1
|
Rebmann E, Hamel JF, Helbert C, Lemasson F, Legendre G, Venara A. Anal incontinence after obstetrical anal sphincter injury significantly impacts quality of life for women: a cohort study. Langenbecks Arch Surg 2024; 409:67. [PMID: 38368278 DOI: 10.1007/s00423-024-03257-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Accepted: 02/12/2024] [Indexed: 02/19/2024]
Abstract
PURPOSE To assess the prevalence of anal incontinence (AI) after obstetrical anal sphincter injuries (OASIS) and its severity, as well as the risk factors for AI and AI episodes ≥ 6 months. METHODS This prospective and observational monocentric cohort study included all the women who had an OASIS between 1 January 2005 and 31 December 2019. Information was collected by using a letter informing for the fecal incontinence quality of life (FIQL) questionnaire and by a phone interview. The main outcome measure was "1 passed or ongoing episode of AI". RESULTS Among the 227 patients included, 19.8% had ongoing AI, and 35.2% had AI passed or ongoing episodes. A total of 46.7% of women with AI reported a change in their quality of life in all fields of the FIQL. Excluding a history of inflammatory bowel disease, no factor was associated with the incidence of an AI episode. Post-obstetrical AI ≥ 6 months (POAI ≥ 6) represented 63.7% of AI cases. This incontinence began with significant incidence in the immediate postpartum period but increased over time, unlike AI < 6 months, which appeared primarily in the immediate postpartum period. Instrumental birth was a protective factor for POAI ≥ 6 (OR = 0.24; CI 95% [0.08-0.78]; p = 0.016), while an increase in parity and BMI were risk factors for POAI ≥ 6 (OR = 4.21; CI 95% [1.01-17.71]; p = 0.05 and OR = 1.15; CI 95% [1.03-1.30]; p = 0.016, respectively). CONCLUSION The prevalence of AI after OASIS is not underestimated. Despite the fact that women do not seek care, the impact of AI on the quality of life is significant. A case of AI that lasts for 6 months after giving birth risks becoming chronic. Therefore, specialist advice should be recommended in this case. CLINICAL TRIAL REGISTRY NCT04940494.
Collapse
Affiliation(s)
- Emeline Rebmann
- Faculty of Health, Angers, France
- Department of Visceral Surgery, CHU Angers, 4 Rue Larrey, 49933, Angers Cedex 09, France
| | - Jean-Francois Hamel
- Faculty of Health, Angers, France
- Department of Biostatistics, CHU Angers, Angers, France
- Ester | Irset Inserm UMR 1085, Angers, France
| | | | | | - Guillaume Legendre
- Faculty of Health, Angers, France
- Department of Gynaecology-Obstetrics, CHU Angers, 4 Rue Larrey, Angers, France
| | - Aurélien Venara
- Faculty of Health, Angers, France.
- Department of Visceral Surgery, CHU Angers, 4 Rue Larrey, 49933, Angers Cedex 09, France.
- Department of Gynaecology-Obstetrics, CHU Angers, 4 Rue Larrey, Angers, France.
- IHFIH, UPRES EA 3859, University of Angers, Angers, France.
- The Enteric Nervous System in Gut and Brain Disorders, Université de Nantes, INSERM, TENS, IMAD, Nantes, France.
| |
Collapse
|
2
|
Ghasemlouei A, Naseri A, Ashjaei A, Sadeghi S, Keshvari A. Evaluation surgical strategies in perianal fistulas treatment: Efficacy draining seton compared to other surgical approaches; a case-control study. Health Sci Rep 2024; 7:e1911. [PMID: 38410496 PMCID: PMC10894753 DOI: 10.1002/hsr2.1911] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2023] [Revised: 12/12/2023] [Accepted: 01/21/2024] [Indexed: 02/28/2024] Open
Abstract
Background and Aims Perianal fistula is a prevalent anorectal condition originating from an infectious crypt extending to the external opening. Multiple surgical methods exist for treating perianal fistulas; however, selecting the appropriate options is still controversial. Our study aims to evaluate seton replacement versus other surgical methods in treating perianal fistula. Methods This study recruited 72 patients presenting with perianal discharge and diagnosed with perianal fistula through intra-sphincteric, trans-sphincteric, and supra-sphincteric examinations at Imam Reza and Besat Hospitals from July 2022 up to March 2023. Regarding case-control design, patients were divided into two groups: the first group (n = 36) underwent seton insertion, while the control group (n = 36) received alternative surgical methods. Follow-up was conducted for 1 month post-discharge, with monthly visits for 6 months. Patients were evaluated for fistula tract healing, seton loosening, and daily secretion rate (based on infected pads) during each visit. Finally, the two groups were compared in terms of improvement rates. Results In the seton group, approximately 94.4% of patients showed improvement. However, the difference between the groups was insignificant (p = 0.494). Seton replacement was performed in 52% of patients, with the majority requiring replacement twice (61%). Improvement rates were highest among cases with two seton replacements, although the difference was not statistically significant (p = 0.073). Following seton replacement, the most common treatment methods were endoanal flap and fistulotomy, with observed improvement in 10 cases for each procedure. Conclusion This study highlights that draining seton remains a primary choice for intermediate treatment due to its satisfactory improvement rate and lower requirement for replacement, especially up to two times.
Collapse
Affiliation(s)
- Amir Ghasemlouei
- Department of Surgery Aja University of Medical Sciences Tehran Iran
| | - Amirhosein Naseri
- Department of Surgery Aja University of Medical Sciences Tehran Iran
| | - Ali Ashjaei
- Department of Surgery Aja University of Medical Sciences Tehran Iran
| | - Shahryar Sadeghi
- Division of Colorectal Surgery, Department of Surgery, Imam-Khomeini Hospital Complex University of Medical Sciences Tehran Iran
| | - Amir Keshvari
- Division of Colorectal Surgery, Department of Surgery, Imam-Khomeini Hospital Complex University of Medical Sciences Tehran Iran
| |
Collapse
|
3
|
Reza L, Gottgens K, Kleijnen J, Breukink S, Ambe PC, Aigner F, Aytac E, Bislenghi G, Nordholm-Carstensen A, Elfeki H, Gallo G, Grossi U, Gulcu B, Iqbal N, Jimenez-Rodriguez R, Leventoglu S, Lisi G, Litta F, Lung P, Millan M, Ozturk E, Sackitey C, Shalaby M, Stijns J, Tozer P, Zimmerman D. European Society of Coloproctology: Guidelines for diagnosis and treatment of cryptoglandular anal fistula. Colorectal Dis 2024; 26:145-196. [PMID: 38050857 DOI: 10.1111/codi.16741] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Revised: 07/11/2023] [Accepted: 08/03/2023] [Indexed: 12/07/2023]
Abstract
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.
Collapse
Affiliation(s)
| | | | - Jos Kleijnen
- KSR Ltd & Maastricht University Medical Center (MUMC+) -CAPHRI, Maastricht, Netherlands
| | | | | | | | | | | | | | | | | | - Ugo Grossi
- Treviso Regional Hospital, Treviso, Italy
| | | | | | | | | | | | | | | | - Monica Millan
- La Fe University and Polytechnic Hospital, Valencia, Spain
| | | | | | | | | | | | | |
Collapse
|
4
|
Tomasicchio G, Giove C, Dezi A, Picciariello A, Lantone V, Martines G, De Fazio M, Rinaldi M. The management of low trans-sphincteric anal fistula during the COVID-19 pandemic: revisiting the role of the seton. Updates Surg 2024; 76:163-167. [PMID: 38123906 DOI: 10.1007/s13304-023-01713-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Accepted: 11/18/2023] [Indexed: 12/23/2023]
Abstract
The management of trans-sphincteric anal fistula (TAF) includes several surgical options; however, during the COVID-19 pandemic, the access to the operating rooms was severely limited, leaving only the choice of minimally invasive procedures. This study aimed to evaluate the safety and effectiveness of the slow cutting seton technique for TAF performed in an outpatient setting during the COVID-19 pandemic.Patients treated for TAF between January 2020 and July 2022 and followed-up for at least 12 months were retrospectively evaluated. A vascular silicone tie used as seton was positioned in the fistula tract using a Lockhart-Mummery fistula probe. The seton was maintained in moderate tension until the sphincter muscle was passed. Percentage and time for healing, recurrence, SF-36, VAS and Vaizey's Score were recorded.Fifty-eight patients [36 male/22 female, median age 56.5 years (IQR 41.25-65.75) [with TAF were included. After a median time of 4 months, complete healing occurred in 53 cases (91.5%), the anal pain VAS decreased from 6 to 0, the anal incontinence scores did not change significantly and the QoL improved significantly in all the SF36 domains. No complications were recorded, but the fistula recurred in five cases (8.5%). Two of them had additional seton treatment, and three underwent other surgical procedures after the COVID-19 emergency.The slow cutting seton technique is a safe and effective treatment for outpatient procedure with minimal patient discomfort. This treatment option in healthcare delivery for TAF should be reconsidered, even outside the limited in-hospital access during the COVID-19 pandemic.
Collapse
Affiliation(s)
- G Tomasicchio
- Surgical Unit "M. Rubino", Department of Precision and Regenerative Medicine and Ionian Area (DiMePRe-J), University Aldo Moro of Bari, Bari, Italy
| | - C Giove
- Surgical Unit "M. Rubino", Department of Precision and Regenerative Medicine and Ionian Area (DiMePRe-J), University Aldo Moro of Bari, Bari, Italy
| | - A Dezi
- Surgical Unit "M. Rubino", Department of Precision and Regenerative Medicine and Ionian Area (DiMePRe-J), University Aldo Moro of Bari, Bari, Italy.
| | - A Picciariello
- Department of Experimental Medicine, University of Salento, Lecce, Italy
| | - V Lantone
- Surgical Unit "M. Rubino", Department of Precision and Regenerative Medicine and Ionian Area (DiMePRe-J), University Aldo Moro of Bari, Bari, Italy
| | - G Martines
- Surgical Unit "M. Rubino", Department of Precision and Regenerative Medicine and Ionian Area (DiMePRe-J), University Aldo Moro of Bari, Bari, Italy
| | - M De Fazio
- Surgical Unit "M. Rubino", Department of Precision and Regenerative Medicine and Ionian Area (DiMePRe-J), University Aldo Moro of Bari, Bari, Italy
| | - M Rinaldi
- Surgical Unit "M. Rubino", Department of Precision and Regenerative Medicine and Ionian Area (DiMePRe-J), University Aldo Moro of Bari, Bari, Italy
| |
Collapse
|
5
|
Khamar J, Sachdeva A, McKechnie T, Lee Y, Tessier L, Hong D, Eskicioglu C. Cutting seton for the treatment of cryptoglandular fistula-in-ano: a systematic review and meta-analysis. Tech Coloproctol 2023; 28:12. [PMID: 38091125 DOI: 10.1007/s10151-023-02886-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2023] [Accepted: 10/21/2023] [Indexed: 12/18/2023]
Abstract
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.
Collapse
Affiliation(s)
- J Khamar
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada
| | - A Sachdeva
- Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - T McKechnie
- Division of General Surgery, Department of Surgery, McMaster University, St. Joseph's Healthcare, 50 Charlton Avenue East, Hamilton, ON, L8N 4A6, Canada
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - Y Lee
- Division of General Surgery, Department of Surgery, McMaster University, St. Joseph's Healthcare, 50 Charlton Avenue East, Hamilton, ON, L8N 4A6, Canada
- Harvard T.H. Chan School of Public Health, Harvard University, Boston, MA, USA
| | - L Tessier
- Division of General Surgery, Department of Surgery, McMaster University, St. Joseph's Healthcare, 50 Charlton Avenue East, Hamilton, ON, L8N 4A6, Canada
| | - D Hong
- Division of General Surgery, Department of Surgery, McMaster University, St. Joseph's Healthcare, 50 Charlton Avenue East, Hamilton, ON, L8N 4A6, Canada
- Division of General Surgery, Department of Surgery, St. Joseph's Healthcare, Hamilton, ON, Canada
| | - C Eskicioglu
- Division of General Surgery, Department of Surgery, McMaster University, St. Joseph's Healthcare, 50 Charlton Avenue East, Hamilton, ON, L8N 4A6, Canada.
- Division of General Surgery, Department of Surgery, St. Joseph's Healthcare, Hamilton, ON, Canada.
| |
Collapse
|
6
|
Schrader L, Brandstrup B, Olaison G. Slowly cutting, loose seton ligature and staged fistulotomy for healing of idiopathic perianal fistula and influence on anal continence. Langenbecks Arch Surg 2023; 408:352. [PMID: 37673848 PMCID: PMC10482758 DOI: 10.1007/s00423-023-03005-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Accepted: 06/27/2023] [Indexed: 09/08/2023]
Abstract
PURPOSE To investigate the ability of a "slowly cutting, loose seton ligature and staged fistulotomy" to heal perianal fistulas, the time needed with the seton ligature, recurrence rate, influence on anal continence, health-related quality of life (HRQoL), and patient satisfaction. METHODS Observational single-center study. We reviewed the medical records of all patients with primary surgeries from January 1, 2009, to December 31, 2018. The patients answered a questionnaire pre- and postoperative on anal continence (St. Mark's incontinence score) and HRQoL (The Short Health Scale). Satisfaction with the operation was answered postoperatively. RESULTS Forty-three patients (37 men, 6 women) were included. Initially 41 of 43 healed (95%). Three patients (7%) had a recurrence, two healed after retreatment. The median follow-up was 55 months (IQR, 4). Thirty-four patients (79%) responded to the questionnaire. At follow-up, forty (93%) patients were healed. The median time treated with a seton ligature in the healed patients was 13 months (IQR, 14). St. Mark's incontinence score preoperative was median 2 (IQR, 9) and after the operation median 1 (IQR, 4). The Short Health Scale improved from median 20 (IQR, 5) preoperatively to 5 (IQR, 5) postoperatively, p < 0.001. Patient satisfaction was median 1 (= very satisfied) (IQR, 1). CONCLUSION A "slowly cutting, loose seton ligature followed by a staged fistulotomy", heals the vast majority of perianal fistulas with minor or none influence on continence and few recurrences. Patient-reported HRQoL improves greatly, and patient satisfaction is high.
Collapse
Affiliation(s)
- Lisa Schrader
- Department of Surgery, Holbaek Hospital, Part of Copenhagen University Hospitals, Smedelundsgade 60, 4300, Holbaek, Denmark.
| | - Birgitte Brandstrup
- Department of Surgery, Holbaek Hospital, Part of Copenhagen University Hospitals, Smedelundsgade 60, 4300, Holbaek, Denmark
- Department of Clinical Medicine, University of Copenhagen, Blegdamsvej 3B, 2200, Copenhagen N, Denmark
| | - Gunnar Olaison
- Department of Surgery, Holbaek Hospital, Part of Copenhagen University Hospitals, Smedelundsgade 60, 4300, Holbaek, Denmark
| |
Collapse
|
7
|
Cai P, Rong H, Zhu Q, Dai X, Zhao J. The potential roles of gut microbiome in anal fistula. AMB Express 2023; 13:58. [PMID: 37301777 DOI: 10.1186/s13568-023-01560-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2023] [Accepted: 05/14/2023] [Indexed: 06/12/2023] Open
Abstract
Anal fistula is a common proctological disease, but the thorough mechanisms of the anal fistula formation are still unclear. An increasing number of studies have revealed the crucial role of gut microbiota in intestinal diseases. We used 16S rRNA gene sequencing to analyze the intestinal microbiome in order to determine whether there are differences in the microbiome between anal fistula patients and healthy individuals. The microbiome samples were extracted by repeatedly wiping the rectal wall with intestinal swab. Before this operation, the whole intestine of all participants was irrigated and the score of the Boston bowel preparation scale reached 9. The biodiversity of gut microbiome of rectum revealed significant difference between anal fistula patients and healthy individuals. 36 discriminative taxa were identified by LEfSe analysis between two groups. At the phylum level, Synergistetes was enriched in anal fistula patients, while Proteobacteria was higher in healthy individuals. We also found that at the genus level, Blautia, Faecalibacterium, Ruminococcus, Coprococcus, Bacteroides, Clostridium, Megamonas and Anaerotruncus were highly enriched in anal fistula patients, while the microbiome of healthy individuals was enriched with Peptoniphilus and Corynebacterium. Spearman correlations showed the extensive and close association among genera and species. Finally, a diagnostic prediction model was constructed by random forest classifier, and the area under curve (AUC) reached 0.990. This study gave an important hint for analyzing gut microbiome of rectum in anal fistula patient.Keypoints.We use the 16S rRNA gene sequencing to test the microbiome samples extracted from the intestinal swab. This is the first study to explore the gut microbiome of rectum using this workflow. We also found the distinct gut microbiome of rectum differences between anal fistula patients and healthy individuals.
Collapse
Affiliation(s)
- Ping Cai
- Ningbo No.2 Hospital, Ningbo, 315000, China
- Ningbo Institute of Life and Health Industry, University of Chinese Academy of Sciences, Ningbo, 315000, China
- Key Laboratory of Diagnosis and Treatment of Digestive System Tumors of Zhejiang Province, Ningbo, 315000, China
| | - Hao Rong
- Ningbo No.2 Hospital, Ningbo, 315000, China.
- The Affiliated Hospital of Medical School of Ningbo University, Ningbo, 315000, China.
- Department of Preventive Medicine, Zhejiang Provincial Key Laboratory of Pathological and Physiological Technology, School of Medicine, Ningbo, 315211, China.
| | - Qiaoqiao Zhu
- Ningbo No.2 Hospital, Ningbo, 315000, China
- Ningbo Institute of Life and Health Industry, University of Chinese Academy of Sciences, Ningbo, 315000, China
- Key Laboratory of Diagnosis and Treatment of Digestive System Tumors of Zhejiang Province, Ningbo, 315000, China
| | - Xiaoyu Dai
- Ningbo No.2 Hospital, Ningbo, 315000, China
- Ningbo Institute of Life and Health Industry, University of Chinese Academy of Sciences, Ningbo, 315000, China
- Key Laboratory of Diagnosis and Treatment of Digestive System Tumors of Zhejiang Province, Ningbo, 315000, China
| | - Jianpei Zhao
- Ningbo No.2 Hospital, Ningbo, 315000, China
- Ningbo Institute of Life and Health Industry, University of Chinese Academy of Sciences, Ningbo, 315000, China
- Key Laboratory of Diagnosis and Treatment of Digestive System Tumors of Zhejiang Province, Ningbo, 315000, China
| |
Collapse
|
8
|
García-Olmo D, Gómez-Barrera M, de la Portilla F. Surgical management of complex perianal fistula revisited in a systematic review: a critical view of available scientific evidence. BMC Surg 2023; 23:29. [PMID: 36740680 PMCID: PMC9901165 DOI: 10.1186/s12893-023-01912-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Accepted: 01/10/2023] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Treating complex perianal fistulas in Crohn's disease patients remains a challenge. Classical surgical treatments for Crohn's disease fistulas have been extrapolated from cryptoglandular fistulas treatment, which have different etiology, and this might interfere with its effectiveness, in addition, they increase fecal incontinence risk. Recently, new surgical techniques with support from biological approaches, like stem cells, have been developed to preserve the function of the sphincter. We have performed a systematic literature review to compare the results of these different techniques in the treatment of Crohn's or Cryptoglandular fistula. METHODS PubMed, EMBASE, Database of Abstracts of Reviews of Effectiveness, Cochrane Central Register of Controlled Trials were searched systematically for relevant articles. We included randomized controlled trials and observational studies that referred to humans, were written in English, included adults 18+ years old, and were published during the 10-year period from 2/01/2010 to 2/29/2020. Evidence level was assigned as designated by the Scottish Intercollegiate Guidelines Network. RESULTS Of the 577 citations screened, a total of 79 were ultimately included in our review. In Crohn's disease patients, classical techniques such as primarily seton, Ligation of Intersphincteric Fistula Tracks, or lay open, healing rates were approximately 50-60%, while in cryptoglandular fistula were around, 70-80% for setons or flaps. In Crohn's disease patients, new surgical techniques using derivatives of adipose tissue reported healing rates exceeding 70%, stem cells-treated patients achieved higher combined remission versus controls (56.3% vs 38.6%, p = 0.010), mesenchymal cells reported a healing rate of 80% at week 12. In patients with cryptoglandular fistulas, a healing rate of 70% using derivatives of adipose tissue or platelets was achieved, and a healing rate of 80% was achieved using laser technology. Fecal incontinence was improved after the use of autologous platelet growth factors and Nitinol Clips. CONCLUSION New surgical techniques showed better healing rates in Crohn's disease patients than classical techniques, which have better results in cryptoglandular fistula than in Crohn's disease. Healing rates for complex cryptoglandular fistulas were similar between the classic and new techniques, being the new techniques less invasive; the incontinence rate improved with the current techniques.
Collapse
Affiliation(s)
- D. García-Olmo
- grid.419651.e0000 0000 9538 1950New Therapies Laboratory, Health Research Institute-Fundación Jiménez Díaz University Hospital (IIS-FJD/UAM), Department of Surgery, Fundación Jiménez Díaz University Hospital (UAM), Avda. Reyes Católicos, 2, 28040 Madrid, Spain
| | - M. Gómez-Barrera
- grid.512746.3Pharmacoeconomics & Outcomes Research Iberia (PORIB), Paseo Joaquín Rodrigo, 4 i, 28224 Pozuelo de Alarcón, Madrid Spain
| | - F. de la Portilla
- grid.9224.d0000 0001 2168 1229Coloproctology Unit, Clinical Management Unit of General and Gastrointestinal Surgery, Division Seville, Biomedical Research Institute (IBIS), University Hospital Virgen del Rocio/CSIC University of Seville, Seville, Spain
| |
Collapse
|
9
|
Besendörfer M, Langer L, Carbon R, Weiss C, Müller H, Diez S. Treatment of pediatric fistula-in-ano-Sphincter-sparing non-cutting seton placement as the future treatment of choice? Front Surg 2023; 10:1144425. [PMID: 37114148 PMCID: PMC10126327 DOI: 10.3389/fsurg.2023.1144425] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2023] [Accepted: 03/23/2023] [Indexed: 04/29/2023] Open
Abstract
Background Therapeutic principles of fistula-in-ano (FIA) are lacking evidence-based consensus on treatment options. Non-cutting, sphincter-sparing options have not been published for infancy and childhood FIA. Patients and methods We are presenting retrospective data on FIA treatment with non-cutting seton placement between 2011 and 2020. Data were collected based on medical records and complemented by patients' contact for follow-up analyses between November 2021 and October 2022. Data were analyzed regarding the outcome variables of recurrent FIA and recurrent perianal abscess. Furthermore, outcomes in different age groups were compared (<1/1.5-12 years of age). Results Treatment duration with non-cutting seton was at a median of 4.6 months and was not associated with recurrent FIA (p = 0.8893). Overall recurrence rate of FIA within an observation time of 9 months postsurgically was at 7% (n = 3/42) and was only seen in infancy, whereas recurrent perianal abscess was mainly observable in children (n = 2, p = 0.2132). Comparison of age groups revealed no significant differences. Of the 42 included patients, 37 responded in the follow-up analysis, resulting in a response rate of 88% with a median follow-up time of 4.9 years. Fecal incontinence was postsurgically only seen in two patients, who were diagnosed prior to surgery and symptoms remained unchanged. Conclusions Non-cutting seton placement might be a promising option in the treatment of FIA in infancy and childhood. Perioperative settings like duration of placed seton and antibiotic treatment have to be discussed in further prospective, enlarged population-based studies.
Collapse
Affiliation(s)
- Manuel Besendörfer
- Friedrich-Alexander-Universität (FAU) Erlangen-Nürnberg, Department of Surgery, Section of Pediatric Surgery, University Hospital Erlangen, Erlangen, Germany
| | - Laurin Langer
- Friedrich-Alexander-Universität (FAU) Erlangen-Nürnberg, Department of Surgery, Section of Pediatric Surgery, University Hospital Erlangen, Erlangen, Germany
| | - Roman Carbon
- Friedrich-Alexander-Universität (FAU) Erlangen-Nürnberg, Department of Surgery, Section of Pediatric Surgery, University Hospital Erlangen, Erlangen, Germany
| | - Christel Weiss
- Department of Medical Statistics, Biomathematics, and Information Processing, Medical Faculty Mannheim of Heidelberg University, Mannheim, Germany
| | - Hanna Müller
- Division of Neonatology and Pediatric Intensive Care, Department of Pediatrics, University Hospital Marburg, University of Marburg, Marburg, Germany
| | - Sonja Diez
- Friedrich-Alexander-Universität (FAU) Erlangen-Nürnberg, Department of Surgery, Section of Pediatric Surgery, University Hospital Erlangen, Erlangen, Germany
- Correspondence: Sonja Diez
| |
Collapse
|
10
|
Gaertner WB, Burgess PL, Davids JS, Lightner AL, Shogan BD, Sun MY, Steele SR, Paquette IM, Feingold DL. The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Management of Anorectal Abscess, Fistula-in-Ano, and Rectovaginal Fistula. Dis Colon Rectum 2022; 65:964-985. [PMID: 35732009 DOI: 10.1097/dcr.0000000000002473] [Citation(s) in RCA: 53] [Impact Index Per Article: 26.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Affiliation(s)
- Wolfgang B Gaertner
- Division of Colon and Rectal Surgery, University of Minnesota, Minneapolis, Minnesota
| | - Pamela L Burgess
- Department of Surgery, Uniformed Services University of the Health Sciences, Eisenhower Army Medical Center, Fort Gordon, Georgia
| | - Jennifer S Davids
- Department of Surgery, University of Massachusetts, Worcester, Massachusetts
| | - Amy L Lightner
- Department of Colon and Rectal Surgery, Cleveland Clinic, Cleveland, Ohio
| | | | - Mark Y Sun
- Department of Surgery, University of Cincinnati, Cincinnati, Ohio
| | - Scott R Steele
- Department of Colon and Rectal Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Ian M Paquette
- Department of Surgery, University of Cincinnati, Cincinnati, Ohio
| | - Daniel L Feingold
- Division of Colorectal Surgery, Rutgers University, New Brunswick, New Jersey
| |
Collapse
|
11
|
Gomez ME, Trencheva K, Symer M, Garrett K, Milsom JW, Shukla PJ. Evaluating the Efficacy of Cutting Setons for the Treatment of Anal Fistulas. Indian J Surg 2021. [DOI: 10.1007/s12262-021-03162-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
|
12
|
Mukherjee S, Sengupta R, Ghosal SR. Seton in high anal fistula. Trop Doct 2021; 52:110-115. [PMID: 34482783 DOI: 10.1177/00494755211042122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The use of seton still remains a reasonably valid option for its simplicity and optimal results in treating high anal fistulae. Ours was a single-centre retrospective study on patients with supra-sphincteric and transsphincteric types of high anal fistula, using the 'kharsutra' as seton. The first group were treated with a seton alone, while the second with a seton and partial fistulotomy. Results were similar and quite acceptable in both groups.
Collapse
Affiliation(s)
- Sreecheta Mukherjee
- Resident Surgeon, Department of General Surgery, M. R. Bangur District Hospital, Kolkata, India
| | - Ritankar Sengupta
- Assistant Professor, Department of General Surgery, Nilratan Sircar Medical College and Hospital, Kolkata, India
| | - Sushil Ranjan Ghosal
- Professor, Department of general Surgery, Nilratan Sircar Medical College and Hospital, Kolkata, India
| |
Collapse
|
13
|
Zhi C, Huang Z, Liu D, Zheng L. Long-term follow-up study of loose combined cutting seton surgery for patients with high anal fistula. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:1160. [PMID: 34430601 PMCID: PMC8350621 DOI: 10.21037/atm-21-3242] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Accepted: 07/14/2021] [Indexed: 11/24/2022]
Abstract
BACKGROUND The treatment of high anal fistula (HAF) is still difficult for clinical surgeons. Our previous study demonstrated the short-term benefit of loose combined cutting seton (LCCS) for patients with HAF. This study aimed to evaluate the long-term effectiveness of LCCS for treating HAF patients. METHODS We retrospectively enrolled consecutive HAF patients who received LCCS therapy in our hospital between March 2014 and July 2017. After enrollment, all patients were followed up by clinical review. The patients' clinical information and most recent follow-up results were collected. Pain was assessed by the visual analog scale (VAS), and the severity of fecal incontinence was assessed by the Wexner Continence Grading Scale. We also assessed the patients' quality of life (QOL) using a the MOS item short from health survey (SF-36) questionnaire. HAF healing was considered the primary outcome, while the fistula recurrence rate, severity of fecal incontinence, and QOL were the secondary outcomes. RESULTS In total, 22 patients (18 male, four female) were enrolled in the final analysis. The mean duration of follow-up was 3.65 years (interquartile range: 3.55-4.22; range, 3.50-5.43). All patients were cured and there was no recurrence during the follow-up period. Eight patients reported a Wexner score of 1, while the remaining patients reported a score of 0 at the final follow-up. Furthermore, one patient had a VAS score of 1, while the remaining patients had a VAS score of 0, which indicated almost no postoperative pain. The QOL of all patients improved significantly. CONCLUSIONS LCCS is an effective method to treat HAF patients. Large, multicenter randomized controlled trials are warranted.
Collapse
Affiliation(s)
- Congcong Zhi
- Proctology Department, China-Japan Hospital, Beijing, China
| | - Zichen Huang
- Graduate School of Beijing University of Chinese Medicine (Master and Doctoral Class of 2020 in China-Japan Friendship Hospital), Beijing, China
| | - Dun Liu
- Graduate School of Beijing University of Chinese Medicine (Master and Doctoral Class of 2020 in China-Japan Friendship Hospital), Beijing, China
| | - Lihua Zheng
- Proctology Department, China-Japan Hospital, Beijing, China
| |
Collapse
|
14
|
Seifarth C, Lehmann KS, Holmer C, Pozios I. Healing of rectal advancement flaps for anal fistulas in patients with and without Crohn's disease: a retrospective cohort analysis. BMC Surg 2021; 21:283. [PMID: 34088303 PMCID: PMC8178918 DOI: 10.1186/s12893-021-01282-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Accepted: 05/26/2021] [Indexed: 02/06/2023] Open
Abstract
Background Surgical closure of anal fistulas with rectal advancement flaps is an established standard method, but it has a high degree of healing failure in some cases. The aim of this study was to identify risk factors for anal fistula healing failure after advancement flap placement between patients with cryptoglandular fistulas and patients with Crohn’s disease (CD). Methods From January 2010 to October 2020, 155 rectal advancement flaps (CD patients = 55, non-CD patients = 100) were performed. Patients were entered into a prospective database, and healing rates were retrospectively analysed. Results The median follow-up period was 189 days (95% CI: 109–269). The overall complication rate was 5.8%. The total healing rate for all rectal advancement flaps was 56%. CD patients were younger (33 vs. 43 years, p < 0.001), more often female (76% vs. 30%, p < 0.001), were administered more immunosuppressant medication (65% vs. 5%, p < 0.001), and had more rectovaginal fistulas (29% vs. 8%, p = 0.001) and more protective stomas (49% vs. 2%, p < 0.001) than patients without CD. However, no difference in healing rate was noted between patients with or without CD (47% vs. 60%, p = 0.088). Conclusions Patients with anal fistulas with and without Crohn’s disease exhibit the same healing rate. Although patients with CD display different patient-specific characteristics, no independent factors for the occurrence of anal fistula healing failure could be determined. Trial registration Not applicable due to the retrospective study design.
Collapse
Affiliation(s)
- Claudia Seifarth
- Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität Zu Berlin and Berlin Institute of Health, Department of General-, Visceral- and Vascular Surgery, Berlin, Germany.
| | - Kai S Lehmann
- Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität Zu Berlin and Berlin Institute of Health, Department of General-, Visceral- and Vascular Surgery, Berlin, Germany
| | - Christoph Holmer
- Department of General and Visceral Surgery, St. Joseph Krankenhaus, Berlin, Germany
| | - Ioannis Pozios
- Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität Zu Berlin and Berlin Institute of Health, Department of General-, Visceral- and Vascular Surgery, Berlin, Germany
| |
Collapse
|
15
|
Ji L, Zhang Y, Xu L, Wei J, Weng L, Jiang J. Advances in the Treatment of Anal Fistula: A Mini-Review of Recent Five-Year Clinical Studies. Front Surg 2021; 7:586891. [PMID: 33644110 PMCID: PMC7905164 DOI: 10.3389/fsurg.2020.586891] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Accepted: 12/15/2020] [Indexed: 12/16/2022] Open
Abstract
Anal fistula, with its complicated pathogenesis, has been considered as a clinical challenge for centuries. The risk of frequent recurrence and incontinence constitutes a considerable threat in the long-term treatment of anal fistula. In this work, we narratively reviewed the scientific literature of new techniques that have been used for anal fistula treatment over the recent 5 years, objectively evaluated the pros and cons of each technique on the basis of clinical outcomes, and tried to disclose the effective strategies for anal fistula treatment. Up to date, surgery is the main method used for treating anal fistula, but there is no simple technique that can completely heal complex anal fistula. In the course of surgery treatment, the healing outcome, and the protection of anal function should be weighed comprehensively. Among the innovative techniques that have emerged in recent years, combined techniques based on drainage Seton and LIFT-plug seem to be the relatively effective therapies, but their effectiveness requires more multi-center prospective randomized controlled trials with large sample size and long-term follow-up to be validated.
Collapse
Affiliation(s)
- Lijiang Ji
- Department of Anorectal Surgery, Changshu Hospital Affiliated to Nanjing University of Chinese Medicine, Changshu, China
| | - Yang Zhang
- Colorectal Disease Center, Nanjing Hospital of Chinese Medicine Affiliated to Nanjing University of Chinese Medicine, Nanjing, China
| | - Liang Xu
- Department of General Surgery, Changshu Hospital Affiliated to Nanjing University of Chinese Medicine, Changshu, China
| | - Jun Wei
- Department of Anorectal Surgery, Changshu Hospital Affiliated to Nanjing University of Chinese Medicine, Changshu, China
| | - Liping Weng
- Department of Anorectal Surgery, Changshu Hospital Affiliated to Nanjing University of Chinese Medicine, Changshu, China
| | - Jie Jiang
- Department of Anorectal Surgery, Changshu Hospital Affiliated to Nanjing University of Chinese Medicine, Changshu, China
| |
Collapse
|
16
|
Ng KS, Kwok AMF, Young CJ. Factors associated with healing, reoperation and continence disturbance in patients following surgery for fistula-in-ano. Colorectal Dis 2020; 22:2204-2213. [PMID: 32947650 DOI: 10.1111/codi.15372] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2020] [Accepted: 07/22/2020] [Indexed: 02/08/2023]
Abstract
AIM Fistula-in-ano (FIA) is associated with high treatment costs and has a deleterious impact on quality of life. A wide range of healing, incontinence and recurrence rates have been reported. This study aimed to identify operative, patient and disease factors that influence these outcomes after surgery for FIA. METHOD An observational cohort study of consecutive patients who were managed for FIA at a tertiary colorectal practice (1999-2019) was performed. Outcome measures included healing, impaired continence and the need to reoperate. Clinico-pathological variables, including patient comorbidities, fistula anatomy and operative approach, were assessed for their association with these outcomes. RESULTS Some 411 procedures were performed on 263 patients [median age 41.8 years (range 17.8-79.7 years), 184 men (70.0%)]. Some 77.9% of patients achieved complete healing, 9.5% experienced some deterioration in continence postoperatively and 37.6% required reoperation at a median time of 19.0 weeks. Poorer healing was associated with Crohn's disease, high trans-sphincteric fistulas, extrasphincteric fistulas and steroid usage. Poorer continence was associated with female sex, age > 40 years, posterior location, suprasphincteric fistulas, seton insertion and having more than three subsequent procedures. The need to reoperate was associated with female sex, high trans-sphincteric fistulas, suprasphincteric fistulas, inflammatory bowel disease and previous operations for FIA. CONCLUSION Minimizing recurrence of FIA and preservation of continence can be competing management goals. More than one in three patients require reoperation, one in five fails to heal completely and one in ten suffers worsened continence following surgery. Awareness of the factors that contribute to these outcomes is important to the process of informed consent and managing patient expectations before surgery.
Collapse
Affiliation(s)
- K-S Ng
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - A M F Kwok
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - C J Young
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| |
Collapse
|
17
|
Zheng L, Shi Y, Zhi C, Yu Q, Li X, Wu S, Zhang W, Liu Y, Huang Z. Loose combined cutting seton for patients with high intersphincteric fistula: a retrospective study. ANNALS OF TRANSLATIONAL MEDICINE 2020; 8:1236. [PMID: 33178768 PMCID: PMC7607110 DOI: 10.21037/atm-20-6123] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Background Achieving a complete cure while maintaining continence constitutes a considerable challenge in the treatment of patients with high anal fistula. This study aimed to evaluate the effectiveness of loose combined cutting seton (LCCS) for treating patients with high intersphincteric fistula. Methods Consecutive patients with high intersphincteric fistula who underwent LCCS were retrospectively enrolled. Patient data including demographics, medical history, comorbidities, details of the fistula, operative procedure, and prognosis were collected. Postoperative pain was assessed using a visual analog scale (VAS), which ranged from 0 (no pain) to 10 (extremely severe pain). The severity of fecal incontinence was assessed using the Wexner Continence Grading Scale, with a total score ranging from 0 (no incontinence) to 20 (complete incontinence). The primary outcome was the healing rate of fistula. Secondary outcomes included the recurrence rate of fistula and the severity of fecal incontinence. Results The 22 patients (male: female =18:4) in our study had a median follow-up of 55 (range, 32–568) days. The healing rate was 100%, and none of the patients experienced fistula recurrence. At the follow-up visit, 19 patients (86.4%) reported no fecal incontinence. The median total Wexner score was 0. 95.5% patients had VAS score of 0 and only 1 patient (4.5%) had a VAS score of 1, which indicated a low level of postoperative pain. Conclusions LCCS achieved a high healing rate with an increased level of continence, as well as a low level of postoperative pain, in most patients with high anal fistula in our study. Further randomized controlled trials are needed to confirm the effectiveness of this novel seton-based technique.
Collapse
Affiliation(s)
- Lihua Zheng
- Proctology Department, China-Japan Hospital, Beijing, China
| | - Yuying Shi
- Proctology Department, China-Japan Hospital, Beijing, China
| | - Congcong Zhi
- Proctology Department, China-Japan Hospital, Beijing, China
| | - Qiuxiang Yu
- Proctology Department, China-Japan Hospital, Beijing, China
| | - Xin Li
- Proctology Department, China-Japan Hospital, Beijing, China
| | - Shanshan Wu
- National Clinical Research Center of Digestive Diseases, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Wen Zhang
- Proctology Department, China-Japan Hospital, Beijing, China
| | - Yanjun Liu
- Proctology Department, China-Japan Hospital, Beijing, China
| | - Zichen Huang
- Qihuang Class of 2017, Beijing University of Chinese Medicine, Beijing, China
| |
Collapse
|
18
|
Mei Z, Wang Q, Zhang Y, Liu P, Ge M, Du P, Yang W, He Y. Risk Factors for Recurrence after anal fistula surgery: A meta-analysis. Int J Surg 2019; 69:153-164. [PMID: 31400504 DOI: 10.1016/j.ijsu.2019.08.003] [Citation(s) in RCA: 74] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2019] [Revised: 07/30/2019] [Accepted: 08/02/2019] [Indexed: 02/05/2023]
Abstract
BACKGROUND Despite a burgeoning literature during the last two decades regarding perioperative risk management of anal fistula, little is known about its risk factors that influence postoperative recurrence. We performed a meta-analysis to summarize and assess the credibility of evidence of potential risk factors for anal fistula recurrence (AFR) after surgery. METHODS Pubmed and EMBASE without language restriction were searched from inception to April 2018 that reported risk factors which predisposed recurrence after anal fistula surgery. We excluded studies that involved patients with anal fistula associated with Crohn's disease. MOOSE guidelines were followed when this meta-analysis was performed. We used random-effects models to pool relative risks (RRs) with 95% confidence intervals (CIs). Evidence from observational studies was graded into high-quality (Class I), moderate-quality (Class II/III) and low-quality (Class IV) based on Egger's P value, total sample size and between-study heterogeneity. RESULTS Of 3514 citations screened, 20 unique observational studies comprising 6168 patients were involved in data synthesis. High-quality evidence showed that AFR was associated with high transsphincteric fistula (RR, 4.77; 95% CI, 3.83 to 5.95), internal opening unidentified (RR, 8.54; 95% CI, 5.29 to 13.80), and horseshoe extensions (RR, 1.92; 95% CI, 1.43 to 2.59). Moderate-quality evidence suggested an association with prior anal surgery (RR, 1.52; 95% CI, 1.04 to 2.23), seton placement surgery (RR, 2.97; 95% CI, 1.10 to 8.06), and multiple fistula tract (RR, 4.77; 95% CI, 1.46 to 15.51). High-quality evidence demonstrated no significant association with gender or smoking; moderate-quality evidence also suggested no association with age, tertiary referral, alcohol use, diabetes mellitus, obesity, preoperative seton drainage, high internal opening, postoperative drainage, mucosal advancement flap surgery, supralevator extensions, location or type of anal fistula. CONCLUSION Several patient, surgery and fistula-related factors are significantly associated with postoperative AFR. These findings strengthen clinical awareness of early warning to identify patients with high-risk disease recurrence for AFR.
Collapse
Affiliation(s)
- Zubing Mei
- Department of Anorectal Surgery, Shuguang Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, China; Anorectal Disease Institute of Shuguang Hospital, Shanghai, China.
| | - Qingming Wang
- Department of Anorectal Surgery, Shuguang Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, China; Anorectal Disease Institute of Shuguang Hospital, Shanghai, China
| | - Yi Zhang
- Department of Pharmacy, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Peng Liu
- Department of Colorectal Surgery, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Maojun Ge
- Department of General Surgery, Shuguang Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Peixin Du
- Department of Anorectal Surgery, Shuguang Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, China; Anorectal Disease Institute of Shuguang Hospital, Shanghai, China
| | - Wei Yang
- Department of Anorectal Surgery, Shuguang Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, China; Anorectal Disease Institute of Shuguang Hospital, Shanghai, China.
| | - Yazhou He
- West China School of Medicine/West China Hospital, Sichuan University, Chengdu, Sichuan, People's Republic of China; The Institute of Genetics and Molecular Medicine, Western General Hospital, University of Edinburgh, UK
| |
Collapse
|
19
|
Abstract
Anorectal pain is common but often misdiagnosed, and patients may suffer in silence if they are too uncomfortable discussing the topic with their healthcare provider. This article reviews rectal anatomy and the signs and symptoms of several common anorectal conditions and how to manage them.
Collapse
|
20
|
Cheung FY, Appleton ND, Rout S, Kalaiselvan R, Nicholson JA, Samad A, Chadwick M, Rajaganeshan R. Video-assisted anal fistula treatment: a high volume unit initial experience. Ann R Coll Surg Engl 2018; 100:37-41. [PMID: 29046093 PMCID: PMC5849203 DOI: 10.1308/rcsann.2017.0187] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/28/2017] [Indexed: 12/21/2022] Open
Abstract
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.
Collapse
Affiliation(s)
- FY Cheung
- Department of General Surgery, St Helens and Knowsley Teaching Hospitals NHS Trust, Whiston Hospital, Prescot, UK
| | - ND Appleton
- Department of General Surgery, St Helens and Knowsley Teaching Hospitals NHS Trust, Whiston Hospital, Prescot, UK
| | - S Rout
- Department of General Surgery, St Helens and Knowsley Teaching Hospitals NHS Trust, Whiston Hospital, Prescot, UK
| | - R Kalaiselvan
- Department of General Surgery, St Helens and Knowsley Teaching Hospitals NHS Trust, Whiston Hospital, Prescot, UK
| | - JA Nicholson
- Department of General Surgery, St Helens and Knowsley Teaching Hospitals NHS Trust, Whiston Hospital, Prescot, UK
| | - A Samad
- Department of General Surgery, St Helens and Knowsley Teaching Hospitals NHS Trust, Whiston Hospital, Prescot, UK
| | - M Chadwick
- Department of General Surgery, St Helens and Knowsley Teaching Hospitals NHS Trust, Whiston Hospital, Prescot, UK
| | - R Rajaganeshan
- Department of General Surgery, St Helens and Knowsley Teaching Hospitals NHS Trust, Whiston Hospital, Prescot, UK
| |
Collapse
|
21
|
Ommer A, Herold A, Berg E, Farke S, Fürst A, Hetzer F, Köhler A, Post S, Ruppert R, Sailer M, Schiedeck T, Schwandner O, Strittmatter B, Lenhard BH, Bader W, Krege S, Krammer H, Stange E. S3-Leitlinie: Kryptoglanduläre Analfisteln. COLOPROCTOLOGY 2016. [DOI: 10.1007/s00053-016-0110-7] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
|
22
|
Clinical Practice Guideline for the Management of Anorectal Abscess, Fistula-in-Ano, and Rectovaginal Fistula. Dis Colon Rectum 2016; 59:1117-1133. [PMID: 27824697 DOI: 10.1097/dcr.0000000000000733] [Citation(s) in RCA: 194] [Impact Index Per Article: 24.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
|
23
|
Narang SK, Keogh K, Alam NN, Pathak S, Daniels IR, Smart NJ. A systematic review of new treatments for cryptoglandular fistula in ano. Surgeon 2016; 15:30-39. [PMID: 26993759 DOI: 10.1016/j.surge.2016.02.002] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2015] [Revised: 01/18/2016] [Accepted: 02/09/2016] [Indexed: 12/11/2022]
Abstract
AIM In 2007 the ACPGBI published a position statement on the management of cryptoglandular fistula in ano. Over the last seven years a number of new treatments have been developed and the aim of this systematic review was to assess their effectiveness. METHOD A systematic review of all English language literature relevant to novel treatment strategies for cryptoglandular fistula in ano, published between 1 January 2007 and 31 Dec 2014 was carried out using MEDLINE (PubMed and Ovid), EMBASE (Ovid) and the Cochrane Library of Systematic Reviews/Controlled Trials for relevant literature. Technical notes, commentaries, letters and meeting abstracts were excluded. The different treatments were assessed with regards to fistula closure rate in relation to length of follow up and reported complications. RESULTS Seventy potential articles published between 1 January 2007 and 31 December 2014 were identified from the initial literature search. Twenty-one articles were included for final analysis although only two were randomized controlled trials, the remainder being retrospective or prospective series. CONCLUSION This systematic review has demonstrated that whilst there have been technological advances to treat complex cryptoglandular fistula in ano, these are in an early stage of evolution and although early results were promising they are difficult to reproduce. Longer follow up data is not currently available and these treatments should not be introduced without further evidence.
Collapse
Affiliation(s)
- Sunil K Narang
- Exeter Surgical Health Services Research Unit (HeSRU), Royal Devon & Exeter NHS Foundation Trust, Barrack Road, Exeter, Devon, EX2 5DW, UK
| | - Kenneth Keogh
- North Bristol NHS Foundation Trust, Frenchay Hospital, Frenchay Park Road, Frenchay, Bristol, BS16 1LE, UK
| | - Nasra N Alam
- Exeter Surgical Health Services Research Unit (HeSRU), Royal Devon & Exeter NHS Foundation Trust, Barrack Road, Exeter, Devon, EX2 5DW, UK
| | - Samir Pathak
- Exeter Surgical Health Services Research Unit (HeSRU), Royal Devon & Exeter NHS Foundation Trust, Barrack Road, Exeter, Devon, EX2 5DW, UK
| | - Ian R Daniels
- Exeter Surgical Health Services Research Unit (HeSRU), Royal Devon & Exeter NHS Foundation Trust, Barrack Road, Exeter, Devon, EX2 5DW, UK
| | - Neil J Smart
- Exeter Surgical Health Services Research Unit (HeSRU), Royal Devon & Exeter NHS Foundation Trust, Barrack Road, Exeter, Devon, EX2 5DW, UK.
| |
Collapse
|
24
|
Bartolo DCC. Management of complex anal fistulae. ANZ J Surg 2015; 85:697. [PMID: 26429507 DOI: 10.1111/ans.13199] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- David C C Bartolo
- Department of Colorectal Surgery, Fiona Stanley Hospital, Murdoch, Western Australia, Australia.,Department of Surgery, University of Western Australia, Crawley, Western Australia, Australia
| |
Collapse
|