Video-Assisted Anal Fistula Treatment for Treatment of Complex Cryptoglandular Anal Fistulas with 2 Years Follow-Up Period: Our Experience

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.

Comparison between recent sphincter-sparing procedures for complex anal fistulas-ligation of intersphincteric tract vs transanal opening of intersphincteric space

Complex anal fistulas are difficult to treat. The main reasons for this are a higher recurrence rate and the risk of disrupting the continence mechanism because of sphincter involvement. Due to this, several sphincter-sparing procedures have been developed in the last two decades. Though moderately successful in simple fistulas (50%-75% healing rate), the healing rates in complex fistulas for most of these procedures has been dismal. Only two procedures, ligation of intersphincteric fistula tract and transanal opening of intersphincteric space have been shown to have good success rates in complex fistulas (60%-95%). Both of these procedures preserve continence while achieving high success rates. In this opinion review, I shall outline the history, compare the pros and cons, indications and contraindications and future application of both these procedures for the management of complex anal fistulas.

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

BACKGROUND

Video-assisted anal fistula treatment (VAAFT) has gained increasing acceptance as a sphincter-sparing procedure for treating complex anorectal fistulas (CAF), but no unequivocal conclusions can yet be drawn regarding its ultimate effectiveness. We reviewed the literature and performed a meta-analysis to evaluate the efficacy and safety of VAAFT in CAF patients.

METHODS

The study protocol was registered with the PROSPERO database (CRD42021279085). A systematic literature search was performed in the PubMed, Embase, and Cochrane Library databases up to June 2021 with no restriction on language based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We used the keywords video-assisted surgery, video-assisted anal fistula treatment, and complex anorectal fistula to identify relevant studies.

RESULTS

Fourteen trials (7 prospective and 7 retrospective) with a total of 1201 patients (mean age 43.5 years) were included. The median follow-up duration was 16.5(8-48) months. Pooled analysis showed that the rates of success, recurrence and postoperative complication across the studies were 83% (95% CI 81-85%, I² = 37.9%), 16% (95% CI 14-18%, I² = 4.8%), 11% (95% CI 7-15%, I² = 72.1%), respectively. The postoperative Jorge-Wexner score used to assess the level of anal incontinence was 1.09 (95% CI, 0.9-1.27, I² = 74.6%). The internal opening detection rate was 97.6% (95% CI 96.1-99.6%, I² = 48.2%). Recurrence rates varied according to the closure method of internal opening from 21.4% after using staplers, 18.7% after suturing, to 23.5% after advancement flap. The hospital stay was 3.15 days (95% CI 2.96-3.35, I² = 49.7%). Subgroup analysis indicated that the risk of heterogeneity in the urine retention group was higher  compared with that of the overall group and that retrospective studies may be the source of heterogeneity for postoperative anal incontinence. r . Sensitivity analysis confirmed the stability of the pooled results. Begg's and Egger's tests showed no evidence of publication bias.

CONCLUSIONS

According to the available evidence, VAAFT may be a valuable alternative to fistulotomy or seton in treating CAF and has the additional long-term benefits of reducing anal incontinence and surgical morbidity, permitting earlier healing and accelerated rehabilitation.

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.

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

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

Video-assisted anal fistula treatment versus fistulectomy and sphincter repair in the treatment of high cryptoglandular anal fistula: a randomized clinical study

Background

Video-assisted anal fistula treatment (VAAFT) may have a recurrence rate comparable to that of fistulectomy and sphincter repair (FSR) in the treatment of high anal fistula and with potential advantages in wound healing, functional outcome and quality of life. The aim and objectives of the study are to compare the outcome of VAAFT with that of FSR for high cryptoglandular anal fistula.

Methods

This was a single-centre randomized controlled trial of adults with high anal fistula comparing FSR with VAAFT. Primary outcome was fistula recurrence. Secondary outcomes were results of anal manometry, quality of life and faecal continence. A power calculation of 33 patients in each arm (1 : 1) was based on recurrence in the FSR and VAAFT groups of 5 per cent and 30 per cent respectively. Follow-up at 6 months after surgery included physical examination, MRI, anal manometry, quality-of-life assessment (RAND SF 36 questionnaire) and faecal-continence assessment (Wexner score).

Results

The study was terminated early due to high recurrence rates in both groups. A total of 45 patients were included. Recurrence rates were 65 per cent for VAAFT and 27 per cent for FSR, with hazard ratio 4.18 (P = 0.016). Length of the fistula was a risk factor with an association with recurrence (hazard ratio 1.8, P = 0.020). There were significant differences in quality of life in favour of FSR and in anal manometry in favour of VAAFT with a significant improvement in Wexner score in both groups.

Conclusion

FSR was associated with a lower recurrence rate than VAAFT in the management of complex anal fistulae in this single-centre study but the study was terminated early due to higher than predicted recurrence rate in both groups.

Registration number

NCT02585167 (http://www.clinicaltrials.org).

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

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

Management of Complex Cryptoglandular Anal Fistula: Challenges and Solutions

Anal fistulae can be a very difficult disease to manage. The management of complex fistulae is even more challenging. The risk to the fecal continence mechanism due to damage to the anal sphincters and refractoriness to the treatment (high recurrence rate) pose the two biggest challenges in the management of this disease. Apart from these, there are several other challenges in the treatment of complex fistulae. The intriguing and uphill task is that satisfactory solutions to most of these challenges are still not known, and there is hardly any consensus on whatever treatment solutions are available. To summarize, there is no gold-standard treatment available for treating complex anal fistulae, and the search for a satisfactory treatment option is still on. In this review, the endeavor has been to discuss and highlight recent path-breaking updates in the management of complex anal fistulae.