Intersphincteric Component in a Complex Fistula-in-Ano Is Like an Abscess and Should Be Treated Like One

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.

Transanal opening of the intersphincteric space (TROPIS): a novel procedure on the horizon to effectively manage high complex anal fistulas

Anal fistulas, especially complex and high fistulas, are difficult to manage. The transanal opening of the intersphincteric space (TROPIS) procedure was first described in 2017, and a high success rate of over 90% was reported in high complex fistulas. Since then, more studies and even a meta-analysis have corroborated the high efficacy of this procedure in high fistulas. Conventionally, the main focus was to close the internal (primary) opening for the fistula to heal. However, most complex fistulas have a component of the fistula tract in the intersphincteric plane. This component is like an abscess (sepsis) in a closed space (2 muscle layers). It is a well-known fact that in the presence of sepsis, healing by secondary intention leads to better results than attempting to heal by primary intention. Therefore, TROPIS is the first procedure in which, instead of closing the internal opening, the opening is widened by laying open the fistula tract in the intersphincteric plane so that healing can occur by secondary intention. Although the drainage of high intersphincteric abscesses through the transanal route was described 5 decades ago, the routine utilization of TROPIS for the definitive management of high complex fistulas was first described in 2017. The external anal sphincter (EAS) is completely spared in TROPIS, as the fistula tract on either side of the EAS is managed separately-inner (medial) to the EAS by laying open the intersphincteric space and outer (lateral) to the EAS by curettage or excision.

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.

Anal fistula and pilonidal sinus disease coexisting simultaneously: An audit in a cohort of 1284 patients

Fistula-in-ano and pilonidal disease are not known to occur together. In a retrospective study, all patients having fistula-pilonidal disease coexisting simultaneously were included. Out of 1284 patients, 933 were operated (fistula-in-ano, 849; pilonidal disease, 77; and coexisting fistula-pilonidal, 7). A total of 351 patients did not undergo any surgery (two patients had coexisting fistula-pilonidal). Thus, a total of nine patients having coexisting fistula-pilonidal sinus were included in the study (mean age 35.8 ± 19.9 years, M/F 7/2). pIn 6/9 patients, the pilonidal tract was communicating with fistula-in-ano, and in 3/9 patients, they were not communicating/connected. The connection could be established preoperatively with the help of MRI. In all patients with communicating fistula-pilonidal sinus (n=6), the fistula was posterior. 6/9 patients had recurrent fistula and all (9/9) had multiple tracts. The fistula was high and complex in 8/9 patients (grade IV-7, grade V-1). 4/9 patients tested positive for tuberculosis while one patient was suffering from hidradenitis suppurativa. The latter improved on medical treatment. One patient did not agree for surgery and seven were operated. The disease healed in four patients, the disease did not heal in one patient, and two patients were in the convalescent stage. Anal fistula and pilonidal disease can coexist in a same patient and can even be connected. Such diseases are more complex and have a higher incidence of associated diseases like tuberculosis. Magnetic resonance imaging plays a pivotal role in diagnosis. If the connection is missed, the disease treatment becomes difficult.

Is fistulotomy still the gold standard in present era and is it highly underutilized?: An audit of 675 operated cases

AIM

Due to fear of incontinence, fistulotomy perhaps remains highly underutilized. The aim was to analyze the efficacy of fistulotomy in a large cohort, to assess the magnitude of underutilization of fistulotomy by current classifications and to identify the subgroup in whom the fistulotomy should be done.

METHODS

All consecutive operated patients of fistula-in-ano were included in the study retrospectively. The fistulas were classified as per existing classifications-Parks, St James University Hospital (SJUH) and Garg classification. Smaller grades of each classification (Parks I, SJUH I-II, Garg I-II) were expected to be simple fistulas and thus amenable to fistulotomy. Objective incontinence scores were done preoperatively and postoperatively.

RESULTS

675 patients were operated over a 5.5 year period (median-27 months). 25 patients were excluded. Fistulotomy was done in 353/650 (54.3%) patients and sphincter-saving procedures (SSP) performed in 297/650 (45.7%) patients. After fistulotomy, 346/353 (98%) fistulas healed after the first operation. Seven patients with recurrent fistula were cured after a repeat fistulotomy surgery. Thus the overall healing rate was 353/353 (100%). There was no significant change in continence scores. The 353 fistulotomy patients were classified as per different classifications- Parks (I-225,II-112,III-16,IV-0), SJUH(I-138,II-87,III-47,IV-65,V-16) and Garg (I-188,II-165,III-0,IV-0,V-0). 123 (36.3%) patients who could undergo fistulotomy successful were erroneously classified as complex fistula by Parks and SJUH classifications. Garg classification accurately identified all 353/353 (100%) patients were amenable to fistulotomy.

CONCLUSIONS

Fistulotomy is a safe procedure with remarkably high success rate (100%) and is gold-standard in majority of patients (>50%). Parks and SJUH classifications are inaccurate in selecting patients for fistulotomy. Garg classification predicts amenability to fistulotomy with very high accuracy.