Clinical Significance of 2 Deep Posterior Perianal Spaces to Complex Cryptoglandular Fistulas

Efficacy and safety of transanal opening of intersphincteric space in the treatment of high complex anal fistula: A meta‑analysis

The best treatment of high complex anal fistula (HCAF) is to avoid anal incontinence while improving the cure rate. On this basis, several surgical procedures for preserving the anal sphincter have been proposed. The purpose of the present study was to evaluate the efficacy and safety of transanal opening of intersphincteric space for treating HCAF. PubMed, Cochrane Library, China National Knowledge Infrastructure and the Wanfang databases were searched to collate all the articles on transanal opening of intersphincteric space for treating HCAF. A total of two researchers independently completed the whole process, from screening and inclusion to data extraction and the data was included in the RevMan 5.3 software for analysis. The main outcomes included the patients' essential characteristics, primary healing rate, management after recurrence, final healing rate, anal incontinence score before and after surgery, postoperative complication rate and types of complications. A total of six articles were included in this meta-analysis. The results showed that the weighted final healing rate of patients following transanal opening of intersphincteric space was 89% [risk differences (RD)=0.89; 95% confidence interval (CI)=0.86-0.92; I2=0%; P<0.00001]. The results of the anal incontinence score showed that there was no significant difference between the results before and after transanal opening of intersphincteric space surgery mean differences [(MD)=-0.04, Cl=-0.10-0.02, I2=0%; P=0.21]. Only 11 patients were reported to have complications, including urinary retention and bleeding following transanal opening of intersphincteric space with a complication rate of 8% (11/138) and the weighted average complication rate was 6% (RD=0.06,95% CI=0.02-0.10; I2=9%; P=0.003). Transanal opening of intersphincteric space has a high cure rate, a favorable anal incontinence score, fewer types of postoperative complications and a low complication rate; it can be used as a minimally invasive and sphincter-preserving surgical method for treating HCAF and is worthy of further promotion and research in clinical practice.

Cutting seton versus decompression and drainage seton in the treatment of high complex anal fistula: a randomized controlled trial

This study aimed to compare the efficacy between decompression and drainage seton (DADS) and cutting seton (CS) in the treatment of high complex anal fistula. Patients were randomly assigned 1:1 to DADS or CS group. The primary outcome was the rate of wound healing. Second outcomes included time taken to return to work, postoperative pain, the severity of fecal incontinence and other complications. A total of 120 patients with a mean age of 39 years were included. There was no significant difference in the rate of complete wound healing at 1 year. The mean time taken to return to work was 5 ± 2 days in DADS group, shorter than CS group (10 ± 3, p < 0.001). Mean vaizey incontinence score and the post-operation pain in DADS group was significantly lower than CS group. No significant difference was found between two groups in the incidence of complications. DADS is as effective as Cutting seton for the treatment of high complex anal fistula but is associated with less postoperative pain and better sphincter function preserving.

Comparison of different methods to manage supralevator rectal opening in anal fistulas: A retrospective cohort study

INTRODUCTION

Supralevator fistula-in-ano are difficult to manage. If these fistulas have an additional supralevator internal-opening in rectum apart from the primary internal-opening at the dentate line, then the management becomes even more difficult. There is no literature/guidelines available on the management of supralevator rectal opening (SRO).

METHODS

All consecutive supralevator fistula-in-ano patients having a SRO were retrospectively analyzed. The operative management of SRO in these fistulas was reviewed. All the fistulas were managed by the same procedure, transanal opening of intersphincteric space (TROPIS). The latter was a modification of LIFT (ligation of intersphincteric tract) procedure in which the intersphincteric tract was opened-up in the rectum rather than ligated (as is done in LIFT). The SRO was managed in three ways, group-1:SRO was laid-open into the rectum in continuity with the primary opening at dentate line, group-2:the mucosa around SRO was cauterized, group-3:nothing could be done to SRO.

RESULTS

Out of 836 patients operated between 2015 and 2020, 138 patients (16.5%) had supralevator extension. Amongst these, 23/138 (16.6%) patients had a SRO. 2 patients were excluded (short follow-up) and 21 patients were included in the analysis. 12/13(92%) patients in group-1, 4/5 (80%) patients in group-2 and 2/3(67%) patients in group-3 got healed (p=0.47, Chi-square test). The overall healing rate was 18/21(86%).

CONCLUSIONS

The supralevator rectal opening (SRO) heals well irrespective of the method utilized. Thus, proper management of the primary opening at the dentate line holds the key to fistula healing and SRO is perhaps not much responsible for persistence of the fistula. However, more studies are needed to corroborate these findings.

A New Anatomical Pathway of Spread of Pus/Sepsis in Anal Fistulas Discovered on MRI and Its Clinical Implications

BACKGROUND

In the anal sphincter complex, the intersphincteric space between the internal and external sphincters is the only conventionally recognized pathway for the spread of sepsis. However, there is another unrecognized space discovered on MRI, the "outer-sphincteric space", between the external anal sphincter and its lateral fascia along which pus can spread. An abscess in the intersphincteric space is easily drained into the rectum via the transanal route and is more likely to spread into the supralevator space. Conversely, an abscess in the outer-sphincteric space is difficult to drain transanally into the rectum and is more likely to become a transsphincteric abscess/fistula.

METHODS

The MRIs of anal fistula patients operated over four years on intersphincteric abscesses were analyzed. The pattern of spread into the ischiorectal fossa and/or supralevator space and ease of drainage into the rectum through the transanal route were studied.

RESULTS

Thirty-six patients were operated on to drain their intersphincteric abscesses through the anal canal. Two distinct patterns were noted. Twenty patients had abscesses in the intersphincteric space, which were easily drained into the rectum. Of them, 6/20 had supralevator extension, while only 1/20 had spread to the ischiorectal fossa. In 16/36 patients, the abscess was in the outer-sphincteric space and could not be drained into the rectum. In 9/16 of these patients, pus spread into the ischiorectal fossa but supralevator spread did not happen in any patient.

CONCLUSION

Apart from the intersphincteric space, there is perhaps another unrecognized anatomical space - the outer-sphincteric space - discovered on MRI, through which pus can spread in anal fistulas or abscesses.

Transanal opening of the intersphincteric space: a novel sphincter-sparing procedure to treat 325 high complex anal fistulas with long-term follow-up

AIM

Sepsis in the intersphincteric plane behaves like an abscess in a closed space and is present in most complex fistulas. Ignoring this sepsis is a cause of recurrence. Complex fistulas can be successfully managed by transanal opening of the intersphincteric space (TROPIS) into the anal canal. The long-term efficacy of the TROPIS procedure was analysed in an exclusive cohort of high complex anal fistulas.

METHODS

All consecutive patients operated for a high complex fistula-in-ano were included prospectively. Preoperative MRI scans were obtained for all the patients. The intersphincteric space and internal opening was laid open into the anal canal while preserving the external sphincter. The external tracts were thoroughly curetted and cleaned. Fistula healing rate and objective incontinence scores (preoperatively and during long-term follow-up) were analysed.

RESULTS

A total of 325 patients (age 39.9 ± 10.9 years, 292 men) were operated with TROPIS and had a follow-up of 7-67 months (median 36 months). In the cohort, 67.4% (219) had recurrent fistulas, 82.8% (269) had multiple tracts, 36.3% (118) had horseshoe tracts, 37.5% (122) had associated abscesses and 24% (78) were supralevator fistulas. Nineteen patients were excluded. Fistulas healed completely in 78.4% (240/306) of patients and did not heal in 21.6% (66/306) of patients. 36/66 of these patients were operated again and the fistulas healed in 28 patients. Thus, the overall healing rate was 87.6% (268/306). The mean preoperative and postoperative incontinence scores were 0.085 ± 0.35 and 0.119 ± 0.48 respectively (P = 0.38). The healing rate of fistulas with associated acute abscesses was similar to the fistulas without abscesses (87% vs. 88%, P = 0.85).

CONCLUSION

Transanal opening of the intersphincteric space is a safe and highly effective sphincter-sparing procedure to manage high complex fistulas-in-ano.

Comparison of different methods to manage supralevator rectal opening in anal fistulas: A retrospective cohort study

INTRODUCTION

Supralevator fistula-in-ano are difficult to manage. If these fistulas have an additional supralevator internal-opening in rectum apart from the primary internal-opening at the dentate line, then the management becomes even more difficult. There is no literature/guidelines available on the management of supralevator rectal opening (SRO).

METHODS

All consecutive supralevator fistula-in-ano patients having a SRO were retrospectively analyzed. The operative management of SRO in these fistulas was reviewed. All the fistulas were managed by the same procedure, transanal opening of intersphincteric space (TROPIS). The latter was a modification of LIFT (ligation of intersphincteric tract) procedure in which the intersphincteric tract was opened-up in the rectum rather than ligated (as is done in LIFT). The SRO was managed in three ways, group-1:SRO was laid-open into the rectum in continuity with the primary opening at dentate line, group-2:the mucosa around SRO was cauterized, group-3:nothing could be done to SRO.

RESULTS

Out of 836 patients operated between 2015 and 2020, 138 patients (16.5%) had supralevator extension. Amongst these, 23/138 (16.6%) patients had a SRO. 2 patients were excluded (short follow-up) and 21 patients were included in the analysis. 12/13(92%) patients in group-1, 4/5 (80%) patients in group-2 and 2/3(67%) patients in group-3 got healed (p=0.47, Chi-square test). The overall healing rate was 18/21(86%).

CONCLUSIONS

The supralevator rectal opening (SRO) heals well irrespective of the method utilized. Thus, proper management of the primary opening at the dentate line holds the key to fistula healing and SRO is perhaps not much responsible for persistence of the fistula. However, more studies are needed to corroborate these findings.

Transanal Opening of Intersphincteric Space for Fistula-in-Ano

BACKGROUND

The role of the intersphincteric space in the pathogenesis of fistula-in-ano is being increasingly recognized. Submucosal and intersphincteric rectal abscesses have been surgically managed by laying open and draining the intersphincteric space as well as by the modified ligation of intersphincteric fistula tract (LIFT) procedure. In 2017, the transanal opening of intersphincteric space (TROPIS) technique was reported for the treatment of high, complex anal fistulae.

AIM

We aim to investigate the advantages of performing the TROPIS procedure in patients with fistula-in-ano.

METHODS

This was a prospective cohort study investigating the outcomes in patients who had undergone a procedure using the TROPIS technique for the treatment of fistula-in-ano. Preoperative magnetic resonance imaging scans and electronic colonoscopies were performed on all patients. A clinical database evaluating the following variables was constructed: age, gender, body mass index (BMI), previous fistula surgery, type of fistula, postoperative complications, duration of follow-up, success rate, and incontinence scores pre- and postoperatively.

RESULTS

The TROPIS procedure was performed on 41 patients with fistula-in-ano with a follow-up time of 6-23 months. The characteristics of the patients were as follows: 36 males, 6 females, mean age 38.6±13.2 years, and mean BMI 23.5±3.9 kg·m^-2. All patients (41) had transsphincteric fistulae, and 90.2% (37) had high fistula. Of the 41 patients, 22% (9) had recurrent fistulae, 29.27% (12) had horseshoe fistulae, 7.3% (3) had supralevator fistulae, and 14.6% (6) had an associated abscess. The fistula healed completely in 85.3% (35) of patients and failed to heal in 14.7% (6) of patients, and the healing of high fistula was 86.5% (32). Of those patients who had not healed completely, 2 were found to have contracted iatrogenic infections due to foreign residues and underwent surgery with the passing of a loose seton. The additional 4 patients who had not healed underwent a fistulotomy and healed completely thereafter. There were no significant changes in incontinence scores. The incontinence scores were .15 ± .36 preoperatively and .22 ± .47 3 months postoperatively (t = -1.438, P = .16).

CONCLUSIONS

The TROPIS technique is a novel sphincter-preserving procedure, which can be effectively used in treating fistula-in-ano.

Two-Stage Complete Deroofing Fistulotomy Approach for Horseshoe Fistula: Successful Surgery Leaving Continence Intact

PURPOSE

Surgery of the horseshoe fistula is challenging due to its complex configuration and sphincter muscle involvement. Complete deroofing fistulotomy for horseshoe fistula is highly curative with the eradication of all fistulous lesions but has been discredited for its high incontinence rate. It was replaced with the more conservative Hanley's procedure leaving the lateral tracts intact, despite its issue of recurrence. Our study aimed to report the outcomes of a procedure dividing complete deroofing fistulotomy for horseshoe fistula into 2 stages to avoid impairment of sphincter function.

METHODS

We retrospectively reviewed 139 patients who underwent surgery for horseshoe fistula using the 2-stage complete deroofing fistulotomy method between 2014 and 2017. The first surgery deroofed the lateral tracts with an arch-like incision severing the anococcygeal ligament. The primary lesion was also drained and curetted. A seton was placed in the primary tract which was laid open in the second surgery after the lateral wound had partially healed.

RESULTS

Recurrence was observed in 12 patients. All were superficial recurrences except for 1, in which recurrence was confirmed in the primary lesion. Those with blind intersphincteric upward extensions had a significantly higher recurrence rate. Furthermore, patients who resided far from the hospital and could not make visits for frequent wound inspections also had a significantly higher recurrence rate. No patient had any continence issues at the end of the follow-up period.

CONCLUSION

Managing horseshoe fistula with the 2-stage deroofing fistulotomy approach allows for eradication of the fistula tract without compromising anal sphincter function.

Significance and Impact of the Intersphincteric Plane Sepsis in the Management of the Perianal Sepsis: Ultrasound Study

Background The intersphincteric plane (ISP) is a potential space between the external and the internal anal sphincters. About 90% of the perianal sepsis is caused by an obstruction of the ducts of anal glands with subsequent secondary bacterial infection. The imaging modalities used to diagnose perianal sepsis are the ultrasound via endoanal and transperineal routes and magnetic resonance imaging.

Objective  The study aimed to identify the various patterns of the ISP sepsis and their incidence among our study group and to clarify the significance of ISP in the pathogenesis of anorectal abscesses and various types of perianal fistula tracts, to optimize the surgical management.

Methods Retrospective descriptive study in which 57 patients with an ISP sepsis were evaluated with full medical history, clinical exam, and ultrasound; the final diagnosis was based on combining the results of ultrasound, digital rectal examination under anesthesia, and the operative results.

Results The current study showed many patterns of the ISP sepsis and estimated the incidence of each pattern among our study group; such patterns could be fistula tracts, sinus tracts, abscesses, intersphincteric abscess with supralevator extension, sinus with abscess formation, fistula with abscess formation, distension of the ISP with free pus, and other complex patterns like horse abscess, abscess with transsphincteric sinus, and ISP fistula/sinus with transsphincteric branches.

Conclusion Understanding the role of the ISP in the pathogenesis of anorectal abscesses and perianal fistula tracts can help in reaching the optimum way of management.

Management of anoperineal lesions in Crohn's disease: a French National Society of Coloproctology national consensus

The French National Society of Coloproctology established national recommendations for the treatment of anoperineal lesions associated with Crohn's disease. Treatment strategies for acute abscesses, active fistulas (active denovo and still active under treatment), fistulas in remission, and rectovaginal fistulas are suggested. Recommendations have been graded following the international recommendations, and when absent, professional agreement has been established. For each situation, practical algorithms have been drawn.

Analysis of Deep Posterior Anal Fistulas by Magnetic Resonance Imaging: Site of Primary Abscess and Extension Patterns According to the Primary Abscess Depth

OBJECTIVES

The aim of this study was to use magnetic resonance imaging (MRI) to elucidate the site and depth of the primary abscesses associated with deep posterior anal fistulas and their extension patterns.

METHODS

We analyzed 176 consecutive patients with deep posterior anal fistulas and classified the fistulas according to whether the MRI-detected site of the primary abscess was at a superficial or a deep external anal sphincter (EAS) level.

RESULTS

The distance between the anal center and the primary abscess center was significantly shorter than the length of the EAS and radius at an angle of 45°. In addition, deep posterior anal fistulas with primary abscesses located at the deep EAS level penetrated the EAS significantly more laterally and made external openings at a significantly more lateral site than when the primary abscess was located at a superficial EAS level.

CONCLUSIONS

Primary abscesses associated with deep posterior anal fistulas are located in the posterior intersphincteric space or in the EAS muscle itself, not in Courtney's space, as had previously been claimed.

Simulation of Supralevator Abscesses and Complex Fistulas in Cadavers: Pelvic Dissemination and Drainage Routes

BACKGROUND

Most perianal abscesses have a cryptoglandular origin, following the pathogenesis described by Parks in 1961. Supralevator abscesses have the most uncommon location. Nevertheless, such pathology results in a high morbidity because of their difficult diagnosis and treatment.

OBJECTIVE

This study aimed to deepen the knowledge of the pathogenesis and management of supralevator abscesses, as well as the complications derived from incorrect treatment, by using simulation in cadavers.

DESIGN

This study is an anatomosurgical description of pelvic and perianal zone and simulation of the different types of supralevator abscesses, their correct drainage routes, and secondary complex fistulas due to incorrect drainage.

SETTINGS

This dynamic article is based on cadaveric simulation.

PATIENTS

Three cadaveric pelvises (2 male and 1 female) were prepared in formalin and sagittally sectioned, and one perineal dissection was performed of a fresh male pelvis. This is an iconographic description of 3 patients treated for supralevator abscesses in our colorectal surgical unit.

MAIN OUTCOME MEASURES

The virtual anatomical spaces map out a correct treatment.

RESULTS

We reproduced the origin of the different types of supralevator abscesses, as well as their locations and possible drainage pathways, and we determined the definitive treatment of secondary fistulas and their morbidity due to their incorrect drainage.

LIMITATIONS

The limitations of this study are inherent to anatomical studies without real case intervention.

CONCLUSIONS

A proper anatomical knowledge of the supralevator abscesses and surgical training by using cadaveric simulations could improve the diagnostic criteria, facilitate the correct decision on surgical drainage pathways, and, thus, decrease postoperative morbidity in patients with this disease.

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

It is over 10 years since the first ACPGBI Position Statement on the management of anal fistula was published in 2007. This second edition is the result of scrutiny of the literature published during this time; it updates the original Position Statement and reviews the published evidence surrounding treatments for anal fistula that have been developed since the original publication.

Understanding and Treating Supralevator Fistula-in-Ano: MRI Analysis of 51 Cases and a Review of Literature

BACKGROUND

Supralevator fistulas are highly complex. The delineation of the supralevator fistula has become accurate because of MRI.

OBJECTIVE

The aim of the study was to analyze the pathophysiology and treatment of different types of supralevator fistulas.

DESIGN

This was a prospective study.

SETTINGS

The study was conducted at a specialized fistula treatment center in North India.

PATIENTS

All of the patients with fistula-in-ano who presented in the outpatient department were assessed with a physical examination and MRI scan. The patients in whom the supralevator extension was confirmed on MRI were included in the study.

MAIN OUTCOME MEASURES

The MRI scans of patients included in the study were analyzed in detail to assess the types of supralevator fistulas and other characteristics of these fistulas. The patients who were operated on were followed for cure rate and deterioration in incontinence.

RESULTS

Of 702 patients with fistula-in-ano who were analyzed by MRI over a period of 3 years, 51 patients with supralevator fistula-in-ano were identified. The mean age was 44.3 ± 12.1 years and the male:female ratio was 16:1. The incidence of supralevator fistulas was 7.26% (51 of 702). In supralevator fistulas, the supralevator extension (upper part) was found to be in the intersphincteric plane in all of the patients. This upper part could be successfully managed by laying it open through the transanal route. The infralevator (lower) part could be of 3 types: intersphincteric (n = 13), low transsphincteric (n = 3), or high transsphincteric (n = 35). The lower part could be managed conventionally. There were no extrasphincteric fistulas. An extensive review of the literature revealed only 2 studies (total fistulas = 16) in which supralevator fistula was studied.

LIMITATIONS

This was a retrospective study.

CONCLUSIONS

The upper supralevator extension in all of the supralevator fistulas is almost always in the intersphincteric plane. This upper part could be laid open through the transanal route. The lower infralevator part could be of 3 types, intersphincteric, low transsphincteric, or high transsphincteric, which could be managed conventionally. Thus, supralevator fistulas could be managed successfully and easily. See Video Abstract at http://links.lww.com/DCR/A630.