Clinical Practice Guideline for the Management of Anorectal Abscess, Fistula-in-Ano, and Rectovaginal Fistula

Systematic review and meta-analysis of the efficacy and safety of stem cell treatment of anal fistulas

BACKGROUND

Since anal fistulas can be challenging to treat; numerous innovative treatments have been proposed, including stem cell therapy. This systematic review aimed to assess pooled rates of fistula healing and adverse events associated with stem cell treatment.

METHODS

In this PRISMA-compliant systematic review we searched PubMed and Scopus for observational and randomized studies reporting outcomes of stem cell treatment for anal fistulas. The main outcome measures were successful healing and adverse effects of stem cell therapy.

RESULTS

In total, 43 studies incorporating 1160 patients (53.6% male) were included. Underlying fistula etiologies were Crohn's disease (30 studies) and cryptoglandular disease (12 studies). The main origin of stem cells was from adipose tissue (34 studies) or bone marrow (6 studies). The median follow-up duration was 12 months. The combined overall pooled healing rate was 58.1% (95% confidence interval (CI) 51.5-64.7%). The pooled healing rate for Crohn's fistulas was 60.4% (95% CI 54.7-66.2%) with adipose-derived stem cells and 63.6% (95% CI 49.4-77.7%) with bone-marrow-derived cells. The pooled healing rate for cryptoglandular fistulas was 53.8% (95% CI 35.5-72.2%) with adipose-derived stem cells. The pooled complication rate was 37.3% (95% CI 27.1-47.5%). Stem cells were associated with higher odds of anal fistula healing (odds ratio (OR): 1.81, p = 0.003) and similar odds of complications (OR: 1, p = 0.986) compared with controls.

CONCLUSIONS

Stem cell treatment of anal fistulas was associated with promising results. The healing rate in Crohn's anal fistulas was higher than in cryptoglandular fistulas. Bone-marrow-derived stem cells were associated with marginally better outcomes than were adipose-derived cells. This finding suggests that the autoimmune inflammatory etiology of Crohn's disease may respond better to autologous myoblasts than does the infectious etiology of cryptoglandular fistulas.

Sphincter repair procedures may be favored in the treatment of obstetrical recto-vaginal fistula: a systematic review of the literature and meta-analysis

BACKGROUND

The management of obstetric rectovaginal fistula (RVF) is challenging for the surgeon. The best surgical procedure to repair RVFs, specifically after obstetric anal sphincter injury, has not been extensively studied. The objective was to compare the success of the different procedures performed to repair obstetric RVF.

METHODS

The literature search was carried out on PubMed® and Web of Science® from database inception until 31 December 2022. Selection criteria were: (1) patients with a diagnosis of obstetric-related RVF; (2) patients treated surgically with no restriction concerning the considered surgery; (3) clinical trials or epidemiological studies. Meta-analysis was conducted considering the network meta-analysis framework to allow studying the relative value of each treatment mentioned in the selected articles.

RESULTS

The quantitative synthesis included 32 studies (18 retrospective and 14 prospective) accounting for 595 patients. The quality of these studies was low because of the lack of prospective randomization. Nineteen procedure types were described and assessed. Most patients (n = 180) underwent endorectal advancement flap (ERAF) followed by excision and layered closure (ELC) (n = 213) and Musset procedure (n = 65). A diverting stoma was performed in 66/132 patients. Only 13 studies reported the functional results of the procedure. In the meta-analysis, the Musset procedure (OR = 4.29; 95% CI: 1.18-16.14), transvaginal ELC (OR = 11.84; 95% CI: 2.18-91.80) and transperineal ELC (OR = 3.56; 95% CI: 1.26-10) significantly improved the anatomical results compared to ERAF.

CONCLUSIONS

A further randomized controlled trial in the literature assessing ERAF and sphincteroplasty to compare the anatomical results, functional results and morbidity of this treatment is needed.

REGISTRATION

PROSPERO CRD42023447875.

Understanding the anatomical basis of anorectal fistulas and their surgical management: exploring different types for enhanced precision and safety

Anorectal fistulas remain one of the most challenging conditions in colorectal surgery and require precise anatomical knowledge for successful management. This comprehensive review synthesizes the current evidence on the anatomical foundations of fistula development and treatment, particularly focusing on the cryptoglandular hypothesis and its clinical implications. A systematic analysis of the recent literature has examined the relationship between anatomical structures and fistula formation, classification systems, diagnostic modalities, and therapeutic approaches. The review revealed that anatomical considerations fundamentally influence treatment outcomes, with modern imaging techniques achieving up to 98% accuracy in delineating fistula anatomy. Key findings demonstrate that surgical success rates vary significantly based on anatomical complexity: 92-97% for simple fistulas versus 40-95% for complex cases using sphincter-sparing techniques. Emerging minimally invasive approaches and regenerative therapies, including mesenchymal stem cells, show promising results with 50-60% healing rates in complex cases. Special considerations are needed for complex cases such as Crohn's disease-related and rectovaginal fistulas. This review provides surgeons with an evidence-based framework for selecting optimal treatment strategies based on anatomical considerations, emphasizing the importance of preserving the anal sphincter function while achieving complete fistula eradication. Integrating advanced imaging, surgical techniques, and emerging therapies offers new possibilities for improving patient outcomes. This review aimed to bridge the gap between anatomical knowledge and practical surgical application, enhance clinical decision-making, and improve patient outcomes in anorectal fistula management.

A single-center retrospective analysis of endorectal advancement flaps used for the treatment of simple rectovaginal fistulas

OBJECTIVE

To investigate the effectiveness of endorectal advancement flaps for middle and low rectovaginal fistulas.

METHODS

A retrospective cohort of 57 patients who underwent surgery via an endorectal advancement flap in the RVF between July 2007 and March 2022 was generated. The clinical features of the patients were reviewed. The associations between fistula closure and diverse clinical parameters, including age, body mass index, diameter of the fistula, prior repair, pathological type, diverting stoma and operative method, were analyzed.

RESULTS

Congenital (n = 19, 33.33%) and obstetric (n = 19, 33.33%) injuries were the most common etiologies of rectovaginal fistulas. The success rate in patients who underwent a first repair was 66.7%, and the overall success rate was 70.2% after repetition of the same technique. There were no significant differences in the closure rate between the success and failure groups in age, body mass index, prior repair, preoperative colostomy, or pathological type (p > 0.05). However, a diameter greater than 1 cm predicted a lower success rate for both the first repair (p < 0.05) and the overall procedure (p < 0.05). Two cases of failure with a diameter greater than 1 cm succeeded after a sphincter repair procedure half a year later.

CONCLUSION

The endorectal advancement flap is safe and effective for removing simple rectovaginal fistulas at the middle and lower positions. A diameter greater than 1 cm is an independent risk factor for this surgical technique, and sphincteroplasty may be a better choice for this condition.

The role of MRI in perianal fistulizing disease: diagnostic imaging and classification systems to monitor disease activity

Perianal fistulizing disease, commonly associated with Crohn's disease, poses significant diagnostic and therapeutic challenges due to its complex anatomy and high recurrence rates. Radiological imaging plays a pivotal role in the accurate diagnosis, classification, and management of this condition. This article reviews the current radiological modalities employed in the evaluation of perianal fistulizing disease, including magnetic resonance imaging (MRI), endoanal ultrasound, and computed tomography (CT). MRI, recognized as the gold standard, offers superior soft tissue contrast and multiplanar capabilities, facilitating detailed assessment of fistula tracts and associated abscesses. CT, although less detailed than MRI, remains valuable in acute settings for detecting abscesses and guiding drainage procedures. This article discusses the advantages and limitations of each modality, highlights the importance of standardized imaging protocols, and underscores the need for interdisciplinary collaboration in the management of perianal fistulizing disease. Future directions include advancements in imaging techniques and the integration of artificial intelligence to enhance diagnostic accuracy and treatment outcomes.

Efficacy of wound care ointment in healing infectious wounds after anorectal surgery: A randomized controlled trial

BACKGROUND

This study evaluates the efficacy of a novel bismuth subgallate-borneol compound ointment as an adjuvant therapy in promoting postoperative healing of infectious incisions after anorectal surgery.

METHODS

From June 2023 to October 2023, 46 patients with perianal abscess and anal fistula treated at our institution's Anorectal Surgery Department were enrolled in this prospective randomized controlled study. Patients were randomly allocated into 2 groups: the experimental group (n = 23) received conventional wound care plus a proprietary ointment containing 4.5% bismuth subgallate and 0.7% d-borneol in a Vaseline base, while the control group (n = 23 cases) received conventional wound care alone (comprising daily wound cleansing, dressing changes and traditional Chinese medicine injection). Image J Software was used for collecting the data of wound area, and the wound healing rate and granulation growth rate of the 2 groups were calculated to evaluate the therapeutic effect of the 2 groups.

RESULTS

The growth rate of cured granulation in the experimental group was higher than that in the control group at all 3 predetermined observation points, with statistically significant difference (P < .05). Furthermore, the wound healing rate of the experimental group showed significant improvement by day 14 (P < .05).

CONCLUSION

The bismuth subgallate-borneol compound ointment, when used as an adjuvant to standard wound care protocols, demonstrates significant efficacy in treating post-anorectal surgery infectious wounds. Its dual-active component formulation appears to effectively promote both granulation tissue formation and wound healing, potentially through its documented antibacterial properties.

The efficacy of acupuncture in relieving postoperative pain in patients with low simple anal fistula: Protocol of a prospective, randomised, controlled trial

BACKGROUND

Anal fistula surgery often leads to postoperative pain, which can hinder recovery and negatively impact patients' quality of life. This prospective, randomised, controlled trial (RCT) aims to investigate the efficacy of acupuncture in alleviating postoperative pain and reducing the usage of analgesic medications following anal fistula surgery.

METHODS

This single-centre, patient-blinded, assessor-blinded, placebo-controlled randomised controlled trial (RCT) will be conducted at a tertiary referral hospital. A total of 66 patients with low simple anal fistula will be randomised at a 1:1 ratio to receive either acupuncture or sham acupuncture. The primary outcome is the difference in the numerical rating scale (NRS) pain score before and after acupuncture at 6 hours post surgery. The secondary outcomes include postoperative analgesic usage (Day 0 to Day 7), complications (including infection, urinary retention, and bleeding from Day 0 to Day 7, as well as delayed wound healing and recurrence within 3 months post surgery), sleep quality (PSQI from Day 0 to Day 7), psychological state (SDS and SAS on Day 0, Day 1, and Day 7), and overall recovery quality (QoR-15 on Day 1, Day 3, and Day 7). The statistical analysis of this trial will be conducted using SPSS software, validating the normality of data and the homogeneity of variance, and employing t-tests, Mann-Whitney U tests, chi-square tests, and repeated measures ANOVA to analyze baseline data, primary and secondary outcome indicators.

DISCUSSION

This study aims to contribute to the expanding evidence base regarding the role of acupuncture in postoperative pain management. Through a comprehensive assessment of pain relief, analgesic usage, and other recovery-related outcomes, our findings will establish a foundation for standardizing acupuncture protocols specifically tailored for anal fistula surgery patients. The strengths of this trial are rooted in its rigorous randomised controlled trial (RCT) design, comprehensive outcome measures, and focused examination of a clinically significant issue. Ultimately, the findings of this trial have the potential to offer valuable insights into the utility of acupuncture as an adjunctive therapy for postoperative pain management among anal fistula patients, thereby informing future clinical practice and research directions.

TRIAL REGISTRATION

This study was registered in the China Clinical Trial Registry on June 1, 2024, with registration number: ChiCTR2400085178.

The bacterial composition signatures of perianal abscess and origin of infecting microbes

Background

Perianal abscess is a common anal condition primarily caused by bacterial infections, yet the precise origins of these infecting bacteria remain unclear. Understanding the distinct microbial signatures associated with periaabscesses is crucial for provide fresh ideas for disease prevention.

Materials and Methods

Samples of anal skin, feces, and abscesses were collected from a cohort of 75 patients diagnosed with perianal abscesses. The microbial composition at each site was analyzed using 16S rRNA gene sequencing to characterize the bacterial communities present.

Results

Analysis using MaAslin2 revealed distinct bacterial compositional signatures among the anal skin, feces, and abscess samples. Alpha diversity analysis indicated significant differences in bacterial diversity between abscesses, anal skin, and feces, with abscesses showing lower diversity compared to higher richness in feces. Biomarker analysis highlighted key taxa such as Bacteroides and Escherichia-Shisgella in fecal samples, and Staphylococcus and Corynebacterium in anal skin samples. The analysis of abscess samples suggested that the bacterial composition may originate from the skin, feces, and potentially other sources.

The Pouch Corner: Perianal Fistulas and Ileal Pouches: Examining Fistulas Before and After Pouch Creation

Patients with ulcerative colitis (UC) and Crohn’s disease (CD) proctocolitis are candidates for an ileal pouch-anal anastomosis (IPAA), provided they do not suffer from complex perianal fistulas or small bowel inflammation. UC patients who develop a simple perianal fistula may still be candidates for an IPAA; however, patients with complex perianal fistulas are precluded from having an ileal pouch. After an IPAA, patients may develop perianal fistulas that arise acutely from a technical complication or an anastomotic leak, or as late-onset fistulas as a result of CD-like inflammation of the pouch.

Microbiome analysis reveals the potential mechanism of herbal sitz bath complementary therapy in accelerating postoperative recovery from perianal abscesses

The herbal sitz bath formula, as a complementary therapy, effectively alleviates postoperative wound pain and accelerates healing time in patients with perianal abscesses. To investigate its mechanism of action, this study conducted 16S rRNA gene sequencing and bioinformatics analysis on wound exudate samples from patients after perianal abscess surgery. Patients were randomly divided into two groups: one receiving the herbal sitz bath as an adjunctive therapy and the other without this adjunctive therapy. Samples were collected on the first and eighth days after surgery to compare the differences in microbial community composition between the two groups on the eighth day and between the first and eighth days within each group. The study revealed that the herbal sitz bath significantly altered the structure of the microbial community, increasing its diversity and abundance. By reducing Enterococcus and increasing Bifidobacterium, Faecalibacterium, and Ruminococcus, the therapy enhanced the wound's anti-infective capacity and accelerated healing. This study explored the potential mechanism of the herbal sitz bath formula as an adjunctive therapy in promoting postoperative recovery from perianal abscesses, providing valuable data for further research on the role of microorganisms in wound care. These findings contribute to optimising postoperative treatment regimens and facilitating patient recovery.

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.

Comparison of clinical outcomes between remodified Hanley procedure and modified Hanley procedure for high complex horseshoe fistula: a retrospective study

BACKGROUND

Treating high horseshoe anal fistula (HHAF) with the modified Halley procedure (MHP) often falls short when focusing solely on deep postanal space (DPAS) drainage. Our study underscores the significance of addressing deep posterior intersphincteric space (DPIS) drainage, prompting MHP modifications.

METHODS

We studied consecutive patients with HHAF treated with either MHP or remodified-MHP (Re-MHP) at Ningbo Medical Center of Lihuili Hospital from January 2018 to December 2021. Postoperative outcomes, encompassing complications, cure rates, pain, anal incontinence, and quality of life, were retrospectively assessed.

RESULTS

Cure rates for MHP and Re-MHP were 95.3% (41/43) and 82.1% (32/39), respectively, without statistical significance (χ2 = 3.7, P = 0.08). VAS-PS, CCF-IS, and QLAF-QS scores significantly increased postsurgery and gradually decreased. Notably, Re-MHP demonstrated significantly lower VAS-PS scores during the first postoperative week, lower QLAF-QS scores on the seventh day, and more drainage secretions on the first day (P < 0.05).

CONCLUSION

Simultaneously enhancing DPAS and DPIS drainage in Re-MHP can enhance the cure rates of HHAF patients while preserving minimally invasive attributes.

Fascia Lata Biological Plug: A Novel Technique for Treating Anal Fistulae

BACKGROUND

An anal fistula is a prevalent condition characterised by an abnormal connection between the epithelialised surface of the anal canal and the skin. Surgeons are continually developing new techniques to effectively treat anal fistulae while preserving the patient's continence. This study aims to evaluate the outcomes and complications associated with the management of high perianal fistulae using the fascia lata biological plug (FBP) technique.

METHODS

This prospective cohort study included all adult patients who presented to the Kasr Al-Ainy Outpatient Surgery Clinic, Cairo, Egypt, between March 2020 and December 2021, with a single-tract high perianal fistula.

RESULTS

A total of 46 eligible patients were included in the study. The insertion of the FBP was associated with complete healing without recurrence in 37 patients (80.4%) at six months post-surgery. Among the 46 patients, only nine (19.6%) experienced fistula recurrence. The recurrence rate increased to 30.4% at 18 months post-surgery, resulting in an overall success rate of 69.6%. Complete continence was maintained in all patients. At 18 months, extra-sphincteric (14.3% vs 0.0%) and supra-sphincteric (21.4% vs 0.0%) types exhibited significantly higher recurrence rates (p=0.006). Anterior fistulae also demonstrated a significantly higher recurrence rate compared to posterior fistulae (64.3% vs 25.0%, p=0.011).

CONCLUSIONS

The use of a FBP for the treatment of single-tract high perianal fistulae yields promising results without compromising patients' continence. It is essential to consider the type and nature of the anal fistula when selecting the most appropriate procedure for effective treatment.

Effect of incision location and type of fistula on postoperative urinary retention after radical surgery for anal fistula: a retrospective analysis

BACKGROUND

Postoperative urinary retention (POUR) is a common complication characterized by fullness of the bladder without the ability to urinate. Its etiology in proctology surgery is multifactorial. This study aimed to identify the risk factors for POUR after radical surgery for anal fistula.

METHODS

We retrospectively reviewed the clinical records of 511 patients who underwent radical surgery for anal fistula at the China-Japan Friendship Hospital from August 2022 to December 2023. Risk factors for POUR were analyzed by means of binary logistic regression analyses.

RESULTS

POUR occurred in 57 patients (11.2%) within 48 h post-surgery, and males were predominantly affected (84.4%). Independent risk factors included a history of urological disease (OR = 6.048; p < 0.001), incisions at position 1 (OR = 2.228; p = 0.046), high anal fistula (OR = 4.768; p < 0.001), VAS score ≥ 7 (OR = 2.805; p = 0.010), and GAD-7 score ≥ 5 (OR = 2.405; P = 0.024).

CONCLUSION

POUR is a significant complication post-radical surgery for anal fistula, particularly among patients with urological disease, high anal fistula, and incisions at position 1. Surgeons should pay more attention to surgical methods for high anal fistulas and fistulas in the anterior rectum, and monitor postoperative bladder volume in high-risk patients. Enhanced postoperative pain and anxiety management can reduce the incidence of POUR and prevent long-term bladder damage.

Efficacy of radial incision combined with tunnel floating line drainage in the treatment of high posterior horseshoe anal fistula and perianal flora: Randomized control trial

BACKGROUND

Due to the high prevalence of posterior horseshoe anal fistula and causing numerous complications, this study aimed to investigate the clinical effect of radial incision combined with tunnel floating line drainage (RCTD) and arc incision internal drainage in the treatment of the disease and the influence on perianal flora.

METHODS

Ninety-six subjects treated with high posterior horseshoe anal fistula were stochastically assigned to a joint group (RCTD), and control group (arc incision internal drainage). The operation-related conditions, complication rate, anal function, and recurrence rate of 6 months after operation were compared, and perianal secretions were collected before operation and 1 day after operation to detect the changes of microbial flora.

RESULTS

After operation, it was corroborated notable difference between joint group and control group in operation time, intraoperative blood loss, wound healing time, visual analogue scale score 6 hours after operation and phase I cure rate. Chi square test analysis showed notable difference between control group (27.08%) and joint group (10.40%) in incidence of complications, in terms of number of pathogens detected around anus, significantly smaller of the incremental change for the joint subgroup versus the control subgroup 1 day after operation.

CONCLUSION

RCTD can be the best choice for patients with high posterior horseshoe anal fistula. This operation method has the advantages of short operation time, less trauma, fewer complications, fast recovery of anal function, and can also reduce perianal pathogenic bacteria infection.

"Emergency Room Incision and Drainage of Perirectal Abscess is Equivalent to Incision and Drainage in the Operating Room"

BACKGROUND

Current guidelines for management of anorectal abscesses make no recommendations for operative vs bedside incision and drainage (I&D). The purpose of this study was to determine if management in the operating room is necessary to adequately drain anorectal abscesses and prevent short-term complications for patients presenting to the emergency department (ED).

METHODS

Patients with perirectal abscesses were identified and divided into two groups based on intervention type: "bedside" or "operative." Demographic, laboratory, and encounter data were obtained from the medical record. Study outcomes included 30-day complications (return to the ED, reintervention, and readmission). Data were analyzed with univariate and multivariate analyses using SPSS (version 28).

RESULTS

A total of 113 patients with anorectal abscesses were identified. Sixty-six (58%) underwent bedside I&D and 47 (42%) operative I&D. The overall complication rate was 10%. A total of 9 patients (6 bedside and 3 operative) returned to the ED. Six of these patients required reintervention (5 bedside and 1 operative), and 1 was readmitted. Two patients from the bedside group required a second I&D during their index admission. Pre-procedure SIRS (P = .02) was found to be associated with 30-day complications. Provider specialty and training level were not associated with 30-day complications.

DISCUSSION

In this study, for patients presenting to the ED, bedside drainage was found to be an adequate management strategy to achieve complete drainage without a significant increase in the rate of complications when compared to operative drainage.

Clinical Course of Isolated Recurrent, Persistent Complex Perianal Fistulas Without Luminal Crohn's Disease: A Multicenter Case Series of 24 Patients

Background

Isolated complex perianal fistulas, without luminal evidence of inflammatory bowel disease in the gastrointestinal tract, pose diagnostic and treatment dilemmas for gastroenterologists and colorectal surgeons. For patients who develop recurrent complex fistulas, a presumptive diagnosis of Crohn's disease may be made. It is unclear whether these cases of isolated perianal disease in the absence of luminal inflammation truly represent isolated severe cryptoglandular fistulas or rather an early presentation of Crohn's disease. We aimed to investigate the clinical course and outcomes of patients with isolated complex perianal fistulas.

Methods

In this retrospective multicenter case series across 6 institutions in the United States, we report the clinical course of patients with isolated recurrent complex perianal fistulas, including their diagnostic evaluation, medical and surgical therapies, and clinical outcomes.

Results

All patients (n = 24) required incision and drainage of perirectal abscesses. The majority received setons (n = 19, 79%), more intensive surgical interventions (n = 15, 62.5%, including fistulotomy/sphincterotomy, advancement flap, and ligation of the intersphincteric fistula tract), antibiotics (n = 17, 71%), and biologic therapy (n = 16, 67%). Nine patients (37.5%) underwent a combined medical-surgical approach with biologics and intensive surgical intervention. Despite surgical and/or medical management, active symptomatic complex perianal fistulas persisted in 58% (n = 14) of patients at follow-up (median 5.5 years, interquartile range 2.5-10 years); symptom remission was achieved in 21% (n = 5), and fistula closure in 21% (n = 5).

Conclusions

These cases highlight a multidisciplinary and multimodal approach when treating isolated complex perianal fistulas and their propensity to persist despite the incorporation of advanced therapies.

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.

Case report: is necrotizing fasciitis in a rectal cancer patient after targeted systemic therapy related to the tumor site? - evidence from a hepatocellular carcinoma patient

Necrotizing fasciitis (NF) is a rare and life-threatening serious infectious disease, characterized by acute onset and rapid progress, leading to extensive necrosis of skin, soft tissue as well as fascia by a variety of aerobic and anaerobic bacteria, localized on external genitalia, scrotum, groin and perianal areas in males. There exist numerous common etiologies for NF, yet NF induced by malignant neoplasms is exceedingly rare. Several studies have reported that NF may be associated with tumor site (rectal/sigmoid colon cancer) and blood supply dysfunction caused by targeted therapy drugs (bevacizumab, aflibercept, ramucirumab). The perforation of colorectal cancer poses a unique risk factor for NF. However, in our two cases, the patient with rectal cancer received CapeOX (oxaliplatin + capecitabine) + bevacizumab + tislelizumab for 3 cycles without perforation but did develop NF. One month after debridement, the patient continued immunotherapy with tislelizumab alone for the fourth cycle and maintained for an additional 3 cycles without any recurrence of NF. Therefore, does the occurrence of NF correlate with the tumor site (rectum) and targeted immunotherapy? Another patient with hepatocellular carcinoma also developed NF after receiving 2 cycles of lenvatinib + sintilimab treatment. The third cycle of sintilimab immunotherapy was administered on the 13th day after operation, which was subsequently maintained for an additional 2 cycles without recurrence of NF. The absence of a direct correlation between hepatocellular carcinoma and rectal tumor location as well as immunotherapy, suggests that NF may be closely linked to targeted therapy.

Diagnostic Value of SAA Levels and Perianal Symptoms in the Complicated Perianal Abscesses Among Mpox-Infected Patients

Objective

Precise prediction of the occurrence of complicated perianal abscesses (PAs) in monkeypox (mpox)-infected patients is important for therapeutic optimization. This study sought to identify risk factors of complicated PA.

Methods

A total of 48 patients with mpox infection (PA group, n = 10; non-PA (NPA) group, n = 38) were enrolled in our study, who were hospitalized in Hangzhou Xixi Hospital, China from 29 June to 3 September 2023. The data of demographic characteristics, and clinical symptoms, serum SAA, PCT, CRP, and IL-6 levels were collected by the Electronic Medical Record. The diagnostic values of these biomarkers were assessed using multivariate logistic regression and ROC curve analyses.

Results

A decrease in serum IL-6, SAA, and CRP levels (all p-value < 0.05), but not PCT, was observed in all mpox-infected patients. A significant positive correlation was also noted between IL-6, SAA, CRP, and PCT levels (all p-value < 0.05). There was a significant increase in IL-6 and SAA levels and the SAA/CRP ratio in serum samples from patients in the PA group. Multivariate logistic regression and ROC curve analyses identified that the combined use of perianal symptoms and SAA was more sensitive than perianal symptoms or SAA alone as predictors of complicated PA. This combination had the highest predictive value for disease progression, with an AUC of 0.920 (p-value < 0.001).

Conclusion

The combination of perianal symptoms and SAA levels was strongly linked to the occurrence of complicated PA in mpox-infected patients. These findings may inform the early diagnosis of this patient population.

Martius flaps for low rectovaginal fistulae: a systematic review and proportional meta-analysis

BACKGROUND

Rectovaginal fistulae (RVF) are notoriously challenging to treat. Martius flap (MF) is a technique employed to manage RVF, among various others, with none being universally successful. We aimed to assess the outcomes of RVF managed with MF interposition.

METHODS

A PRISMA-compliant meta-analysis searching for all studies specifically reporting on the outcomes of MF for RVF was performed. The primary objective was the mean success rate, whilst secondary objectives included complications and recurrence. The MedCalc software (version 20.118) was used to conduct proportional meta-analyses of data. Weighted mean values with 95% CI are presented and stratified according to aetiology where possible.

RESULTS

Twelve non-randomized (11 retrospective, 1 prospective) studies, assessing 137 MF were included. The mean age of the study population was 42.4 (±15.7), years. There were 44 primary and 93 recurrent RVF. The weighted mean success rate for MF when performed for primary RVF was 91.4% (95% CI: 79.45-98.46; I2 = 32.1%; P = 0.183) and that for recurrent RVF was 77.5% (95% CI: 62.24-89.67; I2 = 58.1%; P = 0.008). The weighted mean complication rate was 29% (95% CI: 8.98-54.68; I2 = 85.4%; P < 0.0001) and the overall recurrence rate was 12.0% (95% CI: 5.03-21.93; I2 = 52.3%; P = 0.021). When purely radiotherapy-induced RVF were evaluated, the mean overall success rate was 94.6% (95% CI: 83.33-99.75; I2 = 0%; P = 0.350).

CONCLUSIONS

MF interposition appears to be more effective for primary than recurrent RVF. However, the poor quality of the data limits definitive conclusions being drawn and demands further assessment with randomized studies.

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.

Rectovaginal Fistula: What Is the Role of Martius Flap and Gracilis Muscle Interposition in the Therapeutic Strategy?

BACKGROUND

Although numerous treatments exist for the management of rectovaginal fistula, none has demonstrated its superiority. The role of diverting stoma remains controversial. A few series include Martius flap in the armamentarium.

OBJECTIVE

Determine the role of gracilis muscle interposition and Martius flap in the surgical management of rectovaginal fistula.

DESIGN

Retrospective cohort study of a pooled prospectively maintained database from 3 centers.

PATIENTS

All consecutive eligible patients with rectovaginal fistula undergoing Martius flap and gracilis muscle interposition were included from 2001 to 2022.

MAIN OUTCOME MEASURES

Success was defined by the absence of stoma and rectovaginal fistula.

RESULTS

Sixty-two patients were included with 55 Martius flap and 24 gracilis muscle interposition performed after failures of 164 initial procedures. Total length of stay was longer for gracilis muscle interposition by 2 days ( p = 0.01) without a significant difference in severe morbidity (20% vs 12%, p = 0.53). Twenty-seven percent of the Martius flap interpositions were performed without a stoma, which did not have an impact on overall morbidity ( p = 0.763). Per patient immediate success rates were not significantly different between groups (35% vs 31%, p > 0.99). The success of gracilis muscle interposition after the failure of the Martius flap was not significantly different from an initial gracilis muscle interposition ( p > 0.99). After simple perineal procedures, the immediate success rate rose to 49.4% (49% vs 50%, p > 0.99). After a median follow-up of 23 months, no significant difference was detected in success rate between the 2 procedures (69% vs 69%, p > 0.99). Smoking was the only negative predictive factor ( p = 0.02).

LIMITATIONS

By its retrospective nature, this study is limited in its comparison.

CONCLUSIONS

This novel comparison between Martius flap and gracilis muscle interposition suggests that Martius flap presents several advantages, including shorter length of stay, similar morbidity, and similar success rate. Proximal diversion via a stoma for Martius flap does not appear mandatory. Gracilis muscle interposition could be reserved as a salvage procedure after Martius flap failure. See Video Abstract .

FSTULA RECTOVAGINAL CUL ES EL ROL DEL COLGAJO DE MARTIUS Y LA INTERPOSICIN DEL MSCULO GRACILIS EN LA ESTRATEGIA TERAPUTICA

ANTECEDENTES:Si bien existen numerosos tratamientos para el manejo de la fistula rectovaginal, ninguno ha demostrado su superioridad. El papel del estoma de derivación sigue siendo controvertido. Pocas series incluyen colgajo de Martius en el armamento.OBJETIVO:Determinar el rol de la interposición del músculo gracilis y del colgajo de Martius, en el manejo quirúrgico de la fístula rectovaginal.DISEÑO:Estudio de cohorte retrospectivo de una base de datos mantenida prospectivamente en 3 centros.AJUSTES/PACIENTES:Se incluyeron todos los pacientes elegibles consecutivos con fistula rectovaginal sometidos a colgajo de Martius y la interposición del músculo gracilis desde 2001 hasta 2022.RESULTADOS PRINCIPALES:El éxito se definió por la ausencia de estoma y fistula rectovaginal.RESULTADOS:Se incluyeron 62 pacientes con 55 colgajo de Martius y 24 con interposición del músculo gracilis realizados después de fracasos de 164 procedimientos iniciales. La duración total de la estancia hospitalaria fue dos días más larga para la interposición del músculo gracilis ( p = 0,01) sin una diferencia significativa en la morbilidad grave (20% frente a 12%, p = 0,53). El 27% de los colgajos de Martius se realizaron sin estoma, sin impacto en la morbilidad global ( p = 0,763). Las tasas de éxito inmediato por paciente no fueron significativamente diferentes entre los grupos (35% vs. 31%, p = 1,0). El éxito de la interposición del músculo gracilis después del fracaso del colgajo de Martius no fue significativamente diferente de una interposición del músculo gracilis inicial (p = 1,0). La tasa de éxito inmediato aumentó al 49,4% (49% frente a 50%, p = 1,0) después de procedimientos perineales simples. Después de una mediana de seguimiento de 23 meses, no se detectaron diferencias significativas en la tasa de éxito entre los dos procedimientos (69 % frente a 69 %, p = 1,0). El tabaquismo fue el único factor predictivo negativo ( p = 0,02).LIMITACIONES:Por su naturaleza retrospectiva, este estudio tiene limitaciones en su comparación.CONCLUSIÓN:Esta novedosa comparación entre colgajo de Martius y la interposición del músculo gracilis sugiere que el colgajo de Martius presenta varias ventajas, incluida una estancia prolongada más corta, una morbilidad similar y un éxito. La derivación proximal a través de un estoma para el colgajo de Martius no parece obligatoria. La interposición del músculo gracilis podría reservarse como procedimiento de rescate después de una falla de colgajo de Martius. (Traducción-Dr. Aurian Garcia Gonzalez ).

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.

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.

Accuracy prediction of Goodsall's rule for anal fistulas of crypotogladular origin, is still standing?

Background

Treatment of anal fistulas is still a challenging task because of high recurrence and risk of incontinence. Identification of internal fistula opening is paramount for successful treatment. Goodsall's rule is commonly used to predict the course of fistula and internal opening. However, its accuracy has been questioned by many investigators and its role became a controversial topic.

Method

This is a case series prospective study in which 320 consecutive patients with anal fistula with Mean age 48.9± 6 years ages (ranges from 16 to 64 years) and mean body mass index 24.8± 5.5 average 18.5-30.6) were enroled. Goodsall's rule was applied to all fistulas according to the site of external fistula opening. Location of internal fistula opening as suggested by Goodsall's rule then compared to the exact location of internal opening identified by perineal or pelvic MRI and intraoperative findings. to assess the accuracy and positive predictive value of the Goodsall's rule in predicting the internal opening of the tract.

Results

The overall accuracy rate, positive predictive value (PPV), sensitivity and specificity of Goodsall's rule in this study were 74.75%, 77.1, 74.5, and 72.05, respectively. The accuracy in predicting the internal fistula opening was 52.4% in anterior tracts and 73% in posterior tracts. Goodsall's rule was found to be more accurate in posterior fistulas than anterior fistulas and in short superficial fistulas rather than in long and high fistulas.

Conclusion

Goodsall's rule was accurate in 74.75% of anal fistulas. It was more accurate for posterior long fistulas and anterior short and superficial fistulas. Patients with long (>3 cm) anterior fistulas defied Goodsall's rule when they found to have fistulas tracking to a midline anterior origin. Further, short posterior fistulas were found to open more commonly in a direct radial course rather to midline posteriorly.

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.

Rectovaginal Fistulas Not Involving the Rectovaginal Septum Should Be Treated Like Anal Fistulas: A New Concept and Proposal for a Reclassification of Rectovaginal Fistulas

Background

Many rectovaginal fistulas(RVF), especially low RVF, do not involve/penetrate the RV-septum, but due to lack of proper nomenclature, such fistulas are also managed like RVF (undertaking repair of RV-septum) and inadvertently lead to the formation of a high RVF (involving RV-septum) in many cases. Therefore, REctovaginal Fistulas, Not Involving the Rectovaginal Septum, should be Treated like Anal fistulas(RENISTA) to prevent any risk of injury to the RV septum. This concept(RENISTA) was tested in this study.

Methods

RVFs not involving RV-septum were managed like anal fistulas, and the RV-septum was not cut/incised. MRI, objective incontinence scoring, and anal manometry were done preoperatively and postoperatively. High RVF (involving RV-septum) were excluded.

Results

Twenty-seven patients with low RVF (not involving RV-septum) were operated like anal fistula[age:35.2±9.2 years, median follow-up-15 months (3-36 months)]. 19/27 were low fistula[<1/3 external anal sphincter(EAS) involved] and fistulotomy was performed, whereas 8/27 were high fistula (>1/3 EAS involved) and underwent a sphincter-sparing procedure. Three patients were excluded. The fistula healed well in 22/24 (91.7%) patients and did not heal in 2/24 (8.3%). The healing was confirmed on MRI, and there was no significant change in mean incontinence scores and anal pressures on tonometry. RV-septum injury did not occur in any patient.

Conclusions

RVF not involving RV-septum were managed like anal fistulas with a high cure rate and no significant change in continence. RV-septum injury or formation of RVF with septum involvement did not occur in any patient. The RENISTA concept was validated in the present study. A new classification was developed to prevent any inadvertent injury to the RV-septum.

Perianal Fistula; from Etiology to Treatment - A Review

Anal fistula has been a challenging clinical issue for years due to its complex pathogenesis. The risk of frequent recurrence and incontinence complicates long-term treatment. Recent scientific literature has reviewed new techniques used for anal fistula treatment in recent years, assessing the advantages and disadvantages of each based on clinical outcomes. Although surgery is the main method used to treat anal fistula, there is no simple technique that can completely heal complex anal fistula. The surgical treatment should consider the healing outcome and the protection of anal function comprehensively. Several innovative techniques have emerged in recent years, such as combined techniques based on drainage seton and LIFT-plug, which appear to be relatively effective therapies. However, more multi-center prospective trials with long-term follow-up are needed to validate their effectiveness. In some situations, medical treatment may also be considered.

Cell-assisted lipotransfer in treating uncontrollable sepsis associated perianal fistula: a pilot study

PURPOSE

Surgeons can treat debilitating conditions of uncontrollable complex anorectal fistulas with sepsis, even after repeated fistula surgeries, for curative intention. Adipose-derived stem cells have shown good outcomes for refractory Crohn fistula. Unfortunately, cell therapy has some limitations, including high costs. We have therefore attempted immediate cell-assisted lipotransfer (CAL) in treating refractory complex anal fistulas and observed its outcomes.

METHODS

In a retrospective study, CAL, using a mixture of freshly extracted autologous stromal vascular fraction (SVF) and fat tissues, was used to treat 22 patients of refractory complex anal fistula from March 2018 to May 2021. Preoperative and postoperative assessments were performed with direct visual inspection, digital palpation, and endoanal ultrasonography. A fistula was considered completely healed if (1) the patient had no symptoms of discharge or inflammation; (2) there were no visible secondary openings of fistula tract inside and outside of the anorectal unit and even in the perineum; and (3) there was no primary opening in the anus. The endpoint of complete remission was wound healing without signs of inflammation 3 months after CAL treatment.

RESULTS

In a total of 22 patients who received CAL treatment, 19 patients showed complete remission, 1 patient showed partial improvement, and 2 patients showed no improvement. One of the 2 patients without improvement at primary endpoint showed complete remission 9 months after CAL. There were no significant adverse effects of the procedure.

CONCLUSION

We found that the immediately-collected CAL procedure for refractory complex anal fistula showed good outcomes without adverse side effects. It can be strongly recommended as an alternative surgical option for the treatment of complex anal fistula that is uncontrollable even after repeated surgical procedures. However, considering the unpredictable characteristics of SVF, long-term follow-up is necessary.

Dynamic contrast-enhanced MR imaging in identifying active anal fistula after surgery

BACKGROUND

It is challenging to identify residual or recurrent fistulas from the surgical region, while MR imaging is feasible. The aim was to use dynamic contrast-enhanced MR imaging (DCE-MRI) technology to distinguish between active anal fistula and postoperative healing (granulation) tissue.

METHODS

Thirty-six patients following idiopathic anal fistula underwent DCE-MRI. Subjects were divided into Group I (active fistula) and Group IV (postoperative healing tissue), with the latter divided into Group II (≤ 75 days) and Group III (> 75 days) according to the 75-day interval from surgery to postoperative MRI reexamination. MRI classification and quantitative analysis were performed. Correlation between postoperative time intervals and parameters was analyzed. The difference of parameters between the four groups was analyzed, and diagnostic efficiency was tested by receiver operating characteristic curve.

RESULTS

Wash-in rate (WI) and peak enhancement intensity (PEI) were significantly higher in Group I than in Group II (p = 0.003, p = 0.040), while wash-out rate (WO), time to peak (TTP), and normalized signal intensity (NSI) were opposite (p = 0.031, p = 0.007, p = 0.010). Area under curves for discriminating active fistula from healing tissue within 75 days were 0.810 in WI, 0.708 in PEI, 0.719 in WO, 0.783 in TTP, 0.779 in NSI. All MRI parameters were significantly different between Group I and Group IV, but not between Group II and Group III, and not related to time intervals.

CONCLUSION

In early postoperative period, DCE-MRI can be used to identify active anal fistula in the surgical area.

TRIAL REGISTRATION

Chinese Clinical Trial Registry: ChiCTR2000033072.

National observational study about the surgical treatment of anal fistula: Does the kind of hospital modify the results?

INTRODUCTION

Performing the surgical procedure in a high-volume center has been seen to be important for some surgical procedures. However, this issue has not been studied for patients with an anal fistula (AF).

MATERIAL AND METHODS

A retrospective multicentric study was performed including the patients who underwent AF surgery in 2019 in 56 Spanish hospitals. A univariate and multivariate analysis was performed to analyse the relationship between hospital volume and AF cure and fecal incontinence (FI).

RESULTS

1809 patients were include. Surgery was performed in a low, middle, and high-volume hospitals in 127 (7.0%), 571 (31.6%) y 1111 (61.4%) patients respectively. After a mean follow-up of 18.9 months 72.3% (1303) patients were cured and 132 (7.6%) developed FI. The percentage of patients cured was 74.8%, 75.8% and 70.3% (p = 0.045) for low, middle, and high-volume hospitals. Regarding FI, no statistically significant differences were observed depending on the hospital volume (4.8%, 8.0% and 7.7% respectively, p = 0.473). Multivariate analysis didńt observe a relationship between AF cure and FI.

CONCLUSION

Cure and FI in patients who underwent AF surgery were independent from hospital volume.

The use of core descriptors from the ENiGMA code study in recent literature: a systematic review

AIM

The heterogeneity in data quality presented in studies regarding Crohn's anal fistula (CAF) limit extrapolation into clinical practice. The ENiGMA collaborators established a core descriptor set to standardize reporting of CAF. The aim of this work was to quantify the use of these descriptors in recent literature.

METHOD

We completed a systematic review of PubMed and the Cochrane Library, extracting publications from the past 10 years specific to the clinical interventions and outcomes of CAF, and reported in line with PRISMA guidance. Each article was assessed for inclusion of ENiGMA descriptors. The median number of descriptors per publication was evaluated along with the overall frequency of each individual descriptor. Use of ENiGMA descriptors was compared between medical and procedural publications.

RESULTS

Ninety publications were included. The median number of descriptors was 15 of 37; 16 descriptors were used in over half of the publications while 17 were used in fewer than a third. Descriptors were more frequently used in procedural (n = 16) than medical publications (n = 14) (p = 0.031). In procedural publications, eight descriptors were more frequently used including Faecal incontinence, Number of previous fistula interventions, Presence and severity of anorectal stenosis and Current proctitis. Medical publications were more likely to include Previous response to biological therapy and Duration and type of current course of biological therapy.

CONCLUSION

With many descriptors being used infrequently and variations between medical and procedural literature, the colorectal community should assess the need for all 37 descriptors.

Preoperative assessment of fistula-in-ano using SonoVue enhancement during three-dimensional transperineal ultrasound

Background

Accurate preoperative evaluation of fistula-in-ano can guide the choice of surgical procedure and may improve healing rates. This prospective study aimed to evaluate the accuracy of conventional 3D transperineal ultrasound (3D-TPUS) compared with SonoVue (SVE)-enhanced 3D-TPUS for the detection and classification of anal fistula.

Methods

In this prospective study, 3D-TPUS reconstructions were performed before and after SVE enhancement in 60 patients with fistula-in-ano who intended to undergo surgery at the Department of Anorectal Surgery, Qilu Hospital, Cheeloo College of Medicine, Shandong University (P. R. China) between January 2021 and October 2021. Accuracies of anal fistula classification, complexity classification, detection of anal fistula branches, and detection of internal opening between 3D-TPUS and SVE 3D-TPUS were compared based on a reference standard-intraoperative findings.

Results

This study enrolled 60 patients (mean age, 37.1 ± 11.4 years; mean follow-up, 9 ± 3 months). Intraoperative findings showed that the fistula type was intersphincteric in 23 patients (38.3%), trans-sphincteric in 35 (58.3%; 12 high and 23 low), and suprasphincteric in 2 (3.3%). Moreover, 68 internal openings were found. Compared with the accuracy of 3D-TPUS, that of SVE 3D-TPUS was similar in fistula classification [95.0% (57/60) vs 96.7% (58/60), P = 0.392], but significantly higher in internal opening evaluation [80.9% (55/68) vs 97.1% (66/68), P = 0.001], complexity classification [85.0% (51/60) vs 98.3% (59/60), P = 0.018], and detection of fistula branches [70.4% (19/27) vs 92.6% (25/27), P = 0.031].

Conclusions

SVE 3D-TPUS may be a useful examination for patients with perianal fistulae because of its high accuracy and consistency with intraoperative findings, especially in complex fistula-in-ano and difficult cases.

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.

European Society of Coloproctology: Guidelines for diagnosis and treatment of cryptoglandular anal fistula

AIM

The primary aim of the European Society of Coloproctology (ESCP) Guideline Development Group (GDG) was to produce high-quality, evidence-based guidelines for the management of cryptoglandular anal fistula with input from a multidisciplinary group and using transparent, reproducible methodology.

METHODS

Previously published methodology in guideline development by the ESCP has been replicated in this project. The guideline development process followed the requirements of the AGREE-S tool kit. Six phases can be identified in the methodology. Phase one sets the scope of the guideline, which addresses the diagnostic and therapeutic management of perianal abscess and cryptoglandular anal fistula in adult patients presenting to secondary care. The target population for this guideline are healthcare practitioners in secondary care and patients interested in understanding the clinical evidence available for various surgical interventions for anal fistula. Phase two involved formulation of the GDG. The GDG consisted of 21 coloproctologists, three research fellows, a radiologist and a methodologist. Stakeholders were chosen for their clinical and academic involvement in the management of anal fistula as well as being representative of the geographical variation among the ESCP membership. Five patients were recruited from patient groups to review the draft guideline. These patients attended two virtual meetings to discuss the evidence and suggest amendments. In phase three, patient/population, intervention, comparison and outcomes questions were formulated by the GDG. The GDG ratified 250 questions and chose 45 for inclusion in the guideline. In phase four, critical and important outcomes were confirmed for inclusion. Important outcomes were pain and wound healing. Critical outcomes were fistula healing, fistula recurrence and incontinence. These outcomes formed part of the inclusion criteria for the literature search. In phase five, a literature search was performed of MEDLINE (Ovid), PubMed, Embase (Ovid) and the Cochrane Database of Systematic Reviews by eight teams of the GDG. Data were extracted and submitted for review by the GDG in a draft guideline. The most recent systematic reviews were prioritized for inclusion. Studies published since the most recent systematic review were included in our analysis by conducting a new meta-analysis using Review manager. In phase six, recommendations were formulated, using grading of recommendations, assessment, development, and evaluations, in three virtual meetings of the GDG.

RESULTS

In seven sections covering the diagnostic and therapeutic management of perianal abscess and cryptoglandular anal fistula, there are 42 recommendations.

CONCLUSION

This is an up-to-date international guideline on the management of cryptoglandular anal fistula using methodology prescribed by the AGREE enterprise.

Simplified dressing change after surgery for high anal fistula: A prospective, single centre randomized controlled study on loose combined cutting seton (LCCS) technique

BACKGROUND

Dressing change is the most important part of postoperative wound care. The aim of this study was to evaluate whether a more effective, simple and less painful method of dressing change for anal fistulas could be found without the need for debridement and packing. Data related to postoperative recovery were recorded at postoperative days 3, 7, 14, 21 and 180.

METHODS

In this experiment, 76 subjects diagnosed with high anal fistula were randomly divided into a simplified dressing change (SDC) group and a traditional debridement dressing change(TDDC) group according to a ratio of 1:1.

RESULTS

The SDC group had significantly fewer pain scores, bleeding rates, dressing change times, inpatient days and lower average inpatient costs than the TDDC group. There were no significant differences in wound healing time, area and depth and Wexner score between the two groups.

CONCLUSIONS

Studies have shown that the use of simplified dressing changes does not affect cure or recurrence rates, but significantly reduces dressing change times and pain during changes, reducing patient inpatient length of stay and costs.

Cutting seton for the treatment of cryptoglandular fistula-in-ano: a systematic review and meta-analysis

BACKGROUND

The use of cutting seton (CS) for the management of cryptoglandular fistula-in-ano has remained controversial because of reports of fecal incontinence, postoperative pain, and extended healing time. The aim of this review was to provide the first synthesis of studies investigating the use of CS for the treatment of cryptoglandular fistula-in-ano.

METHODS

MEDLINE, Embase, and CENTRAL were searched up to October 2022. Randomized controlled trials and observational studies comparing CS with alternative interventions were included, along with single-arm studies evaluating CS alone. The primary outcome was fistula-in-ano recurrence, and secondary outcomes included incontinence, healing time, proportion with complete healing, and postoperative pain. Inverse variance random-effects meta-analyses were used to pool effect estimates.

RESULTS

After screening 661 citations, 29 studies were included. Overall, 1513 patients undergoing CS (18.8% female, mean age: 43.1 years) were included. Patients with CS had a 6% (95% CI: 3-12%) risk of recurrence and a 16% (95% CI: 5-38%) risk of incontinence at 6 months. CS patients had an average healing time of 14.6 weeks (95% CI: 10-19 weeks) with 73% (95% CI: 48-89%) of patients achieving complete healing at 6 months postoperatively. There was no difference in recurrence between CS and fistulotomy, advancement flap, two-stage seton fistulotomy, or draining seton.

CONCLUSIONS

Overall, this analysis shows that CS has comparable recurrence and incontinence rates to other modalities. However, this may be at the expense of more postoperative pain and extended healing time. Further comparative studies between CS and other modalities are warranted.

Sacral Neuromodulation for defecation disorders after non oncologic pelvic surgery

PURPOSE

Defecation disorders (DD) can sometimes affect the outcomes of pelvic or colorectal surgery. The aim of the present study is to evaluate the role of sacral neuromodulation for the treatment of constipation and other evacuation disorders after surgery.

METHODS

A retrospective analysis in all the consecutive patients that underwent sacral nerve modulation (SNM) for DD arisen or worsened after pelvic or colorectal surgery was performed from January 2010 to December 2020. DD were defined starting from Rome IV Criteria, and according to manometric results, all patients were further divided into the two subgroups: inadequate defecatory propulsion and dyssynergic defecation. Cleveland Clinic Constipations Score (CCCS) and SF-36 have been evaluated in the time.

RESULTS

Thirty-seven patients have been included in the study. Twenty-seven out of thirty-seven (73.3%) patients had experienced sufficient benefits to implant the definitive device, and 22 patients (59.4% of tested and 81.5% of permanently implanted) still had the device functioning after a mean follow-up of 6.3 years. The most represented manometric pattern was inadequate propulsive function (59% of patients). CCCS at preoperative assessment for all patients was 17.5 with a reduction to 10.4 at the first year of follow-up (p < 0.001).

CONCLUSION

SNM appears to be a feasible, safe, and well-tolerated procedure with durable benefit in the long-term treatment of defecatory dysfunction after pelvic or colorectal surgery for benign diseases.

Role of Microbiome in the Outcomes Following Surgical Repair of Perianal Fistula: Prospective Cohort Study Design and Preliminary Results

BACKGROUND

Anal fistulae are common, predominantly cryptoglandular, and almost invariably require surgical treatment. Recurrences are common for procedures other than fistulotomy regardless of technique and adequacy of repair. Growing evidence supports the pivotal role of specific intestinal bacteria in anastomotic failures after bowel resection. Anal crypts harbor colonic microbiota suggesting that similar mechanisms to anastomotic healing might prevail after anal fistula repair and hence influence healing. This study aims at assessing the potential role of the intestinal microbiome in the clinical outcomes after surgical repair of cryptoglandular anal fistula.

METHODS

This is a pilot prospective cohort study enrolling patients with anal fistula undergoing endoanal advancement flap. For microbiome analysis, stool samples are taken via rectal swab before the procedure; additionally, a portion of the fistula is collected intraoperatively after fistulectomy. Samples from groups with treatment failure are compared to samples from patients who healed after surgical repair. Alpha and beta diversities and differential abundance of microbial taxa are determined and compared between groups with DADA2 analytical pipeline.

RESULTS

Five patients have been enrolled to date (one female, four male). At median follow-up of 6 months (2-11), one patient experienced disease recurrence at 3 months. DNA from the 5 rectal swab and tissue samples was extracted, showing increased relative abundance of Enterococcus faecalis in samples from the patient who developed a recurrent fistula but not in those without recurrence.

CONCLUSION

These very preliminary data suggest that intestinal microbiome may represent a crucial determinant of the surgical outcomes after anal fistula surgery.

Turnbull-Cutait Pull-Through Procedure Is an Alternative to Permanent Ostomy in Patients With Complex Pelvic Fistulas

BACKGROUND

A permanent stoma is frequently recommended in the setting of complex or recurrent rectovaginal fistulas because of the high failure rate of reconstructive procedures. The Turnbull-Cutait pull-through procedure is a salvage operation for motivated patients desiring to avoid permanent fecal diversion.

OBJECTIVE

To analyze the cure rates of complex rectovaginal fistulas after the Turnbull-Cutait pull-through procedure based on cause.

DESIGN

After the institutional review approval board, a retrospective review of women who underwent the procedure (1993-2018) for a rectovaginal fistula was conducted. Patients' demographics, cause, and postoperative outcomes were analyzed.

SETTING

Colorectal surgery department at a tertiary center in the United States.

PATIENTS

Adult women with a rectovaginal fistula who underwent a colonic pull-through procedure were included.

MAIN OUTCOME MEASURES

Recurrence after the colonic pull-through procedure.

RESULTS

There were 81 patients who underwent colonic pull-through; of those, 26 patients had a rectovaginal fistula, had a median age of 51 (43-57) years, and had a mean BMI of 28 ± 3.2 kg/m 2 . A total of 4 patients (15%) had a recurrence and 85% of the patients healed. Ninety-three percent of the patients healed after the prior anastomotic leak. Patients with a Crohn's disease-related fistula had a 75% cure rate. The Kaplan-Meier analysis showed a cumulative incidence of recurrence of 8% (95% CI, 0%-8%) within 6 months after surgery and 12% at 12 months.

LIMITATIONS

Retrospective design.

CONCLUSIONS

The Turnbull-Cutait pull-through procedure may be the last option to preserve intestinal continuity and successfully treat rectovaginal fistulas in 85% of cases.

EL PROCEDIMIENTO PULLTHROUGH DE TURNBULLCUTAIT ES UNA ALTERNATIVA A LA OSTOMA PERMANENTE EN PACIENTES CON FSTULAS PLVICAS COMPLEJAS

ANTECEDENTES:Con frecuencia se recomienda un estoma permanente en el contexto de una fístula rectovaginal compleja o recurrente debido a la alta tasa de fracaso de los procedimientos reconstructivos. El procedimiento de extracción de Turnbull-Cutait es una operación de rescate para pacientes motivados que desean evitar la desviación fecal permanente.OBJETIVO:Analizar las tasas de curación de la fístula rectovaginal compleja después del procedimiento de extracción de Turnbull-Cutait según la etiología.DISEÑO:Después de la junta de aprobación de revisión institucional, se realizó una revisión retrospectiva de mujeres que se sometieron a un procedimiento (1993-2018) por fístula rectovaginal. Se analizaron los datos demográficos, la etiología y los resultados posoperatorios de los pacientes.AJUSTE:Departamento de cirugía colorrectal en un centro terciario en los Estados Unidos.PACIENTES:Mujeres adultas con fístula rectovaginal que se sometieron a extracción del colon.RESULTADO PRINCIPAL:recurrencia después de la extracción del colon.RESULTADOS:Hubo 81 pacientes que tenían extracción colónica, de esas 26 fístulas rectovaginales con una mediana de edad de 51 (43 - 57) años, y un índice de masa corporal promedio de 28 ± 3,2 kg/m2. Un total de 4 (15%) pacientes tuvieron una recurrencia y el 85% de los pacientes se curaron. El noventa y tres por ciento de los pacientes se curaron después de la fuga anastomótica previa. Los pacientes con fístula relacionada con EC tuvieron una tasa de curación del 75%. El análisis de Kaplan Meier mostró una incidencia acumulada de recurrencia del 8% [95% intervalo de confianza 0%-18%] dentro de los 6 meses posteriores a la cirugía y del 12% a los 12 meses.LIMITACIONES:Diseño retrospectivo.CONCLUSIONES:El procedimiento de extracción de Turnbull-Cutait puede ser la última opción que se puede ofrecer para preservar la continuidad intestinal y tratar la fístula rectovaginal con éxito en el 85% de los casos. (Traducción-Yesenia.Rojas-Khalil).

Video Capsule Endoscopy can Identify Occult Luminal Crohn's Disease in Patients with Isolated Perianal Fistulas

BACKGROUND

Accurate tools to distinguish Crohn's disease [CD] from cryptoglandular disease in patients with perianal fistulas without detectable luminal inflammation on ileocolonoscopy and abdominal enterography (isolated perianal fistulas [IPF]) are lacking. We assessed the ability of video capsule endoscopy [VCE] to detect luminal inflammation in patients with IPF.

METHODS

We studied consecutive adults [>17 years] with IPF who were evaluated by VCE after a negative ileocolonoscopy and abdominal enterography between 2013 and 2022. We defined luminal CD by VCE as diffuse erythema, three or more aphthous ulcers, or a Lewis score greater than 135. We compared rates of intestinal inflammation in this cohort with age- and sex-matched controls without perianal fistulas, who underwent VCE for other indications. We excluded persons with pre-existing inflammatory bowel disease [IBD] and exposure to non-steroidal anti-inflammatory drugs or immunosuppressive treatments.

RESULTS

A total of 45 patients with IPF underwent VCE without complications. Twelve patients [26%] met our definition of luminal CD. Luminal CD was more common in patients with IPF than in controls [26% vs 3%; p <0.01]. Among patients with IPF, male sex (OR [odds ratio], 9.2; 95% confidence interval [CI] [1.1-79.4]), smoking (OR, 4.5; 95% CI [0.9-21.2]), abscess (OR, 6.3; 95% CI [1.5-26.8]), rectal enhancement on magnetic resonance imaging [MRI] (OR, 9.0; 95% CI [0.8-99.3]), and positive antimicrobial serology (OR, 7.1; 95% CI, [0.7-70.0]) were more common in those with a positive VCE study.

CONCLUSIONS

VCE detected small intestinal inflammation suggestive of luminal CD in approximately one-quarter of patients with IPF. Larger studies are required to validate these findings.

Efficacy of different surgical treatments for management of anal fistula: a network meta-analysis

PURPOSE

Currently, the anal fistula treatment which optimises healing and preserves bowel continence remains unclear. The aim of our study was to compare the relative efficacy of different surgical treatments for AF through a network meta-analysis.

METHODS

Systematic searches of MEDLINE, EMBASE and CENTRAL databases up to October 2022 identified randomised controlled trials (RCTs) comparing surgical treatments for anal fistulae. Fistulae were classified as simple (inter-sphincteric or low trans-sphincteric fistulae crossing less than 30% of the external anal sphincter (EAS)) and complex (high trans-sphincteric fistulae involving more than 30% of the EAS). Treatments evaluated in only one trial were excluded from the primary analyses to minimise bias. The primary outcomes were rates of success in achieving AF healing and bowel incontinence.

RESULTS

Fifty-two RCTs were included. Of the 14 treatments considered, there were no significant differences regarding short-term (6 months or less postoperatively) and long-term (more than 6 months postoperatively) success rates between any of the treatments in patients with both simple and complex anal fistula. Ligation of the inter-sphincteric fistula tract (LIFT) ranked best for minimising bowel incontinence in simple (99.1% of comparisons; 3 trials, n = 70 patients) and complex anal fistula (86.2% of comparisons; 3 trials, n = 102 patients).

CONCLUSIONS

There is insufficient evidence in existing RCTs to recommend one treatment over another regarding their short and long-term efficacy in successfully facilitating healing of both simple and complex anal fistulae. However, LIFT appears to be associated with the least impairment of bowel continence, irrespective of AF classification.

Clinical characterization of patients with anal fistula during follow-up of anorectal abscess: a large population-based study

PURPOSE

Approximately 15-50% of patients with an anorectal abscess will develop an anal fistula, but the true incidence of this entity is currently unknown. The aim of the study was to determine the incidence of anorectal abscess and development of a fistula in a specific population area and to identify potential risk factors associated with demographic, socioeconomic and pre-existing disease (e.g. diabetes and inflammatory bowel disease).

METHODS

A longitudinal observational study was designed including a large cohort study in an area with 7,553,650 inhabitants in Spain 1st january 2014 to 31st december 2019. Adults who attended for the first time with an anorectal abscess and had a minimum of 1-year follow-up were included. The diagnosis was made using ICD-10 codes for anorectal abscess and anal fistula.

RESULTS

During the study period, we included 27,821 patients with anorectal abscess. There was a predominance of men (70%) and an overall incidence of 596 per million population. The overall incidence of anal fistula developing from abscesses was 20%, with predominance in men, and a lower incidence in the lowest income level. The cumulative incidence of fistula was higher in men and in younger patients (p < 0.0001). On multivariate analysis, patients aged 60-69 years (hazard ratio 2.0) and those with inflammatory bowel disease (hazard ratio 1.8-2.0) had a strong association with fistula development (hazard ratio 2.0).

CONCLUSIONS

One in five patients with an anorectal abscess will develop a fistula, with a higher likelihood in men. Fistula formation was strongly associated with inflammatory bowel disease.

Surgical treatment trends and outcomes for anal fistula: fistulotomy is still accurate and safe. Results from a nationwide observational study

PURPOSE

The aim of the present study was to analyse current surgical treatment preferences for anal fistula (AF) and its subtypes and nationwide results in terms of success and complications.

METHODS

A retrospective multicentre observational cohort study was conducted. The study period was 1 year (2019), with a follow-up period of at least 1 year. A descriptive analysis of patient characteristics and trends regarding technical options was performed. Univariate and multivariate Cox regression models were used to analyse factors associated with healing and faecal incontinence (FI).

RESULTS

Fifty-one hospitals were involved, providing data on 1628 patients with AF. At a median follow-up of 18.3 (9.9-28.3) months, 1231 (75.9%) patients achieved healing, while 390 (24.1%) did not; failure was catalogued as persistence in 279 (17.2.0%) patients and as recurrence in 111 (6.8%). On multivariate analysis, factors associated with healing were fistulotomy (OR 5.5; 95% CI 3.8-7.9; p < 0.001), simple fistula (OR 2.1; 95% CI 1.5-2.8; p < 0.001), single tract (HR 1.9; 95% CI 1.3-2.8; p < 0.001) and number of preparatory surgeries (none vs. 3; HR 1.8; 95% CI 1.2-2.8; p = 0.006). Regarding de novo FI, in the multivariate analysis previous anal surgery (OR 1.5, 95% CI 1.0-2.4, p = 0.037), age (OR 1.02, 95% CI 1.00-1.04, p = 0.002) and being female (OR 1.7, 95% CI 1.1-2.5, p = 0.008) were statistically related.

CONCLUSIONS

Anal fistulotomy is the most used procedure for AF, especially for simple AF, with a favourable overall balance between healing and continence impairment. Sphincter-sparing or minimally invasive sphincter-sparing techniques resulted in lower rates of healing. In spite of their intended sphincter-sparing design, a certain degree of FI was observed for several of these techniques.