Continence disorders after anal surgery--a relevant problem?

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.

Impact of Internal Anal Sphincter Division on Continence Disturbance in Female Patients

BACKGROUND

Few studies measured the pre- and postoperative anatomic and functional anal canal using 3-dimensional endoanal ultrasound and anal manometry and correlated sphincter division with fecal incontinence, severity, and function.

OBJECTIVE

To assess the incidence of fecal incontinence in patients who underwent internal anal sphincter division for anal fissure or intersphincteric anal fistula and correlate severity of symptoms with percentage of divided muscle, anatomical measurements, and anal pressures.

DESIGN

Prospective cohort study.

SETTINGS

Colorectal surgery unit, tertiary referral center.

PATIENTS

Patients underwent clinical assessment using the Cleveland Clinic Florida Fecal Incontinence score for severity of symptoms, manometry, and ultrasound.

MAIN OUTCOMES MEASURES

Ultrasound measurements of length, percentage, and angle of divided internal anal sphincter, anterior external anal sphincter, posterior external anal sphincter plus puborectalis, and gap lengths.

RESULTS

Sixty-three women (mean age, 44 years) were divided into 2 groups: 30 (48%) underwent fistulotomy for intersphincteric anal fistula and 33 (52%) underwent sphincterotomy for chronic anal fissure with high anal resting pressure. Forty-six percent experienced some measure of fecal incontinence after internal anal sphincter division. Incidence of fecal incontinence, severity of symptoms, and angle of the divided internal anal sphincter were similar between the groups. Length and percentage of the divided internal anal sphincter were significantly higher in the intersphincteric anal fistula. External anal sphincter and external anal sphincter plus puborectalis lengths were similar in both groups. Gap length was significantly longer in chronic anal fissures with high anal resting pressure.

LIMITATIONS

Single-institution, exclusion of males.

CONCLUSIONS

Fecal incontinence was reported in half of the patients who underwent internal anal sphincter division. Despite the greater length and percentage of internal anal sphincter division in patients who underwent fistulotomy, incidence and severity of fecal incontinence were similar in both groups. Three-dimensional endoanal ultrasound showed greater gap length in the sphincterotomy group, which may be functionally significant after the division of the shorter internal anal sphincter but with a similar impact on fecal incontinence in both groups.

IMPACTO DE LA DIVISIN DEL ESFNTER ANAL INTERNO EN LA ALTERACIN DE LA CONTINENCIA EN PACIENTES DE SEXO FEMENINO

ANTECEDENTES:Pocos estudios han medido el canal anal anatómico y funcional antes y después de la cirugía mediante ecografía endoanal tridimensional y manometría anal, y correlacionado la división del esfínter con la incontinencia fecal, la gravedad y la función.OBJETIVO:Evaluar la incidencia de incontinencia fecal en pacientes sometidos a división del esfínter anal interno por fisura anal o fístula anal interesfinteriana, y correlacionar la gravedad de los síntomas con el porcentaje de músculo dividido, las medidas anatómicas y las presiones anales.DISEÑO:Estudio de cohorte prospectivo.AJUSTE:Unidad de cirugía colorrectal, centro de referencia de tercer nivel.PACIENTES:Pacientes sometidos a una evaluación clínica utilizando la puntuación de incontinencia fecal de Cleveland Clinic Florida para la gravedad de los síntomas, la manometría y la ecografía.PRINCIPALES MEDIDAS DE RESULTADO:Mediciones por ultrasonido de la longitud, el porcentaje y el ángulo del esfínter anal interno dividido y el esfínter anal externo anterior, el esfínter anal externo posterior más el puborrectal y las longitudes del espacio.RESULTADOS:Sesenta y tres mujeres (edad media, 44 años) se dividieron en 2 grupos: 30 (48%) sometidos a fistulotomía por fístula anal interesfinteriana y 33 (52%) sometidos a esfinterotomía por fisura anal crónica con alta presión anal en reposo. El 46% experimentó algún grado de incontinencia fecal después de la división del esfínter anal interno. La incidencia de incontinencia fecal, la gravedad de los síntomas y el ángulo del esfínter anal interno dividido fueron similares entre los grupos. La longitud y el porcentaje del esfínter anal interno dividido fueron significativamente mayores en la fístula anal interesfinteriana. Las longitudes del esfínter anal externo y del esfínter anal externo más el puborrectal fueron similares en ambos grupos. La longitud del espacio fue significativamente mayor en la fisura anal crónica con alta presión anal en reposo.LIMITACIONES:Institución única, exclusión de varones.CONCLUSIÓN:La incontinencia fecal se reportó en la mitad de los pacientes sometidos a división del esfínter anal interno. A pesar de la mayor longitud y porcentaje de división del esfínter anal interno en los pacientes sometidos a fistulotomía, la incidencia y gravedad de la incontinencia fecal fue similar en ambos grupos. La ecografía endoanal tridimensional mostró una mayor longitud del espacio en el grupo de esfinterotomía, lo que puede ser funcionalmente significativo después de la división del esfínter anal interno más corto, pero con un impacto similar en la incontinencia fecal en ambos grupos. (Traducción-Dr. Fidel Ruiz Healy ).

Current Therapy of Cryptoglandular Anal Fistula: Gold Standards and Alternative Methods

Cryptoglandular anal fistulas are one of the most common colorectal diseases and occur with an incidence of about 20/100,000. Anal fistulas are defined as an inflammatory junction between the anal canal and the perianal skin. They develop from an abscess or chronic infection of the anorectum. Surgical treatment of the disease is the method of choice. Even when treating an acute abscess, its cause should be sought at the same time. If there is a connection to the anal canal without affecting relevant parts of the sphincter muscles, primary fistulotomy should be performed. If larger parts of the sphincter muscle are involved, the insertion of a seton drain is usually useful. There are essentially two recommendations for the elective treatment of cryptoglandular anal fistulas. Distal fistulas should be excised, with the proviso that as little sphincter muscle as possible is sacrificed. In the case of highly proximally located and complex fistulas, sphincter-preserving surgical techniques should be used. In this case, the method of choice is the mucosal or advancement flap. Alternatively, clips, fibrin injections, fistula plugs, fistula ligatures, or laser-based procedures are described in the literature. In the case of intermediate fistulas, a fistulectomy with primary sphincter reconstruction can be useful. Every operation is carried out as a compromise between definitive healing of the fistula and a potential risk to the patient's continence. It is often difficult to make a reliable prognosis about the continence function to be expected postoperatively. In addition to the fistula morphology, particular attention should be paid to whether previous proctological operations have already been performed, the gender of the patient, and whether there are pre-existing sphincter dysfunctions. Since the surgeon's expertise plays a decisive role in the success of the treatment, the procedure should be carried out in a specialist proctological centre, especially in the case of complex fistulas or in the case of a condition after previous operations. In addition to the classic procedures, such as fistulectomy or the plastic fistula closure, this article examines alternative methods and their areas of application.

MRI of Recurrent Fistula-in-Ano: Is it Different from Treatment-Naïve Fistula-in-Ano and How Does it Correlate with Anal Sphincter Morphology?

Objectives  The main aim of this study was to compare magnetic resonance imaging (MRI) findings of recurrent and treatment-naïve fistula-in-ano and to correlate imaging findings with anal sphincter morphology in recurrent fistula-in-ano. Methods  This is a retrospective study of adult patients who underwent MRI for suspected fistula-in-ano in 2018. After excluding patients with alternative diagnosis, patients were stratified into recurrent ( n  = 103) and treatment-naïve ( n  = 106) fistula-in-ano groups. Two blinded radiologists reread MRI scans in consensus for fistula characteristics and anal sphincter morphology. We compared imaging features of recurrent and treatment-naïve fistula-in-ano, assessed the incidence of anal sphincter scarring among patients with recurrent fistula-in-ano, and studied its association with fistula features. Results  Two-hundred nine patients (187 males) with mean age of 40.6 (standard deviation: 12.2) years were included. Trans-sphincteric, inter-sphincteric, extra-sphincteric, and supra-sphincteric fistula-in-ano were seen in 63.6, 33, 2.9, and 0.5%, respectively. There were secondary tracts, supralevator extension, and secondary cause for fistula in 49.3, 12.9, and 14.8%, respectively. There was no difference between the fistula features of recurrent and treatment-naïve fistula-in-ano, except for significantly fewer external openings among recurrent fistula-in-ano ( p  = 0.005). Among patients with recurrent fistula-in-ano, MRI detected anal sphincter defect/scarring was seen in 53.4% ( n  = 55) and was significantly associated with posterior fistula-in-ano ( p  = 0.031), collections and/or supralevator extension ( p  = 0.010), and secondary tracts ( p  = 0.015). Conclusion  Fistula features of recurrent and treatment-naïve patients were mostly similar. There was high incidence (53.4%) of MRI-identified anal sphincter scarring/defect among recurrent fistula-in-ano, which was significantly associated with posterior fistula, collections, supra or translevator extension, and secondary tracts. Key Points MRI-identified anal sphincter scarring is very common among patients with recurrent fistula-in-ano and seen in more than half of them.There was significantly higher incidence of sphincter scarring among patients who had posterior fistula, collections, supralevator/translevator extension, and secondary tracts.

Faecal incontinence in adults

Faecal incontinence, which is defined by the unintentional loss of solid or liquid stool, has a worldwide prevalence of ≤7% in community-dwelling adults and can markedly impair quality of life. Nonetheless, many patients might not volunteer the symptom owing to embarrassment. Bowel disturbances, particularly diarrhoea, anal sphincter trauma (obstetrical injury or previous surgery), rectal urgency and burden of chronic illness are the main risk factors for faecal incontinence; others include neurological disorders, inflammatory bowel disease and pelvic floor anatomical disturbances. Faecal incontinence is classified by its type (urge, passive or combined), aetiology (anorectal disturbance, bowel symptoms or both) and severity, which is derived from the frequency, volume, consistency and nature (urge or passive) of stool leakage. Guided by the clinical features, diagnostic tests and therapies are implemented stepwise. When simple measures (for example, bowel modifiers such as fibre supplements, laxatives and anti-diarrhoeal agents) fail, anorectal manometry and other tests (endoanal imaging, defecography, rectal compliance and sensation, and anal neurophysiological tests) are performed as necessary. Non-surgical options (diet and lifestyle modification, behavioural measures, including biofeedback therapy, pharmacotherapy for constipation or diarrhoea, and anal or vaginal barrier devices) are often effective, especially in patients with mild faecal incontinence. Thereafter, perianal bulking agents, sacral neuromodulation and other surgeries may be considered when necessary.

STAPLED HEMORRHOIDOPEXY: RESULTS, LATE COMPLICATIONS, AND DEGREE OF SATISFACTION AFTER 16 YEARS OF FOLLOW-UP

Stapled hemorrhoidopexy has been widely used for the treatment of hemorrhoids, but concerns about complications and recurrences after prolonged follow-up are still under debate.

Pain relieving effect of music on patients during transrectal ultrasonography: A pilot study

Background

Patient discomfort is often inevitable during transrectal ultrasonography (TRUS), a widely used modality for evaluating benign prostate hyperplasia/lower urinary tract symptoms. Music has been suggested as a method of pain relief during urologic procedures. In this study, we investigated the effect of music on pain relief during TRUS.

Methods

In a pilot study conducted from March to June 2019, pain scores of 316 patients who underwent TRUS with or without music were quantified using the visual analog scale (VAS). One-to-one propensity score matching was performed by matching the subjects between the groups. Patients with hemorrhoids of grade ≥ III were excluded (n = 4).

Results

Among the 312 patients included in the study (VAS score = 3.3 ± 2.4), 177 listened to music during the procedure. There were significant differences in age, prostate-specific antigen, prostate volume, International Prostate Symptom Score symptom/life score, and VAS score between the music (+) and music (−) groups. After adjusting for relevant variables, VAS scores were significantly lower in male patients aged ≥65.0 years who underwent music intervention than in those who did not (1.5 ± 1.4 vs. 3.0 ± 1.4, p = 0.002).

Conclusion

Age was negatively associated with pain during TRUS, and music had a relieving effect on pain in patients aged ≥65.0 years. Our findings may help improve the quality of examinations in urologic outpatient offices.

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.

Still a Case of "No Pain, No Gain"? An Updated and Critical Review of the Pathogenesis, Diagnosis, and Management Options for Hemorrhoids in 2020

The treatment of haemorrhoids remains challenging: multiple treatment options supported by heterogeneous evidence are available, but patients rightly demand a tailored approach. Evidence for newer surgical techniques that promise to be less painful has been conflicting. We review the current evidence for management options in patients who present with varying haemorrhoidal grades. A review of the English literature was performed utilizing MEDLINE/PubMed, Embase, and Cochrane databases (31 May 2019). The search terms (haemorrhoid OR haemorrhoid OR haemorrhoids OR haemorrhoids OR “Hemorrhoid”[Mesh]) were used. First- and second-degree haemorrhoids continue to be managed conservatively. The easily repeatable and cost-efficient rubber band ligation is the preferred method to address minor haemorrhoids; long-term outcomes following injection sclerotherapy remain poor. Conventional haemorrhoidectomies (Ferguson/Milligan-Morgan/Ligasure haemorrhoidectomy) still have their role in third- and fourth-degree haemorrhoids, being associated with lowest recurrence; nevertheless, posthaemorrhoidectomy pain is problematic. Stapled haemorrhoidopexy allows quicker recovery, albeit at the costs of higher recurrence rates and potentially serious complications. Transanal Haemorrhoidal Dearterialization has been promoted as nonexcisional and less invasive, but the recent HubBLe trial has questioned its overall place in haemorrhoid management. Novel “walk-in-walk-out” techniques such as radiofrequency ablations or laser treatments will need further evaluation to define their role in modern-day haemorrhoid management. There are numerous treatment options for haemorrhoids, each with their own evidence-base. Newer techniques promise to be less painful, but recurrence rates remain an issue. The balance continues to be sought between long-term efficacy, minimisation of postoperative pain, and preservation of anorectal function.

[Surgical reconstruction of traumatic sphincter muscle defects]

BACKGROUND

Traumatic anal sphincter muscle defects often occur after childbirth and surgery and can lead to fecal incontinence that requires further treatment.

OBJECTIVE

The aim of this article is to illustrate the etiology of traumatic sphincter muscle defects, the treatment options of subsequent fecal incontinence and their evaluation on the basis of current studies.

MATERIAL AND METHODS

Selected studies are presented.

RESULTS

Fecal incontinence presenting with a traumatic sphincter muscle defect is often due to multiple factors especially in the aged and makes the use of extended diagnostic tools necessary; however, the subjective complaints do not always correlate with morphological or functional diagnostic findings. Besides reconstructive procedures, such as sphincteroplasty and graciloplasty, sphincter augmentation techniques and sacral nerve stimulation can also be applied in traumatic sphincter muscle defects that are often associated with a loss of efficacy in the long term or a high rate of adverse events.

CONCLUSION

The fecal incontinence associated with traumatic sphincter insufficiency represents a diagnostic and therapeutic challenge due to the multifactorial origin. It is not uncommon that patients have to undergo several surgical and conservative interventions.

Fistulotomy and primary sphincteroplasty for anal fistula: long-term data on continence and patient satisfaction

BACKGROUND

The aim of this study was to evaluate the safety and long-term efficacy of fistulotomy and primary sphincteroplasty (FIPS). Secondary endpoints were its impact on postoperative continence status and patients' satisfaction.

METHODS

A retrospective study was conducted on patients with cryptoglandular anal fistula (AF) who had FIPS between June 2006 and May 2017. Patients were evaluated with standardized telephone interviews and clinical/instrumental assessment. Main outcome measures included fistula healing rate, continence status, and patient satisfaction. Incontinence was defined as an inability to hold either gas, liquid, or solid stools, as well as postdefecation soiling, and was measured by the Cleveland Clinic fecal incontinence score. Patient satisfaction was evaluated by an 11-point numeric rating scale.

RESULTS

There were 203 patients (139 males; mean age: 48.7 years) who had FIPS. The overall healing rate was 93% (188 patients) with a mean follow-up period of 56 ± 31 months. Half of the total cohort (51%) had a complex fistula. Preoperatively, 8 (4%) patients complained of postdefecation soiling and 2 (1%) of gas incontinence. Postoperatively, 26 (13%) patients had continence impairment (de novo n = 24), mainly consisting of postdefecation soiling (10%). In univariate analysis, patients with recurrent (RR 6.153 95% CI 2.097-18.048; p = 0.002) or complex (RR 3.005 95% CI 1.203-7.506; p = 0.012) AF and those with secondary tracts (RR 8.190 95% CI 2.188-30.654; p = 0.004) or previous set on drainage (RR 5.286 95% CI 2.235-12.503; p = 0.0001) were at higher risk of incontinence. In multivariate analysis, no significant predictors were found, although fistula complexity approached statistical significance (RR 5.464 95% CI 0.944-31.623; p = 0.050). The mean patient satisfaction numeric rating scale was 9.3 ± 1.6. Lower satisfaction rates were found in patients with transphincteric (p = 0.011) or complex (p = 0.0001) AF, with secondary tracts (p = 0.041) or previous seton drainage (p = 0.008), and in those with postoperative continence impairment (p = 0.0001). Postoperative onset of incontinence was the only significant factor in multivariate analysis (p = 0.0001).

CONCLUSIONS

FIPS should be considered a valid therapeutic option for selected AF. However, the risk of postoperative minor fecal incontinence exists, and should be discussed during preoperative patient counselling.

Mucosal advancement flap for recurrent complex anal fistula: a repeatable procedure

PURPOSE

Mucosal advancement flap (MAF) is the best option for complex anal fistula (AF) treatment. Recurrence is not rare and the best surgical option for his handling is a challenge considering the incontinence risk and the healing rate. We aimed to determine the feasibility and outcomes of a second MAF for recurrent complex AF previously treated with mucosal advancement flap.

METHODS

We retrospectively identified 32 patients undergoing two or more MAF for recurrent AF in a larger cohort of 121 consecutive cases of MAF operated by the same senior colorectal surgeon. Only complex AF of cryptoglandular origin was enrolled. A long-term follow-up was performed collecting clinical and functional data.

RESULTS

Among 121 patients (group A) treated with mucosal advancement flap, 32 (26.4%) (group B) recurred with a complex AF requiring a second mucosal advancement flap procedure. Success rate of group B is 78.1%. Six patients of group B recurred a second time, another MAF was performed with healing in all cases. Complication rate (Clavien Dindo 3b) of group B is 9.4% compared to 8.3% of group A. A slight continence deficit (Miller score 1, 2, and 4) was detected after the first MAF in 3 patients. The Miller score for these patients did not change after the subsequent MAF.

CONCLUSIONS

MAF is effective for treatment of complex recurrent AF. A pre-existing MAF procedure does not worsen the healing rate of the second flap. The rate of surgical complications is similar with those reported in the literature for MAFs.

The evaluation of the effect of vaginal delivery and aging on anal sphincter anatomy and function

OBJECTIVE

This study was conducted to evaluate the effect of vaginal delivery and aging on anal sphincter anatomy and function.

METHOD

Asymptomatic thirty women were included in this prospective study. Group 1 included 10 women (age range: 18-50) who had never been pregnant. Group 2 included 10 women (age range: 18-50) who had vaginal delivery. Group 3 included 10 women over 50 who had vaginal delivery.

RESULTS

There was no statistically significant difference between the three groups in terms of resting and squeeze pressures. It was found that sphincter thickness showed statistically significant difference between the group 1 and group 3, and also group 2 and group 3. There was not statistically significant difference between the group 1 and group 2 in terms of sphincter thickness. There was a positive correlation between the age and sphincter thickness in all groups. In terms of sphincter thickness and pressure findings there was a positive correlation between the squeeze pressure and external anal sphincter thickness only in group 3.

CONCLUSION

The vaginal delivery did not have a negative influence on the structure and function of the anal sphincter in asymptomatic women. However, it was found that anal sphincter thickness changed strongly in a positive manner with aging.

Video-assisted anal fistula treatment: a high volume unit initial experience

Introduction Perianal fistulas are a common problem. Video-assisted anal fistula treatment is a new technique for the management of this difficult condition. We describe our initial experience with the technique to facilitate the treatment of established perianal fistulas. Methods We reviewed a prospectively maintained database relating to consecutive patients undergoing video-assisted anal fistula treatment in a single unit. Results Seventy-eight consecutive patients had their perianal fistulas treated with video-assistance from November 2014 to June 2016. Complete follow-up data were available in 74 patients, with median follow-up of 14 months (interquartile range 7-19 months). There were no complications and all patients were treated as day cases. Most patients had recurrent disease, with 57 (77%) having had previous fistula surgery. At follow-up, 60 (81%) patients reported themselves 'cured' (asymptomatic) including 5 patients with Crohn's disease and one who had undergone 10 previous surgical procedures. Logistical stepwise regression did not demonstrate any statistically significant factors that may have been considered to affect outcome (age, gender, diabetes, previous I&D, Crohn's disease, smoking, type of fistula). Conclusions Our data have shown that video-assisted anal fistula treatment is safe and effective in the management of perianal fistulas in our patients and this suggests it may be applied to all patients regardless of comorbidity, underlying pathology or type of fistula.

Early outcomes of fluorescence angiography in the setting of endorectal mucosa advancement flaps

BACKGROUND

Fistula-in-ano has a reported incidence of 31-34%. Besides fistulotomy, options for fistula repair are seton placement, endorectal advancement flap (ERAF), fibrin sealant, anal fistula plug and ligation of the intersphincteric fistula tract. Despite having a reported success rate as high as 75-98%, ERAF is not without complications, including flap breakdown, recurrence and fecal incontinence. Traditionally, maintaining a broad base to preserve blood supply has been advocated to reduce flap failure. And the aim of the present study was to evaluate outcomes of adult patients who underwent ERAF for complex fistula-in-ano with the use of intraoperative fluorescence angiography (FA) at our institution between July 2014 and July 2016.

METHODS

We retrospectively reviewed consecutive cases of complex fistula-in-ano repair with ERAF and FA from a prospectively maintained dataset of adult patients with complex fistula-in-ano. Demographics, intraoperative data and 60-day outcomes were recorded and reviewed.

RESULTS

Six patients [five males and one female with a mean age of 40 years (range 25-46 years)], with a total of seven fistulas, were identified. Six (85.7%) of these patients had undergone prior surgery for fistula-in-ano. No recurrences or complications of any type were noted at 2-week and 8-week follow-up. The majority of patients (71.4%) required flap revision based on intraoperative FA prior to flap fixation.

CONCLUSIONS

FA is safe and offers real-time assessment of flap perfusion prior to and after fixation in anal fistula repair. The rate of flap ischemia may be underestimated, and therefore, to improve outcomes in ERAF, intraoperative FA should be included in the surgical armamentarium.

A novel method for treatment of chronic anal fissure: adipose-derived regenerative cells - a pilot study

AIM

The purpose of this study was to investigate the safety and feasibility of autologous adipose-derived regenerative cells (ADRC) in the treatment of chronic anal fissure.

METHOD

A prospective pilot study was conducted in six patients with chronic anal fissures at the First Surgical Clinic, Clinical Center of Serbia and at the BelPrime Clinic, Belgrade, Serbia. All patients were candidates for surgical treatment. The average duration of symptoms was 24 months. Pain assessment was quantified using a visual analogue scale and bowel continence was assessed using the Wexner incontinence score. Both were assessed before treatment and during each postoperative outpatient visit. Liposuction was performed under local or general anaesthesia. Extraction of ADRC was achieved with a closed automated medical device. The fat and ADRC were injected subcutaneously into the edge of the fissure. The rest of the pellet was infiltrated into the internal anal sphincter. The study has been registered at ClinicalTrials.gov (NCT02628522).

RESULTS

Complete healing of the anal fissure and the disappearance of symptoms was achieved in all patients. The average time to complete pain cessation was 33.7 ± 15.0 days. All fissures healed after 3 months and remained healed 12 months after the procedure. There were no complications related to the procedure.

CONCLUSION

The application of ADRC may be an alternative to lateral sphincterotomy and a reliable procedure which avoids faecal incontinence.

German S3 guidelines: anal abscess and fistula (second revised version)

BACKGROUND

The incidence of anal abscess and fistula is relatively high, and the condition is most common in young men.

METHODS

This is a revised version of the German S3 guidelines first published in 2011. It is based on a systematic review of pertinent literature.

RESULTS

Cryptoglandular abscesses and fistulas usually originate in the proctodeal glands of the intersphincteric space. Classification depends on their relation to the anal sphincter. Patient history and clinical examination are diagnostically sufficient in order to establish the indication for surgery. Further examinations (endosonography, MRI) should be considered in complex abscesses or fistulas. The goal of surgery for an abscess is thorough drainage of the focus of infection while preserving the sphincter muscles. The risk of abscess recurrence or secondary fistula formation is low overall. However, they may result from insufficient drainage. Primary fistulotomy should only be performed in case of superficial fistulas. Moreover, it should be done by experienced surgeons. In case of unclear findings or high fistulas, repair should take place in a second procedure. Anal fistulas can be treated only by surgical intervention with one of the following operations: laying open, seton drainage, plastic surgical reconstruction with suturing of the sphincter (flap, sphincter repair, LIFT), and occlusion with biomaterials. Only superficial fistulas should be laid open. The risk of postoperative incontinence is directly related to the thickness of the sphincter muscle that is divided. All high anal fistulas should be treated with a sphincter-saving procedure. The various plastic surgical reconstructive procedures all yield roughly the same results. Occlusion with biomaterial results in lower cure rate.

CONCLUSION

In this revision of the German S3 guidelines, instructions for diagnosis and treatment of anal abscess and fistula are described based on a review of current literature.

Gracilis muscle transposition as a workhorse flap for anal incontinence: Quality of life and functional outcome in adults

BACKGROUND/PURPOSE

Anal incontinence is one of the most psychologically and socially debilitating conditions in an otherwise healthy individual. It can lead to social isolation, loss of self-esteem, self-confidence and depression. This study is devoted to the problem of anal incontinence in the adult patients. The aim of our study is to analyse the results of gracilis muscle transposition for anal incontinence and improvement in quality of life (QOL) of patients.

MATERIALS AND METHODS

This was a retrospective study. A total of 18 patients with complaint of anal incontinence were enrolled in this study. All patients were treated with gracilis muscle transposition.

RESULTS

All patients are continent, and there is an improvement in their QOL.

CONCLUSION

Gracilis muscle transposition is a good option for patients of anal incontinence who are not treated by non-surgical means.

[Management of complications of fissure and fistula surgery]

BACKGROUND

Fistula-in-ano and anal fissures are common proctological diseases. In most cases of anal fissures conservative treatment provides good clinical results, whereas for fistula-in-ano operative treatment is the only option.

OBJECTIVE

The most important and for the patient most stressful long-term complication is postoperative incontinence, especially as the deliberate severance of the anal sphincter musculature is part of the treatment for many patients. In this article the causes and treatment options are discussed.

RESULTS

The therapy of choice for patients with persisting symptoms caused by an anal fissure is fissurectomy. Incontinence disorders develop due to severance of parts of the internal sphincter or resection of the anoderm. In patients with anal fistulas the occurrence of incontinence disorders depends on the anatomical relationship of the fistula to the sphincter, the surgical procedure and also on pre-existing damage, e.g. from childbirth or other sphincter trauma and scar formation, notably in patients with multiple surgical interventions. Severance of the sphincter muscles in proximal transsphincteric and suprasphincteric fistulas in particular bears a high risk of postoperative incontinence. Data from the literature regarding postoperative fecal incontinence vary enormously due to different follow-up intervals and also variable definitions of the term fecal incontinence.

CONCLUSION

Options for the treatment of postoperative fecal incontinence are limited. Treatment of postoperative incontinence should first be conservative. Surgical repair of damaged sphincter muscles is often of limited success and sacral nerve stimulation might be an option in selected patients. Especially in patients with fissure-in-ano the indications for surgery should be strictly adhered to. For fistula-in-ano the least invasive and most sphincter-preserving procedure should be selected.

Stapled hemorrhoidopexy: functional results, recurrence rate, and prognostic factors in a single center analysis

PURPOSE

Since its introduction, stapled hemorrhoidopexy (SHP), the so-called Longo procedure, became a widely accepted treatment option for prolapsing hemorrhoids. Nevertheless, from the early years, concerns grew about the early functional results and potential recurrences. In order to evaluate of SHP with special respect to early defecation disorders und recurrences, our single institute high-volume results were evaluated.

METHOD

One thousand one hundred forty-four consecutive patients with SHP for prolapsing hemorrhoids were evaluated in a period from January 2007 to December 2013. In a prospective analysis, patients were followed with special respect to postoperative complications, functional disorders, mainly perianal irritation, stenosis, and recurrence.

RESULTS

During the timeframe, a total of 663 men and 481 women were treated for prolapsing hemorrhoids. The mean age was 52.6 years (±14.4 years). Indication for surgery was prolapsing hemorrhoids in all cases. In addition to prolapse, 90 patients (7.9 %) suffered from bleeding, 96 patients (8.4 %) had itching, and 95 (8.3 %) had anal wetness; the mean operative time was 11 min (±4 min). Patients were treated as inpatients; the mean hospital stay was 3 days (±1 day). Early complications were observed in 14 patients (1.2 %). The follow-up revealed inflammatory reaction at the stapleline in 8 patients (0.7 %) and rectal stenosis in 22 cases (1.9 %), and recurrence was observed in 46 cases (4.0 %).

CONCLUSION

The data presented here provide evidence that SHP is a save procedure with a very low rate for functional disorders and low recurrence rate. Therefore, in our hands, SHP remains standard for prolapsing hemorrhoids.

Stapled haemorrhoidopexy: is it time to move on?

Stapled haemorrhoidectomy was proposed as an 'ideal' solution for symptomatic haemorrhoids, with minimal postoperative pain, no perianal wound requiring postoperative wound care and a relatively short operative time. Some randomised controlled trials and reviews confirmed these findings, claiming that stapled haemorrhoidopexy is the most effective and safe procedure for haemorrhoids. However, there are increasing number of publications highlighting that the technique is associated with serious and life threatening complications. Maybe it is now the time to accept that stapled haemorrhoidopexy has done its role in directing our attention to the fact that modern surgical treatment of haemorrhoids should avoid excision of anorectal skin but should instead aim at treatment intervention above the dentate line.

Classical treatment of hemorrhoids

Radical and definitive surgical treatment is indicated in approximately one out of ten patients with hemorrhoidal disease. The Milligan and Morgan hemorrhoidectomy technique is the most widely performed in France: the technique is well-codified and results are satisfactory and durable if the indications and the post-operative follow-up are appropriately respected. Post-operative pain can be adequately controlled.

Endosonography and magnetic resonance imaging in the diagnosis of high anal fistulae - a comparison

Anal fistula is a benign inflammatory disease with unclear etiology which develops in approximately 10 in 100 000 adult patients. Surgical treatment of fistulae is associated with a risk of damaging anal sphincters. This usually happens in treating high fistulae, branched fistulae, and anterior ones in females. In preoperative diagnosis of anal fistulae, endosonography and magnetic resonance imaging play a significant role in planning the surgical technique. The majority of fistulae are diagnosed in endosonography, but magnetic resonance is performed when the presence of high fistulae, particularly branched ones, and recurrent is suspected.

THE AIM OF THIS PAPER

The aim of this paper was to compare the roles of the two examinations in preoperative assessment of high anal fistulae.

MATERIAL AND METHODS

The results of endosonographic and magnetic resonance examinations performed in 2011-2012 in 14 patients (4 women and 10 men) with high anal fistulae diagnosed intraoperatively were subject to a retrospective analysis. The patients were aged from 23 to 66 (mean 47). The endosonographic examinations were performed with the use of a BK Medical Pro Focus system with endorectal 3D transducers with the frequency of 16 MHz. The magnetic resonance scans were performed using a Siemens Avanto 1.5 T scanner with a surface coil in T1, T1FS, FLAIR, T2 sequences and in T1 following contrast medium administration. The sensitivity and specificity of endosonography and magnetic resonance imaging were analyzed. A surgical treatment served as a method for verification. The agreement of each method with the surgery and the agreement of endosonography and magnetic resonance imaging were compared in terms of the assessment of the fistula type, localization of its internal opening and branches. The agreement level was determined based on the percentage of consistent assessments and Cohen's coefficient of agreement, κ. The integrity of the anal sphincters was assessed in each case.

RESULTS

In determining the fistula type, magnetic resonance imaging agreed with intraoperative assessment in 79% of cases, and endosonography in 64% of cases. Endosonography agreed with magnetic resonance in 57% of cases. In the assessment of internal opening, the agreement between endosonography and intraoperative assessment was 65%, between magnetic resonance and intraoperative assessment - 41% and between endosonography and magnetic resonance - 53%. In the assessment of fistula branches, endosonography agreed with intraoperative assessment in 67% of cases, magnetic resonance in 87% of cases, and the agreement between the two methods tested was 67%.

CONCLUSIONS

Magnetic resonance is a more accurate method than endosonography in determining the type of high fistulae and the presence of branches. In assessing the internal opening, endosonography proved more accurate. The agreement between the two methods ranges from 53-67%; the highest level of agreement was noted for the assessment of branching.

Clinical Outcome Following Hemorrhoid Surgery: a Narrative Review

Surgical therapy guaranties satisfactory results, which are significantly better than those obtained with conservative therapies, especially for Grade III and IV hemorrhoids. In this review, we present and discuss the results of the most diffuse surgical techniques for hemorrhoids. Traditional surgery for hemorrhoids aims to remove the hemorrhoids, with closure (Fergusson's technique) or without closure (Milligan-Morgan procedure) of the ensuing defect. This traditional approach is effective, but causes a significant postoperative pain because of wide external wounds in the innervated perianal skin. Stapled hemorrhoidopexy, proposed by Longo, has gained a vast acceptance because of less postoperative pain and faster return to normal activities. In the recent literature, a significant incidence of recurrence after stapled hemorrhoidopexy was reported, when compared with conventional hemorrhoidectomy. Double stapler hemorrhoidopexy may be an alternative to simple stapled hemorrhoidopexy to reduce the recurrence in advanced hemorrhoidal prolapse. Transanal hemorrhoidal deartertialization was showed to be as effective as stapled hemorrhoidopexy in terms of treatment success, complications, and incidence recurrence. However, further high-quality trials are recommended to assess the efficacy and safety of this technique.

Appraisal of the LIFT and BIOLIFT procedure: initial experience and short-term outcomes of 33 consecutive patients

PURPOSE

A new sphincter-saving technique known as the LIFT (ligation of intersphincteric tract) procedure has gained growing interest. Use of a bioprosthetic device has also been suggested to augment the LIFT procedure (BIOLIFT). This study evaluates outcomes of patients undergoing LIFT and BIOLIFT for repair of complex anal fistulae.

METHODS

This study is a single-surgeon, single-centre retrospective review of a prospectively collected database. Study was conducted at Royal Prince Alfred Hospital Department of Colorectal Surgery, Sydney, Australia, from May 2009 to April 2012. Thirty-three patients were evaluated. Twenty-nine LIFTs and five BIOLIFT procedures were evaluated. Primary success is defined as successful healing from initial procedure while secondary success is successful healing after management of failure or recurrence.

RESULTS

In a cohort of predominantly female (67 %) and 94 % transsphincteric fistulae, primary success was 63 %. At a median follow-up of 20 weeks (6-81 weeks), there were 11 failures and one recurrence. The median time to failure/recurrence was 3 weeks (1-25 weeks). Six patients had a subsequent fistulotomy and three patients had a BIOLIFT for non-successful outcomes. The median follow-up for those with failures/recurrences is 60 weeks (range 20-76 weeks) and secondary success was 88 %. Post-operative anal manometry studies showed a 9 % reduction of resting and 11 % reduction of squeeze pressures but this was not statistically significant. There was also no post-operative incontinence. Anterior fistulas were noted do significantly worse (47%) compared with non-anteriorly located fistulas (84 %; p = 0.03).

CONCLUSIONS

LIFT and BIOLIFT procedures can be performed safely and effectively in a technically demanding study cohort of predominantly females with complex fistulas. Anterior fistulas have a higher risk of failure but present early and are amendable to repeat procedures. In particular, fistulotomies are useful in downstaged tracts and performing BIOLIFTs is an alternative in the management of LIFT failures and recurrences.

Fistulotomy in the tertiary setting can achieve high rates of fistula cure with an acceptable risk of deterioration in continence

INTRODUCTION

Surgery is the mainstay of treatment of anal fistulas. Low fistulas are often laid open, but higher fistulas present a more difficult problem. Patient choice centres on a compromise between risk of recurrence and risk of impairment of continence. We aimed to determine the efficacy and safety of fistulotomy at a tertiary referral centre, in particular the additional risk of impairment of continence following fistulotomy of the often recurrent, multiply-operated patients seen.

METHODS

Patients undergoing surgery under the senior author (RKSP) for an anal fistula during the study period (2005-2006) were identified, and a thorough review of the patients' clinical records was undertaken. Demographic, fistula anatomy, treatment and follow-up data were obtained.

RESULTS

Eighty-four patients underwent either fistulotomy (50), insertion of permanent loose (drainage) seton (28) or EUA with or without drainage of abscess. Mean length of follow up was 11 months (SD 14.22). In the fistulotomy group, we found an overall success rate of 93 %. Secondary extensions were associated with failure to achieve cure (P = 0.008). Nine patients (20 %) suffered deterioration in continence after surgery. A longer time to referral was associated with impaired final continence. In the group referred from a surgeon in secondary care, 91 % of patients were cured, and continence impairment (mostly minor) rose from 32 % at referral to 40 % after surgery.

CONCLUSIONS

We have shown that it is safe and reasonable to offer fistulotomy to appropriate patients despite previous surgery and within the tertiary setting. By so doing, a very high rate of healing can be achieved in patients who have previously failed. The additional risk of impairment of continence is around one in five, and in the majority will represent only minor incontinence.

Operative strategy for fistula-in-ano without division of the anal sphincter

INTRODUCTION

The treatment of perianal fistulas is diverse because no single technique is universally effective. Fistulotomy remains the most effective way of eradicating the pathology but it renders the patient at some risk of faecal incontinence, which many patients are reluctant to take. There are no data in the literature to indicate the healing rate of perianal fistulas when using an operative strategy that routinely avoids division of any part of the anal sphincter. The aim of this paper is to present the long-term results with an operative strategy that aims to avoid division of any part of the anal sphincter complex when treating all types of perianal fistulas, thereby minimising/eliminating the risk of postoperative incontinence.

METHODS

We report 54 consecutive cases of anal fistula that presented electively and as an emergency. Patients with known or subsequently diagnosed inflammatory bowel disease or malignancy were excluded from the study.

RESULT

Overall, 46 patients (37 male and 9 female) with a median age at presentation of 42 years (range: 19-73 years) were treated by lay-open of the subcutaneous tract of the perianal fistula and insertion of a loose seton for the part of the fistula tract related to the sphincter complex. The types of fistula treated were intersphincteric (89%), transsphincteric (4%) and high suprasphincteric (7%). The median length of time that the seton was left in place was 7 months (range: 1.5-24 months). The healing rate was 86% with a recurrence rate of 19% and a median follow-up duration of 42 months.

CONCLUSIONS

Patients who are reluctant to take any risk of faecal incontinence could be treated using an operative strategy that routinely avoids division of any part of the anal sphincter complex as this has a recurrence rate that compares well with other treatment modalities.

One-year outcome of haemorrhoidectomy: a prospective multicentre French study

AIM

An evaluation was performed of the 1-year outcome of open haemorrhoidectomy (Milligan and Morgan alone or with posterior mucosal anoplasty [the Leopold Bellan procedure]).

METHOD

A prospective, multicentre, observational study included all patients having a planned haemorrhoidectomy from January 2007 to June 2008. Data were collected before surgery, and at 3 months and 1 year after surgery. Patients assessed their anal symptoms and quality of life (SF-36).

RESULTS

Six-hundred and thirty-three patients (median age = 48 years, 56.5% women) underwent haemorrhoidectomy either by the Milligan and Morgan procedure alone (n = 231, 36.5%) or together with the Leopold Bellan procedure (posterior mucosal anoplasty) for resection of a fourth haemorrhoid (n = 345, 54.5%), anal fissure (n = 56, 8.9%) or low anal fistula (n = 1, 0.16%). The median healing time was 6 weeks. Early complications included urinary retention (n = 3), bleeding (n = 11), local infection (n = 7) and faecal impaction (n = 9). At 1 year, the main complications included skin tags (n = 2) and anal stenosis (n = 23). There were three recurrences requiring a second haemorrhoidectomy. On a visual analogue scale, anal pain at 1 year had fallen from a median of 5.5/10 before treatment to 0.1/10 (p < 0.001), anal discomfort from 5.5/10 to 0.1/10 (P < 0.001) and the Knowles-Eckersley-Scott Symptom (KESS) constipation score from 9/45 to 6/45 (P < 0.001). The median Wexner score for anal incontinence was unchanged (2/20). De-novo anal incontinence (a Wexner score of >5) affected 8.5% of patients at 1 year, but preoperative incontinence disappeared in 16.7% of patients with this symptom. All physical and mental domains of quality of life significantly improved, and 88% of patients were satisfied or very satisfied.

CONCLUSION

Complications of open haemorrhoidectomy were infrequent. Anal continence was not altered. Comfort and well-being were significantly improved at 1 year after surgery. Patient satisfaction was high despite residual anal symptoms.

Identification of the internal anal opening and seton placement improves the outcome of deep postanal space abscess

AIM

This study aimed to determine if successful seton placement at the initial drainage procedure improves outcomes in the management of deep postanal space abscesses.

METHOD

A retrospective review was performed of all patients who underwent initial drainage of a DPA space abscess between December 2002 and August 2010. A seton was placed through the internal opening if it could be identified.

RESULTS

Thirty-two patients of median age 41 (21-64) years formed the study group. Twenty-four (75.0%) had a seton inserted at the initial drainage procedure. The patients underwent a total of 56 operations. The median interval from the initial to the final operation was 5 (2-18) months with 17 (70.8%) patients having the final operation within 6 months. In the 8 (25.0%) patients whose internal opening could not be found, 26 operations were required with a median interval from the initial to the final surgery of 11 (3-24) months. Patients who had a seton successfully inserted at drainage underwent significantly earlier definitive surgery and required fewer operations (P < 0.038).

CONCLUSION

Identification of an internal opening with placement of a seton at the initial drainage procedure is associated with earlier definitive surgery and fewer operations.

DG-RAR for the treatment of symptomatic grade III and grade IV haemorrhoids: a 12-month multi-centre, prospective observational study

Background

Ultrasound-guided techniques represent a new treatment option in the treatment of haemorrhoids. Doppler-guided haemorrhoidal artery ligation (DG-HAL) proved efficacious in early haemorrhoidal disease, but lacks efficacy for stages III/IV. For these patients, haemorrhoidal artery ligation (HAL) has been combined with a running suture to reduce prolapsing haemorrhoidal tissue (recto-anal repair (RAR)).

Methods

A prospective observational study was conducted in 184 patients with grade III (58 %) or grade IV (42 %) haemorrhoids in seven coloproctological centres. Primary endpoints were the recurrence of symptoms and need of further treatment (medical or surgical).

Results

Post-operative complications were seen in 8 % of patients. After a follow-up of 3 months, 91 % of patients were free of symptoms and 91 % of patients were satisfied with the result. After a follow-up of 12 months, 89 % of patients were free of symptoms and 88 % were satisfied with the result. Nineteen per cent of patients received further medical or surgical treatment.

Conclusions

Doppler-guided recto-anal repair (DG-RAR) proves to be an effective treatment option for the treatment of advanced haemorrhoidal disease that shows equal results to other established treatment options.

Effect of vaginal delivery and ageing on the anatomy of the female anal canal assessed by three-dimensional anorectal ultrasound

AIM

The effect of vaginal delivery and ageing on the anatomy of the anal canal was assessed using three-dimensional anorectal ultrasound to determine the interobserver reliability.

METHOD

One-hundred and eighteen asymptomatic women without sphincter damage were grouped according to parity and mode of delivery. They were then stratified by age (≤50 years vs >50 years). Group I consisted of 35 nulliparous women, of mean ages 36 years (n = 20) and 62 years (n = 15), Group II consisted of multiparous women, having one or more vaginal deliveries (n = 43), of mean ages 43 years (n = 20) and 60 years (n = 23) and Group III consisted of women who had a Caesarean section (n = 40) of mean ages 41 years (n = 20) and 56 years (n = 20). The groups were compared with regard to the length and the thickness of the external anal sphincter, the internal anal sphincter, the posterior external sphincter and the puborectalis in all quadrants and the anterior gap. Interobserver variability was assessed.

RESULTS

In women having vaginal delivery the length of the anterior external sphincter was shorter (P = 0.0004) and the gap was longer (P = 0.0306). The external sphincter tended to be thinner in individuals having vaginal delivery (P = 0.0677) and in those subjects over 50 years of age having had a vaginal delivery (P = 0.0164). In nulliparous women, the internal sphincter was thicker in subjects over 50 years of age (P = 0.0229). The intraclass correlation coefficient was 0.755-0.916 for sphincter muscle and gap length and 0.446-0.769 for muscle thickness.

CONCLUSION

Vaginal delivery was associated with a shorter anterior external sphincter, a longer gap and a thinner anterior external sphincter in asymptomatic women. Age was correlated with sphincter thickness, and nulliparous women >50 years of age had a thicker internal sphincter. Three-dimensional ultrasound was found to be a reliable method for measuring anal structures.

German S3 guideline: anal abscess

BACKGROUND

The incidence of anal abscess is relatively high, and the condition is most common in young men.

METHODS

A systematic review of the literature was undertaken.

RESULTS

This abscess usually originates in the proctodeal glands of the intersphincteric space. A distinction is made between subanodermal, intersphincteric, ischioanal, and supralevator abscesses. The patient history and clinical examination are diagnostically sufficient to establish the indication for surgery. Further examinations (endosonography, MRI) should be considered in recurrent abscesses or supralevator abscesses. The timing of the surgical intervention is primarily determined by the patient's symptoms, and acute abscess is generally an indication for emergency treatment. Anal abscesses are treated surgically. The type of access (transrectal or perianal) depends on the abscess location. The goal of surgery is thorough drainage of the focus of infection while preserving the sphincter muscles. The wound should be rinsed regularly (using tap water). The use of local antiseptics is associated with a risk of cytotoxicity. Antibiotic treatment is only necessary in exceptional cases. Intraoperative fistula exploration should be conducted with extreme care if at all; no requirement to detect fistula should be imposed. The risk of abscess recurrence or secondary fistula formation is low overall, but they can result from insufficient drainage. Primary fistulotomy should only be performed in case of superficial fistulas and by experienced surgeons. In case of unclear findings or high fistulas, repair should take place in a second procedure.

CONCLUSION

In this clinical S3 guideline, instructions for diagnosis and treatment of anal abscess are described for the first time in Germany.

Partial stapled hemorrhoidopexy versus circular stapled hemorrhoidopexy for grade III-IV prolapsing hemorrhoids: a two-year prospective controlled study

BACKGROUND

Circular stapled hemorrhoidopexy (CSH) is an effective technique for treating prolapsing hemorrhoids; but urgency and anal stenosis are common postoperative complications. The aim of this study was to assess the efficacy and postoperative outcomes of partial stapled hemorrhoidopexy (PSH), compared with CSH.

METHODS

Seventy-two consecutive patients with grade III and IV hemorrhoids who met the inclusion/exclusion criteria were divided in a non-randomized manner to undergo either PSH (n = 34) or CSH (n = 38). Intraoperative and postoperative parameters in both groups were collected and compared.

RESULTS

The postoperative visual analog score for pain at first defecation was significantly lower in the PSH group than that in the CSH group (P = 0.001). Fewer patients in the PSH group experienced postoperative urgency, compared with those in the CSH group at 12 h, 1 day, and 7 days after surgery (P = 0.025, P = 0.019, and P = 0.043, respectively). Gas incontinence occurred in 3 patients (7.9%) in the CSH group, but in none of patients in the PSH group (P = 0.242). Postoperative anal stenosis developed in one patient (2.6%) in the CSH group, but in none of the patients in the PSH group (P = 1.0). The 2-year recurrence rate was 2.9 and 5.3%, respectively, in the PSH and CSH groups (P = 1.0).

CONCLUSIONS

The 2-year recurrence rate is similar in patients with grade III-IV hemorrhoids treated with PSH or CSH. However, PSH is associated with less postoperative pain, fewer episodes of urgency, and no anal incontinence or anal stenosis.

[Consensus statement haemorrhoidal disease]

Haemorrhoidal disease belongs to the most common benign disorders in the lower gastrointestinal tract. Treatment options comprise conservative as well as surgical therapy still being applied arbitrarily in accordance with the surgeon's expertise. The aim of this consensus statement was therefore to assess a stage-dependent approach for treatment of haemorrhoidal disease to derive evidence-based recommendations for clinical routine. The most common methods are discussed with respect of haemorrhoidal disease in extraordinary conditions like pregnancy or inflammatory bowel disease and recurrent haemorrhoids. Tailored haemorrhoidectomy is preferable for individualized treatment with regard to the shortcomings of the traditional Goligher classification in solitary or circular haemorrhoidal prolapses.

Underlying functional bowel disorder may explain patient dissatisfaction after haemorrhoidal surgery

AIM

The aim of this study was to assess patient dissatisfaction and functional symptoms following haemorrhoid surgery, aspects of which are seldom covered in other published series.

METHOD

A self-administered questionnaire was mailed to 359 consecutive patients (prospective database; 198 men, 161 women; median follow up, 59 [1-120] months) who underwent either Milligan-Morgan haemorrhoidectomy (n=205) or stapled haemorrhoidopexy (n=154).

RESULTS

The response rate was 72%; 2.4% of patients had no opinion, 13.6% were dissatisfied, 33.0% were satisfied, and 51.0% were very satisfied with the treatment. Dissatisfied patients were more likely to be women and more likely to have a long history of constipation and irritable bowel syndrome. The duration of surgery and the rates of pre- and postoperative complications did not differ between groups. Residual bleeding (49% vs 32%), prolapse (67% vs 31%) and pain (91% vs 55%) occurred more frequently in the dissatisfied group compared with the satisfied group (P<0.001). Incontinence (4 [0-16] vs 1 [0-15]; P=0.0003) and constipation (19 [1-34] vs 8 [0-31]; P<0.0001) scores were significantly higher in the dissatisfied group compared with satisfied patients. Anal pain was the predominant symptom associated with dissatisfaction in a logistic regression model.

CONCLUSION

Persistent pain remains the major long-term factor associated with dissatisfaction after surgery for haemorrhoids.

Partial stapled hemorrhoidopexy: a minimally invasive technique for hemorrhoids

PURPOSE

This study was designed to assess the safety, efficacy, and postoperative outcomes of partial stapled hemorrhoidopexy (PSH).

METHODS

A prospective study was conducted between February and March 2010. PSH was performed with single-window anoscopes for single isolated hemorrhoids, bi-window anoscopes for two isolated hemorrhoids, and tri-window anoscopes for three isolated hemorrhoids or circumferential hemorrhoids. The data pertaining to demographics, preoperative characteristics and postoperative outcomes were collected and analyzed.

RESULTS

Forty-four eligible patients underwent PSH. Single-window anoscopes were used in 2 patients, and bi- and tri-window anoscopes in 6 and 36 patients. The blood loss in patients with single-window, bi-window, and tri-window anoscopes was 6.0 ml (range 5.0-7.0 ml), 5.0 ml (range 5.0-6.5 ml), and 5.0 ml (4.5-14.5 ml) (P = 0.332). The mean postoperative visual analog scale score for pain was 3 (range, 1-4), 2 (range 1-4), 3 (range 2-6), 1 (range 0-3), 1 (range 0-2) and 2 (range 2-4) at 12 h, days 1, 2, 3, and 7, and at first defecation. The rate of urgency was 9.1%. No patients developed anal incontinence or stenosis. The 1-year recurrence rate of prolapsing hemorrhoids was 2.3%.

CONCLUSIONS

Partial stapled hemorrhoidopexy appears to be a safe and effective technique for grade III-IV hemorrhoids. Encouragingly, PSH is associated with mild postoperative pain, few urgency episodes, and no stenosis or anal incontinence.

Cryptoglandular anal fistulas

BACKGROUND

Cryptoglandular anal fistula arises in 2 per 10 000 persons per year and is most common in young men. Improper treatment can result in fecal incontinence and thus in impaired quality of life.

METHOD

This S3 guideline is based on a systematic review of the pertinent literature.

RESULTS

The level of evidence for treatment is low, because relevant randomized trials are scarce. Anal fistulae are classified according to the relation of the fistula channel to the sphincter. The indication for treatment is established by the clinical history and physical examination. During surgery, the fistula should be probed and/or dyed. Endo-anal ultrasonography and magnetic resonance imaging are of roughly the same diagnostic value and may be useful as additional studies for complex fistulae. Surgical treatment is with one of the following operations: laying open, seton drainage, plastic surgical reconstruction with suturing of the sphincter, and occlusion with biomaterials. Only superficial fistulae should be laid open. The risk of postoperative incontinence is directly related to the thickness of sphincter muscle that is divided. All high anal fistulae should be treated with a sphincter-saving procedure. The various plastic surgical reconstructive procedures all yield roughly the same results. Occlusion with biomaterials yields a lower cure rate.

CONCLUSION

This is the first German S3 guideline for the treatment of cryptoglandular anal fistula. It includes recommendations for the diagnostic evaluation and treatment of this clinical entity.

Anal fistula: Intraoperative difficulties and unexpected findings

Anal fistula surgery is a commonly performed procedure. The diverse anatomy of anal fistulae and their proximity to anal sphincters make accurate preoperative diagnosis essential to avoid recurrence and fecal incontinence. Despite the fact that proper preoperative diagnosis can be reached in the majority of patients by simple clinical examination, endoanal ultrasound or magnetic resonance imaging, on many occasions, unexpected findings can be encountered during surgery that can make the operation difficult and correct decision-making crucial. In this article we discuss the difficulties and unexpected findings that can be encountered during anal fistula surgery and how to overcome them.

Why do we have to review our experience in managing cases with idiopathic fistula-in-ano regularly?

“Why do we have to review our experience in managing idiopathic fistula-in-ano regularly?” In order to answer this apparently simple question, we reviewed our clinical and surgical cases and most important relevant literature to find a rational and scientific answer. It would appear that whatever method you adopt in fistula management, there is a price to pay regarding either rate of recurrence (higher with conservative methods) or impairment of continence (higher with traditional surgery). Since, at the moment, reliable data to identify a treatment as a gold standard in the management of anal fistulas are lacking, the correct approach to this condition must consider all the anatomic and clinicopathological aspects of the disease; this knowledge joined to an eclectic attitude of the surgeon, who should be familiar with different types of treatment, is the only guarantee for a satisfactory treatment. As a conclusion, it is worthwhile to remember that adequate initial treatment significantly reduces recurrence, which, when it occurs, is usually due to failure to recognise the tract and primary opening at the initial operation.

Long-term results after stapled hemorrhoidopexy: a prospective study with a 6-year follow-up

BACKGROUND

Stapled hemorrhoidopexy was introduced in 1998 as a new technique for treating advanced hemorrhoidal disease. Despite a clear perioperative advantage regarding pain and patient comfort, literature reviews indicate a higher recurrence rate for stapled hemorrhoidopexy than for conventional techniques.

OBJECTIVE

Our aim was to present long-term on the use of this technique.

DESIGN

Observational study.

SETTING AND PATIENTS

Consecutive patients with hemorrhoid prolapse treated at a regional surgical center from May 27, 1999, through December 31, 2003.

INTERVENTION

Stapled hemorrhoidopexy with accompanying resection of residual hemorrhoidal nodules if necessary.

MAIN OUTCOME MEASURES

Standardized patient questionnaire regarding satisfaction, resolution of symptoms, and performance of further interventions.

RESULTS

Of 257 patients (82 female, 175 male, mean age 53 ± 13 years) undergoing stapled hemorrhoidopexy, follow-up data were available for 224 patients (87.2%) with a mean duration of 6.3 ± 1.2 years. Of these, 195 patients (87.1%) were satisfied or very satisfied with the operation outcome; 19 patients (8.5%) were moderately satisfied; and 10 (4.5%) were not satisfied. Regarding preoperative anal symptoms, complete relief was observed in 179 patients (80.6%) for prolapse, 172 (77.5%) for bleeding, 139 (85.3%) for mucus discharge, 139 (78.5%) for burning sensation, and 115 (75.5%) for itching. Considering all recorded symptoms, 194 patients (86.6%) reported absence and or an improvement at follow-up. Twelve patients (5.4%) reported newly developed incontinence in the sense of urge symptoms; 42 patients out of 51 patients (82.4%) with preexisting incontinence reported an improvement. Local or topical retreatment (ointment, suppositories, sclerotherapy) was performed in 48 patients (21.4%). Reoperation for residual or newly developed hemorrhoidal nodules was needed in 8 patients (3.6%).

LIMITATIONS

Lack of a comparative group.

CONCLUSION

Our long-term results show that this strategy for stapled hemorrhoidopexy can achieve a high level of patient satisfaction and symptom control, with a low rate of reoperation for recurrent hemorrhoidal symptoms.

Anatomic characteristics of anal fistula on three-dimensional anorectal ultrasonography

BACKGROUND

Surgery for anal fistula is often associated with continence disorders due to the transection of sphincter muscles. Extensive knowledge of anal canal anatomy and anal fistula can help prevent this outcome.

OBJECTIVE

This study aimed to correlate the anatomical conformation of the anal canal, the fistula track, and the internal opening according to sex and hemicircumference (anterior vs posterior) by use of 3-dimensional ultrasonography.

METHODS

One hundred sixty-five patients with fistula were evaluated with 3-dimensional ultrasound and grouped according to sex, fistula type, internal opening, and track position. Fistulas were transsphincteric in 128 subjects and intersphincteric in 37 subjects. The study measured the external and internal anal sphincter, the puborectalis, the distance from the internal opening to the distal edge of the external and internal sphincter, the length of the internal and external sphincter compromised by the track, and the percentage of compromised muscle.

RESULTS

The anal canal muscles were longer in males. The distance from the internal opening to the internal sphincter was greater for the posterior hemicircumference. The point where the fistulous track crossed the anterior external sphincter was similar for the 2 sexes, but the percentage of compromised muscle was greater in females. The point where the fistulous track crossed the internal sphincter was similar for the 2 sexes, but the percentage of compromised internal sphincter was greater in males for the posterior hemicircumference. The study was limited by the absence of testing for interobserver and intraobserver agreement.

CONCLUSION

The anal canal muscles are longer in males and the pectinate line is asymmetrical. In females, the percentage of compromised external sphincter was greater in the anterior hemicircumference because of the shorter external sphincter, whereas in males the percentage of compromised internal sphincter was greater in the posterior hemicircumference.

Early result of ligation of the intersphincteric fistula tract for fistula-in-ano

PURPOSE

The ligation of the intersphincteric fistula tract is a new surgical procedure without any use of biologic material. The purpose of this study is to present our early results with this novel technique.

METHODS

A retrospective review of patients who underwent the procedure for high transsphincteric fistulas was analyzed. The procedure was performed by a single surgeon. Patient and fistula characteristics, complications, and recurrences were reviewed.

RESULTS

Twenty-five patients underwent the ligation of intersphincteric fistula tract procedure. All the patients had transsphincteric fistulas that were not suitable for fistulotomy. All patients underwent the procedure on an outpatient basis with a median follow-up of 24 weeks (range, 8-52 wk). Of the 25 patients, 17 (68%) healed completely and did not require any further surgical treatment. Eight of the 25 patients had persistent symptoms: 5 patients had a clear tract with an internal opening, 2 patients had a draining sinus without an identifiable internal opening, and 1 patient presented with an intersphincteric fistula, which was at the site of the intersphincteric groove incision. There were no statistically significant differences in recurrence rates with regard to the presence of a seton at the time of surgery, history of previous operations such as mucosal advancement flap, or seton placement.

CONCLUSION

The ligation of intersphincteric fistula is a promising sphincter-preserving procedure that is simple and safe, and it does not require expensive biologic material. Our early data confirm a low recurrence rate with a primary healing rate of 68%.