Is simple fistula-in-ano simple?

Use of 3D Anorectal Ultrasonography in the Preoperative Assessment of Complex Anal Fistulas and Patterns of Healing, Failure, and Recurrence After Ligation of the Intersphincteric Fistula Tract (LIFT)

OBJECTIVES

To use three-dimensional anorectal ultrasonography (3D-US) to evaluate the outcome of ligation of the intersphincteric fistula tract (LIFT) in patients with crypto-glandular transsphincteric fistula and describing the patterns of healing, failure, and recurrence rate.

METHODS

After classifying the fistula and determining the length of the sphincter muscle to be transected, the patients were submitted to LIFT. The accuracy of pre- and postoperative 3D-US with 360° endoprobe (16 MHz) with automatic scanning and clinical findings was evaluated against surgical findings. Three outcomes were considered: healing, failure (persistent anal fistula through the original external opening or intersphincteric), and recurrence (reappearance of the anal fistula).

RESULTS

Sixty-three patients of both sexes were evaluated. The 3D-US assessment revealed primary healing in 50 (79.3%) patients, although in 6 (9.5%) cases healing was delayed and the cavity was without communication with the anal canal. The procedure failed in 9 (15.9%) and fistula recurred in 4 (6.3%), all of whom underwent a second surgery based on a new 3D-US, resulting in a 92.3% (12/13) healing rate on 3D-US.

CONCLUSIONS

A 3D-US was found to be useful in the preoperative assessment of fistulas by quantifying the percentage of muscle to be transected, and in the postoperative assessment by identifying healing, types of failure, and recurrence. The 3D-US was accurate and consistent with surgical findings.

Cell-assisted lipotransfer in treating uncontrollable sepsis associated perianal fistula: a pilot study

PURPOSE

Surgeons can treat debilitating conditions of uncontrollable complex anorectal fistulas with sepsis, even after repeated fistula surgeries, for curative intention. Adipose-derived stem cells have shown good outcomes for refractory Crohn fistula. Unfortunately, cell therapy has some limitations, including high costs. We have therefore attempted immediate cell-assisted lipotransfer (CAL) in treating refractory complex anal fistulas and observed its outcomes.

METHODS

In a retrospective study, CAL, using a mixture of freshly extracted autologous stromal vascular fraction (SVF) and fat tissues, was used to treat 22 patients of refractory complex anal fistula from March 2018 to May 2021. Preoperative and postoperative assessments were performed with direct visual inspection, digital palpation, and endoanal ultrasonography. A fistula was considered completely healed if (1) the patient had no symptoms of discharge or inflammation; (2) there were no visible secondary openings of fistula tract inside and outside of the anorectal unit and even in the perineum; and (3) there was no primary opening in the anus. The endpoint of complete remission was wound healing without signs of inflammation 3 months after CAL treatment.

RESULTS

In a total of 22 patients who received CAL treatment, 19 patients showed complete remission, 1 patient showed partial improvement, and 2 patients showed no improvement. One of the 2 patients without improvement at primary endpoint showed complete remission 9 months after CAL. There were no significant adverse effects of the procedure.

CONCLUSION

We found that the immediately-collected CAL procedure for refractory complex anal fistula showed good outcomes without adverse side effects. It can be strongly recommended as an alternative surgical option for the treatment of complex anal fistula that is uncontrollable even after repeated surgical procedures. However, considering the unpredictable characteristics of SVF, long-term follow-up is necessary.

The risk factors for failure and recurrence of LIFT procedure for fistula in ano

Objectives

Fistula in ano (FIA) is a common anorectal problem. There are several techniques that have been used for treatment; however, all of them carry risks of recurrence and incontinence. Ligation intersphincteric fistula tract (LIFT) is a type of treatment with a promising result of preserving the anal sphincter function. This study aimed to evaluate the outcome and risk factor of LIFT failure and to demonstrate the pattern of recurrence. The research funding was supported by Rajavithi Hospital.

Material and Methods

From January 2015 to January 2020, there were 250 cases of fistula in ano operations. A total of 148 patients underwent LIFT operation. The patients' average age was 39.72 ± 10.55 years and the average follow-up period was 111.86 ± 79.73 days. The average time to diagnose the recurrence was 99.12 ± 30.08 days. In addition, average time to perform a surgery after the diganosis was 64.67 ± 25.76 days. The study's analyses used data on age, sex, type of fistula, operative intervention, healing time, reinterventions, and recurrence.

Results

There were 22.97% of recurrence among 148 LIFT patients. Half of the patients who underwent the operation had a preoperative imaging study with MRI or endoanal ultrasonography in the first time due to the complexity of the disease. Factors associated with operation failure were collection, fistula tract size more than 5 millimeters, and the failure of ligating the tract in one attempt.

Conclusion

LIFT procedure is one of the several sphincter saving procedures to treat FIA. Recurrence is related with the complexity of the disease. Most of the recurrence is diseases that are easier to treat, such as performing a re-operation or fistulotomy.

Would Surgeons Like to Be Submitted to Anal Fistulotomy? An International Web-Based Survey

Traditional fistulotomy is the most performed surgical procedure in anal fistula surgery. We conducted an international online survey to explore colorectal surgeons' opinions and preferences on fistulotomy. Considering the healing and continence impairment rates reported in the literature, surgeons were invited to answer as a hypothetic patient susceptible to being submitted to fistulotomy for low and high anal fistula. A total of 767 surgeons completed the survey from 72 countries. The majority of respondents were consultants, having treated more than 20 anal fistulas in the last year. Most of them declared that anal fistula would be able to negatively affect quality of life and would be worried/anxious about it. Taking into account all aspects, 87.5% and 37.8% of respondents would agree to be treated with a fistulotomy in case of a low and high fistula, respectively, with an acceptance rate that varied worldwide. At multivariate analysis, factors correlated to the acceptance of anal fistulotomy were male gender (p = 0.003), practice of less than 20 fistula operations during last year (p = 0.020), and low fistula (p < 0.001). Surgeons recognized the extreme complexity of this approach. This study highlighted the necessity of an accurate patients' selection and the adoption of alternative strategy to reduce the risk of anal continence impairment.

Complex Anal fistula treated with IFTAK (Interception of fistulous track with application of ksharsutra) technique- A case report

BACKGROUND

An anal fistula is a common benign anorectal disease that tends to reoccur simple or low-type fistulas can be treated without affecting the sphincter mechanism; however, repairing a complex ano fistula without compromising anal continence can be difficult for a surgeon.

CASE PRESENTATION

Here, we present an anal fistula of complex clinical appearance managed successfully by the IFTAK (Interception of fistulous track with application of ksharsutra) technique practiced at Banaras Hindu University, Varanasi, India. The diagnosis was made via visual and bi-manual digital rectal examination then confirmed by Endoanal ultrasonography (EAUS). The patient showed remarkable improvement and the fistula healed completely in due course of time without impairing the anal continence status of the patient. At four months of follow-up the patient was healthy and no recurrence was found.

CONCLUSION

IFTAK is a minimally invasive technique and very effective in managing complex fistula in ano of cryptoglandular origin. The main cause of recurrence in complex anal fistula is non-identification of an infected anal crypt, secondary extensions, associated sepsis, or abscess at the time of examination or surgery. So, precise diagnosis and appropriate surgical measures play an equal role in the successful outcome of anal fistula treatment, failure to either will result in non-healing or recurrence.

VAAFT PROCEDURE (Video-assisted Anal Fistula Treatment) versus Open Method in the Treatment of High Fistula in Ano

Background A common acquired anorectal condition is anal fistula. The treatment approaches that have been employed have been linked to erratic outcomes and sometimes life-threatening consequences. Video-assisted anal fistula treatment (VAAFT), a minimally invasive method, was introduced for adult patients in 2011.

Objective To know the efficacy of the VAAFT procedure in treating high anal fistulas and to compare it to open methods in the Basrah province.

Methods The present study was performed on 200 patients with high fistulas in ano in Basrah province. We divided the patients into 2 groups: Group A: treated by the VAAFT technique and Group B: treated by open fistulotomy

Results The patients treated with VAFFT revealed no occurrence of the following postoperative complication: Infection, incontinence, recurrence, anal stenosis, and bleeding. There was lower incidence of pain, short time for wound healing, rapid return to work, and more patient satisfaction compared with open fistulotomy

Conclusion An innovative method for managing ano fistula is VAAFT. Compared with traditional methods, it has a lot of benefits. It is day case surgeryno open wound.no damage to anal sphincter and no risk of incontinence, it is more affordable.it allow for clear identification of internal office, whole tract and its associated branches and cavity. The instrument can be used for multiple patients after good sterilization and disinfection.

Advancements in Rectal Drug Delivery Systems: Clinical Trials, and Patents Perspective

The rectal route is an effective route for the local and systemic delivery of active pharmaceutical ingredients. The environment of the rectum is relatively constant with low enzymatic activity and is favorable for drugs having poor oral absorption, extensive first-pass metabolism, gastric irritation, stability issues in the gastric environment, localized activity, and for drugs that cannot be administered by other routes. The present review addresses the rectal physiology, rectal diseases, and pharmaceutical factors influencing rectal delivery of drugs and discusses different rectal drug delivery systems including suppositories, suspensions, microspheres, nanoparticles, liposomes, tablets, and hydrogels. Clinical trials on various rectal drug delivery systems are presented in tabular form. Applications of different novel drug delivery carriers viz. nanoparticles, liposomes, solid lipid nanoparticles, microspheres, transferosomes, nano-niosomes, and nanomicelles have been discussed and demonstrated for their potential use in rectal administration. Various opportunities and challenges for rectal delivery including recent advancements and patented formulations for rectal drug delivery have also been included.

Clinicopathological determinants of recurrence after surgical treatment of fistula-in-ano in a Ghanaian teaching hospital

AIM

The aim of this work is to describe the clinicopathological and surgical aspects of fistula-in-ano and assess the risks associated with recurrence of the disease in a Ghanaian teaching hospital.

METHOD

This was a retrospective observational study assessing all fistula-in-ano surgeries performed at the Korle Bu Teaching hospital from January 2014 to January 2021 that had completed follow up of at least 3 months after wound healing. Demographic, clinical, pathological and surgical data were extracted from patient records. Logistic regression analysis was used to test for association between these variables and recurrence.

RESULTS

A total of 105 patients underwent 124 fistula surgeries. Their median age was 41 years, the male:female ratio was 4:1 and 12 had comorbidities including human immunodeficiency virus infection and diabetes mellitus. Thirty-one per cent (39/124) of fistulas had previously been operated on. At surgery, 51% (64/124) of fistulas followed a single straight tract, 30% (37/124) a single curved tract and 19% (23/124) had multiple curved tracts. More than half (65/124) were trans-sphincteric, 35% (44/124) suprasphincteric, 10% (12/124) subsphincteric and 2% (3/124) were intersphincteric. Sixty per cent of fistulas were treated with a ligation of intersphincteric fistula tract (74/124), 35% (44/124) a fistulectomy and 5% a fistulotomy. Recurrence after surgery was 22.5% (28/124); this was significantly higher for fistulas with multiple curved tracts (OR 4.153, 95% CI 1.431-12.054, p = 0.012) and fistulas with comorbidities (OR 3.222, 95% CI 1.076-9.647, p = 0.037).

CONCLUSION

There was high recurrence after fistula surgery with increased risk for fistulas with multiple tracts and the presence of comorbidities.

Loose Thick Seton Suture Stimulates Rapid Healing and Lower Recurrence Rate in the Treatment of High Type Fistula in Ano

BACKGROUND: Fistula in ano is a chronic problem for the patients. It causes distressing because of foul odor and soiling with recurrent infection and discharge. Recurrence and anal sphincter injury were the most critical complications following surgery. Loose, thick seton placement was the most promising surgical operation. AIM: To reduce the time of seton placement, therefore, decreasing the suffering of patients from soiling and multiple dressing. PATIENTS AND METHODS: A retrospective study, one hundred patients with high type fistula in ano treated surgically in Al-Sader Medical city and Al-Najaf daily private clinic, Najaf city, Iraq, from February 2018 to March 2019. Fistulography and magnetic resonance imaging have taken from all patients. After that, fistulectomy with loose, thick seton suture placed for 3 months. Patients with the persistence of high fistula tract underwent a second surgery and third operation until complete healing. RESULTS: One hundred patients with high type fistula in ano with male 96 (96%) and female patients were 4 (4%). The rate of complete healing among male patients after the first operation was 90 (93%), while female patients showed a 4 (100%) rate of complete healing after the first operation. Three of the remaining male patients with persistently high fistula tract showed complete healing after the second operation, whereas 3 (3%) the rate of complete healing was 100% after the third operation. CONCLUSION: A loose, thick seton placed in high type fistula tract for 3 months provides excellent protection to the external anal sphincter with less recurrence rate and rapid healing.

Simple fistula-in-ano: is it all simple? A systematic review

BACKGROUND

Simple anal fistula is one of the most common causes of proctological surgery and fistulotomy is considered the gold standard. This procedure, however, may cause complications. The aim of this systematic review was to assess the surgical treatment of simple anal fistula with traditional and sphincter-sparing techniques.

METHODS

A literature research was performed using PubMed, Cochrane, and Google Scholar to identify studies on the surgical treatment of simple anal fistulas. Observational studies and randomized clinical trials were included. We assessed the risk of bias of included studies using the Jadad scale for randomized controlled trials, and the MINORS Scale for the remaining studies.

RESULTS

The search returned 456 records, and 66 studies were found to be eligible. The quality of the studies was generally low. A total of 4883 patients with a simple anal fistula underwent a sphincter-cutting procedure, mainly fistulotomy, with a weighted average healing rate of 93.7%, while any postoperative continence impairment was reported in 12.7% of patients. Sphincter-sparing techniques were adopted to treat 602 patients affected by simple anal fistula, reaching a weighted average success rate of 77.7%, with no study reporting a significant postoperative incontinence rate. The postoperative onset of fecal incontinence and the recurrence of the disease reduced patients' quality of life and satisfaction.

CONCLUSIONS

Surgical treatment of simple anal fistulas with sphincter-cutting procedures provides excellent cure rates, even if postoperative fecal incontinence is not a negligible risk. A sphincter-sparing procedure could be useful in selected patients.

Anatomical characteristics of anal fistula evaluated by three-dimensional anorectal ultrasonography: is there a correlation with Goodsall's theory?

Purpose We aimed to correlate the course of the anal fistula tract (T), location of the external opening (EO) and internal opening (IO) in anterior (A) and posterior (P) circumference using 3D-US according to Goodsall's rule.

Methods 151 patients with primary cryptoglandular Transsphincteric fistulas were examined with 3D-US and compared with surgical finding. The type of the T (straight or curved), EO and IO were identified and divided into 3 Groups: GI: EO and IO are located in a position; GII: EO and IO are located in P position and GIII: OE and OI are located in the opposite position. The findings were correlated with Goodsall's rule.

Results 74/151(49%) were included in GI, of them, 41 (55%) were male (33/44% had straight tract and 8/11% curved) and 33 (45%) female (15/20%-straight and 18/25%-curved). GII included 68 (45%), of them, 50 (74%) were male (39/57%-straight and 11/15%-curved) and 18 (26%) female (14/20%-straight and 04/8%-curved). GIII = 9 (6%) and all of them had curved tract. The overall concordance between 3D-US and surgical finding was 98% for tract and 96% for IO.

Conclusion The 3D-US findings correlate with the Goodsall's rule in transsphincteric fistulas located in the anterior circumference straight type, in male, while in females the distribution of curved and straight paths is similar. In the posterior circumference no correlation was observed in both the sexes.

The effect of suture selection in complex anal fistulas on the success of cutting seton placement and patient comfort

Objective:

The aim of our study was to compare the success rates of suture selection, recovery times and pain associated with local wound infection and seton placement in patients undergoing cutting seton placement for complex anal fistula.

Methods:

The study included a total of 90 patients who were admitted with the diagnosis of complex anal fistula between January 2015 and July 2018.

Results:

The first session and other revision appointments demonstrated that the number of patients who required fistulotomy was significantly higher in group-1 as the seton failed to complete the transection (p = 0.001). When the patients were asked to rate pain for 3 different conditions according to numeric rating scale (NRS), the patients in group-2 had significantly higher pain in all 3 cases compared to the patients in group-1 (p 0.001). The impact of the suture material on local infection was examined and it was determined that the results of cultures for seton material were significantly more positive in group-1 (p = 0.001).

Conclusions:

We conclude that a multi-stage tight seton placement with silk material can lead to satisfactory results by aiming to shorten the cutting time of silk seton.

Video-Assisted Anal Fistula Treatment (VAAFT) for complex anorectal fistula: efficacy and risk factors for failure at 3-year follow-up

BACKGROUND

The aim of this study was to assess the 3-year objective and subjective outcomes of patients with complex anorectal fistula treated with Video-Assisted Anal Fistula Treatment (VAAFT). Furthermore, we evaluated the risk factors associated with recurrence.

METHODS

All consecutive patients with complex anorectal fistula who underwent VAAFT in Beata Vergine Hospital of Mendrisio, Switzerland, from January 2013 to January 2016, were enrolled. Patients with suspicion or diagnosis of Crohn's disease, malignancy, previous history of radiotherapy or radical pelvic surgery were excluded. Preoperative clinical assessment based upon medical history, physical examination and endosonography, was performed in all patients. Data regarding subjective outcomes (the Patient Global Impression of Improvement, patient satisfaction scores and Wexner score), objective cure rate (absence of fistula at clinical examination), and adverse events were collected during follow-up. Uni and multivariate analysis were performed to investigate outcomes.

RESULTS

One hundred and four patients had VAAFT. At 3-year follow-up, 96 patients (92.3%) were available for the evaluation. At 3 years after surgery, 81 of 96 patients (84.4%) declared themselves cured (p = 0.60). Similarly, at 3-year evaluation, 80 of 96 patients (83.3%) were objectively cured (p = 0.52). No serious intraoperative or postoperative complications were reported. All recurrences were treated with a repeat VAAFT procedure resulting in a complete healing. Uni and multivariate analysis of variables potentially involved in the failure of VAAFT showed that age ≥ 50 years was the only factor associated at risk of recurrence.

CONCLUSIONS

VAAFT is a highly effective safe procedure for the treatment of anorectal fistula, with a low recurrence rate at 3-year follow-up. However, our study demonstrated that age ≥ 50 years is a risk factor for failure of VAAFT.

Hot topics in global perianal fistula research: A scopus-based bibliometric analysis

BACKGROUND

The number of citations a scientific paper has received indicates its impact within any medical field. We performed a bibliometric analysis to highlight the key topics of the most frequently cited 100 articles on perianal fistula to determine the advances in this field.

METHODS

The Scopus database was searched from 1960 to 2018 using the search terms "perianal fistula" or "anal fistula" or "fistula in ano" or "anal fistulae" or "anorectal fistulae" including full articles. The topic, year of publication, publishing journal, country of origin, institution, and department of the first author were analyzed.

RESULTS

The median number of citations for the top 100 of 3431 eligible papers, ranked in order of the number of citations, was 100 (range: 65-811), and the number of citations per year was 7.5 (range: 3.8-40.1). The most-cited paper (by Parks et al in 1976; 811citations) focused on the classification of perianal fistula. The institution with the highest number of publications was St Mark's Hospital, London, UK. The most-studied topic was surgical management (n = 47). The country and the decade with the greatest number of publications in this field were the USA (n = 34) and the 2000s (n = 50), respectively.

CONCLUSION

The 100 most frequently cited manuscripts showed that surgical management had the greatest impact on the study of perianal fistula. This citation analysis provides a reference of what could be considered the most classic papers on perianal fistula, and may serve as a reference for researchers and clinicians as to what constitutes a citable paper in this field.

Autologous adipose-derived stem cells for the treatment of Crohn's fistula-in-ano: an open-label, controlled trial

BACKGROUND

Crohn's fistula-in-ano is a refractory disease in colorectal and anal surgery. Although autologous adipose-derived stem cell (ADSC) has been used in the treatment of Crohn's fistula-in-ano because of its convenience, non-incision of normal tissue, good tolerance, repeatability, quick recovery, less pain, less damage to anal function, and high quality of life during the perioperative period, there are no reports of its use in China. This is the first clinical trial in China on the treatment of Crohn's fistula-in-ano with ADSC to evaluate its efficacy and safety.

METHODS

A total of 22 patients with Crohn's fistula-in-ano were enrolled in this study from January 2018 to October 2018 in the Colorectal Disease Center of Nanjing Hospital of Chinese Medicine Affiliated to Nanjing University of Chinese Medicine. Patients were divided (1:1) into an observation group (ADSC) and a control group (incision-thread-drawing procedure). Primary efficacy endpoint evaluated at months 3, 6, and 12 was the closure of fistulas (closure of all treated fistulas at baseline, confirmed by doctor's clinical assessment and magnetic resonance imaging or transrectal ultrasonography). The patients additionally completed some scoring scales at each follow-up including simplified Crohn's Disease Activity Index (CDAI), Perianal Disease Activity Index (PDAI), Inflammatory Bowel Disease Questionnaire (IBDQ), pain scores with visual analog score (VAS), and Wexner score. The data of inflammatory indexes were also collected.

RESULTS

The healing rates of the observation group and the control group at months 3, 6, and 12 were as follows: 10/11(90.9%) vs 5/11(45.5%), 8/11(72.7%) vs 6/11(54.5%), and 7/11(63.6%) vs 6/11(54.5%), respectively. There was no statistical difference between the two groups. In addition, the improvement in simplified CDAI, PDAI, IBDQ, VAS, and Wexner score of the observation group were better than that of the control group at each follow-up. The inflammatory indexes decreased in both the observation group and the control group at 3 months follow-up. And there were no significant differences in the changes of inflammatory indexes between two groups at month 3 compared with the baseline. Safety was maintained throughout month 12, and adverse events occurred in 63.6% of patients in the observation group and 100% patients in the control group. And no adverse event associated with ADSC injection was observed in the study.

CONCLUSION

ADSC is a feasible and effective treatment for Crohn's fistula-in-ano, compared with traditional incision and thread-drawing. It can protect anal function of patients, relieve pain, allow quick recovery, be well-tolerated, and improve the quality of life during perioperative period.

TRIAL REGISTRATION

China Clinical Trials Registry, No. ChiCTR1800014599. Registered 23 January 2018.

Comparison of surgical outcomes between video-assisted anal fistula treatment and fistulotomy plus seton for complex anal fistula: A propensity score matching analysis - Retrospective cohort study

BACKGROUND

Video-assisted anal fistula treatment (VAAFT) is a new minimally invasive technique for treating complex anal fistula (CAF). This study aimed to compare the efficacy and safety of VAAFT with fistulotomy plus seton (FPS) for treatment of CAF.

MATERIALS AND METHODS

We included 148 patients with CAF receiving surgical treatment at our hospital between January 2017 and December 2018. Propensity score matching (PSM) analysis was conducted with patients' baseline characteristics, and surgical outcomes were compared between the matched groups. Logistic analysis was performed to identify the risk factors for fistula recurrence after VAAFT.

RESULTS

Among the study population, 68 and 80 patients underwent VAAFT and FPS, respectively. After PSM, 64 matched pairs of patients were created with no significant differences in baseline characteristics. Compared with FPS, VAAFT had greater efficiency of locating internal openings (90.6% vs. 100%), less intraoperative blood loss (26 ± 15 vs. 12 ± 5 mL), lower incidence of postoperative bleeding (10.9% vs. 1.5%), shorter postoperative hospital stay (6.8 ± 5.1 vs. 5.0 ± 3.3 days), reduced postoperative pain, and decreased wound secretion (all P < 0.05). VAAFT showed a significantly lower Wexner incontinence score than FPS (0.9 ± 1.7 vs. 1.9 ± 2.6, P = 0.003) at 3 months postoperatively, but no significant difference in the healing rate was observed either at 3-month or 1-year (P = 1.000) follow-up. A total of 12 patients (17.6%) developed fistula recurrence after VAAFT, and logistic analysis revealed that multiple fistula tracts, prolonged operating time and severe postoperative wound secretion were independent risk factors (odds risk = 2.18, 3.25 and 3.04, respectively, all adjusted P < 0.05).

CONCLUSION

Compared with FPS, VAAFT offers some advantages for treatment of CAF, including minimal damage, less pain, rapid recovery, fewer complications and better sphincter preservation.

Risk Factors for Recurrence after anal fistula surgery: A meta-analysis

BACKGROUND

Despite a burgeoning literature during the last two decades regarding perioperative risk management of anal fistula, little is known about its risk factors that influence postoperative recurrence. We performed a meta-analysis to summarize and assess the credibility of evidence of potential risk factors for anal fistula recurrence (AFR) after surgery.

METHODS

Pubmed and EMBASE without language restriction were searched from inception to April 2018 that reported risk factors which predisposed recurrence after anal fistula surgery. We excluded studies that involved patients with anal fistula associated with Crohn's disease. MOOSE guidelines were followed when this meta-analysis was performed. We used random-effects models to pool relative risks (RRs) with 95% confidence intervals (CIs). Evidence from observational studies was graded into high-quality (Class I), moderate-quality (Class II/III) and low-quality (Class IV) based on Egger's P value, total sample size and between-study heterogeneity.

RESULTS

Of 3514 citations screened, 20 unique observational studies comprising 6168 patients were involved in data synthesis. High-quality evidence showed that AFR was associated with high transsphincteric fistula (RR, 4.77; 95% CI, 3.83 to 5.95), internal opening unidentified (RR, 8.54; 95% CI, 5.29 to 13.80), and horseshoe extensions (RR, 1.92; 95% CI, 1.43 to 2.59). Moderate-quality evidence suggested an association with prior anal surgery (RR, 1.52; 95% CI, 1.04 to 2.23), seton placement surgery (RR, 2.97; 95% CI, 1.10 to 8.06), and multiple fistula tract (RR, 4.77; 95% CI, 1.46 to 15.51). High-quality evidence demonstrated no significant association with gender or smoking; moderate-quality evidence also suggested no association with age, tertiary referral, alcohol use, diabetes mellitus, obesity, preoperative seton drainage, high internal opening, postoperative drainage, mucosal advancement flap surgery, supralevator extensions, location or type of anal fistula.

CONCLUSION

Several patient, surgery and fistula-related factors are significantly associated with postoperative AFR. These findings strengthen clinical awareness of early warning to identify patients with high-risk disease recurrence for AFR.

Platelet-rich plasma (PRP) versus fibrin glue in cryptogenic fistula-in-ano: a phase III single-center, randomized, double-blind trial

PURPOSE

To compare the clinical outcome of autologous platelet-rich growth factor (PRP) with commercial fibrin glue in the management of high cryptogenic fistulae-in-ano.

METHOD

The study was conducted at a single center between July 2012 and July 2015 and performed as a phase III, randomized, double-blind comparison of autologously prepared PRP versus fibrin glue for cryptoglandular anal fistulae without active sepsis. Patients were assessed with clinical and endosonographic follow-up. Patients were followed up at 1 week and then at 3, 6, and 12 postoperative months. The primary outcome measure was the fistula healing rate (complete, partial, and non-healing) with secondary outcome measures assessing fistula recurrence, continence status, quality of life, and visual analog pain scores.

RESULTS

Of the 56 enrolled patients, 32 were PRP-treated and 24 were fibrin-treated. The groups were well matched for fistula type with an improved overall healing rate for PRP-treated over fibrin-treated cases (71% vs. 58.3%, respectively; P = 0.608); a complete healing rate of 48.4% vs. 41.7%, respectively; and a partial healing rate of 22.6% vs. 16.7%, respectively. The median pain scores of PRP-treated patients were lower at the first visit with a greater initial pain decrease early during follow-up. Improvements in pain reduction impacted the quality of life measures (P = 0.035). All adverse events were minor and no patient experienced a negative impact on continence.

CONCLUSION

Treatment of complex cryptoglandular anal fistula with autologous PRP is as effective as fibrin glue with less cost and no adverse effect on continence.

Factors Increasing the Risk of Recurrence in Fistula-in-ano

Anal fistula, or fistula-in-ano, is a condition involving the anal region that is common yet debilitating. Surgery is the mainstay of treatment for an anal fistula and the chances of recurrence are quite high even after corrective surgical procedures. The risk factors for recurrence can be broadly classified into four categories: 1) risk factors related to the fundamental anatomy of the fistula and presence of comorbidities, 2) lack of proper preoperative assessment of the fistula, which includes failure to recognize the internal opening and overall structure of the fistula and not supplementing the proctologic examination with sufficient imaging, 3) intraoperative loopholes that include improper procedure selection, inexperience of the surgeon, and failure to get rid of the entire tract along with its ramifications, and 4) lack of proper postoperative care in the early and late periods following the surgery.

The aim of this paper, therefore, is to highlight the factors that could increase the risk of recurrence in different types of anal fistulae. Once surgeons know these risk factors, they can anticipate any complication and detect recurrence early.

Persistent Fistula After Anorectal Abscess Drainage: Local Experience of 11 Years

BACKGROUND

The characteristics of patients who develop a fistula-in-ano after an anorectal abscess are unclear.

OBJECTIVE

Our study explored this relationship and patient factors associated with fistula development.

DESIGN

International Classification of Diseases, 10 Revision, and Classification of Interventions and Procedures, version 4, codes were used to identify all of the patients with a primary anorectal abscess. Multivariable analysis was used to identify factors predictive of fistula formation.

SETTINGS

The study was conducted in a district general hospital.

PATIENTS

Patients with anorectal abscess who were admitted to our institution (2004-2015) were included.

MAIN OUTCOMES MEASURES

The rate of subsequent fistula formation was measured.

RESULTS

A total of 1970 abscess patients were identified; 70.0% (n = 1379) were men, and 7.3% (n = 144) had Crohn's disease. Fistulas occurred in 16.2% (n = 319) at a median of 7 months (interquartile range, 3-7 mo). Patients with Crohn's disease were more than twice as likely to develop a fistula than patients without Crohn's disease (32.6% vs 14.9%; OR = 2.5 (95% CI, 1.7-3.7); p < 0.001). Patients with Crohn's disease with a fistula were more likely to be women (55.3% vs 34.6%; p = 0.007) and aged <30 years (51.1% vs 24.3%; p< 0.001) versus patients without Crohn's disease with a fistula. At multivariable analysis of the entire cohort, male sex (OR = 0.7 (95% CI, 0.5-0.9); p = 0.005) and diabetes mellitus (OR = 0.5 (95% CI, 0.3-0.9); p = 0.027) were associated with a reduced likelihood of developing a fistula after abscess formation.

LIMITATIONS

The study was limited by its single-center scope, retrospective analysis, and lack of a standardized definition for Crohn's disease.

CONCLUSIONS

Abscesses are more common in men, but progression to fistula is more likely in women. The rate of fistula progression in Crohn's disease is twice that in patients without Crohn's disease. Identification of patients at risk may help delineate those who will benefit from a more conservative surgical approach, enhanced follow-up, or investigation after abscess drainage. See Video Abstract at http://links.lww.com/DCR/A798.

CAN THREE-DIMENSIONAL ANORECTAL ULTRASONOGRAPHY BE INCLUDED AS A DIAGNOSTIC TOOL FOR THE ASSESSMENT OF ANAL FISTULA BEFORE AND AFTER SURGICAL TREATMENT?

BACKGROUND

There is no a clear knowledge concerning the division of any part of the anal sphincter complex and the effect of this procedure on the function of the anal canal during the treatment of perianal fistula.

OBJECTIVE

To evaluate the usefulness of 3D anorectal ultrasound in the assessment of anal fistula, quantifying the length of the sphincter muscle to be transected, selecting patients for different approaches and identifying healing, failure or recurrence after the surgical treatment.

METHODS

A prospective study included patients with primarily cryptogenic transsphincteric anal fistula assessed by fecal Incontinence score, tri-dimensional anorectal ultrasound and anal manometry before and after surgery. Based on 3D-AUS, patients with ≥50% external sphincter or external sphincter+puborectalis muscle involvement in males and ≥40% external sphincter or external sphincter+puborectalis muscle in females were referred for the ligation of the intersphincteric tract (LIFT) or seton placement and subsequent fistulotomy; and with <50% involvement in males and <40% in females were referred to one-stage fistulotomy. After surgery, the fibrosis (muscles divided) and residual muscles were measured and compared with the pre-operative.

RESULTS

A total of 73 patients was included. The indication for the LIFT was significantly higher in females (47%), one-stage fistulotomy was significantly higher in the males (46%) and similar in seton placement. The minor postoperative incontinence was identified in 31% of patients underwent sphincter divided and were similar in both genders. The 3D-AUS identified seven failed cases.

CONCLUSION

The 3D ultrasound was shown to be an effective method in the preoperative assessment of anal fistulas by quantifying the length of muscle to be divided, as the results were similar at the post-operative, providing a safe treatment approach according to the gender and percentage of muscle involvement. Additionally, 3D ultrasound successfully identified the healing tissue and the type of failure or recurrence.

Anal incontinence and quality of life following operative treatment of simple cryptoglandular fistula-in-ano: a prospective study

Background

Anal incontinence is a known complication following operative treatment of fistula-in-ano which can significantly impact the quality of life. This study was aimed to objectively assess the impact of operative treatment of simple fistula-in-ano on quality of life related to anal incontinence. Therefore, a prospective study was conducted in 34 patients who underwent surgery for fistula-in-ano over a period of 24 months. Quality of life and incontinence were assessed using fecal incontinence quality of life (FIQL) scale and Cleveland clinic incontinence score (CCIS) preoperatively and after a minimum of 12 months follow up (mean-27 months, range 12–40 months). The difference in FIQL and CCIS was analysed using Wilcoxon Rank test and Mann–Whitney U test.

Results

The median age of the participants was 42.5 years (range 22–63, males = 30). The majority had a trans-sphincteric tract (n = 22, 65%). Superficial tracts and inter-sphincteric tracts were found in 8 (24%) and 4 patients (12%). The overall preoperative and postoperative rates of incontinence were 18 and 38% respectively, but the severity was low. The mean overall FIQL was 16.0 (SD ± 0.4) preoperatively and 16.1 (SD ± 0.4) postoperatively. Considerable difference was seen in the scale measuring “depression/self-perception” (p = 0.012). Only 1 patient (3%) had reduction in scale “lifestyle” which measures the impact of incontinence on day-to-day activities.

Conclusions

Analysis of a cohort of simple cryptoglandular fistula-in-ano with low pre-operative incontinence showed no worsening in the FIQL following successful treatment despite minor worsening of incontinence. Since greater improvement was noted in scale measuring depression/self-perception, psychological interventions may be helpful before surgery to improve quality of life.

A Systematic review and meta-analysis of the efficacy and safety of video-assisted anal fistula treatment (VAAFT)

BACKGROUND

Video-assisted anal fistula treatment (VAAFT) is a novel, minimally invasive technique for the treatment of fistula-in-ano (FIA). This review aimed to search the literature for the outcome of VAAFT regarding the recurrence and complication rates of the technique.

METHODS

A systematic literature search was conducted in compliance with the PRISMA screening guidelines. PubMed/MEDLINE and Scopus were searched for articles reporting the outcomes of VAAFT procedure from inception through April 2017. The main outcomes were patients' characteristics, technical aspects, operation time, recurrence, and complication rates.

RESULTS

Eleven studies (n = 788 patients) were included. The mean age of the patients was 39.5 years. 66.5% of patients had high or complex FIA and 18.4% underwent previous fistula surgery. The internal opening of the fistula was detected in 85.7% of patients. The mean operation time was 42 ± 14.2 min. The weighed mean rate of detection of internal opening was 93.3%. Recurrence occurred in 112 (14.2%) patients after a median follow-up of 9 months. Recurrence rates varied according to method of closure of internal opening from 15.3% after using staplers, 17.7% after suturing, to 25% after advancement flap. The weighted mean recurrence rate across the studies was 17.7%. The weighted mean complication rate was 4.8%.

CONCLUSION

VAAFT may be considered an effective diagnostic tool and a safe method for the treatment of complex and high FIA attaining satisfactory outcome and acceptably low complications. Recurrence after VAAFT may be related to previous fistula surgery and the method of closure of the internal opening.

Prognostic factors affecting outcomes in fistulating perianal Crohn's disease: a systematic review

BACKGROUND

One in three patients with Crohn's disease will develop a perianal fistulae, and one third of these will achieve long-term healing or closure. A barrier to conducting well-designed clinical trials for these patients is a lack of understanding of prognostic factors. This systematic review sets out to identify factors associated with prognosis of perianal Crohn's fistulae.

METHODS

This review was registered on the PROSPERO database (CRD42016050316) and conducted in line with PRISMA guidelines along a predefined protocol. English-language studies assessing baseline factors related to outcomes of fistulae treatment in adult patients were included. Searches were performed on MEDLINE and Embase databases. Screening of abstracts and full texts for eligibility was performed prior to extraction of data into predesigned forms. Bias was assessed using the QUIPS tool.

RESULTS

Searches identified 997 papers. Following removal of duplicates and secondary searches, 923 were screened for inclusion. Forty-seven papers were reviewed at full-text level and 13, 2 of which were randomised trials, were included in the final qualitative review. Two studies reported distribution of Crohn's disease as a prognostic factor for healing. Two studies found that CARD15 mutations decreased response of fistulae to antibiotics. Complexity of fistulae anatomy was implicated in prognosis by 4 studies.

CONCLUSIONS

This systematic review has identified potential prognostic markers, including genetic factors and disease behaviour. We cannot, however, draw robust conclusions from this heterogeneous group of studies; therefore, we recommend that a prospective cohort study of well-characterised patients with Crohn's perianal fistulae is undertaken.

Association of Coloproctology of Great Britain and Ireland consensus exercise on surgical management of fistulating perianal Crohn's disease

AIM

Management of fistulating perianal Crohn's disease (fpCD) is a significant challenge for a colorectal surgeon. A recent survey of surgical practice in this condition showed variation in management approaches. As a result we set out to devise recommendations for practice for UK colorectal surgeons.

METHOD

Results from a national survey were used to devise a set of potential consensus statements. Consultant colorectal surgeons were invited to participate in the exercise via the previous survey and the mailing list of the professional society. Iterative voting was performed on each statement using a five-point Likert scale and electronic voting, with opportunity for discussion and refinement between each vote. Consensus was defined as > 80% agreement.

RESULTS

Seventeen surgeons and two patient representatives voted upon 51 statements. Consensus was achieved on 39 items. Participants advocated a patient-centred approach by a colorectal specialist, within strong multidisciplinary teamworking. The use of anti-TNFα therapy is advocated. Where definitive surgical techniques are considered they should be carefully selected to avoid adverse impact on function. Ano/rectovaginal fistulas should be managed by specialists in fistulating disease. Stoma or proctectomy could be discussed earlier in a patient's treatment pathway to improve choice, as they may improve quality of life.

CONCLUSION

This consensus provides principles and guidance for best practice in managing patients with fpCD.

Predictive factors for recurrence of cryptoglandular fistulae characterized by preoperative three-dimensional endoanal ultrasound

AIM

Precise information regarding the location of an anal fistula and its relationship to adjacent structures is necessary for selecting the best surgical strategy. Retrospective and cross-sectional studies were performed to determine predictive factors for recurrence of anal fistula from preoperative examination by three-dimensional endoanal ultrasound (3D-EAUS).

METHOD

Patients in our tertiary centre and in a private centre specialized in proctology undergoing preoperative 3D-EAUS for cryptoglandular anal fistulae between 2002 and 2012 were included. A questionnaire was sent in September 2013 to assess the patient's condition with regard to recurrence. Variables checked for association with recurrence were gender, type of centre, previous fistula surgery, secondary track formation and classification of the fistula.

RESULTS

There were 143 patients of whom 96 had a low fistula treated by fistulotomy, 28 a high fistula treated by fistulectomy and 19 a high fistula treated by fistulectomy combined with a mucosal advancement flap. The median duration of follow-up was 26 (2-118) months. The fistula recurred in 40 (27%) patients. Independent risk factors included the presence of secondary track formation [hazard ratio 2.4 (95% CI 1.2-51), P = 0.016] and previous fistula surgery [hazard ratio 1.2 (95% CI 1.0-4.6), P = 0.041]. Agreement between the 3D-EAUS examination and the evaluation under anaesthesia regarding the site of the internal opening, classification of the fistula and the presence of secondary tracks was 97%, 98% and 78%.

CONCLUSION

The identification of secondary tracks by preoperative 3D-EAUS examination was the strongest independent risk factor for recurrence. This stresses the importance of preoperative 3D-EAUS in mapping the pathological anatomy of the fistula and a thorough search for secondary track formation during surgery.

Management of low transsphincteric anal fistula with serial setons and interval muscle-cutting fistulotomy

This study evaluates low transsphincteric anal fistula managed by serial setons and interval fistulotomy, with attention to healing without recurrence and preservation of continence. Following Institutional Review Board approval, consecutive anal fistula operations performed by a single surgeon from January 1, 2009 to December 31, 2013 were retrospectively reviewed using electronic medical records and telephone interviews for patients lost to follow up. Of the 71 patients, 26 (37%) had low transsphincteric fistula (23 males and 3 females; mean age: 46 years), treated at our institution by seton placement followed by interval surgical muscle cutting and subsequent seton replacement or final fistulotomy. Of the 26 patients, 22 (85%) were initially referred due to previous failed treatment, with a 30.6 month mean duration of fistula prior to referral and a mean of 2.2 (range: 0 -6) prior anorectal surgeries. At a mean follow-up of 11.9 months, none of the 21 patients experienced recurrence or fecal incontinence. Serial seton with interval muscle-cutting sphincterotomy followed by complete fistulotomy is an effective treatment for the management of patients who are either initially seen for low transsphincteric fistula, or referred after failed anorectal surgery for that condition.

Video-assisted anal fistula treatment

Background and Objectives:

Fistula in ano is a common disease seen in the surgical outpatient department. Many procedures are advocated for the treatment of fistula in ano. However, none of the procedures is considered the gold standard. The latest addition to the list of treatment options is video-assisted anal fistula treatment (VAAFT). It is a minimally invasive, sphincter-saving procedure with low morbidity. The aim of our study was to compare the results with a premier study done previously.

Methods:

The procedure involves diagnostic fistuloscopy and visualization of the internal opening, followed by fulguration of the fistulous tract and closure of the internal opening with a stapling device or suture ligation. The video equipment (Karl Storz, Tuttlingen, Germany) was connected to an illuminating source.

Results:

The study was conducted from July 2010 to March 2014. Eighty-two patients with fistula in ano were operated on with VAAFT and were followed up according to the study protocol. The recurrence rate was 15.85%, with recurrences developing in 13 cases. Postoperative pain and discomfort were minimal.

Conclusion:

VAAFT is a minimally invasive procedure performed under direct visualization. It enables visualization of the internal opening and secondary branches or abscess cavities. It is a sphincter-saving procedure and offers many advantages to patients. Our initial results with the procedure are quite encouraging.

Direct MRI fistulography with hydrogen peroxide in patients with recurrent perianal fistulas: a new proposal of extended diagnostics

Background

Perianal fistulas are malformations of the anorectal area. Accurate preoperative assessment of perianal fistula tract is a main assumption in diagnosis of the disease, affecting the operation efficiency. The aim of the study was to present our experience in application of a new diagnostic protocol based on the magnetic resonance imaging (MRI) examination using a mixture of hydrogen peroxide (HP) and gadolinium as a direct contrast medium in evaluation of recurrent fistulas tract. The method is referred to as HPMRI.

Material/Methods

The study group consisted of 12 subjects operated on from 2011. Direct HPMRI fistulography was performed in all subjects before the operation. All types of fistulas were precisely evaluated by HPMRI examination.

Results

Intraoperative state confirmed complete course of fistulas in 11 cases. In 1 case, an internal opening was not found.

Conclusions

We suggest that this new method of direct HPMRI fistulography may improve visualization of the tracts of recurrent fistulas and improve efficacy of surgical procedures.

Prospective pilot study of anorectal fistula closure with the OTSC Proctology

AIM

The OTSC Proctology is a surgical device for anorectal fistula closure. It consists of a super-elastic nitinol clip, which is placed (with the aid of a transanal applicator) on the internal fistula opening to achieve healing of the fistula track. A prospective, two-centre clinical pilot study was undertaken to assess the efficacy and safety of the OTSC Proctology in patients with a complex high anorectal fistula.

METHOD

In patients with a complex anorectal fistula the primary track was debrided using a special brush and the clip was applied to the internal fistula opening. After 6 months the postoperative clinical course and fistula healing were assessed.

RESULTS

Twenty patients with a cryptoglandular anorectal fistula (14 with a transsphincteric fistula and six with a suprasphincteric fistula) were included in the study. There were no intra-operative technical or surgical complications. Postoperatively no patient reported intolerable discomfort or a sensation of a foreign body in the anal region. At 6 months after surgery, 18 (90%) patients had no clinical signs or symptoms of fistula and were considered healed, whereas in two the fistula persisted. In 13 (72%) of these 18 patients, the clip was still in place without causing problems, whereas in three patients the clip had spontaneously detached. In the two remaining patients it was necessary to remove the clip due to discomfort and delayed wound healing.

CONCLUSION

Anorectal fistula closure with the OTSC Proctology is an innovative, sphincter-preserving minimally invasive procedure with promising initial results and a high rate of patient satisfaction.

Ligation of intersphincteric fistula tract (LIFT) to treat anal fistula: systematic review and meta-analysis

Sphincter-preserving approaches to treat anal fistula do not jeopardize continence; however, healing rates are suboptimal. In this context, ligation of the intersphincteric fistula tract (LIFT) can be considered promising offering high success rates and a relatively simple procedure. This review aimed to investigate the outcomes of LIFT to treat anal fistula. We conducted a systematic review of the Pubmed, Web of Science, and Cochrane databases, to retrieve all relevant scientific original articles and scientific abstracts (Web of Science) related to the LIFT procedure for anal fistula between January 2007 and March 2013. The search yielded 24 original articles including 1,110 patients; these included one randomized controlled study, three case control studies, and 20 case series. Most studies included patients with trans-sphincteric or complex fistula, not amenable to fistulotomy. During a pooled mean 10.3 months of follow-up, the mean success, incontinence, intraoperative, and postoperative complication rates were 76.4, 0, 0, and 5.5%, respectively. A sensitivity analysis showed that the impact on success in terms of follow-up duration, study size, and combining other procedures was limited. There was no association between pre-LIFT drainage seton and success of LIFT. Ligation of the intersphincteric fistula tract appears to be an effective and safe treatment for trans-sphincteric or complex anal fistula. Combining other procedures and a pre-LIFT drainage seton does not seem to confer any added benefit in terms of success. However, given the lack of prospective randomized trials, interpretation of these data must be cautious. Further trials are mandatory to identify predictive factors for success, and true effectiveness of the LIFT compared to other sphincter-preserving procedures to treat anal fistula.

Fistula-in-Ano Complicated by Fournier's Gangrene Our Experience in North-Eastern Region of Nigeria

BACKGROUND

Fistula-in-ano when complicated by Fournier's gangrene is an unusual finding and always carries high morbidity. This study details our experience in managing 10 cases.

METHODS OF STUDY

Case files of all patients managed in University of Maiduguri Teaching Hospital and Federal Medical Center of Yola and Gombe from January, 2007 to December, 2011 were retrieved from Medical Record Departments and other Hospital Records. These were analyzed for demographic, clinical and pathological variables, the type of treatment and follow-up.

RESULTS

A total of 10 men with a mean age of 50.5 years (35-60) were managed in the period of study. Nearly, 50% of the patients were farmers, 30% businessmen and 20% were civil servant. 7 (70%) of these patients presented with Fournier's gangrene within 4 weeks of development of fistula-in-ano and the rest within 8 weeks. 4 (40%) of these patients had inadequate drainage of their perianal abscess and 2 (20%) had incision and drainage. Another 4 (40%) had spontaneously rupture of the perianal abscess. 6 (60%) of the fistula-in-ano was submuscular, 30% subcutaneous and 10% were complex or recurrent. Nearly, 20% of patients had fistulotomy and seton application for adequate drainage. Mucosal advancement flap was performed in 5 (50%) and fistulotomy in 3 (30%) patients. Another 30% had fistulotomy and continuing sitz bath.

CONCLUSION

Cryptoglandular infection is an important cause of perianal abscesses and fistula-in-ano and if poorly managed results in Fournier's gangrene. Early broad spectrum parenteral antibiotic therapy and primary surgical treatment can prevent Fournier's gangrene.

Transperineal ultrasonography in perianal Crohn's disease and recurrent cryptogenic fistula-in-ano

AIM

Successful anal fistula care is aided by specialized imaging accurately defining the site of the internal opening and fistula type. Imaging techniques are complementary, designed to answer specific anatomical questions. There are limited data concerning the clinical value of transperineal ultrasound (TP-US) in both cryptogenic fistula-in-ano and perianal Crohn's disease (PACD). The aim of the study was to assess the accuracy of TP-US compared with operative findings in patients with perirectal sepsis.

METHOD

Patients with recurrent cryptogenic anal fistula and PACD referred for sonography were examined using TP-US by a single examiner blinded to the operative results. Fistulae were categorized by the Parks classification predicting the site of the internal fistula opening. Ancillary horseshoe collections, abscesses and secondary tracks were defined.

RESULTS

Fourteen patients with PACD and 27 patients with recurrent cryptogenic fistula-in-ano were analysed with comparative images and operative data. Correlation of fistula type for cryptogenic and PACD patients respectively was 23/27 (85.2%) and 12/14 (85.7%), with a correlative internal opening site (when found at surgery) of 16/22 (72.3%) and 12/14 (85.7%). Misclassification of fistula type in cryptogenic cases occurred in the presence of ancillary abscesses with associated acoustic shadowing. In PACD patients, TP-US was used when anal stenosis precluded endoanal ultrasonography, assisting in the diagnosis of recto-vaginal fistulae.

CONCLUSION

TP-US is a useful complementary technique to assess fistula-in-ano and has special advantage when there is anal canal distortion, complex fistula type or suspicion of a recto-vaginal fistula.

Transperineal ultrasonography as a complementary diagnostic tool in identifying acute perianal sepsis

BACKGROUND

Successful anal fistula care in complex cases can be assisted by specialized imaging which accurately defines the site of the internal fistula opening and the fistula type. There are currently limited data concerning the clinical indications for and accuracy of transperineal ultrasound (TP-US) in acute perianal sepsis. The aims of this study were to compare the anatomical interpretation of TP-US images with magnetic resonance imaging (MRI) and surgical findings in an unselected patient cohort presenting with acute perianal sepsis.

METHODS

Sixty-seven consecutive patients with acute anorectal sepsis referred from the surgical department were examined using TP-US and Gadolinium-enhanced MRI with both examiners blinded to the surgical results. Fistulae were categorized by the Parks' classification of fistula type.

RESULTS

Thirty-six abscesses were detected by MRI, 38 by TP-US and 30 by surgical examination. Operatively discordant cases showed only ischiorectal panniculitis. TP-US was more accurate in the diagnosis of superficial sepsis and MRI in the diagnosis of deep-seated perirectal infection. TP-US and MRI show concordance with operative findings in fistula diagnosis with a tendency for TP-US to overdiagnose trans-sphincteric fistulae and MRI to over diagnose extra-sphincteric fistulae. Comparison of TP-US with MRI showed good agreement for perianal abscess diagnosis (τ = 0.82) and for fistula diagnosis (τ = 0.68). For fistulae, TP-US showed moderate agreement with surgery (τ = 0.43) with only fair agreement between MRI and surgery (τ = 0.29).

CONCLUSIONS

Transperineal ultrasound complements other imaging modalities in the anatomical diagnosis of acute perianal abscesses and fistulae. It has specific advantages over other techniques and is accurate in the detection of superficially located perirectal sepsis showing concordance with MRI and surgical findings.

Traditional Chinese surgical treatment for anal fistulae with secondary tracks and abscess

AIM: To evaluate the efficacy and safety of traditional Chinese surgical treatment for anal fistulae with secondary tracks and abscess.

METHODS: Sixty patients with intersphincteric or transsphincteric anal fistulas with secondary tracks and abscess were randomly divided into study group [suture dragging combined with pad compression (SDPC)] and control group [fistulotomy (FSLT)]. In the SDPC group, the internal opening was excised and incisions at external openings were made for drainage. Silk sutures were put through every two incisions and knotted in loose state. The suture dragging process started from the first day after surgery and the pad compression process started when all sutures were removed as wound tissue became fresh and without discharge. In the FSLT group, the internal opening and all tracts were laid open and cleaned by normal saline postoperatively till all wounds healed. The time of healing, postoperative pain score (visual analogue scale), recurrence rate, patient satisfaction, incontinence evaluation and anorectal manometry before and after the treatment were examined.

RESULTS: There were no significant differences between the two groups regarding age, gender and fistulae type. The time of healing was significantly shorter (24.33 d in SDPC vs 31.57 d in FSLT, P < 0.01) and the patient satisfaction score at 1 mo postoperative follow-up was significantly higher in the SDPC group (4.07 in SDPC vs 3.37 in FSLT, P < 0.05). The mean maximal postoperative pain scores were 5.83 ± 2.5 in SDPC vs 6.37 ± 2.33 in FSLT and the recurrence rates were 3.33 in SDPC vs 0 in FSLT. None of the patients in the two groups experienced liquid and solid fecal incontinence and lifestyle alteration postoperatively. The Wexner score after treatment of intersphincter fistulae were 0.17 ± 0.41 in SDPC vs 0.40 ± 0.89 in FSLT and trans-sphincter fistulae were 0.13 ± 0.45 in SDPC vs 0.56 ± 1.35 in FSLT. The maximal squeeze pressure and resting pressure declined after treatment in both groups. The maximal anal squeeze pressures after treatment were reduced (23.17 ± 3.73 Kpa in SDPC vs 22.74 ± 4.47 Kpa in FSLT) and so did the resting pressures (12.36 ± 2.15 Kpa in SDPC vs 11.71 ± 1.87 Kpa in FSLT), but there were neither significant differences between the two groups and nor significant differences before or after treatment.

CONCLUSION: Traditional Chinese surgical treatment SDPC for anal fistulae with secondary tracks and abscess is safe, effective and less invasive.

Video-assisted anal fistula treatment (VAAFT): a novel sphincter-saving procedure for treating complex anal fistulas

Background

Video-assisted anal fistula treatment (VAAFT) is a novel minimally invasive and sphincter-saving technique for treating complex fistulas. The aim of this report is to describe the procedural steps and preliminary results of VAAFT.

Methods

Karl Storz Video Equipment is used. Key steps are visualization of the fistula tract using the fistuloscope, correct localization of the internal fistula opening under direct vision, endoscopic treatment of the fistula and closure of the internal opening using a stapler or cutaneous-mucosal flap. Diagnostic fistuloscopy under irrigation is followed by an operative phase of fulguration of the fistula tract, closure of the internal opening and suture reinforcement with cyanoacrylate.

Results

From May 2006 to May 2011, we operated on 136 patients using VAAFT. Ninety-eight patients were followed up for a minimum of 6 months. No major complications occurred. In most cases, both short-term and long-term postoperative pain was acceptable. Primary healing was achieved in 72 patients (73.5%) within 2–3 months of the operation. Sixty-two patients were followed up for more than 1 year. The percentage of the patients healed after 1 year was 87.1%.

Conclusions

The main feature of the VAAFT technique is that the procedure is performed entirely under direct endoluminal vision. With this approach, the internal opening can be found in 82.6% of cases. Moreover, fistuloscopy helps to identify any possible secondary tracts or chronic abscesses. The VAAFT technique is sphincter-saving, and the surgical wounds are extremely small. Our preliminary results are very promising.

The distribution of the anal glands and the variable regional occurrence of fistula-in-ano: is there a relationship?

BACKGROUND

Fistula in ano is a rather common condition, but the disease process is not yet fully understood. The aim of our study was to determine how the distribution of anal glands contributes to the variable occurrence of fistula-in-ano in the perineum.

METHODS

we conducted a blinded two-phase prospective study. In the first phase, the perineum of the patients with primary fistulae was anatomically divided into right upper and lower and left upper and lower quadrants in the lithotomy position. The fistulae were classified according to what quadrant the external and internal openings and the tract pathway were in. In the second phase, using 10 human cadaver specimens, full thickness tissue samples were taken from each quadrant of the anus. Samples were histologically evaluated for the volume fractions of the anal glands in each quadrant.

RESULTS

The new classification system we propose revealed that the largest number of fistulae 43% (17/39) were in the right lower quadrant, and 22% (9/39), 12% (5/39) and 8% (3/39) were in the left lower, right upper and left upper quadrants, respectively. It was also observed that 14% (5/39) of fistulae were in more than one quadrant. The volume fractions of each quadrant showed that the largest volume fraction of the anal glands was in the right lower quadrant (right lower quadrant: 0.64, left lower quadrant: 0.35, right upper quadrant: 0.26 and left upper quadrant: 0.22, P = 0.001).

CONCLUSIONS

To the best of our knowledge, this is the first study that has objectively shown that the distribution of the anal glands is variable, and the highest density of anal glands is in the right lower quadrant of the anus. This variable distribution may be associated with the variable occurrence in fistula in ano.

Risk factors for recurrence and incontinence after anal fistula surgery

OBJECTIVE

Fistula-in-ano continues to raise problems that require important therapeutic decisions. Our aim was to evaluate its recurrence and incontinence risk factors.

METHOD

We analysed a series of 279 patients who had undergone anal fistula surgery with long-term follow-up.

RESULTS

42.7% of the fistulae were considered complex and 46% had been referred from other institutions. There was delayed healing or recurrence in 7.2% patients, which appeared at a median of 4 months. The factors associated with recurrence were the type of fistula (extrasphincteric/suprasphincteric), nonidentification of internal opening (IO), recurrent or complex fistulae (CF), and associated chronic abscess. Only CF and nonidentification of IO were statistically significant in the multivariate analysis. Preoperative incontinence was a risk factor for postoperative incontinence, as were suprasphincteric, recurrent and CF. The age and gender of the patient did not influence postoperative continence, nor did the surgeon or surgical technique appear as a risk factor, although after excluding preoperative incontinent patients, fistulotomy was the technique that showed a higher risk of incontinence. Multivariate analysis only confirmed previous incontinence as a RF.

CONCLUSION

The overall recurrence rate is acceptable, but high fistulae continue to be difficult to treat. IO identification is also essential for obtaining good results. It is important to identify the patients with preoperative incontinence as they are at a greater risk of deterioration after surgery.