Abstract

Aim

The primary aim of the European Society of Coloproctology (ESCP) Guideline Development Group (GDG) was to produce high-quality, evidence-based guidelines for the management of cryptoglandular anal fistula with input from a multidisciplinary group and using transparent, reproducible methodology.

Methods

Previously published methodology in guideline development by the ESCP has been replicated in this project. The guideline development process followed the requirements of the AGREE-S tool kit. Six phases can be identified in the methodology. Phase one sets the scope of the guideline, which addresses the diagnostic and therapeutic management of perianal abscess and cryptoglandular anal fistula in adult patients presenting to secondary care. The target population for this guideline are healthcare practitioners in secondary care and patients interested in understanding the clinical evidence available for various surgical interventions for anal fistula. Phase two involved formulation of the GDG. The GDG consisted of 21 coloproctologists, three research fellows, a radiologist and a methodologist. Stakeholders were chosen for their clinical and academic involvement in the management of anal fistula as well as being representative of the geographical variation among the ESCP membership. Five patients were recruited from patient groups to review the draft guideline. These patients attended two virtual meetings to discuss the evidence and suggest amendments. In phase three, patient/population, intervention, comparison and outcomes questions were formulated by the GDG. The GDG ratified 250 questions and chose 45 for inclusion in the guideline. In phase four, critical and important outcomes were confirmed for inclusion. Important outcomes were pain and wound healing. Critical outcomes were fistula healing, fistula recurrence and incontinence. These outcomes formed part of the inclusion criteria for the literature search. In phase five, a literature search was performed of MEDLINE (Ovid), PubMed, Embase (Ovid) and the Cochrane Database of Systematic Reviews by eight teams of the GDG. Data were extracted and submitted for review by the GDG in a draft guideline. The most recent systematic reviews were prioritized for inclusion. Studies published since the most recent systematic review were included in our analysis by conducting a new meta-analysis using Review manager. In phase six, recommendations were formulated, using grading of recommendations, assessment, development, and evaluations, in three virtual meetings of the GDG.

Results

In seven sections covering the diagnostic and therapeutic management of perianal abscess and cryptoglandular anal fistula, there are 42 recommendations.

Conclusion

This is an up-to-date international guideline on the management of cryptoglandular anal fistula using methodology prescribed by the AGREE enterprise.

Summary

Transjugular intrahepatic portosystemic shunt (TIPS) placement is a well-established procedure for managing complications of portal hypertension. In recent years, the field of TIPS has seen rapid advances, particularly in technical approaches, prognostic modelling, and an expanding range of indications. The aim of these EASL guidelines is to comprehensively address all aspects of TIPS in patients with cirrhosis. Other related topics, such as the use of TIPS in surgical settings and in vascular liver disorders, are covered in separate dedicated clinical practice guidelines.

Summary

Vascular diseases of the liver include portal vein thrombosis (with or without cirrhosis), portosinusoidal vascular disorder, Budd-Chiari syndrome, sinusoidal obstruction syndrome, non-obstructive sinusoidal dilatation and peliosis, splanchnic artery aneurysms, and hepatic arteriovenous fistulas. Except for portal vein thrombosis in cirrhosis, these are all rare conditions. Since the last Clinical Practice Guidelines were issued by the European Association for the Study of the Liver in 2016, much data has been published on the diagnosis and management – medical and interventional – of patients with vascular liver diseases. Based on a thorough review of the relevant literature, recommendations are provided to address key clinical dilemmas. The document emphasises personalised care, considering individual risk factors and clinical presentation. Multidisciplinary management involving hepatologists, haematologists, pathologists, interventional radiologists and surgeons is essential in this area. Our aim is to provide guidance on the management of patients with vascular liver diseases based on the best available evidence.

Abstract

Objectives

To provide a consensus statement and recommendations on MR imaging in primary sclerosing cholangitis (PSC).

Methods

The European Society of Gastrointestinal and Abdominal Radiology (ESGAR) convened a multinational European panel of experts selected based on a literature review and their leadership in the field. A modified Delphi process was adopted to draft a list of statements. For each statement, the panelists indicated the level of agreement using a 5-point Likert scale, where 1 means “no agreement,” 2 means “poor agreement,” 3 means “slight agreement,” 4 means “fair agreement,” and 5 means “complete agreement.” The median score for each statement was collected. The level of evidence was reported according to the Oxford Centre for Evidence-Based Medicine. Descriptive statistics were used to rate agreement levels and the consensus’ internal reliability.

Results

The 12 voting committee members were from Italy (n = 4, 33.4%), Austria (n = 2, 16.7%), Sweden (n = 1, 8.3%), France (n = 1, 8.3%), the United States (n = 1, 8.3%), Switzerland (n = 1, 8.3%), and Belgium (n = 2, 16.7%). The final questionnaire consisted of 55 statements. The agreement reached by the expert panel was complete for 23 statements (41.8%), fair for 16 (29.1%), slight for 15 (27.2%), and poor for 1 (1.9%). Statements that received complete agreement were used to structure a reporting template.

Conclusions

This statement paper recommends how and when to perform MRI in PSC patients. A structured reporting template has been created to improve quality care and communication among radiologists and clinicians.

Key Points

Question A standard MR protocol and the most common imaging features to be reported are fundamental for the correct evaluation of primary sclerosing cholangitis (PSC) patients.

Findings Twelve expert radiologists reported which are the most important imaging features and how and when to perform MR in PSC patients.

Clinical relevance The identified statements reported in this paper and the structured reporting template are useful for radiologists and clinicians to help correctly manage PSC patients.

ABSTRACT

Abstract

Background

Choledocholithiasis presents in a considerable proportion of patients with gallbladder disease. There are several management options, including preoperative or intraoperative endoscopic cholangiopancreatography (ERCP), and laparoscopic common bile duct exploration (LCBDE).

Objective

To develop evidence-informed, interdisciplinary, European recommendations on the management of common bile duct stones in the context of intact gallbladder with a clinical decision to intervene to both the gallbladder and the common bile duct stones.

Methods

We updated a systematic review and network meta-analysis of LCBDE, preoperative, intraoperative, and postoperative ERCP. We formed evidence summaries using the GRADE and the CINeMA methodology, and a panel of general surgeons, gastroenterologists, and a patient representative contributed to the development of a GRADE evidence-to-decision framework to select among multiple interventions.

Results

The panel reached unanimous consensus on the first Delphi round. We suggest LCBDE over preoperative, intraoperative, or postoperative ERCP, when surgical experience and expertise are available; intraoperative ERCP over LCBDE, preoperative or postoperative ERCP, when this is logistically feasible in a given healthcare setting; and preoperative ERCP over LCBDE or postoperative ERCP, when intraoperative ERCP is not feasible and there is insufficient experience or expertise with LCBDE (weak recommendation). The evidence summaries and decision aids are available on the platform MAGICapp (https://app.magicapp.org/#/guideline/nJ5zyL).

Conclusion

We developed a rapid guideline on the management of common bile duct stones in line with latest methodological standards. It can be used by healthcare professionals and other stakeholders to inform clinical and policy decisions.

Guideline registration number

IPGRP-2022CN170.

Summary