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International audience; Introduction: for localized T1N0 squamous cell carcinoma of the anus (SCCA) standard radiotherapy (RT) may result in overtreatment and alternative strategies are debated. Methods: T1N0M0 SCCA treated between 2015 and 2020 by local excision (LE) or RT were analyzed from the French prospective FFCD ANABASE cohort. Treatment strategies, recurrence-free and colostomy-free survivals (RFS, CFS) and prognostic factors were reported. Results: among 1135 SCCA patients, 99 T1N0M0 were treated by LE(n = 17,17.2%), or RT ( n = 82,82.8%) including RT alone ( n = 65,79.2%) or chemo-RT ( n = 17, 20.7%). Median follow-up was 27.2 months [0.03 and ndash;54.44]. Median tumor size were 11.4 mm [0.9 and ndash;20] and 15.3 mm [2 and ndash;20] in the LE and RT groups respectively. Mean RT tumor dose was 59.4 Gy [18 and ndash;69.4 Gy]. One patient in LE group and 9 in RT group had a pelvic recurrence, either local (60%), nodal (10%) or both (30%). RFS and CFS at 24 months were 92.2%[95%CI,83.4 and ndash;96.4] and 94.6%[95%CI,86.1 and ndash;98.0], at 36 months 88.1%[95%CI,77.1 and ndash; 94.2] and 88.5%[95%CI,77.0 and ndash;94.5], in LE and RT group respectively, without any significative difference (HR = 0.57;[95%CI,0.07 and ndash;4.45];p= 0.60). By univariate analysis, male gender was the only prognostic fac-tor(HR = 5.57;95%CI, 1.76 and ndash;17.63; p = 0.004). Conclusion: this cohort confirms the heterogeneity of T1N0M0 SCCA management, questioning the place of RT alone, reduced dose or RT volume, and the safety of LE. (c) 2021 Editrice Gastroenterologica Italiana S.r.l. Published by Elsevier Ltd. All rights reserved.

Background: Infliximab is the only medical therapy that has been proven to be effective in fistulizing Crohn's disease (CD), but the recurrence rate of fistulas is high despite maintenance therapy. The aim of this prospective study was to evaluate the short- and long-term efficacy of a combined schedule with infliximab, methotrexate, and sphincter-sparing surgery in patients with severe fistulizing anoperineal CD. Methods: From January 2006 to November 2007, all consecutive patients in three referral centers with severe fistulizing anoperineal CD were prospectively included after primary drainage. At inclusion, patients received three infliximab infusions at weeks 0, 2, and 6, and maintenance therapy with methotrexate. A second optimized surgical step consisting of at least removal of setons was performed between the second and the third infliximab infusions. Results: Thirty-four CD patients (26 women; median age 38.5 years) with complex anoperineal fistula were enrolled (including 9 with recto-vaginal fistulas, and 10 with anorectal stenosis). At week 14 the response rate was 85% with 74% complete responders. At 1 year, 50% were still responders; luminal CD worsening was the major cause of relapse. Median Perineal Disease Activity Index (PDAI) and magnetic resonance imaging (MRI) scores significantly decreased from baseline to week 50. Conclusions: A combined approach with infliximab induction, two surgical sphincter-sparing steps and methotrexate is effective in achieving short-term response in severe fistulizing anoperineal CD. The best maintenance regimen remains to be determined. (Inflamm Bowel Dis 2011;)

Transanal excision of rectal villous adenomas is a widely used surgical technique, because it is a one-step procedure, requiring no sophisticated instrumentation, and allowing complete histologic analysis of the excised tumor. Therefore, it ranks alongside radical surgery and palliative destructive procedures, but its results are highly variable in the published series. This discrepancy may be explained by the variable completeness of tumor excision because of potential dissection difficulties. Because intraoperative exposure may be a major limiting factor, one of us (JF) has developed a tractable cutaneomucous flap procedure to lower the rectal tumor to the anal verge, where control of the dissection line is easier. This retrospective review of consecutive patients operated on during ten-year period reports long-term results after transanal excision for large rectal villous adenomas with the tractable flap technique.From 1978 to 1988, 207 consecutive patients (100 males), mean age 68 (range, 24-90) years, were operated on for an apparently benign villous rectal adenoma. Twenty-one patients (10 percent) were referred after failure of previous treatments: 11 endoscopic, 8 surgical, 1 laser, 1 radiotherapy. Mean distance of lower tumor edge from anal margin was 5.6 (range, 0-13) cm and was10 cm in 82 percent.Three patients (1.5 percent), including one with a Tis carcinoma, underwent a secondary treatment for immediate gross failure of resection: one further local excision and two palliative laser destructions. Immediate postoperative course was uneventful for 96 percent; there was one death from perineal gangrenous infection, four cases of hemorrhage, and three urinary retentions. Subsequently one case of transient fecal incontinence and 11 medically managed stenoses were noted. Mean size of resected tumor was 5.4 (range, 1-17) cm. Deep excision margins concerned the rectal muscular layers in 199 patients (96 percent) and perirectal fat in 8 (4 percent). Specimen margins were negative for cancer in 175 (85 percent) and positive or unknown in 32 cases. Histologic evaluation demonstrated in situ cancer in 28 (14 percent) and invasive carcinoma in 9 (4 percent). In three patients (1 percent), two abdominoperineal resections were immediately performed (one T2 with a mucinous contingent, one T3) and one adjuvant radiotherapy (one undifferentiated T2). Four patients (2 percent) did not return for postoperative evaluation. For the remaining 198 patients, mean follow-up was 74 +/- 34 (median, 75; range, 1-168) months. Forty-four died from unrelated causes. Recurrence occurred in seven (3.6 percent) and was malignant in two, who subsequently died. Specific recurrence-free probability was 99.5 percent at one year, 96 percent at five years, and 95 percent at ten years. A lesion size6 cm (10 vs. 1 percent for smaller tumors) and the presence of an invasive carcinoma (20 vs. 3 percent without invasive carcinoma) were significantly associated with an increased probability of recurrence at five years.Providing that adequate intraoperative exposure is obtained and advanced malignant tumors receive immediate secondary treatment, transanal resection of clinically benign, large rectal villous adenomas is safe and effective. It is an alternative to rectal resection, which exposes the patient to potentially adverse effects, and also to destructive procedures, which preclude any histologic evaluation of the tumor.

Background Somatostatin is localized in the intestinal and pelvic nerves of the anorectum and it seems to act as an important neurotransmitter. However, previous analyses of octreotide (a somatostatin analog) effects on anal function showed conflicting results. By use of a dynamic model in healthy subjects, with comparison to the myogenic effect of glucagon, the aim of our study was to further investigate the pharmacologic targets of octreotide. Methods This was a placebo-controlled, randomized, double-blinded crossover study performed in 12 healthy volunteers who received octreotide, glucagon, or placebo intravenously on separate days. During each sequence, several pressure steps in 3 different protocols of rectal isobaric distension were applied with an electronic barostat. Manometric responses of the anal canal, adaptative volumes, and perception scores of the rectum were recorded. Results During both phasic and stepwise distensions, a significant drug effect was encountered at the anal level. Compared with placebo, octreotide significantly increased pressures at both upper and lower levels of the anal canal. In contrast, glucagon decreased pressures at the upper part of the anal canal. Octreotide significantly decreased rectal volumes to phasic distension, but glucagon did not induce any change on rectal adaptation. In addition, neither drug modified perception scores. Conclusion This study suggests that octreotide acts on reflex arcs and rectal myenteric neurons rather than on anal myogenic targets that respond to glucagon. Clinical Pharmacology & Therapeutics (1998) 64, 424–432; doi

AIM Work-up of anoperineal lesions usually includes indices of clinical activity as well as diagnostic criteria of Crohn's disease but their prognostic implication remains unclear. This prospective study was conducted in order to evaluate the overall incidence of anoperineal lesions and their relation to the natural history of underlying intestinal Crohn's disease with special reference to the steroid-dependent state of the patients. PATIENTS AND METHODS One hundred and one patients (46 males, 55 females, aged 34 +/- 14 years; range: 15-79) were consecutively referred to our institution (May 1991 to May 1994) for intestinal symptoms related to Crohn's disease (mean duration 66 +/- 66 months). They all underwent a proctological examination regardless of perineal symptoms. The Cardiff classification was used to describe anoperineal lesions. Patients with anal lesions (64) differed from those without (37): male predisposition (53% vs. 32%, P

Schistosomiasis, an infection with the three anthropophilic species of Schistosoma, is endemic throughout wide areas of the tropics and subtropics with an estimated rate of over 200 million people infected worldwide. Whereas symptoms and signs of vesical and gastrointestinal forms of the infection are recognized readily, cutaneous manifestations are still a challenging diagnosis particularly in Western countries. A case is described of a 34-year-old Caucasian pregnant woman who presented to our department and was diagnosed with a cutaneous schistosomiasis involvement of the perianal region. Shistosoma haematobium was shown to be present in the lesion by histopathology and was considered to be the causative organism of the disease. Treatment with a course of oral praziquantel in a dose of 40mg/kg allowed resolution of the symptoms.

BACKGROUNDPerception of, and adaptation of the rectum to, distension probably play an important role in the maintenance of continence, but perception studies in faecal incontinence provide controversial conclusions possibly related to methodological biases. In order to better understand perception disorders, the aim of this study was to analyse anorectal adaptation to rectal isobaric distension in subjects with incontinence.PATIENTS/METHODSBetween June 95 and December 97, 97 consecutive patients (nine men and 88 women, mean (SEM) age 55 (1) years) suffering from incontinence were evaluated and compared with 15 healthy volunteers (four men and 11 women, mean age 48 (3) years). The patients were classified into three groups according to their perception status to rectal isobaric distensions (impaired, 22; normal, 61; enhanced, 14). Anal and rectal adaptations to increasing rectal pressure were analysed using a model of rectal isobaric distension.RESULTSThe four groups did not differ with respect to age, parity, or sex ratio. Magnitude of incontinence, prevalence of pelvic disorders, and sphincter defects were similar in the incontinent groups. When compared with healthy controls, anal pressure and rectal adaptation to distension were decreased in incontinent patients. When compared with incontinent patients with normal perception, patients with enhanced perception experienced similar rectal adaptation but had reduced anal pressure. In contrast, patients with impaired perception showed considerably decreased rectal adaptation but had similar anal pressure.CONCLUSIONAbnormal sensations during rectal distension are observed in one third of subjects suffering from incontinence. These abnormalities may reflect hyperreactivity or neuropathological damage of the rectal wall.

Background High recovery rates of continence are observed after surgical procedures for rectal prolapse. Increases in rectal compliance but no obvious rise in anal pressures have been reported. The authors' hypothesis was that decreased rectal adaptation to distension may contribute to incontinence in patients suffering from overt rectal prolapse. Methods This was a prospective study conducted in 20 consecutive incontinent patients suffering from overt rectal prolapse with no mucosal change (two men and 18 women; mean(s.e.m.) age 50(3) years). They were compared with 20 age- and sex-matched patients with incontinence without rectal prolapse and ten age- and sex-matched healthy volunteers observed during the same period. The subjects were submitted to phasic isobaric distension of the rectum with an electronic barostat. Anal pressures, perception scores and rectal volumes were recorded at six different preselected pressures. Results Compared with healthy subjects, maximum rectal volumes (mean(s.e.m) 98(6) versus 167(11) ml; P = 0·005), volumes related to compliance (56(5) versus 100(9) ml; P = 0·004) and tone (41(3) versus 67(4) ml; P = 0·003) were decreased significantly in the rectal prolapse group. Prolapse and incontinence groups did not differ significantly with respect to rectal adaptation for all three parameters and steps of distension considered. Conclusion Patients suffering from overt rectal prolapse had markedly impaired rectal adaptation to distension which may contribute to incontinence.

But L’infliximab est le traitement de reference des fistules ano-perineales de la maladie de Crohn (MC) [1,2]. Cependant, son effet semble suspensif et les trajets fistuleux persistent en IRM. Le but de cette etude prospective etait d’evaluer, au cours des fistules ano-perineales complexes de MC, l’efficacite a court et a long terme d’un traitement associant infliximab en induction, methotrexate en traitement de fond, et chirurgie proctologique optimale. Patients et Methodes Entre janvier 2006 et novembre 2007, tous les malades avec fistules ano-perineales complexes de MC ont ete inclus prospectivement et consecutivement apres le drainage initial de la suppuration. A l’inclusion, tous recevaient un traitement par methotrexate (25 mg/semaine pendant toute la duree de l’etude) et trois perfusions d’infliximab (5 mg/kg aux semaines 0, 2 et 6). Lors du deuxieme temps chirurgical proctologique, realise a la semaine 4, les setons etaient retires et une procedure optimale etait realisee. L’infliximab etait interrompu apres l’induction et le methotrexate etait poursuivi en entretien. La reponse clinique initiale etait definie par une diminution d’au moins 50 % du nombre des ecoulements fistuleux lors d’au moins deux visites consecutives. L’objectif principal de l’etude etait la reponse clinique a la semaine 14. Les objectifs secondaires etudies etaient : 1) le delai median de perte de reponse chez les repondeurs a la semaine 14 ; 2) l’evolution du Perineal Disease Activity Index (PDAI) et du score IRM de Van Assche ; 3) la tolerance du traitement. Resultats Trente-quatre malades (26 femmes, âge median : 38,5 ans) atteints de fistules ano-perineales fistules complexes ont ete inclus : 29 % avaient une stenose ano-rectale et 26 % une fistule recto-vaginale ; 62 % etaient cortico-dependants ou cortico-resistants, 62 % avaient deja recu de l’azathioprine et 26 % de l’infliximab. Le deuxieme temps chirurgical proctologique a consiste en une ablation simple de seton (n = 7), une fistulotomie (4), une application de colle biologique (10), un lambeau (11), une intervention de Musset (2). A la semaine 14, 85 % des malades etaient repondeurs dont 73,5 % de reponse complete. Le delai median de perte de reponse etait de 69 semaines. Aux semaines 0, 14 et 50, le PDAI median etait respectivement de 11, 3 puis 0 (p Conclusion Un traitement associant infliximab en induction et chirurgie proctologique optimisee permet d’obtenir une reponse clinique rapide en cas de fistules ano-perineales complexes de MC. Le traitement d’entretien par le methotrexate en monotherapie permet ensuite de maintenir cette reponse clinique et anatomique (IRM) pendant plus d’un an. Le methotrexate pourrait etre compare a l’infliximab en traitement d’entretien de la MC ano-perineale fistulisante.

Background: Treatment with infliximab (IFX) can result in immunogenicity through the formation of human anti-chimeric antibodies (HACAs). These antibodies are associated with a decreased duration of response, whereas therapeutic levels of IFX are associated with durable clinical response. We evaluated the clinical utility of measuring serum IFX and HACA levels. Methods: We retrospectively reviewed charts of patients with inflammatory bowel disease who had IFX drug and HACA levels measured over a three-year period from 2005-2008. The clinical utility of these tests was assessed by determining whether the result affected clinical management. The management and subsequent clinical response to therapeutic changes based on test results was evaluated. Fisher's exact test and log-rank test for discontinuation were used for statistical analysis. Results: One hundred and fifty-five patients underwent IFX level and HACA status testing. The median time to initial testing after IFX initiation was 50 weeks (IQR: 22.7-120). The main indications for testing were: loss of response to IFX (50.3%), partial response after initiation of IFX (22.6%) and possible autoimmune/delayed hypersensitivity reaction (14.8%). HACAs were identified in 35 patients (22.6%) and therapeutic IFX levels were found in 51 (32.9%). Of 177 total tests assessed, the results impacted treatment decisions in 73.4% (95% CI: 66-80%). In those with positive HACAs, change to another anti-TNF was associated with a complete or partial response in 91.6% of patients whereas increasing the dose had a response of 16.7% (p