Recurrent anal fistulae:Limited surgery supported by stem cells

AIM:To study the results of stem-cell therapy under a Compassionate-use Program for patients with recurrent anal fistulae.METHODS:Under controlled circumstances,and approved by European and Spanish laws,a Compassionate-use Program allows the use of stem-cell therapy for patients with very complex anal fistulae.Candidates had previously undergone multiple surgical interventions that had failed to resolve the fistulae,and presented symptomatic recurrence.The intervention consisted of limited surgery(with closure of the internal opening),followed by local implant of stem cells in the fistula-tract wall.Autologous expanded adipose-derived stem cells were the main cell type selected for implant.The first evaluation was performed on the 8th postoperative week;outcome was classified as response or partial response.Evaluation one year after the intervention confirmed if complete healing of the fistula was achieved.RESULTS:Ten patients(8 male)with highly recurrent and complex fistulae were treated(mean age:49years,range:28-76 years).Seven cases were nonCrohn’s fistulae,and three were Crohn’s-associated fistulae.Previous surgical attempts ranged from 3to 12.Two patients presented with preoperative incontinence(Wexner scores of 12 and 13 points).After the intervention,six patients showed clinical response on the 8th postoperative week,with a complete cessation of suppuration from the fistula.Three patients presented a partial response,with an evident decrease in suppuration.A year later,six patients(60%)remained healed,with complete reepithelization of the external opening.Postoperative Wexner Scores were 0 in six cases.The two patients with previous incontinence improved their scores from12 to 8 points and from 13 to 5 points.No adverse reactions or complications related to stem-cell therapy were reported during the study period.CONCLUSION:Stem cells are safe and useful for treating anal fistulae.Healing can be achieved in severe cases,sparing fecal incontinence risk,and improving previous scoring.

Second-look surgery plus hyperthermic intraperitoneal chemotherapy for patients with colorectal cancer at high risk of peritoneal carcinomatosis:Does it really save lives?

The treatment of peritoneal carcinomatosis (PC) of colorectal origin with cytoreductive surgery(CRS) plus hyperthermic intraperitoneal chemotherapy (HIPEC) has a 5-year recurrence-free or cure rate of at least 16%, so it is no longer labeled as a fatal disease, and offers prolonged survival for patients with a low peritoneal carcinomatosis index. Metachronous PC of colorectal origin is so predictable that there is a model which has been used to successfully determine the individual risk of each patient. Patients at risk are clearly identified; those with the highest risk have small peritoneal nodules present in the first surgery (70% probability of developing PC), ovarian metastases(60%), perforated tumor onset or intraoperative tumor rupture(50%). Current clinical, biological and imaging techniques still lack sufficient sensitivity to diagnose PC in its initial stages, when CRS plus HIPEC has a greater impact and a higher cure rate. Second-look surgery with HIPEC or prophylactic HIPEC at the time of the first intervention have been proposed as means of preventing and/or anticipating clinical or radiological relapse in at-risk patients. Both techniques have shown a significant decrease in peritoneal relapses and should be considered essential weapons in the management of colorectal cancer.