Recent advances in medical and surgical therapy were achieved during the last two decades in the management of Crohn's disease (CD). Anti-tumor necrosis factor (anti-TNF) agents are widely used worldwide. However, a significant proportion of patients still need surgical resections. The impact of previous exposure to these agents on the perioperative and postoperative outcomes is still controversial. In this critical review, we aimed to position the strategy of intentional preoperative use of anti-TNF agents in the management of CD. The indications and contraindications for this strategy are detailed, and despite scarce evidence, the possible advantages and disadvantages of the intentional use of anti-TNF agents before abdominal surgery in CD are discussed.
Crohn Disease* ; Humans ; Necrosis* ; Preoperative Care ; Tumor Necrosis Factor-alpha

Purpose: Standard therapy for grade III hemorrhoids is rubber band ligation (RBL) and hemorrhoidectomy. The long-term clinical and patient-reported outcomes of these treatments in a tertiary referral center for proctology were evaluated. Methods: A retrospective analysis was performed in all patients with grade III hemorrhoids who were treated between January 2013 and August 2018. Medical history, symptoms, reinterventions, complications, and patient-reported outcome measurements (PROM) were retrieved from individual electronic patient files, which were prospectively entered as standard questionnaires in our clinic. Results: Overall, 327 patients (163 males) were treated by either RBL (n=182) or hemorrhoidectomy (n=145). The median follow-up was 44 months. The severity of symptoms and patient preference led to the treatment of choice. The most commonly experienced symptoms were prolapse (83.2%) and blood loss (69.7%). Hemorrhoidectomy was effective in 95.9% of the cases as a single procedure, while a single RBL procedure was only effective in 51.6%. In the RBL group, 34.6% received a second RBL session. Complications were not significantly different, 11 (7.6%) after hemorrhoidectomy versus 6 (3.3%) after RBL. However, 4 fistulas developed after hemorrhoidectomy and none after RBL (P<0.05). The pre-procedure PROM score was higher in the hemorrhoidectomy group whereas the post-procedure PROM score did not significantly differ between the groups. Conclusion Treatment of grade III hemorrhoids usually requires more than one session RBL whereas 1-time hemorrhoidectomy suffices. Complications were more common after hemorrhoidectomy. The patient-related outcome did not differ between procedures.