlled by medical treatment (P = 0.004), and low stimulation intensity (P = 0.02) were associated with improved short-term outcomes. Multivariate analysis confirmed that loose stool consistency and low stimulation intensity were related to a favourable outcome. Conclusion Stool consistency and low stimulation intensity have been identified as predictive factors for the short-term outcome of SNS.

Aliment Pharmacol Ther 31, 1178–1185 Summary Background Efficacy of infliximab in treating ulcerative proctitis remains unknown. Aim To evaluate the clinical, biological and endoscopic efficacy of infliximab therapy in refractory proctitis. Methods The charts of 420 patients treated with infliximab for ulcerative colitis were reviewed. Thirteen patients were treated with infliximab for refractory ulcerative proctitis in six referral centres between 2005 and 2009. Results Following infliximab therapy induction, 9/13 patients (69%) had a complete response (defined as absence of diarrhoea and blood), 2/13 (15%) had a partial response and 2/13 (15%) were primary nonresponders. The median follow-up was 17 months (range, 3–48). Among the 11 patients with clinical response after infliximab induction therapy, 9 (82%) patients maintained response at last follow-up. Disappearance of rectal disorders was observed in all nine patients who maintained clinical response at last follow-up. Following infliximab induction therapy, the mean CRP level fell from 12.8 mg/L to 4.7 mg/L. Endoscopic evaluation was performed before and after infliximab in seven patients, showing an improvement in mucosal lesions in four patients, persistent mild endoscopic activity in two patients and no improvement in one patient. One patient underwent proctocolectomy. Conclusion Infliximab therapy seems to be effective in inducing and maintaining a clinical response in refractory ulcerative proctitis.

Summary Background In Crohn’s disease, anal ulcers and stricture can be disabling. Aim To evaluate long-term outcome of non-fistulizing perianal Crohn’s disease under infliximab. Methods The medical records of 99 patients with non-fistulizing perianal Crohn’s disease at first infliximab infusion were reviewed. Complete responses (ulcer healing or stricture regression) after induction infliximab therapy and at the maximal follow-up were assessed. Results Ninety-four patients (94.9%) had ulcers, 22 (22.2%) had stricture and 31 (31.3%) had draining perianal fistulas at first infliximab infusion. After infliximab induction therapy, 40/94 (42.5%) patients with ulcers, 4/22 (18.2%) with stricture and 10/31 (32.2%) with fistulas had a complete response. Eight patients were lost to follow-up. After a median follow-up of 175 weeks (range, 13–459), complete response rates for ulcers, stricture and fistulas were 72.3% (68/94), 54.5% (12/22) and 54.8% (20/31) respectively. Long-term response for cavitating ulcer was positively associated with concomitant immunosuppressant use (P = 0.017) and older age (P = 0.049). Among the 12 patients with complete regression of stricture, 6 patients also had anal dilatation. Complete response was associated with perianal pain relief and disappearance of soiling. Three patients with ulcers developed an anal abscess. Conclusions Infliximab therapy may be effective in inducing and maintaining response for ulcers.

Resume La constipation d’evacuation est une situation peu satisfaisante a la fois pour les malades qui s’en plaignent et les medecins consultes. Les premiers ont des reticences a evoquer des symptomes juges degradants. Les seconds ont des difficultes de prise en charge liees a des strategies peu differenciees (constipation). Cependant, une evaluation symptomatique precise (consistance des selles), un examen dynamique anorectal (anisme, rectocele) et un test d’expulsion au ballonnet permettent de planifier la prise en charge dans les situations les plus habituelles.

International audience; OBJECTIVE: Since the first paper published by Matzel et al., in 1995, on the efficacy of sacral nerve stimulation (SNS) in patients with faecal incontinence, the indications, the contraindications, the stimulation technique and follow up of implanted patients have changed. The aim of this article was to provide a consensus opinion on the management of patients with faecal incontinence treated with SNS. METHOD: Recommendations were based on a critical review of the literature when available and on expert opinions in areas with insufficient evidence. RESULTS: We have reviewed the indications and contraindications, proposed an algorithm for patient management showing the place of SNS. The temporary test technique, the implantation technique, the patient follow up and the approach in case of treatment failure were discussed. CONCLUSION: We hope not only to provide a guide on patient management to clinical practitioners interested in SNS but also to harmonize our practices.

Rectal prolapse is frequently associated with fecal incontinence; however, the relationship is questionable. The study was designed to evaluate fecal incontinence in a large consecutive series of patients who suffered from rectal prolapse, focusing on both past history, anal physiology, and imaging. Eighty-eight consecutive patients who suffered from an overt rectal prolapse (72 women, 16 men; mean age, 51.1 ± 19.5 years) as a main symptom were analyzed; 48 patients also experienced fecal incontinence compared with 40 without incontinence. Logistic regression analyses were performed. The two groups of patients did not differ with respect to parity, weekly stool frequency, main duration of symptoms before referral, occurrence of dyschezia, and digital help to defecate. Patients with prolapse who were older than 45 years (odds ratio (OR), 4.51 (1.49–13.62); P = 0.007) and those with a past history of hemorrhoidectomy (OR, 9.05 (1.68–48.8); P = 0.01) were significantly more incontinent. Incontinent group showed frequent internal anal sphincter defect compared with the continent group (60 vs. 6.2 percent; P = 0.0018). In patients with overt rectal prolapse, the occurrence of fecal incontinence needs special consideration for age and previous hemorrhoid surgery as causative factors. Anal weakness and sphincter defects are frequently observed.

Summary Aim This study was designed to ascertain the perception of patients (and their parents) followed-up for inflammatory bowel disease (IBD) concerning the transition from pediatric to adult care. Patients and methods Forty-eight youths with IBD who had transited from pediatric to adult care were surveyed. Their age at transition was 17.9 ± 0.9 years. Thirty-four patients (71%) had been referred to a gastroenterologist working in the same hospital and, in 27 cases, after having attended a joint pediatric–adult care visit. Results The response rate was 71%. Twenty-nine patients (85%) and 25 parents (74%) felt they were ready to transit into adult care. Seven patients (22%) and 10 parents (32%) were apprehensive about transition to adult gastroenterology. All patients considered the joint medical visit beneficial in terms of transmitting information from their medical records and 93% considered it beneficial for building confidence in the new gastroenterologist. All parents considered the joint medical visit helpful for building the children's confidence in their new doctor. At the time of the survey, 29 patients (85%) were continuing to be followed-up by the same gastroenterologist. Conclusion Effective planning, including a joint medical visit, enabled successful, well-coordinated transition to adult medical-care follow-up.

De nombreux essais cliniques, meta-analyses et recommandations aident a la prise en charge de la fissure anale, mais les evaluations de pratique clinique sont rares. Le but de cette enquete est de decrire les criteres diagnostiques et le mode de prise en charge de la fissure anale aigue et chronique par les specialistes. Un questionnaire a ete envoye en mai 2006 par voie postale a 3350 gastroenterologues et chirurgiens digestifs sur leurs habitudes de prise en charge de la fissure anale a partir des patients vus dans le mois precedant l’enquete. Trois cent soixante-dix-huit praticiens (11 %) ont repondu avant le 31 octobre 2006. Ils avaient vu 2483 malades souffrant d’une fissure anale (moyenne 6,6 malades/mois/praticien). Les symptomes etaient la douleur (100 %), des saignements (90 %), une constipation (57 %), un prurit (26 %). Un quart des praticiens se satisfaisaient du simple examen visuel pour confirmer le diagnostic de fissure et 60 % y ajoutaient le toucher anal ou l’anuscopie. La fissure etait chronique pour 1081 malades (44 %). La definition de la chronicite reposait pour 39 % des praticiens sur une evolution superieure a six mois, la presence d’une marisque sentinelle pour 64 %, de bords decolles pour 44 %, de la presence d’une papille hypertrophiee pour 35 % et de fibres sphincteriennes visibles au fond de la fissure pour 32 %. Les traitements proposes figurent dans le tableau: L’intervention chirurgicale pratiquee etait deux fois sur trois une fissurectomie sans dilatation ni sphincterotomie (9/10, il s’agissait d’une fissurectomie avec anoplastie muqueuse). Les criteres diagnostiques de la fissure anale chronique les plus consensuels sont obtenus par l’examen physique. Le traitement des formes aigues et chroniques differe surtout par la rapidite de la prise en charge chirurgicale. La fissurectomie avec anoplastie muqueuse sans sphincterotomie est la technique la plus souvent employee.

Summary Aim To evaluate colorectal cancer risk among patients with sporadic duodenal neoplasia using a case–control protocol. Methods Cases were 35 patients referred for the management of sporadic duodenal adenoma and who underwent colonoscopy. Colonoscopy findings among cases were compared with those from a control group matched for age and sex (two controls per case) without duodenal adenoma. Colonoscopy findings were categorized as adenoma, advanced adenoma, cancer or advanced neoplasia. The two groups were compared using the chi-squared test. Odds ratio and 95% confidence intervals were calculated. Results Colorectal adenoma was present in 31% of cases vs. 24% of controls, advanced neoplasia in 29% vs. 4%, advanced adenoma in 23% vs. 3% and adenocarcinoma in 6% vs. 1%. The relative risks of advanced colorectal adenoma and advanced colorectal neoplasia in cases were 10.1 (95% CI: 1.8–100.1, P = 0.003) and 8.9 (95% CI: 2.1–53.3, P = 0.001), respectively. Conclusions The relative risk of advanced colorectal adenoma and advanced neoplasia in cases was nine- to 10-fold that among controls. Patients with sporadic duodenal adenoma represent a high-risk group for advanced colorectal neoplasia and should therefore undergo complete colonoscopy.

Aim To test efficacy and safety of polydimethylsiloxane elastomer implants, a silicone biomaterial, in patients with severe faecal incontinence related to an impaired internal anal sphincter. Methods Subjects were randomized to receive three injections of 2.5 mL of either physiological saline or polydimethylsiloxane elastomer. After local anaesthesia, an 18 gauge, 2.5-in needle was inserted through the perianal skin and laid down into the intersphincteric space. Treatment (saline or polydimethylsiloxane elastomer) was administered by means of a ratchet gun. Three injections of 2.5 mL each were performed in the area of the internal anal sphincter at 3, 7 and 11 o’clock positions. Main end point was the percentage of subjects in each treatment arm experiencing a successful treatment, defined as a Cleveland Clinic Florida-Faecal Incontinence score

A. Senejoux, Y. Panis, L. Siproudhis, E. Mitry 1 Service de Coloproctologie, Hopital Leopold-Bellan, 19-21, rue Vercingetorix, F-75014 Paris, France 2 Service de Chirurgie colorectale, CHU Beaujon, 100, boulevard du General-Leclerc, F-92110 Clichy, France 3 Service des Maladies de l’appareil digestif, Hopital Pontchaillou, 2, rue Henri-Le-Guilloux, F-35033 Rennes Cedex 09, France 4 Service d’Hepatogastroenterologie, Hopital Ambroise-Pare, 9, avenue Charles-de-Gaulle, F-92104 Boulogne-Billancourt Cedex, France

International audience; Background: One-third of patients with fecal incontinence (FI) do not have any anal dysfunction. The aim was to characterize patients with FI with normal anal function compared with patients with anal weakness. Methods: The general characteristics and data of anal manometry, endosonography, and defecography of patients who were evaluated for FI at a single institution from 2005 to 2015 were prospectively assessed. Fecal incontinence was defined by the Cleveland Clinic Incontinence Score (CCIS) >4. Anal weakness was defined by one or more of the three following parameters: 63 years; odds ratio [OR] = 0.29), higher weight (>65 kg; OR = 1.69), fecal urgency (OR = 1.58), less severe FI score (CCIS score >10; OR = 0.52), higher abdominal pressure (>36 mmHg; OR = 2.15), and paradoxical puborectal contraction (OR = 2.07) in a multivariate analysis model. Conclusion & inferences: Fecal incontinence with normal anal function is a specific phenotype that involves distal constipation and may be an early stage of FI with anal weakness. Physicians should adapt their management to focus on the treatment of constipation. © 2016 John Wiley & Sons Ltd

National audience; Objectifs Le spina bifida peut être responsable de dysfonctionnements vésico-sphinctériens variables avec des atteintes typiquement « en mosaïque ». Il existe très peu de données sur la prévalence des diverses symptômes du bas appareil urinaires chez les patients spina bifida. L’objectif de ce travail était de décrire les troubles urinaires du bas appareil observés dans une cohorte de patients spina bifida. Méthodes Une étude prospective a été menée entre 2007 et 2015 incluant tous les patients spina bifida consultant consécutivement dans un centre. Lors de la première consultation, un recueil exhaustif du fonctionnement de l’appareil urinaire de chaque patient a été réalisé comprenant notamment : antécédents de chirurgie urologique, le type de spina bifida, le niveau neurologique sensitif et moteur selon la classification AIS, mode de déplacement, mode mictionnel, les scores USP et Qualiveen, données du bilan urodynamique. Les variables quantitatives étaient exprimées en moyenne et écart-type et les variables qualitatives en proportion. Résultats Trois cent soixante et onze patients ont été inclus. L’âge médian était de 33 ans (2–88). Le niveau lésionnel était thoracique, lombaire et sacrée chez respectivement 4,5 % ; 85,5 % et 10 % des patients. Le mode de déplacement des patients était : fauteuil, fauteuil/marche, marche avec cannes et marche sans cannes pour respectivement, 27 % ; 9 % ; 7 % et 57 %. Le mode mictionnel majoritaire était la cathétérisme intermittent par voie urétrale chez (51,2 %). Le score Qualiveen moyen était de 2,6 (± 0,9) et 227 patients avaient un score ≥ 3 (61,1 %). Cent quatre-vingt-neuf patients présentaient une incontinence urinaire lors de leur première consultation (51 %). La plainte principale des patients était urologique, digestive ou locomotrice dans respectivement 29 ; 17 et 16 % des cas. Conclusion Les troubles urinaires sont fréquents chez les patients spina bifida. Seul un tiers des patients urine par miction spontanée, l’autosondage par voie urétrale étant le mode mictionnel le plus fréquent

International audience; BACKGROUND: Screening for anal dysplasia in human immunodeficiency virus (HIV)-infected patients is not standardized. High-resolution imaging is not adequate for mass screening, and anal cytology requires expertise. New biomarkers, selected because of their use in cervical cancer mass screening, have been originally tested for targeted and easy-to-perform screening. METHODS: 120 HIV-infected individuals (males 96.4%, mean age 47±11 years) were referred for clinical examination, anoscopy, and cytological studies on anal swab. Dysplasia grading, Human Papilloma Virus genotyping, E6/E7mRNA detection and p16(INK4A)/Ki-67 immunostaining were performed. High-grade lesions were histologically confirmed by anal biopsies after high-resolution anoscopy. RESULTS: Among the 120 anal swabs analyzed, 36 (30%) had low grade and 6 (5%) had high-grade lesions. Virus genotype was identified in 88 patients (73.3%), and 77 (64.2%) were positive for high-risk genotype(s). High-risk genotype was associated to low-grade or high-grade lesions with a sensitivity of 0.93 and a specificity of 0.51. For E6/E7mRNA, sensitivity and specificity for low-grade and high-grade lesions were, respectively, 0.88 and 0.78. Combination of genotyping, E6/E7mRNA and p16(INK4A)/Ki-67 appropriately ruled out dysplasia in 55% of patients. CONCLUSIONS: Three routine biomarkers may avoid unnecessary invasive procedures with the perspective of an improvement of patient compliance. A decision making algorithm, based on the combination of these three biomarkers, is proposed.

International audience; Background - In case of a loss of response to adalimumab, some patients with Crohn's disease may derive benefit from increasing the dosing frequency to 40 mg weekly. Efficacy and safety of adalimumab 80 mg weekly remain unknown. Methods - From February 2011 to September 2012, all adults who had active Crohn's disease, defined at least by Crohn's disease activity index >150 and 1 objective sign of inflammation, and required an adalimumab dose escalation to 80 mg weekly were enrolled in a prospective multicenter cohort study. Crohn's disease activity index and C-reactive protein levels were recorded during the first 14 weeks following adalimumab optimization and at 6 months. All adverse events were recorded. Results - Forty-two patients were included. The median age was 33 years, and the median disease duration was 8.6 years. Adalimumab was associated with steroids in 28% of cases and with immunomodulators in 10% of patients. Within the 14 weeks after adalimumab optimization, 14 patients (33.3%) achieved clinical remission (Crohn's disease activity index

Background Rectal disorders during ulcerative colitis (UC) drastically alter the quality of life and may result from an impairment of rectal perception and compliance. This study aims to assess anorectal disorders in patients with mild-to-moderate UC. Methods Anal pressures and the rectal responses to phasic rectal isobaric distension in 10 patients with mild-to-moderate UC were prospectively compared with those in 10 healthy volunteers (HVs). Key Results The patients in each group were similar regarding age, gender, and delivery. In the resting state, the anal canal pressures were similar between the groups. Only the squeeze pressures of the lower anal canal were significantly lower in UC patients than in HVs. During phasic isobaric distension, rectal sensitivity was similar between the groups, whatever the step of distension. Isobaric rectal distension resulted in a significant decrease of the rectoanal inhibitory reflex and a decrease in rectal tone and a significant drop in rectal compliance in UC patients compared with HVs. Conclusions & Inferences Patients showing mild-to-moderate UC experience rectal compliance and innervation disorders without a significant change in rectal sensitivity. The findings of this work suggest impairment not only of the properties of the rectal wall but also of intrinsic innervation. Repeated evaluation over time may be helpful for analyzing the reversibility of the process after healing.

International audience; Background and aims: Closing the internal opening by a clip ovesco has been recently proposed for healing the fistula tract, but, to date, data on benefit are poorly analyzed. The aim was to report a preliminary multicenter experience. Materials and methods Retrospective study was undertaken in six different French centers: surgical procedure, immediate complications, and follow-up have been collected. Results Nineteen clips were inserted in 17 patients (M/F, 4/13; median age, 42 years [29–54]) who had an anal fistula: 12 (71 %) high fistulas (including 4 rectovaginal fistulas), 5 (29 %) lower fistulas (with 3 rectovaginal fistulas), and 6 (35 %) Crohn’s fistulas. Out of 17 patients, 15 had a seton drainage beforehand. The procedure was easy in 8 (47 %) patients and the median operative time was 27.5 min (20–36.5). Postoperative period was painful for 11 (65 %) patients. A clip migration was noted in 11 patients (65 %) after a median follow-up of 10 days (5.5–49.8). Eleven patients (65 %) who failed had reoperation including 10 new drainages within the first month (0.5–5). After a mean follow-up of 4 months (2–7),, closing the tract was observed in 2 patients (12 %) following the first insertion of the clip and in another one after a second insertion. Conclusion: Treatment of anal fistula by placing a clip on the internal opening is disappointing and deleterious for some patients. A better assessment before dissemination is recommended.

The perception patients consulting for primary care have of anorectal disorders has never been evaluated. Our aim was to analyze proctological complaints among outpatients consulting general practitioners.Among 1484 physicians who responded to a nationwide mailing in France, 161 enrolled 437 females and 358 males consulting between October 2004 and December 2005.Females were younger than males (46 +/- 15 vs 51 +/- 13 years) (p0.0001). Intermediate and upper social-occupational categories were overrepresented as compared with the general population. Symptoms were pain (48%), bleeding (37%), swelling (26%) and pruritus (24%). For 76%, these symptoms persisted for less than one month and 58% mentioned earlier visits or prior treatment. The first manifestation was correlated with a pregnancy in 31% of women. Present symptoms were secondary to acute constipation (52%), stress (33%), ingestion of spices (29%) or alcohol (20%), and diarrhea (8%). Symptoms were considered important in 61% or a cause of anxiety in 33% of patients. Treatment was prescribed for all patients: ointments (90%), phlebotonics (66%) or suppositories (51%), in combination for 75% of prescriptions. Patients preferred oral medicines (41%), ointments (30%) and suppositories (7%).Proctological complaints are a reason for repeated visits to the general practitioner and lead to repeated prescriptions. Patients appreciate anti-hemorrhoidal treatments variably.

Lateral internal sphincterotomy is widely used in the treatment of chronic anal fissure. However, it is associated with a high rate of irreversible incontinence. For this reason the botulinum toxin has become a medical means of reversible sphincterotomy. Indeed, this neurotoxin induces relaxation of the smooth internal anal sphincter lasting one to three months after one injection. We reviewed the published studies about the use of this technique in the management of chronic anal fissure. Healing occurred in more than 70% of fissures without irreversible incontinence. Although further studies are needed to determine the best modalities of administration, especially due to the remaining significant recurrence rate, this toxin may be a valuable treatment for chronic anal fissure in the future.

Despite frequent occurrence, functional defecation disorders and related conditions have been infrequently reported in population studies. This study was designed to assess symptoms, lifestyle-behavioral changes, and medical care seeking related to functional defecation disorders in alarge household community survey. A large household community survey was conducted in 10,000 individuals aged 15 years or older. A mailed questionnaire was used to assess ten common anorectal complaints; frequency, association, impact on quality of life, and medical care seeking were quantified. Evaluation was obtained in 7,196 patients (3,455 males). During the previous 12-month period, 2,097 patients (29.1 percent) experienced functional defecation disorders: outlet constipation and fecal incontinence were reported in 22.4 and 16.8 percent respectively. Compared with patients with no anorectal complaint, patients with functional defecation disorders had a different gender status (females, 63.3 vs. 47.6 percent; P < 0.01). Based on symptom severity, functional defecation disorders were perceived as the main anorectal complaint in 1,192 patients. In this group, emptying difficulties, unsatisfied defecation, gas, and fecal incontinence occurred at least once per month in 71.6, 56.1, 77.9, and 49 percent respectively: 66.6 percent with outlet constipation and 85.6 percent with incontinence revealed impairment in quality of life. Incontinent patients more frequently avoided medical care than those complaining of outlet constipation (67.4 vs. 46.4 percent; P < 0.01). Functional defecation disorders concerns at least one of four French individuals. Outlet constipation and fecal incontinence frequently occur in association. Despite a low rate of patients seeking care, symptoms often are severe and related to quality of life impairment.

Summary Background : Although antidepressants are used for functional gastrointestinal disorders, the mechanisms of their effects on gut are incompletely understood. Aim : To assess the effects of two types of antidepressants (tricyclic, serotoninergic) on anorectal motility and visceral perception. Methods : A placebo-controlled, randomized, double-blind, crossover study was performed in 12 healthy male volunteers who received a single oral dose of amitriptyline (80 mg), fluoxetine (40 mg) or placebo. Drug effects were assessed using phasic isobaric distensions of the rectum with an electronic barostat (11 levels from 1 to 51 mmHg) 4 h after drug intake. Maximal rectal volume and pressure, mean and residual pressures at upper anal canal, mean pressure at lower anal canal, defecation sensation (5-level scale) and visceral perception (visual analogue scale) were recorded at each level of distending pressure. Results : Ten subjects completed the study. Compared with placebo, neither amitriptyline nor fluoxetine modified rectal compliance or visceral perception. Compared with placebo, antidepressants significantly reduced mean and residual pressures at upper anal canal (−18%, P = 0.0019, and −27%, P = 0.0002, respectively, for amitriptyline; −26%, P = 0.0001, and −33%, P = 0.0001, respectively, for fluoxetine) whereas only amitriptyline significantly reduced mean pressure at lower anal canal (−16%, P = 0.0008). Conclusion : Both antidepressants similarly relaxed the internal anal sphincter, probably through a non-specific mechanism, without modifying visceral perception. Only amitriptyline relaxed the external anal sphincter.

OBJECTIVES Three recently identified NOD2/CARD15 mutations have been described associated with an increased susceptibility Crohn's disease (CD). Our aim was to examine the potential association of these NOD2 mutations with CD and different subsets of CD phenotypes in our population. METHODS Two hundred and five well-defined CD patients from north-western France and 95 ethnically matched healthy controls were genotyped for mutations R702W, G908R and Leu1007insC by DNA sequencing. Allele and genotype frequencies of NOD2 variants were examined in the whole series of CD and in different subgroups of CD phenotypes defined by the clinical characteristics of the Vienna classification (age at diagnosis, location and behaviour) or by histological features (granuloma). RESULTS Carriers of at least one NOD2/CARD15 variant were significantly more frequent in CD than in controls (38.0% versus 20.0%, P < 0.002), and the R702W allele was the most significant contributor to this NOD2 association with CD. Homozygotes and compound heterozygotes combined had a higher risk of CD (odds ratio = 12.0, P < 0.0026) than simple heterozygotes for any variant (odds ratio = 2.2, P < 0.013) compared with subjects with no variant. Univariate analysis revealed that carriage of at least one NOD2 mutation was significantly associated with ileal involvement (P < 0.03), and stricturing evolution (P < 0.0015). Granuloma was associated with an excess of the R702W allele (16.1% versus 8.0%, Pc < 0.035), and was correlated with a young age at diagnosis, whatever the NOD2/CARD15 genotype. Multivariate analysis demonstrated that carriage of NOD2/CARD15 mutants, especially R702W, was primarily and independently associated both with stricturing evolution of CD and the presence of granuloma. CONCLUSIONS In our population, all NOD2/CARD15 mutant genotypes, especially compound heterozygosity, were found to increase the risk of CD, but R702W was the sole allele showing a significant association with CD. In addition, we confirm the positive and independent association of the R702W mutation with stricturing behaviour and describe a second one with the presence of granuloma.

International audience; Letter to the Editor

Summary Background and aim: Hypertonicity of internal anal sphincter plays a major role in the persistence of chronic anal fissure. Botulinum toxin could induce internal anal sphincter relaxation without the adverse effects of surgery (long-term faecal incontinence) or topical nitrates (anal burning, headaches, hypotension). Methods: We conducted a placebo-controlled, randomised, double-blind study to assess the efficacy of a single injection of botulinum toxin in the internal anal sphincter of patients with chronic anal fissure in six ambulatory care clinics. Eligibility criteria included a mean value of post-defecation anal pain ≥ 30 mm on a 100 mm visual analogue scale over the week preceding inclusion. Main endpoint was the proportion of patients with symptomatic improvement during the fourth week after inclusion (post-defecation anal pain below 10 mm). Results: Forty-four patients (22 in each group) were included. At inclusion, there was no significant difference between groups on age, sex ratio, pain duration, post-defecation anal pain, analgesic consumption and stool frequency. Ten (45%) and 11 (50%) patients reported symptomatic improvement on the main endpoint (P=0.76) in placebo and botulinum toxin groups, respectively. Ten patients (five in each group) had healed fissure at week 4 and ten patients (five in each group) required surgical treatment between weeks 4 and 12. Similarly, there was no significant difference between groups on other variables between weeks 4 and 12. Conclusions: The efficacy of a single injection of botulinum toxin in the internal anal sphincter does not differ from that of a placebo in patients with chronic anal fissure.

Summary Aims The presence of stools in the rectum might affect the quality of the abdominal pressure curve during filling cystometry, but, to date, no study has evaluated the impact of bowel preparation before urodynamics. We evaluated the influence of a sodium phosphate enema before urodynamics on the quality of the abdominal pressure curve. Methods A prospective, controlled, single-blind study was conducted in a single center from May to June 2013. The patients were divided into 2 consecutive groups: patients seen in outpatient clinics during the first 6 weeks (group A) who underwent urodynamics without bowel preparation and patients seen in outpatient clinics during the second 6 weeks (group B) who had a prescription of sodium phosphate enema before urodynamics. The primary endpoint was the quality of the abdominal pressure curve evaluated independently by three physicians who were blinded to the study group. The following data were also collected: age, gender, the presence of a neurological disorder, complicated nature of urodynamics and bother related to preparation for it, assessed using a Likert scale (0 to 10), and the equipment used. A per protocol analysis and an intent-to-treat analysis were conducted. Results One hundred and thirty-nine patients were included: 54 in group A and 85 in group B. One-third of patients had neurological conditions. 14 patients in group B did not perform their scheduled enema. Thus, 68 patients performed an enema before urodynamics and 71 did not. There was no difference between groups A and B regarding the complicated nature of urodynamics (Likert scale: 3.12 vs. 3.18; P = 0.91) or bother related to preparation for it (Likert scale: 3.46 vs. 2.97; P = 0.43). In the per protocol analysis, the abdominal pressure curve was considered perfectly interpretable (PI) in 69% of patients who did not receive an enema before urodynamics and in 65% of patients who did ( P = 0.61). The between-group difference was not statistically significant in intent-to-treat analysis ( P = 0.99). In patients who did not receive an enema before urodynamics, the only factors statistically associated with better quality of abdominal pressure curves were age P = 0.001) and the urodynamic equipment used (Dantec ® > Laborie ® ; P = 0.01). Conclusion In this prospective study, routine enema before urodynamics did not improve the quality of the abdominal pressure curve and did not increase the complicated nature of urodynamics or the bother of preparation for it. Level of evidence 3.

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.

Background Assessment of perianal Crohn's disease remains challenging. European Crohn's and Colitis Organisation (ECCO) recommend magnetic resonance imaging (MRI) as a gold standard, but both accuracy and advantages remain limited compared to systematic clinical assessment. The aim of this study was to define their actual diagnostic value. Methods We performed a retrospective analysis of a prospective database of consecutive patients with perianal Crohn's disease assessed by magnetic resonance imaging and clinical examination from 2006 to 2012. At each outpatient visit, perianal activity (Perianal Disease Activity Index) and perianal phenotype (Cardiff-Hughes classification) were noted. MRI was interpreted according to Cardiff-Hughes and Van Assche classifications. Results Overall, 122 combined evaluations were assessed in 70 patients. Radiological imaging failed to show superficial ulcerations in 20/21 patients (95%) and severe ulcerations in 13/15 patients (87%). It consistently failed to diagnose anal stenosis ( n = 21, 100%). For fistulising lesions, the global agreement between the two methods was 71/122 (58%) in assessing complex fistulas. Clinical assessment underestimated 44/68 (65%) of multiple or ramified fistula tracts. Clinical examination failed to diagnose half of the radiological abscesses. Conclusions Current ECCO guidelines should be applied with some caution because of the low sensitivity of MRI for the diagnosis of non-fistulising perianal disease. Combining clinical and MRI assessments improves diagnostic accuracy.

International audience; Background - Fecal incontinence is frequently associated with rectal prolapse, but little is known about recovery after treatment of the prolapse. Objective - We therefore aimed to investigate the long-term outcome of fecal incontinence in a cohort of patients suffering from full-thickness rectal prolapse. Design - A database of 145 patients diagnosed with full-thickness rectal prolapse was compiled prospectively over a 7-year period (2003-2010). Main outcome measures - Patients were referred to a single institution and assessed by standardized questionnaires, anorectal manometry, endosonography, and evacuation proctography. Fecal incontinence was evaluated according to the Cleveland Clinic Score; continence improvement was defined by ≥50% improvement of the Cleveland Clinic Score. Results - Among the population studied (134 women, 11 men; median follow-up, 38.9 months [range, 21.2-67.2]), 103 patients (71%) underwent operation for their prolapse and 42 (29%) did not. According to the Cleveland Clinic Score, 139 patients (96%) suffered from fecal incontinence before treatment and 64 (46%) reported improvement at the end of the follow-up. Pretreatment history of incontinence symptoms for >2 years (hazard ratio [HR], 1.99; 95% CI, 1.14-3.46; P = .015) and ventral rectopexy (HR, 1.86; 95% CI, 1.026-3.326; P = .04) were associated with continence improvement. Patients who underwent an operative procedure other than ventral rectopexy had similar outcome as compared with nonoperated patients. Conversely, chronic pelvic pain precluded fecal incontinence improvement (HR, 0.32; 95% CI, 0.135-0.668; P = .0017). Limitations - Follow-up, returned questionnaires, and the heterogeneous reasons put forth for declining surgery may introduce some methodologic bias. Conclusion - Fecal incontinence in patients suffering from rectal prolapse is improved when ventral rectopexy is performed compared with other operative or medical therapies.

SummaryBackground The natural history of nonfistulising perianal Crohn's disease (PCD) remains unknown. Aim To assess the long-term outcome of anorectal strictures. Methods All outcomes of PCD patients with anorectal stricture followed in a single unit from 2005 to 2013 were reviewed, as well as subsequent therapeutic management. Cumulative incidence of stricture healing (disappearance of the anal stricture) was estimated using a Kaplan–Meier method and factor associated with an unfavourable course (persistent stricture S2, persistent stoma or proctectomy) with nonparametric test. Results A total of 102 patients (M/F: 37/65) were included. The duration of CD at diagnosis was 8.9 years. After a median follow-up period of 2.8 years, 52 of the 88 followed patients (59%) achieved anorectal stricture healing. Two patients (2%) developed anal adenocarcinoma. Female gender [HR 2.05 (1.1–4.03), P = 0.0221], disease duration of CD of less than 10 years [HR 1.94 (1.01–3.63), P = 0.0271], and anal fistula at stricture diagnosis [HR 2.36 (1.21–5.05), P = 0.0106) were significantly associated with anorectal stricture healing in a multivariate analysis model. Twenty-eight patients (32%) had an unfavourable course at the end of follow-up. Gender and introduction or optimisation of TNFα antagonist treatment decreased the risk of unfavourable course in multivariate analysis. Conversely, the Luminal B2 phenotype at CD diagnosis was the only factor associated with unfavourable course. Conclusions Anorectal stricture does not imply a nonreversible and complicated condition related to severe perianal Crohn's disease. However, both the diagnosis of cancer and sepsis drainage remain challenging in this situation.