Tube in tract technique: a simple alternative to a loose draining seton in the management of complex fistula-in-ano--a video vignette

Efficacy of irrigation tubes in the management of para rectal cavities associated with complex fistula-in-ano

BACKGROUND

Surgical management of complex perianal fistula associated with pararectal cavities can be challenging. We hypothesised that healing of the pararectal cavities prior to healing of the fistula leads to a better outcome. We aimed to assess the efficacy of irrigation catheters in the healing of pararectal cavities associated with fistula-in-ano.

METHODS

This study design was consistent with IDEAL stage 2a (development) and was conducted at the Professorial Surgical Unit, National Hospital of Sri Lanka, Colombo. Thirty-two patients with complex fistulae with a pararectal cavity (detected by 2D-Endoanal ultrasounography-EAUS) were included. All patients underwent examination under anaesthesia (EUA), during which insertion of an irrigation catheter to the pararectal cavity and tagging of the primary fistula tract with a drainage seton was done. Patients were advised to irrigate with antiseptic solution and were followed-up at three weekly intervals to assess cavity reduction.

RESULTS

The majority were males (96.8%, n = 31). The primary fistula tract in 26 patients (81.2%) was trans-sphincteric and was inter-sphincteric in 6 patients (18.7%). Mean time of cavity contraction was 34.78 (range, 21-112) days. Complete healing was seen in 87.5% (n = 28), with 3 patients (9.37%) being lost to follow-up and 1 patient (3.12%) having a persistent perianal fistula after 6 months of follow-up. Those who had complete healing were followed up for a median duration of 6 (range, 3-20) months and there were no recurrences.

CONCLUSIONS

Irrigation in the management of pararectal cavities yielded satisfactory results. A case control trial with larger numbers and assessment of cavity size pre and post procedure by 3D-EAUS/MRI evaluation would be necessary for more objective evaluation of the efficacy of this novel intervention.

Outcome of hybrid seton placement for the treatment of high complex anal fistulas with and without tube drainage: A prospective comparative study

The aim of this study was to investigate the efficacy of treatment for complex anal fistula with cutting hybrid seton combined with tube drainage. A total of 66 consecutive patients with complex anorectal fistulae were divided into two groups: experimental group (group A with 36 patients) underwent cutting hybrid seton placement plus tube drainage and control group (group B with 30 patients) underwent same procedure without tube drainage. Comparison of clinical outcomes between two groups was conducted. The success rate, time for healing of the wound, postoperative pain, and recurrence rate were analyzed. No patient was lost to follow-up. Some major clinical outcomes presented significant differences. Experimental group was superior than the control group in the aspects of success rate, time for healing of the wound, postoperative pain score, and recurrence rate. We can conclude that cutting hybrid seton placement with tube drainage was an effective procedure and valid alternative for complex anorectal fistula with a favorable result on higher healing rate, less postoperative pain, and few impact on the function of sphincter.

PERFACT procedure to treat supralevator fistula-in-ano: A novel single stage sphincter sparing procedure

AIM: To prospectively perform the PERFACT procedure in supralevator anal fistula/abscess.

METHODS: Magnetic resonance imaging was done preoperatively in all the patients. Proximal cauterization around the internal opening, emptying regularly of fistula tracts and curettage of tracts (PERFACT) was done in all patients with supralevator fistula or abscess. All types of anal fistula and/or abscess with supralevator extension, whether intersphincteric or transsphincteric, were included in the study. The internal opening along with the adjacent mucosa was electrocauterized. The resulting wound was left open to heal by secondary intention so as to heal (close) the internal opening by granulation tissue. The supralevator tract/abscess was drained and thoroughly curetted. It was regularly cleaned and kept empty in the postoperative period. The primary outcome parameter was complete fistula healing. The secondary outcome parameters were return to work and change in incontinence scores (Vaizey objective scoring system) assessed preoperatively and at 3 mo after surgery.

RESULTS: Seventeen patients were prospectively enrolled and followed for a median of 13 mo (range 5-21 mo). Mean age was 41.1 ± 13.4 years, M:F - 15:2. Fourteen (82.4%) had a recurrent fistula, 8 (47.1%) had an associated abscess, 14 (82.4%) had multiple tracts and 5 (29.4%) had horseshoe fistulae. Infralevator part of fistula was intersphincteric in 4 and transsphincteric in 13 patients. Two patients were excluded. Eleven out of fifteen (73.3%) were cured and 26.7% (4/15) had a recurrence. Two patients with recurrence were reoperated on with the same procedure and one was cured. Thus, the overall healing rate was 80% (12/15). All the patients could resume normal work within 48 h of surgery. There was no deterioration in incontinence scores (Vaizey objective scoring system). This is the largest series of supralevator fistula-in-ano (SLF) published to date.

CONCLUSION: PERFACT procedure is an effective single step sphincter saving procedure to treat SLF with minimal risk of incontinence.