Anorectal infection: abscess-fistula

Hydrogen peroxide-enhanced magnetic resonance imaging: A novel approach for diagnosing anorectal-fistula

In this editorial, a commentary on the article by Chang et al has been provided, the course of treatment of anorectal fistulas, especially complex and recurring ones, require accurate diagnostic procedures for determining ideal surgical procedures. Conventional ways of imaging sometimes fall short, offering insufficient insights in aggravated instances. In this editorial, a novel application of hydrogen peroxide-enhanced magnetic resonance imaging (HP-MRI) that promises significant improvements in the imaging of anorectal fistula. Study is based on a retrospective investigation of 60 patients, contrasts the new HP-MRI with conventional diagnostic techniques such as physical examination, trans-perineal ultrasonography and poor spatial resolution MRI. The findings demonstrate HP-MRI's incredible diagnostic performance, with sensitivity and specificity rates of 96.08% and 90.91%, respectively, and unparalleled interobserver agreement (Kappa values ranging from 0.80 to 0.89). It has been a significant advancement for assessment of anorectal fistulas providing a better roadmap for surgical planning, lowering recurrence rates as well as reduced personal and financial burden on patients by reducing the need for repeated treatment and extended hospital stays. The remaining funds can be utilized for treatment of other medical need. Ultimately HP-MRI provides us a healthier & more efficient society by improvising patients well-being & optimized healthcare infrastructure.

Hydrogen peroxide-enhanced magnetic resonance imaging: A novel approach for diagnosing anorectal-fistula

In this editorial, a commentary on the article by Chang et al has been provided, the course of treatment of anorectal fistulas, especially complex and recurring ones, require accurate diagnostic procedures for determining ideal surgical procedures. Conventional ways of imaging sometimes fall short, offering insufficient insights in aggravated instances. In this editorial, a novel application of hydrogen peroxide-enhanced magnetic resonance imaging (HP-MRI) that promises significant improvements in the imaging of anorectal fistula. Study is based on a retrospective investigation of 60 patients, contrasts the new HP-MRI with conventional diagnostic techniques such as physical examination, trans-perineal ultrasonography and poor spatial resolution MRI. The findings demonstrate HP-MRI's incredible diagnostic performance, with sensitivity and specificity rates of 96.08% and 90.91%, respectively, and unparalleled interobserver agreement (Kappa values ranging from 0.80 to 0.89). It has been a significant advancement for assessment of anorectal fistulas providing a better roadmap for surgical planning, lowering recurrence rates as well as reduced personal and financial burden on patients by reducing the need for repeated treatment and extended hospital stays. The remaining funds can be utilized for treatment of other medical need. Ultimately HP-MRI provides us a healthier & more efficient society by improvising patients well-being & optimized healthcare infrastructure.

A systematic review and meta-analysis of the use of packing in the management of perianal abscesses

BACKGROUND

Perianal abscesses are common presentations and reasons for emergency general surgery admissions. Management involves incision and drainage of the abscess and packing the cavity with internal wound dressings. This meta-analysis aimed to assess in adults if packing an abscess or leaving it unpacked leads to a significant difference in the outcomes of pain on wound dressing, time to healing, rate of fistulation and abscess recurrence.

METHODS

Randomised controlled trials (RCTs) with participants aged 18 years or older that compared packing of perianal abscess cavities with no packing between 2002 and 2022 were searched for in December 2022 on OVID Medline and Embase, the CENTRAL register of trials, PubMed and Google Scholar. Risk of bias was assessed using the Cochrane Risk of Bias tool. Random effects meta-analysis was conducted on the data extracted.

RESULTS

Three RCTs involving 490 patients were analysed for the outcomes of abscess recurrence and postoperative fistula formation; the data were not adequate to assess pain on dressing and time to healing. For unpacked versus packed, the pooled relative risk of abscess recurrence was 1.57 (95% confidence interval (CI) 0.764, 3.29, p=0.219) and for fistula formation 0.686 (95% CI 0.430, 1.09, p=0.114). These results suggest there is no significant benefit to packing abscess cavities.

CONCLUSIONS

Analysis of the outcomes suggests there is no significant difference with regards to rates of abscess recurrence or fistula formation between the packed and unpacked groups; however, appropriately powered RCTs are required in this area to provide more primary evidence to inform best practice and clinical management.

Sinus pilonidalis-elastic ligature as an optimal outpatient treatment

BACKGROUND

The incidence of pilonidal sinus shows a steadily rising tendency, especially in the patient age group of up to 40 years. Treatment of this condition is often protracted involving lengthy sick leave and an increased risk of recurrence. The optimal treatment of pilonidal sinus remains open to debate, but it should focus on decreasing the length of hospitalization, promoting a rapid return to daily life, maintaining low pain levels, and keeping costs at a minimum.

MATERIALS AND METHODS

In our study conducted between 2017 and 2021, we focused on treatment of pilonidal sinus. We performed 50 elastic ligature procedures with a median observation time of 30 months. The patients were divided into three groups according to the characteristics of pilonidal sinus: (1) acute primary abscess; (2) acute recurrent abscess; and (3) chronic fistula.

RESULTS

Out of a total of 50 patients with a subsequent 30-month follow-up, we observed complete recovery in 47 patients and recurrence in three patients. Return to work was possible immediately after the operation, with an average total treatment time of 1 month for complete healing of the defect.

CONCLUSION

The current results suggest that the technique of elastic ligature is a desirable solution for pilonidal sinus, because of the initial low costs, no need for hospitalization, and good patient tolerance.

Proposal for a new classification of anorectal abscesses based on clinical characteristics and postoperative recurrence

BACKGROUND

Current surgical procedures for anorectal abscesses, including incision and drainage alone or combined concurrent fistulotomy, remain controversial primarily due to the unpredictability of postoperative recurrence or the progression to anal fistula.

AIM

To evaluate factors that predict postoperative recurrence of anorectal abscesses and propose a new classification to guide surgical procedures.

METHODS

In this retrospective study, 525 patients with anorectal abscesses treated by incision and drainage alone, at a tertiary general hospital from August 2012 to July 2022, were included. A new classification for anorectal abscesses based on their propensity to develop into fistulas, considering 18 other potential risk factors, was established. These factors, from electronic medical records, were screened for significance using the χ² test and subsequently analyzed with multivariate logistic regression to evaluate their relationship with postoperative recurrence of anorectal abscesses.

RESULTS

One year post-follow-up, the overall recurrence rate was 39%:81.0% and 23.5% for fistula-prone and non-fistula-prone abscesses, respectively. Univariate χ² analysis showed significant differences in recurrence rates based on anatomical classifications and pus culture results (P < 0.05). Fistula-prone abscess, ≥ 7 days between symptom onset and surgery, chronic diarrhea, preoperative antibiotic use, and local anesthesia were risk factors for recurrence, while diabetes mellitus was protective (P < 0.05). Moreover, fistula-prone abscess [odds ratio (OR) = 7.651, 95%CI: 4.049-14.458, P < 0.001], ≥ 7 days from symptom onset to surgery (OR = 2.137, 95%CI: 1.090-4.190, P = 0.027), chronic diarrhea (OR = 2.508, 95%CI: 1.216-5.173, P = 0.013), and local anesthesia (OR = 2.308, 95%CI: 1.313-4.059, P = 0.004) were independent risk factors for postoperative anorectal abscess recurrence using multivariate logistic regression. Body mass index ≥ 28 (OR = 2.935, 95%CI: 1.203-7.165, P = 0.018) was an independent risk factor for postoperative recurrence of non-fistula-prone abscess.

CONCLUSION

The choice of surgical procedure for treating anorectal abscesses should follow this new classification. Prompt and thorough incision and drainage can significantly reduce postoperative recurrence.

Anorectal Abscess

Anorectal abscesses are a common colorectal emergency. The hallmark of treatment is obtaining source control while avoiding injury to the underlying sphincter complex. Understanding the anatomy of an anorectal abscess is critical to planning the appropriate drainage strategy and decreasing the risk of complex fistula formation. Use of antibiotics should be reserved for those with extensive cellulitis, signs of systemic infection, or patients who are immunocompromised. Whether antibiotics prevent future fistula formation is an area of active research. Primary fistulotomy at time of the index drainage is controversial; however, there may be situations where it is appropriate. It is important to counsel patients that after effective drainage of an anorectal abscess, they have a 30 to 50% chance of developing an anal fistula that will then require further treatment.

Efficacy and Efficiency of Cyanoacrylate Glue in Fistula-in-Ano

AIMS AND OBJECTIVE

Most research on fistula-in-ano (FIA) is being done to improve surgical outcomes and reduce complications. Cyanoacrylate glue (CAG) is one of the promising options. We evaluated the efficacy and efficiency of CAG in the treatment of FIA.

MATERIALS AND METHODS

A cohort of 30 patients were included who underwent treatment using CAG. Each patient followed up at one, three, and six months to evaluate improvement in pain, discomfort, and recurrence. Patients with recurrence were treated with fistulectomy.

RESULT

The mean age of the cohort was 48.2±14.5 years, with a male-to-female ratio of 6:1, having four diabetic patients. Inter-sphincteric (16.54%) and trans-sphincteric (13.43%) fistulae were more common than extra-sphincteric (1.4%) fistula. The efficacy of CAG was 73%, and the procedure was found efficient with significant improvement in discomfort (p-value: 0.017). The recurrence rate was 27%, which occurred more in diabetic patients (p-value: 0.001) and trans-sphincteric fistula (p-value: 0.035).  Conclusion: The CAG application is a simple and safe daycare procedure. However, the incidence of discharge and relief in pain was significantly less, but it cannot be advised to every patient of FIA. A young patient without comorbidities and with inter-sphincteric low fistula can best be treated by this method.

Does microbiology of perianal abscesses affect the length of hospital stay?

BACKGROUND

Perianal abscess is a common disease among adults, necessitating surgical drainage. We aimed to assess the role of microbiology and other factors in prolonged hospitalization of patients with perianal abscesses.

METHODS

This retrospective study included all patients aged 18 or older who underwent surgical incision and drainage for perianal abscess in a single medical center between 2016 and 2020. Data regarding demographics, bacteriological cultures, and length of hospital stay were collected via electronic patient charts. A prolonged hospital stay was defined as a LOS longer than 3 days.

RESULTS

A total of 791 patients were included, of which 77.5% were male, with a mean age of 43.2. Overall, 46.1% of patients had positive cultures, of which 69.9% were polymicrobial. The most common pathogen found in obtained cultures was Escherichia coli (69.9%), followed by streptococcus species (36.7%) and Bacteroides (26.0%). Females had a significantly longer hospital stay (p = 0.03). Prolonged hospital stay was associated with older age (p < 0.0001), female gender (p = 0.04), and positive cultures for Enterococcus (p = 0.02).

CONCLUSIONS

This study identified clinical and microbiological risk factors for prolonged hospitalization in patients with perianal abscesses. Further studies are needed to evaluate the association between specific pathogens and rates of complications.

Evaluating the efficacy of multi-incision and tube-dragging therapy combined with laser closure for high horseshoe-shaped anal fistula: Protocol of a prospective, randomized, controlled trial

INTRODUCTION

High horseshoe-shaped anal fistula (HHAF) is a complicated and challenging condition that presents considerable obstacles in treatment. We are presently investigating a novel surgical technique involving a combination of multi-incision and tube-dragging therapy, and laser closure (MITD-LaC) for the management of HHAF. Due to the current scarcity of rigorous evidence evaluating this approach, it is essential to perform a well-designed randomized controlled trial to compare the effectiveness of this new method with incision and thread-drawing therapy.

METHODS AND ANALYSIS

This trial is a prospective, randomized, controlled and interventional study. After preliminary screening of qualified outpatients, a total of 64 adult patients will be enrolled in the trial and randomly allocated to either the MITD-LaC group or the control group (n = 32 per group). These patients will receive either MITD-LaC or incision and thread-drawing therapy. The design aims to allow for a robust comparison between the two treatment modalities. The primary endpoint is the wound healing time, while secondary endpoints include postoperative anal pain at 1, 3, and 5 days (measured with visual analogue scale), fecal incontinence score within 30 days after operation (measured with Cleveland Clinic Florida incontinence score), and the occurrence of postoperative complications within 1 month after surgery, and quality of life up to six months postoperatively (evaluated by The Quality of Life in patients with Anal Fistula Questionnaire Score).

DISCUSSION

This study represents the first randomized controlled trial evaluating the short-term outcomes of MITD-LaC, thereby aiming to contribute high-quality evidence to guide clinical practice. Moreover, this trial incorporates comprehensive outcome measures assessing both subjective and objective dimensions. Because of this multidimensional assessment, MITD-LaC offers a promising potential for broader application in the treatment of HHAF. Consequently, obtaining more definitive and authoritative evidence through scientifically rigorous clinical trials is of utmost importance in further validating this treatment approach.

ETHICS AND DISSEMINATION

We have submitted the clinical study protocol to the Ethics Committee, and it has been approved under ethical approval number 2021-1036-111-01. The results of the trial will be disseminated through peer-reviewed academic journals and presentations at professional conferences.

REGISTRATION NUMBER

ChiCTR2100053556.

Role of prolonged packing in postoperative anorectal abscess management: a systematic review and meta-analysis

BACKGROUND

Prolonged packing of anorectal abscess cavities with internal dressings after incision and drainage is frequently used, but the efficacy of this practice remains controversial. Some studies highlight its use in hemostasis and preventing fistula and abscess recurrence, whereas others describe its economic burden and increase in pain. In this systematic review, we examine current evidence on the impact of packing after incision and drainage for anorectal abscesses.

METHODS

The medical librarian conducted a comprehensive literature search on January 5, 2023. We conducted the meta-analysis using RevMan 5.4.1 software with a Mantel-Haenszel random-effects model.

RESULTS

We identified 3 randomized controlled trials, comprising 490 patients. Of those, 241 patients (49%) received postoperative packing; most patients were male (n = 158, 65.6%), with a median age of 40.5 years and a follow-up of 6 months. Meta-analysis showed that prolonged wound packing was associated with delayed wound healing and increased pain, but no difference in abscess recurrence or fistula formation.

CONCLUSION

In this systematic review of current evidence highlighting the impact of packing after incision and drainage for anorectal abscesses, we found that the practice is not associated with significant differences in abscess recurrence and fistula formation, but is associated with increased postoperative pain and delayed wound healing.

Development of a new patient-reported outcome measure for complex cryptoglandular fistulas (20-Item complex cryptoglandular fistula questionnaire™): a qualitative study

BACKGROUND

There are limited tools to measure the burden of disease and effectiveness of medical/surgical interventions in patients with cryptoglandular fistulas. The aim of this study was to explore concepts that are relevant and important to patients with complex cryptoglandular fistulas (CCF) and to develop a patient-centred, disease-specific, patient-reported outcome measure (PROM) to assess symptom burden and impacts of CCF.

METHODS

A targeted literature review was conducted, followed by one-to-one telephone interviews with five colorectal surgeons (USA, n = 3; UK, n = 1; Spain, n = 1) and 20 US adult patients with CCF to inform the development of a conceptual model and a CCF-specific PROM. The targeted literature review informed the development of the preliminary conceptual model and identified a PROM in the literature that was used as a reference to generate the draft CCF-specific PROM. The colorectal surgeon interviews provided insights on the experience of patients with CCF to refine the conceptual model, formulate probing questions for use in patient interviews, and to develop the draft CCF-specific PROM. Patients' descriptions of their experiences with symptoms and the impacts on their lives and evaluation of the draft CCF-specific PROM in concept elicitation and cognitive interviews were used to develop the final conceptual model and final CCF-specific PROM.

RESULTS

Ten symptoms (odour, pain during bowel movement, abscess, post-operative pain, discharge/drainage/leakage, anal/perianal pain, inflammation/swelling, skin irritation, bleeding and itchiness) and 11 impacts (discomfort, inability to exercise, embarrassment, difficulty sitting, worry about disease, adapted life to maintain hygiene, negatively impacted social life/isolation, inability to perform daily activities, reduced interest in sex, negatively impacted intimate relationships and negatively impacted mood) were reported as most salient by patients. The patient experience, clinician perspective, and literature review provided input to item generation. Evaluation of relevance and patient understanding through cognitive interviews with patients provided evidence for the content validity of the new patient-reported outcome measure: the 20-item Complex Cryptoglandular Fistula Questionnaire™ (CCFQ-20™).

CONCLUSION

The CCFQ-20™ is a new clinician-guided, patient-validated, disease-specific patient-reported outcome measure that measures disease impact and quality of life in patients with CCF.

Current update on the role of endoanal ultrasound: a primer for radiologists

Endoanal ultrasound (EAUS) is a valuable imaging modality for the evaluation of anal and perianal pathologies. It provides detailed information about the anatomy and physiology of the anorectal region and has been used in pre-and post-operative settings of anorectal pathologies. EAUS is not only useful in the evaluation of benign pathologies but also in loco-regional staging of anal and rectal tumors. EAUS has several advantages over MRI, including reduced cost, better patient tolerance, and improved scope of application in patients with contraindications to MRI. Despite its benefits, EAUS is not widely performed in many centers across the globe. This article aims to educate radiologists, trainees, and surgeons about the indications, contraindications, patient preparation, imaging technique, and findings of EAUS. We will also highlight the technical difficulties, diagnostic challenges, and procedural complications encountered during EAUS, along with a comparative analysis of EAUS with other imaging approaches.

Causal relationship between obesity and anorectal abscess: a Mendelian randomization study

Background

Observational studies have indicated that obesity is a risk factor for anorectal abscess (ARB). However, it remains unclear whether a causal genetic relationship exists between obesity and ARB.

Methods

Univariate and multivariate Mendelian randomization (MR) were conducted using data from a large, published genome-wide association study (GWAS) of European ancestry to infer a causal relationship between obesity and ARB. Inverse variance weighted (IVW) analysis served as the primary analysis method, with results reported as odds ratios (OR).

Results

MR analysis revealed that body mass index (BMI) positively affects ARB (OR 1.974, 95% confidence interval (CI) 1.548-2.519, p = 4.34 × 10-8). The weighted median method (OR = 1.879, 95% CI 1.248-2.829, p = 0.002) and Bayesian model averaging (BMA) (OR = 1.88, 95% CI 1.477-2.392, p = 2.85 × 10-7) also demonstrated consistent results. Subsequently, the impact of several obesity-related characteristics on ARB was assessed. Body fat percentage (BF), whole body fat mass (FM), waist circumference (WC), and hip circumference (HC) were found to be causally associated with an increased risk of ARB. However, these associations vanished after adjusting for BMI effects.

Conclusion

The study confirms a positive causal effect of obesity on ARB, highlighting that reasonable weight control is an important strategy to reduce the incidence of ARB.

A Systematic Review and Meta-Analysis of Comparing Drainage Alone versus Drainage with Primary Fistula Treatment for the Perianal Abscess in Children

This systematic review and meta-analysis of nonrandomized studies (NRSs) aimed to evaluate the clinical efficacy and safety of two types of surgical interventions (respectively drainage alone and drainage with primary fistula treatment) for perianal abscesses (PAs) in children. Studies from 1992 to July 2022 were searched in 10 electronic databases. All relevant NRSs with available data which compared surgical drainage with or without primary fistula treatment were included. Patients with underlying diseases which led to abscess formation were excluded. The Newcastle-Ottawa Scale was used to assess the risk of bias and quality of the included studies. The outcomes were the healing rate, fistula formation rate, fecal incontinence, and wound healing duration. A total of 16 articles with 1,262 patients were considered suitable for the final meta-analysis. Primary fistula treatment was associated with a significantly higher healing rate when compared with incision and drainage alone (odds ratio [OR]: 5.76, 95% confidence interval [CI]: 4.04-8.22). This aggressive procedure for PA resulted in an 86% reduction in the fistula formation rate (OR: 0.14, 95% CI: 0.06-0.32). Limited data showed patients who underwent primary fistula treatment have a minor effect on postoperative fecal incontinence. Primary fistula treatment demonstrates a better clinical efficacy in promoting the healing rate and decreasing the formation of fistulas in PAs in children. The available evidence for a minor impact on anal function after this intervention is less strong.

Anal Cryptoglandular Suppuration: Evidence-Based Management

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.

Management of acute perianal abscess: is surgeon specialization associated with improved outcomes?

BACKGROUND

Acute surgical units (ASU) are increasingly being adopted and in our system are staffed by colorectal and non-colorectal general surgeons. This study aims to evaluate whether surgeon specialization was associated with improved outcomes in perianal abscess.

METHODS

Patients with perianal abscess admitted to the ASU between 2016 and 2020 were identified from a prospective database and their medical records reviewed. Patients with IBD, treatment for fistula-in-ano within the preceding year, or perianal sepsis of non-cryptoglandular origin were excluded. Patients admitted under an ASU colorectal (CR) consultant were compared with those under a non-CR general surgeon in a retrospective cohort study. Primary outcome was perianal abscess recurrence. For those without initial fistula, hazard of recurrent abscess or fistula was analysed. Multivariable Cox PH regression analysis was performed.

RESULTS

Four-hundred and eight patients were included (150 CR, 258 non-CR). The CR group more frequently had a fistula identified at index operation (34.0% versus 10.9%, P < 0.0001). However, Cox multivariable analysis found no difference in hazard of recurrent abscess between groups (HR 1.12, 95% CI 0.65-1.95, P = 0.681)). Abscess recurred in 18.7% CR and 15.5% non-CR. Subsequent fistula developed in 14.7% in both groups. For patients without initial fistula, there was no difference between groups in hazard of recurrent abscess or fistula (HR 1.18, 95% CI 0.69-2.01, P = 0.539).

CONCLUSION

Surgeon specialization was not associated with improved outcomes for ASU patients with perianal abscess, albeit with potential selection bias. CR surgeons were more proactive identifying fistulas; this raises the possibility that drainage alone may be adequate treatment.

Septic Pulmonary Embolism Secondary to Klebsiella Pneumonia Perianal Abscesses: A Case Report

Septic pulmonary embolism (SPE) represents the occurrence of septic thrombi in circulation, originating from an extrapulmonary infectious source. Perianal and perirectal abscesses are frequently encountered anorectal issues, often stemming from obstructed anal crypt glands, resulting in pus accumulation within the subcutaneous tissue and intersphincteric plane. Timely surgical drainage is essential upon diagnosis of anorectal abscesses. Adult males exhibit a twofold higher incidence of anorectal abscesses and fistulae compared to females, with common symptoms including excruciating anal or rectal pain. This case report details the presentation and management of a 42-year-old male patient afflicted by Klebsiella pneumonia perianal abscesses that led to SPE. The report underscores the importance of recognizing and treating anorectal abscesses promptly to avert potentially life-threatening complications such as sepsis and fistulae.

Efficacy of amoxicillin/clavulanic acid after surgical drainage of perianal abscess in the prevention of the development of anal fistula (PERIQxA study): study protocol for a multicenter randomized, double-blind clinical trial

BACKGROUND

Anorectal fistula, which is a relatively common pathology, is the chronic manifestation of the acute perirectal process that forms an anal abscess. The development of a fistula after incision and drainage of an anal abscess is seen in approximately 26-37%. Its treatment is a relevant topic, and the role of the use of antibiotic therapy in its prevention remains controversial, after the publication of several studies with contradictory results and several methodological limitations. Our hypothesis is that the combination of amoxicillin and clavulanic acid will reduce the incidence of anal fistula.

METHOD

The aim of this study is to evaluate the efficacy of antibiotherapy after surgical drainage of perianal abscess in the development of perianal fistula. The PERIQxA study is a multicenter, randomized, double-blind controlled trial. The study has been designed to include 286 adult patients who will be randomly (1:1) assigned to either the experimental (amoxicillin/clavulanic acid 875/125 mg TDS for 7 days) or the control arm (placebo). The primary outcome measure is the percentage of patients that develop perianal fistula after surgery and during follow-up (6 months).

DISCUSSION

This clinical trial is designed to evaluate the efficacy and safety of amoxicillin/clavulanic in the prevention of perianal fistula. The results of this study are expected to contribute to stablish the potential role of antibiotherapy in the therapeutics for anal abscess.

TRIAL REGISTRATION

EudraCT Number: 2021-003376-14. Registered on November 26, 2021.

Restricted cubic spline model analysis of the association between anal fistula and anorectal abscess incidence and body mass index

Objective

The epidemiological profile of anal fistula and anorectal abscess has not been well studied. Based on the results of a retrospective cross-sectional survey, we aimed to investigate the potential influential factors associated with anal fistula and anorectal abscess.

Methods

We conducted a retrospective analysis of outpatients who visited the proctology department at China-Japan Friendship Hospital between January 2017 and May 2022. A comprehensive questionnaire was designed to collect potential influential factors, and according to formal anorectal examination and the corresponding diagnostic criteria, all the participants were divided into patients with anal fistula or perianal abscess and healthy control group. Multiple logistic regression was used to identify factors in significant association with anal fistula and perianal abscess. Additionally, we combined restricted cubic spline regression to examine the dose-response relationship between factors and the risk of developing anal fistula or anorectal abscess.

Results

The present study included 1,223 participants, including 1,018 males and 206 females, with 275 anal fistulas, 184 anorectal abscesses, and 765 healthy controls. We found no statistically significant differences between patients and controls in basic information and preoperative assessment of life factors, except for body mass index. It was indicated that people with overweight or obesity were more prone to anal fistula (OR overweight = 1.35, 95% CI: 1.00-1.82, P = 0.047; OR obesity = 3.44, 95% CI: 2.26-5.26, P < 0.001) or anorectal abscess (OR overweight = 1.41, 95% CI: 1.00-1.99, P = 0.05; OR obesity: 2.24, 95% CI: 1.37-3.67, P = 0.001) than normal-weight individuals. The dose-response research indicated the J-shaped trend between the ascending BMI levels and the higher risk of suffering from anal fistula and anorectal abscess.

Conclusions

Our findings indicate that overweight and obesity are risk factors for anal fistula and anorectal abscess, which plays a role in the prevention of anorectal diseases. This provides some theoretical basis for clinicians to provide health education to their patients.

Contemporary management of anorectal fistula

Anorectal fistula is a common, chronic condition, and is primarily managed surgically. Herein, we provide a contemporary review of the relevant etiology and anatomy anorectal fistula, treatment recommendations that summarize relevant outcomes and alternative considerations, in particular when to refer to a fistula expert.

Fistula development after anal abscess drainage-a multicentre retrospective cohort study

PURPOSE

Anal abscesses are common and, despite correct treatment with surgical drainage, carry the risk of developing fistulas. Studies identifying risk factors for the development of anal fistulas are sparse. This study aimed to identify the risk factors for anal fistulas after anal abscess surgery.

METHODS

This was a multicentre, retrospective cohort study of patients undergoing acute surgery for anal abscesses in the Capital Region of Denmark between 2018 and 2019. The patients were identified using ICD-10 codes for anal abscesses. Predefined clinicopathological factors and postoperative courses were extracted from patient records.

RESULTS

A total of 475 patients were included. At a median follow-up time of 1108 days (IQR 946-1320 days) following surgery, 164 (33.7%) patients were diagnosed with an anal fistula. Risk factors for developing fistulas were low intersphincteric (OR 2.77, 95CI 1.50-5.06) and ischioanal (OR 2.48, 95CI 1.36-4.47) abscesses, Crohn's disease (OR 5.96, 95CI 2.33-17.2), a history of recurrent anal abscesses (OR 4.14, 95CI 2.47-7.01) or repeat surgery (OR 5.96, 95CI 2.33-17.2), E. coli-positive pus cultures (OR 4.06, 1.56-11.4) or preoperative C-reactive protein (CRP) of more than 100 mg/L (OR 3.21, 95CI 1.57-6.71).

CONCLUSION

Several significant clinical risk factors were associated with fistula development following anal abscess surgery. These findings are clinically relevant and could influence the selection of patients for specialised follow-up, facilitate expedited diagnosis, and potentially prevent unnecessarily long treatment courses.

Anorectal Emergencies

Anorectal emergencies are rare presentations of common anorectal disorders, and surgeons are often called on to assist in their diagnosis and management. Although most patients presenting with anorectal emergencies can be managed nonoperatively or with a bedside procedure, surgeons must also be able to identify surgical anorectal emergencies, such as gangrenous rectal prolapse. This article provides a review of pertinent anatomy; examination techniques; and workup, diagnosis, and management of common anorectal emergencies including thrombosed hemorrhoids, incarcerated hemorrhoids, anal fissure, anorectal abscess, rectal prolapse, and pilonidal abscess and unique situations including rectal foreign body and anorectal sexually transmitted infections.

Efficacy and safety of video-assisted anal fistula treatment in anorectal fistula: a meta-analysis

INTRODUCTION

By searching relevant literature, the recurrence rate, complication rate after video-assisted anal fistula treatment (VAAFT), and efficacy and safety of the treatment were analyzed.

EVIDENCE ACQUISITION

Articles that reported the outcomes of VAAFT up to December 2020 were searched in PubMed (Medline) and Cochrane Library, in accordance with the preferred reporting items for systematic review and meta-analysis (PRISMA) screening guidelines. Two researchers independently completed the whole process from screening and inclusion to quality evaluation and bias risk assessment, and the data was included in the RevMan 5.3 software for analysis. The main outcomes were demographic data of patients, detection rate, classification of internal opening of anorectal fistula, postoperative recurrence rate, and incidence of complications.

EVIDENCE SYNTHESIS

A total of 10 articles were included (779 patients). The average age of the patients was 44 years old, average operation time was 60 min, and the average follow-up time was 22 months. The ratio of male to female was 2.4:1, the ratio of high anorectal fistula to low anorectal fistula was 6.6:1, the detection rate of internal openings was 98%, the weighted recurrence rate was 24%, and the weighted complication rate was 1%.

CONCLUSIONS

VAAFT is effective and safe in the treatment of anorectal fistulas.

The Impact of Computed Tomography Scans on the Management and Wait Times in Perianal Abscess Diagnoses

Background Diagnosis and management of perianal abscesses (PAA) are based on history and clinical examination. Imaging is not indicated except in complicated cases, as determined by the surgical team. The monetary, ionizing radiation, and resource utilization costs of a computed tomography (CT) scan in the emergency room must be considered when used for diagnostic purposes of PAAs. Methods A retrospective analysis of 129 patients diagnosed with a diagnosis of PAA between 2015-2020 was performed. The primary endpoints included length of stay, CT performed, time from patient presentation to CT, and CT scan completion prior to surgical consultation. Data is reported as n (%) or median (IQR). Results Of the 129 patients diagnosed with PAA, 81 underwent CT, and 48 did not. General surgery was consulted in 88% of cases. There were no statistically significant differences in age (p=0.562), sex (p=0.531), or ethnicity (p=0.356). The median hospitalization time was two days when CT was performed (p=0.001). The median time elapsed from presentation to the emergency department and CT scan performed was 16 hours (p=0.001). CT scans were ordered before the surgical consultation in 65% of cases (p=0.001) and 17% after a surgical consultation was placed (p=0.009). Conclusion Performing CT scans prior to surgical evaluation for the diagnosis of PAA is not a responsible practice. The cost, resources, and radiation exposure must be considered. This study demonstrated that more CT scans are ordered prior to surgical consultation for PAA, resulting in a prolonged wait time in the emergency department.

A Systematic Review of Epidemiology and Outcomes Associated with Local Surgical and Intersphincteric Ligation Procedures for Complex Cryptoglandular Fistulas

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).

Primary sphincter repair after fistulectomy: A simple and safe option for complex fistula-in-ano

Complete tract excision for complex fistula-in-ano, where the sphincter, is divided is increasingly being followed by immediate sphincter repair. We concluded, by a prospective study conducted on 60 consecutive patients, that this procedure is feasible and safe, and polydioxanone and polyglactin 910 in repair result in a comparable outcome.

Elderly Patients Managed Non-Operatively with Abscesses of the Anorectal Region Have Five Times Higher Rate of Mortality Compared to Non-Elderly

This study's purpose was to investigate risk factors for mortality from anorectal abscesses through a more comprehensive examination. This was a retrospective study that evaluated National Inpatient Sample patient data of adult and elderly patients emergently admitted with a primary diagnosis of anorectal abscess. Data was stratified by variables of interest and examined through statistical analysis, including backward logistic regression modelling. Roughly 40,000 adult patients and nearly 7000 elderly patients were admitted emergently with a primary diagnosis of abscess in anorectal regions. The mean age of adult male patients was 43 years while elderly male patients were, on average, 73 years old. Both adult males (69.0%) and elderly males (63.9%) were more frequently seen in the hospital for anorectal abscess compared to females. Mortality rates were lower in adult patients as only 0.2% (n = 62) of adult patients and 1.0% (n = 73) of elderly patients died in the hospital. Age increased the odds of mortality (OR = 1.03; 95% CI: 1.02-1.04, p < 0.001) as did hospital length of stay (OR = 1.02; 95% CI: 1.01-1.03, p < 0.001). Surgical procedure decreased the odds of mortality by more than 50% (OR = 0.49; 95% CI: 0.33-0.71, p < 0.001). Risk factors for mortality from anorectal abscess included age and non-operative management, which leads to prolonged hospital length of stay. Surgical management of anorectal abscesses offered protective benefits.

Pain Trajectory after Short-Stay Anorectal Surgery: A Prospective Observational Study

The evolution of pain after anorectal surgery has not been well characterized. The main objective of this study is to evaluate patterns in acute postoperative pain in patients undergoing short-stay anorectal surgery. A total of 217 patients were included in the study, which used group-based trajectory modeling to estimate postoperative pain and then examined the relationships between sociodemographic or surgical factors and pain trajectories. Three distinct postoperative pain trajectories were determined: hemorrhoidectomy (OR, 0.15), higher anxiety (OR, 3.26), and a higher preoperative pain behavior score (OR, 3.15). In multivariate analysis, they were associated with an increased likelihood of being on the high pain trajectory. The pain trajectory group was related to postoperative analgesic use (p < 0.001), with the high-low group needing more nonsteroidal analgesics. The study showed that there were three obvious pain trajectories after anorectal surgery, including an unreported low-moderate-low type. More than 60% of patients maintained moderate to severe pain within 7 days after the operation. These postoperative pain trajectories were predominantly defined by surgery factors and patient factors.

Sex-based analysis of characteristics contributing to anorectal abscesses requiring acute care surgery

Background

Males present more frequently with anorectal abscesses than females. Factors contributing to this difference are not clear. The purpose of this study is to evaluate comorbidities and demographic features at presentation that may contribute to the male predominance in this disease process.

Methods

This is a retrospective study on patients who underwent acute care surgery for anorectal abscess at an urban safety-net hospital from 2015 to 2020. Bivariate analysis was used to determine factors associated with the sex difference in anorectal abscesses requiring acute care surgery.

Results

This study included 208 patients, of which 160 were male (76.9%). At the time of surgery, males had a higher rate of current tobacco use compared to females (25.6% vs. 8.3%, p = 0.009). Additionally, males who presented for surgery were older compared to females, (42.5 ± 10.8 years vs. 37.2 ± 13.4 years, p = 0.005). No differences were found between males and females with respect to comorbidities including diabetes, hypertension, body mass index (BMI), cardiovascular disease, or end stage renal disease.

Conclusion

This study suggests that the male predominance in anorectal abscess necessitating acute care surgery may be partially explained by current tobacco use and older age.

Serum Depletion of Complement Component 5a Is Associated With Increased Inflammation and Poor Clinical Outcomes in Patients With Perianal Fistulas

BACKGROUND

Persistent disease is a significant issue in the management of perianal fistulas, with up to 50% of patients requiring additional treatment after surgery.

OBJECTIVE

This study aimed to identify a novel prognostic modality in hopes of risk-stratifying patients for persistent disease following corrective surgery.

DESIGN

This was a retrospective study based on prospectively collected data using a combination of histopathology, high-throughput proteomic arrays, and ELISA-based methods.

SETTINGS

This study used data obtained from patients who underwent corrective surgery for perianal fistulas at the University of Illinois Hospital between June 2019 and July 2020.

PATIENTS

A cohort of 22 consecutive patients who had corrective surgery for perianal fistulas were included in this study. The patients were divided into 2 groups: those with resolving fistulas (N = 13) and those with persisting fistulas (N = 9).

MAIN OUTCOME MEASURES

Nonresolving fistulas were determined by disease representation within 2 months of corrective surgery.

RESULTS

Serum samples from patients with persistent perianal fistulas displayed a consistent decrease in the expression of complement pathway component C5a compared with either healthy controls or patients with resolving forms of disease. This was paralleled by an increase in the fistula expression of C5a and an associated increase in tissue infiltrating leukocytes and interleukin-1β expression.

LIMITATIONS

This study was limited by its retrospective design, relatively small sample size, and single-center data analysis.

CONCLUSIONS

These results suggest that C5a is modestly depleted in patients with nonresolving forms of disease and traffics to the site of tissue damage and inflammation. Accordingly, serum C5a warrants continued investigation as a prognostic biomarker and predictor of recurrence in patients presenting with perianal fistulas. See Video Abstract at http://links.lww.com/DCR/B982 .

LA DEPLECIN SRICA DEL COMPONENTE A DEL COMPLEMENTO SE ASOCIA CON UN AUMENTO DE LA INFLAMACIN Y MALOS RESULTADOS CLNICOS EN PACIENTES CON FSTULAS PERIANALES

ANTECEDENTES:La persistencia de la enfermedad es un problema significativo en el manejo de las fístulas perianales, presente hasta en el 50 % de los pacientes después de la cirugía y que requieren tratamiento adicional.OBJETIVO:DISEÑO:Se trata de un estudio retrospectivo basado en datos recolectados prospectivamente usando una combinación de histopatología, arreglos proteómicos de alto rendimiento y métodos basados en ELISA.ENTORNO CLÍNICO:Este estudio utilizó datos de pacientes que se sometieron a cirugía correctiva por fístulas perianales en el Hospital de la Universidad de Illinois entre junio de 2019 y julio de 2020.PACIENTES:Se incluyó en este estudio una cohorte de 22 pacientes consecutivos que se sometieron a cirugía correctiva de fístulas perianales. Los pacientes se dividieron en 2 grupos: aquellos con fístulas en resolución (N = 13) y aquellos con fístulas persistentes (N = 9).PRINCIPALES MEDIDAS DE VALORACIÓN:Las fístulas que no se resuelven fueron determinadas por la reaparición de la enfermedad dentro de los 2 meses posteriores a la cirugía correctiva.RESULTADOS:Las muestras de suero de pacientes con fístulas perianales persistentes mostraron una disminución constante en la expresión del componente C5a de la vía del complemento en comparación con controles sanos o pacientes con formas de resolución de la enfermedad. Esto fue paralelo a un aumento en la expresión de C5a en la fístula y un aumento asociado en los leucocitos que se infiltran en el tejido y la expresión de IL-1β.LIMITACIONES:El estudio estuvo limitado por su diseño retrospectivo, tamaño de muestra relativamente pequeño y análisis de datos de un solo centro.CONCLUSIONES:Estos resultados sugieren que C5a se reduce moderadamente en pacientes con formas de enfermedad que no se resuelven y se desplaza al sitio del daño tisular e inflamación. En consecuencia, el C5a sérico justifica una investigación continua como biomarcador pronóstico y predictor de recurrencia en pacientes que presentan fístulas perianales. Consulte Video Resumen en http://links.lww.com/DCR/B982 . (Traducción- Dr. Ingrid Melo ).

Drainage of anorectal abscesses in the operating room is associated with a decreased risk of abscess recurrence and fistula formation

BACKGROUND

Timely incision and drainage (I&D) is first line management for anorectal abscesses. We aimed to define current practices in anorectal abscess management and identify factors associated with abscess recurrence and fistula formation.

METHODS

Index episodes of anorectal abscesses treated with I&D in 2014-2018 at a multi-hospital healthcare system were included. Association with one-year abscess recurrence or fistula formation was evaluated using Cox proportional hazard regression. Fistulae were captured only among patients without fistulae at the index operation.

RESULTS

A total of 458 patients met study criteria. One-year rate of abscess recurrence or fistula formation was 20.3%. When compared to bedside procedures, drainage in the operating room was associated with a reduced risk of either recurrence or fistula formation (aHR 0.20 [95%CI 0.114-0.367]).

CONCLUSIONS

Improved exposure and patient comfort in the operating room may allow more complete drainage contributing to decreased rates of abscess recurrence or fistula formation.

Evaluation of the Effectiveness of a Combination of Chinese Herbal Fumigation Sitz-Bath and Red Ointment in Managing Postoperative Wound Healing and Pain Control in Anal Fistula Patients

Objective

To explore the efficacy of Chinese herbal fumigation and sitz-bath combined with red ointment in the treatment of postoperative wound healing and pain control in anal fistula patients.

Methods

A total of 118 anal fistula patients were selected as the study population, randomly divided into two groups, i.e., the research group (n = 60) and the control group (n = 60). The control group was treated with red ointment therapy for postoperative wound healing and pain while the research group was treated with a combination of ointment and traditional Chinese medicine fumigation sitz-bath, Postoperative wound healing, pain control, and safety evaluation were compared between the two groups. Results. The total effective rate in the research group was 96.67%, which was significantly higher than that in the control group (93.10%), and the difference was statistically significant (P < 0.05). The VAS scores and postoperative wound healing times in the research group were significantly lower than those in the control group. The difference was statistically significant (P < 0.05). A day after postoperative treatment, there was no significant difference (P > 0.05) in TNF-α and IL-6 levels between the two study groups; however, from day 3 to day 14 the levels were statistically different. TNF-α and IL-6 levels in research group were significantly lower than those in the control group. The difference was statistically significant (P < 0.05). The incidence of postoperative complications in the research group at 6.67% was statistically significant (P < 0.05), significantly lower than 13.79% in the control group. Conclusion. Postoperative intervention with Chinese herbal fumigation and sitz-bath combined with red ointment can effectively reduce the wound healing duration and lower the degree of pain experienced by anal fistula patients, thereby improving their quality of life.

Treatment of cryptoglandular fistulas with the fistula tract laser closure (FiLaC™) method in comparison with standard methods: first results of a multicenter retrospective comparative study in the Netherlands

BACKGROUND

Current surgical closure techniques for sphincter-sparing treatment of high cryptoglandular fistulas in the Netherlands include the mucosal advancement flap procedure (MAF) and ligation of the intersphincteric fistula tract (LIFT). A relatively novel treatment is the fistula tract laser closure (FiLaC™) method. The aim of this study was to investigate the differences in healing and recurrence rates between FiLaC™ and current standard practices.

METHODS

This multicenter retrospective cohort study included both primary and recurrent high cryptoglandular anorectal fistulas, treated with either FiLaC™ or standard methods (MAF or LIFT) between September 2015 and July 2020. Patients with extrasphincteric fistulas, Crohn's disease, multiple fistulas, age < 18 years or missing data regarding healing time or recurrence were excluded. The primary outcomes were the clinical primary and secondary healing and recurrence rates. Primary healing was defined as a closed external opening without fluid discharge within 6 months of treatment on examination, while secondary healing was the same endpoint after secondary treatment. Secondary outcomes included healing time and complaints.

RESULTS

A total of 162 high fistulas from 3 Dutch hospitals were included. Ninety-nine high fistulas were treated with FiLaC™ and 63 with either MAF or LIFT. There were no significant differences between FiLaC™ and MAF/LIFT in terms of clinical healing (55.6% versus 58.7%, p = .601), secondary healing (70.0% versus 69.2%, p = .950) or recurrence rates (49.5% versus 54%, p = .420), respectively. Median follow-up duration was 7.1 months in the FiLaC™ group (interquartile range [IQR] 4.1-14.4 months) versus 6 months in the control group (IQR 3.5-8.1 months).

CONCLUSIONS

FiLaC™ treatment of high anorectal fistulas does not appear to be inferior to MAF or LIFT. Based on these preliminary results, FiLaC™ can be considered as a worthwhile treatment option for high cryptoglandular fistulas. Prospective studies with a longer follow-up period and well-determined postoperative parameters such as complication rates, magnetic resonance imaging for confirmation of fistula healing, incontinence and quality of life are warranted.

Anorectal Malignancies Presenting as a Perianal Abscess or Fistula

BACKGROUND

Acute anorectal abscess and fistula are common conditions that usually presents as a painful lump close to the anal margin. Tumors in the distal rectum and in the perianal region may mimic the symptoms and signs of anorectal sepsis, thereby leading to a delay in diagnosis and management. The purpose of this study was to describe patients presenting with acute perianal abscess or fistula who were subsequently diagnosed with anorectal cancer.

METHODS

We performed a retrospective, review of all cases presenting with acute perianal abscess or fistula who were subsequently found to have anorectal carcinoma on biopsy in two tertiary centers. We analyzed the data focusing on the clinical features, laboratory values, clinical staging of the tumors, the subsequent management, the pathological staging, and the outcome of each patient.

RESULTS

Overall, 3219 patients presenting with anorectal abscess or fistula were reviewed. Cancer was diagnosed in 16 (.5%) patients, 12 with adenocarcinoma of the rectum and 4 with squamous cell carcinoma of the anus. In 5 patients (31.2%), cancer was diagnosed in the setting of chronic perianal fistula, 4 of them had Crohn's disease. In 10 patients (62.5%), cancer was not diagnosed during the initial evaluation of the acute symptoms.

CONCLUSIONS

A high index of suspicion is required to make the diagnosis of perianal tumors when assessing patients presenting with perianal sepsis, particularly those with Crohn's disease, a long history of persistent perianal disease, and an advanced age. In most cases, proper drainage followed by proximal diversion are the surgical treatment of choice in the acute setting.

Fistula in Ano-A 2-Year Prevalence Study on North Indian Rural Population

Perianal fistula (PF) is a common inflammatory condition affecting the perianal region including the sphincter muscles, ischioanal fossae, and the perianal skin. It is notorious to recur and, as a result, causes significant morbidity in both urban and rural population. Magnetic resonance imaging (MRI) has revolutionized imaging in PFs as it provides excellent anatomical visualization of the fistulous tracts, their origin, course, number, chronicity, opening in the external and internal anal sphincter, length of sphincter, evidence of active disease and abscess formation along the tract. It is also very useful in presurgical mapping and reduce the chances of recurrence. Most of the studies done on PFs are based on the urban population. Rural population have a completely different lifestyle which makes them susceptible to various diseases, less prevalent in the urban population. Hence, the purpose of this article is to find the prevalence of different grades in North Indian rural region close to the NCR (National Capital Region). In the study including 98 patients, the maximum number of patients were classified into grade 1 and grade 4 by MRI according to St. James' University Hospital MRI classification. This is the second reported study on prevalence of different grades of PFs in rural population in India. The higher prevalence of grade 4 PFs in our study might be secondary to illiteracy, social stigma, poor hygiene, or higher recurrence rate. Closely understanding the difference in dynamics of urban and rural population, our goal of the study is to determine the prevalence of different grades of PFs in the rural population. We also aim to familiarize physicians, radiologists, and surgeons with the MRI evaluation and grading of PF to help in presurgical mapping and thus, reducing the chances of recurrence. We also recommend further studies to evaluate psycho-social factors as a barrier in seeking early medical care in rural population.

Anorectal pathology in the HIV population: a guide for radiologists

Patients with human immunodeficiency virus (HIV) can present with a wide range of different acute and chronic pathologies. Anorectal conditions are particularly common in this unique patient population, including pathologies, such as proctitis, anorectal abscess, anorectal fistula, and anal squamous cell carcinoma. The radiologist plays a critical role in the assessment of these common forms of anorectal disease, as these conditions can present with various findings on imaging assessment. Pelvic CT, MRI, and FDG-PET/CT are among the most common modalities used for assessment of anorectal disease in the HIV patient population. Knowledge of the fundamental clinical and imaging findings associated with these pathologies in HIV patients is critical for radiologists.

Role of Transcutaneous Perianal Ultrasonography in Evaluation of Perianal Fistulae with MRI Correlation

Purpose: The aim of this study was to evaluate the role of transcutaneous perianal ultrasonography (TPUS) in patients with perianal fistula and to correlate the findings with magnetic resonance imaging (MRI) as gold standard.

Materials and Methods: This prospective study included patients who presented with suspicion of perianal fistula. After clinical examination, TPUS and MRI of perianal region were performed on each of them. Clockwise position of internal opening of the fistula was described. The entire length of the tract was evaluated up to the external opening. Also, any ramifications along the primary tract were described. Parks et al and St James's University Hospital MR Imaging Classification of Perianal Fistulas were used for classifying the fistulas.

Results: Out of total 37 patients, the most common age group of presenting individuals was 45 to 60 years with male to female ratio of 6.4:1. There was excellent agreement between TPUS and MRI for detecting primary fistulous tract with kappa correlation coefficient of 1. The kappa correlation coefficient for detecting secondary fistulous tracts and abscess on TPUS and MRI was 0.839 and 0.937 showing excellent agreement. Moderate agreement was seen with kappa correlation coefficient of 0.839 in the detection of internal opening on TPUS and MRI.

Conclusion: TPUS showed promising results in diagnosis and classification of perianal fistulae with MRI as gold standard. A wide availability, cost-effectiveness, and better tolerability of TPUS can make it an imaging modality of first choice for evaluating perianal fistulae.

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.

Perianal fistulas: A review with emphasis on preoperative imaging

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.

Mesenchymal Stem Cells for Cryptoglandular Anal Fistula: Current State of Art

Anal fistula is a common disease that needs surgical treatment to be resolved. Despite a variety of surgical options, the major problem is still to cure complex fistulas without any recurrence in the long-term follow-up but, at the same time, to avoid an impairment of continence. In recent years, one solution has been the application of mesenchymal stem cells derived from adipose tissue, especially in association with other treatments, such as the use of fibrin glue or the previous application of a seton. Their initial use in fistulas associated with Crohn's disease has shown encouraging results. In this non-systematic review our aim is to analyze the use in cryptoglandular fistulas: the rate of healing is not so high, and the number of studies is limited. Therefore, further randomized controlled trials are needed to establish their efficacy in the case of complex cryptoglandular anal fistulas and their possible complications.

Long term efficacy of Video-Assisted Anal Fistula Treatment (VAAFT) for complex fistula-in-ano: a single-centre Australian experience

BACKGROUND

Video-Assisted Anal Fistula Treatment (VAAFT) is a novel minimally invasive & sphincter-saving technique for treating complex fistula-in-ano involving endoscopic assessment & treatment of perianal fistula. This retrospective, non-randomized, observational study is the first Australian study of VAAFT. It is also the longest study of VAAFT to-date.

METHODS

From January 2014 to September 2019, 59 patients with a complex anal fistula were identified via MRI & underwent VAAFT. Fourteen patients had undergone previous definitive surgery for anal fistula. Specialized Karl Storz video equipment (fistuloscope) was used in the procedure. The rigid fistuloscope was used to directly visualize the fistula tract/s & internal opening. Closure of the internal opening was then performed. The fistula tract/s were then treated via fulguration. The external opening was kept patent & dressed. Patients were then followed up for a mean 59.5 months.

RESULTS

67.9% (n = 38) of patients achieved primary healing (needing nil further intervention) at a median of 13 weeks. 12.5% (n = 7) experienced healing followed by recurrence while 19.6% (n = 11) experienced non-healing. Of the recurrence/non-healing groups, 11/18 underwent repeat VAAFT with healing occurring in 10/11 patients at a median of 7 weeks. The mean operating time was 41.1 min. There were no major complications & continence scores were not affected. Three patients were lost to follow up.

CONCLUSION

VAAFT is both effective & safe for the treatment of complex fistula-in-ano. Its minimally invasive nature means that in the instance of recurrence or persistence, VAAFT can be repeated with minimal morbidity & reasonable likelihood of success.

Recurrence and incidence of fistula after urgent drainage of an anal abscess. Long-term results

INTRODUCTION

Anal abscess is the most frequent urgent proctological problem. The recurrence rate and reported incidence of fistula after drainage and debridement of an anal abscess is widely variable. The objective of this study is to analyse the long-term recurrence rate and the incidence of fistula after drainage and urgent debridement of an anal abscess.

METHODS

Retrospective observational study of a prospective cohort with anal abscess of cryptoglandular origin. All patients (n = 303) were evaluated two months and one year after the intervention. At the 5^th year, all the medical records were reviewed and a telephone call or appointment was made for an assessment if necessary. Specific antecedents of anal pathology, abscess characteristics, time and type of recurrence, presence of symptoms in the first revision and presence of clinical and/or ultrasound fistula were recorded.

RESULTS

Mean follow-up 119.7 months. Recurrence rate 48.2% (82.2% in the first year). Two hundred twenty-two ultrasounds performed. Incidence of ultrasound fistula: 70% symptomatic vs. 2.4% asymptomatic (p < 0.001). Global incidence of fistula 40.3%. The history of anal pathology and the presence of symptoms in the postoperative review significantly increase the possibility of recurrence (p < 0.001). The fistula is statistically more frequent if the abscess recurs (p < 0.001).

CONCLUSION

After drainage and debridement of an anal abscess, half of the patients relapse and 40% develop fistula especially in the first year, so longer follow-ups are not necessary. Endoanal ultrasound for the evaluation of the presence of fistula is highly questionable in the absence of signs or symptoms.

LIFT: a feasible option for primary and recurrent fistulas

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.

ACR Appropriateness Criteria® Anorectal Disease

This review summarizes the relevant literature for the selection of the initial imaging in 4 clinical scenarios in patients with suspected inflammatory disease or postoperative complication of the anorectum. These clinical scenarios include suspected perianal fistula or abscess; rectovesicular or rectovaginal fistula; proctitis or pouchitis; and suspected complication following proctectomy, coloproctectomy, or colectomy with a pouch or other anastomosis. The appropriateness of imaging modalities as they apply to each clinical scenario is rated as usually appropriate, may be appropriate, and usually not appropriate to assist the selection of the most appropriate imaging modality in the corresponding clinical scenarios of anorectal disease. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.