Faecal incontinence after seton treatment for anal fistulae with and without surgical division of internal anal sphincter: a systematic review

Cell-assisted lipotransfer in treating uncontrollable sepsis associated perianal fistula: a pilot study

PURPOSE

Surgeons can treat debilitating conditions of uncontrollable complex anorectal fistulas with sepsis, even after repeated fistula surgeries, for curative intention. Adipose-derived stem cells have shown good outcomes for refractory Crohn fistula. Unfortunately, cell therapy has some limitations, including high costs. We have therefore attempted immediate cell-assisted lipotransfer (CAL) in treating refractory complex anal fistulas and observed its outcomes.

METHODS

In a retrospective study, CAL, using a mixture of freshly extracted autologous stromal vascular fraction (SVF) and fat tissues, was used to treat 22 patients of refractory complex anal fistula from March 2018 to May 2021. Preoperative and postoperative assessments were performed with direct visual inspection, digital palpation, and endoanal ultrasonography. A fistula was considered completely healed if (1) the patient had no symptoms of discharge or inflammation; (2) there were no visible secondary openings of fistula tract inside and outside of the anorectal unit and even in the perineum; and (3) there was no primary opening in the anus. The endpoint of complete remission was wound healing without signs of inflammation 3 months after CAL treatment.

RESULTS

In a total of 22 patients who received CAL treatment, 19 patients showed complete remission, 1 patient showed partial improvement, and 2 patients showed no improvement. One of the 2 patients without improvement at primary endpoint showed complete remission 9 months after CAL. There were no significant adverse effects of the procedure.

CONCLUSION

We found that the immediately-collected CAL procedure for refractory complex anal fistula showed good outcomes without adverse side effects. It can be strongly recommended as an alternative surgical option for the treatment of complex anal fistula that is uncontrollable even after repeated surgical procedures. However, considering the unpredictable characteristics of SVF, long-term follow-up is necessary.

Video-assisted anal fistula treatment (VAAFT) combined with ozonide oil dressing: standardization of technique in pediatric patients

BACKGROUND

Anal fistula and perianal abscess are commonly acquired anorectal pathologies in children. Surgical treatment options commonly adopted are fistulotomy, fistulectomy, cutting seton placement, and more recently video-assisted anal fistula treatment (VAAFT). Optimal postoperative wound dressing remains debated. This study aimed to report our series of pediatric patients, who received VAAFT and postoperative wound dressing using ozonide oil.

METHODS

All patients who underwent VAAFT between August 2018 and May 2023 were included in the study. Demographics, clinical features, pre-operative imaging, surgical details, outcome, and mid-term outcome data were retrospectively reviewed for each patient. All VAAFT procedures were performed under general anesthesia and using a 10-Ch fistuloscope.

RESULTS

Thirty-three VAAFT procedures were performed in 30 patients over the study period. The median patient age was 5.7 years (range 1.75-14). Anal fistula was idiopathic in 26/30 (86.6%), iatrogenic in 2/30 (6.7%), and secondary to Crohn's disease in 2/30 (6.7%). The median duration of surgery was 23 min (range 18-40). All patients received ozonide oil dressing twice a day for 5 weeks postoperatively. The median hospital stay was 24 h (range 9-36). The median healing time was 28 days (range 17-39). With a median follow-up of 2 years (range 0.5-5), disease recurrence occurred in 3/30 (10%) patients with idiopathic fistula, who were re-operated using the same technique, with no further recurrence. No fecal incontinence or soiling was observed.

CONCLUSION

Our series confirmed that VAAFT is a safe and effective technique to treat children with perianal fistula. The technique is versatile, allowing to treat fistulae of different etiologies. Postoperative course was painless and fast. Future comparative prospective studies are needed to better establish these conclusions.

The management of low trans-sphincteric anal fistula during the COVID-19 pandemic: revisiting the role of the seton

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.

Exploring Health-Related Quality of Life in Patients with Anal Fistulas: A Comprehensive Study

Anal fistulas often cause significant impairment to patients' health-related quality of life (HRQOL). This cross-sectional study aimed to compare the HRQOL between patients with anal fistulas with inflammatory bowel disease (IBD) and those without, hypothesizing significant differences in HRQOL scores between these groups. The secondary objectives were to identify specific aspects of life quality most affected and explore potential variables influencing HRQOL. The study was conducted at the Clinical Emergency Hospital "Pius Brinzeu" in Timisoara, Romania, using a convenience sample of 175 adult patients diagnosed with anal fistulas, stratified into IBD and non-IBD groups. Quality of life was evaluated at initial hospital admission and three months post-treatment using four questionnaires: SF-36, GIQLI, HADS, and the WHOQOL-BREF. Initial SF-36 scores were marginally lower in the IBD group, with mean physical and mental scores of 52.0 and 54.5, respectively. Both groups showed an improvement after intervention, but the mean difference was higher in the IBD group, with an increase of 1.1 in physical score. Initial GIQLI scores were significantly lower in the IBD group (110) compared to the non-IBD group (116). Post-intervention, the mean scores increased to 116 and 121, respectively. HADS scores suggested higher anxiety levels in the non-IBD group (7.5 vs. 6.1), although depression scores were similar. Post-intervention, anxiety scores decreased more substantially in the non-IBD group (-0.9 vs. -0.3). The WHOQOL-BREF scores were lower across all domains for the IBD group at the initial test (physical health: 12.4, psychological health: 14.9, social relationships: 14.4, environment: 13.0). Post-intervention, scores increased marginally in the IBD group (physical health: 12.7, psychological health: 15.9, social relationships: 14.1, environment: 13.8) but varied in the non-IBD group. HRQOL, as measured by multiple questionnaires, is impacted differently in anal fistula patients with and without IBD. These findings highlight the importance of a tailored approach to managing this patient population to improve their quality of life post-treatment.

Clinical value of combined serum MMP-2, MMP-9 and TIMP-1 for the prognosis of perianal fistula patients who received minimally invasive surgery

OBJECTIVE

This study aimed to investigate the clinical value of combined serum matrix metalloproteinases (MMPs) and tissue inhibitors of metalloproteinases (TIMPs) for the prognosis of perianal fistula patients.

METHODS

Patients diagnosed and treated for perianal fistula by minimally invasive surgery (MIS) were enrolled. The concentrations of serum MMP-2, MMP-9 and TIMP-1 were measured at 24 h after surgery. Different levels of wound secretion, growth of granulation tissue and wound pain were used as criteria to evaluate surgical incision healing. The receiver operating characteristic curve was used to analyze the predicted assessment value.

RESULTS

The concentrations of serum MMP-2 and MMP-9 were significantly higher, while the concentrations of serum TIMP-1 at 24 h after surgery were significantly lower in the poor healing group than in the good healing group. It was further found that high levels of serum MMP-2 and MMP-9 were risk factors for poor healing, while high concentrations of serum TIMP-1 at 24 h after surgery were protective factors for poor healing.

CONCLUSION

High concentrations of serum MMP-2 and MMP-9 and low concentrations of serum TIMP at 24 h after surgery are risk factors for poor healing in perianal fistula patients who receive MIS, and the combined test has a higher predictive value.

The potential roles of gut microbiome in anal fistula

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.

Predictors of outcome in cryptoglandular anal fistula according to magnetic resonance imaging: A systematic review

Background and Aims

Anal fistula (AF) with cryptoglandular origin tends to recur, and multiple risk factors are implicated. Recently, some magnetic resonance imaging (MRI) findings with predictive value for disease outcomes have been proposed. These intrinsic anatomic features include those of the AF and its surrounding structures. This study aims to clarify the prognostic role of MRI in AF.

Methods

We performed a systematic search of PubMed, Embase, and EBSCO databases. Two independent reviewers conducted the search and screened the articles. We selected studies that used MRI to assess AF and reported its relationship to disease outcome. We extracted data regarding the study design, type of intervention, outcome, MRI-measured items, and their significance.

Results

Out of 1230 retrieved articles, 18 were eligible for final inclusion, and a total of 4026 patients were enrolled in the selected studies. For preoperative MRI, the significant items affecting the outcome were the length of the fistula, horseshoe type, presence of multiple tracts, supralevator extension, and apparent diffusion coefficient (ADC) value. Other studies investigated the healing process using postoperative MRI.

Conclusion

This review found that MRI can be useful in the management of AF, both preoperatively and postoperatively. Factors, such as fistula length, horseshoe type, presence of multiple tracts, supralevator extension, and ADC value were found to be significantly associated with treatment outcomes. The presence of the fistula tract and the development of new abscesses on postoperative MRI was found to hinder the healing process. Further studies are needed to confirm these findings.

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.

Jump Technique versus Seton Method for Anal Fistula Repair: A Randomized Controlled Trial

BACKGROUND

The treatment of anal fistula has been a conundrum for surgeons over the years. Various methods such as fistulotomy, fistulectomy, seton, ligation of the intersphincteric fistula tract (LIFT), advancement flaps, fibrin glue, and plugs are well-known techniques. Yet, they may be followed by several considerable complications, including incontinency and recurrence.

METHODS

In this study, the outcomes of the "Jump" and "Seton" techniques are compared. A randomized controlled trial consisting of 130 cases with cryptoglandular anal fistula randomly sorted into two groups was conducted. Group A underwent the "Jump technique" while group B underwent the "Seton technique." Outcomes, incontinency and recurrences in particular, were evaluated after a year of treatment. Data were analyzed by Fisher Exact, Chi-Square and Mann Whitney Tests.

RESULTS

Group A with 65 cases underwent the "Jump technique" while group B with 65 cases underwent the "Seton Method." Recurrence was reported in 12 (20%) cases in group A and 10 (15.6%) cases in group B (p=0.687). Overall incontinence was reported in 3 (4.6%) cases in group A and 18 (27.7%) cases in group B (P=0.001). The total St. Mark's scores for incontinency of group A (0.092±0.52) and group B (1.8±02.47) significantly differed (p<0.001).

CONCLUSIONS

The "Jump technique", named after a runner who jumped over hurdles, has obviated these complications. The "Jump technique" had satisfactory results and can be utilized as a first-line approach for all types of fistulas. Moreover, it can be redone for cases with recurrences without affecting the continence, paving the way to change the technique during operations.

OPTIMIZATION OF PARARECTAL FISTULA SURGICAL TREATMENT

OBJECTIVE

The aim: To improve the results of treatment of complex PF by the ligation of the intersphincteric fistula tract (LIFT).

PATIENTS AND METHODS

Materials and methods: 27 patients with transsphincteric fistulas of the rectum of different complexity have been operated by two methods: by ligature method ("cutting seton") and by the ligation of the intersphincteric fistula tract (LIFT).

RESULTS

Results: No early complications were noticed in patients who had been applied the technique of fistula ligation in the postoperative period. The pain syndrome was expressed insignificantly. The rehabilitation period was less than 12 days. Having analyzed the long-term results of the observation period lasting up to 26 months, we arrived at the conclusion that the choice of surgical treatment had little effect on the recurrence rate of pararectal fistula (21.4 and 15.38%, respectively). However, one LIFT patient had gas incontinence within 1 year of surgery in contrast to 4 patients who had had a cutting ligature method having anal incontinence for 1 year and 1 patient - during the observation period.

CONCLUSION

Conclusions: Ligation of the fistula in the intersphincter tract is an effective sphincter-preserving operation, does not require additional equipment and expensive consumables, is characterized by minimal damage to the anal sphincter and a high percentage of closure of PF (84.6%). The recurrence rate does not exceed 15.38%.

Seton in high anal fistula

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.

Evaluation of the inflammatory response induced by different materials in the treatment of perianal fistulas: experimental study in rats

The medical literature has no study evaluating the effectiveness of different materials used as setons in the treatment of perianal fistulas; therefore, there is no evidence of availability of a more effective material than others for this purpose.

Objective To evaluate the inflammatory response induced by different materials used as seton in perianal fistulas in rats.

Method Thirty Wistar rats, which were initially submitted for the construction of a perianal fistula by passing transfixing steel wire into the anal canal, were used. The rats were kept for 30 days; after this period, and with confirmation of the formation of the perianal fistula, the setons were introduced (10 rats – cotton thread #0; 10 rats – rubber; and 10 rats – silastic); after 30 days the animals were euthanized, and then the area of the fistula repaired by the seton was resected, and the material retrieved was submitted to histological analysis. The results were analyzed statistically.

Results The mean degree of inflammatory process observed by histological analysis after 30 days was 2.3 for the cotton group; 1 for the rubber group; and 1.2 for the silastic group.

Conclusion A greater inflammatory response was observed in the group treated with a cotton seton. In the remaining groups, a lower inflammatory response, with equal intensity for rubber and silastic-treated rats, was noted.

A necktie fashion vascular loop seton tie may simplify the treatment of perianal fistula

Seton for treatment of perianal fistula can be of the cutting or a loose type. We adopted a simple technique for tighten the seton by applying a necktie shape tie on the vascular loop, hence it can be used for drainage on the beginning, and for cutting purpose later on. In this retrospective study we report our experience on this seton tie method.

Material and methods Patients operated for perianal fistula between 2012 and 2014 were reviewed.

Results Of 63 patients operated, 23 (35%) had a necktie-tie seton. There were 15 (65%) men. Age 34.1 ± 10.6. Six (26%) had a recurrent fistula, 2 (9%) with loose seton in place. The external opening: anterior four (17%), lateral fifteen (65%), posterior three (13%), one patient (4%) had two opening. The internal opening was identified: posterior seventeen (74%), anterior four (17%) and right posterior two (8%). Nineteen (82%) had a trans-sphenteric tract, four (17%) females had an anterior location. Operative time was 32 min (range 22–55). The seton was tightened 4 times (range 2–5) with 2 weeks interval. Healing was achieved in 7 weeks (range 5–11). In 24 months (range 12–35) follow-up, no reported anal incontinence. Recurrence was observed in one patient (4%).

Conclusion The necktie tightening of the vascular loop seton is a simple, safe, easily performed and may simplify the seton management of perianal fistulae.

Efficacy and safety of an innovatively modified cutting seton technique for the treatment of high anal fistula: A protocol for a randomized controlled trial

BACKGROUND

Anal fistula is a common anorectal disease. So far, operation is still the optimal method to cure anal fistula. High anal fistula (HAF) is an even more clinically difficult disease to treat. Evidence suggested that seton placement can be a definitive treatment for HAF. However, tightening the seton brings great pain to patients, which affects the clinical application of the therapy. Also, this may lead to difficulty in controlling anal fluids and gas because of the larger scar left and the local defect in the anal after the operation. We propose an innovative seton technique for the treatment of HAF, after long term attempts, the operation of the modified seton cutting technique. The aim of our present study is to compare the difference of anal function, healing time, pain severity, recurrence, and complications between the procedure of the modified seton cutting technique and the conventional cutting seton operation against HAF with a randomized, controlled, prospective study.

METHODS

204 participants in this trial will be randomly divided into treatment group (procedure of the modified seton cutting technique) and control group (cutting seton technique) in a 1:1 ratio. The outcomes of continence state, pain severity after tightening, complete healing of fistula, duration to healing, operation time, recurrence rates, and postoperative complications will be recorded at 1, 2, 3, 4 weeks, then every month in the outpatient clinic. Data will be analyzed by SPSS version 22.

CONCLUSIONS

The findings of the study will help to explore the efficacy and safety of the procedure of the modified seton cutting technique against AF.

TRIAL REGISTRATION NUMBER

DOI 10.17605/OSF.IO/V6G2S.

How to deal with complex anal fistula in an immunosuppressed patient

We describe a practical approach to the management of complex anal fistula in an immunocompromised patient. We define our treatment motifs: to close the internal opening, maintain external drainage until internal opening and tract healed; minimize sphincter damage. We hope other authors can build on this case technique to improve fistula surgery outcomes.

Longterm outcome of anal fistula - A retrospective study

This retrospective observational study analyses the outcomes of patients undergoing surgery for anal fistula at a single centre in order to assess recurrence and re-operation rates after different surgical techniques. During January 2005 and May 2013, all patients with anal fistula were included. Baseline characteristics, details of presentation, fistula anatomy, type of surgery, post-surgical outcomes and follow-up data were collected. The primary endpoints were long-term closure rate and recurrence rate after 2 years. Secondary endpoints were persistent pain, postoperative complications and continence status. A total of 65 patients were included. From a total amount of 93 operations, 65 were fistulotomies, 13 mucosal advancement flaps, 7 anal fistula plugs and 8 cutting-setons. The mean follow up was 80 months. Healing was achieved in 85%. The highest recurrence rate was seen in anal fistula plug with 42%. On the other hand, no recurrence was observed in the cutting-seton procedures. For all included operation no persistent postoperative pain nor incontinence was observed. In conclusion, despite all existing anal fistula operations up to date, the optimal technique with low recurrence rate and assured safety for the anal sphincter is still lacking. Nonetheless, according to our promising results for the cutting-seton technique, this technique, otherwise considered obsolete, should be further evaluated in a prospective study.

Inflammatory bowel disease position statement of the Italian Society of Colorectal Surgery (SICCR): Crohn's disease

The Italian Society of Colorectal Surgery (SICCR) promoted the project reported here, which consists of a position statement of Italian colorectal surgeons to address the surgical aspects of Crohn's disease management. Members of the society were invited to express their opinions on several items proposed by the writing committee, based on evidence available in the literature. The results are presented, focusing on relevant points. The present paper is not an alternative to available guidelines; rather, it offers a snapshot of the attitudes of SICCR surgeons about the surgical treatment of Crohn's disease. The committee was able to identify some points of major disagreement and suggested strategies to improve quality of available data and acceptance of guidelines.

Risk Factors for Recurrence after anal fistula surgery: A meta-analysis

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.

Perianal fistulas and the lift procedure: results, predictive factors for success, and long-term results with subsequent treatment

Background

Treatment of a perianal fistula is difficult due to the risk of fecal incontinence and recurrence. The ligation of intersphincteric tract (LIFT) procedure is a sphincter-saving procedure associated with success rates ranging from 57 to 94%. The aim of our study was to find predictors for a favorable outcome of the LIFT procedure, evaluation of postoperative fecal incontinence, quality of life, and subsequent treatment with long-term follow-up.

Methods

This study was performed in patients who underwent LIFT between 2013 and 2015 at our institution. Their medical data were retrieved from the electronic patient files. The fistula characteristics were described by physical examination, three-dimensional endoanal ultrasound, and perioperative evaluation. Recurrence rate, postoperative fecal incontinence, and quality of life were assessed with the Patient-Reported Outcome Measurement (PROM). Thirty-two months later, long-term follow-up including subsequent procedures was evaluated.

Results

Forty-five patients [17 men, mean age 40 years (range 24–67 years)] were included. In 41 (84%) patients, the fistula was classified as complex; 32 (71%) were referrals with a history of previous fistula surgery. The initial success rate was 18 (40%). Only the height of the internal fistula opening (≥ 15 mm p < 0.03) was associated with recurrence. The LIFT procedure did not affect the occurrence of fecal incontinence or soiling. Recurrence showed a trend with a lower PROM (p = 0.07). Twenty-four months later, further surgery leads to cure in 34 (75%), asymptomatic fistulas in 7 (16%), and persisting active fistulas in 4 (9%) patients.

Conclusions

Initial LIFT had a success rate of 40% and with subsequent surgical treatment 75%. Recurrence after LIFT is related to the height of the internal fistula opening and is associated with diminished quality of life. Continence was not affected by initial LIFT.

Factors Increasing the Risk of Recurrence in Fistula-in-ano

Anal fistula, or fistula-in-ano, is a condition involving the anal region that is common yet debilitating. Surgery is the mainstay of treatment for an anal fistula and the chances of recurrence are quite high even after corrective surgical procedures. The risk factors for recurrence can be broadly classified into four categories: 1) risk factors related to the fundamental anatomy of the fistula and presence of comorbidities, 2) lack of proper preoperative assessment of the fistula, which includes failure to recognize the internal opening and overall structure of the fistula and not supplementing the proctologic examination with sufficient imaging, 3) intraoperative loopholes that include improper procedure selection, inexperience of the surgeon, and failure to get rid of the entire tract along with its ramifications, and 4) lack of proper postoperative care in the early and late periods following the surgery.

The aim of this paper, therefore, is to highlight the factors that could increase the risk of recurrence in different types of anal fistulae. Once surgeons know these risk factors, they can anticipate any complication and detect recurrence early.

Management of anoperineal lesions in Crohn's disease: a French National Society of Coloproctology national consensus

The French National Society of Coloproctology established national recommendations for the treatment of anoperineal lesions associated with Crohn's disease. Treatment strategies for acute abscesses, active fistulas (active denovo and still active under treatment), fistulas in remission, and rectovaginal fistulas are suggested. Recommendations have been graded following the international recommendations, and when absent, professional agreement has been established. For each situation, practical algorithms have been drawn.

The Impact of the Outcome of Treating a High Anal Fistula by Using a Cutting Seton and Staged Fistulotomy on Saudi Arabian Patients

PURPOSE

A cutting seton is used after a partial distal fistulotomy to treat patients with a high exrasphincteric fistula in ano to avoid fecal incontinence and recurrence. In Saudi Arabia, religious practices necessitate complete cleanness, which makes conditions affecting anal continence a major concern to patients affected by an anal fistula. Therefore, we aimed to evaluate the efficiency of the cutting seton in treating a high anal fistula among Saudi Arabians.

METHODS

Between January 2005 and December 2014, a prospective study was done for 372 Saudi Arabian patients diagnosed as having a high anal fistula and treated with a cutting seton at Al-Ansar General Hospital, Medina, Saudi Arabia. 0-silk sutures were used. All patients underwent the same preoperative assessment, operative technique, and postoperative follow-up. Weekly, the seton was tightened in outpatient clinics.

RESULTS

Two hundred ninety-eight patients (80.1%) were males and 74 (19.9%) females. The duration of symptoms varied from 3-21 months. The fistula healed completely in 363 patients (97.6%); 58 patients (15.6%) reported some degree of incontinence to flatus, but none to feces. In 9 patients (2.4%) the fistula recurred.

CONCLUSION

The utilization of the cutting seton method in the treatment of patients with a high anal fistula is highly efficient as it simultaneously drains the abscess, cuts the fistulous tract, and causes fibrosis along the tract. Treatment of a high anal fistula by using a staged fistulotomy with a cutting seton was very rewarding to Saudi Arabian patients who feared anal incontinence for religious reasons and was associated with low postoperative complication and recurrence rates.

The treatment of anal fistula: second ACPGBI Position Statement - 2018

It is over 10 years since the first ACPGBI Position Statement on the management of anal fistula was published in 2007. This second edition is the result of scrutiny of the literature published during this time; it updates the original Position Statement and reviews the published evidence surrounding treatments for anal fistula that have been developed since the original publication.

Draining Setons as Definitive Management of Fistula-in-Ano

BACKGROUND

The ideal management for fistula-in-ano would resolve the disease while preserving anal continence.

OBJECTIVE

The purpose of this study was to determine the efficacy of draining seton alone in achieving resolution or significant amelioration of symptoms for patients with fistula-in-ano.

DESIGN

This was a retrospective case series involving chart review and telephone interviews. A single colorectal surgeon performed surgeries between June 1, 2005, and June 30, 2014.

SETTINGS

The study was conducted by a single surgeon in a large urban city.

PATIENTS

Patient ≥18 years of age presenting with fistula-in-ano of cryptoglandular origin were included.

MAIN OUTCOME MEASURES

Resolution of symptoms or significant symptom improvement requiring no additional surgical management and rate of recurrence were measured.

RESULTS

A total of 76 patients (53 men) met the inclusion criteria. Mean age was 45 years (range, 19-73 y). The average time to seton removal was 36.6 weeks (range, 6.0-188.0 wk). Mean follow-up was 63 months (range, 7-121 mo). Fifty-seven patients (75%) were reached for telephone interview. Fifty-six patients (73.7%) had complete symptom resolution, and 14 (18.4%) had significant amelioration of symptoms with no additional surgical management required. Six (7.9%) had persistent severe symptoms. Five (7.1%) had a recurrence after seton removal. Rates of symptom resolution and recurrence were similar between patients whose setons were removed before or after 26 weeks (median time of seton removal) from the time of placement. Twenty-one patients (27.6%) required 1 or more additional operative procedures before planned seton removal to unroof a collection and/or replace the seton, and this represented the most significant risk factor for failure of resolution or improvement or recurrence (relative risk = 7.0).

LIMITATIONS

This study was retrospective and represents a single surgeon experience.

CONCLUSIONS

Placement of draining seton alone is a viable treatment option for definitive symptomatic management of fistula-in-ano. Because draining setons are sphincter and function preserving, their use should be considered as primary management for fistula-in-ano. See Video Abstract at http://links.lww.com/DCR/A552.

Outcomes of Rectovaginal Fistula Repair

OBJECTIVES

Rectovaginal fistulae (RVF) often represent surgical challenges, and treatment must be individualized. We describe outcomes after primary surgical repair stratified by fistula etiology and surgical approach.

METHODS

This retrospective cohort study included women who underwent surgical management of RVF at a tertiary care center between July 1, 2001 and December 31, 2013. Cases were stratified according to the following etiology: cancer (RVF-C), inflammatory bowel disease or infectious (RVF-I), and other (RVF-O). Patients with prior surgical treatment of RVF were excluded. Surgical approaches included local (seton, plug), transvaginal or endorectal, abdominal, diversion alone, or definitive (completion proctocolectomy with permanent colostomy or pelvic exenteration). Recurrence-free survival was estimated using the Kaplan-Meier method, and comparisons between subgroups were evaluated based on fitting Cox proportional hazards models. Censoring occurred at last relevant clinical follow-up. Factors contributing to recurrence-free survival were evaluated including age, body mass index, smoking status, fistula etiology, ileostomy, and surgical approach.

RESULTS

During the study period, 107 women underwent surgical repair of RVF. The most common fistula etiology was RVF-I (54.2%), followed by RVF-O (23.4%), and RVF-C (22.4%). Ninety-four women underwent fistula repair by the local (29.9%), transvaginal/endorectal (25.2%), abdominal approach (19.6%), or diversion alone (13.1%), whereas 13 underwent definitive surgery (12.2%). Recurrence-free survival was significantly different depending on surgical approach (P < 0.001), but not etiology (P = 0.71). Recurrence-free survival (95% confidence interval) at 1 year after surgery was 35.2% (21.8%-56.9%) for the local approach, 55.6% (37.0%-83.3%) for the transvaginal or endorectal approach, 95% (85.9%-100%) for the abdominal approach, and 33.3% (15%-74.2%) for those with diversion only.

CONCLUSIONS

Recurrence rates after RVF repair are high and did not differ by fistula etiology. Abdominal repair of RVF had significantly fewer recurrences.

Association of Coloproctology of Great Britain and Ireland consensus exercise on surgical management of fistulating perianal Crohn's disease

AIM

Management of fistulating perianal Crohn's disease (fpCD) is a significant challenge for a colorectal surgeon. A recent survey of surgical practice in this condition showed variation in management approaches. As a result we set out to devise recommendations for practice for UK colorectal surgeons.

METHOD

Results from a national survey were used to devise a set of potential consensus statements. Consultant colorectal surgeons were invited to participate in the exercise via the previous survey and the mailing list of the professional society. Iterative voting was performed on each statement using a five-point Likert scale and electronic voting, with opportunity for discussion and refinement between each vote. Consensus was defined as > 80% agreement.

RESULTS

Seventeen surgeons and two patient representatives voted upon 51 statements. Consensus was achieved on 39 items. Participants advocated a patient-centred approach by a colorectal specialist, within strong multidisciplinary teamworking. The use of anti-TNFα therapy is advocated. Where definitive surgical techniques are considered they should be carefully selected to avoid adverse impact on function. Ano/rectovaginal fistulas should be managed by specialists in fistulating disease. Stoma or proctectomy could be discussed earlier in a patient's treatment pathway to improve choice, as they may improve quality of life.

CONCLUSION

This consensus provides principles and guidance for best practice in managing patients with fpCD.

Predictive factors for recurrence of high transsphincteric anal fistula after placement of seton

BACKGROUND

The optimal surgical treatment for high transsphincteric fistula-in-ano (FIA) should attain complete eradication of the fistulous track and, in the same time, not compromising the anal sphincters. The present study aimed to investigate the predictive factors for recurrence of high transsphincteric FIA after placement of draining seton and to evaluate the efficacy and complications of seton treatment for high cryptoglandular anal fistula.

MATERIALS AND METHODS

This is a retrospective case-control study of patients with high transsphincteric FIA who were treated with seton placement. Variables analyzed were the characteristics of FIA, incidence of recurrence, postoperative complications including fecal incontinence (FI), and the predictive factors for recurrence.

RESULTS

A total of 251 patients (232 males) with high transsphincteric FIA were treated with loose seton placement. Patients were followed for a median period of 16 mo. Recurrence of FIA was recorded in 26 of patients (10.3%) after a mean duration of 12.2 ± 3.9 mo of seton removal. Previously recurrent fistula (odds ratio [OR] = 2.81, P = 0.02), supralevator extension (OR = 3.19, P = 0.01) and anterior fistula (OR = 3.36, P = 0.004), and horseshoe fistula (OR = 5.66, P = 0.009) were the most significant predictors of recurrence. FI was detected in eight patients (3.2%). Female gender (OR = 15.2, P = 0.0003) and horseshoe fistula (OR = 8.66, P = 0.01) were the significant risk factors for FI after the procedure.

CONCLUSIONS

Significant risk factors for recurrence of FIA were previous fistula surgery, anterior anal fistula, and presence of secondary tracks or branches as supralevator extension, and horseshoe fistula.

German S3 guidelines: anal abscess and fistula (second revised version)

BACKGROUND

The incidence of anal abscess and fistula is relatively high, and the condition is most common in young men.

METHODS

This is a revised version of the German S3 guidelines first published in 2011. It is based on a systematic review of pertinent literature.

RESULTS

Cryptoglandular abscesses and fistulas usually originate in the proctodeal glands of the intersphincteric space. Classification depends on their relation to the anal sphincter. Patient history and clinical examination are diagnostically sufficient in order to establish the indication for surgery. Further examinations (endosonography, MRI) should be considered in complex abscesses or fistulas. The goal of surgery for an abscess is thorough drainage of the focus of infection while preserving the sphincter muscles. The risk of abscess recurrence or secondary fistula formation is low overall. However, they may result from insufficient drainage. Primary fistulotomy should only be performed in case of superficial fistulas. Moreover, it should be done by experienced surgeons. In case of unclear findings or high fistulas, repair should take place in a second procedure. Anal fistulas can be treated only by surgical intervention with one of the following operations: laying open, seton drainage, plastic surgical reconstruction with suturing of the sphincter (flap, sphincter repair, LIFT), and occlusion with biomaterials. Only superficial fistulas should be laid open. The risk of postoperative incontinence is directly related to the thickness of the sphincter muscle that is divided. All high anal fistulas should be treated with a sphincter-saving procedure. The various plastic surgical reconstructive procedures all yield roughly the same results. Occlusion with biomaterial results in lower cure rate.

CONCLUSION

In this revision of the German S3 guidelines, instructions for diagnosis and treatment of anal abscess and fistula are described based on a review of current literature.

Using autologous platelet-rich plasma for the treatment of complex fistulas

OBJECTIVE

This study aims to demonstrate the effectiveness and safety of autologous fibrin gel rich in platelet growth factors for the treatment of complex perianal fistulas.

MATERIAL AND METHODS

Prospective epidemiological study. Patients with complex perianal fistula or perianal fistula mere alteration of continence are included. identification of both holes and the journey, curettage of it and instillation of Vivostat PRF® in the way it is done to observe excess material by OFE. The variables analyzed were: age, sex, use of prior Seton clinic prevalent type of fistula, postoperative complications, fistula closure and impaired quality of life using the SF-36 test (v2).

RESULTS

From January 2011 to May 2013 have involved 23 patients, 12 men and 11 women, with an average age of 49 years and a minimum follow-up of 12 months. Two dropped out. 17 patients had low transsphincteric fistulas, 2 and 2 high transsphincteric intersphincteric with impaired continence. The most common symptom is the discharge. Twelve patients had a loose seton (62%), of which nine cured. Of all the patients we have operated the success rate is 62%. No patient developed incontinence after treatment. Only two reported a worse quality of life after surgery.

CONCLUSION

This study demonstrates that there is a clear benefit to the use of Vivostat PRF® as a treatment for complex perianal fistulas. It is a highly reproducible technique with acceptable results and does not produce impairment of continence.

Surgical Management of Fistula-in-ano Among Patients With Crohn's Disease: Analysis of Outcomes After Fistulotomy or Seton Placement-Single-Center Experience

BACKGROUND AND AIM

Fistula-in-ano is a common problem among patients with Crohn's disease and carries significant morbidity. We aimed to study the outcomes of surgical treatment of fistula-in-ano after fistulotomy or seton placement in patients with perianal fistulizing Crohn's disease.

MATERIAL AND METHODS

A retrospective observational study of 59 patients diagnosed with Crohn's disease, who were treated surgically for fistula-in-ano between 2010 and 2014 in our department. The assessment of disease complexity included a detailed physical examination, magnetic resonance imaging of the rectum, and examination under anesthesia. Outcomes for analysis included wound healing rate and postoperative incontinence.

RESULTS

High transsphincteric fistula was found in 44% of the patients, while mid or low transsphincteric fistulas were found in 51%. Three women (5%) had a rectovaginal fistula. All patients with high transsphincteric fistulas were treated with loose seton placement. Patients with mid- or low-level transsphincteric fistula were offered either fistulotomy or seton placement based on the clinical evaluation. The mean follow-up duration was 1.6 ± 1.1 years. In terms of recurrence, one patient treated with seton placement presented with recurrence 6 months after seton removal and one patient with fistulotomy failed to achieve wound healing. Minor incontinence was found in six patients treated with fistulotomy and in three patients treated with seton placement; however, this difference was not significant (chi-square = 1.723, df = 1, Monte-Carlo: p = 0.273).

CONCLUSION

Fistulotomy could achieve good results in terms of wound healing and incontinence in strictly selected patients with Crohn's disease suffering from low-lying transsphincteric fistulae. For more high-lying or complicated fistulae, seton placement is more appropriate. For high transsphincteric fistulae, the only option is placement of loose seton.

Definitive seton management for transsphincteric fistula-in-ano: harm or charm?

AIM

The treatment of transsphincteric anal fistula requires a balance between eradication of the disease and preservation of faecal control. A cutting seton is an old tool that is now out of vogue for many surgeons. We hypothesized that the concept remains reliable and safe with results that exceed those reported for many of the more recently described methods.

METHOD

A retrospective review was conducted of real-time electronic health records (single institution, single surgeon) of patients presenting during the 14 years between 2001 and 2014 with a transsphincteric anal fistula who were treated with a cutting seton. Excluded were patients with Crohn's disease, fistulae related to malignancy or a previous anastomosis and patients whose fistula was treated by another method including a loose draining seton. Data collection included demographics, duration of the disease, duration of the treatment, outcome and continence.

RESULTS

In all, 121 patients (80 men) of mean age 40.2 ± 12.2 years (range 18-76) with a mean follow-up of 5.1 ± 3.3 (1-24) months were included in the analysis. The median duration of symptoms was 6 (1-84) months; 36% had failed other fistula surgery, 12% had a complex fistula with more than one track and 35% had some form of comorbidity. The median time to healing was 3 (1-18) months; 7.4% required further surgery, but eventually 98% had complete fistula healing. The incontinence rate decreased postoperatively to 11.6% from 19% before treatment with 17/121 with pre-existing incontinence resolved and 8/107 new cases developing.

CONCLUSION

Despite its retrospective non-comparative design, the study has demonstrated that a cutting seton is a safe, well tolerated and highly successful treatment for transsphincteric anal fistula and is followed overall by improved continence. The results compare very favourably with other techniques.

Evaluation of the cutting seton as a method of treatment for perianal fistula

BACKGROUND

Perianal fistulas are distressing for the patient and sometimes a challenge for the surgeon. Different methods for the treatment of perianal fistulas have a range of success rates and use of the cutting seton is still debatable.

OBJECTIVES

We evaluated the recurrence, success rate and incontinence with the cutting seton method for treating perianal fistula.

DESIGN

Prospective, descriptive study.

SETTING

Al-Hada Armed Forces Hospital, Department of General Surgery, Taif, Saudi Arabia.

PATIENTS AND METHODS

We studied all patients with high perianal fistula admitted to the department of general surgery in our hospital with a diagnosis of perianal fistula in the period from December 2012 to December 2013 (12 months). Patients were followed for postoperative recurrence and incontinence rate.

MAIN OUTCOME MEASURE(S)

The primary outcome measured was either complete cure or recurrence.

RESULTS

Fifty-one patients underwent cutting seton insertion for fistula in ano. The recurrence rate was 9.8%. The postoperative rate of incontinence was 15.7% to flatus and 5.9% to fluid stools. There was no incontinence to solid stools.

CONCLUSION

The cutting seton is a valid option for a complex fistula in ano, but in female patients and those with previous peri-anal surgery, other surgical options are advised.

LIMITATIONS

Patients with low perianal fistula, Crohn's disease, acute perianal abscess and patients with major incontinence were excluded.

Pulling Seton: Combination of mechanisms

BACKGROUND

Seton-based techniques are among popular methods for treating high type anal fistula. These techniques are categorized to cutting and noncutting regarding their mechanism of action. In this report we are about to describe a new technique, which is a combination of both mechanisms; we call it Pulling Seton.

MATERIALS AND METHODS

In this technique after determining internal and external orifice of fistula, fistulectomy is done from both ends to the level of external sphincteric muscle. Finally, a remnant of fistula, which remains beneath external sphincteric muscle is excised, and Seton is passed instead of it and tied externally. After the wound heals, patient is asked to pull down the Seton for 3-4 min, 4 times a day. We prospectively enrolled 201 patients with high type anal fistula in this study.

RESULTS

Seton gradually passes through external sphincteric muscle till it is displaced outwards or removed by a surgeon via a small incision. 94% of patients treated by this method accomplished their treatment completely without recurrence. None of the patients developed permanent fecal or gas incontinence. Only 5% of patients developed with recurrence of fistula. Since Seton traction is not permanent in this technique, Seton cuts external sphincter slowly, and minimal rate of incontinence is reported.

CONCLUSION

Pulling Seton seems to be an efficient way in treating high type anal fistula with minimal rate of recurrence and complications such as incontinence and authors suggest further randomized studies to compare its efficacy with other Seton-based techniques.

The outcome of fistulotomy for anal fistula at 1 year: a prospective multicentre French study

AIM

The study aimed to evaluate outcome at 1 year of one- and two-stage fistulotomy for anal fistula in a large group of patients.

METHOD

A prospective multicentre observational study was designed to include patients with anal fistula treated by one- or two-stage fistulotomy. Data were collected using a self-administered questionnaire before surgery, during healing and at 1 year after surgery.

RESULTS

Group A (133 patients) with a low anal fistula underwent a one-stage fistulotomy. The median Wexner scores before and after surgery were 1.0 (0-11) and 2.0 (0-18) (P = 0.032) and the median Vaizey scores were 2.0 (0-14) and 3.0 (0-21) (P = 0.055). The Wexner scores and percentage of patients before and after fistulotomy were as follows: 0-5: 88%, 86%; 6-10: 10.7%, 10.7%; 11-15: 1.0%, 2.6%; and 16-20: 0%, 2%. Eighty-seven per cent of the patients were satisfied. Group B (62 patients) underwent two-stage fistulotomy for a high transsphincteric fistula. The Wexner scores and percentage of patients before the first stage and 1 year after the second stage were as follows: 0-5: 86%, 66%; 6-10: 4.5%, 20%; 11-15: 9%, 11%; and 16-20: 0%, 2%. The median Wexner scores before the first stage and after the second stage were 1 (0-14) vs. 4 (0-19) (P < 0.001), and the median Vaizey scores were 1.5 (0-11) vs. 4 (0-20) (P < 0.001). Eighty-eight per cent of the patients were satisfied.

CONCLUSION

Low transsphincteric anal fistula can be treated by fistulotomy without clinically significant continence disturbance. Treating high transsphincteric anal fistulae with two-stage fistulotomy is followed by mild continence disturbance. Satisfaction rates were high.

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.

Appraisal of the LIFT and BIOLIFT procedure: initial experience and short-term outcomes of 33 consecutive patients

PURPOSE

A new sphincter-saving technique known as the LIFT (ligation of intersphincteric tract) procedure has gained growing interest. Use of a bioprosthetic device has also been suggested to augment the LIFT procedure (BIOLIFT). This study evaluates outcomes of patients undergoing LIFT and BIOLIFT for repair of complex anal fistulae.

METHODS

This study is a single-surgeon, single-centre retrospective review of a prospectively collected database. Study was conducted at Royal Prince Alfred Hospital Department of Colorectal Surgery, Sydney, Australia, from May 2009 to April 2012. Thirty-three patients were evaluated. Twenty-nine LIFTs and five BIOLIFT procedures were evaluated. Primary success is defined as successful healing from initial procedure while secondary success is successful healing after management of failure or recurrence.

RESULTS

In a cohort of predominantly female (67 %) and 94 % transsphincteric fistulae, primary success was 63 %. At a median follow-up of 20 weeks (6-81 weeks), there were 11 failures and one recurrence. The median time to failure/recurrence was 3 weeks (1-25 weeks). Six patients had a subsequent fistulotomy and three patients had a BIOLIFT for non-successful outcomes. The median follow-up for those with failures/recurrences is 60 weeks (range 20-76 weeks) and secondary success was 88 %. Post-operative anal manometry studies showed a 9 % reduction of resting and 11 % reduction of squeeze pressures but this was not statistically significant. There was also no post-operative incontinence. Anterior fistulas were noted do significantly worse (47%) compared with non-anteriorly located fistulas (84 %; p = 0.03).

CONCLUSIONS

LIFT and BIOLIFT procedures can be performed safely and effectively in a technically demanding study cohort of predominantly females with complex fistulas. Anterior fistulas have a higher risk of failure but present early and are amendable to repeat procedures. In particular, fistulotomies are useful in downstaged tracts and performing BIOLIFTs is an alternative in the management of LIFT failures and recurrences.

Fistulotomy in the tertiary setting can achieve high rates of fistula cure with an acceptable risk of deterioration in continence

INTRODUCTION

Surgery is the mainstay of treatment of anal fistulas. Low fistulas are often laid open, but higher fistulas present a more difficult problem. Patient choice centres on a compromise between risk of recurrence and risk of impairment of continence. We aimed to determine the efficacy and safety of fistulotomy at a tertiary referral centre, in particular the additional risk of impairment of continence following fistulotomy of the often recurrent, multiply-operated patients seen.

METHODS

Patients undergoing surgery under the senior author (RKSP) for an anal fistula during the study period (2005-2006) were identified, and a thorough review of the patients' clinical records was undertaken. Demographic, fistula anatomy, treatment and follow-up data were obtained.

RESULTS

Eighty-four patients underwent either fistulotomy (50), insertion of permanent loose (drainage) seton (28) or EUA with or without drainage of abscess. Mean length of follow up was 11 months (SD 14.22). In the fistulotomy group, we found an overall success rate of 93 %. Secondary extensions were associated with failure to achieve cure (P = 0.008). Nine patients (20 %) suffered deterioration in continence after surgery. A longer time to referral was associated with impaired final continence. In the group referred from a surgeon in secondary care, 91 % of patients were cured, and continence impairment (mostly minor) rose from 32 % at referral to 40 % after surgery.

CONCLUSIONS

We have shown that it is safe and reasonable to offer fistulotomy to appropriate patients despite previous surgery and within the tertiary setting. By so doing, a very high rate of healing can be achieved in patients who have previously failed. The additional risk of impairment of continence is around one in five, and in the majority will represent only minor 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.