In France, about 2000 new cases of anal cancer are diagnosed annually. Squamous cell carcinoma is the most common histological type, mostly occurring secondary to persistent HPV16 infection. Invasive cancer is preceded by precancerous lesions. In addition to patients with a personal history of precancerous lesions and anal cancer, three groups are at very high risk of anal cancer: (i) men who have sex with men and are living with HIV, (ii) women with a history of high-grade squamous intraepithelial lesions (HSILs) or vulvar HPV cancer, and (iii) women who received a solid organ transplant more than 10 years ago. The purpose of screening is to detect HSILs so that they can be treated, thereby reducing the risk of progression to cancer. All patients with symptoms should undergo a proctological examination including standard anoscopy. For asymptomatic patients at risk, an initial HPV16 test makes it possible to target patients at risk of HSILs likely to progress to cancer. Anal cytology is a sensitive test for HSIL detection. Its sensitivity is greater than 80% and exceeds that of proctological examination with standard anoscopy. It is indicated in the event of a positive HPV16 test. In the presence of cytological abnormalities and/or lesions and a suspicion of dysplasia on clinical examination, high-resolution anoscopy is indicated. Performance is superior to that of proctological examination with standard anoscopy. However, this technique is not widely available, which limits its use. If high-resolution anoscopy is not possible, screening by a standard proctological examination is an alternative. There is a need to develop high-resolution anoscopy and triage tests and to evaluate screening strategies.

Since our last publication of algorithms for the management of perianal fistulas in patients with Crohn’s disease, researchers have proposed a treat to target strategy systematic combotherapy for anal lesions, and indications for stem cell injection. In the absence robust publications, the Société Nationale Française de Coloproctologie (French National Society of Coloproctology [SNFCP]) wished to establish a group consensus using the Delphi method. From October 2020 to January 2021, a scientific committee and panel of gastroenterologists and surgeons established answers which were submitted to the members of the SNFCP during a national conference in November 2020. Three questions were clarified and reformulated, and then submitted during a third and final round of consultation of members of the SNFCP. The target was defined as being the response obtained in every domain (symptoms, physical and radiological evaluation) which could be considered satisfactory, without the need to intensify therapeutic management. By consensus, the time required for clinical evaluation of the efficacy of treatment was 6 months. A response on magnetic resonance imaging (MRI) should include the absence of a collection of 10 mm or more in size at 6 months, and a frank decrease or complete disappearance of hyperintensity in T1 and T2 sequences of the main tract at 12 months. Systematic association of an immunosuppressant with tumor necrosis factor inhibitors did not reach the consensus level for adalimumab (50%), but just did for infliximab (70%). The majority of the respondents considered failure of one, or even two lines of different biotherapies to be potential indications for injection of stem cells. These findings reinforce the importance of composite targets including MRI evaluation, and underscore the need for precise timing of evaluation. Combotherapy is only recommended with infliximab. Injection of stem cells is a second- or third-line option.

AIM:Over the past 10 years, several studies have focused on sexuality in patients with Crohn's disease. Very few of them specifically focused on perianal disease (PD). This study aimed to compare the prevalence of sexual dysfunction (SD) in Crohn's disease patients with active PD versus controls without active PD. METHOD:Patients from 14 French centres with active PD, defined by the presence of symptomatic ulceration, fistula or stenosis, were arbitrarily included. They were compared with controls from the existing SEXIA cohort. Men completed the International Index of Erectile Function (IIEF) and women the Female Sexual Function Index (FSFI). The primary end-point was SD defined by FSFI < 26.55 in women and IIEF < 42.9 in men. RESULTS:Ninety-seven patients (64 women, 33 men) and 238 controls (131 women, 107 men) were included. SD was found in 66% of the female patients versus 50% of the controls (P = 0.04). In the male population, SD was found in 30% of the cases versus 16% of the controls (P = 0.06). Erectile dysfunction affected 46% of the male patients and 43% of the controls (P = 0.8). On multivariate analysis, the predictive factor most strongly associated with SD in women was severely active anal PD defined by a perineal disease activity index > 4 [OR = 13.05 (2.32-73.44)]. CONCLUSION:Women with active PD had an increased prevalence of SD compared with controls without active PD. In the male population, the study was unable to determine whether there was a difference as it was underpowered.

Management of rectovaginal fistula (RVF) in Crohn’s disease (CD) is challenging. Available studies are heterogeneous and retrospective, with short-term follow-up. The aim of this study was to assess the overall long-term medico-surgical treatment results in women with RVF due to CD. A retrospective study was conducted on consecutive patients operated on for RVF in CD from September 1996 to November 2019 at a tertiary teaching hospital. All surgeries were classified as preliminary, closure, or salvage procedures. Primary outcome was fistula remission defined as the combination of fistula closure and no stoma, at least 6 months since last procedure. Thirty-two patients (median age 34 [range 21–55] years), with a median follow-up of 11.3 years (0–23.7) after first surgery, were included. Altogether, 138 procedures were performed; 36 (26%) preliminary, 80 (58%) closure, and 13 (9%) salvage procedures. RVF remission was obtained in 7/32 patients (22%). At the end of follow-up, a stoma was present in 13/32 patients (41%). The percentage of time on biologics was 86% for patients in remission, versus 36% for the others (p = 0.0057). After univariate analysis, only anti-TNF-α was significantly related to successful closure techniques (p = 0.007). The RVF remission rate in CD was low in the long term. However, patients underwent a succession of interventions, and the stoma rate was high. Combination of biologics with surgical management was crucial.

Le spectateur placé sur le bord de la route qui attend le passage du peloton du Tour de France est souvent déçu, tout passe si vite qu'il n'a pas eu le temps d'identifier les coureurs.On peut avoir la même perception de l'évolution des modes de communication professionnels et sociaux.Nous devons nous adapter aujourd'hui à des modèles changeant sans cesse de formats.Par exemple, la sacro-sainte revue dont on attendait patiemment la réception, qu'on décachetait, dont on lisait le sommaire puis qu'on posait délicatement sur un coin de son bureau pour lui réserver un temps apaisé de lecture : est-ce cliché et dépassé dans le flot des informations qui nous arrive plusieurs fois par heure ?Une enquête par autoquestionnaire a été récemment réalisée auprès des sociétaires et des praticiens qui participent aux Journées annuelles de la SNFCP.Les 193 réponses ont paru de nature à aider nos choix sur la politique de communication et d'échanges de notre Société.Chers coloproctologues, les absents aux dernières journées nous disent manquer de temps et avoir des contraintes professionnelles qui les empêchent de participer à la formation continue.Et pourtant le format et les thèmes abordés pendant les journées conviennent à plus de 84 % d'entre vous.Si le site de la SNFCP peut s'enorgueillir aujourd'hui• développer des espaces d'échanges entre les profession- nels de santé militants et/ou acteurs mais aussi avec les

Objectif : L’absence de standardisation des objectifs à atteindre par les traitements des fistules anopérinéales (FAP) de la maladie de Crohn limite les possibilités d’analyse et de comparaison des données issues des études disponibles. L’élaboration d’une liste standardisée d’objectifs à atteindre permettrait de résoudre ces problèmes. Cette étude valide la liste d’objectifs cruciaux (core outcome set [COS]) à atteindre pour le Crohn fistulisant. Méthode : Les objectifs susceptibles d’être retenus ont été définis par une revue de la littérature et des interviews de patients. La sélection consensuelle a été établie à l’issue d’un processus Delphi en trois étapes en évaluant sur une échelle de Likert en neuf points, l’importance que ces objectifs avaient pour définir la réussite d’un traitement. Des représentants de chacun des trois groupes impliqués dans ces traitements ont été recrutés à l’échelle nationale (chirurgiens et radiologistes, gastroentérologues et infirmières spécialisées en maladies inflammatoires intestinales, et enfin patients). Chaque intervenant a noté les différents objectifs possibles, puis a corrigé ses notes après avoir pris connaissance des autres notes données par les membres de son groupe (au deuxième tour) puis encore une fois après avoir pris connaissance des notations données par tous les participants (au troisième tour). Résultats : Au total, 295 objectifs potentiels ont été identifiés à partir d’une revue de la littérature et d’interviews, ils ont été catégorisés en 92 domaines. Cent quatre-vingt-sept participants (taux de réponse : 78,5 %) ont accordé la priorité à 49 objectifs à l’issue d’une méthode Delphi à trois cycles. Une réunion de consensus finale de 41 experts et patients s’est accordée sur un COS comprenant huit catégories d’objectifs. Ce COS comprenait trois catégories d’objectifs importants pour le patient (qualité de vie, incontinence et score combiné des priorités du patient) et cinq catégories d’objectifs retenus par les praticiens (activité de la maladie périanale, développement d’un nouvel abcès périanal, fistule nouvelle/récidivante, chirurgie non planifiée et dérivation fécale). Conclusion : Un COS sur les FAP de laMC a été élaboré par tous les acteurs clés de cette maladie. L’utilisation du COS diminuera l’hétérogénéité dans l’expression des résultats des traitements, ce qui rendra plus pertinente la comparaison des traitements entre eux, la synthèse des données et, en fin de compte, les soins rendus aux patients.

Fistulising ano-perineal (FAP) lesions occur in more than 20% of patients with Crohn's disease (CD). Despite advanced surgery techniques and anti-tumour necrosis factor (anti-TNF) agents use, relapse rate of FAP-CD remains 30%. The objective of the present study was to identify predictors of a subsequent ano-perineal abscess in patients with FAP-CD in remission. We conducted a retrospective study including all consecutive FAP-CD patients achieving clinical ano-perineal remission between 2007 and 2015 in one referral centre. Remission was defined by the absence of any draining fistula or abscess within 3 months after the last drainage surgery. Patient characteristics were collected at drainage, at 3 months – corresponding to the inclusion date - and during follow-up. Primary outcome was the occurrence of a subsequent ano-perineal abscess related to FAP-CD and confirmed by examination under anaesthesia and/or MRI. Predictive factors of subsequent abscess were determined in anti-TNF naïve and anti-TNF treated populations. One hundred and thirty-seven patients (57% female, median age 35 years) corresponding to 157 abscesses [120 (76.4%) treated by anti-TNF at inclusion] were included. Patients not treated by anti-TNF at inclusion were significantly older (40 years vs. 34 years, p = 0.005) and had more often simple fistulas [10 (29%) vs. 66 (58%), p = 0.004]. During the follow-up period [median duration of 43 (IQR 26–63) months], 35 (22%) experienced a subsequent abscess, which occurred within a median time of 1.8 years. Survival without abscess was 96.7% at 1 year, 78.4% at 3 years and 74.4% at 5 years. In the subgroup of 120 patients treated with anti-TNF agents (84 infliximab and 36 adalimumab) at inclusion, ileo-colonic (OR 5.19, p = 0.017) location, stricturing phenotype (OR 5.32, p = 0.013) and discontinuation of anti-TNF therapy during the follow-up period (OR 3.37, p = 0.049) were associated with a subsequent abscess in multi-variate analysis. Conversely, discontinuation of immunosuppressive therapy was associated with a reduced risk of a new abscess (OR 0.22, p = 0.29). Neither the type of anti-TNF agent nor combotherapy use were associated to FAP-CD relapse. In CD patients with fistulising ano-perineal disease achieving remission, survival without subsequent abscess was approximately 75% at 5 years. Colonic disease location, stricturing phenotype and discontinuation of anti-TNF therapy were associated with a higher risk of new abscess.

Any gastroenterologist must be trained to properly diagnose anoperineal lesions in patients with Crohn's disease (APLOC). The aim of this study was to establish whether adding pictures would improve teaching effectiveness of the diagnosis of APLOC to French gastroenterology trainees. Method: Trainees were asked to answer a first web-based survey consisting of evaluating 12 pictures of APLOC with a closed answer questionnaire. They were then randomized in 2 groups. Group A received an online teaching with typical pictures and APLOC definitions and group B definitions only. Trainees were asked again seven days later to answer a second survey with 12 other pictures of APLOC and 14 experts also answered this survey. Diagnostic scores were expressed in %. The primary endpoint was the comparison of the score of survey 2 between the two groups of trainees. Secondary endpoints were to compare results of survey 2 between trainees of both groups and experts, and assess diagnosis of each lesion. Results: Two hundred fourty eight trainees among 465 answered survey 1, and 195 survey 2. The diagnostic score was 71.9% for groups A and B and 74.6% for experts (differences NS). After training diagnosis of ulceration was 72% for group A and 72.9% for group B, fistulae 85.2% versus 85.8%, erythema 44.1% vs. 55.6%, anoperineal scars 67.5% vs. 65.6%, and abscess 100% (differences NS). Conclusion: There was no difference between the two teaching methods. Further research should be performed aiming at improving teaching material and quotation baremes. (C) 2018. Published by Elsevier Masson SAS.

Anal fistulas negatively impact prognostic in patients with Crohn’s disease. Recommended initial treatment associates surgical drainage with seton insertion, and biotherapy to control luminal and anal disease activity. After this preliminary treatment, options concerning fistula tract treatment are still debated. Especially surgical tract closure efficacy has been rarely evaluated, and not always in patients under biotherapy. In this prospective, multi-centric study, all patients with an anal fistula having responded to an initial treatment by drainage and seton insertion, plus adalimumab injections (ADA) were randomised between sole seton ablation or surgical closure of the tract by any technique (glue, flap, LIFT, etc.). Patients were included when local conditions indicated inflammatory remission (no abscess, minimal drainage) after at least a 3 month treatment with ADA, without active luminal disease. Main end-point was fistula closure at 12 months (Present criteria). Secondary end-points were ano-perineal symptoms PDAI score, quality of life IBDQ score, continence Wexner score, and perineal RMN evaluation at 6 and 12 months. Sixty-four patients (24M, 40F), mean age 36 years (19–63) have been randomised (31 sole seton ablation vs. 33 seton ablation plus surgical fistula tract closure). Fistulas were classified as simple and complex in respectively 16 (25%), and 48 patients (75%) (including 8 ano-vaginal). At 3, 6, and 12 months, fistula healing was obtained in, respectively 56%, 59%, and 59% of the patients, without any significant difference between sole seton ablation or fistula closure. In patients with simple and complex fistulas rates were respectively. 69%, 80%, and 80%, and 51%, 52%, and 52% (p = 0.035 at 12 months between simple and complex fistulas), with no difference between the two arms in any category of fistulas. Initial and 12 month mean PDAI score were 11 [9–20] and 6 [8–18] (p < 0.0001) after seton ablation, and 12 [7–21] and 8 [5–16] (p < 0.0001) after fistula closure, without any difference between the two arms. At 12 months RMN demonstrated no hyperfixation after gadolinium injection in 82% of the patients with a closed fistula, without any difference between the two arms. At 12 months Van Assche and Wexner scores were not different between the two arms. IBDQ did not change during follow-up and was not different between the two arms. In patients with Crohn’s disease and an anal fistula, having responded to initial treatment with surgical drainage and ADA injections, healing rates at 12 months were not different after closure of the fistula tract or simple seton ablation. Globally at 1 year under ADA treatment, healing rates for simple and complex anal fistulas were, respectively, 80% and 50%.

The French National Society of Coloproctology established national recommendations for the treatment of anoperineal lesions associated with Crohn's disease. Treatment strategies for anal ulcerations and anorectal stenosis are suggested. Recommendations have been graded following international recommendations, and when absent professional agreement was established. For each situation, practical algorithms have been drawn.

The French National Society of Coloproctology established national recommendations for the treatment of anoperineal lesions associated with Crohn’s disease. Treatment strategies for acute abscesses, active fistulas (active denovo and still active under treatment), fistulas in remission, and rectovaginal fistulas are suggested. Recommendations have been graded following the international recommendations, and when absent, professional agreement has been established. For each situation, practical algorithms have been drawn.

Anoperineal lesion (APL) occurrence is a significant event in the evolution of Crohn’s disease (CD). Management should involve a multidisciplinary approach combining the knowledge of the gastroenterologist, the colorectal surgeon and the radiologist who have appropriate experience in this area. Given the low level of evidence of available medical and surgical strategies, the aim of this work was to establish a French expert consensus on management of anal Crohn’s disease. These recommendations were led under the aegis of the Société Nationale Française de Colo-Proctologie (SNFCP). They report a consensus on the management of perianal Crohn’s disease lesions, including fistulas, ulceration and anorectal stenosis and propose an appropriate treatment strategy, as well as sphincter-preserving and multidisciplinary management.

La résection par voie transanale est la technique qui permet l’exérèse locale des tumeurs rectales avec l’outillage le plus simple. Cette technique historique a été supplantée par l’avancée de la « microchirurgie » effectuée à l’aide d’un rectoscope spécifique ou d’un port monotrocard. Toutefois, cette technique reste une option valable pour les tumeurs du tiers inférieur du rectum, région où l’exposition n’est pas la plus facile avec les appareils de microchirurgie. La technique est simple mais doit toutefois respecter les règles de la chirurgie carcinologique. Les indications de la chirurgie locale se sont restreintes avec le temps et elle n’est plus discutée que pour les cancers les plus superficiels présentant des critères histologiques favorables.

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.

qui est un clin d'oeil à mon parcours professionnel.