Preliminary results of video-assisted anal fistula treatment (VAAFT) in children

Video-assisted anal fistula treatment (VAAFT) combined with ozonide oil dressing: standardization of technique in pediatric patients

BACKGROUND

Anal fistula and perianal abscess are commonly acquired anorectal pathologies in children. Surgical treatment options commonly adopted are fistulotomy, fistulectomy, cutting seton placement, and more recently video-assisted anal fistula treatment (VAAFT). Optimal postoperative wound dressing remains debated. This study aimed to report our series of pediatric patients, who received VAAFT and postoperative wound dressing using ozonide oil.

METHODS

All patients who underwent VAAFT between August 2018 and May 2023 were included in the study. Demographics, clinical features, pre-operative imaging, surgical details, outcome, and mid-term outcome data were retrospectively reviewed for each patient. All VAAFT procedures were performed under general anesthesia and using a 10-Ch fistuloscope.

RESULTS

Thirty-three VAAFT procedures were performed in 30 patients over the study period. The median patient age was 5.7 years (range 1.75-14). Anal fistula was idiopathic in 26/30 (86.6%), iatrogenic in 2/30 (6.7%), and secondary to Crohn's disease in 2/30 (6.7%). The median duration of surgery was 23 min (range 18-40). All patients received ozonide oil dressing twice a day for 5 weeks postoperatively. The median hospital stay was 24 h (range 9-36). The median healing time was 28 days (range 17-39). With a median follow-up of 2 years (range 0.5-5), disease recurrence occurred in 3/30 (10%) patients with idiopathic fistula, who were re-operated using the same technique, with no further recurrence. No fecal incontinence or soiling was observed.

CONCLUSION

Our series confirmed that VAAFT is a safe and effective technique to treat children with perianal fistula. The technique is versatile, allowing to treat fistulae of different etiologies. Postoperative course was painless and fast. Future comparative prospective studies are needed to better establish these conclusions.

Surgery of Simple and Complex Anal Fistulae in Adults: A Review of the Literature for Optimal Surgical Outcomes

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.

Video-assisted anal fistula treatment for complex anorectal fistulas in adults: a systematic review and meta-analysis

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.

Predictive Risk Factors of the Conversion from Video-Assisted Treatment of Anal Fistula to Seton Fistulotomy

Background: To identify the risk factors of converting from video-assisted anal fistula treatment (VAAFT) to seton fistulotomy. Materials and Methods: A total of 180 patients registered to undergo VAAFT between January 2016 and June 2020 at the Erlonglu Hospital. Intraoperative examination of the fistula tract revealed that the patients were assigned to undergo the VAAFT operation and seton fistulotomy. Results: Among 180 patients aged 37 (±10.4) years who underwent intraoperative examination of the fistula tract, 101 completed the standard VAAFT and 79 converted to seton fistulotomy. Univariate analyses revealed that age, necrotic cavity diameter ≥1 cm, scars at the anal entrance, tissue edema, Parks classification, fistula stenosis, and fistula branches were significantly different between the VAAFT and converted groups (P < .05). Multivariate analysis revealed a significant correlation between the risk of surgery conversion and the presence of necrotic cavity with a diameter of ≥1 cm (odds ratio [OR]: 3.668, 95% confidence interval [CI]: 1.366-9.853, P = .01), scars at the anal entrance (OR: 9.462, 95% CI: 1.562-57.32, P = .014), fistula stenosis (OR: 25.14, 95% CI: 5.211-121.3, P < .001), and fistula branches (OR: 2.90, 95% CI: 1.088-7.73, P = .033). The nomogram based on the logistic model was fitted with high accuracy and area under curve of 0.793 (95% CI: 0.726-0.861). Conclusions: The independent risk factors of conversion from surgery for VAAFT to seton fistulotomy were the presence of necrotic cavity with a diameter of ≥1 cm, scars at the anal entrance, fistula stenosis, and fistula branches. The protocol of this systematic review was registered a priori in the Chinese Clinical Trial Registry (ChiCTR) under the registration number of ChiCTR1900022810.

Treatment of Complex Anal Fistula by Video-Assisted Anal Fistula Treatment Combined with Anal Fistula Plug: A Single-Center Study

Objective. The surgical treatment of complex anal fistulae is very challenging because of the incidence of incontinence after traditional approaches. There are no studies on the role of video-assisted anal fistula treatment (VAAFT) combined with anal fistula plug (AFP) in the complex anal fistulae. The aim of this study was to demonstrate the efficacy of treating complex anal fistulae using VAAFT combined with AFP. Method. This was a retrospective, nonrandomized observational study. 57 consecutive patients with complex anal fistulae who had undergone the VAAFT with AFP in our hospital between April 2016 and December 2019 were included. The primary outcomes were the cure rate, recurrence rate, and Wexner incontinence scores; the secondary outcomes were surgery time, blood loss, wound healing time postoperatively, pain, and patient satisfaction. Results. All 57 patients completed the surgery and follow-up, with an average follow-up time of 28 months; 6 patients suffered with recurrence (recurrence rate: 10.5%). The average surgery time was 57.9 minutes, and the average wound healing time was 46 days. There were no severe postoperative complications, and anal sphincter function was protected in all patients. Conclusions. The treatment of complex anal fistula by VAAFT combined with AFP is safe and effective, has a high healing rate and few postoperative complications, and is a promising surgery that can effectively protect the patient's anal sphincter function.

Treatment of Perianal Abscess and Fistula in Infants and Young Children: From Basic Etiology to Clinical Features

Perianal abscess and anal fistula are 2 common anorectal diseases in infants and young children. However, their causes, clinical diagnosis, and treatment remain controversial. Compared to adults, infants with these 2 diseases exhibit unique clinical characteristics. Blind pursuit of conservative treatment or surgery may worsen the condition, resulting in increased pain in young patients and greater economic burden and psychological harm to parents. Therefore, it is crucial to select correct and effective treatments. This review summarizes the relevant literature from the past 10 years and systematically explains the pathogenesis, clinical characteristics, and treatment measures of perianal abscess and anal fistula in infants with the goal of providing clinicians a deeper understanding of perianal abscess and anal fistula in infants and summarizing safe and effective treatment methods.

Efficacy of video-assisted anal fistula treatment combined with closure of the internal opening using a stapler for Parks II anal fistula

Background

To explore the efficacy of video-assisted anal fistula treatment (VAAFT) combined with an internal-opening closure technique using a stapler in the treatment of Parks II anal fistula.

Methods

From September 2017 to June 2019, 75 patients with Parks II anal fistulas in Beijing Erlonglu Hospital were enrolled and randomly allocated into two groups. The 37 patients in the treatment group received VAAFT combined with internal-opening closure techniques, and the 38 patients in the control group were treated with anal fistulotomy with seton placement. The primary outcomes included the healing rate and recurrence, the fecal incontinence severity index (FISI) score, and the Wexner incontinence score during the 6-month postoperative follow-up.

Results

Thirty-two cases were healed in the treatment group (86.5%) and thirty-six cases were cured in the control group (94.7%). There was no notable difference in the healing rate between the two groups (P=0.487). Significant differences between the groups were observed in the Wexner incontinence and FISI scores at 1, 3, and 6 months after the operation (P=0.001). Furthermore, the wound healing time in the treatment group was significantly shorter than in the control group (P<0.05), while the numerical rating scale (NRS) for postoperative pain on the first day and 1 week after the operation were significantly lower in the treatment group than in the control group (P<0.05).

Conclusions

VAAFT combined with closure of the internal opening using a stapler is effective and safe for Parks II anal fistula, and should be promoted as a promising treatment.

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

BACKGROUND

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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

Evaluation and management of perianal abscess and anal fistula: SICCR position statement

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.

The treatment of anal fistula: second ACPGBI Position Statement - 2018

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.

Anorectal Complaints: Hemorrhoids, Fissures, Abscesses, Fistulae

Anorectal complaints are not uncommon in pediatric care, but the etiology and management can differ significantly from adults. Age is an important factor when considering etiology and management, distinguishing between infants, children, and adolescents. For all ages, malignancy is rarely a consideration, but a thorough examination of infants and children typically requires deep sedation or general anesthesia. Very little primary literature or evidence exists to guide care; so there are many opportunities for careful study to enhance our understanding beyond personal experience and historical practice patterns.

Short-term efficacy and safety of three novel sphincter-sparing techniques for anal fistulae: a systematic review

BACKGROUND

The surgical treatment of complex anal fistulae, particularly those involving a significant portion of the anal sphincter in which fistulotomy would compromise continence, is challenging. Video-assisted anal fistula treatment (VAAFT), fistula tract laser closure (FiLaC™) and over-the-scope clip (OTSC^®) proctology system are all novel sphincter-sparing techniques targeted at healing anal fistulae. In this study, all published articles on these techniques were reviewed to determine efficacy, feasibility and safety.

METHODS

A systematic search of major databases was performed using defined terms. All studies reporting on experience of these techniques were included and outcomes (fistula healing and safety) evaluated.

RESULTS

Eighteen studies (VAAFT-12, FiLaC™-3, OTSC^®-3) including 1245 patients were analysed. All were case series, and outcomes were heterogeneous with follow-up ranging from 6 to 69 months and short-term (< 1 year) healing rates of 64-100%. Morbidity was low with only minor complications reported. There was one report of minor incontinence following the first reported study of FiLaC™, and this was treated successfully at 6 months with rubber band ligation of hypertrophied prolapsed mucosa. There are inconsistencies in the technique in studies of VAAFT and FiLaC™.

CONCLUSIONS

All three techniques appear to be safe and feasible options in the management of anal fistulae, and short-term healing rates are acceptable with no sustained effect on continence. There is, however, a paucity of robust data with long-term outcomes. These techniques are thus welcome additions; however, their long-term place in the colorectal surgeon's armamentarium, whether diagnostic or therapeutic, remains uncertain.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Video-Assisted Anal Fistula Treatment (VAAFT) in Cryptoglandular fistula-in-ano: A systematic review and proportional meta-analysis

BACKGROUND

Video-Assisted Anal Fistula Treatment (VAAFT) is a relatively new minimally invasive videoendoscopic procedure for treating fistula-in-ano. We reviewed and performed metaanalysis to evaluate the efficacy of this procedure.

METHODS

Studies from the period 2010 to 2016 were searched in PubMed, Medline, Scopus, Embase, Ovid, SCI database, Cochrane Central Register of Controlled Trials (CENTRAL) & Google Scholar database. All studies which utilized VAAFT to treat fistula-in-ano were extracted. The studies in which the Cryptoglandular fistula were treated were included. Procedure's done in patients with Crohn's disease, pediatric patients and associated malignancy were excluded from the study. The primary outcome parameter was success rate in fistula healing and the secondary outcome parameters were operating time, hospital stay, return to work, incontinence rate and complication rate.

RESULTS

A total of 1378 studies were screened. Out of these, eight studies were finally included for meta-analysis. The analysis (n = 786) demonstrated a net Proportion Meta-analysis pooled rate of 76.01% (95% CI = 68.1 to 83.9) for success rate, 16.2% (95% CI = 12.1 to 20.2) for complications, 44.7 min (95% CI = 38.3 to 51.2) for operating time, 1-4.1 days for mean hospital stay and 1-11 days for return to work. None of the studies reported worsening of continence levels.

CONCLUSIONS

VAAFT is a safe videoendoscopic method to treat fistula-in-ano with an overall success rate of 76% (net Proportion Meta-analysis pooled rate). The main benefit of the procedure is minimal risk to incontinence, minimal hospital stay and early return to work.