Late results of treatment of anal fistulas

Treatment of Complex Anal Fistula by Video-Assisted Anal Fistula Treatment Combined with Anal Fistula Plug: A Single-Center Study

Objective. The surgical treatment of complex anal fistulae is very challenging because of the incidence of incontinence after traditional approaches. There are no studies on the role of video-assisted anal fistula treatment (VAAFT) combined with anal fistula plug (AFP) in the complex anal fistulae. The aim of this study was to demonstrate the efficacy of treating complex anal fistulae using VAAFT combined with AFP. Method. This was a retrospective, nonrandomized observational study. 57 consecutive patients with complex anal fistulae who had undergone the VAAFT with AFP in our hospital between April 2016 and December 2019 were included. The primary outcomes were the cure rate, recurrence rate, and Wexner incontinence scores; the secondary outcomes were surgery time, blood loss, wound healing time postoperatively, pain, and patient satisfaction. Results. All 57 patients completed the surgery and follow-up, with an average follow-up time of 28 months; 6 patients suffered with recurrence (recurrence rate: 10.5%). The average surgery time was 57.9 minutes, and the average wound healing time was 46 days. There were no severe postoperative complications, and anal sphincter function was protected in all patients. Conclusions. The treatment of complex anal fistula by VAAFT combined with AFP is safe and effective, has a high healing rate and few postoperative complications, and is a promising surgery that can effectively protect the patient's anal sphincter function.

Quality of life following fistulotomy - short term follow-up

AIM

Anal fistula causes pain and discharge of pus and blood. Treatment by fistulotomy has the highest success, but can risk continence; treatment needs to balance cure with continence. This study assessed the impact of fistulotomy on quality of life (QOL) and continence.

METHOD

Patients selected for fistulotomy prospectively completed the St Mark's Continence Score (full incontinence = 24) and Short Form-36 questionnaires preoperatively at two institutions with an interest in anal fistula. Patients were reassessed 3 months' postoperatively.

RESULTS

There were 52 patients with a median age of 44 (range 19-82) years; 10 were women. Preoperative continence scores were median 0 (range 0-23) and there was no significant difference compared with postoperative scores (median 1, range 0-24). Following fistulotomy QOL was significantly improved in four of eight domains - Bodily Pain (P < 0.001), Vitality (P < 0.01), Social Functioning (P < 0.05) and Mental Health (P < 0.001) - and returned to that of the general population. QOL for patients with intersphincteric fistula improved postfistulotomy, and for those with trans-sphincteric fistula it remained the same. Data were further examined in two groups, with and without deterioration in continence score. Where continence improved postoperatively, QOL improved in three domains; where continence deteriorated QOL improved in two domains (P < 0.05). Patients with postoperative continence scores of < 5 had worse QOL than those scoring 4 or less.

CONCLUSION

QOL significantly improved at 3 months' follow-up after fistulotomy where continence was maintained or a small reduction occurred.

Unexpected complication after radical (inguinal) orchidectomy: trans-sphincteric anoscrotal fistula

Anoscrotal fistula is an extremely rare condition involving an epithelialised tract between the anal canal and scrotal wall. It is more commonly seen as a congenital phenomenon in the paediatric population, and has not previously been described in the literature in adults. We present the case of a man aged 52 years who developed a complex anoscrotal fistula after a radical inguinal orchidectomy for an intratesticular seminoma. A postsurgical wound-site infection developed into a chronically discharging wound refractory to antibiotic treatment prompting further investigation. By way of MRI, a 10 cm long trans-sphincteric anoscrotal fistula was found. The patient was successfully treated by fistuloscopic curettage, internal closure using an Ovesco clip, and negative pressure dressing. We present for the first time a rare anoscrotal fistula in an adult.

A new minimally invasive treatment for anal fistula

In colorectal surgery, eradicating the fistula and maintaining continence are still complex challenges for a colorectal surgeon. A minimally invasive method using a novel device was performed to consecutively treat 14 patients with anal fistula from August 2008 to November 2009. After a follow-up period of 36 months, 13 patients achieved successful closure of their fistula tracts, and recurrence occurred only in one patient. Recurrence was due to the delay of dressing change. No patient had interference with continence, and no major intra- and postoperative complications were identified. Using the novel device with invasive methods can be a promising alternative for managing anal fistulas.

Endosonography and magnetic resonance imaging in the diagnosis of high anal fistulae - a comparison

Anal fistula is a benign inflammatory disease with unclear etiology which develops in approximately 10 in 100 000 adult patients. Surgical treatment of fistulae is associated with a risk of damaging anal sphincters. This usually happens in treating high fistulae, branched fistulae, and anterior ones in females. In preoperative diagnosis of anal fistulae, endosonography and magnetic resonance imaging play a significant role in planning the surgical technique. The majority of fistulae are diagnosed in endosonography, but magnetic resonance is performed when the presence of high fistulae, particularly branched ones, and recurrent is suspected.

THE AIM OF THIS PAPER

The aim of this paper was to compare the roles of the two examinations in preoperative assessment of high anal fistulae.

MATERIAL AND METHODS

The results of endosonographic and magnetic resonance examinations performed in 2011-2012 in 14 patients (4 women and 10 men) with high anal fistulae diagnosed intraoperatively were subject to a retrospective analysis. The patients were aged from 23 to 66 (mean 47). The endosonographic examinations were performed with the use of a BK Medical Pro Focus system with endorectal 3D transducers with the frequency of 16 MHz. The magnetic resonance scans were performed using a Siemens Avanto 1.5 T scanner with a surface coil in T1, T1FS, FLAIR, T2 sequences and in T1 following contrast medium administration. The sensitivity and specificity of endosonography and magnetic resonance imaging were analyzed. A surgical treatment served as a method for verification. The agreement of each method with the surgery and the agreement of endosonography and magnetic resonance imaging were compared in terms of the assessment of the fistula type, localization of its internal opening and branches. The agreement level was determined based on the percentage of consistent assessments and Cohen's coefficient of agreement, κ. The integrity of the anal sphincters was assessed in each case.

RESULTS

In determining the fistula type, magnetic resonance imaging agreed with intraoperative assessment in 79% of cases, and endosonography in 64% of cases. Endosonography agreed with magnetic resonance in 57% of cases. In the assessment of internal opening, the agreement between endosonography and intraoperative assessment was 65%, between magnetic resonance and intraoperative assessment - 41% and between endosonography and magnetic resonance - 53%. In the assessment of fistula branches, endosonography agreed with intraoperative assessment in 67% of cases, magnetic resonance in 87% of cases, and the agreement between the two methods tested was 67%.

CONCLUSIONS

Magnetic resonance is a more accurate method than endosonography in determining the type of high fistulae and the presence of branches. In assessing the internal opening, endosonography proved more accurate. The agreement between the two methods ranges from 53-67%; the highest level of agreement was noted for the assessment of branching.

Horseshoe tract of anal fistula: bad luck or an avoidable extension? Lessons from 82 cases

AIM

The aim of this study was to analyse the characteristics of horseshoe tract formation in anal fistula.

METHOD

We retrospectively analysed the data from all consecutive patients who underwent surgery for an anal fistula from November 2004 to March 2011. A horseshoe tract was defined as a circumferential extension connecting both sides of the anorectum.

RESULTS

During the period of analysis, 1876 patients were operated on for a fistula. Of these, 82 (4.4%) had a horseshoe extension. The majority (72%) were male and the median age was 46 (17-84) years. The primary tract was high transsphincteric in 90% of cases and the primary opening was posterior in 65% of cases. The location of the horseshoe extension was posterior in 66% of cases with spread in the deep perianal space in 62%. In all, 71% were cryptoglandular and 24% were seen in Crohn's disease (20). Of the 62 non-Crohn's patients previous treatment was common and included surgery (42), antibiotics alone (41) and non-steroidal anti-inflammatory drugs (21).

CONCLUSION

Horseshoe extension in anal fistula is uncommon. With Crohn's disease excepted, the majority had had previous treatment.

Anal fistula: Intraoperative difficulties and unexpected findings

Anal fistula surgery is a commonly performed procedure. The diverse anatomy of anal fistulae and their proximity to anal sphincters make accurate preoperative diagnosis essential to avoid recurrence and fecal incontinence. Despite the fact that proper preoperative diagnosis can be reached in the majority of patients by simple clinical examination, endoanal ultrasound or magnetic resonance imaging, on many occasions, unexpected findings can be encountered during surgery that can make the operation difficult and correct decision-making crucial. In this article we discuss the difficulties and unexpected findings that can be encountered during anal fistula surgery and how to overcome them.

Perianal fistulae in Crohn's Disease: current and future approaches to treatment

: affecting sphincter integrity and continence. Traditional surgical and medical approaches are not without their limitations and may result in either comorbidity, such as fecal incontinence, or incomplete healing of the fistulae. Over the last 2 decades these limitations have led to a paradigm shift toward the use of biomaterials, and more recently cell-based therapies, which have met with variable degrees of success. This review discusses the traditional and current methods of treatment, as well as emerging and possible alternative approaches that may improve fistula healing.

Incontinence rates after cutting seton treatment for anal fistula

OBJECTIVE

To determine the incidence of anal incontinence after the use of cutting seton treatment for anal fistula.

METHOD

Literature searches were performed on PubMed, MEDLINE and Google Scholar using the words 'cutting seton(s)', 'seton(s)' and 'anal fistula'. An analysis of the data in the collected references was performed.

RESULTS

The average rate of incontinence following cutting seton use was 12%. The rate of incontinence increased as the location of the internal opening of the fistula moved more proximally. In the studies that described the types of incontinence, liquid stool was the most common followed closely by flatus incontinence. Incontinence associated with the treatment of fistulas defined as nonspecific cryptoglandular in nature was 18%.

CONCLUSION

The high incontinence rates that result from the use of cutting setons suggest that this commonly used therapy can damage the continence musculature. Other techniques that do not involve cutting the sphincter, when available, should be preferred, especially for higher fistulas.

Length of follow-up after fistulotomy and fistulectomy associated with endorectal advancement flap repair for fistula in ano

BACKGROUND

The length of follow-up required after surgical repair of cryptoglandular fistula in ano has not been established. This prospective study determined the follow-up time needed to establish that an anal fistula has been cured after elective fistulotomy or fistulectomy associated with endorectal advancement flap (ERAF) repair.

METHODS

Between January 2001 and June 2004, consecutive patients with anal fistula of cryptoglandular aetiology were included provided that they lived within the catchment area of the hospital and agreed to participate in a follow-up programme, which comprised scheduled visits every month until complete wound healing and annually thereafter.

RESULTS

Some 206 of 219 eligible patients were evaluable; fistulotomy was performed in 115 and ERAF repair in 91. Median follow-up was 42 (range 24-65) months. Eighteen patients had recurrence of the fistula during follow-up, with a median time to relapse of 5.0 (range 1.0-11.7) months. There were no recurrences after 1 year.

CONCLUSION

Recurrence of fistula in ano of cryptoglandular origin treated by means of fistulotomy or ERAF repair occurs within the first year of operation.