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Garg P, Bhattacharya K, Yagnik VD, Mahak G. Recent advances in the diagnosis and treatment of complex anal fistula. Ann Coloproctol 2024; 40:321-335. [PMID: 39228196 DOI: 10.3393/ac.2024.00325.0046] [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: 06/04/2024] [Accepted: 07/01/2024] [Indexed: 09/05/2024] Open
Abstract
Anal fistula can be a challenging condition to manage, with complex fistulas presenting even greater difficulties. The primary concerns in treating this condition are a risk of damage to the anal sphincters, which can compromise fecal continence, and refractoriness to treatment, as evidenced by a high recurrence rate. Furthermore, the treatment of complex anal fistula involves several additional challenges. Satisfactory solutions to many of these obstacles remain elusive, and no consensus has been established regarding the available treatment options. In summary, complex anal fistula has no established gold-standard treatment, and the quest for effective therapies continues. This review discusses and highlights groundbreaking advances in the management of complex anal fistula over the past decade.
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Affiliation(s)
- Pankaj Garg
- Department of Colorectal Surgery, Garg Fistula Research Institute, Panchkula, India
| | - Kaushik Bhattacharya
- Department of Surgery, Mata Gujri Memorial Medical College and Lions Seva Kendra Hospital, Kishanganj, India
| | - Vipul D Yagnik
- Department of Surgery, Banas Medical College and Research Institute, Palanpur, Palanpur, India
| | - G Mahak
- Department of Clinical Research, Garg Fistula Research Institute, Panchkula, India
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Akinmoladun O, Hatch QM. Anal Cryptoglandular Suppuration: Evidence-Based Management. Surg Clin North Am 2024; 104:491-501. [PMID: 38677815 DOI: 10.1016/j.suc.2023.11.002] [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] [Indexed: 04/29/2024]
Abstract
Anal suppurative processes are commonly encountered in surgical practice. While the initial therapeutic intervention is philosophically straightforward (incision and drainage), drainage of the appropriate space and treatment of the subsequent fistula in ano require a thorough understanding of perianal anatomy and nuanced decision making. Balancing the risk of fecal incontinence with simple fistulotomy versus the higher risk of fistula recurrence with all sphincter-sparing fistula treatments can be a challenge for surgeons and patients alike.
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Affiliation(s)
- Oladapo Akinmoladun
- Department of Surgery, Madigan Army Medical Center General Surgery, Joint Base Lewis-McChord, WA 98431, USA
| | - Quinton M Hatch
- Department of Surgery, Madigan Army Medical Center General Surgery Residency, Joint Base Lewis-McChord, WA 98431, USA.
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Yagnik VD, Kumar S, Thakur A, Bhattacharya K, Dawka S, Garg P. Recent Advances in the Understanding and Management of Anal Fistula from India. Indian J Surg 2024. [DOI: 10.1007/s12262-024-04050-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2023] [Accepted: 02/05/2024] [Indexed: 07/26/2024] Open
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Mateescu T, Fulger L, Tummala D, Nelluri A, Kakarla M, Stelea L, Dumitru C, Noditi G, Dobrescu A, Paleru C, Toma AO. Exploring Health-Related Quality of Life in Patients with Anal Fistulas: A Comprehensive Study. Life (Basel) 2023; 13:2008. [PMID: 37895390 PMCID: PMC10608709 DOI: 10.3390/life13102008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Revised: 09/08/2023] [Accepted: 09/25/2023] [Indexed: 10/29/2023] Open
Abstract
Anal fistulas often cause significant impairment to patients' health-related quality of life (HRQOL). This cross-sectional study aimed to compare the HRQOL between patients with anal fistulas with inflammatory bowel disease (IBD) and those without, hypothesizing significant differences in HRQOL scores between these groups. The secondary objectives were to identify specific aspects of life quality most affected and explore potential variables influencing HRQOL. The study was conducted at the Clinical Emergency Hospital "Pius Brinzeu" in Timisoara, Romania, using a convenience sample of 175 adult patients diagnosed with anal fistulas, stratified into IBD and non-IBD groups. Quality of life was evaluated at initial hospital admission and three months post-treatment using four questionnaires: SF-36, GIQLI, HADS, and the WHOQOL-BREF. Initial SF-36 scores were marginally lower in the IBD group, with mean physical and mental scores of 52.0 and 54.5, respectively. Both groups showed an improvement after intervention, but the mean difference was higher in the IBD group, with an increase of 1.1 in physical score. Initial GIQLI scores were significantly lower in the IBD group (110) compared to the non-IBD group (116). Post-intervention, the mean scores increased to 116 and 121, respectively. HADS scores suggested higher anxiety levels in the non-IBD group (7.5 vs. 6.1), although depression scores were similar. Post-intervention, anxiety scores decreased more substantially in the non-IBD group (-0.9 vs. -0.3). The WHOQOL-BREF scores were lower across all domains for the IBD group at the initial test (physical health: 12.4, psychological health: 14.9, social relationships: 14.4, environment: 13.0). Post-intervention, scores increased marginally in the IBD group (physical health: 12.7, psychological health: 15.9, social relationships: 14.1, environment: 13.8) but varied in the non-IBD group. HRQOL, as measured by multiple questionnaires, is impacted differently in anal fistula patients with and without IBD. These findings highlight the importance of a tailored approach to managing this patient population to improve their quality of life post-treatment.
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Affiliation(s)
- Tudor Mateescu
- Department of General Surgery, “Victor Babes” University of Medicine and Pharmacy, Eftimie Murgu Square 2, 300041 Timisoara, Romania; (T.M.); (L.F.); (G.N.); (A.D.)
- Doctoral School, “Victor Babes” University of Medicine and Pharmacy, Eftimie Murgu Square 2, 300041 Timisoara, Romania
| | - Lazar Fulger
- Department of General Surgery, “Victor Babes” University of Medicine and Pharmacy, Eftimie Murgu Square 2, 300041 Timisoara, Romania; (T.M.); (L.F.); (G.N.); (A.D.)
| | - Durganjali Tummala
- Department of General Medicine, K.S. Hegde Medical Academy, Nityanandanagar, Deralakatte, Mangaluru 575018, India;
| | - Aditya Nelluri
- School of General Medicine, Sri Siddhartha Medical College, Tumakuru 572107, India
| | - Manaswini Kakarla
- Kamineni Institute of Medical Sciences, School of Medicine, Hyderabad 500001, India
| | - Lavinia Stelea
- Department of Obstetrics and Gynecology, “Victor Babes” University of Medicine and Pharmacy, Eftimie Murgu Square 2, 300041 Timisoara, Romania;
| | - Catalin Dumitru
- Department of Obstetrics and Gynecology, “Victor Babes” University of Medicine and Pharmacy, Eftimie Murgu Square 2, 300041 Timisoara, Romania;
| | - George Noditi
- Department of General Surgery, “Victor Babes” University of Medicine and Pharmacy, Eftimie Murgu Square 2, 300041 Timisoara, Romania; (T.M.); (L.F.); (G.N.); (A.D.)
| | - Amadeus Dobrescu
- Department of General Surgery, “Victor Babes” University of Medicine and Pharmacy, Eftimie Murgu Square 2, 300041 Timisoara, Romania; (T.M.); (L.F.); (G.N.); (A.D.)
| | - Cristian Paleru
- Department of Thoracic Surgery, “Carol Davila” University of Medicine and Pharmacy, Bulevardul Eroii Sanitari 8, 050474 Bucuresti, Romania;
| | - Ana-Olivia Toma
- Department of Dermatology, “Victor Babes” University of Medicine and Pharmacy, Eftimie Murgu Square 2, 300041 Timisoara, Romania
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Garg P. Newer procedures need to demonstrate efficacy in high complex anal fistulas. Ann Coloproctol 2023; 39:371-372. [PMID: 36918404 PMCID: PMC10475806 DOI: 10.3393/ac.2022.01109.0158] [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: 12/09/2022] [Revised: 12/30/2022] [Accepted: 01/01/2023] [Indexed: 03/16/2023] Open
Affiliation(s)
- Pankaj Garg
- Department of Colorectal Surgery, Garg Fistula Research Institute, Panchkula, 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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Perianal fistulas: A review with emphasis on preoperative imaging. Adv Med Sci 2022; 67:114-122. [PMID: 35134600 DOI: 10.1016/j.advms.2022.01.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2021] [Revised: 11/24/2021] [Accepted: 01/14/2022] [Indexed: 02/06/2023]
Abstract
PURPOSE We aim to present a comprehensive literature review which focuses on the preoperative imaging of perianal fistulas. MATERIAL/METHODS Pelvic magnetic resonance imaging (MRI) and endoanal ultrasound (EAUS) are the two first-line imaging modalities for the preoperative evaluation of patients with perianal fistulas. We conducted a search in PubMed, Scopus and Google Scholar concerning articles comparing pelvic MRI with EAUS, which were published from 1994 until 2019. RESULTS In most articles, pelvic MRI is superior to EAUS for the evaluation of perianal fistulas (especially for supralevator and extrasphincteric ones). Preoperative pelvic MRI is associated with statistically significant better results and prognosis after surgical treatment of the disease. Preoperative EAUS poses high sensitivity and specificity in identifying intersphincteric and transsphincteric perianal fistulas, as well as the internal opening of a fistula-in-ano. There is only one meta-analysis which compares the diagnostic accuracy of the two mentioned imaging modalities in preoperative fistula detection. Sensitivity of both - pelvic MRI and EAUS, is acceptably high (0.87). Specificity of pelvic MRI is 0.69 in comparison to EAUS (0.43), but both values are considered low. CONCLUSIONS Future well-designed prospective studies are needed to investigate the diagnostic accuracy of pelvic MRI and EAUS in the preoperative assessment of patients with perianal fistulas. Moreover, the combination of pelvic MRI and EAUS should also be studied, since several published articles suggest that it could lead to improved diagnostic accuracy. A novel treatment algorithm for perianal fistulas could arise from this study.
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Increased Risk of Bleeding with Topical Metronidazole in a Postoperative Wound after Anal Fistula and Hemorrhoid Surgery: A Propensity Score-Matched Case–Control Study. Clin Pract 2022; 12:133-139. [PMID: 35200268 PMCID: PMC8870643 DOI: 10.3390/clinpract12010017] [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: 12/10/2021] [Revised: 01/24/2022] [Accepted: 02/15/2022] [Indexed: 02/05/2023] Open
Abstract
Background: Topical metronidazole (TM) is commonly used in many infective conditions and postoperative wounds including after anorectal surgery. TM was prescribed in patients operated for benign anorectal conditions (anal fistula and hemorrhoids) to hasten wound healing. After the initiation of this protocol, the incidence of postoperative wound bleeding seemed to increase. There are no data in the literature suggesting that topical metronidazole increases the risk of bleeding. Objective: Analysis of the association of TM with an increased risk of bleeding in postoperative anorectal wounds. Design: This was an observational and a retrospective study. Propensity score matching was performed. Setting: This study was conducted at a specialized center for anorectal disorders in postoperative patients suffering from anal fistula and hemorrhoids. Materials: The incidence of postoperative bleeding in the patients in whom TM was used (study group) was retrospectively compared with the patients operated one year before this period in whom TM was not used (control group). Sample size: There were 35 patients in the study group and 181 patients in the control group. Main outcome measures: The incidence of bleeding and the number of bleeding episodes were evaluated. Results: The incidence of bleeding was significantly higher in the study group as compared to the control group (8/35 (22.8%) vs. 8/181 (4.4%), respectively, p = 0.0011). In most cases, bleeding was controlled with conservative measures. The number of bleeding episodes was also significantly higher in the study group (14 vs. 11, respectively, p = 0.0001). The number of patients requiring operative intervention was also higher in the study group (2/35—5.7%) as compared to the control group (1/181—0.56%), but this was not statistically significant (p = 0.069). Conclusions: The study highlighted that application of topical metronidazole in postoperative anorectal wounds increased the risk of bleeding. Most of the bleeding episodes were controlled with conservative measures but they caused considerable patient anxiety and apprehension.
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Dawka S, Yagnik VD. Comparison Between the Modified Parks and Garg Classifications of Cryptoglandular Anal Fistulas. Dis Colon Rectum 2021; 64:e589. [PMID: 34310514 DOI: 10.1097/dcr.0000000000002208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
| | - Vipul D Yagnik
- Nishtha Surgical Hospital and Research Centre, Patan, Gujarat, India
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Garg P, Goyal A, Yagnik VD, Dawka S, Menon GR. Diagnosis of anorectal tuberculosis by polymerase chain reaction, GeneXpert and histopathology in 1336 samples in 776 anal fistula patients. World J Gastrointest Surg 2021; 13:355-365. [PMID: 33968302 PMCID: PMC8069068 DOI: 10.4240/wjgs.v13.i4.355] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Revised: 02/11/2021] [Accepted: 04/14/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND The association of tuberculosis (TB) with anal fistulas can make its treatment quite difficult. The main challenge is timely detection of TB in anal fistulas and its proper management. There is little data available on diagnosis and management of TB in anal fistulas.
AIM To detect TB in fistula-in-ano patients were analyzed in different methods utilized.
METHODS A retrospective analysis of different methods, polymerase chain-reaction (PCR), GeneXpert and histopathology (HPE), utilized to detect tuberculosis in fistula-in-ano patients, treated between 2014-2020, was performed. The sampling was done for tissue (fistula tract lining) and pus (when available). The detection rate of various tests to detect TB and prevalence rate of TB in simple vs complex fistulae were studied.
RESULTS In 1336 samples (776 patients) tested, TB was detected in 133 samples (122 patients). TB was detected in 52/703 (7.4%) samples tested by PCR-tissue, in 77/331 (23.2%) samples tested by PCR-pus, 3/197 (1.5%) samples tested with HPE-tissue and 1/105 (0.9%) samples tested by GeneXpert. To detect TB, PCR-tissue was significantly better than HPE-tissue (52/703 vs 3/197 respectively) (P = 0.0012, significant, Fisher’s exact test) and PCR-pus was significantly better than PCR-tissue (77/331 vs 52/703 respectively) (P < 0.00001, significant, Fisher’s exact test). TB fistulas were more complex than non-tuberculous fistulas [78/113 (69%) vs 278/727 (44.3%) respectively] (P < 0.00001, significant, Fisher’s exact test) but the overall healing rate was similar in tuberculous and non-tuberculous fistula groups [90/102 (88.2%) vs 518/556 (93.2%) respectively] (P = 0.10, not significant, Fisher’s exact test).
CONCLUSION This is the largest study of anorectal TB to be published. The detection of TB by polymerase chain-reaction was significantly higher than by histopathology and GeneXpert. Amongst polymerase chain-reaction, pus had a higher detection rate than tissue. TB fistulas were more complex than non-tuberculous fistulas but aggressive diagnosis and meticulous treatment led to comparable overall success rates in both groups.
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Affiliation(s)
- Pankaj Garg
- Department of Colorectal Surgery, Indus International Hospital, Mohali 140507, Punjab, India
- Department of Colorectal Surgery, Garg Fistula Research Institute, Panchkula 134113, Haryana, India
| | - Ankita Goyal
- Department of Pathology, Gian Sagar Medical College and Hospital, Patiala 140506, Punjab, India
| | - Vipul D Yagnik
- Department of Surgery, Nishtha Surgical Hospital and Research Centre, Patan 384265, Gujarat, India
| | - Sushil Dawka
- Department of Surgery, SSR Medical College, Belle Rive, Mauritius
| | - Geetha R Menon
- Department of Statistics, Indian Council of Medical Research, New Delhi 110029, India
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Garg P, Sodhi SS, Garg N. Management of Complex Cryptoglandular Anal Fistula: Challenges and Solutions. Clin Exp Gastroenterol 2020; 13:555-567. [PMID: 33204136 PMCID: PMC7667587 DOI: 10.2147/ceg.s198796] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2020] [Accepted: 10/15/2020] [Indexed: 12/16/2022] Open
Abstract
Anal fistulae can be a very difficult disease to manage. The management of complex fistulae is even more challenging. The risk to the fecal continence mechanism due to damage to the anal sphincters and refractoriness to the treatment (high recurrence rate) pose the two biggest challenges in the management of this disease. Apart from these, there are several other challenges in the treatment of complex fistulae. The intriguing and uphill task is that satisfactory solutions to most of these challenges are still not known, and there is hardly any consensus on whatever treatment solutions are available. To summarize, there is no gold-standard treatment available for treating complex anal fistulae, and the search for a satisfactory treatment option is still on. In this review, the endeavor has been to discuss and highlight recent path-breaking updates in the management of complex anal fistulae.
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Affiliation(s)
- Pankaj Garg
- Department of Colorectal Surgery, Garg Fistula Research Institute, Panchkula, Haryana, India
| | - Sohail Singh Sodhi
- Department of General Surgery, Dayanand Medical College and Hospital, Ludhiana, Punjab, India
| | - Navdeep Garg
- Department of General Surgery, Government Medical College and Hospital, Chandigarh, India
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