Fistulotomy and sphincter reconstruction in the treatment of complex fistula-in-ano: long-term clinical and manometric results

Evaluation of the outcomes of fistulotomy with primary sphincter reconstruction in the management of high trans-sphincteric fistula and supra-sphincteric fistula-in-ano : A single-center prospective cohort study

BACKGROUND

Supra-sphincteric and high trans-sphincteric fistula are very challenging procedures for both the patient and the surgeon. We aimed to evaluate the outcomes of anal sphincter repair in the management of supra-sphincteric and high trans-sphincteric fistula-in-ano in terms of postoperative wound infection, bleeding, incontinence to flatus or stool, and recurrence within 1 year.

PATIENTS AND METHODS

This single-center prospective cohort trial conducted from June 2020 to December 2023 at the Ain Shams University Hospitals included 20 patients who presented with supra-sphincteric or high trans-sphincteric fistula. There were nine (45%) male and 11 (55%) female patients, with a mean age of 41.5 years postoperatively.

RESULTS

The mean duration of the procedure was 90.3 min (SD ± 11.9). During the first 2 weeks, ten (50%) patients scored their postoperative pain as mild, eight (40%) as moderate, and two (10%) as severe. Wound infection occurred in two (10%) patients and postoperative bleeding in three (15%) patients in the form of spotting after defecation. There were no cases of incontinence to stool. However, there were three (15%) cases of incontinence to gases. There were two cases (10%) of recurrence at the 1‑year follow-up. Postoperative patient satisfaction was assessed on a 5‑point Likert scale after 2 weeks: One patient (5%) was very dissatisfied, three (15%) patients were dissatisfied, and two (10%) patients were unsure, while five (25%) patients were satisfied and nine (45%) were very satisfied.

CONCLUSION

Immediate sphincter repair in supra-sphincteric and high trans-sphincteric fistula through a lay-open procedure was determined to be safe, easier than classic operations, and associated with a low incidence of recurrence at the 1‑year follow-up and a high quality of life.

Computed tomography imaging and clinical significance of bacterium-positive pulmonary tuberculosis complicated with diabetes

BACKGROUND

The increasing prevalence of tuberculosis (TB) and diabetes on a global scale poses a significant health challenge, particularly due to their co-occurrence, which amplifies the severity, recurrence and mortality rates associated with both conditions. This highlights the need for further investigation into their inter-relationship.

AIM

To explore the computed tomography (CT) imaging and clinical significance of bacterium-positive pulmonary TB (PTB) combined with diabetes.

METHODS

There were 50 patients with bacterium-positive PTB and diabetes, and 50 with only bacterium-positive PTB. The latter were designated as the control group. The CT imaging of the two groups of patients was compared, including lesion range, shape, density and calcification.

RESULTS

No significant differences were observed in age, gender, smoking and drinking history, high blood pressure, hyperlipidemia and family genetic factors between the groups. However, compared to the patients diagnosed solely with simple bacterium-positive PTB, those with concurrent diabetes showed a wider range of lesions and more complex and diverse morphology on CT images. Among them, intrapulmonary tuberculosis lesions were often accompanied by manifestations of pulmonary infection, such as cavity formation and bronchiectasis. At the same time, diabetes-related signs were often seen on CT images, such as pulmonary infection combined with diabetic pulmonary lesions. Logistic regression analysis identified age and medical history as significant factors influencing the degree of pulmonary infection and CT imaging outcomes in patients with both TB and diabetes. This suggests that older age and specific medical histories may increase the risk or severity of pulmonary damage in these patients.

CONCLUSION

CT imaging reveals more complex lesions in PTB patients with diabetes, emphasizing the need for careful evaluation and comprehensive analysis to enhance diagnostic accuracy.

Tsay A, Abbass M. Immediate sphincter repair following fistulotomy for anal fistula: does it impact the healing rate and septic complications?

PURPOSE

Fistulotomy is considered the most effective treatment for anal fistula; however, it carries a risk of incontinence. Sphincteroplasty in the setting of fistulotomy is not standard practice due to concerns regarding healing and potential infectious complications. We aimed to compare the outcomes of patients who underwent fistulotomy with primary sphincteroplasty to those who did not undergo repair.

METHODS

This was a retrospective review of consecutive patients who underwent fistulotomy for cryptoglandular anal fistula. All operations were performed by one colorectal surgeon. Sphincteroplasty was performed for patients perceived to be at higher risk for continence disturbance. The main outcome measures were the healing rate and postoperative septic complications.

RESULTS

In total, 152 patients were analyzed. Group A (fistulotomy with sphincteroplasty) consisted of 45 patients and group B (fistulotomy alone) included 107 patients. Both groups were similar in age (P=0.16) and sex (P=0.20). Group A had higher proportions of multiple fistulas (26.7% vs. 6.5%, P<0.01) and complex fistulas (mid to high transsphincteric, 37.8% vs. 10.3%; P<0.01) than group B. The median follow-up time was 8 weeks. The overall healing rate was similar in both groups (93.3% vs. 90.6%, P=0.76). No significant difference between the 2 groups was noted in septic complications (6.7% vs. 3.7%, P=0.42).

CONCLUSION

Fistulotomy with primary sphincter repair demonstrated a comparable healing rate to fistulotomy alone, without an increased risk of postoperative septic complications. Further prospective randomized studies are needed to confirm these findings and to explore the functional outcomes of patients who undergo sphincteroplasty.

Long term results of video-assisted anal fistula treatment for complex anal fistula: another shattered dream?

AIM

Complex anal fistula represents a burden for patients, and its management is a challenge for surgeons. Video-assisted anal fistula treatment (VAAFT) is one sphincter-sparing technique. However, data on its long-term effectiveness are scant. We aimed to explore the outcomes of VAAFT in a retrospective cohort of patients referred to a tertiary centre.

METHOD

Consecutive adult patients with a minimum of 2 years' follow-up after VAAFT were reviewed. Patients were followed up to 5 years postoperatively. Failure was defined as incomplete healing of the external orifice(s) during the first 6 months. Recurrence was defined as new radiologically and/or clinically confirmed onset of the fistula after primary healing. A generalized linear model was fitted to evaluate the association between failure and sociodemographic characteristics. Predictors of recurrence were determined in a subgroup analysis of patients found to be free from disease at 6 months postoperatively.

RESULTS

Overall, 106 patients (70% male; mean age 41 years) were reviewed. Of these 86% had a previous seton placement. Fistulas were either high trans-sphincteric (74%), suprasphincteric (12%) or extrasphincteric (13%). Eight (7%) patients experienced postoperative complications, none of which required reintervention. Mean follow-up was 53 ± 13.2 months. VAAFT failed in 14 (13%) patients. The overall recurrence rate ranged from 29% at 1 year to 63% at 5 years. Multiple external orifices, suprasphincteric fistula, younger age, previous surgery and higher complexity of the fistulous tract were independent risk factors for recurrence.

CONCLUSION

VAAFT is a safe sphincter-sparing technique. The initially high success rate decreases over time and relates to a higher degree of complexity.

A comparative study between high ligation of the inter-sphincteric fistula tract via lateral Approach Versus Fistulotomy and primary sphincteroplasty in High Trans-Sphincteric Fistula-in-Ano: a randomized clinical trial

BACKGROUND

Trans-sphincteric fistula management is very challenging and everyday new techniques are introduced to reach the safest and the most effective technique. In this study two of the most effective techniques are compared based on their post-operative outcomes.

OBJECTIVE

To compare the efficacy of high ligation of the inter-sphincteric fistula tract by lateral approach (modified LIFT) and Fistulotomy and primary sphincteroplasty (FIPS) in the management of high trans-sphincteric fistula regarding their post-operative outcomes in the form of post-operative pain, time of wound healing in weeks, wound infection, incontinence and recurrence within one year.

PATIENTS AND METHODS

The current study is single-blind, prospective, randomized, controlled, single-center trial conducted from June 2020 to June 2022 in the colorectal surgical unit of Ain Shams University Hospitals, which included 80 patients presented with high trans-sphincteric perianal fistula 55 (68.75%) males and 25 (31.25%) including a one-year follow-up postoperative.

RESULTS

There were 80 patients in our study 40 patients in each group. The mean age of group (I) is 46.65 with standard deviation 6.6. while, in group (II) the mean age is 45.85 with standard deviation 6.07 (p = 0.576). From the included 80 patients 55(68.7%) were males and 25 (31.25%) were females (p = 0.469). Regarding, postoperative wound infection occurred in 2(5%) Patients in group (I) and 7(17.5%) patients in group (II) (p = 0.154). There were no cases of incontinence in group I. However, there were 6(15%) cases of incontinence to gases only scored by Wexner score 3/20 in group II (p = 0.026) and its significant difference between the two techniques. Postoperative pain was assessed for one week duration by the visual analogue score (VAS) from 0 to 10 in which, zero is the least and 10 is the maximum. In group (I) 18(45%) patients scored their pain mild from 1 to 3, 20(50%) patients scored their pain moderate from 4 to 6 and 2(5%) patients scored severe pain from 7 to 9. While, in group (II) 14(35%) patients scored their pain mild from 1 to 3, 22(55%) patients their pain moderate from 4 to 6 and 4(10%) patients scored their pain severe from 7 to 9 (p = 0.275). Recurrence in one-year follow-up occurred in 13(32.5%) patients in group (I) about 7 patients had recurrence in the form of inter-sphincteric fistula and 6 patients in the form of trans-sphincteric fistula. While, in group II recurrence occurred in 1 (2.5%) patient in the form of subcutaneous fistula at the healing site (p = 0.001).

CONCLUSION

Fistulotomy and primary sphincteroplasty is an effective and preferred technique for the trans-sphincteric fistula repair with high statistically significant lower incidence of recurrence in one-year follow-up as compared to modified LIFT technique. Although, there is higher incidence regarding incontinence to gases only post-operative. This work recommends fistulotomy and primary sphincter reconstruction procedure in high trans-sphincteric perianal fistulas to be more popular, to be implemented as a corner stone procedure along various and classic operations for such cases as it's easy, feasible.

Anal fistulotomy with one-stage shaped skin grafting for intersphincter anal fistulas: study protocol on a multicentre randomised controlled trial

BACKGROUND

Anal fistulas are mainly treated via surgery. They can be difficult to treat without surgical intervention. Numerous procedures, such as fistulectomy and fistulotomy, are performed to treat anal fistulas and achieve good effects. However, the wounds created through fistulectomy and fistulotomy take a long time to heal. Therefore, a multicentre randomised controlled trial (RCT) is proposed to study the efficacy of one-stage shaped skin grafting at the surgical wound to heal low simple intersphincter anal fistulas.

METHODS

This study is a multicentre, hospital-based RCT. It will be performed at three hospitals. A total of 104 patients with low simple intersphincter anal fistulas who meet the inclusion criteria will be included in this trial and will be allocated randomly to two groups (test and control groups). The patients in the test group will receive one-stage anal fistulotomy surgery combined with shaped skin grafting, and those in the control group will undergo anal fistulotomy only. All the operations will be performed by attending colorectal surgeons or surgeons of a higher level. Effectiveness and safety indicators will be observed, recorded and analysed.

DISCUSSION

Anal fistulotomy can heal low simple intersphincter anal fistulas effectively and safely with a low recurrence rate. Skin grafts promote wound epithelisation significantly. We believe that skin grafting can treat low simple intersphincter fistulas with a short healing time.

TRIAL REGISTRATION

Chinese Clinical Trial Register, ChiCTR2000039174. Registered on 28 October 2020.

Current Therapy of Cryptoglandular Anal Fistula: Gold Standards and Alternative Methods

Cryptoglandular anal fistulas are one of the most common colorectal diseases and occur with an incidence of about 20/100,000. Anal fistulas are defined as an inflammatory junction between the anal canal and the perianal skin. They develop from an abscess or chronic infection of the anorectum. Surgical treatment of the disease is the method of choice. Even when treating an acute abscess, its cause should be sought at the same time. If there is a connection to the anal canal without affecting relevant parts of the sphincter muscles, primary fistulotomy should be performed. If larger parts of the sphincter muscle are involved, the insertion of a seton drain is usually useful. There are essentially two recommendations for the elective treatment of cryptoglandular anal fistulas. Distal fistulas should be excised, with the proviso that as little sphincter muscle as possible is sacrificed. In the case of highly proximally located and complex fistulas, sphincter-preserving surgical techniques should be used. In this case, the method of choice is the mucosal or advancement flap. Alternatively, clips, fibrin injections, fistula plugs, fistula ligatures, or laser-based procedures are described in the literature. In the case of intermediate fistulas, a fistulectomy with primary sphincter reconstruction can be useful. Every operation is carried out as a compromise between definitive healing of the fistula and a potential risk to the patient's continence. It is often difficult to make a reliable prognosis about the continence function to be expected postoperatively. In addition to the fistula morphology, particular attention should be paid to whether previous proctological operations have already been performed, the gender of the patient, and whether there are pre-existing sphincter dysfunctions. Since the surgeon's expertise plays a decisive role in the success of the treatment, the procedure should be carried out in a specialist proctological centre, especially in the case of complex fistulas or in the case of a condition after previous operations. In addition to the classic procedures, such as fistulectomy or the plastic fistula closure, this article examines alternative methods and their areas of application.

Platelet-rich plasma in the treatment of anal fistula: a systematic review and meta-analysis

OBJECTIVE

To analyse the safety and effectiveness of platelet-rich plasma (PRP) in anal fistula patients.

METHODS

Online databases including PubMed, Embase, Cochrane Library, and Web of Science were searched from inception to December 5, 2022, for eligible studies about evaluating the efficacy of platelet-rich plasma (PRP) in treating anal fistula. Literature search, screening, data extraction, and quality assessment were carried out by two independent investigators. The overall cure rate, the complete cure rate, the recurrence rate, and the adverse event rate with their 95% confidence intervals (95% CI) were the primary calculation indexes. Subgroup analyses were conducted primarily according to whether PRP was combined with other treatments. Softwares of MedCalc 18.2 and Review Manager 5.3 were used for meta-analysis.

RESULTS

A total of 14 studies with 514 patients were included in the meta-analysis. The overall cure rate of 14 studies was 72.11% (95% CI 0.64-0.79). The cure rate of PRP alone was 62.39% (95% CI 0.55-0.69). The combined cure rate of PRP with other treatments was 83.12% (95% CI 0.77-0.88). The cure rate of interventions involving PRP were superior to the cure rate of surgery methods without using PRP significantly in the 4 randomized controlled studies (RR = 1.30, 95% CI 1.10-1.54, p = 0.002). The complete cure rate of the 8 studies was 66.37% (95% CI 0.52-0.79). The recurrence rate of the 12 studies was 14.84% (95% CI 0.08-0.24). The adverse event rate of the 12 studies was 6.31% (95% CI 0.02-0.12).

CONCLUSION

PRP showed favorable safety and effectiveness in the treatment of anal fistula, especially combined with other treatment procedures.

Fistulectomy and primary sphincteroplasty in complex anal fistula treatment: a hospital-based long-term follow-up study

BACKGROUND

Currently, there is no agreement on the best treatment for complex anal fistulas with the least recurrence and lowest complication rate. The aim of this study was to evaluate the long-term recurrence and incontinence after fistulectomy and primary sphincteroplasty (FIPS) in a group of patients with complex perianal fistula.

METHODS

This prospective observational study was done at the colorectal ward of Taleghani Hospital of Tehran from January 2010 to December 2020. Patients with anal fistula who underwent FIPS were studied. After surgery, patients were evaluated regularly by a colorectal surgeon for fistula recurrence and incontinence. Recurrence was described as a new fistula tract formation after the initial cure and failure of healing in the operation site or any purulent discharge from the fistula tract and openings. In addition, the patient's continence was assessed based on the Wexner score.

RESULTS

There were 335 patients (66 men and 269 women, mean age 42.74 ± 12.44 years), 191 of them with low fistula and 144 with high fistula. Thirteen patients (3.90%) experienced recurrence (all had a low fistula). Thirty-nine patients (11.64%), 19 patients with high and 20 patients with low fistula, had a Wexner score ≥ 3 during the follow-up. Fifteen patients were lost to follow-up. Male patients (OR = 2.67, 95% CI 0.84, 8.45, p = 0.094, adjusted OR = 4.41, 95% CI 1.05, 18.48, p = 0.042), patients with low fistula (p = 0.001), and recurrent cases had a significantly higher rate of recurrence (OR = 10.38, 95% CI 3.24-33.20 p ≤ 0.001, adjusted OR = 23.36, 95% CI 4.35-125.39, p ≤ 0.001). A significant correlation between body mass index > 35 kg/m² and incontinence was found (OR = 4.40, 95% CI 1.35, 14.33, p = 0.014).

CONCLUSIONS

In the present study, an acceptable healing rate and a low percentage of complications following FIPS were seen in patients with complex anal fistula. Randomized clinical trials with appropriate follow-up duration and sample size comparing different surgical methods in these patients are needed to confirm these results.

Minimally Invasive Treatment of Recurrent Anal Fistulas with Autologous Platelet-Rich Plasma Combined With Internal Orifice Closure

AIM

Minimally invasive procedures for the treatment of anal fistulas are gaining more and more popularity. For this purpose, Platelet-Rich Plasma (PRP) are administered to accelerate the healing process of various difficult wounds or lesions. The aim of this study was to evaluate preliminary results of PRP injection into the tissues adjacent to anal fistulas.

PATIENTS AND METHODS

A cohort of 42 patients with recurrent anal fistula, who underwent at least one cutting procedure previously, were enrolled into this preliminary and prospective trial. Closure of internal orifice was performed in all investigated patients, however, in 22 patients from group I, that procedure was combined with topical injection of PRP. In the postoperative period, the PRP administration could be repeated in case of incomplete fistula closure. Follow-up consisted of out-patient visits in a fortnight, 1, 2, and 12 months.

RESULTS

Complete closure of anal fistulas was achieved in 16 (75%) patients from group I and 10 (45,5%) patients from group II. The fistulas were healed in 9 patients from group I after single application of PRP. In the next 9 patients with incomplete fistula closure, the injection was repeated 2 to 4 times every fortnight leading finally to complete recovery in 6 of them.

CONCLUSIONS

Surgical fistula closure with local PRP application spares the anal sphincter and gives the opportunity to repeat the procedure several times if necessary. Treatment of recurrent anal fistulas with PRP can be considered as last resort therapy.

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

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

[Modern surgical technologies in the treatment of patients with chronic paraproctitis]

The development of minimally invasive surgical technologies in the treatment of chronic paraproctitis is a promising young trend in coloproctology. Increasingly, in clinical practice, coloproctologists use laser technologies in the outpatient treatment of extra- and transsphincteric pararectal fistulas, in particular, laser technology FiLaC (Fistula Laser Closure).

OBJECTIVE

Conducting a comparative retrospective and prospective cohort study of immediate and long-term results of treatment of complicated transsphincteric and extrasphincteric fistulas using the developed modified FiLaC technology with the «traditional» FiLaC technology, and standard excision of the fistulous tract with plasty of the internal fistula opening with a full-thickness flap of the rectal wall.

MATERIAL AND METHODS

The study included 270 patients with trans- and extrasphincter pararectal fistulas, which were divided into three groups. In group 1 (n=90) the traditional FiLaC technology was used for the treatment of fistulas, in group 2 (n=90) the modified FiLaC technology was used, providing for the opening of purulent streaks and laser coagulation (FiLaC) of the intrasphincter part of the fistula with a Biolitec laser, 12 W, 100 J/cm, in group 3 (n=90), excision of the fistula tract with plastic surgery of the internal fistula opening with a full-thickness flap of the rectal wall was used.

RESULTS

The results of treatment in patients of the three groups were monitored for 19-36 months. after surgery (median 31 months). The analysis of the results showed that in group 2 (modified FiLaC technology) healing of fistulas occurred faster (7.3±0.5 weeks versus 12.6±0.7 weeks) compared to group 3 (excision of the fistula with plasty of the internal fistula opening). The indicators of sphincterometry in the long-term period in patients of the 2nd group were restored in relation to the initial ones, and in the th group 3 they were reduced compared to the initial values. Postoperative complications were most common in patients of group 3 (32.2%), and least often in patients of group 2 - 8.9%. At the same time, late postoperative complications were most common (24.4%) in patients of group 1. None of the patients in group 2 had late postoperative complications, while 11.1% of postoperative complications were recorded in group 3. In patients who underwent excision of the AC (group 3), relapses were most common: early - 15.6%, late - in 21.1%. The least frequent relapses were observed in patients who underwent modified FiLaC technology (Group 2): 6.7% - early relapses and 11.1% - late relapses.

CONCLUSION

The use of the modified FiLaC technology in the treatment of trans- and extrasphincteric fistulas of the rectum made it possible to minimize postoperative complications, fully preserve the function of anal holding, and achieve healing of fistulas in 82.5% of cases with a median follow-up of 31 months.

[Modern approaches to the rehabilitation of patients with chronic paraproctitis in the early postoperative period]

Along with the classical methods of surgical treatment of rectal fistulas, new minimally invasive technologies have appeared using video endoscopic support for processing the fistulous tract and closing the internal fistula opening, intrasphincter ligation of the fistulous tract LIFT, however, they do not exclude relapses in the late postoperative period. The FiLaC (Fistula Laser Closure) laser technology based on the use of a radial flexible laser light guide, which does not cause damage to the anal canal mucosa, pain in the postoperative period, rectal postoperative bleeding and strictures, is quite promising in the further development of outpatient minimally invasive surgery for anal fistulas. anal canal. However, even with this technique, complications and relapses were observed in 10-12% of cases, which dictates the need to develop not only a patient-oriented approach to the surgical treatment of patients with chronic paraproctitis, but also to develop postoperative rehabilitation programs in the early postoperative period.

OBJECTIVE

To study the effect of complex rehabilitation programs used in the early postoperative period on the efficacy of the therapy in patients with pararectal fistulas.

MATERIAL AND METHODS

The study included 90 patients with chronic paraproctitis, (the average age was 43±3.4 years, the average duration of the disease was 5.1±1.5 years), who underwent a surgery using the modified FiLac technology. The patients were divided into 3 groups (30 patients in each group) depending on the rehabilitation method used during the postoperative period (2 days after the surgery): 1^st group underwent a 4-component rehabilitation complex (intravenous ozone therapy, rectal laser therapy, recto-tibialmyostimulation of the pelvic floor muscles and biofeedback therapy); 2^nd group underwent a 2-component rehabilitation complex (intravenous ozone therapy and rectal laser therapy); 3^rd group has received a standard medical complex, which served as a background in 1^st group and 2^nd group. Therapeutic efficacy was assessed according to the assessment of pain syndrome (on the VAS scale), the results of anal sphincterometry (the Peritron 9600 device), the incidence of postoperative complications and relapses at different follow-up periods (up to 5 years).

RESULTS

A comparative analysis of the nature of the course of the postoperative period, depending on the type of postoperative rehabilitation was carried out. In multiple comparisons using the parametric ANOVA method, it was found that there were statistically significant differences between the 1st group and the 3^rd group in terms of pain intensity, duration of pain, the timing of wound healing, the frequency of complications, and the timing of return to work. The results in the 2^nd group were slightly lower than in the 1^st group, but they also differed significantly from the data of the 3^rd group. During the analysis of the early and late p/o complications and relapses in patients with chronic paraproctitis after surgery the most significant were obtained from the 1^st group (only 1 case of early p/o complications and relapse within 1 to 5 years), while in the 3^rd group there were 2 (6.6%) cases of early p/o complications, 2 cases (6.6%) of relapses within a period of up to 1 year and 6 (20%) cases in the period from 1 to 5 years. In patients of the 2^nd group, results close to the results of the 1^st group were obtained: 2 (6.6%), 2 (6.6%) and 3 (9.9%) cases respectively.

CONCLUSION

The use of expanded rehabilitation complexes among the patients with chronic paraproctitis in the early postoperative period after surgery, including intravenous ozone therapy, rectal laser therapy, recto-tibialmyostimulation and bifidobac therapy, made it possible to significantly improve therapeutic efficacy, which was confirmed by faster pain relief, fewer early and late p/o complications. The data obtained indicate the need for the use of rehabilitation programs in the early postoperative period for the treatment and prevention of complications after surgery.

Is fistulotomy with immediate sphincter reconstruction (FISR) a sphincter preserving procedure for high anal fistula? A systematic review and meta-analysis

AIM

This systematic review aimed to assess the outcomes of fistulotomy or fistulectomy and immediate sphincter repair (FISR) in relation to healing, incontinence and sphincter dehiscence both overall and in patients with high anal fistulae.

METHODS

Medline, Embase and The Cochrane library were searched for studies of patients undergoing FISR for anal fistula. Data regarding healing, continence and sphincter dehiscence were extracted overall and for high anal fistulae. The DerSimonian-Laird random-effects method was used for pooled analysis, heterogeneity between studies was assessed based on the significance of between-study heterogeneity, and on the size of the I²  value. Risk of bias was assessed using the Cochrane risk of bias tool and the Newcastle-Ottawa scale.

RESULTS

We identified 21 studies evaluating 1700 patients. Pooled analysis of healing reached 93% (95% CI: 91%-95%, I²  = 51% p-value for heterogeneity = 0.004), with continence disturbance and worsening continence reaching 11% (95% CI: 6%-18%, I²  = 87% p < 0.001) and 8% (95% CI: 4%-13%, I²  = 74% p < 0.001), respectively. Subgroup analysis according to fistula height could only be conducted on limited data. Pooled healing in high anal fistulae was 89% (95% CI: 84%-94%, I²  = 76% p < 0.001), 16% suffered disturbance of continence (95% CI: 7%-27%, I²  = 89% p < 0.001), 8% worsening continence from baseline (95% CI: 2%-16%, I²  = 80% p < 0.001) and 2% suffered sphincter dehiscence (95% CI: 0%-10%, I²  = 89% p < 0.001).

CONCLUSION

The evidence suggests FISR is a safe, effective procedure. However, data are limited by inconsistencies in reporting of continence and definition of fistula height, particularly high anal fistulae. Significant heterogeneity means that outcomes in high fistulae remain uncertain.

Long-term Evaluation of Fistulotomy and Immediate Sphincteroplasty as a Treatment for Complex Anal Fistula

BACKGROUND

Fistulotomy with immediate sphincteroplasty is a technique that can heal fistulas and decrease fecal incontinence more effectively than fistulotomy alone, in selected patients.

OBJECTIVE

We aimed to perform a long-term evaluation of fecal incontinence after fistulotomy and immediate sphincteroplasty in patients with complex anal fistula.

DESIGN

This prospective study included patients undergoing fistulotomy and immediate sphincteroplasty for complex anal fistula from January 2000 to December 2010.

SETTINGS

The study was conducted by 2 colorectal surgeons in the coloproctology unit of the General Hospital of Elche.

PATIENTS

We included patients aged ≥18 years with complex anal fistulas of cryptoglandular origin.

MAIN OUTCOME MEASURES

Main outcomes were recurrence and continence after fistulotomy and immediate sphincteroplasty, according to fistula tract height and preoperative continence status.

RESULTS

A total of 107 patients were included; 68.2% were men, with a mean age of 48 years and mean fistula duration of 12.8 months. The range and median follow-up period were 84 to 204 and 96 months. Thirty-seven fistulas were not primary. The overall healing rate was 84.1%. Primary fistulas healed by the end of follow-up in 58 (82.9%) of 70 patients; recurrent fistulas healed in 32 (86.5%) of 37; high tracts healed in 31 (83.8%) of 37, and nonhigh fistulas healed in 59 (84.3%) of 70. Male sex (OR = 0.66 (95% CI, 0.20-2.13); p > 0.05) and recurrent fistulas (OR = 0.43 (95% CI, 0.11-1.68); p > 0.05) could have a protective effect against postoperative fecal incontinence; however, more studies with larger sample sizes are necessary to confirm this result, whereas high fistulas showed a 4-fold increased risk of incontinence (range, 1.22-13.06; p < 0.01). One in 5 high-tracts patients experienced continence deterioration.

LIMITATIONS

This was a prospective study, and randomized clinical trials with more patients and longer follow-up are needed to compare fistulotomy and immediate sphincteroplasty with other sphincter-preserving techniques.

CONCLUSIONS

Fistulotomy and immediate sphincteroplasty are good options for treating complex anal fistulas, especially for recurrent fistulas, men, and patients with nonhigh tracts, with acceptable recurrence and incontinence rates. See Video Abstract at http://links.lww.com/DCR/B498.

EVALUACIN A LARGO PLAZO DE LA FISTULOTOMA Y LA ESFINTEROPLASTIA INMEDIATA COMO TRATAMIENTO PARA LA FSTULA ANAL COMPLEJA

ANTECEDENTES:La fistulotomía y la esfinteroplastia inmediata es una técnica que puede curar las fístulas y disminuir la incontinencia fecal de manera más efectiva que la fistulotomía sola, en pacientes seleccionados.OBJETIVO:Nuestro objetivo fue realizar una evaluación a largo plazo de la incontinencia fecal después de la fistulotomía y la esfinteroplastia inmediata en pacientes con fístula anal compleja.DISEÑO:Este estudio prospectivo incluyó pacientes sometidos a fistulotomía y esfinteroplastia inmediata por fístula anal compleja, desde enero de 2000 hasta diciembre de 2010.ENTORNO CLINICO:El estudio fue realizado por dos cirujanos colorrectales de la Unidad de Coloproctología del Hospital General de Elche.PACIENTES:Se incluyeron pacientes ≥ 18 años con fístulas anales complejas de origen criptoglandular.PRINCIPALES MEDIDAS DE VALORACION:Los principales resultados fueron la recurrencia y la continencia después de la fistulotomía y la esfinteroplastia inmediata, de acuerdo con la altura del trayecto de la fístula y el estado de continencia preoperatoria.RESULTADOS:Se incluyeron un total de 107 pacientes; El 68,2% eran varones, con una edad media de 48 años y una duración media de la fístula de 12,8 meses. El rango y la mediana del período de seguimiento fue de 84-204 y 96 meses, respectivamente. Treinta y siete fístulas no fueron primarias. La tasa de curación general fue del 84,1%. Las fístulas primarias cicatrizaron al final del seguimiento en 58/70 (82,9%) pacientes; las fístulas recurrentes cicatrizaron en 32/37 (86,5%); los tractos altos cicatrizaron en 31/37 (83,8%) y las fístulas no altas cicatrizaron en 59/70 (84,3%). El sexo masculino (razón de posibilidades: 0,66 [0,20-2,13], p > 0,05) y las fístulas recurrentes (razón de posibilidades: 0,43 [0,11-1,68], p > 0,05) podrían tener un efecto protector contra la incontinencia fecal postoperatoria, sin embargo, más estudios con una muestra más grande son necesarios para confirmar este resultado. Fistulas altas mostraron un riesgo cuatro veces mayor de incontinencia ([1.22-13.06], p < 0.01). Uno de cada cinco pacientes con tractos altos experimentó un deterioro de la continencia.LIMITACIONES:Este fue un estudio prospectivo y se necesitan ensayos clínicos aleatorios con más pacientes y un seguimiento más prolongado para comparar la fistulotomía y la esfinteroplastia inmediata con otras técnicas de preservación del esfínter.CONCLUSIÓN:La fistulotomía y la esfinteroplastia inmediata son buenas opciones para el tratamiento de fístulas anales complejas, especialmente para fístulas recurrentes, varones y pacientes con tractos no altos, con tasas aceptables de recurrencia e incontinencia. Consulte Video Resumen en http://links.lww.com/DCR/B498.

ASSESSMENT OF RECURRENT ANAL FISTULAS TREATMENT WITH PLATELET-RICH PLASMA

BACKGROUND

Surgical treatment of recurrent anal fistulas can lead to numerous complications, including fecal incontinence. Therefore, sphincter preserving techniques are gaining more popularity.

OBJECTIVE

The aim of the study was to assess effectiveness of platelet-rich plasma (PRP) therapy in the patients with recurrent cryptoglandular anal fistulas.

METHODS

A cohort of 18 patients with anal fistulas was enrolled into a preliminary and prospective trial. They were divided into two groups consisting of eight and ten patients respectively. PRP was injected locally in all patients, however in the group II it was applied after 7 days drainage of fistulas with polyurethane foam or negative pressure wound therapy. On average, three doses of PRP were administered, but with the opportunity to double the number of applications if it was clinically justified. The patients were evaluated in an out-patient department after fortnight and then in 1, 6, and 12 months following the last PRP application.

RESULTS

Anal fistulas were closed in 4 (50%) patients from the group I and in 7 (70%) patients form the group II. Although, the difference between both groups was not statistically significant, PRP therapy should be preceded with fistulous tract drainage in all patients. Summarizing, that successful result was achieved in 11 (60%) patients from the entire group of 18 participants.

CONCLUSION

The rate of recurrent cryptoglandular anal fistulas closure reaching 60%, after topical treatment with PRP, exceeds the results of other sphincter-saving methods of treatment. Therefore, it might become a novel method of anal fistulas therapy.

Management of cryptoglandular fistula-in-ano among gastrointestinal surgeons in the Netherlands

BACKGROUND

Management of cryptoglandular fistula-in-ano (FIA) can be challenging. Despite Dutch and international guidelines determining optimal therapy is still quite difficult. The aim of this study was to report current practices in the management of cryptoglandular FIA among gastrointestinal surgeons in the Netherlands.

METHODS

Dutch surgeons and residents who are treating FIA regularly were sent a survey invitation by email. The survey was available online from September 19 to December 1 2019. The questionnaire consisted of 28 questions concerning diagnostic and surgical techniques in the treatment of intersphincteric and transsphincteric FIA.

RESULTS

In total, 147 (43%) surgeons responded and completed the survey. Magnetic resonance imaging was the preferred diagnostic imaging modality (97%) followed by the endo-anal ultrasound (12%). In case of a high FIA, 86% used a non-cutting seton. Most respondents removed a seton between 6 weeks and 3 months (n = 84, 58%). Fistulotomy was the procedure of preference in low transsphincteric (86%) and low intersphincteric FIA (92%). Mucosal advancement flap (MAF) and ligation of intersphincteric fistula tract (LIFT), with 78% and 46%, respectively, were the procedures that were applied most often in high transsphincteric FIA. In high intersphincteric FIA 67% performed a MAF and 33% a fistulotomy. Thirty-three percent of all respondents stated that they habitually closed the internal fistula opening, half of them used a Z-plasty. For debridement of the fistula tract the preferred method was curettage (78%).

CONCLUSIONS

Dutch gastrointestinal surgeons use various techniques in the management of FIA. Novel promising techniques should be investigated adequately in sufficient large trials to increase consensus. A core outcome measurement and a prospective international database would help in comparing results. Until then, treatment should be adjusted to the individual patient, governed by fistula characteristics and patient choice.

Enteral resorbable diet versus standard diet in primary sphincter reconstruction: a prospective randomised trial

AIM

Bowel movements after reconstructive anorectal surgery may negatively affect surgical outcome. This study was aimed to assess any differences between a standard diet (SD) and the enteral resorbable diet (ED) in terms of operative outcomes and patient tolerance after fistulectomy with primary sphincter reconstruction.

METHOD

Adult patients undergoing elective fistulectomy with primary sphincter reconstruction for anorectal and rectovaginal fistulas were eligible for inclusion. Patients were intraoperatively randomised to receive either the ED and peristalsis-inhibiting medication (ED) or a SD. The primary endpoint was the healing rate. Secondary endpoints included continence scores, complications and quality of life. Sample size calculation resulted in the analysis of 60 patients to detect a difference in fistula recurrence of 30% with 70% power and a 5% significance level.

RESULTS

Sixty-six patients (24 women) were prospectively and randomly assigned to the ED (n = 34: 51%) or a SD (n = 32; 48%); mean age was 47 (18-74) years. The primary healing rate was 64 out of 66 patients (96%). No statistical difference in healing rate was seen between the groups. However, patient satisfaction was significantly higher in the SD group (P < 0.0001).

CONCLUSIONS

Fistulectomy with primary sphincter reconstruction is a safe method with low complication rates. Postoperative stool behaviour has no significant influence on the healing rate but has a significant negative impact on patient satisfaction. Therefore, maintaining a standard diet seems to be preferable following reconstructive anal surgery.

TRIAL REGISTRATION

The trial was registered with the German Clinical Trials Register ( DRKS00020524 ).

[Regenerative effect of comprehensive physiotherapeutic programs in the early postoperative period in patients with chronic paraproctitis]

The modern lifestyle is often associated with low physical activity and blood stasis in the pelvic organs, which leads to increased incidence of proctological diseases, and increasingly in people of young working age. Chronic paraproctitis is the third most common proctological disorder that requires surgical treatment. The disease occurs commonly in the age group of 30-50 years, predominantly in men, which determines its socio-economic significance. It indicates the urgent need for advanced comprehensive physiotherapeutic programs for early rehabilitation of patients after surgery for chronic paraproctitis, and the application of new diagnostic technologies for assessment of surgery effectiveness and postoperative changes to provide adequate and effective medical rehabilitation. One of the main goals in the early postoperative period is the acceleration of adequate scar formation and reduction of the postoperative wound healing time; therefore, it seems reasonable to assess regeneration processes using transrectal ultrasound examination and sonoelastography of the scar tissue, which have great potential for use in coloproctology.

OBJECTIVE

To study the role of the medical rehabilitation program in the early postoperative period on the adequate scar formation and postoperative wound healing processes (by transrectal ultrasound investigation and scar tissue sonoelastography) as well as postoperative complications rate and long-term (up to 12 months) treatment outcomes in patients with chronic paraproctitis.

MATERIAL AND METHODS

The study included 60 patients 20-69 years with chronic pararectal fistulas (ICD-10: K60.4). The patients were assigned into two groups. The control group consisted of 30 patients who received standard of care in the early postoperative period, including analgesics, local antibacterial ointments (Levomekol, etc.), and rectal suppositories (Relief Pro, etc.). The main group also consisted of 30 patients who received standard of care and a 5-day comprehensive physiotherapeutic program starting the second day after the surgery. Effectiveness was assessed by complex transrectal ultrasound investigation with color Doppler mapping, Doppler sonography, and sonoelastography at various post-surgery time points.

RESULTS

The higher efficacy of the rehabilitation program, including intravenous ozone therapy, rectal laser therapy, recto-tibial myostimulation, and biofeedback therapy in the early postoperative period, versus the standard of care, was shown.

CONCLUSION

The introduction of rehabilitation program including intravenous ozone therapy, rectal laser therapy, recto-tibial myostimulation, and biofeedback therapy in the early postoperative period significantly reduced the average postoperative wound healing time by accelerating the formation of an adequate scar (according to transrectal ultrasound investigation and scar tissue sonoelastography) and the incidence of postoperative complications and improved the long-term treatment outcomes (up to 12 months) in patients with chronic paraproctitis.

Fistelchirurgie und primäre Sphinkterrekonstruktion

Die operative Therapie transsphinktärer Fisteln zeichnet sich durch eine variantenreiche Methodik aus. Die zumeist durchgeführten Techniken sind wohl die Fistulektomie mit Lappenplastik, die Fistulotomie mit oder ohne Sphinkterrepair und die (modifizierte) LIFT-Technik (Ligatur des intersphinktären Fisteltrakts). Ungeklärt aber ist die genaue Definition der Indikation einer Technik zu allen definierten Fisteltypen, was zum Teil dem Studiendesign anzuschulden ist und zu einer Variabilität der Auswertungen führt. Im vorliegenden Beitrag wird der Frage nach bisher vorhandenen Erfahrungen und Studien zur operativen Technik mit primärem Sphinkterrepair bei bestimmten Fisteltypen nachgegangen. In den letzten Jahrzehnten sind randomisierte Studien zu hoch- und suprasphinktären sowie zu rezidivierenden Fisteln mit guten Heilungs- und postoperativen Inkontinenzraten zur Technik der Fistulotomie mit Exzision des Fistelgewebes und primärem Sphinkterrepair erschienen. Die Technik wird in großen retrospektiven Studien jedoch bei allen transsphinktären Fisteln als erfolgreiche Therapieoption mit guter Kontinenzerhaltung beschrieben.

Photodynamic Therapy for the Treatment of Complex Anal Fistula

BACKGROUND AND OBJECTIVES

To validate and analyze the results of intralesional photodynamic therapy in the treatment of complex anal fistula.

STUDY DESIGN/MATERIALS AND METHODS

This prospective multicentric observational study enrolled patients treated for complex anal fistula who underwent intralesional photodynamic therapy (i-PDT). The included patients were treated from January 2016 to December 2018 with a minimum follow-up of 1 year to evaluate recurrence, continence and postoperative morbidity. Intralesional 5-aminolevulinic acid (ALA) gel (2%) was injected directly into the fistula. The internal and external orifices were closed. After an incubation period of 2 hours, the fistula was irradiated using an optical fiber connected to a red laser (Multidiode 630 PDT) operating at 1 W/cm for 3 minutes (180 J).

RESULTS

In total, 49 patients were included (61.2% male). The mean age was 48 years, and the mean duration of fistula was 13 months. Of the fistulas included, 75.5% were medium transphincteric, and 24.5% were high transphincteric. The median fistula length was 4 ± 1,14 cm (range: 3-5). A total of 41 patients (83.7%) had a previous history of fistula surgery. Preoperatively, some degree of anal incontinence was found in 5 patients (10.2%). No center reported any other procedure-related complications intraoperatively. Phototoxicity was found in one patient. In the first 48 hours after the procedure, fever was reported in 2 patients (4%). At the end of follow-up, total healing was observed in 32/49 patients (65.3%). No patient reported new incontinence postoperatively.

CONCLUSION

i-PDT could be considered a good choice in patients with complex anal fistulas to avoid surgery and its complications. Lasers Surg. Med. © 2019 Wiley Periodicals, Inc.

One stage fistulectomy for high anal fistula with reconstruction of anal sphincter without fecal diversion

Perianal sepsis and fistula is a troublesome disease in the field of colorectal surgery in term of recurrence and fecal incontinence. The aim of our study is to evaluate the role of 'one stage complex anal fistula excision with reconstruction of anal sphincter without stool diversion' regarding fecal incontinence and recurrence. This was prospective cohort study on 175 patients of complex high peri-anal fistulae, the patients were subjected to fistulectomy and reconstruction (primary suture repair) of anal sphincter without stool diversion, the patients were followed up 1 year postoperatively after complete healing of the wound regarding their continence to stool and gases using Wexner score and recurrence of the fistula which is examined clinically and radio-logically using MRI. Among the 175 patients only four had developed fecal incontinence with varying degrees in which 2 patients developed gas incontinence and 2 patients developed soiling, after 3 months 8 patients had recurrence and after 6-9 months 6 patients developed recurrence . Also at the end of follow up period upon performing the confirmatory MRI, 2 patients showed hidden fistulous tracts ending into a high abscess cavity. This ends up into total of 16 recurrent cases. Five patients experienced delayed wound healing. In conclusion, Compared to other treatment modalities for complex anal fistula found in literature, it had been found that one stage surgery (fistulectomy with primary sphincter repair) has good results regarding healing of the fistula with low risk of incontinence, low recurrence rate and good wound healing.

Japanese Practice Guidelines for Anal Disorders II. Anal fistula

Anal fistulas usually result from an anal gland infection in the intersphincteric space, which is caused by bacteria entering through the anal crypt (cryoptglandular infection). Reports of anal fistulas have been as high as 21 people in 100,000. Anal fistulas are 2-6 times more prevalent in males than females, with the condition occurring most frequently in patients in their 30s and 40s. Anal abscess symptoms include sudden onset of anal pain, swelling, redness, and fever. Purulent discharge or intermittent perianal swelling and pain are most often consistent with anal fistula symptoms. Methods for diagnosing anal fistulas include visual inspection, palpation, digital examination, anoscopic examination, barium enema, fistulography, as well as imaging, such as ultrasound, CT, and MRI. Parks classification is widely adapted in the West; however, Japan usually employs Sumikoshi classification. Antibiotics should be administered in cases of perianal abscess with surrounding cellulitis, or concomitant systemic disease, or those not alleviated by incision and drainage. The site and size of incision and drainage depend upon the abscess type and location. Incisions should be performed taking care not to damage the sphincter muscles and with possible future fistula surgery in mind. As spontaneous recovery is rare, except in the case of children, surgery is the principle approach to anal fistulas. Several approaches are utilized for anal fistulas. A specific procedure may be chosen depending upon curability and anal function. Postsurgical outcomes vary from study to study. Fecal incontinence may occur after fistula surgery, but reports vary.

Fistulectomy with primary sphincter reconstruction

AIM

Despite modern medical techniques, anatomically proximal (high) anal fistulas are still a challenge in colorectal surgery. In previous years, the standard of care was complete fistulectomy with a high rate of continence disorders. Over the past 20 to 30 years, sphincter-saving procedures have gained wide acceptance. They represent the technique used in these cases. Additionally, many patients received indefinite treatment, namely the placement of a seton to maintain surgical drainage. The main problem with all fistula surgical possibilities is the high recurrence rate of 30 to 50% in flap procedures and 100% persistence in seton treatments. In recent years, a direct repair (primary reconstruction) in distal fistulas was instigated and shows excellent results. It allowed our technique for proximal (high) anal fistulas to evolve.

METHOD

All patients who underwent surgery at the University Medical Center Mannheim, Department of Colo-proctology (from 06/2003 to 11/2015), were retrospectively evaluated using a prospective database. Patients who underwent fistulectomy with primary sphincter reconstruction were all included.

RESULTS

The primary healing rate, after a mean follow-up of 11 months (7 to 200 months), was 88.2% (374 of 424). Taking into account revisionary surgeries with secondary sphincter repair, this rate reaches 95.8% (406 of 424). Factors such as gender and fistula location as related to the sphincter had significant influence on the study outcome, whereas variables such as the amount of reconstructed muscle (in mm), number of revisions, patient age, other anal operations, and concomitant medication did not. The incontinence of a subgroup of 148 patients was evaluated in detail by way of a questionnaire. Even at a preoperative baseline, 9.6% of those patients reported some minor degree of continence disorders. After the procedure, incontinence disorders were observed in 34 patients (23.0%), with 23 of these patients suffering from flatus incontinence (15.5%), 10 patients from liquid incontinence (6.8%), and 1 patient from solid fecal incontinence.

CONCLUSION

Fistulectomy with primary sphincter reconstruction is a feasible procedure resulting in a low recurrence rate. No other procedure has shown better results in transsphincteric fistulas. Continence disorders seem to be of minor relevance/consequence for these patients.

3D high-resolution anorectal manometry in patients with perianal fistulas: comparison with 3D-anal ultrasound

BACKGROUND

Perianal fistula surgery can damage the anal sphincters which may cause faecal incontinence. By measuring regional pressures, 3D-HRAM potentially provides better guidance for surgical strategy in patients with perianal fistulas. The aim was to measure regional anal pressures with 3D-HRAM and to compare these with 3D-EUS findings in patients with perianal fistulas.

METHODS

Consecutive patients with active perianal fistulas who underwent both 3D-EUS and 3D-HRAM at a clinic specialised in proctology were included. A group of 30 patients without fistulas served as controls. Data regarding demographics, complaints, previous perianal surgical procedures and obstetric history were collected. The mean and regional anal pressures were measured with 3D-HRAM. Fistula tract areas detected with 3D-EUS were analysed with 3D-HRAM by visual coding and the regional pressures of the corresponding and surrounding area of the fistula tract areas were measured. The study was granted by the VUmc Medical Ethical Committee.

RESULTS

Forty patients (21 males, mean age 47) were included. Four patients had a primary fistula, 19 were previously treated with a seton/abscess drainage and 17 had a recurrence after previously performed fistula surgery. On 3D-HRAM, 24 (60%) fistula tract areas were good and 8 (20%) moderately visible. All but 7 (18%) patients had normal mean resting pressures. The mean resting pressure of the fistula tract area was significantly lower compared to the surrounding area (47 vs. 76 mmHg; p < 0.0001). Only 2 (5%) patients had a regional mean resting pressure < 10 mmHg of the fistula tract area. Using a Δ mean resting pressure ≥ 30 mmHg difference between fistula tract area and non-fistula tract area as alternative cut-off, 21 (53%) patients were identified. In 6 patients 3D-HRAM was repeated after surgery: a local pressure drop was detected in one patient after fistulotomy with increased complaints of faecal incontinence.

CONCLUSIONS

Profound local anal pressure drops are found in the fistula tract areas in patients normal mean resting pressures. Fistulotomy may affect local sphincter pressure. This might influence surgical decision making in future.

Video-assisted anal fistula treatment: a high volume unit initial experience

Introduction Perianal fistulas are a common problem. Video-assisted anal fistula treatment is a new technique for the management of this difficult condition. We describe our initial experience with the technique to facilitate the treatment of established perianal fistulas. Methods We reviewed a prospectively maintained database relating to consecutive patients undergoing video-assisted anal fistula treatment in a single unit. Results Seventy-eight consecutive patients had their perianal fistulas treated with video-assistance from November 2014 to June 2016. Complete follow-up data were available in 74 patients, with median follow-up of 14 months (interquartile range 7-19 months). There were no complications and all patients were treated as day cases. Most patients had recurrent disease, with 57 (77%) having had previous fistula surgery. At follow-up, 60 (81%) patients reported themselves 'cured' (asymptomatic) including 5 patients with Crohn's disease and one who had undergone 10 previous surgical procedures. Logistical stepwise regression did not demonstrate any statistically significant factors that may have been considered to affect outcome (age, gender, diabetes, previous I&D, Crohn's disease, smoking, type of fistula). Conclusions Our data have shown that video-assisted anal fistula treatment is safe and effective in the management of perianal fistulas in our patients and this suggests it may be applied to all patients regardless of comorbidity, underlying pathology or type of fistula.

Photodynamic therapy for the treatment of complex anal fistula

BACKGROUND

Photodynamic therapy (PDT) is a new procedure for the treatment of anal fistula. This preliminary study was designed to investigate the safety and effectiveness of this new technique in the treatment of anal fistula.

METHODS

Ten patients were treated with PDT. Intralesional 5-aminolevulinic acid (ALA) 2% was directly injected into the fistula. The internal and external orifices were closed. After an incubation period of 2 h, the fistula was irradiated using an optical fibre connected to a red laser (MULTIDIODE 630 PDT, INTERmedic, Spain) operating at 1 W/cm for 3 min (180 Joules). Patient demographics, operation notes and complications were recorded.

RESULTS

There were no complications. The average length of patient follow-up was 14.9 months (range 12-20 months). We could observe primary healing in eight patients (80%). Two patients (20%) showed persistence of suppuration after the operation. No patient reported incontinence postoperatively.

CONCLUSIONS

PDT is a potential sphincter-saving procedure that is safe, simple and minimally invasive and has a high success rate.

Management of Complex Anal Fistulas

Complex anal fistulas require careful evaluation. Prior to any attempts at definitive repair, the anatomy must be well defined and the sepsis resolved. Several muscle-sparing approaches to anal fistula are appropriate, and are often catered to the patient based on their presentation and previous repairs. Emerging technologies show promise for fistula repair, but lack long-term data.

Therapeutic management of complex anal fistulas by installing a nitinol closure clip: study protocol of a multicentric randomised controlled trial--FISCLOSE

INTRODUCTION

Complex anal fistulas are responsible for pain, faecal incontinence and impaired quality of life. The rectal mucosa advancement flap (RMAF) procedure to cover the internal opening of the fistula remains a strategy of choice. However, a new procedure for closing anal fistulas is now available with the use of a nitinol closure clip (OTSC Proctology, OVESCO), which should ensure a better healing rate. This procedure is currently becoming more widespread, though without robust scientific validation, and it is therefore essential to carry out a prospective evaluation in order to determine the efficacy and safety of this new medical device for complex anal fistulas.

METHODS AND ANALYSIS

The FISCLOSE trial is aimed at evaluating the efficacy and safety of a nitinol closure clip compared to the RMAF procedure for the management of complex anal fistulas. This trial is a prospective, randomised, controlled, single-blind, bicentre and interventional study. Patients (n=46 per group) will be randomly assigned for management with either a closure clip or RMAF. The main objectives are to improve the healing rate of the anal fistula, lessen the postoperative pain and faecal incontinency, enhance the quality of life, and lower the number of reinterventions and therapeutic management costs. The primary outcome is the proportion of patients with a healed fistula at 3 months. The secondary outcomes are anal fistula healing (6 and 12 months), proctological pain (visual analogue scale), the faecal incontinence score (Jorge and Wexner questionnaire), digestive disorders and quality of life (Gastrointestinal Quality of Life Index and Euroqol EQ5D-3 L) up to 1 year.

ETHICS AND DISSEMINATION

The study was approved by an independent medical ethics committee 1 (IRB00008526, CPP Sud-Est 6, Clermont-Ferrand, France) and registered by the competent French authority (ANSM, Saint Denis, France). The results will be disseminated in a peer-reviewed journal and presented at international congresses.

TRIAL REGISTRATION NUMBER

NCT02336867; pre-result.

Cone-like resection, fistulectomy and mucosal rectal sleeve partial endorectal pull-through in paediatric Crohn's disease with perianal complex fistula

BACKGROUND

Perianal abscesses and fistulae have been reported in approximately 15% of patients with paediatric Crohn's disease and they are associated with poor quality of life. Several surgical techniques were proposed for the treatment of perianal Crohn's disease, characterized by an elevated incidence of failure, incontinence, and relapse. Aim of our study was to present the technical details and results of our surgical technique in case of recurrent, persistent, complex perianal ano-rectal destroying Crohn's disease not responding to medical treatment.

METHODS

Data of patients who underwent surgical treatment (cone-like resection, fistulectomy, sphincter reconstruction, endorectal advancement sleeve flaps like in Soave endorectal pull-through) for complicated high-level trans, inter or suprasphincteric fistulae between January 2009 and June 2014 were retrospectively reviewed.

RESULTS

20 surgical procedures were performed in 11 patients (males 72.7%) with transsphincteric (n=5), intersphincteric (n=4) and suprasphincteric (n=2) fistulae. Three patients needed a second treatment. Two patients needed more than 2 surgeries and one temporary colostomy. No patient presented anal incontinence at 15 months' median follow-up.

CONCLUSIONS

Although several procedures may be required to obtain a complete remission of perianal lesions, in our series the proposed surgical technique seemed effective and safe, preserving anal continence in all treated cases and reducing the need of faecal diversion.

Long-term follow-up after surgery for simple and complex cryptoglandular fistulas: fecal incontinence and impact on quality of life

BACKGROUND

Surgical management of cryptoglandular fistulas is a challenge because the consequences of anal surgery potentially include fecal incontinence and impaired quality of life.

OBJECTIVE

To assess factors associated with fecal incontinence after surgery for simple and complex cryptoglandular fistulas and to determine the impact of incontinence on quality of life.

DESIGN

The design is retrospective and cross-sectional.

SETTINGS

This study was conducted at an academic tertiary center and at a private center specializing in proctologic surgery.

PATIENTS

All patients who underwent preoperative endoanal ultrasound for cryptoglandular fistula between 2002 and 2012.

MAIN OUTCOME MEASURES

A questionnaire was sent out in October 2013 to evaluate incontinence (Wexner-score) and its impact on quality of life (FIQL). Variables tested for association were patient demographics, fistula type, number of incised abscesses (0, 1, >1), number of fistulotomies (0, 1, >1) and number of sphincter-sparing procedures (0, 1, >1).

RESULTS

Of the 141 patients participating, 116 (82%; 76 men, 40 women) returned all the questionnaires. Median follow-up from the first perianal fistula surgery was 7.8 years (range, 2.1-18.1 years). Thirty-nine patients (34%) experienced incontinence. Surgical fistulotomy, multiple abscess drainages and a high transsphincteric or suprasphincteric fistula tract were associated with incontinence. As compared to simple fistula (Wexner score, 1.2 [SD, 2.1]), incontinence was worse after surgery for complex fistula (Wexner score, 4.7 [SD, 6.2], p = 0.001), as were quality of life elements, including lifestyle (p = 0.030), depression (p = 0.077) and embarrassment (p < 0.001).

LIMITATIONS

Mainly retrospective design without a standardized treatment protocol.

CONCLUSION

Surgical fistulotomy is the strongest risk factor for fecal incontinence. The severity of incontinence increases with the complexity of the fistula, negatively influencing quality of life. Special attention should be paid to these patients so as to mitigate symptoms later in life. A shift to sphincter-sparing procedures appears warranted.

Management of Fistula-in-Ano-The Current Evidence

Successful treatment for fistula in ano has eluded most surgeons. To choose the right surgery has been made more difficult, with new surgeries being added in the last decade. This article discusses the various accepted surgeries for fistula in ano - their pros & cons, & attempts to provide the status of the various procedures as it stands today.

Fistulectomy with primary sphincter reconstruction in the treatment of high transsphincteric anal fistulas

PURPOSE

The treatment of transsphincteric anal fistulas is a challenge between recurrence rate and incontinence. Many surgical and conservative procedures have been described in the treatment of anal fistulas. Fistulectomy and primary sphincter reconstruction (FPSR) has not gained great popularity in this field due to the risk of sphincter damage. The aim of this study is to evaluate FPSR in the treatment of transsphincteric fistulas.

METHODS

We retrospectively analyzed 50 patients with high transsphincteric fistulas of cryptoglandular origin that were treated with FPSR between 2005 and 2008. Preoperative assessment included physical and proctologic examination. Continence and pain scores were evaluated preoperatively and postoperatively.

RESULTS

In our 50 patients, 22 patients (44 %) had a previous proctologic operation and 11 patients (22 %) presented with recurrent fistulas. The fistulas existed for an average of 8 months. The operation time was 28 ± 16 min. Mean follow-up was 22± months. The fistula healed in 44 patients (88 %) who developed no recurrence. In five patients (10 %), the fistula healed, but they developed a recurrence in the observation period. In one patient (2 %), the fistula did not heal. Three patients developed low-grade incontinence for flatus, and one patient with 2° incontinence improved. Preoperatively and postoperatively calculated continence and pain scores showed a slight but significant elevation in the Clinical Continence Score, the German Society of Coloproctology Score showed no significant difference, and preexisting pain was reduced significantly by surgery.

CONCLUSIONS

FPSR is a safe surgical procedure for the treatment of high transsphincteric anal fistula. The primary healing rate is high with a low risk of recurrence or incontinence.

[Perianal fistula and anal fissure]

CRYPTOGLANDULAR ANAL FISTULA: Perianal abscesses are caused by cryptoglandular infections. Not every abscess will end in a fistula. The formation of a fistula is determined by the anatomy of the anal sphincter and perianal fistulas will not heal on their own. The therapy of a fistula is oriented between a more aggressive approach (operation) and a conservative treatment with fibrin glue or a plug. Definitive healing and the development of incontinence are the most important key points. ANAL FISSURES: Acute anal fissures should be treated conservatively by topical ointments, consisting of nitrates, calcium channel blockers and if all else fails by botulinum toxin. Treatment of chronic fissures will start conservatively but operative options are necessary in many cases. Operation of first choice is fissurectomy, including excision of fibrotic margins, curettage of the base and excision of the sentinel pile and anal polyps. Lateral internal sphincterotomy is associated with a certain degree of incontinence and needs critical long-term observation.