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Iglay K, Bennett D, Kappelman MD, Zhang X, Aldridge M, Karki C, Cook SF. A Systematic Review of Epidemiology and Outcomes Associated with Local Surgical and Intersphincteric Ligation Procedures for Complex Cryptoglandular Fistulas. Adv Ther 2023; 40:1926-1956. [PMID: 36905499 PMCID: PMC10129974 DOI: 10.1007/s12325-023-02452-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Accepted: 02/01/2023] [Indexed: 03/12/2023]
Abstract
INTRODUCTION This systematic literature review (SLR) assessed incidence/prevalence of cryptoglandular fistulas (CCF) and outcomes associated with local surgical and intersphincteric ligation procedures for CCFs. METHODS Two trained reviewers searched PubMed and Embase for observational studies evaluating the incidence/prevalence of cryptoglandular fistula and clinical outcomes of treatments for CCF after local surgical and intersphincteric ligation procedures for CCF. RESULTS In total 148 studies met a priori eligibility criteria for all cryptoglandular fistulas and all intervention types. Of those, two assessed incidence/prevalence of cryptoglandular fistulas. Eighteen reported clinical outcomes of surgeries of interest in CCF and were published in the past 5 years. Prevalence was reported as 1.35/10,000 non-Crohn's patients, and 52.6% of non-IBD patients were found to progress from anorectal abscess to fistula over 12 months. Primary healing rates ranged from 57.1% to 100%; recurrence occurred in a range of 4.9-60.7% and failure in 2.8-18.0% of patients. Limited published evidence suggests postoperative fecal incontinence and long-term postoperative pain were rare. Several of the studies were limited by single-center design with small sample sizes and short follow-up durations. DISCUSSION This SLR summarizes outcomes from specific surgical procedures for the treatment of CCF. Healing rates vary according to procedure and clinical factors. Differences in study design, outcome definition, and length of follow-up prevent direct comparison. Overall, published studies offer a wide range of findings with respect to recurrence. Postsurgical incontinence and long-term postoperative pain were rare in the included studies, but more research is needed to confirm rates of these conditions following CCF treatments. CONCLUSION Published studies on the epidemiology of CCF are rare and limited. Outcomes of local surgical and intersphincteric ligation procedures show differing success and failure rates, and more research is needed to compare outcomes across various procedures. (PROSPERO; registration number CRD42020177732).
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Affiliation(s)
- Kristy Iglay
- CERobs Consulting, LLC, 2612 North Lumina Ave., Wrightsville Beach, NC 28480 USA
| | - Dimitri Bennett
- Takeda Pharmaceuticals, Cambridge, MA 02139 USA
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104 USA
| | - Michael D. Kappelman
- Pediatric Gastroenterology, University of North Carolina, Chapel Hill School of Medicine, Chapel Hill, NC 27599 USA
| | - Xinruo Zhang
- CERobs Consulting, LLC, 2612 North Lumina Ave., Wrightsville Beach, NC 28480 USA
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599 USA
| | - Molly Aldridge
- CERobs Consulting, LLC, 2612 North Lumina Ave., Wrightsville Beach, NC 28480 USA
| | | | - Suzanne F. Cook
- CERobs Consulting, LLC, 2612 North Lumina Ave., Wrightsville Beach, NC 28480 USA
- Takeda Pharmaceuticals, Cambridge, MA 02139 USA
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García-Olmo D, Gómez-Barrera M, de la Portilla F. Surgical management of complex perianal fistula revisited in a systematic review: a critical view of available scientific evidence. BMC Surg 2023; 23:29. [PMID: 36740680 PMCID: PMC9901165 DOI: 10.1186/s12893-023-01912-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Accepted: 01/10/2023] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Treating complex perianal fistulas in Crohn's disease patients remains a challenge. Classical surgical treatments for Crohn's disease fistulas have been extrapolated from cryptoglandular fistulas treatment, which have different etiology, and this might interfere with its effectiveness, in addition, they increase fecal incontinence risk. Recently, new surgical techniques with support from biological approaches, like stem cells, have been developed to preserve the function of the sphincter. We have performed a systematic literature review to compare the results of these different techniques in the treatment of Crohn's or Cryptoglandular fistula. METHODS PubMed, EMBASE, Database of Abstracts of Reviews of Effectiveness, Cochrane Central Register of Controlled Trials were searched systematically for relevant articles. We included randomized controlled trials and observational studies that referred to humans, were written in English, included adults 18+ years old, and were published during the 10-year period from 2/01/2010 to 2/29/2020. Evidence level was assigned as designated by the Scottish Intercollegiate Guidelines Network. RESULTS Of the 577 citations screened, a total of 79 were ultimately included in our review. In Crohn's disease patients, classical techniques such as primarily seton, Ligation of Intersphincteric Fistula Tracks, or lay open, healing rates were approximately 50-60%, while in cryptoglandular fistula were around, 70-80% for setons or flaps. In Crohn's disease patients, new surgical techniques using derivatives of adipose tissue reported healing rates exceeding 70%, stem cells-treated patients achieved higher combined remission versus controls (56.3% vs 38.6%, p = 0.010), mesenchymal cells reported a healing rate of 80% at week 12. In patients with cryptoglandular fistulas, a healing rate of 70% using derivatives of adipose tissue or platelets was achieved, and a healing rate of 80% was achieved using laser technology. Fecal incontinence was improved after the use of autologous platelet growth factors and Nitinol Clips. CONCLUSION New surgical techniques showed better healing rates in Crohn's disease patients than classical techniques, which have better results in cryptoglandular fistula than in Crohn's disease. Healing rates for complex cryptoglandular fistulas were similar between the classic and new techniques, being the new techniques less invasive; the incontinence rate improved with the current techniques.
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Affiliation(s)
- D. García-Olmo
- grid.419651.e0000 0000 9538 1950New Therapies Laboratory, Health Research Institute-Fundación Jiménez Díaz University Hospital (IIS-FJD/UAM), Department of Surgery, Fundación Jiménez Díaz University Hospital (UAM), Avda. Reyes Católicos, 2, 28040 Madrid, Spain
| | - M. Gómez-Barrera
- grid.512746.3Pharmacoeconomics & Outcomes Research Iberia (PORIB), Paseo Joaquín Rodrigo, 4 i, 28224 Pozuelo de Alarcón, Madrid Spain
| | - F. de la Portilla
- grid.9224.d0000 0001 2168 1229Coloproctology Unit, Clinical Management Unit of General and Gastrointestinal Surgery, Division Seville, Biomedical Research Institute (IBIS), University Hospital Virgen del Rocio/CSIC University of Seville, Seville, Spain
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Schneider R, Ommer A. Spaltung von Analfisteln – noch zeitgemäß? COLOPROCTOLOGY 2022. [DOI: 10.1007/s00053-021-00583-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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A Novel Modification of the Endorectal Advancement Flap for Complex Anal Fistulas: Surgical Technique and Outcomes. Int Surg 2021. [DOI: 10.9738/intsurg-d-21-00008.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Objective
A modification of the endorectal advancement flap (EAF) procedure is described with outcomes in a single-center, large retrospective cohort study.
Summary of background data
Fistula-in-ano is a common problem encountered by surgeons that can be classified as either simple or complex. Complex fistulas (CFs) cause higher morbidity and are much more challenging to treat. Although numerous treatment options are available for CF, none are proven to be 100% effective. The endorectal advancement flap (EAF) procedure was developed as an alternative to conventional surgical treatments for CF.
Methods
Charts were reviewed of patients with CF who underwent EAF between 2004 and 2019. The conventional EAF procedure was modified by performing transverse imbrication of the internal sphincter over the internal fistula opening. The incidence of new-onset fecal incontinence and recurrence were analyzed at the last available date of in-person follow-up.
Results
With a median follow-up of 6.6 months (range, 3.3–24 months), 99 patients with CFs underwent a modified EAF. Of these, 93% (92 of 99) had resolution of fistula without adverse outcomes, 7% (7 of 99) experienced recurrence, and 1% (1 of 99) experienced new-onset fecal incontinence. Systemic steroid or immunomodulatory therapy use (P = 0.001) and patients with diagnosed inflammatory bowel disease (P < 0.0001) were associated with increased rate of recurrence.
Conclusions
EAF with transverse imbrication of the internal opening using interrupted, absorbable suture is an effective technique to treat complex or recurrent anal fistulas. It is associated with a low risk of recurrence (7%) and fecal incontinence (1%) and is a valid treatment option for CFs.
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Chaveli Diaz C, Esquiroz Lizaur I, Marzo Virto J, Oteiza Martínez F, Gonzalez Álvarez G, de Miguel Velasco M, Ciga Lozano MÁ. Fistulectomy and endorectal advancement flap repair for cryptoglandular anal fistula: recurrence and functional outcome over 10 years of follow-up. Int J Colorectal Dis 2021; 36:841-846. [PMID: 33580275 DOI: 10.1007/s00384-021-03867-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/27/2021] [Indexed: 02/04/2023]
Abstract
PURPOSE To examine long-term recurrence and anal continence of patients with anal fistula treated by fistulectomy and endorectal advancement flap repair. METHOD Retrospective analysis of a prospective cohort of 115 patients (77.4% males, mean age 48.9 years) requiring 130 procedures, with a minimum follow-up of 10 years. Recurrence included reappearance of fistula after wound healing or presence of an abscess or chronic suppuration in the operated area at follow-up. Fecal incontinence was evaluated by the Cleveland Clinic Florida (CCF-FI) fecal incontinence scoring system. RESULTS The mean and SD duration of the follow-up period was 155.5 (21.7) months. Recurrence developed in 31 (23.8%) cases, 28 (90.3%) of which within the first year, with a mean time to recurrence of 4.9 (2.9) months. The success rate was 76.2%. Anal continence was normal in 80% of patients before surgery, 63.8% at 1-year follow-up, and 71.5% at the end of follow-up (p < 0.001). Overall, continence worsened in 16.9% of cases. The mean (95% CI) CCF-FI score was 0.78 (0.35-1.21) preoperatively, 1.04 (0.64-1.43) at 1 year after surgery, 0.90 (0.52-1.29) at 5 years, and 1.16 (0.66-1.67) at the end of the study (p < 0.05). Neither recurrence nor continence was significantly associated with previous anal or fistula surgical procedures or complexity of the fistula. CONCLUSION In this study, fistulectomy and endorectal advancement flap repair was associated with a long-term high rate of success. Most recurrences occurred within the first year and continence showed a mild deterioration over time. CLINICAL TRIAL REGISTRATION Not applicable.
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Affiliation(s)
- Carlos Chaveli Diaz
- Unit of Colorectal Surgery, Department of Surgery, Complejo Hospitalario de Navarra, C/ Irunlarrea 3, Secretaría de Cirugía, Pabellón H3, E-31008, Pamplona, Spain.
| | - Irene Esquiroz Lizaur
- Unit of Colorectal Surgery, Department of Surgery, Complejo Hospitalario de Navarra, C/ Irunlarrea 3, Secretaría de Cirugía, Pabellón H3, E-31008, Pamplona, Spain
| | - José Marzo Virto
- Unit of Colorectal Surgery, Department of Surgery, Complejo Hospitalario de Navarra, C/ Irunlarrea 3, Secretaría de Cirugía, Pabellón H3, E-31008, Pamplona, Spain
| | - Fabiola Oteiza Martínez
- Unit of Colorectal Surgery, Department of Surgery, Complejo Hospitalario de Navarra, C/ Irunlarrea 3, Secretaría de Cirugía, Pabellón H3, E-31008, Pamplona, Spain
| | - Gregorio Gonzalez Álvarez
- Unit of Colorectal Surgery, Department of Surgery, Complejo Hospitalario de Navarra, C/ Irunlarrea 3, Secretaría de Cirugía, Pabellón H3, E-31008, Pamplona, Spain
| | - Mario de Miguel Velasco
- Unit of Colorectal Surgery, Department of Surgery, Complejo Hospitalario de Navarra, C/ Irunlarrea 3, Secretaría de Cirugía, Pabellón H3, E-31008, Pamplona, Spain
| | - Miguel Ángel Ciga Lozano
- Unit of Colorectal Surgery, Department of Surgery, Complejo Hospitalario de Navarra, C/ Irunlarrea 3, Secretaría de Cirugía, Pabellón H3, E-31008, Pamplona, Spain
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Zhang H, Xu T, Zhang XD. Efficacy of flap repair for anal fistula: study protocol for a systematic review of randomized controlled trial. Medicine (Baltimore) 2019; 98:e16856. [PMID: 31415418 PMCID: PMC6831420 DOI: 10.1097/md.0000000000016856] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND Clinical trials have reported that flap repair (FR) can treat anal fistula (AF) effectively. However, no study systematically investigated its efficacy and safety for patients with AF. This study will systematically assess its efficacy and safety of AF. METHODS We will retrieve MEDLINE, EMBASE, Cochrane Library, Elsevier, Springer, Web of Science, Scopus, Chinese Biomedical Literature Database, China National Knowledge Infrastructure, VIP Information, and Wanfang Data from their inceptions to May 1, 2019 without any language limitations. The primary outcome is fistula cure rate. The secondary outcomes consist of fistula recurrence rate, fecal continence, quality of life, and complications. RevMan 5.3 software will be used for methodological quality assessment, data synthesis, subgroup analysis and sensitivity analysis. RESULTS The results of this study will summarize a high-quality synthesis of current evidence for the treatment of FR for patients with AF. CONCLUSION The findings of this proposed study will provide evidence for judging whether FR is an effective and safety intervention for AF or not.PROSPERO registration number: PROSPERO CRD42019135507.
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Affiliation(s)
- Hao Zhang
- Department of Plastic Burn and Cosmetic Center
| | - Tao Xu
- Department of Medical Imaging, First Affiliated Hospital of Jiamusi University, Jiamusi, China
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Lin H, Jin Z, Zhu Y, Diao M, Hu W. Anal fistula plug vs rectal advancement flap for the treatment of complex cryptoglandular anal fistulas: a systematic review and meta-analysis of studies with long-term follow-up. Colorectal Dis 2019; 21:502-515. [PMID: 30506546 DOI: 10.1111/codi.14504] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2018] [Accepted: 11/09/2018] [Indexed: 12/13/2022]
Abstract
AIM The aim was to compare the effectiveness of the anal fistula plug (AFP) with the rectal advancement flap (RAF) for complex cryptoglandular anal fistulas. METHODS We conducted a literature search to identify relevant available articles published without language restriction from Embase and PubMed databases and the Cochrane Library. Studies comparing outcomes with the AFP vs RAF for complex cryptoglandular anal fistulas were eligible for inclusion. RESULTS A total of 11 articles with 810 patients were included in this meta-analysis. Four RCTs and one observational clinical study provided long-term follow-up. The pooled analysis of all 11 studies indicated that there was no significant difference between the AFP and RAF in terms of healing rate, recurrence rate and incidence of fistula complications. However, the pooled results of studies with long-term follow-up revealed that the RAF group had a significantly higher healing rate (OR 0.32, 95% CI 0.13, 0.78, P = 0.01) and lower recurrence rate (OR 4.45, 95% CI 1.45, 13.65, P = 0.009) than the AFP group. CONCLUSIONS For the treatment of complex cryptoglandular anal fistulas, the RAF was superior to the AFP in terms of healing and recurrence rate after pooling of randomized controlled trials with long-term follow-up, even though a comparison based on the pooling of all studies showed no significant difference.
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Affiliation(s)
- H Lin
- Department of Intensive Care Unit, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, China.,Department of Surgery, Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Z Jin
- Hangzhou Geriatric Hospital, Hangzhou First People's Hospital Group, Hangzhou, China
| | - Y Zhu
- Department of Intensive Care Unit, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - M Diao
- Department of Intensive Care Unit, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - W Hu
- Department of Intensive Care Unit, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, China
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Ommer A, Herold A, Berg E, Farke S, Fürst A, Hetzer F, Köhler A, Post S, Ruppert R, Sailer M, Schiedeck T, Schwandner O, Strittmatter B, Lenhard BH, Bader W, Krege S, Krammer H, Stange E. S3-Leitlinie: Kryptoglanduläre Analfisteln. COLOPROCTOLOGY 2016. [DOI: 10.1007/s00053-016-0110-7] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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Kontovounisios C, Tekkis P, Tan E, Rasheed S, Darzi A, Wexner SD. Adoption and success rates of perineal procedures for fistula-in-ano: a systematic review. Colorectal Dis 2016; 18:441-58. [PMID: 26990602 DOI: 10.1111/codi.13330] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2015] [Accepted: 01/04/2016] [Indexed: 12/11/2022]
Abstract
AIM Several sphincter-preserving techniques have been described with extremely encouraging initial reports. However, more recent studies have failed to confirm the positive early results. We evaluate the adoption and success rates of advancement flap procedures (AFP), fibrin glue sealant (FGS), anal collagen plug (ACP) and ligation of intersphincteric fistula tract (LIFT) procedures based on their evolution in time for the management of anal fistula. METHOD A PubMed search from 1992 to 2015. An assessment of adoption, duration of study and success rate was undertaken. RESULTS We found 133 studies (5604 patients): AFP (40 studies, 2333 patients), FGS (31 studies, 871 patients), LIFT (19 studies, 759 patients), ACP (43 studies, 1641 patients). Success rates ranged from 0% to 100%. Study duration was significantly associated with success rates in AFP (P = 0.01) and FGS (P = 0.02) but not in LIFT or ACP. The duration of use of individual procedures since first publication was associated with success rate only in AFP (P = 0.027). There were no statistically significant differences in success rates relative to the number of the patients included in each study. CONCLUSION Success and adoption rates tend to decrease with time. Differences in patient selection, duration of follow-up, length of availability of the individual procedure and heterogeneity of treatment protocols contribute to the diverse results in the literature. Differences in success rates over time were evident, suggesting that both international trials and global best practice consensus are desirable. Further prospective randomized controlled trials with homogeneity and clear objective parameters would be needed to substantiate these findings.
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Affiliation(s)
- C Kontovounisios
- Department of Colorectal Surgery, The Royal Marsden Hospital, London, UK.,Department of Colorectal Surgery, Chelsea and Westminster Hospital, London, UK
| | - P Tekkis
- Department of Colorectal Surgery, The Royal Marsden Hospital, London, UK.,Department of Colorectal Surgery, Chelsea and Westminster Hospital, London, UK
| | - E Tan
- Department of Colorectal Surgery, Chelsea and Westminster Hospital, London, UK
| | - S Rasheed
- Department of Colorectal Surgery, The Royal Marsden Hospital, London, UK
| | - A Darzi
- Department of Colorectal Surgery, The Royal Marsden Hospital, London, UK
| | - S D Wexner
- Department of Colorectal Surgery in the Digestive Disease Center, Cleveland Clinic, Weston, FL, USA
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