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Bhat S, Xu W, Varghese C, Dubey N, Wells CI, Harmston C, O'Grady G, Bissett IP, Lin AY. Efficacy of different surgical treatments for management of anal fistula: a network meta-analysis. Tech Coloproctol 2023; 27:827-845. [PMID: 37460830 PMCID: PMC10485107 DOI: 10.1007/s10151-023-02845-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Accepted: 07/06/2023] [Indexed: 09/09/2023]
Abstract
PURPOSE Currently, the anal fistula treatment which optimises healing and preserves bowel continence remains unclear. The aim of our study was to compare the relative efficacy of different surgical treatments for AF through a network meta-analysis. METHODS Systematic searches of MEDLINE, EMBASE and CENTRAL databases up to October 2022 identified randomised controlled trials (RCTs) comparing surgical treatments for anal fistulae. Fistulae were classified as simple (inter-sphincteric or low trans-sphincteric fistulae crossing less than 30% of the external anal sphincter (EAS)) and complex (high trans-sphincteric fistulae involving more than 30% of the EAS). Treatments evaluated in only one trial were excluded from the primary analyses to minimise bias. The primary outcomes were rates of success in achieving AF healing and bowel incontinence. RESULTS Fifty-two RCTs were included. Of the 14 treatments considered, there were no significant differences regarding short-term (6 months or less postoperatively) and long-term (more than 6 months postoperatively) success rates between any of the treatments in patients with both simple and complex anal fistula. Ligation of the inter-sphincteric fistula tract (LIFT) ranked best for minimising bowel incontinence in simple (99.1% of comparisons; 3 trials, n = 70 patients) and complex anal fistula (86.2% of comparisons; 3 trials, n = 102 patients). CONCLUSIONS There is insufficient evidence in existing RCTs to recommend one treatment over another regarding their short and long-term efficacy in successfully facilitating healing of both simple and complex anal fistulae. However, LIFT appears to be associated with the least impairment of bowel continence, irrespective of AF classification.
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Affiliation(s)
- S Bhat
- Surgical and Translational Research Centre, Department of Surgery, The University of Auckland, Auckland, New Zealand
- Department of Surgery, Te Whatu Ora MidCentral, Palmerston North, New Zealand
| | - W Xu
- Surgical and Translational Research Centre, Department of Surgery, The University of Auckland, Auckland, New Zealand
- Department of Surgery, Te Whatu Ora Te Toka Tumai, Whangārei, New Zealand
| | - C Varghese
- Surgical and Translational Research Centre, Department of Surgery, The University of Auckland, Auckland, New Zealand
| | - N Dubey
- Department of General Medicine, Tauranga Hospital, Te Whatu Ora, Tauranga, New Zealand
| | - C I Wells
- Surgical and Translational Research Centre, Department of Surgery, The University of Auckland, Auckland, New Zealand
- Department of Surgery, Te Whatu Ora Te Toka Tumai, Auckland, New Zealand
| | - C Harmston
- Surgical and Translational Research Centre, Department of Surgery, The University of Auckland, Auckland, New Zealand
- Department of Surgery, Te Whatu Ora Te Toka Tumai, Whangārei, New Zealand
| | - G O'Grady
- Surgical and Translational Research Centre, Department of Surgery, The University of Auckland, Auckland, New Zealand
- Auckland Bioengineering Institute, The University of Auckland, Auckland, New Zealand
| | - I P Bissett
- Surgical and Translational Research Centre, Department of Surgery, The University of Auckland, Auckland, New Zealand
| | - A Y Lin
- Department of Surgery and Anaesthesia, University of Otago, Wellington, New Zealand.
- Department of Surgery, Wellington Regional Hospital, Te Whatu Ora, Wellington, New Zealand.
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Ahn HS, Hu R, Gilbert R, Zwiep T, Moloo H, Williams L, Raiche I, Boushey RP, Friedlich M, Musselman RP. Comparison of BioLIFT versus LIFT for the treatment of trans-sphincteric anal fistula: a protocol for systematic review and meta-analysis. BMJ Open 2023; 13:e065876. [PMID: 37612106 PMCID: PMC10450130 DOI: 10.1136/bmjopen-2022-065876] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Accepted: 08/23/2022] [Indexed: 08/25/2023] Open
Abstract
INTRODUCTION Identifying the optimal treatment for anal fistula has been challenging. Since first reported in 2007, the ligation of the intersphincteric fistula tract (LIFT) procedure has reported healing rates between 40% and 95% and is being increasingly adopted. The BioLIFT is an augmentation of the LIFT with an intersphincteric bioprosthetic mesh and has reported healing rates between 69% and 94%. Despite increased costs and potential complications associated with mesh, the evidence comparing healing rates between BioLIFT and LIFT is unknown. This study details the protocol for a systematic review and meta-analysis of BioLIFT and LIFT to compare outcomes associated with each procedure. METHODS AND ANALYSIS MEDLINE, EMBASE and the Cochrane Database will be searched from inception using a search strategy designed by an information specialist. Randomised controlled trials, prospective and retrospective cohort studies, consecutive series, cross-sectional studies and case series with more than five patients will be included. Both comparative and single group studies will be included. The eligible population will be adult patients undergoing BioLIFT or LIFT for trans-sphincteric anal fistula. The primary outcome will be primary healing rate. Secondary outcomes will capture secondary healing rate and complications. Abstract, full text and data extraction will be completed independently and in duplicate by two reviewers. Study risk of bias will be assessed using Risk of Bias In Non-randomized Studies - of Interventions and the Risk of Bias (RoB 2.0) tool. Quality of evidence for outcomes will be evaluated using Grading of Recommendations, Assessment, Development and Evaluations criteria. A meta-analysis will be performed using a random-effects inverse variance model. Subgroup and sensitivity analyses will be explored in relation to complex fistula characteristics and patients who have undergone previous LIFT. Heterogeneity will be assessed using the I2 statistic. ETHICS AND DISSEMINATION This review does not require research ethics board approval. This study will be completed in September 2022. The findings of this study will be disseminated through peer-reviewed international conferences and journals. PROSPERO REGISTRATION NUMBER CRD42020127996.
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Affiliation(s)
| | - Richard Hu
- General Surgery, University of Ottawa, Ottawa, Ontario, Canada
| | - Richard Gilbert
- General Surgery, University of Ottawa, Ottawa, Ontario, Canada
| | - Terry Zwiep
- General Surgery, University of Western Ontario, London, Ontario, Canada
| | - Husein Moloo
- General Surgery, University of Ottawa, Ottawa, Ontario, Canada
| | - Lara Williams
- General Surgery, University of Ottawa, Ottawa, Ontario, Canada
| | - Isabelle Raiche
- General Surgery, University of Ottawa, Ottawa, Ontario, Canada
| | - Robin P Boushey
- General Surgery, University of Ottawa, Ottawa, Ontario, Canada
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Olajide TO, Bode CO. Closure of Fistula-in-Ano Using a Radial-Emitting Laser Probe: Initial Experience in Lagos, Nigeria. JOURNAL OF THE WEST AFRICAN COLLEGE OF SURGEONS 2023; 13:101-106. [PMID: 37538211 PMCID: PMC10395862 DOI: 10.4103/jwas.jwas_108_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Accepted: 06/06/2023] [Indexed: 08/05/2023]
Abstract
Background Fistula-in-ano treatment has remained quite challenging with high failure rates and a potential for damage to the anal sphincteric complex leading to flatal or faecal incontinence. The treatment of fistula-in-ano using the fistula laser closure (FiLaC) as a minimally invasive, sphincter-saving procedure for complex disease has recently been documented. Objectives This review aimed to report the outcome of using it at the Lagos University Teaching Hospital. Patients and Methods The procedures were performed with a radially emitting laser fibre from Biolitec AG-CeramOptec (Bonn, Germany). The duration of symptoms, type of fistula, duration of the procedures, and postoperative complications were evaluated. Results Eleven male patients had laser fistula-in-ano closure. The age range was 33-51 years, with a median age of 39 years and an interquartile range (IQR) of 37-47 years. Five patients were noted to have high fistula/e, whereas six had low fistula/e, seven had a single tract each, and three had three tracts each. The duration of surgery ranged, approximately from 3 to 60 min, with a median of 19 min and IQR of 9-33 min. Postoperative pain was mild in all patients and were all discharged as day case. There was no postoperative wound infection, anal incontinence, anal stenosis, and subcutaneous abscess. However, there was a recurrence in two patients. Conclusions FiLaC has been demonstrated to be a reliable and safe sphincter-saving procedure for treating fistula-in-ano even for complex and high fistulae that is feasible in our subregion.
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Affiliation(s)
- Thomas Olagboyega Olajide
- General Surgery Unit, College of Medicine, University of Lagos/Lagos University Teaching Hospital, Lagos, Nigeria
| | - Christopher O. Bode
- Paediatric Surgery Unit, Department of Surgery, College of Medicine, University of Lagos/Lagos University Teaching Hospital, Lagos, Nigeria
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Hariprasad CP, Kumar A, Kumar M, Kumar M, Paswan SS, Rohit G, Kishor S, Kumar P. The efficacy of Ksharsutra, Fistulectomy and Ligation of Intersphincteric Fistula Tract (LIFT) procedure in management of Fistula in ano a prospective observational study. BMC Surg 2023; 23:70. [PMID: 36991427 PMCID: PMC10061687 DOI: 10.1186/s12893-023-01969-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2022] [Accepted: 03/22/2023] [Indexed: 03/31/2023] Open
Abstract
BACKGROUND Fistula in ano is always a troublesome condition for the clinician and the patients owing to its complexity, recurrences, and high morbidity since ancient times. There is no gold standard treatment modality to date documented in the literature for complex fistula in ano. MATERIAL AND METHODS We enrolled 60 consecutive adult patients attending the surgical outpatient department of a tertiary care centre in India, diagnosed with complex fistula in ano. Among them, 20 each in the Ligation of intersphincteric fistula tract (LIFT), Fistulectomy andKsharsutra(Special medicated seton) group were respectively recruited randomly. A prospective observational study was conducted. The primary outcomes were postoperative recurrence and morbidity. Post-operative morbidity is measured in terms of postoperative pain, postoperative bleeding, pus discharge and post-operative incontinence. The result of the study were analysed after 6 months of follow-up by clinical examination at outpatient department and at 18 months follow up done telephonically. RESULTS At 6 months of follow-up, 2 patients (10%) had a recurrence in the Ligation of intersphincteric fistula tract procedure group, 3 patients (15%) in the fistulectomy group and 6 patients (30%) in Ksharsutra group, however 3(15%), 4(20%) and 9(45%) patients developed recurrence in Ligation of Intersphincteric fistula tract, Fistulectomy and Ksharsutra group respectively at 18 month of follow-up. The differences in the recurrence were not statistically significant.The mean Visual analogue score for postoperative pain after 24 h as well as after 48 h were statistically significant in Ligation of intersphincteric fistula tract versus Ksharsutra group (p < 0.05). The Visual analogue score for post-operative pain was also significant in the Ligation of the intersphincteric fistula tract versus the Fistulectomy group (p < 0.05). The patients treated via Fistulectomy and Ksharsutra had a higher proportion of bleeding (15%) as compared to the Ligation of intersphincteric fistula tract procedure. Postoperative morbidity was statistically significant between the Ligation of intersphincteric fistula tract versus the Ksharsutra and the Ligation of intersphincteric fistula tract versus Fistulectomy. CONCLUSION Ligation of intersphincteric fistula tract had less postoperative morbidity compared to Fistulectomy and Ksharsutra procedure; although recurrence was less compared to other methods it was statistically not significant.
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Affiliation(s)
| | - Anil Kumar
- Department of General Surgery, All India Institute of Medical Sciences, Patna, India.
| | - Manoj Kumar
- Department of General Surgery, All India Institute of Medical Sciences, Patna, India
| | - Manoj Kumar
- Department of General Surgery, All India Institute of Medical Sciences, Patna, India
| | - Shiv Shankar Paswan
- Department of General Surgery, All India Institute of Medical Sciences, Patna, India
| | - Gupta Rohit
- Department of General Surgery, All India Institute of Medical Sciences, Patna, India
| | - Shiv Kishor
- Department of General Surgery, All India Institute of Medical Sciences, Patna, India
| | - Prem Kumar
- Department of Radiodiagnosis, All India Institute of Medical Sciences, Patna, India
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Charalampopoulos A, Papakonstantinou D, Bagias G, Nastos K, Perdikaris M, Papagrigoriadis S. Surgery of Simple and Complex Anal Fistulae in Adults: A Review of the Literature for Optimal Surgical Outcomes. Cureus 2023; 15:e35888. [PMID: 36911578 PMCID: PMC9993441 DOI: 10.7759/cureus.35888] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/08/2023] [Indexed: 03/11/2023] Open
Abstract
Anal fistulas are common anorectal conditions, and surgery is the primary treatment option. In the last 20 years of literature, there exist a large number of surgical procedures, especially for the treatment of complex anal fistulas, as they present more recurrences and continence problems than simple anal fistulas. To date, there are no guidelines for choosing the best technique. We conducted a recent literature review, mainly the last 20 years, based on the PubMed and Google Scholar medical databases, with the goal of identifying the surgical procedures with the highest success rates, lowest recurrence rates, and best safety profiles. Clinical trials, retrospective studies, review articles, comparative studies, recent systematic reviews, and meta-analyses for various surgical techniques, as well as the latest guidelines of the American Society of Colon and Rectal Surgeons, the Association of Coloproctology of Great Britain and Ireland, and the German S3 guidelines on simple and complex fistulas were reviewed. According to the literature, there is no recommendation for the optimal surgical technique. The etiology, complexity, and many other factors affect the outcome. In simple intersphincteric anal fistulas, fistulotomy is the procedure of choice. In simple low transsphincteric fistulas, the patient's selection is crucial in order to perform a safe fistulotomy or another sphincter-saving technique. The healing rate in simple anal fistulas is higher than 95% with low recurrence and without significant postoperative complications. In complex anal fistulas, only sphincter-saving techniques should be used; the optimal outcomes are obtained by the ligation of the intersphincteric fistulous tract (LIFT) and rectal advancement flaps. Those techniques assure high healing rates of 60-90%. The novel technique of the transanal opening of the intersphincteric space (TROPIS) is under evaluation. The novel sphincter-saving techniques of fistula laser closure (FiLac) and video-assisted anal fistula treatment (VAAFT) are safe, with reported healing rates ranging from 65% to 90%. Surgeons should be familiar with all sphincter-saving techniques in order to face the variability of the fistulas-in-ano. Currently, there is no universally superior technique that can treat all fistulas.
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Affiliation(s)
- Anestis Charalampopoulos
- Third Department of Surgery, "Attikon" University General Hospital/National and Kapodistrian University of Athens, School of Medicine, Athens, GRC
| | - Dimitrios Papakonstantinou
- Third Department of Surgery, "Attikon" University General Hospital/National and Kapodistrian University of Athens, School of Medicine, Athens, GRC
| | - George Bagias
- Third Department of Surgery, "Attikon" University General Hospital/National and Kapodistrian University of Athens, School of Medicine, Athens, GRC
| | - Konstantinos Nastos
- Third Department of Surgery, "Attikon" University General Hospital/National and Kapodistrian University of Athens, School of Medicine, Athens, GRC
| | - Markos Perdikaris
- Third Department of Surgery, "Attikon" University General Hospital/National and Kapodistrian University of Athens, School of Medicine, Athens, GRC
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Qi W, Wang L, Xu J, Gao J. The efficacy and safety of Chinese herbal medicine for reducing wound complications after anal fistula surgery: A protocol for systematic review and meta-analysis. Medicine (Baltimore) 2022; 101:e32021. [PMID: 36482572 PMCID: PMC9726318 DOI: 10.1097/md.0000000000032021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Anal fistula is one of the most common diseases in anorectal surgery. The wound healing after surgery can affect the prognosis of patients. We conducted a protocol for systematic review and meta-analysis to assess the efficacy and safety of Chinese herbal medicine for reducing wound complications after anal fistula surgery. METHODS We have prepared this protocol in accordance with the Preferred Reporting Item for Systematic Review and Meta-analysis (PRISMA-P) statement. We will search the following databases: the China National Knowledge Infrastructure, Wanfang Database, Chinese Science and Technology Periodical Database, Chinese Biomedical Literature Database, Pubmed, Embase, Web of Science, and the Cochrane library. Two authors will independently assess the risk of bias of the included studies based on the bias risk assessment tool recommended in the Cochrane "Risk of bias" assessment tool. All calculations are carried out with STATA13.0 software. RESULTS A synthesis of current evidence of Chinese herbal medicine for wound management after anal fistula surgery will be shown in this protocol. CONCLUSION This study may provide more convincing evidence to help clinicians make decisions when dealing with anal fistula patients after surgery.
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Affiliation(s)
- Wenyue Qi
- Hebei University of Chinese Medicine, Hebei, China
| | - Linyue Wang
- Hebei University of Chinese Medicine, Hebei, China
| | - Jiancheng Xu
- Department of Proctology, the First Affiliated Hospital of Hebei University of Chinese Medicine, Hebei, China
| | - Jihua Gao
- Department of Proctology, the First Affiliated Hospital of Hebei University of Chinese Medicine, Hebei, China
- * Correspondence: Jihua Gao, Department of Proctology, the First Affiliated Hospital of Hebei University of Chinese Medicine, Hebei 050011, China (e-mail: )
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Kadhim AM, Altaraikhim MHO. VAAFT PROCEDURE (Video-assisted Anal Fistula Treatment) versus Open Method in the Treatment of High Fistula in Ano. JOURNAL OF COLOPROCTOLOGY 2022. [DOI: 10.1055/s-0042-1759607] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Abstract
Background A common acquired anorectal condition is anal fistula. The treatment approaches that have been employed have been linked to erratic outcomes and sometimes life-threatening consequences. Video-assisted anal fistula treatment (VAAFT), a minimally invasive method, was introduced for adult patients in 2011.
Objective To know the efficacy of the VAAFT procedure in treating high anal fistulas and to compare it to open methods in the Basrah province.
Methods The present study was performed on 200 patients with high fistulas in ano in Basrah province. We divided the patients into 2 groups: Group A: treated by the VAAFT technique and Group B: treated by open fistulotomy
Results The patients treated with VAFFT revealed no occurrence of the following postoperative complication: Infection, incontinence, recurrence, anal stenosis, and bleeding. There was lower incidence of pain, short time for wound healing, rapid return to work, and more patient satisfaction compared with open fistulotomy
Conclusion An innovative method for managing ano fistula is VAAFT. Compared with traditional methods, it has a lot of benefits. It is day case surgeryno open wound.no damage to anal sphincter and no risk of incontinence, it is more affordable.it allow for clear identification of internal office, whole tract and its associated branches and cavity. The instrument can be used for multiple patients after good sterilization and disinfection.
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Wolthuis AM. Subcutaneous incision of the fistula tract and internal sphincterotomy: A novel surgical procedure for transsphincteric anal fistula. Colorectal Dis 2022; 24:1458-1459. [PMID: 36576414 DOI: 10.1111/codi.16422] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Affiliation(s)
- Albert M Wolthuis
- Department of Abdominal Surgery, University Hospital Leuven, Leuven, Belgium
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Gaertner WB, Burgess PL, Davids JS, Lightner AL, Shogan BD, Sun MY, Steele SR, Paquette IM, Feingold DL. The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Management of Anorectal Abscess, Fistula-in-Ano, and Rectovaginal Fistula. Dis Colon Rectum 2022; 65:964-985. [PMID: 35732009 DOI: 10.1097/dcr.0000000000002473] [Citation(s) in RCA: 52] [Impact Index Per Article: 26.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Affiliation(s)
- Wolfgang B Gaertner
- Division of Colon and Rectal Surgery, University of Minnesota, Minneapolis, Minnesota
| | - Pamela L Burgess
- Department of Surgery, Uniformed Services University of the Health Sciences, Eisenhower Army Medical Center, Fort Gordon, Georgia
| | - Jennifer S Davids
- Department of Surgery, University of Massachusetts, Worcester, Massachusetts
| | - Amy L Lightner
- Department of Colon and Rectal Surgery, Cleveland Clinic, Cleveland, Ohio
| | | | - Mark Y Sun
- Department of Surgery, University of Cincinnati, Cincinnati, Ohio
| | - Scott R Steele
- Department of Colon and Rectal Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Ian M Paquette
- Department of Surgery, University of Cincinnati, Cincinnati, Ohio
| | - Daniel L Feingold
- Division of Colorectal Surgery, Rutgers University, New Brunswick, New Jersey
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10
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Tian Z, Li YL, Nan SJ, Xiu WC, Wang YQ. Video-assisted anal fistula treatment for complex anorectal fistulas in adults: a systematic review and meta-analysis. Tech Coloproctol 2022; 26:783-795. [PMID: 35347492 DOI: 10.1007/s10151-022-02614-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Accepted: 03/08/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND Video-assisted anal fistula treatment (VAAFT) has gained increasing acceptance as a sphincter-sparing procedure for treating complex anorectal fistulas (CAF), but no unequivocal conclusions can yet be drawn regarding its ultimate effectiveness. We reviewed the literature and performed a meta-analysis to evaluate the efficacy and safety of VAAFT in CAF patients. METHODS The study protocol was registered with the PROSPERO database (CRD42021279085). A systematic literature search was performed in the PubMed, Embase, and Cochrane Library databases up to June 2021 with no restriction on language based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We used the keywords video-assisted surgery, video-assisted anal fistula treatment, and complex anorectal fistula to identify relevant studies. RESULTS Fourteen trials (7 prospective and 7 retrospective) with a total of 1201 patients (mean age 43.5 years) were included. The median follow-up duration was 16.5(8-48) months. Pooled analysis showed that the rates of success, recurrence and postoperative complication across the studies were 83% (95% CI 81-85%, I2 = 37.9%), 16% (95% CI 14-18%, I2 = 4.8%), 11% (95% CI 7-15%, I2 = 72.1%), respectively. The postoperative Jorge-Wexner score used to assess the level of anal incontinence was 1.09 (95% CI, 0.9-1.27, I2 = 74.6%). The internal opening detection rate was 97.6% (95% CI 96.1-99.6%, I2 = 48.2%). Recurrence rates varied according to the closure method of internal opening from 21.4% after using staplers, 18.7% after suturing, to 23.5% after advancement flap. The hospital stay was 3.15 days (95% CI 2.96-3.35, I2 = 49.7%). Subgroup analysis indicated that the risk of heterogeneity in the urine retention group was higher compared with that of the overall group and that retrospective studies may be the source of heterogeneity for postoperative anal incontinence. r . Sensitivity analysis confirmed the stability of the pooled results. Begg's and Egger's tests showed no evidence of publication bias. CONCLUSIONS According to the available evidence, VAAFT may be a valuable alternative to fistulotomy or seton in treating CAF and has the additional long-term benefits of reducing anal incontinence and surgical morbidity, permitting earlier healing and accelerated rehabilitation.
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Affiliation(s)
- Z Tian
- Department of Anorectal Center, Qilu Hospital (Qingdao), Cheeloo College of Medicine, Shandong University, Qingdao, Shandong, China
| | - Y L Li
- The Affiliated Hospital of Qingdao University, Qingdao, Shandong, China
| | - S J Nan
- Department of Anorectal Center, Qilu Hospital (Qingdao), Cheeloo College of Medicine, Shandong University, Qingdao, Shandong, China
| | - W C Xiu
- Department of Anorectal Center, Qilu Hospital (Qingdao), Cheeloo College of Medicine, Shandong University, Qingdao, Shandong, China
| | - Y Q Wang
- Department of Anorectal Center, Qilu Hospital (Qingdao), Cheeloo College of Medicine, Shandong University, Qingdao, Shandong, China.
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11
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Adegbola SO, Sahnan K, Tozer P, Warusavitarne J. Emerging Data on Fistula Laser Closure (FiLaC) for the Treatment of Perianal Fistulas; Patient Selection and Outcomes. Clin Exp Gastroenterol 2021; 14:467-475. [PMID: 34908858 PMCID: PMC8664604 DOI: 10.2147/ceg.s269464] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Accepted: 11/22/2021] [Indexed: 12/14/2022] Open
Abstract
Fistula laser closure (FiLaC) is a relatively new sphincter-sparing technique in fistula surgery that was initially reported in 2011. It involves the radial dissipation of laser energy in the fistula tract and, through a combination of coagulation and shrinkage of the tract, is proposed to result in progressive sealing of fistulas. Early studies have suggested minimal impact on continence and touted the advantage of minimal morbidity with potential of repeat procedures if the technique fails initially. Despite early promising results, ten years on, questions remain on the technique, patient selection and long-term outcomes. This narrative review assesses the evidence reported to-date of radially emitting laser fistula surgery in the treatment of perianal fistulas.
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Affiliation(s)
- Samuel O Adegbola
- Robin Phillips Fistula Research Unit, St Mark's Hospital and Academic Institute, Harrow, UK.,Department of Surgery and Cancer, Imperial College, London, UK
| | - Kapil Sahnan
- Robin Phillips Fistula Research Unit, St Mark's Hospital and Academic Institute, Harrow, UK.,Department of Surgery and Cancer, Imperial College, London, UK
| | - Phillip Tozer
- Robin Phillips Fistula Research Unit, St Mark's Hospital and Academic Institute, Harrow, UK.,Department of Surgery and Cancer, Imperial College, London, UK
| | - Janindra Warusavitarne
- Robin Phillips Fistula Research Unit, St Mark's Hospital and Academic Institute, Harrow, UK.,Department of Surgery and Cancer, Imperial College, London, UK
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Iqbal N, Dilke SM, Geldof J, Sahnan K, Adegbola S, Bassett P, Tozer P. Is fistulotomy with immediate sphincter reconstruction (FISR) a sphincter preserving procedure for high anal fistula? A systematic review and meta-analysis. Colorectal Dis 2021; 23:3073-3089. [PMID: 34623747 DOI: 10.1111/codi.15945] [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] [Received: 05/11/2021] [Revised: 06/22/2021] [Accepted: 07/19/2021] [Indexed: 12/23/2022]
Abstract
AIM This systematic review aimed to assess the outcomes of fistulotomy or fistulectomy and immediate sphincter repair (FISR) in relation to healing, incontinence and sphincter dehiscence both overall and in patients with high anal fistulae. METHODS Medline, Embase and The Cochrane library were searched for studies of patients undergoing FISR for anal fistula. Data regarding healing, continence and sphincter dehiscence were extracted overall and for high anal fistulae. The DerSimonian-Laird random-effects method was used for pooled analysis, heterogeneity between studies was assessed based on the significance of between-study heterogeneity, and on the size of the I2 value. Risk of bias was assessed using the Cochrane risk of bias tool and the Newcastle-Ottawa scale. RESULTS We identified 21 studies evaluating 1700 patients. Pooled analysis of healing reached 93% (95% CI: 91%-95%, I2 = 51% p-value for heterogeneity = 0.004), with continence disturbance and worsening continence reaching 11% (95% CI: 6%-18%, I2 = 87% p < 0.001) and 8% (95% CI: 4%-13%, I2 = 74% p < 0.001), respectively. Subgroup analysis according to fistula height could only be conducted on limited data. Pooled healing in high anal fistulae was 89% (95% CI: 84%-94%, I2 = 76% p < 0.001), 16% suffered disturbance of continence (95% CI: 7%-27%, I2 = 89% p < 0.001), 8% worsening continence from baseline (95% CI: 2%-16%, I2 = 80% p < 0.001) and 2% suffered sphincter dehiscence (95% CI: 0%-10%, I2 = 89% p < 0.001). CONCLUSION The evidence suggests FISR is a safe, effective procedure. However, data are limited by inconsistencies in reporting of continence and definition of fistula height, particularly high anal fistulae. Significant heterogeneity means that outcomes in high fistulae remain uncertain.
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Affiliation(s)
- Nusrat Iqbal
- Robin Phillips' Fistula Research Unit, St Mark's Hospital and Academic Institute, Harrow, UK
| | - Stella Maye Dilke
- Department of Colorectal Surgery, St Mark's Hospital and Academic Institute, London, UK
| | - Jeroen Geldof
- Department of Gastroenterology and Hepatology, University Hospital, Ghent, Belgium
| | - Kapil Sahnan
- Robin Phillips' Fistula Research Unit, St Mark's Hospital and Academic Institute, Harrow, UK
| | - Samuel Adegbola
- Robin Phillips' Fistula Research Unit, St Mark's Hospital and Academic Institute, Harrow, UK
| | | | - Philip Tozer
- Robin Phillips' Fistula Research Unit, St Mark's Hospital and Academic Institute, Harrow, UK
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13
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Jayne DG, Scholefield J, Tolan D, Gray R, Senapati A, Hulme CT, Sutton AJ, Handley K, Hewitt CA, Kaur M, Magill L. A Multicenter Randomized Controlled Trial Comparing Safety, Efficacy, and Cost-effectiveness of the Surgisis Anal Fistula Plug Versus Surgeon's Preference for Transsphincteric Fistula-in-Ano: The FIAT Trial. Ann Surg 2021; 273:433-441. [PMID: 32516229 DOI: 10.1097/sla.0000000000003981] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To undertake a randomized comparison of the Biodesign Surgisis anal fistula plug against surgeon's preference in treating cryptoglandular transsphincteric fistula-in-ano. SUMMARY BACKGROUND DATA The efficacy of the Biodesign Surgisis anal fistula plug in healing anal fistulae is uncertain. METHODS Participants were randomized to the fistula plug with surgeon's preference (advancement flap, cutting seton, fistulotomy, Ligation of the Intersphincteric Fistula Tract procedure). The primary outcome was faecal incontinence quality of life (FIQoL) at 12-months. Secondary outcomes were fistula healing, incontinence rates, and complication and reintervention rates. RESULTS Between May 2011 and March 2016, 304 participants were randomized to fistula plug or surgeon's preference. No differences were seen in FIQoL between the 2 groups at 12 months. Clinical fistula healing was reported in 66/122 (54%) of the fistula plug and 66/119 (55%) of the surgeon's preference groups at 12 months. Fecal incontinence rates improved marginally in both the groups. Complications and reinterventions were frequent, with significantly more complications in the fistula plug group at 6-weeks (49/142, 35% vs 25/137, 18%; P=0.002). The mean total costs were £2738 (s.d. £1151) for the fistula plug and £2308 (s.d. £1228) for the surgeon's preference group (mean difference +£430, P=0.0174). The average total quality adjusted life years (QALYs) gained was marginally higher in the fistula plug group. The fistula plug was 35% to 45% likely to be cost-effective across a willingness to pay threshold of £20,000 to £30,000 / QALY. CONCLUSIONS The Biodesign Surgisis anal fistula plug is associated with similar FIQoL and healing rates to surgeon's preference at 12 months. Higher costs and highly uncertain gains in QALYs mean that the fistula plug may not be considered as a cost-effective treatment in the UK NHS.
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Affiliation(s)
| | | | | | - Richard Gray
- Nuffield Department of Population Health Medicine Sciences Division, University of Oxford, Oxford, UK
| | | | - Claire T Hulme
- Academic Unit of Health Economics, Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | | | - Kelly Handley
- Birmingham Clinical Trials Unit (BCTU), University of Birmingham, Birmingham, UK
| | - Catherine A Hewitt
- Birmingham Clinical Trials Unit (BCTU), University of Birmingham, Birmingham, UK
| | - Manjinder Kaur
- Birmingham Clinical Trials Unit (BCTU), University of Birmingham, Birmingham, UK
| | - Laura Magill
- Birmingham Clinical Trials Unit (BCTU), University of Birmingham, Birmingham, UK
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14
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Ji L, Zhang Y, Xu L, Wei J, Weng L, Jiang J. Advances in the Treatment of Anal Fistula: A Mini-Review of Recent Five-Year Clinical Studies. Front Surg 2021; 7:586891. [PMID: 33644110 PMCID: PMC7905164 DOI: 10.3389/fsurg.2020.586891] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Accepted: 12/15/2020] [Indexed: 12/16/2022] Open
Abstract
Anal fistula, with its complicated pathogenesis, has been considered as a clinical challenge for centuries. The risk of frequent recurrence and incontinence constitutes a considerable threat in the long-term treatment of anal fistula. In this work, we narratively reviewed the scientific literature of new techniques that have been used for anal fistula treatment over the recent 5 years, objectively evaluated the pros and cons of each technique on the basis of clinical outcomes, and tried to disclose the effective strategies for anal fistula treatment. Up to date, surgery is the main method used for treating anal fistula, but there is no simple technique that can completely heal complex anal fistula. In the course of surgery treatment, the healing outcome, and the protection of anal function should be weighed comprehensively. Among the innovative techniques that have emerged in recent years, combined techniques based on drainage Seton and LIFT-plug seem to be the relatively effective therapies, but their effectiveness requires more multi-center prospective randomized controlled trials with large sample size and long-term follow-up to be validated.
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Affiliation(s)
- Lijiang Ji
- Department of Anorectal Surgery, Changshu Hospital Affiliated to Nanjing University of Chinese Medicine, Changshu, China
| | - Yang Zhang
- Colorectal Disease Center, Nanjing Hospital of Chinese Medicine Affiliated to Nanjing University of Chinese Medicine, Nanjing, China
| | - Liang Xu
- Department of General Surgery, Changshu Hospital Affiliated to Nanjing University of Chinese Medicine, Changshu, China
| | - Jun Wei
- Department of Anorectal Surgery, Changshu Hospital Affiliated to Nanjing University of Chinese Medicine, Changshu, China
| | - Liping Weng
- Department of Anorectal Surgery, Changshu Hospital Affiliated to Nanjing University of Chinese Medicine, Changshu, China
| | - Jie Jiang
- Department of Anorectal Surgery, Changshu Hospital Affiliated to Nanjing University of Chinese Medicine, Changshu, China
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15
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Shimojima Y, Matsushima M, Matsushima S, Watanabe Y, Beniya A, Hikosaka Y, Katori R, Matsumura N, Kono Y, Okamoto K, Fukano M, Kuromizu J. A Novel Surgical Technique for Anal Fistula Surgery Designed to Preserve the Anal Sphincter Function and Anoderm. JOURNAL OF THE ANUS RECTUM AND COLON 2021; 5:25-33. [PMID: 33537497 PMCID: PMC7843142 DOI: 10.23922/jarc.2020-032] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Accepted: 08/29/2020] [Indexed: 12/18/2022]
Abstract
Objectives: We reviewed surgical outcomes after introducing a novel surgical technique for anal fistula surgery designed to preserve anal sphincter function and the anoderm. Methods: We studied 200 male patients who underwent a functional preservative operative technique (FPOT group) for anal fistulas and 200 patients who underwent resection of trans-sphincteric anal fistulas (fistulectomy group) between February 2014 and September 2015. We compared complications, such as those affecting anal sphincter function, recurrence, and incontinence. Results: Fistulas recurred in three (1.5%) patients in the FPOT group and two (1%) patients in the fistulectomy group. This difference was not significant. Other complications included gas leakage and other forms of incontinence in 1 (0.5%) and 14 (7%) patients in the FPOT and fistulectomy groups, respectively. Anal function assessment demonstrated that the FPOT was significantly better at preserving function than fistulectomy in all patients. Conclusions: There were no significant differences between the FPOT and fistulectomy in terms of recurrence or complication rates. Also, because there was no decrease in postoperative anal function, we concluded that the FPOT is an effective preservative surgical technique for treating trans-sphincteric anal fistulas.
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Affiliation(s)
| | | | | | | | - Ayumi Beniya
- Coloproctology Centre, Matsushima Hospital, Yokohama, Japan
| | | | - Remi Katori
- Coloproctology Centre, Matsushima Hospital, Yokohama, Japan
| | | | - Yoichi Kono
- Coloproctology Centre, Matsushima Hospital, Yokohama, Japan
| | - Kosuke Okamoto
- Coloproctology Centre, Matsushima Hospital, Yokohama, Japan
| | | | - Joji Kuromizu
- Coloproctology Centre, Matsushima Hospital, Yokohama, Japan
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16
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Frountzas M, Stergios K, Nikolaou C, Bellos I, Schizas D, Linardoutsos D, Kontzoglou K, Vaos G, Williams AB, Toutouzas K. Could FiLaC™ be effective in the treatment of anal fistulas? A systematic review of observational studies and proportional meta-analysis. Colorectal Dis 2020; 22:1874-1884. [PMID: 32445614 DOI: 10.1111/codi.15148] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2020] [Accepted: 04/30/2020] [Indexed: 02/08/2023]
Abstract
AIM Fistula Laser Closure (FiLaC™) is a novel sphincter-preserving technique that is based on new technologies and shows promising results in repairing anal fistulas whilst maintaining external sphincter function. The aim of the present meta-analysis is to present the efficacy and the safety of FiLaC™ in the management of anal fistula disease. METHOD The present proportional meta-analysis was designed using the PRISMA and AMSTAR guidelines. We searched MEDLINE, Scopus, clinicaltrials.gov, Embase, Cochrane Central Register of Controlled Trials CENTRAL and Google Scholar databases from inception until November 2019. RESULTS Overall, eight studies were included that recruited 476 patients. The pooled success rate of the technique was 63% (95% CI 50%-75%). The pooled complication rate was 8% (95% CI 1%-18%). Sixty-six per cent of patients had a transsphincteric fistula and 60% had undergone a previous surgical intervention, mainly the insertion of a seton (54%). The majority had a cryptoglandular fistula. Operation time and follow-up period were described for each study. CONCLUSION FiLaC™ seems to be an efficient therapeutic option for perianal fistula disease with an adequate level of safety that preserves quality of life. Nevertheless, randomized trials need to be designed to compare FiLaC™ with other procedures for the management of anal fistulas such as ligation of intersphincteric fistula tract, anal advancement flaps, fibrin glue, collagen paste, autologous adipose tissue, fistula plug and video-assisted anal fistula treatment.
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Affiliation(s)
- M Frountzas
- Laboratory of Experimental Surgery and Surgical Research, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece.,First Propaedeutic Department of Surgery, School of Medicine, Hippocration General Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - K Stergios
- Laboratory of Experimental Surgery and Surgical Research, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - C Nikolaou
- Laboratory of Experimental Surgery and Surgical Research, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - I Bellos
- Laboratory of Experimental Surgery and Surgical Research, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - D Schizas
- First Department of Surgery, School of Medicine, Laikon General Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - D Linardoutsos
- First Propaedeutic Department of Surgery, School of Medicine, Hippocration General Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - K Kontzoglou
- Laboratory of Experimental Surgery and Surgical Research, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - G Vaos
- Department of Paediatric Surgery, School of Medicine, Attikon University General Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - A B Williams
- Department of Colorectal Surgery, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - K Toutouzas
- First Propaedeutic Department of Surgery, School of Medicine, Hippocration General Hospital, National and Kapodistrian University of Athens, Athens, Greece
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17
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Lau YC, Brown KGM, Cheong J, Byrne C, Lee PJ. LIFT and BioLIFT: a 10-Year Single-Centre Experience of Treating Complex Fistula-In-Ano With Ligation of Intersphincteric Fistula Tract Procedure With or Without Bio-prosthetic Reinforcement (BioLIFT). J Gastrointest Surg 2020; 24:671-676. [PMID: 31240556 DOI: 10.1007/s11605-019-04305-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2019] [Accepted: 06/10/2019] [Indexed: 01/31/2023]
Abstract
PURPOSE To assess the outcome of ligation of intersphincteric fistula tract (LIFT) and bioprosthetic graft (BioLIFT) in the management of transsphincteric perianal fistula. METHODS A single-institution retrospective analysis of all patients undergoing LIFT and BioLIFT from January 2009 to June 2018 was performed. Only patients who had LIFTs and BioLIFT performed as their primary sphincter-preserving procedure was included. Primary outcome measured was primary healing. Secondary outcomes measured were secondary healing, morbidity, time to recurrence, and pre- and post-operative anorectal manometry. Chi-square analysis was used to determine predictive factors. RESULTS A total of 116 patients were identified. One hundred five had LIFT and 11 had BioLIFT. The total primary healing rate was 60.3% (62.9% and 34.9% for LIFT and BioLIFT respectively). The overall secondary healing rate was 80.2% (80.0% and 81.9% for LIFT and BioLIFT respectively). There was no inpatient morbidity or post-procedural faecal incontinence reported. There was no significant change in the pre- and post-operative manometries in either group (P = 0.417 and P = 0.834 for LIFT and BioLIFT respectively). The only predictor for primary failure identified was anteriorly located fistula. CONCLUSION LIFT and BioLIFT compare favourably with other sphincter-preserving procedures. LIFT and BioLIFT can be performed safely, with minimal morbidity and with no reported loss of sphincteric function.
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Affiliation(s)
- Yee Chen Lau
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, Australia. .,Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, PO Box M157, Missenden Road, Sydney, NSW, 2050, Australia.
| | - Kilian G M Brown
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, Australia.,Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, PO Box M157, Missenden Road, Sydney, NSW, 2050, Australia.,The Institute of Academic Surgery at RPA, Sydney, Australia
| | - Juyong Cheong
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, Australia.,Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, PO Box M157, Missenden Road, Sydney, NSW, 2050, Australia
| | - Christopher Byrne
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, Australia.,Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, PO Box M157, Missenden Road, Sydney, NSW, 2050, Australia.,The Institute of Academic Surgery at RPA, Sydney, Australia
| | - Peter J Lee
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, Australia.,Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, PO Box M157, Missenden Road, Sydney, NSW, 2050, Australia.,The Institute of Academic Surgery at RPA, Sydney, Australia
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18
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Amato A, Bottini C, De Nardi P, Giamundo P, Lauretta A, Realis Luc A, Piloni V. Evaluation and management of perianal abscess and anal fistula: SICCR position statement. Tech Coloproctol 2020; 24:127-143. [DOI: 14) evaluation and management of perianal abscess and anal fistula: siccr position statement.a.amato, c.bottini, p.de nardi, p.giamundo, a.lauretta, a.realis luc & v.piloni.tech coloproctol 2020 24:127-143 doi 10.1007/s10151-019-02144-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2019] [Accepted: 12/23/2019] [Indexed: 09/10/2023]
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19
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Evaluation and management of perianal abscess and anal fistula: SICCR position statement. Tech Coloproctol 2020; 24:127-143. [PMID: 31974827 DOI: 10.1007/s10151-019-02144-1] [Citation(s) in RCA: 47] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2019] [Accepted: 12/23/2019] [Indexed: 02/07/2023]
Abstract
Perianal sepsis is a common condition ranging from acute abscess to chronic anal fistula. In most cases, the source is considered to be a non-specific cryptoglandular infection starting from the intersphincteric space. Surgery is the main treatment and several procedures have been developed, but the risks of recurrence and of impairment of continence still seem to be an unresolved issue. This statement reviews the pertinent literature and provides evidence-based recommendations to improve individualized management of patients.
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20
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Sammut M, Skaife P. The management of cryptoglandular fistula-in-ano. Br J Hosp Med (Lond) 2020; 81:1-9. [PMID: 32003630 DOI: 10.12968/hmed.2019.0353] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Idiopathic cryptoglandular fistula-in-ano is a common pathological condition. Fistula-in-ano has been managed by a number of surgical techniques, and there is still no consensus regarding the management of this condition. Surgical techniques aim to treat and cure the fistula-in-ano with minimal risk of recurrence or complications, and to maintain patient continence. This article discusses the evidence available to inform the management of idiopathic cryptoglandular fistula-in-ano, and problems that surgeons face because of the lack of high-quality evidence.
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Affiliation(s)
- Matthew Sammut
- Colorectal Department, Aintree University Hospital NHS Foundation Trust, Liverpool, UK
| | - Paul Skaife
- Colorectal Department, Aintree University Hospital NHS Foundation Trust, Liverpool, UK
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21
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Sun XL, Wen K, Chen YH, Xu ZZ, Wang XP. Long-term outcomes and quality of life following ligation of the intersphincteric fistula tract for high transsphincteric fistulas. Colorectal Dis 2019; 21:30-37. [PMID: 30184334 DOI: 10.1111/codi.14405] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2018] [Accepted: 08/13/2018] [Indexed: 12/13/2022]
Abstract
AIM Published outcomes following ligation of the intersphincteric fistula tract (LIFT) for high transsphincteric fistulas (HTFs) are equivocal probably because most trials are small and comprise mixed patient populations. The aim of this study was to highlight the long-term efficacy of LIFT for HTFs in a large homogeneous sample and to determine the risk factors that contribute to non-healing resulting in failure and recurrence. METHOD A retrospective study was performed which assessed patients with HTFs treated by LIFT without prior loose setons from September 2012 to December 2017. Continence function was evaluated by the Wexner incontinence scale and anal manometry. Quality of life was assessed by using the faecal incontinence quality of life (FIQL) scale with four domains: lifestyle, coping, depression and embarrassment. RESULTS Seventy patients with HTFs underwent 71 LIFT procedures. The primary healing rate was 81.7% with a median follow-up duration of 16.5 (range 4.5-68) months. The healing rates of mature and immature fistulas were 83.7% and 77.3%, respectively. Two patients suffered failure with an unhealed intersphincteric wound. Recurrence occurred in 11 patients. Incontinence of flatus, present in four patients before surgery, improved postoperatively. Two patients undergoing LIFT combined with fistulotomy complained of flatus incontinence after surgery. No significant differences between preoperative and postoperative Wexner score, maximum resting pressure and maximum squeeze pressure were detected. The FIQL was improved in lifestyle, coping and depression. No risk factor for non-healing was found. CONCLUSION LIFT has a promising long-term outcome for HTFs, with negligible impairment on continence and improved quality of life.
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Affiliation(s)
- X-L Sun
- Department of Colorectal Surgery, Suzhou Affiliated Hospital of Nanjing University of Chinese Medicine, Suzhou, 215000, Jiangsu Province, China
| | - K Wen
- Department of Colorectal Surgery, Suzhou Affiliated Hospital of Nanjing University of Chinese Medicine, Suzhou, 215000, Jiangsu Province, China
| | - Y-H Chen
- Department of Colorectal Surgery, Suzhou Affiliated Hospital of Nanjing University of Chinese Medicine, Suzhou, 215000, Jiangsu Province, China
| | - Z-Z Xu
- Department of Colorectal Surgery, Suzhou Affiliated Hospital of Nanjing University of Chinese Medicine, Suzhou, 215000, Jiangsu Province, China
| | - X-P Wang
- Department of Colorectal Surgery, Suzhou Affiliated Hospital of Nanjing University of Chinese Medicine, Suzhou, 215000, Jiangsu Province, China
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22
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Koh SZ, Tsang CB. Reprint of: The LIFT procedure. SEMINARS IN COLON AND RECTAL SURGERY 2018. [DOI: 10.1053/j.scrs.2018.11.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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23
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Araújo SEA, Marcante MT, Mendes CRS, Bertoncini AB, Seid VE, Horcel LA, Perez RO, Klajner S. INTERESFINCTERIAL LIGATION OF FISTULA TRACT (LIFT) FOR PATIENTS WITH ANAL FISTULAS: A BRAZILIAN BI-INSTITUTIONAL EXPERIENCE. ACTA ACUST UNITED AC 2018; 30:235-238. [PMID: 29340544 PMCID: PMC5793138 DOI: 10.1590/0102-6720201700040002] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2017] [Accepted: 09/21/2017] [Indexed: 02/06/2023]
Abstract
Background: The best treatment for anal fistula should extirpate infection and promote healing of the tract, whilst preserving the anal sphincter complex and full continence. Aim: To analyze the success rate after a modified technique for ligation of the intersphincteric fistula tract (LIFT) for patients with anal fistulas. Methods: A prospective (observational cohort study) Brazilian bi-institutional experience with a modified (ligation of the intersphincteric fistula tract without excision) LIFT technique was undertaken. A clinical database was settled for the following variables: age, gender, BMI, comorbidities, distance between external orifice and the anus, previous fistula surgery, type of fistula, operative time, intra- and postoperative complications, duration of follow-up, and success rate. Results: Between November 2015 and January 2017, 38 patients with transsphincteric fistulas were operated on using the modified LIFT procedure. Seventeen (44.7%) were men. Median age was 41 (18-67) years. Median BMI was 26.4 (22-38) kg/m2. Five (13.2%) had undergone previous surgery. The fistula was transsphincteric in all cases. Median follow-up was 32 (range, 14-56) weeks. Success was observed in 30 (79%) patients. Conclusions: The LIFT technique without excision of the fistula tract proved to be safe and effective for transsphincteric anal fistulas.
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Affiliation(s)
| | | | | | | | | | | | | | - Sidney Klajner
- Coloproctology, Hospital Israelita Albert Einstein, São Paulo, SP
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24
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Murad-Regadas SM, Regadas Filho FSP, Holanda EDC, Veras LB, Vilarinho ADS, Lopes MS. CAN THREE-DIMENSIONAL ANORECTAL ULTRASONOGRAPHY BE INCLUDED AS A DIAGNOSTIC TOOL FOR THE ASSESSMENT OF ANAL FISTULA BEFORE AND AFTER SURGICAL TREATMENT? ARQUIVOS DE GASTROENTEROLOGIA 2018; 55Suppl 1:18-24. [PMID: 30088534 DOI: 10.1590/s0004-2803.201800000-42] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/28/2018] [Accepted: 07/03/2018] [Indexed: 12/20/2022]
Abstract
BACKGROUND There is no a clear knowledge concerning the division of any part of the anal sphincter complex and the effect of this procedure on the function of the anal canal during the treatment of perianal fistula. OBJECTIVE To evaluate the usefulness of 3D anorectal ultrasound in the assessment of anal fistula, quantifying the length of the sphincter muscle to be transected, selecting patients for different approaches and identifying healing, failure or recurrence after the surgical treatment. METHODS A prospective study included patients with primarily cryptogenic transsphincteric anal fistula assessed by fecal Incontinence score, tri-dimensional anorectal ultrasound and anal manometry before and after surgery. Based on 3D-AUS, patients with ≥50% external sphincter or external sphincter+puborectalis muscle involvement in males and ≥40% external sphincter or external sphincter+puborectalis muscle in females were referred for the ligation of the intersphincteric tract (LIFT) or seton placement and subsequent fistulotomy; and with <50% involvement in males and <40% in females were referred to one-stage fistulotomy. After surgery, the fibrosis (muscles divided) and residual muscles were measured and compared with the pre-operative. RESULTS A total of 73 patients was included. The indication for the LIFT was significantly higher in females (47%), one-stage fistulotomy was significantly higher in the males (46%) and similar in seton placement. The minor postoperative incontinence was identified in 31% of patients underwent sphincter divided and were similar in both genders. The 3D-AUS identified seven failed cases. CONCLUSION The 3D ultrasound was shown to be an effective method in the preoperative assessment of anal fistulas by quantifying the length of muscle to be divided, as the results were similar at the post-operative, providing a safe treatment approach according to the gender and percentage of muscle involvement. Additionally, 3D ultrasound successfully identified the healing tissue and the type of failure or recurrence.
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Affiliation(s)
- Sthela Maria Murad-Regadas
- Universidade Federal do Ceará, Faculdade de Medicina, Departamento de Cirurgia, Fortaleza, CE, Brasil.,Universidade Federal do Ceará, Hospital das Clínicas, Unidade do Assoalho Pélvico e Fisiologia Anorretal, Fortaleza, CE, Brasil.,Hospital São Carlos, Unidade do Assoalho Pélvico e Fisiologia Anorretal, Departamento de Cirurgia Colorretal, Fortaleza, CE, Brasil
| | - Francisco Sergio P Regadas Filho
- Hospital São Carlos, Unidade do Assoalho Pélvico e Fisiologia Anorretal, Departamento de Cirurgia Colorretal, Fortaleza, CE, Brasil
| | - Erico de Carvalho Holanda
- Universidade Federal do Ceará, Faculdade de Medicina, Departamento de Cirurgia, Fortaleza, CE, Brasil
| | - Lara Burlamaqui Veras
- Hospital São Carlos, Unidade do Assoalho Pélvico e Fisiologia Anorretal, Departamento de Cirurgia Colorretal, Fortaleza, CE, Brasil
| | - Adjra da Silva Vilarinho
- Hospital São Carlos, Unidade do Assoalho Pélvico e Fisiologia Anorretal, Departamento de Cirurgia Colorretal, Fortaleza, CE, Brasil
| | - Manoel S Lopes
- Universidade Federal do Ceará, Faculdade de Medicina, Departamento de Cirurgia, Fortaleza, CE, Brasil
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Wright M, Thorson A, Blatchford G, Shashidharan M, Beaty J, Bertelson N, Aggrawal P, Taylor L, Ternent CA. What happens after a failed LIFT for anal fistula? Am J Surg 2017; 214:1210-1213. [PMID: 29146001 DOI: 10.1016/j.amjsurg.2017.08.042] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2017] [Revised: 07/27/2017] [Accepted: 08/05/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND Ligation of the intersphincteric fistula tract (LIFT) was developed to treat transsphincteric anal fistulas. The aftermath of a failed LIFT has not been well documented. METHODS Retrospective chart review of LIFT procedure for transsphincteric anal fistula between March 2012 and September 2016. RESULTS 53 patients with LIFT procedure were identified, 20 (37.7%) had persistent fistula with median followup of 4 months. Following LIFT, recurrence of fistula was transsphincteric (75%) or intersphincteric (25%) (p = NS). Persistent transsphincteric fistulas after LIFT were treated with seton (71.4%) followed by advancement flap (20%) or fistulotomy (50%). Of the recurrent intersphincteric fistulas, 50% underwent seton placement followed by fistulotomy, or advancement flap. Of the patients who underwent surgery after failed LIFT, 50% have had resolution of the fistula; 31.7% are still undergoing treatment. CONCLUSION Patients who underwent surgery after failed LIFT had 50% healing with placement of seton followed by fistulotomy or rectal advancement flap.
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Affiliation(s)
- Moriah Wright
- Section of Colon and Rectal Surgery, Creighton University School of Medicine, CHI Medical Center, Omaha, NE, USA
| | - Alan Thorson
- Section of Colon and Rectal Surgery, Creighton University School of Medicine, CHI Medical Center, Omaha, NE, USA
| | - Garnet Blatchford
- Section of Colon and Rectal Surgery, Creighton University School of Medicine, CHI Medical Center, Omaha, NE, USA
| | - Maniamparampil Shashidharan
- Section of Colon and Rectal Surgery, Creighton University School of Medicine, CHI Medical Center, Omaha, NE, USA
| | - Jennifer Beaty
- Section of Colon and Rectal Surgery, Creighton University School of Medicine, CHI Medical Center, Omaha, NE, USA
| | - Noelle Bertelson
- Section of Colon and Rectal Surgery, Creighton University School of Medicine, CHI Medical Center, Omaha, NE, USA
| | - Piyush Aggrawal
- Section of Colon and Rectal Surgery, Creighton University School of Medicine, CHI Medical Center, Omaha, NE, USA
| | - Lindsay Taylor
- Section of Colon and Rectal Surgery, Creighton University School of Medicine, CHI Medical Center, Omaha, NE, USA
| | - Charles A Ternent
- Section of Colon and Rectal Surgery, Creighton University School of Medicine, CHI Medical Center, Omaha, NE, USA.
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Placer Galán C, Lopes C, Múgica JA, Saralegui Y, Borda N, Enriquez Navascues JM. Patrones de recurrencia/persistencia en la operación de LIFT para la fístula anal de origen criptoglandular. Estudio observacional a largo plazo. Cir Esp 2017; 95:385-390. [DOI: 10.1016/j.ciresp.2017.05.010] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2017] [Revised: 05/30/2017] [Accepted: 05/30/2017] [Indexed: 12/28/2022]
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Sheedy SP, Bruining DH, Dozois EJ, Faubion WA, Fletcher JG. MR Imaging of Perianal Crohn Disease. Radiology 2017; 282:628-645. [PMID: 28218881 DOI: 10.1148/radiol.2016151491] [Citation(s) in RCA: 65] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Pelvic magnetic resonance (MR) imaging is currently the standard for imaging perianal Crohn disease. Perianal fistulas are a leading cause of patient morbidity because closure often requires multimodality treatments over a prolonged period of time. This review summarizes clinically relevant anal sphincter anatomy, imaging methods, classification systems, and treatment objectives. In addition, the MR appearance of healing perianal fistulas and fistula complications is described. Difficult imaging tasks including the assessment of rectovaginal fistulas and ileoanal anastomoses are highlighted, along with illustrative cases. Emerging innovative treatments for perianal Crohn disease are now available and have the promise to better control sepsis and maintain fecal continence. Different treatment modalities are selected based on fistula anatomy, patient factors, and management goals (closure versus sepsis control). Radiologists can help maximize patient care by being familiar with MR imaging features of perianal Crohn disease and knowledgeable about what features may influence therapy decisions. © RSNA, 2017 Online supplemental material is available for this article.
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Affiliation(s)
- Shannon P Sheedy
- From the Departments of Radiology (S.P.S., J.G.F.), Internal Medicine (D.H.B., W.A.F.), and Surgery (E.J.D.), Mayo Clinic, 200 First St SW, Rochester, MN 55905
| | - David H Bruining
- From the Departments of Radiology (S.P.S., J.G.F.), Internal Medicine (D.H.B., W.A.F.), and Surgery (E.J.D.), Mayo Clinic, 200 First St SW, Rochester, MN 55905
| | - Eric J Dozois
- From the Departments of Radiology (S.P.S., J.G.F.), Internal Medicine (D.H.B., W.A.F.), and Surgery (E.J.D.), Mayo Clinic, 200 First St SW, Rochester, MN 55905
| | - William A Faubion
- From the Departments of Radiology (S.P.S., J.G.F.), Internal Medicine (D.H.B., W.A.F.), and Surgery (E.J.D.), Mayo Clinic, 200 First St SW, Rochester, MN 55905
| | - Joel G Fletcher
- From the Departments of Radiology (S.P.S., J.G.F.), Internal Medicine (D.H.B., W.A.F.), and Surgery (E.J.D.), Mayo Clinic, 200 First St SW, Rochester, MN 55905
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Jiang HH, Liu HL, Li Z, Xiao YH, Li AJ, Chang Y, Zhang Y, Lv L, Lin MB. Video-Assisted Anal Fistula Treatment (VAAFT) for Complex Anal Fistula: A Preliminary Evaluation in China. Med Sci Monit 2017; 23:2065-2071. [PMID: 28456815 PMCID: PMC5421740 DOI: 10.12659/msm.904055] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Although many attempts have been made to advance the treatment of complex anal fistula, it continues to be a difficult surgical problem. This study aimed to describe the novel technique of video-assisted anal fistula treatment (VAAFT) and our preliminary experiences using VAAFT with patients with complex anal fistula. MATERIAL AND METHODS From May 2015 to May 2016, 52 patients with complex anal fistula were treated with VAAFT at Yangpu Hospital of Tongji University School of Medicine, and the clinical data of these patients were reviewed. RESULTS VAAFT was performed successfully in all 52 patients. The median operation time was 55 minutes. Internal openings were identified in all cases. 50 cases were closed with sutures, and 2 were closed with staplers. Complications included perianal sepsis in 3 cases and bleeding in another 3 cases. Complete healing without recurrence was achieved in 44 patients (84.6%) after 9 months of follow-up. No fecal incontinence was observed. Furthermore, a significant improvement in Gastrointestinal Quality of Life Index (GIQLI) score was observed from preoperative baseline (mean, 85.5) to 3-month follow-up (mean, 105.4; p<0.001), and this increase was maintained at 9-months follow-up (mean, 109.6; p<0.001). CONCLUSIONS VAAFT is a safe and minimally invasive technique for treating complex anal fistula with preservation of anal sphincter function.
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Affiliation(s)
- Hui-Hong Jiang
- Department of General Surgery, Yangpu Hospital, Tongji University School of Medicine, Shanghai, China (mainland)
| | - Hai-Long Liu
- Department of General Surgery, Yangpu Hospital, Tongji University School of Medicine, Shanghai, China (mainland)
| | - Zhen Li
- Department of General Surgery, Yangpu Hospital, Tongji University School of Medicine, Shanghai, China (mainland)
| | - Yi-Hua Xiao
- Department of General Surgery, Yangpu Hospital, Tongji University School of Medicine, Shanghai, China (mainland)
| | - A-Jian Li
- Department of General Surgery, Yangpu Hospital, Tongji University School of Medicine, Shanghai, China (mainland)
| | - Yi Chang
- Department of General Surgery, Yangpu Hospital, Tongji University School of Medicine, Shanghai, China (mainland)
| | - Yong Zhang
- Department of General Surgery, Yangpu Hospital, Tongji University School of Medicine, Shanghai, China (mainland)
| | - Liang Lv
- Department of General Surgery, Yangpu Hospital, Tongji University School of Medicine, Shanghai, China (mainland)
| | - Mou-Bin Lin
- Department of General Surgery, Yangpu Hospital, Tongji University School of Medicine, Shanghai, China (mainland).,Center for Translational Medicine, Yangpu Hospital, Tongji University School of Medicine, Shanghai, China (mainland)
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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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30
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Clinical Practice Guideline for the Management of Anorectal Abscess, Fistula-in-Ano, and Rectovaginal Fistula. Dis Colon Rectum 2016; 59:1117-1133. [PMID: 27824697 DOI: 10.1097/dcr.0000000000000733] [Citation(s) in RCA: 194] [Impact Index Per Article: 24.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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31
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Ligation of Intersphincteric Fistula Tract vs Ligation of the Intersphincteric Fistula Tract Plus a Bioprosthetic Anal Fistula Plug Procedure in Patients With Transsphincteric Anal Fistula. Ann Surg 2016; 264:917-922. [DOI: 10.1097/sla.0000000000001562] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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32
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Direct and indirect costs for anal fistula in Sweden. Int J Surg 2016; 35:129-133. [DOI: 10.1016/j.ijsu.2016.09.082] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2016] [Revised: 09/20/2016] [Accepted: 09/21/2016] [Indexed: 11/19/2022]
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Abstract
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.
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Wang C, Rosen L. Management of low transsphincteric anal fistula with serial setons and interval muscle-cutting fistulotomy. JOURNAL OF INTEGRATIVE MEDICINE-JIM 2016; 14:154-8. [PMID: 26988437 DOI: 10.1016/s2095-4964(16)60229-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
This study evaluates low transsphincteric anal fistula managed by serial setons and interval fistulotomy, with attention to healing without recurrence and preservation of continence. Following Institutional Review Board approval, consecutive anal fistula operations performed by a single surgeon from January 1, 2009 to December 31, 2013 were retrospectively reviewed using electronic medical records and telephone interviews for patients lost to follow up. Of the 71 patients, 26 (37%) had low transsphincteric fistula (23 males and 3 females; mean age: 46 years), treated at our institution by seton placement followed by interval surgical muscle cutting and subsequent seton replacement or final fistulotomy. Of the 26 patients, 22 (85%) were initially referred due to previous failed treatment, with a 30.6 month mean duration of fistula prior to referral and a mean of 2.2 (range: 0 -6) prior anorectal surgeries. At a mean follow-up of 11.9 months, none of the 21 patients experienced recurrence or fecal incontinence. Serial seton with interval muscle-cutting sphincterotomy followed by complete fistulotomy is an effective treatment for the management of patients who are either initially seen for low transsphincteric fistula, or referred after failed anorectal surgery for that condition.
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Affiliation(s)
- Chen Wang
- Department of Colorectal Surgery, Cleveland Clinic Florida, Weston, FL 33331, USA
- Department of Anorectal Surgery, Longhua Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai 200032, China
| | - Lester Rosen
- Department of Colorectal Surgery, Cleveland Clinic Florida, Weston, FL 33331, USA
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Abstract
Complex anal fistulas require careful evaluation. Prior to any attempts at definitive repair, the anatomy must be well defined and the sepsis resolved. Several muscle-sparing approaches to anal fistula are appropriate, and are often catered to the patient based on their presentation and previous repairs. Emerging technologies show promise for fistula repair, but lack long-term data.
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Affiliation(s)
| | - Kyle G Cologne
- Division of Colorectal Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California
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Narang SK, Jones C, Alam NN, Daniels IR, Smart NJ. Delayed absorbable synthetic plug (GORE® BIO-A®) for the treatment of fistula-in-ano: a systematic review. Colorectal Dis 2016; 18:37-44. [PMID: 26542191 DOI: 10.1111/codi.13208] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2015] [Accepted: 09/10/2015] [Indexed: 02/08/2023]
Abstract
AIM Recent advances in the treatment of fistula-in-ano have focused on surgical techniques that preserve sphincter integrity. Plugs that obliterate the lumen of the fistula track have been proposed as one such method, and may be derived from biological or delayed absorbable synthetic materials. Biological plugs have highly variable results and have not been widely adopted. The aim of this systematic review was to assess the effectiveness and safety of a delayed absorbable synthetic plug (GORE® BIO-A®) for treatment of anal fistula. METHOD A systematic review of all literature in the English language relevant to the use of a plug to treat anal fistula and published between 1 January 2008 and 15 February 2015 was carried out by searching MEDLINE, EMBASE and the Cochrane Library of Systematic Reviews/Controlled Trials for relevant literature. Relevant articles were identified, quality assessed using the methodological index for nonrandomized studies criteria and data were extracted by two independent researchers (SKN and NNA). The identified articles were assessed with regard to fistula healing rate, duration of follow-up and complication rates related to the use of delayed absorbable synthetic fistula plugs. RESULTS Twenty six potential articles were identified from the literature search. Using the predefined inclusion and exclusion criteria, six were included in the final analysis, data extraction and data synthesis. Of these included in the review only three were prospective in design. Complete data were available for 187 of the 221 patients who underwent this treatment. The age of the participants ranged from 19 to 82 years. The fistula healing rates were reported to be between 15.8% and 72.7% at a follow-up ranging between 2 and 19 months. Early or delayed plug extrusion occurred in 16 (8.5%) of the 187 patients. Deterioration in continence was reported in 11 (5.8%) of 187 patients. CONCLUSION There are insufficient high-quality data on the delayed absorbable synthetic (GORE® BIO-A®) fistula plug to draw meaningful conclusions regarding its effectiveness. It does, however, appear to be a simple and safe technique associated with low complication rates and a minor deterioration in continence in a few cases.
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Affiliation(s)
- S K Narang
- Exeter Surgical Health Services Research Unit (HeSRU), Royal Devon and Exeter Hospital, Exeter, Devon, UK
| | - C Jones
- University of Exeter Medical School, Exeter, Devon, UK
| | - N N Alam
- Exeter Surgical Health Services Research Unit (HeSRU), Royal Devon and Exeter Hospital, Exeter, Devon, UK
| | - I R Daniels
- Exeter Surgical Health Services Research Unit (HeSRU), Royal Devon and Exeter Hospital, Exeter, Devon, UK
| | - N J Smart
- Exeter Surgical Health Services Research Unit (HeSRU), Royal Devon and Exeter Hospital, Exeter, Devon, UK
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Dawson H, Serra S. Tumours and inflammatory lesions of the anal canal and perianal skin revisited: an update and practical approach. J Clin Pathol 2015; 68:971-81. [DOI: 10.1136/jclinpath-2015-203056] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Tumours of the anal and perianal region are relatively rare, and clinically often interpreted as innocuous lesions, leading to frequent delays in diagnosis and adequate treatment. Although squamous cell neoplasia represents the most common entity encountered in this anatomically complex area, many conditions, both neoplastic and inflammatory, may occur. Adding to the challenge of correct diagnosis and patient management, recent years have seen major updates in the terminology of squamous cell neoplasia, created to reflect advances in our understanding of the role of human papilloma virus and unify previous terminologies used for different sites in the anogenital tract. However, squamous cell neoplasia in the anal canal and perianal region may differ in terms of histology, biological behaviour, staging and treatment. The aim of this review is to present an overview of neoplastic and non-neoplastic lesions that may be seen in this area, an update on important developments and terminology, potential pitfalls that may be encountered in routine pathology practice and a practical approach on how to resolve these issues.
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Adapting fistula surgery to fistula tract and patient condition: towards a tailored treatment. Eur Surg 2015. [DOI: 10.1007/s10353-015-0357-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Evaluation and management of perianal abscess and anal fistula: a consensus statement developed by the Italian Society of Colorectal Surgery (SICCR). Tech Coloproctol 2015; 19:595-606. [PMID: 26377581 DOI: 10.1007/s10151-015-1365-7] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2015] [Accepted: 08/11/2015] [Indexed: 12/14/2022]
Abstract
Perianal sepsis is a common condition ranging from acute abscess to chronic fistula formation. In most cases, the source is considered to be a non-specific cryptoglandular infection starting from the intersphincteric space. The key to successful treatment is the eradication of the primary track. As surgery may lead to a disturbance of continence, several sphincter-preserving techniques have been developed. This consensus statement examines the pertinent literature and provides evidence-based recommendations to improve individualized management of patients.
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40
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Limura E, Giordano P. Modern management of anal fistula. World J Gastroenterol 2015; 21:12-20. [PMID: 25574077 PMCID: PMC4284327 DOI: 10.3748/wjg.v21.i1.12] [Citation(s) in RCA: 100] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2014] [Revised: 09/16/2014] [Accepted: 11/11/2014] [Indexed: 02/07/2023] Open
Abstract
Ideal surgical treatment for anal fistula should aim to eradicate sepsis and promote healing of the tract, whilst preserving the sphincters and the mechanism of continence. For the simple and most distal fistulae, conventional surgical options such as laying open of the fistula tract seem to be relatively safe and therefore, well accepted in clinical practise. However, for the more complex fistulae where a significant proportion of the anal sphincter is involved, great concern remains about damaging the sphincter and subsequent poor functional outcome, which is quite inevitable following conventional surgical treatment. For this reason, over the last two decades, many sphincter-preserving procedures for the treatment of anal fistula have been introduced with the common goal of minimising the injury to the anal sphincters and preserving optimal function. Among them, the ligation of intersphincteric fistula tract procedure appears to be safe and effective and may be routinely considered for complex anal fistula. Another technique, the anal fistula plug, derived from porcine small intestinal submucosa, is safe but modestly effective in long-term follow-up, with success rates varying from 24%-88%. The failure rate may be due to its extrusion from the fistula tract. To obviate that, a new designed plug (GORE BioA®) was introduced, but long term data regarding its efficacy are scant. Fibrin glue showed poor and variable healing rate (14%-74%). FiLaC and video-assisted anal fistula treatment procedures, respectively using laser and electrode energy, are expensive and yet to be thoroughly assessed in clinical practise. Recently, a therapy using autologous adipose-derived stem cells has been described. Their properties of regenerating tissues and suppressing inflammatory response must be better investigated on anal fistulae, and studies remain in progress. The aim of this present article is to review the pertinent literature, describing the advantages and limitations of new sphincter-preserving techniques.
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Management of complex anorectal fistulas with seton drainage plus partial fistulotomy and subsequent ligation of intersphincteric fistula tract (LIFT). Tech Coloproctol 2014; 19:89-95. [PMID: 25403769 DOI: 10.1007/s10151-014-1245-6] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2014] [Accepted: 11/04/2014] [Indexed: 02/07/2023]
Abstract
BACKGROUND Ligation of intersphincteric fistula tract (LIFT) is a relatively new technique in the treatment of complex anorectal fistulas. As it spares the anal sphincter, rates of post-operative incontinence may be lower when compared to conventional treatment. To date, there have not been enough reports of long-term fistula recurrence rates. We performed a long-term follow-up study of 75 patients who underwent LIFT following seton drainage and partial fistulotomy. METHODS Only patients with complex cryptogenic anorectal fistulas were included. After seton insertion and partial fistulotomy, the tract was reviewed at 4 months for the absence of anorectal sepsis. Patients then underwent LIFT in a day surgery setting. Operative time, complications, recurrences and incontinence were evaluated. RESULTS Between May 2008 and June 2013, 75 patients [51 men, mean age 49.5 years, standard error of the mean (SEM) 1.4 years] were treated with a LIFT protocol. The mean operating time for LIFT was 13.2 min (SEM 1.5 min). Complications included minor bleeding, superficial wound dehiscence and perianal pain. At a mean follow-up of 14.6 months (SEM 1.7 months), there were nine (12 %) recurrences, diagnosed at a mean 9.2 months (SEM 2.7 months). They were treated with seton insertion followed by LIFT with biomesh or anorectal advancement flap, and there were no subsequent recurrences. Review of preoperative and post-operative continence scores revealed only one (1.3 %) patient with minor incontinence following LIFT. Recurrences were significantly related to fistulas with multiple tracts (p < 0.001). CONCLUSIONS Our results suggest that the protocol of seton insertion and partial fistulotomy followed by LIFT is associated with a low recurrence rate comparing well with published results from studies involving other techniques and protocols for treating anal fistula.
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Combined partial fistulectomy and electro-cauterization of the intersphincteric tract as a sphincter-sparing treatment of complex anal fistula: clinical and functional outcome. Tech Coloproctol 2014; 18:1105-11. [DOI: 10.1007/s10151-014-1208-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2014] [Accepted: 07/07/2014] [Indexed: 12/19/2022]
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