1
|
Khamar J, Sachdeva A, McKechnie T, Lee Y, Tessier L, Hong D, Eskicioglu C. Cutting seton for the treatment of cryptoglandular fistula-in-ano: a systematic review and meta-analysis. Tech Coloproctol 2023; 28:12. [PMID: 38091125 DOI: 10.1007/s10151-023-02886-z] [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: 08/27/2023] [Accepted: 10/21/2023] [Indexed: 12/18/2023]
Abstract
BACKGROUND The use of cutting seton (CS) for the management of cryptoglandular fistula-in-ano has remained controversial because of reports of fecal incontinence, postoperative pain, and extended healing time. The aim of this review was to provide the first synthesis of studies investigating the use of CS for the treatment of cryptoglandular fistula-in-ano. METHODS MEDLINE, Embase, and CENTRAL were searched up to October 2022. Randomized controlled trials and observational studies comparing CS with alternative interventions were included, along with single-arm studies evaluating CS alone. The primary outcome was fistula-in-ano recurrence, and secondary outcomes included incontinence, healing time, proportion with complete healing, and postoperative pain. Inverse variance random-effects meta-analyses were used to pool effect estimates. RESULTS After screening 661 citations, 29 studies were included. Overall, 1513 patients undergoing CS (18.8% female, mean age: 43.1 years) were included. Patients with CS had a 6% (95% CI: 3-12%) risk of recurrence and a 16% (95% CI: 5-38%) risk of incontinence at 6 months. CS patients had an average healing time of 14.6 weeks (95% CI: 10-19 weeks) with 73% (95% CI: 48-89%) of patients achieving complete healing at 6 months postoperatively. There was no difference in recurrence between CS and fistulotomy, advancement flap, two-stage seton fistulotomy, or draining seton. CONCLUSIONS Overall, this analysis shows that CS has comparable recurrence and incontinence rates to other modalities. However, this may be at the expense of more postoperative pain and extended healing time. Further comparative studies between CS and other modalities are warranted.
Collapse
Affiliation(s)
- J Khamar
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada
| | - A Sachdeva
- Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - T McKechnie
- Division of General Surgery, Department of Surgery, McMaster University, St. Joseph's Healthcare, 50 Charlton Avenue East, Hamilton, ON, L8N 4A6, Canada
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - Y Lee
- Division of General Surgery, Department of Surgery, McMaster University, St. Joseph's Healthcare, 50 Charlton Avenue East, Hamilton, ON, L8N 4A6, Canada
- Harvard T.H. Chan School of Public Health, Harvard University, Boston, MA, USA
| | - L Tessier
- Division of General Surgery, Department of Surgery, McMaster University, St. Joseph's Healthcare, 50 Charlton Avenue East, Hamilton, ON, L8N 4A6, Canada
| | - D Hong
- Division of General Surgery, Department of Surgery, McMaster University, St. Joseph's Healthcare, 50 Charlton Avenue East, Hamilton, ON, L8N 4A6, Canada
- Division of General Surgery, Department of Surgery, St. Joseph's Healthcare, Hamilton, ON, Canada
| | - C Eskicioglu
- Division of General Surgery, Department of Surgery, McMaster University, St. Joseph's Healthcare, 50 Charlton Avenue East, Hamilton, ON, L8N 4A6, Canada.
- Division of General Surgery, Department of Surgery, St. Joseph's Healthcare, Hamilton, ON, Canada.
| |
Collapse
|
2
|
Ambulatory seton placement followed by fistulotomy: efficacy and safety for perianal fistula treatment. Eur J Gastroenterol Hepatol 2021; 33:956-960. [PMID: 32925500 DOI: 10.1097/meg.0000000000001913] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
PURPOSE To evaluate the efficacy and safety of ambulatory seton placement followed by superficial fistulotomy as treatment of perianal fistula. METHODS Retrospective observational analysis of patients with cryptogenic perianal fistula aged 18-90 years, followed in a central hospital proctology consultation between 2006 and 2017. Data were obtained through clinical record's analysis. Fistula was characterized, using Parks Classification. A probe was passed through the fistula tract, followed by a seton, which remained in situ until superficial fistulotomy was possible. RESULTS Ninety-six patients were included (66.67% males, mean age 56 ± 15 years old). Nineteen patients (19.89%) had previous history of perianal fistula and 14 (14.58%) previous anorectal surgery. Seventy-four patients (78.72%) were submitted to fistulotomy, three (3.19%) had seton fistulotomy and one had no seton progression. Intention-to-treat and per-protocol efficacy analyses were 80.2 and 98.7%, respectively. Among the 74 patients who completed the procedure, type of fistula and time with seton were distributed as followed: 47 (63.51%) intersphincteric fistula (15 ± 31 weeks), 26 (35.14%) transsphincteric fistula (32 ± 47 weeks), one (1.35%) suprasphincteric fistula (11 weeks). Previous fistula was associated with a longer time with seton (P = 0.018). Incontinence was reported in two (2.7%) patients, who had previous perianal fistula or anorectal surgery. Two patients (2.7%) had recurrence after fistulotomy. CONCLUSION Placement of seton followed by superficial fistulotomy in an ambulatory setting is a safe and effective method for simple low perianal fistula treatment. Incontinence rate may be higher in patients with previous perianal fistula or anorectal surgery.
Collapse
|
3
|
Villiger R, Cabalzar-Wondberg D, Zeller D, Frei P, Biedermann L, Schneider C, Scharl M, Rogler G, Turina M, Rickenbacher A, Misselwitz B. Perianal fistulodesis – A pilot study of a novel minimally invasive surgical and medical approach for closure of perianal fistulae. World J Gastrointest Surg 2021; 13:187-197. [PMID: 33643538 PMCID: PMC7898183 DOI: 10.4240/wjgs.v13.i2.187] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Revised: 11/20/2020] [Accepted: 12/23/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Perianal fistulae strongly impact on quality of life of affected patients.
AIM To challenge and novel minimally invasive treatment options are needed.
METHODS Patients with Crohn’s disease (CD) in remission and patients without inflammatory bowel disease (non-IBD patients) were treated with fistulodesis, a method including curettage of fistula tract, flushing with acetylcysteine and doxycycline, Z-suture of the inner fistula opening, fibrin glue instillation, and Z-suture of the outer fistula opening followed by post-operative antibiotic prophylaxis with ciprofloxacin and metronidazole for two weeks. Patients with a maximum of 2 fistula openings and no clinical or endosonographic signs of a complicated fistula were included. The primary end point was fistula healing, defined as macroscopic and clinical fistula closure and lack of patient reported fistula symptoms at 24 wk.
RESULTS Fistulodesis was performed in 17 non-IBD and 3 CD patients, with a total of 22 fistulae. After 24 wk, all fistulae were healed in 4 non-IBD and 2 CD patients (overall 30%) and fistula remained closed until the end of follow-up at 10-25 mo. In a secondary per-fistula analysis, 7 out of 22 fistulae (32%) were closed. Perianal disease activity index (PDAI) improved in patients with fistula healing. Low PDAI was associated with favorable outcome (P = 0.0013). No serious adverse events were observed.
CONCLUSION Fistulodesis is feasible and safe for perianal fistula closure. Overall success rates is at 30% comparable to other similar techniques. A trend for better outcomes in patients with low PDAI needs to be confirmed.
Collapse
Affiliation(s)
- Roxanne Villiger
- Department of Gastroenterology and Hepatology, University Hospital of Zurich, Zurich 8091, Switzerland
| | | | - Daniela Zeller
- Department of Surgery, Zeller Surgery, Zurich 8008, Switzerland
| | - Pascal Frei
- Department of Gastroenterology and Hepatology, University Hospital of Zurich, Zurich 8091, Switzerland
| | - Luc Biedermann
- Department of Gastroenterology and Hepatology, University Hospital of Zurich, Zurich 8091, Switzerland
| | - Christian Schneider
- Department of Gastroenterology and Hepatology, University Hospital of Zurich, Zurich 8091, Switzerland
| | - Michael Scharl
- Department of Gastroenterology, University Hospital of Zurich, Zurich 8091, Switzerland
| | - Gerhard Rogler
- Department of Gastroenterology and Hepatology, University Hospital of Zurich, Zurich 8091, Switzerland
| | - Matthias Turina
- Visceral- and Transplant Surgery, University Hospital of Zurich, Zurich 8091, Switzerland
| | - Andreas Rickenbacher
- Visceral- and Transplant Surgery, University Hospital of Zurich, Zurich 8091, Switzerland
| | - Benjamin Misselwitz
- Department of Gastroenterology and Hepatology, University Hospital of Zurich, Zurich 8091, Switzerland
- Visceral Surgery and Medicine, University Hospital of Bern, Bern 3010, Switzerland
| |
Collapse
|
4
|
Ding W, Sun YR, Wu ZJ. Treatment of Perianal Abscess and Fistula in Infants and Young Children: From Basic Etiology to Clinical Features. Am Surg 2020; 87:927-932. [PMID: 33284051 DOI: 10.1177/0003134820954829] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
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.
Collapse
Affiliation(s)
- Wei Ding
- North Sichuan Medical College, Nanchong, China
| | - Yao-Ran Sun
- North Sichuan Medical College, Nanchong, China
| | - Zhi-Jiu Wu
- Department of Anorectal, 117913The Affiliated Hospital of North Sichuan Medical College, Nanchong, China
| |
Collapse
|
5
|
Frountzas M, Stergios K, Nikolaou C, Bellos I, Schizas D, Linardoutsos D, Kontzoglou K, Vaos G, Williams AB, Toutouzas K. Could FiLaC™ be effective in the treatment of anal fistulas? A systematic review of observational studies and proportional meta-analysis. Colorectal Dis 2020; 22:1874-1884. [PMID: 32445614 DOI: 10.1111/codi.15148] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2020] [Accepted: 04/30/2020] [Indexed: 02/08/2023]
Abstract
AIM Fistula Laser Closure (FiLaC™) is a novel sphincter-preserving technique that is based on new technologies and shows promising results in repairing anal fistulas whilst maintaining external sphincter function. The aim of the present meta-analysis is to present the efficacy and the safety of FiLaC™ in the management of anal fistula disease. METHOD The present proportional meta-analysis was designed using the PRISMA and AMSTAR guidelines. We searched MEDLINE, Scopus, clinicaltrials.gov, Embase, Cochrane Central Register of Controlled Trials CENTRAL and Google Scholar databases from inception until November 2019. RESULTS Overall, eight studies were included that recruited 476 patients. The pooled success rate of the technique was 63% (95% CI 50%-75%). The pooled complication rate was 8% (95% CI 1%-18%). Sixty-six per cent of patients had a transsphincteric fistula and 60% had undergone a previous surgical intervention, mainly the insertion of a seton (54%). The majority had a cryptoglandular fistula. Operation time and follow-up period were described for each study. CONCLUSION FiLaC™ seems to be an efficient therapeutic option for perianal fistula disease with an adequate level of safety that preserves quality of life. Nevertheless, randomized trials need to be designed to compare FiLaC™ with other procedures for the management of anal fistulas such as ligation of intersphincteric fistula tract, anal advancement flaps, fibrin glue, collagen paste, autologous adipose tissue, fistula plug and video-assisted anal fistula treatment.
Collapse
Affiliation(s)
- M Frountzas
- Laboratory of Experimental Surgery and Surgical Research, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece.,First Propaedeutic Department of Surgery, School of Medicine, Hippocration General Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - K Stergios
- Laboratory of Experimental Surgery and Surgical Research, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - C Nikolaou
- Laboratory of Experimental Surgery and Surgical Research, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - I Bellos
- Laboratory of Experimental Surgery and Surgical Research, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - D Schizas
- First Department of Surgery, School of Medicine, Laikon General Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - D Linardoutsos
- First Propaedeutic Department of Surgery, School of Medicine, Hippocration General Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - K Kontzoglou
- Laboratory of Experimental Surgery and Surgical Research, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - G Vaos
- Department of Paediatric Surgery, School of Medicine, Attikon University General Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - A B Williams
- Department of Colorectal Surgery, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - K Toutouzas
- First Propaedeutic Department of Surgery, School of Medicine, Hippocration General Hospital, National and Kapodistrian University of Athens, Athens, Greece
| |
Collapse
|
6
|
Dong X, Jia Z, Yu B, Zhang X, Xu F, Tan L. Effect of intersphincteric fistula tract ligation versus anal fistulectomy on pain scores and serum levels of vascular endothelial growth factor and interleukin-2 in patients with simple anal fistulas. J Int Med Res 2020; 48:300060520949072. [PMID: 32967495 PMCID: PMC7521059 DOI: 10.1177/0300060520949072] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2019] [Accepted: 07/21/2020] [Indexed: 12/29/2022] Open
Abstract
OBJECTIVE This study was performed to explore the effects of ligation of the intersphincteric fistula tract (LIFT) on pain scores and serum levels of vascular endothelial growth factor (VEGF) and interleukin (IL)-2 in patients with simple anal fistulas. METHODS Ninety patients with simple anal fistulas were evenly randomized into a study group (treated with LIFT) and a control group (treated with traditional anal fistulectomy) according to a random number table. The surgical outcomes, basic operation conditions (operation time, hospital stay, and anal continence), and postoperative wound healing rates were compared between the two groups. RESULTS The study group had significantly better operation conditions (better anal continence and shorter length of hospital stay), a higher postoperative wound healing rate, lower pain scores, higher VEGF and IL-2 levels, and higher overall efficacy rate than the control group. However, the incidence of postoperative complications was not significantly different between the two groups. CONCLUSIONS Patients who underwent LIFT had better surgical outcomes, higher wound healing rates, better anal continence, a shorter length of hospital stay, and less severe postoperative pain than those who underwent simple anal fistulectomy. Increased levels of VEGF and IL-2 after surgery may promote wound healing.
Collapse
Affiliation(s)
| | - Zhanbo Jia
- Zhanbo Jia, Anorectal Department, Dongying People’s Hospital, No. 317 Nanyi Road, Dongying District, Dongying City, Shandong Province 257091, China.
| | - Bianfang Yu
- Anorectal Department, Dongying People’s Hospital, Dongying, Shandong, China
| | - Xuebin Zhang
- Anorectal Department, Dongying People’s Hospital, Dongying, Shandong, China
| | - Fagang Xu
- Anorectal Department, Dongying People’s Hospital, Dongying, Shandong, China
| | - Longtao Tan
- Anorectal Department, Dongying People’s Hospital, Dongying, Shandong, China
| |
Collapse
|
7
|
Tantiphlachiva K, Sahakitrungruang C, Pattanaarun J, Rojanasakul A. Effects of preoperative endoanal ultrasound on functional outcome after anal fistula surgery. BMJ Open Gastroenterol 2019; 6:e000279. [PMID: 31139426 PMCID: PMC6506025 DOI: 10.1136/bmjgast-2019-000279] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2019] [Revised: 02/17/2019] [Accepted: 02/23/2019] [Indexed: 12/12/2022] Open
Abstract
Objective Endoanal ultrasound (EAUS) is a recommended preoperative investigation for fistula-in-ano (FiA) which aims to provide the best chance of healing and preservation of continence function. This study aims are (1) to assess effect of EAUS on functional outcome and (2) to determine factors associated with clinical outcomes after FiA surgery. Design Retrospective analysis of subjects with cryptogenic FiA between January 2011 and December 2016, in a tertiary hospital, was performed by comparing EAUS and no-EAUS groups. Postoperative change in St. Mark’s faecal incontinence severity score (cFISS=FISS at 6 months after surgery–FISS before surgery) were compared. General linear model was used to determine factors associated with cFISS. Binary logistic regression was used to assess factors related to clinical outcomes. A p-value of <0.05 is considered significant. Results We enrolled 339 subjects; 109 (M:F 91:18, mean age 41.7±13.6 years) of 115 in EAUS group and 230 in no-EAUS group (M:F 195:35, mean age 42.6±13.0 years). There were higher proportions of recurrent cases (24.8% vs 13.9%, p=0.014) and complex FiA (80.7% vs 50.4%, p=0.001) in EAUS group. Postoperative FISS (mean±SE) were increased in both groups; preoperative versus postoperative FISS were 0.36±0.20 versus 0.59±0.25 in EAUS group (p=0.056) and 0.31±0.12 versus 0.76±0.17 in no-EAUS group (p<0.001). EAUS had significant effects on cFISS in both univariate analysis, F(1,261)=4.053, p=0.045; and multivariate analysis, F(3,322)=3.147, p=0.025, Wilk’s Lambda 0.972. Other associated factors included recurrent fistula (F(3,322)=0.777, p=0.007, Wilk’s Lambda 0.993) and fistula classification (F(3,322)=16.978, p<0.001, Wilk’s Lambda 0.863). After a mean follow-up of 33.6±28.6 weeks, success rate was 63.3%(EAUS) and 60% (no-EAUS), p=0.822. Factors associated with clinical outcomes were fistula complexity, number of tracts, recurrence, number of previous surgery and type of operations. Accuracy of EAUS was 90.8% and not related to clinical outcomes (p=0.522). Conclusion EAUS had favourable effects on functional outcome after FiA surgery while multiple factors were associated with clinical outcomes. EAUS is useful, accurate, inexpensive and can be the first tool for planning of complex and recurrent FiA.
Collapse
|
8
|
Abstract
Pediatric anal fistulae commonly result from recurrent perianal abscesses, of which nearly 50 per cent develop an anal fistula. The purpose of this study was to report the results of using fibrin glue to treat anal fistula in pediatric patients. Infants and children with recurrent perianal abscesses and anal fistulae were treated with either fistulectomy or fibrin glue. Demographic and clinical characteristics and outcomes were compared between the groups. A total of 34 children were included; 27 received fistulectomy (median age eight months) and seven received fibrin glue treatment (median age 14 months). No significant differences in demographic or clinical characteristics were found between the two groups (all, P > 0.05). Median follow-up duration was significantly higher in the fibrin glue group compared with that in the fistulectomy group (five months vs one month, P = 0.003). There was one recurrence in the fistulectomy group, and no recurrences in the fibrin glue group (P = 1.0). No complications occurred in either group. Fibrin glue treatment is a simple and effective treatment alternative in the management of anal fistula in children, offering the advantage of sphincter muscle-sparing and reduced risk of fecal incontinence.
Collapse
Affiliation(s)
- Fan-Ting Liao
- School of Medicine, Fu-Jen Catholic University, New Taipei City, Taiwan
| | - Chi-Jen Chang
- School of Medicine, Fu-Jen Catholic University, New Taipei City, Taiwan
- Division of Pediatric Surgery, Department of Surgery, Shin-Kong Wu Ho-Su Memorial Hospital, Taipei City, Taiwan
| |
Collapse
|
9
|
Abstract
BACKGROUND The ideal management for fistula-in-ano would resolve the disease while preserving anal continence. OBJECTIVE The purpose of this study was to determine the efficacy of draining seton alone in achieving resolution or significant amelioration of symptoms for patients with fistula-in-ano. DESIGN This was a retrospective case series involving chart review and telephone interviews. A single colorectal surgeon performed surgeries between June 1, 2005, and June 30, 2014. SETTINGS The study was conducted by a single surgeon in a large urban city. PATIENTS Patient ≥18 years of age presenting with fistula-in-ano of cryptoglandular origin were included. MAIN OUTCOME MEASURES Resolution of symptoms or significant symptom improvement requiring no additional surgical management and rate of recurrence were measured. RESULTS A total of 76 patients (53 men) met the inclusion criteria. Mean age was 45 years (range, 19-73 y). The average time to seton removal was 36.6 weeks (range, 6.0-188.0 wk). Mean follow-up was 63 months (range, 7-121 mo). Fifty-seven patients (75%) were reached for telephone interview. Fifty-six patients (73.7%) had complete symptom resolution, and 14 (18.4%) had significant amelioration of symptoms with no additional surgical management required. Six (7.9%) had persistent severe symptoms. Five (7.1%) had a recurrence after seton removal. Rates of symptom resolution and recurrence were similar between patients whose setons were removed before or after 26 weeks (median time of seton removal) from the time of placement. Twenty-one patients (27.6%) required 1 or more additional operative procedures before planned seton removal to unroof a collection and/or replace the seton, and this represented the most significant risk factor for failure of resolution or improvement or recurrence (relative risk = 7.0). LIMITATIONS This study was retrospective and represents a single surgeon experience. CONCLUSIONS Placement of draining seton alone is a viable treatment option for definitive symptomatic management of fistula-in-ano. Because draining setons are sphincter and function preserving, their use should be considered as primary management for fistula-in-ano. See Video Abstract at http://links.lww.com/DCR/A552.
Collapse
|