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Murad-Regadas SM, Regadas FSP, Regadas Filho FSP, Nogueira FR, Holanda EDC, Dias Mont'Alverne RE, da Cunha CMQ, Ferreira DG. Use of 3D Anorectal Ultrasonography in the Preoperative Assessment of Complex Anal Fistulas and Patterns of Healing, Failure, and Recurrence After Ligation of the Intersphincteric Fistula Tract (LIFT). JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2024. [PMID: 39051749 DOI: 10.1002/jum.16533] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/23/2024] [Revised: 07/09/2024] [Accepted: 07/14/2024] [Indexed: 07/27/2024]
Abstract
OBJECTIVES To use three-dimensional anorectal ultrasonography (3D-US) to evaluate the outcome of ligation of the intersphincteric fistula tract (LIFT) in patients with crypto-glandular transsphincteric fistula and describing the patterns of healing, failure, and recurrence rate. METHODS After classifying the fistula and determining the length of the sphincter muscle to be transected, the patients were submitted to LIFT. The accuracy of pre- and postoperative 3D-US with 360° endoprobe (16 MHz) with automatic scanning and clinical findings was evaluated against surgical findings. Three outcomes were considered: healing, failure (persistent anal fistula through the original external opening or intersphincteric), and recurrence (reappearance of the anal fistula). RESULTS Sixty-three patients of both sexes were evaluated. The 3D-US assessment revealed primary healing in 50 (79.3%) patients, although in 6 (9.5%) cases healing was delayed and the cavity was without communication with the anal canal. The procedure failed in 9 (15.9%) and fistula recurred in 4 (6.3%), all of whom underwent a second surgery based on a new 3D-US, resulting in a 92.3% (12/13) healing rate on 3D-US. CONCLUSIONS A 3D-US was found to be useful in the preoperative assessment of fistulas by quantifying the percentage of muscle to be transected, and in the postoperative assessment by identifying healing, types of failure, and recurrence. The 3D-US was accurate and consistent with surgical findings.
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Affiliation(s)
- Sthela M Murad-Regadas
- Department of Surgery, School of Medicine of the Federal University of Ceará, Fortaleza, Brazil
| | | | | | - Felipe R Nogueira
- Department of Surgery, School of Medicine of the Federal University of Ceará, Fortaleza, Brazil
| | - Erico de C Holanda
- Department of Surgery, School of Medicine of the Federal University of Ceará, Fortaleza, Brazil
| | | | | | - David G Ferreira
- Department of Surgery, School of Medicine of the Federal University of Ceará, Fortaleza, Brazil
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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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Zahra A, Malla J, Selvaraj R, Dhanoa RK, Venugopal S, Shoukrie SI, Selvamani TY, Hamouda RK, Hamid P. A Comparison of Different Surgical Treatments for Complex Anal Fistula: A Systematic Review. Cureus 2022; 14:e28289. [PMID: 36176822 PMCID: PMC9512314 DOI: 10.7759/cureus.28289] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Accepted: 08/23/2022] [Indexed: 11/05/2022] Open
Abstract
Fistula-in-ano is a common proctological condition that primarily affects younger people and leads to chronic morbidity. An anal fistula is divided into simple and complex fistulas. A complex fistula is a challenging problem due to higher recurrence rates and incontinence associated with surgery. Many new methods have been developed for the closure of complex fistula-in-ano, but there is no single best method. The aim of this study is to identify a superior surgical technique for treating complex/high cryptoglandular perianal fistulas (HCPFs). A literature search was done using PubMed and Google Scholar for the period of 2012-2021. Articles that contain surgical treatment for complex anal fistula in the English language published in the last 10 years were included. The types of studies included were randomized controlled trials (RCTs), meta-analyses, systematic reviews, cohort studies, and traditional reviews. Articles excluded were those done more than 10 years ago, in other languages, and containing simple fistula management only. Nine studies were included in the review; a systematic review and meta-analysis concluded that no single method is effective. The ligation of the intersphincteric fistula tract (LIFT) procedure seems to be a promising and effective technique as it has a low rate of fecal incontinence as compared to other methods. Biological techniques give variable success rates so does fistula plug (FP). Mucosal advancement flap (MAF) and rerouting seton give good results according to one study. Fistula plug gives variable results and is not a preferred method. Ligation of the intersphincteric fistula tract (LIFT) seems to be a promising new technique for complex anal fistulas, but the data available is not enough to determine the best method. More randomized trials are required to compare traditional techniques and emerging new biological methods to see the best technique available.
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Hegab AM, Baheeg M, Shehata MS, Zaghloul T, Kamel MI, Hasan A. Long-term outcome of ligation of inter-sphincteric fistula tract (LIFT) for management of trans-sphincteric anal fistula. INTERNATIONAL JOURNAL OF SURGERY OPEN 2022. [DOI: 10.1016/j.ijso.2022.100461] [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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Van Hoof S, Van Dessel E, Cools P. LIFT: a feasible option for primary and recurrent fistulas. Acta Chir Belg 2021; 121:420-426. [PMID: 33108254 DOI: 10.1080/00015458.2020.1841488] [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: 10/23/2022]
Abstract
BACKGROUND The development of a surgical solution for anal fistulas with minimal recurrence and morbidity remains a challenge. Ligation of the intersphincteric fistula tract (LIFT), however, is a sphincter sparing technique that provides complete resolution of the transsphincteric fistula as well as minimizing recurrence and fecal incontinence. Our goal is to evaluate the efficacy of fistula tract ligation for primary and recurrent fistulas. METHODS A retrospective single-center case study was conducted from data between 2015 and 2019 in a large district hospital in Antwerp, Belgium. Patients who underwent LIFT were included. Demographic patient data as well as primary outcome during the follow-up period were collected. A systematic literature review and analysis was conducted with terms [ANAL FISTULA] [TREATMENT] [LIFT] [LIGATION OF INTERSPHINCTERIC FISTULA]. Primary healing and recurrence associated with surgical modifications were investigated. RESULTS 4 out of 25 patients presented with early failure (84% primary success rate) after a median follow-up period of 7 months. The median time until recurrence was 105 days. The success rate after a redo ligation was 100%. Twenty-eight studies were included for review and divided into three groups depending on the technical variation of the used technique. The success rate was 74.2% for the LIFT group, 72.9% in the LIFT + group, and 77.5% in the mLIFT group p = .92. CONCLUSION LIFT is a feasible treatment option for primary and recurrent fistulas, with excellent success rates where fistula characteristics rather than chosen technique dictate the surgical outcome.
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Parnasa SY, Helou B, Mizrahi I, Gefen R, Abu-Gazala M, Pikarsky AJ, Shussman N. External sphincter-sparing anal fistulotomy (ESSAF): a simplified technique for the treatment of fistula-in-ano. Tech Coloproctol 2021; 25:1311-1318. [PMID: 34599414 DOI: 10.1007/s10151-021-02525-5] [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: 04/17/2021] [Accepted: 09/07/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND Fistula-in-ano due to cryptoglandular disease is a common condition. While a simple anal fistula can be treated successfully by a fistulotomy, the risk of potential damage to the anal sphincters and subsequent poor functional outcomes persist in a large portion of patients with complex fistulae. Several sphincter-preserving treatment procedures have been described for complex fistulae over the past 3 decades, with variable results and complication rates, and no procedure is proven to be superior to the others. We developed external sphincter-sparing anal fistulotomy (ESSAF), a reproducible simple modification of the ligation of intersphincteric fistula tract (LIFT) technique for the treatment of complex fistula-in-ano.. The aim of the present study was to describe the technique and our outcomes. METHODS This was a retrospective review of all patients who underwent ESSAF for a complex anal fistula at our institution from January 2014 to December 2019. The primary outcome measure of this study was the primary fistula healing rate. Secondary outcome measures included fecal and/or gas incontinence and postoperative complications. During the ESSAF procedure, the mucosa and skin overlying the fistula tract are incised to allow complete exposure of the sphincter complex. Then the internal sphincter muscle fibers overlying the tract are divided and the tract is meticulously curetted and debrided. Next, the internal opening of the tract traversing the external sphincter muscle is suture-ligated with absorbable sutures. Then, a minimal amount of mucosa is advanced and the incision is partially closed with absorbable sutures, while its external portion is left open for drainage. RESULTS Fifty-nine patients [43 males, median age was 50 years (range 36-63 years)] underwent ESSAF for complex anal fistula during the study period. Mean follow-up was 12 ± 14.7 months. Of the 59 patients, 42 (71.2%) experienced fistula closure, with a median healing time of 8 weeks (IQR 4-16 weeks). None of the patients developed significant anal incontinence following the procedure. One patient (1.7%) suffered from soiling and another patient (1.7%) developed postoperative bleeding. There were no infectious complications. Of the 17 patients (28.8%) who failed to heal successfully, 9 (15.2%) did not heal primarily and 8 (16%) experienced recurrence after complete healing. Thirteen (76%) of these patients underwent reoperation with complete recovery after ESSAF (n = 4), fistulotomy (n = 8) or endorectal advancement flap (ERAF) (n = 1). Overall ESSAF initiated recovery in 93.2% of the patients. CONCLUSIONS ESSAF is a feasible, safe, reproducible and effective sphincter-sparing procedure for the treatment of complex anal fistulae.
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Affiliation(s)
- S Y Parnasa
- Department of General Surgery, Hadassah Medical Organization and Faculty of Medicine, Hebrew University of Jerusalem, POB 12000, Jerusalem, 91120, Israel
| | - B Helou
- Department of General Surgery, Hadassah Medical Organization and Faculty of Medicine, Hebrew University of Jerusalem, POB 12000, Jerusalem, 91120, Israel
| | - I Mizrahi
- Department of General Surgery, Hadassah Medical Organization and Faculty of Medicine, Hebrew University of Jerusalem, POB 12000, Jerusalem, 91120, Israel
| | - R Gefen
- Department of General Surgery, Hadassah Medical Organization and Faculty of Medicine, Hebrew University of Jerusalem, POB 12000, Jerusalem, 91120, Israel
| | - M Abu-Gazala
- Department of General Surgery, Hadassah Medical Organization and Faculty of Medicine, Hebrew University of Jerusalem, POB 12000, Jerusalem, 91120, Israel
| | - A J Pikarsky
- Department of General Surgery, Hadassah Medical Organization and Faculty of Medicine, Hebrew University of Jerusalem, POB 12000, Jerusalem, 91120, Israel
| | - N Shussman
- Department of General Surgery, Hadassah Medical Organization and Faculty of Medicine, Hebrew University of Jerusalem, POB 12000, Jerusalem, 91120, Israel.
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Deep Learning-Based CT Image Characteristics and Postoperative Anal Function Restoration for Patients with Complex Anal Fistula. JOURNAL OF HEALTHCARE ENGINEERING 2021; 2021:1730158. [PMID: 34367532 PMCID: PMC8337139 DOI: 10.1155/2021/1730158] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Revised: 06/24/2021] [Accepted: 07/07/2021] [Indexed: 12/23/2022]
Abstract
Objective This study aimed to optimize the CT images of anal fistula patients using a convolutional neural network (CNN) algorithm to investigate the anal function recovery. Methods 57 patients with complex anal fistulas admitted to our hospital from January 2020 to February 2021 were selected as research subjects. Of them, CT images of 34 cases were processed using the deep learning neural network, defined as the experimental group, and the remaining unprocessed 23 cases were in the control group. Whether to process CT images depended on the patient's own wish. The imaging results were compared with the results observed during the surgery. Results It was found that, in the experimental group, the images were clearer, with DSC = 0.89, precision = 0.98, and recall = 0.87, indicating that the processing effects were good; that the CT imaging results in the experimental group were more consistent with those observed during the surgery, and the difference was notable (P < 0.05). Furthermore, the experimental group had lower RP (mmHg), AMCP (mmHg) scores, and postoperative recurrence rate, with notable differences noted (P < 0.05). Conclusion CT images processed by deep learning are clearer, leading to higher accuracy of preoperative diagnosis, which is suggested in clinics.
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Lee JL, Yoon YS, Yu CS. Treatment Strategy for Perianal Fistulas in Crohn Disease Patients: The Surgeon's Point of View. Ann Coloproctol 2021; 37:5-15. [PMID: 33730796 PMCID: PMC7989558 DOI: 10.3393/ac.2021.02.08] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Accepted: 02/08/2021] [Indexed: 12/12/2022] Open
Abstract
Perianal fistula is a frequent complication and one of the subclassifications of Crohn disease (CD). It is the most commonly observed symptomatic condition by colorectal surgeons. Accurately classifying a perianal fistula is the initial step in its management in CD patients. Surgical management is selected based on the type of perianal fistula and the presence of rectal inflammation; it includes fistulotomy, fistulectomy, seton procedure, fistula plug insertion, video-assisted ablation of the fistulous tract, stem cell therapy, and proctectomy with stoma creation. Perianal fistulas are also managed medically, such as antibiotics, immunomodulators, and biologics including anti-tumor necrosis factor-alpha agents. The current standard treatment of choice for perianal fistula in CD patients is the multidisciplinary approach combining surgical and medical management; however, the rate of long-term remission is low and is reported to be 50% at most. Therefore, the optimum management strategy for perianal fistulas associated with CD remains controversial. Currently, the goal of management for CD-related perianal fistulas are controlling symptoms and maintaining long-term anal function without proctectomy, while monitoring progression to anorectal carcinoma. This review evaluates perianal fistula in CD patients and determines the optimal surgical management strategy based on recent evidence.
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Affiliation(s)
- Jong Lyul Lee
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Yong Sik Yoon
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Chang Sik Yu
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Zhang J, Hao X, Zhu Y, Luan R. Efficacy and safety of ligation of intersphincteric fistula tract in the treatment of anal fistula: A protocol for systematic review and meta-analysis. Medicine (Baltimore) 2021; 100:e23700. [PMID: 33530171 PMCID: PMC7850721 DOI: 10.1097/md.0000000000023700] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Accepted: 11/16/2020] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND Anal fistula is characterized with perianal cellulitis, anorectal pain, smelly or bloody drainage of pus, and difficulty in controlling bowel movements. Ligation of intersphincteric fistula tract (LIFT) technique is a recently developed approach against anal fistula, and it could alleviate the pain of the patient, with little postoperative trauma, which can greatly shorten the wound healing time and hospitalization stay. We conduct the meta-analysis and systematic review to systematically evaluate the clinical efficacy and safety of LIFT in the treatment of anal fistula. METHODS Randomized controlled trials of LIFT against anal fistula will be searched in several Chinese and English databases. Two reviewers will independently conduct the literature extraction and risk of bias assessment. Statistical analysis will be conducted in RevMan 5.3. RESULTS AND CONCLUSIONS The study will help to systematically evaluate the clinical efficacy and safety of LIFT in the treatment of anal fistula. OSF REGISTRATION NUMBER DOI 10.17605/OSF.IO/T4FUH.
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Emile SH, Khan SM, Adejumo A, Koroye O. Ligation of intersphincteric fistula tract (LIFT) in treatment of anal fistula: An updated systematic review, meta-analysis, and meta-regression of the predictors of failure. Surgery 2019; 167:484-492. [PMID: 31648932 DOI: 10.1016/j.surg.2019.09.012] [Citation(s) in RCA: 49] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2019] [Revised: 08/30/2019] [Accepted: 09/11/2019] [Indexed: 12/16/2022]
Abstract
BACKGROUND Ligation of intersphincteric fistula tract has gained increasing popularity as a sphincter-sparing technique for complex anal fistula. The present review aimed to investigate the pooled success and complication rates of ligation of intersphincteric fistula tract in the published literature and to explore the risk factors for failure after ligation of intersphincteric fistula tract. METHODS A Preferred Reporting Items for Systematic Reviews and Meta-Analyses-compliant literature search was conducted. Electronic databases were searched in the period of January 2007 through April 2019 for studies that assessed the outcome of the ligation of intersphincteric fistula tract procedure. The main outcomes of the review were the pooled success and complication rates of ligation of intersphincteric fistula tract, predictors of failure after ligation of intersphincteric fistula tract, operation time, hospital stay, and how failures were managed. RESULTS Twenty-six studies comprising 1,378 patients (996 male) were included in this review. The mean age of patients was 42.3 ± 4.2 years. The weighted mean rate of success was 76.5%. The median follow-up duration was 16.5 months. The weighted mean complication rate was 13.9%. The most common complication was wound dehiscence. Fecal incontinence was recorded in 1.4% of patients. Factors that were statistically significantly associated with failure after the ligation of intersphincteric fistula tract procedure were horseshoe fistulas, fistulas associated with Crohn's disease, and those with a history of previous fistula surgery. CONCLUSION The pooled success and complication rates of the ligation of intersphincteric fistula tract procedure were about 76% and 14%, respectively. Horseshoe fistulas, Crohn's disease, and previous fistula surgery were identified as predictors for failure after ligation of intersphincteric fistula tract procedure.
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Affiliation(s)
- Sameh Hany Emile
- Colorectal Surgery Unit, General Surgery Department, Mansoura University Hospitals, Mansoura University, Egypt.
| | - Sualeh Muslim Khan
- Dow Medical College, Dow University of Health Sciences, Karachi, Pakistan
| | - Adeyinka Adejumo
- Division of General Surgery, Department of Surgery, Federal Medical Center, Keffi, Nigeria
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Göttgens KWA, Wasowicz DK, Stijns J, Zimmerman D. Ligation of the Intersphincteric Fistula Tract for High Transsphincteric Fistula Yields Moderate Results at Best: Is the Tide Turning? Dis Colon Rectum 2019; 62:1231-1237. [PMID: 31490832 DOI: 10.1097/dcr.0000000000001448] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Ligation of the intersphincteric fistula tract is a well-accepted and often used surgical procedure for perianal fistulas. OBJECTIVE This study aims to confirm results of the ligation of the intersphincteric fistula tract in a specialized colorectal center. DESIGN This is a retrospective cohort study. SETTING This study took place in a large colorectal surgical department with a tertiary referral center for perianal fistulas. PATIENTS Consecutive patients were operated on with ligation of the intersphincteric fistula tract for a transsphincteric perianal fistula between 2012 and December 2018. INTERVENTIONS Patients underwent ligation of the intersphincteric fistula tract. MAIN OUTCOME MEASURES The primary outcome measured was the healing rate. The secondary outcomes measured were conversion into an intersphincteric perianal fistula, risk of recurrence, complications, and postoperative continence status. RESULTS Forty-six patients were treated with a ligation of intersphincteric fistula tract procedure. All patients (100%) had preoperative imaging in their workup. Forty patients (87%) had a high transsphincteric fistula. The primary healing rate was a disappointing 17 of 46 patients (37%). The median time until failure was 4.2 months (interquartile range, 3.5-6.5). Of the failures, 16 converted to an intersphincteric fistula (55% of failures and 35% of all patients). The mean duration of follow-up in patients without a recurrence was 9.5 months (SD 11.9). Four patients (9%) were lost to follow-up. The mean Fecal Incontinence Severity Index postoperatively was only 2.35 (SD 5.7; range, 0-30). This resulted in 9 patients (20%) having a newly impaired continence status postoperatively. Continence impairment was mild in all these patients. The risk of developing a recurrence 1 year after surgery is 64.2% (95% CI, 49%-80%). LIMITATIONS This study was limited by its retrospective design and the small numbers with possible selection bias. CONCLUSIONS Results with the ligation of intersphincteric fistula tract procedure were not as good as hoped. The effect on fecal continence, however, was minimal. The procedure might be more suitable for low transsphincteric fistulas. See Video Abstract at http://links.lww.com/DCR/A992. LA LIGADURA DEL TRACTO DE LA FÍSTULA INTERESFINTÉRICA PARA UNA FÍSTULA TRANSESFINTÉRICA ALTA, PRODUCE RESULTADOS MODERADOS EN EL MEJOR DE LOS CASOS: ¿ESTÁ CAMBIANDO LA MAREA?: La ligadura del tracto de la fístula interesfintérica es un procedimiento quirúrgico bien aceptado y de uso frecuente para las fístulas perianales. OBJETIVO Confirmar los resultados de la ligadura del tracto de la fístula interesfintérica en un centro colorrectal especializado. DISEÑO:: Estudio de cohorte retrospectivo. AJUSTE Gran departamento de cirugía colorrectal y con centro de referencia terciaria para fístulas perianales. PACIENTES Pacientes consecutivos operados con ligadura del tracto de la fístula interesfintérica para una fístula perianal transesfintérica, entre 2012 y diciembre de 2018. INTERVENCIONES Ligadura del tracto de fístula interesfintérica. PRINCIPALES MEDIDAS DE RESULTADO Tasa de cicatrización, resultados secundarios: conversión a una fístula perianal interesfintérica, riesgo de recurrencia, complicaciones y estado de continencia postoperatoria. RESULTADOS Cuarenta y seis pacientes fueron tratados con una ligadura del tracto de la fístula interesfintérica. Todos los pacientes (100 por ciento) tenían imagenología en su preparación preoperatoria. Cuarenta pacientes (87 por ciento) tenían una fístula transesfintérica alta. La tasa de cicatrización primaria fue decepcionante en 17 de 46 pacientes (37 por ciento). El tiempo medio hasta el fracaso fue de 4.2 meses (rango intercuartil 3.5-6.5). De los fracasos, 16 se convirtieron en una fístula interesfintérica (55 por ciento de los fracasos y 35 por ciento de todos los pacientes). La duración media del seguimiento en pacientes sin recurrencia fue de 9.5 meses (desviación estándar de 11.9). Se perdieron durante el seguimiento a cuatro pacientes (9 por ciento). Después de la operación, el promedio del índice de severidad de incontinencia fecal fue de solo 2.35 (desviación estándar de 5.7, rango 0-30). Esto resultó en que 9 pacientes (20 por ciento) tuvieran una continencia deteriorada postoperatoria. El deterioro de la continencia fue leve en todos estos pacientes. El riesgo de desarrollar una recurrencia a un año después de la cirugía es del 64.2 por ciento (intervalo de confianza del 95 por ciento: 49-80 por ciento). LIMITACIONES Diseño retrospectivo, números pequeños con posible sesgo de selección. CONCLUSIONES Los resultados del procedimiento con la ligadura del tracto de fístula interesfintérica no fueron tan buenos como se esperaba. El efecto sobre la continencia fecal, sin embargo, fue mínimo. El procedimiento podría ser más adecuado para las fístulas transesfintéricas bajas. Vea el Resumen del video en http://links.lww.com/DCR/A992.
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Mei Z, Wang Q, Zhang Y, Liu P, Ge M, Du P, Yang W, He Y. Risk Factors for Recurrence after anal fistula surgery: A meta-analysis. Int J Surg 2019; 69:153-164. [PMID: 31400504 DOI: 10.1016/j.ijsu.2019.08.003] [Citation(s) in RCA: 74] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2019] [Revised: 07/30/2019] [Accepted: 08/02/2019] [Indexed: 02/05/2023]
Abstract
BACKGROUND Despite a burgeoning literature during the last two decades regarding perioperative risk management of anal fistula, little is known about its risk factors that influence postoperative recurrence. We performed a meta-analysis to summarize and assess the credibility of evidence of potential risk factors for anal fistula recurrence (AFR) after surgery. METHODS Pubmed and EMBASE without language restriction were searched from inception to April 2018 that reported risk factors which predisposed recurrence after anal fistula surgery. We excluded studies that involved patients with anal fistula associated with Crohn's disease. MOOSE guidelines were followed when this meta-analysis was performed. We used random-effects models to pool relative risks (RRs) with 95% confidence intervals (CIs). Evidence from observational studies was graded into high-quality (Class I), moderate-quality (Class II/III) and low-quality (Class IV) based on Egger's P value, total sample size and between-study heterogeneity. RESULTS Of 3514 citations screened, 20 unique observational studies comprising 6168 patients were involved in data synthesis. High-quality evidence showed that AFR was associated with high transsphincteric fistula (RR, 4.77; 95% CI, 3.83 to 5.95), internal opening unidentified (RR, 8.54; 95% CI, 5.29 to 13.80), and horseshoe extensions (RR, 1.92; 95% CI, 1.43 to 2.59). Moderate-quality evidence suggested an association with prior anal surgery (RR, 1.52; 95% CI, 1.04 to 2.23), seton placement surgery (RR, 2.97; 95% CI, 1.10 to 8.06), and multiple fistula tract (RR, 4.77; 95% CI, 1.46 to 15.51). High-quality evidence demonstrated no significant association with gender or smoking; moderate-quality evidence also suggested no association with age, tertiary referral, alcohol use, diabetes mellitus, obesity, preoperative seton drainage, high internal opening, postoperative drainage, mucosal advancement flap surgery, supralevator extensions, location or type of anal fistula. CONCLUSION Several patient, surgery and fistula-related factors are significantly associated with postoperative AFR. These findings strengthen clinical awareness of early warning to identify patients with high-risk disease recurrence for AFR.
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Affiliation(s)
- Zubing Mei
- Department of Anorectal Surgery, Shuguang Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, China; Anorectal Disease Institute of Shuguang Hospital, Shanghai, China.
| | - Qingming Wang
- Department of Anorectal Surgery, Shuguang Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, China; Anorectal Disease Institute of Shuguang Hospital, Shanghai, China
| | - Yi Zhang
- Department of Pharmacy, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Peng Liu
- Department of Colorectal Surgery, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Maojun Ge
- Department of General Surgery, Shuguang Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Peixin Du
- Department of Anorectal Surgery, Shuguang Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, China; Anorectal Disease Institute of Shuguang Hospital, Shanghai, China
| | - Wei Yang
- Department of Anorectal Surgery, Shuguang Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, China; Anorectal Disease Institute of Shuguang Hospital, Shanghai, China.
| | - Yazhou He
- West China School of Medicine/West China Hospital, Sichuan University, Chengdu, Sichuan, People's Republic of China; The Institute of Genetics and Molecular Medicine, Western General Hospital, University of Edinburgh, UK
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13
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Vander Mijnsbrugge GJH, Felt-Bersma RJF, Ho DKF, Molenaar CBH. Perianal fistulas and the lift procedure: results, predictive factors for success, and long-term results with subsequent treatment. Tech Coloproctol 2019; 23:639-647. [PMID: 31317361 PMCID: PMC6692447 DOI: 10.1007/s10151-019-02023-9] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2018] [Accepted: 06/20/2019] [Indexed: 12/13/2022]
Abstract
Background Treatment of a perianal fistula is difficult due to the risk of fecal incontinence and recurrence. The ligation of intersphincteric tract (LIFT) procedure is a sphincter-saving procedure associated with success rates ranging from 57 to 94%. The aim of our study was to find predictors for a favorable outcome of the LIFT procedure, evaluation of postoperative fecal incontinence, quality of life, and subsequent treatment with long-term follow-up. Methods This study was performed in patients who underwent LIFT between 2013 and 2015 at our institution. Their medical data were retrieved from the electronic patient files. The fistula characteristics were described by physical examination, three-dimensional endoanal ultrasound, and perioperative evaluation. Recurrence rate, postoperative fecal incontinence, and quality of life were assessed with the Patient-Reported Outcome Measurement (PROM). Thirty-two months later, long-term follow-up including subsequent procedures was evaluated. Results Forty-five patients [17 men, mean age 40 years (range 24–67 years)] were included. In 41 (84%) patients, the fistula was classified as complex; 32 (71%) were referrals with a history of previous fistula surgery. The initial success rate was 18 (40%). Only the height of the internal fistula opening (≥ 15 mm p < 0.03) was associated with recurrence. The LIFT procedure did not affect the occurrence of fecal incontinence or soiling. Recurrence showed a trend with a lower PROM (p = 0.07). Twenty-four months later, further surgery leads to cure in 34 (75%), asymptomatic fistulas in 7 (16%), and persisting active fistulas in 4 (9%) patients. Conclusions Initial LIFT had a success rate of 40% and with subsequent surgical treatment 75%. Recurrence after LIFT is related to the height of the internal fistula opening and is associated with diminished quality of life. Continence was not affected by initial LIFT.
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Affiliation(s)
| | - R J F Felt-Bersma
- Proctos Kliniek, Bilthoven, The Netherlands. .,Department of Gastroenterology and Hepatology, Amsterdam UMC, Location VUmc, P.O. Box 7057, 1007 MB, Amsterdam, The Netherlands.
| | - D K F Ho
- Department of Gastroenterology and Hepatology, Amsterdam UMC, Location VUmc, P.O. Box 7057, 1007 MB, Amsterdam, The Netherlands
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14
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Stellingwerf ME, van Praag EM, Tozer PJ, Bemelman WA, Buskens CJ. Systematic review and meta-analysis of endorectal advancement flap and ligation of the intersphincteric fistula tract for cryptoglandular and Crohn's high perianal fistulas. BJS Open 2019; 3:231-241. [PMID: 31183438 PMCID: PMC6551488 DOI: 10.1002/bjs5.50129] [Citation(s) in RCA: 75] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2018] [Accepted: 11/08/2018] [Indexed: 12/13/2022] Open
Abstract
Background High perianal fistulas require sphincter‐preserving surgery because of the risk of faecal incontinence. The ligation of the intersphincteric fistula tract (LIFT) procedure preserves anal sphincter function and is an alternative to the endorectal advancement flap (AF). The aim of this study was to evaluate outcomes of these procedures in patients with cryptoglandular and Crohn's perianal fistulas. Methods A systematic literature search was performed using MEDLINE, Embase and the Cochrane Library. All RCTs, cohort studies and case series (more than 5 patients) describing one or both techniques were included. Main outcomes were overall success rate, recurrence and incontinence following either technique. A proportional meta‐analysis was performed using a random‐effects model. Results Some 30 studies comprising 1295 patients were included (AF, 797; LIFT, 498). For cryptoglandular fistula (1098 patients), there was no significant difference between AF and LIFT for weighted overall success (74·6 (95 per cent c.i. 65·6 to 83·7) versus 69·1 (53·9 to 84·3) per cent respectively) and recurrence (25·6 (4·7 to 46·4) versus 21·9 (14·8 to 29·0) per cent) rates. For Crohn's perianal fistula (64 patients), no significant differences were observed between AF and LIFT for overall success rate (61 (45 to 76) versus 53 per cent respectively), but data on recurrence were limited. Incontinence rates were significantly higher after AF compared with LIFT (7·8 (3·3 to 12·4) versus 1·6 (0·4 to 2·8) per cent). Conclusion Overall success and recurrence rates were not significantly different between the AF and LIFT procedure, but continence was better preserved after LIFT.
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Affiliation(s)
- M E Stellingwerf
- Department of Surgery Amsterdam UMC, University of Amsterdam Amsterdam the Netherlands
| | - E M van Praag
- Department of Surgery Amsterdam UMC, University of Amsterdam Amsterdam the Netherlands
| | - P J Tozer
- Robin Phillips Fistula Research Unit, St Mark's Hospital and Academic Institute Harrow HA1 3UJ UK
| | - W A Bemelman
- Department of Surgery Amsterdam UMC, University of Amsterdam Amsterdam the Netherlands
| | - C J Buskens
- Department of Surgery Amsterdam UMC, University of Amsterdam Amsterdam the Netherlands
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15
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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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16
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Abstract
Sphincter-sparing procedures for rectal fistulas are becoming more popular among coloproctologists. However, the outcomes are not optimal that forces surgeons to seek new approaches in order to improve results. Seton drainage prior to radical stage is one of these methods. The effect of seton drainage on the outcomes is reviewed in the article. Elibrary, Pubmed and Google Scholar databases were analyzed. We have assessed 14 out of 151 trials for the period 1984 - 2017. There were no significant advantages of seton drainage compared with single-stage approach (χ2 = 3.84, p> 0.05, RR = 0.95, CI 95% 0.84 - 1.08). The same situation is observed for mucomuscular flap bringing down to close internal fistula. Fistula healing was more common after seton drainage deployment within 4 - 8 weeks. Bringing down of the flap to anal canal should be preferred after drainage due to less incidence of recurrences. Further trials are necessary to determine advisability of seton drainage and optimal surgical approach.
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Affiliation(s)
- A I Musin
- Pirogov Russian National Research Medical University of Healthcare Ministry of the Russian Federation, Chair of Hospital-Based Surgery No. 1 of the Faculty of Medicine, Moscow, Russia
| | - I V Kostarev
- Ryzhikh State Research Center of Coloproctology of Healthcare Ministry of the Russian Federation, Moscow, Russia
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17
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Williams G, Williams A, Tozer P, Phillips R, Ahmad A, Jayne D, Maxwell-Armstrong C. The treatment of anal fistula: second ACPGBI Position Statement - 2018. Colorectal Dis 2018; 20 Suppl 3:5-31. [PMID: 30178915 DOI: 10.1111/codi.14054] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2017] [Accepted: 02/16/2018] [Indexed: 02/08/2023]
Abstract
It is over 10 years since the first ACPGBI Position Statement on the management of anal fistula was published in 2007. This second edition is the result of scrutiny of the literature published during this time; it updates the original Position Statement and reviews the published evidence surrounding treatments for anal fistula that have been developed since the original publication.
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Affiliation(s)
- G Williams
- Royal Wolverhampton NHS Trust, Wolverhampton, UK
| | - A Williams
- Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - P Tozer
- St Mark's Hospital, Harrow, London, UK
| | | | - A Ahmad
- Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - D Jayne
- University of Leeds, Leeds, UK
| | - C Maxwell-Armstrong
- National Institute for Health Research Nottingham Digestive Diseases Biomedical Research Unit, Nottingham University Hospitals NHS Trust and University of Nottingham, Nottingham, UK
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18
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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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19
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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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20
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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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21
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Rosen DR, Kaiser AM. Definitive seton management for transsphincteric fistula-in-ano: harm or charm? Colorectal Dis 2016; 18:488-95. [PMID: 26382283 DOI: 10.1111/codi.13120] [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: 04/26/2015] [Accepted: 07/15/2015] [Indexed: 02/08/2023]
Abstract
AIM The treatment of transsphincteric anal fistula requires a balance between eradication of the disease and preservation of faecal control. A cutting seton is an old tool that is now out of vogue for many surgeons. We hypothesized that the concept remains reliable and safe with results that exceed those reported for many of the more recently described methods. METHOD A retrospective review was conducted of real-time electronic health records (single institution, single surgeon) of patients presenting during the 14 years between 2001 and 2014 with a transsphincteric anal fistula who were treated with a cutting seton. Excluded were patients with Crohn's disease, fistulae related to malignancy or a previous anastomosis and patients whose fistula was treated by another method including a loose draining seton. Data collection included demographics, duration of the disease, duration of the treatment, outcome and continence. RESULTS In all, 121 patients (80 men) of mean age 40.2 ± 12.2 years (range 18-76) with a mean follow-up of 5.1 ± 3.3 (1-24) months were included in the analysis. The median duration of symptoms was 6 (1-84) months; 36% had failed other fistula surgery, 12% had a complex fistula with more than one track and 35% had some form of comorbidity. The median time to healing was 3 (1-18) months; 7.4% required further surgery, but eventually 98% had complete fistula healing. The incontinence rate decreased postoperatively to 11.6% from 19% before treatment with 17/121 with pre-existing incontinence resolved and 8/107 new cases developing. CONCLUSION Despite its retrospective non-comparative design, the study has demonstrated that a cutting seton is a safe, well tolerated and highly successful treatment for transsphincteric anal fistula and is followed overall by improved continence. The results compare very favourably with other techniques.
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Affiliation(s)
- D R Rosen
- Department of Colorectal Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - A M Kaiser
- Department of Colorectal Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
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22
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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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23
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Altomare DF. Anal fistula closure with FiLaC: new hope or the same old story? Tech Coloproctol 2015; 19:441-2. [PMID: 26187539 DOI: 10.1007/s10151-015-1347-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2015] [Accepted: 07/06/2015] [Indexed: 12/30/2022]
Affiliation(s)
- D F Altomare
- Department of Emergency and Organ Transplantation, Aldo Moro University, Bari, Italy,
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