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Tang XL, Xu ZY, Yang J, Yang Z, Wang ZG, Zhang ZY, Yao J. Assessing the suitability of video-assisted anal fistula treatment for obese patients compared to conventional surgery: a question worth investigating. Int J Colorectal Dis 2024; 39:108. [PMID: 39008124 PMCID: PMC11249763 DOI: 10.1007/s00384-024-04683-y] [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] [Accepted: 07/05/2024] [Indexed: 07/16/2024]
Abstract
BACKGROUND AND AIMS Video-assisted anal fistula treatment (VAAFT) is an innovative surgical approach enabling the direct visualization of the fistula tract structure. This study aims to assess the efficacy of VAAFT in comparison with that of traditional surgical methods and explore potential risk factors contributing to fistula recurrence to provide new recommendations for surgical selection. MATERIALS AND METHODS Information was collected from 100 patients with complex anal fistula (CAF) in our hospital who underwent surgical treatment from January 2021 to January 2023. We compared the baseline information and surgical outcomes of two groups, analyzed the risk factors for fistula recurrence by using logistic regression analysis, and conducted further exploration by using the body mass index. RESULTS Equal numbers of patients underwent VAAFT and traditional surgeries, and no significant differences in baseline information were observed. Patients who received VAAFT experienced less intraoperative bleeding (15.5 (14.0-20.0) vs. 32.0 (25.0-36.0)), shorter hospital stays (2.0 (2.0-2.5) vs. 3.0 (3.0-3.5)), reduced postoperative pain and wound discharge, but longer operative times (43.3 ± 6.9 vs. 35.0 (31.5-40.0)) compared with patients who underwent traditional surgeries. No significant differences in recurrence rates were found three and six months after operation (the p-values were 0.790 and 0.806, respectively). However, the Wexner scores of the VAAFT group were significantly low in the first follow-up (0 (0-1.0) vs. 2.0 (1.0-2.0)). Postoperative recurrence of fistulas may be associated with obesity (p-value = 0.040), especially in patients undergoing traditional surgeries (p-value = 0.036). CONCLUSION VAAFT offers advantages, such as less pain, less trauma, and faster recovery, compared with traditional surgical treatment. Obese patients with CAF are prone to recurrence, and we recommend that they undergo VAAFT treatment rather than traditional surgeries.
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Affiliation(s)
- Xiao-Li Tang
- Department of Surgery, Shanghai Sixth Peoples Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, 200233, China
| | - Zi-Yang Xu
- Department of Surgery, Shanghai Sixth Peoples Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, 200233, China
| | - Jun Yang
- Department of Surgery, Shanghai Sixth Peoples Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, 200233, China
| | - Zhe Yang
- Department of Surgery, Shanghai Sixth Peoples Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, 200233, China
| | - Zhi-Gang Wang
- Department of Surgery, Shanghai Sixth Peoples Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, 200233, China.
| | - Zheng-Yun Zhang
- Department of Surgery, Shanghai Sixth Peoples Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, 200233, China.
| | - Jing Yao
- Department of Surgery, Shanghai Sixth Peoples Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, 200233, China.
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Akinmoladun O, Hatch QM. Anal Cryptoglandular Suppuration: Evidence-Based Management. Surg Clin North Am 2024; 104:491-501. [PMID: 38677815 DOI: 10.1016/j.suc.2023.11.002] [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] [Indexed: 04/29/2024]
Abstract
Anal suppurative processes are commonly encountered in surgical practice. While the initial therapeutic intervention is philosophically straightforward (incision and drainage), drainage of the appropriate space and treatment of the subsequent fistula in ano require a thorough understanding of perianal anatomy and nuanced decision making. Balancing the risk of fecal incontinence with simple fistulotomy versus the higher risk of fistula recurrence with all sphincter-sparing fistula treatments can be a challenge for surgeons and patients alike.
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Affiliation(s)
- Oladapo Akinmoladun
- Department of Surgery, Madigan Army Medical Center General Surgery, Joint Base Lewis-McChord, WA 98431, USA
| | - Quinton M Hatch
- Department of Surgery, Madigan Army Medical Center General Surgery Residency, Joint Base Lewis-McChord, WA 98431, USA.
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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.
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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
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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.
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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
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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.
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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.
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Sluckin TC, Gispen WH, Jongenotter J, Hazen SJA, Smeets S, van der Bilt JDW, Smeenk RM, Schouten R. Treatment of cryptoglandular fistulas with the fistula tract laser closure (FiLaC™) method in comparison with standard methods: first results of a multicenter retrospective comparative study in the Netherlands. Tech Coloproctol 2022; 26:797-803. [PMID: 35749023 DOI: 10.1007/s10151-022-02644-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Accepted: 05/20/2022] [Indexed: 01/23/2023]
Abstract
BACKGROUND Current surgical closure techniques for sphincter-sparing treatment of high cryptoglandular fistulas in the Netherlands include the mucosal advancement flap procedure (MAF) and ligation of the intersphincteric fistula tract (LIFT). A relatively novel treatment is the fistula tract laser closure (FiLaC™) method. The aim of this study was to investigate the differences in healing and recurrence rates between FiLaC™ and current standard practices. METHODS This multicenter retrospective cohort study included both primary and recurrent high cryptoglandular anorectal fistulas, treated with either FiLaC™ or standard methods (MAF or LIFT) between September 2015 and July 2020. Patients with extrasphincteric fistulas, Crohn's disease, multiple fistulas, age < 18 years or missing data regarding healing time or recurrence were excluded. The primary outcomes were the clinical primary and secondary healing and recurrence rates. Primary healing was defined as a closed external opening without fluid discharge within 6 months of treatment on examination, while secondary healing was the same endpoint after secondary treatment. Secondary outcomes included healing time and complaints. RESULTS A total of 162 high fistulas from 3 Dutch hospitals were included. Ninety-nine high fistulas were treated with FiLaC™ and 63 with either MAF or LIFT. There were no significant differences between FiLaC™ and MAF/LIFT in terms of clinical healing (55.6% versus 58.7%, p = .601), secondary healing (70.0% versus 69.2%, p = .950) or recurrence rates (49.5% versus 54%, p = .420), respectively. Median follow-up duration was 7.1 months in the FiLaC™ group (interquartile range [IQR] 4.1-14.4 months) versus 6 months in the control group (IQR 3.5-8.1 months). CONCLUSIONS FiLaC™ treatment of high anorectal fistulas does not appear to be inferior to MAF or LIFT. Based on these preliminary results, FiLaC™ can be considered as a worthwhile treatment option for high cryptoglandular fistulas. Prospective studies with a longer follow-up period and well-determined postoperative parameters such as complication rates, magnetic resonance imaging for confirmation of fistula healing, incontinence and quality of life are warranted.
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Affiliation(s)
- T C Sluckin
- Department of Surgery, Flevoziekenhuis, Almere, the Netherlands
| | - W H Gispen
- Department of Surgery, Flevoziekenhuis, Almere, the Netherlands
| | - J Jongenotter
- Department of Surgery, Albert Schweitzer Hospital, Dordrecht, the Netherlands
| | - S J A Hazen
- Department of Surgery, Albert Schweitzer Hospital, Dordrecht, the Netherlands
| | - S Smeets
- Department of Surgery, Flevoziekenhuis, Almere, the Netherlands
| | | | - R M Smeenk
- Department of Surgery, Albert Schweitzer Hospital, Dordrecht, the Netherlands
| | - R Schouten
- Department of Surgery, Flevoziekenhuis, Almere, the Netherlands.
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Yu Q, Zhi C, Jia L, Li H. Cutting seton versus decompression and drainage seton in the treatment of high complex anal fistula: a randomized controlled trial. Sci Rep 2022; 12:7838. [PMID: 35551237 PMCID: PMC9098520 DOI: 10.1038/s41598-022-11712-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Accepted: 04/22/2022] [Indexed: 11/21/2022] Open
Abstract
This study aimed to compare the efficacy between decompression and drainage seton (DADS) and cutting seton (CS) in the treatment of high complex anal fistula. Patients were randomly assigned 1:1 to DADS or CS group. The primary outcome was the rate of wound healing. Second outcomes included time taken to return to work, postoperative pain, the severity of fecal incontinence and other complications. A total of 120 patients with a mean age of 39 years were included. There was no significant difference in the rate of complete wound healing at 1 year. The mean time taken to return to work was 5 ± 2 days in DADS group, shorter than CS group (10 ± 3, p < 0.001). Mean vaizey incontinence score and the post-operation pain in DADS group was significantly lower than CS group. No significant difference was found between two groups in the incidence of complications. DADS is as effective as Cutting seton for the treatment of high complex anal fistula but is associated with less postoperative pain and better sphincter function preserving.
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Affiliation(s)
- Qiuxiang Yu
- Department of Proctology, China-Japan Friendship Hospital, No 2 Yinghua East Street, Chaoyang District, Beijing, 100029, China
| | - Congcong Zhi
- Department of Proctology, China-Japan Friendship Hospital, No 2 Yinghua East Street, Chaoyang District, Beijing, 100029, China
| | - Lansi Jia
- Department of Proctology, China-Japan Friendship Hospital, No 2 Yinghua East Street, Chaoyang District, Beijing, 100029, China
| | - Hui Li
- Department of Proctology, China-Japan Friendship Hospital, No 2 Yinghua East Street, Chaoyang District, Beijing, 100029, China.
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Elshamy MT, Emile SH, Abdelnaby M, Khafagy W, Elbaz SA. A pilot randomized controlled trial on ligation of intersphincteric fistula tract (LIFT) versus modified parks technique and two-stage seton in treatment of complex anal fistula. Updates Surg 2022; 74:657-666. [PMID: 35038136 DOI: 10.1007/s13304-022-01240-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2021] [Accepted: 01/07/2022] [Indexed: 10/19/2022]
Abstract
Complex anal fistula (CAF) is a challenging condition for surgeons. This randomized trial aimed to compare ligation of the intersphincteric fistula tract (LIFT), modified Parks technique, and two-stage seton in the treatment of complex anal fistula in terms of the success of treatment and complications. This was a pilot randomized trial conducted in the period of January 2019 to December 2019 on adult patients with CAF who were allocated to one of three groups: LIFT, modified Parks technique, and two-stage seton. The main outcome measures were healing rates, time to healing, complications, operation time, and quality of life. Sixty-six patients (75.7% males) of a mean age of 45.2 years were included. Mean operation time of LIFT was significantly shorter than the other two procedures (p < 0.0001). There was a significant difference between the three groups in terms of success rate (p = 0.04) but not in regard to complications (p = 0.59). The modified Parks technique had a significantly higher success rate than LIFT (95.2% vs 68.1%, p = 0.045) whereas the success rates of two-stage seton and LIFT were not significantly different (86.9% vs 68.1%, p = 0.16). The average time to healing after LIFT was significantly shorter than the other two procedures. The quality-of-life scores were comparable among the three groups. There was a significant difference in healing rates after the three procedures as the modified Parks technique achieved the highest success rate followed by two-stage seton and then the LIFT procedure. Time to complete healing after LIFT was significantly shorter than the other two procedures. The three procedures achieved similar quality of life and complication rates.
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Affiliation(s)
- Mohamed Tarek Elshamy
- Colorectal Surgery Unit, General Surgery Department, Mansoura University Hospitals, Mansoura University, 60 El-Gomhouria Street, Mansoura, 35516, Dakahlia, Egypt
| | - Sameh Hany Emile
- Colorectal Surgery Unit, General Surgery Department, Mansoura University Hospitals, Mansoura University, 60 El-Gomhouria Street, Mansoura, 35516, Dakahlia, Egypt.
| | - Mahmoud Abdelnaby
- Colorectal Surgery Unit, General Surgery Department, Mansoura University Hospitals, Mansoura University, 60 El-Gomhouria Street, Mansoura, 35516, Dakahlia, Egypt
| | - Wael Khafagy
- Colorectal Surgery Unit, General Surgery Department, Mansoura University Hospitals, Mansoura University, 60 El-Gomhouria Street, Mansoura, 35516, Dakahlia, Egypt
| | - Samy Abbas Elbaz
- Colorectal Surgery Unit, General Surgery Department, Mansoura University Hospitals, Mansoura University, 60 El-Gomhouria Street, Mansoura, 35516, Dakahlia, Egypt
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Seton Technique in Perianal Fistula: Clinical Results of Two Separate Seton Materials. ANADOLU KLINIĞI TIP BILIMLERI DERGISI 2021. [DOI: 10.21673/anadoluklin.903232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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10
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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.
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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
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Management of cryptoglandular fistula-in-ano among gastrointestinal surgeons in the Netherlands. Tech Coloproctol 2021; 25:709-719. [PMID: 33860363 PMCID: PMC8124037 DOI: 10.1007/s10151-021-02446-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Accepted: 04/01/2021] [Indexed: 02/06/2023]
Abstract
BACKGROUND Management of cryptoglandular fistula-in-ano (FIA) can be challenging. Despite Dutch and international guidelines determining optimal therapy is still quite difficult. The aim of this study was to report current practices in the management of cryptoglandular FIA among gastrointestinal surgeons in the Netherlands. METHODS Dutch surgeons and residents who are treating FIA regularly were sent a survey invitation by email. The survey was available online from September 19 to December 1 2019. The questionnaire consisted of 28 questions concerning diagnostic and surgical techniques in the treatment of intersphincteric and transsphincteric FIA. RESULTS In total, 147 (43%) surgeons responded and completed the survey. Magnetic resonance imaging was the preferred diagnostic imaging modality (97%) followed by the endo-anal ultrasound (12%). In case of a high FIA, 86% used a non-cutting seton. Most respondents removed a seton between 6 weeks and 3 months (n = 84, 58%). Fistulotomy was the procedure of preference in low transsphincteric (86%) and low intersphincteric FIA (92%). Mucosal advancement flap (MAF) and ligation of intersphincteric fistula tract (LIFT), with 78% and 46%, respectively, were the procedures that were applied most often in high transsphincteric FIA. In high intersphincteric FIA 67% performed a MAF and 33% a fistulotomy. Thirty-three percent of all respondents stated that they habitually closed the internal fistula opening, half of them used a Z-plasty. For debridement of the fistula tract the preferred method was curettage (78%). CONCLUSIONS Dutch gastrointestinal surgeons use various techniques in the management of FIA. Novel promising techniques should be investigated adequately in sufficient large trials to increase consensus. A core outcome measurement and a prospective international database would help in comparing results. Until then, treatment should be adjusted to the individual patient, governed by fistula characteristics and patient choice.
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Comparin BC, Santos CHMD, Dourado DM, Reichel PMG, Paola RSD, Pontes ERJC. Treatment of rats anal fistula with glycerin Aloe barbadensis Miller extract. JOURNAL OF COLOPROCTOLOGY 2021. [DOI: 10.1016/j.jcol.2018.05.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Abstract
Rationale There is a need for a low cost treatment for complex anal fistulas that can heal without causing fecal incontinence, with room for the study of herbal medicines.
Objective To evaluate the effect of the glycerin Aloe barbadensis Miller extract in the treatment of anal fistula in rats.
Method Thirty Wistar rats underwent peritoneal anesthesia with ketamine and Xylasine, followed by transfixation of the anal sphincter with a steel wire, which remained for 30 days to develop the anal fistula. After this period, the steel wire was removed and three groups with 10 animals were formed: A (control), without treatment; B (seton), in which a cotton seton was introduced; C (therapeutic seton), in which a cotton thread was introduced as a seton, and Aloe barbadensis Miller extract was daily dripped in the seton; after 30 days, the setons of groups B and C were removed, and after two weeks without a seton euthanasia and removal of specimens was conducted, and the fistula closure and the inflammatory process were analyzed.
Results Fistula persistence was observed in all animals in Group A, six in Group B and three in Group C (p = 0.015). The mean local inflammation levels were 0.9 in Group A; 0.8 in Group B, and 0 in Group C (p = 0.015).
Conclusion The use of a seton soaked in a glycerin Aloe barbadensis Miller extract was effective in the healing of anal fistulas in rats, in addition to causing less inflammatory process than the non-phytotherapeutic seton.
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Affiliation(s)
- Bruno Cabral Comparin
- Universidade Federal de Mato Grosso do Sul (UFMS), Hospital Universitário Maria Aparecida Pedrossian, Campo Grande, MS, Brazil
| | - Carlos Henrique Marques dos Santos
- Universidade Federal de Mato Grosso do Sul (UFMS), Hospital Universitário Maria Aparecida Pedrossian, Campo Grande, MS, Brazil
- Universidade Anhanguera (Uniderp), Campo Grande, MS, Brazil
| | | | - Pâmela Micaela Gomes Reichel
- Universidade Federal de Mato Grosso do Sul (UFMS), Hospital Universitário Maria Aparecida Pedrossian, Campo Grande, MS, Brazil
| | - Roberta Silva de Paola
- Universidade Federal de Mato Grosso do Sul (UFMS), Hospital Universitário Maria Aparecida Pedrossian, Campo Grande, MS, Brazil
| | - Elenir Rose Jardim Cury Pontes
- Universidade Federal de Mato Grosso do Sul (UFMS), Hospital Universitário Maria Aparecida Pedrossian, Campo Grande, MS, Brazil
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Galvão MO, dos Santos CHM, Falcão GR. Evaluation of the inflammatory response induced by different materials in the treatment of perianal fistulas: experimental study in rats. JOURNAL OF COLOPROCTOLOGY 2021. [DOI: 10.1016/j.jcol.2015.08.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
AbstractThe 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.
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Cheung XC, Fahey T, Rogers AC, Pemberton JH, Kavanagh DO. Surgical Management of Idiopathic Perianal Fistulas: A Systematic Review and Meta-Analysis. Dig Surg 2021; 38:104-119. [PMID: 33503621 DOI: 10.1159/000512652] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Accepted: 10/25/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND Perianal fistula is a common colorectal condition with an incidence of 9 per 100,000. Many surgical treatments exist, all aiming to eliminate symptoms with minimal risk of recurrence and impact upon continence. Despite extensive evaluation of the therapeutic modalities, no clear consensus exists as to what is the gold standard approach. This systematic review aimed to examine all available evidence pertaining to the surgical management of perianal fistulas. Primary outcomes examined were recurrence and incontinence. SUMMARY This study was conducted according to PRISMA guidelines. Primary outcomes were analyzed for each group and expressed as pooled odds ratio with confidence intervals of 95%. 687 studies were identified from which 28 relevant studies were included. There was no significant difference in rates of incontinence identified between various surgical approaches. Glues and plugs show higher recurrence rates. Newer treatments continue to emerge with promise but lack supporting evidence of benefit over conventional therapies. Key Messages: While we await more robust randomized data, we will continue to proceed cautiously trying to offset the benefits of fistula healing against the inherent risk of altered continence.
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Affiliation(s)
| | - Tom Fahey
- Department of Postgraduate Studies, RCSI, Dublin, Ireland
| | - Ailin C Rogers
- Department of Postgraduate Studies, RCSI, Dublin, Ireland
| | | | - Dara Oliver Kavanagh
- Department of Surgery, Tallaght University Hospital, Dublin, Ireland, .,Department of Surgical Affairs, RCSI, Dublin, Ireland,
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Knotless seton for perianal fistulas: feasibility and effect on perianal disease activity. Sci Rep 2020; 10:16693. [PMID: 33028875 PMCID: PMC7541651 DOI: 10.1038/s41598-020-73737-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Accepted: 09/15/2020] [Indexed: 02/05/2023] Open
Abstract
Patients with perianal fistulas are frequently treated by a knotted seton which is well-known for causing complaints. We aimed to assess the feasibility of the knotless SuperSeton and advantages with respect to perianal disease activity. In a prospective cohort study, we included all consecutive adult patients with a knotted seton in situ or a perianal fistula requiring new seton drainage. Primary endpoint was seton feasibility (maintenance of the connection for minimally three months). Secondary endpoints included improvement of the Perianal Disease Activity Index (PDAI), complications and re-interventions within three months of follow-up. PDAI scores of patients with a knotted seton were crossover compared to PDAI scores after knotless seton replacement. Sixty patients (42% male, mean age 42 (SD 13.15), 41 with Crohn’s disease) were included between August 2016 and April 2018. Of 79 knotless setons, 69 (87.3%) stayed connected for ≥ 3 months. Overall, the knotless seton significantly decreased discharge (P = 0.001), pain (P < 0.001) and induration (P < 0.001) measured by the PDAI when compared to baseline. In patients with a knotted seton, replacement by the knotless seton significantly decreased discharge (P = 0.005) and pain (P < 0.001) measured by the PDAI. Furthermore, 71% of patients reported fewer cleaning problems compared to the knotted seton. Ten patients developed a perianal abscess, and five patients required a re-intervention. This study supports the feasibility of the knotless seton with promising short-term results. The knotless seton might be preferred over the knotted seton in terms of perianal disease activity.
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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.
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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
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Loss of seton in patients with complex anal fistula: a retrospective comparison of conventional knotted loose seton and knot-free seton. Tech Coloproctol 2020; 24:1043-1046. [PMID: 32562152 DOI: 10.1007/s10151-020-02254-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Accepted: 05/25/2020] [Indexed: 12/15/2022]
Abstract
BACKGROUND Loose setons are often utilized. Replacements after seton loss are frequent, but the exact incidence of this loss of seton (LOS) in patients is unknown. The aim of the present study was to assess the incidence of LOS in a population with complex anal fistula, comparing the knot-free loose seton with the conventional knotted loose seton. METHODS All consecutive patients treated with a loose seton for complex anal fistula in two large teaching hospitals in the Netherlands between January 2017 and December 2019 were included in the present study. The incidence of loss of a conventional knotted loose seton was compared with the loss of commercially available knot-free setons. RESULTS There were 212 patients. Fifty-two patients were included in the knotted loose group and 160 patients were included in the knot-free seton group. Sixteen patients who were treated with both a knotted and a knot-free loose seton were included in both groups. The incidence of LOS was 12% in the knotted seton group and 28% in the knot-free loose seton group (p = 0.02). Median time to LOS was 36 days for the knotted loose seton and 89 days for the knot-free loose seton (p = 0.36). Sex (p = 0.61), age at the time of seton placement (p = 0.60), and presence of inflammatory bowel disease (p = 0.28) were not significantly associated with LOS. CONCLUSIONS LOS occurs frequently in patients treated for complex anal fistulas. The incidence of LOS is significantly higher in patients treated with a knot-free loose seton. Further developments in seton manufacturing should be focussed on optimisation of the closure mechanism.
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Akici M, Ersen O. The effect of suture selection in complex anal fistulas on the success of cutting seton placement and patient comfort. Pak J Med Sci 2020; 36:816-820. [PMID: 32494280 PMCID: PMC7260917 DOI: 10.12669/pjms.36.4.1920] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Objective: The aim of our study was to compare the success rates of suture selection, recovery times and pain associated with local wound infection and seton placement in patients undergoing cutting seton placement for complex anal fistula. Methods: The study included a total of 90 patients who were admitted with the diagnosis of complex anal fistula between January 2015 and July 2018. Results: The first session and other revision appointments demonstrated that the number of patients who required fistulotomy was significantly higher in group-1 as the seton failed to complete the transection (p = 0.001). When the patients were asked to rate pain for 3 different conditions according to numeric rating scale (NRS), the patients in group-2 had significantly higher pain in all 3 cases compared to the patients in group-1 (p 0.001). The impact of the suture material on local infection was examined and it was determined that the results of cultures for seton material were significantly more positive in group-1 (p = 0.001). Conclusions: We conclude that a multi-stage tight seton placement with silk material can lead to satisfactory results by aiming to shorten the cutting time of silk seton.
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Affiliation(s)
- Murat Akici
- Dr. Murat Akici. Department of General Surgery, Afyonkarahisar Health Sciences University, Afyon, Turkey
| | - Ogun Ersen
- Dr. Ogun Ersen, Department of General Surgery, Afyonkarahisar Health Sciences University, Afyon, Turkey
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Sammut M, Skaife P. The management of cryptoglandular fistula-in-ano. Br J Hosp Med (Lond) 2020; 81:1-9. [PMID: 32003630 DOI: 10.12968/hmed.2019.0353] [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: 11/11/2022]
Abstract
Idiopathic cryptoglandular fistula-in-ano is a common pathological condition. Fistula-in-ano has been managed by a number of surgical techniques, and there is still no consensus regarding the management of this condition. Surgical techniques aim to treat and cure the fistula-in-ano with minimal risk of recurrence or complications, and to maintain patient continence. This article discusses the evidence available to inform the management of idiopathic cryptoglandular fistula-in-ano, and problems that surgeons face because of the lack of high-quality evidence.
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Affiliation(s)
- Matthew Sammut
- Colorectal Department, Aintree University Hospital NHS Foundation Trust, Liverpool, UK
| | - Paul Skaife
- Colorectal Department, Aintree University Hospital NHS Foundation Trust, Liverpool, UK
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Carr JA. Relocation and silastic tension only (RASTO) procedure for very long anal fistula tracts: Initial case series with results of a new surgical technique. INTERNATIONAL JOURNAL OF SURGERY OPEN 2020. [DOI: 10.1016/j.ijso.2020.07.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Tanus OAV, Santos CHMD, Dourado DM, Conde AL, Giuncanse F, Souza IFD, Costa IO, Costa RL. PRIMARY SPHINCTEROPLASTY COMPARING TWO DIFFERENT STITCHES IN ANAL FISTULA TREATMENT: EXPERIMENTAL STUDY IN RATS. ARQUIVOS BRASILEIROS DE CIRURGIA DIGESTIVA : ABCD = BRAZILIAN ARCHIVES OF DIGESTIVE SURGERY 2019; 32:e1459. [PMID: 31826086 PMCID: PMC6902890 DOI: 10.1590/0102-672020190001e1459] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/25/2019] [Accepted: 05/30/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND Anal fistula is by definition the communication between the rectum or anal canal with the perineal region, which may be epithelialized and has cryptoglandular origin in 90% of cases. There are a large number of techniques for successfully treating trans-sphincteric fistulas of 20-50%, including primary sphincteroplasty, but it is not clear whether the material used would influence the outcome. AIM To analyze the efficacy of polydioxanone and polypropylene wire in primary post-fistulotomy sphincteroplasty in the treatment of trans-sphincteric fistulas in rats. METHODS Thirty Wistar rats had transfixation of the anal sphincter with steel wire, which remained for 30 days for the development of the anal fistula. After this period, it was removed and four groups were formed: A (control) without treatment; B (fistulotomy) submitted to such procedure and curettage only; C (polidioxanone) in which sphincteroplasty was performed after fistulotomy with polydioxanone wire; D (polypropylene) submitted to the same treatment as group C, but with polypropylene wire. After 30 days, euthanasia and removal of the specimens were performed for qualitative histopathological analysis, measurement of the area between the muscular cables edges and evaluation of the degree of local fibrosis. RESULTS There was persistence of the anal fistula in all animals of group A. There were no significant differences between groups B, C and D regarding the distance of the muscular cables (p=0.078) and the degree of fibrosis caused by the different treatments (p=0.373). CONCLUSIONS There was no difference between polydioxanone and polypropylene wires in post-fistulotomy primary sphincteroplasty, and this technique was not superior to simple fistulotomy in relation to the distance of the muscular cables nor did it present differences in relation to the degree of local fibrosis.
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Affiliation(s)
- Otávio Augusto Vendas Tanus
- General Surgery Department, Universitary Hospital Maria Aparecida Pedrossian, Federal University of Mato Grosso do Sul; Campo Grande, MS, Brazil
| | - Carlos Henrique Marques Dos Santos
- General Surgery Department, Universitary Hospital Maria Aparecida Pedrossian, Federal University of Mato Grosso do Sul; Campo Grande, MS, Brazil
- Anhanguera-Uniderp University, Campo Grande, MS, Brazil
| | | | - Andrea Lima Conde
- General Surgery Department, Universitary Hospital Maria Aparecida Pedrossian, Federal University of Mato Grosso do Sul; Campo Grande, MS, Brazil
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Drainage Seton Versus External Anal Sphincter-Sparing Seton After Rerouting of the Fistula Tract in the Treatment of Complex Anal Fistula: A Randomized Controlled Trial. Dis Colon Rectum 2019; 62:980-987. [PMID: 31162376 DOI: 10.1097/dcr.0000000000001416] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Complex anal fistula is one of the challenging anorectal conditions. Several treatments have been proposed for complex anal fistula, yet none proved to be ideal. OBJECTIVE This randomized trial aimed to assess the efficacy of external anal sphincter-sparing seton in comparison with the conventional drainage seton in the treatment of complex anal fistula. DESIGN This was a prospective, randomized, single-blind controlled study. SETTINGS The study was conducted at the Colorectal Surgery Unit of Mansoura University Hospitals. PATIENTS Adult patients of both sexes with complex anal fistula were recruited and evaluated with MRI before surgery. INTERVENTIONS Patients were randomly divided into 2 groups; group 1 was treated with conventional drainage seton and group 2 was treated with external anal sphincter-sparing seton using a rerouting technique. MAIN OUTCOME MEASURES The duration of healing, incidence of recurrence or persistence, postoperative pain, and complications including fecal incontinence were measured. RESULTS Sixty patients (56 men) with a mean age of 43 years were included. Mean operation time in group 1 was significantly shorter than group 2 (29.8 ± 4.3 vs 43.8 ± 4.5 min; p < 0.0001). The mean pain score at 24 hours in group 1 was 8.1 ± 1.6 versus 5.3 ± 1.3 in group 2 (p < 0.0001). Five patients (17%) in group 1 experienced complications versus 2 (7%) in group 2. All of the patients in group 1 required a second-stage fistulotomy versus 2 patients (7%) in group 2 (p < 0.0001). Time to complete healing in group 1 was significantly (p < 0.0001) longer than group 2 (103 ± 47 vs 46 ± 18 d). Four patients (13%) in group 1 and 1 patient (3%) in group 2 experienced persistence or recurrence of anal fistula (p = 0.35). LIMITATIONS This was a single-center study with relatively small numbers in each group. CONCLUSIONS Patients treated with external anal sphincter-sparing seton after rerouting of the fistula tract achieved quicker healing and less postoperative pain than those with conventional drainage seton. Postoperative complication and recurrence rates were comparable in both groups. See Video Abstract at http://links.lww.com/DCR/A963. TRIAL REGISTRATION clinicaltrials.gov identifier: NCT03636997 (https://clinicaltrials.gov/ct2/show/NCT03636997).
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Calis H. Anal Fistülün Tedavisinde Konvansiyonel Bir Prosedür Olarak Gevşek Seton Tekniği ve Uzun Dönem Sonuçları. ACTA MEDICA ALANYA 2019. [DOI: 10.30565/medalanya.487261] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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Saigusa N, Saigusa JI, Shinozaki M, Yokoyama T, Yokoi Y, Takami H, Miyahara R, Yokoyama Y. A series of seton techniques involving "top-down therapy" for patients with Crohn's disease who initially presented with perianal fistulas. J Anus Rectum Colon 2018; 2:122-129. [PMID: 31559354 PMCID: PMC6752135 DOI: 10.23922/jarc.2017-044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2017] [Accepted: 03/06/2018] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVES We determined the outcomes of seton treatment through a series of techniques using biological agents (BIOs) in 18 patients with Crohn's disease (CD) who initially presented with perianal fistulas. METHODS The patients underwent seton drainage using three seton types: a Penrose tube for fistulas with massive purulent discharge, a vessel loop for a small amount of discharge, and a rubber band for unproductive fistulas. If the distal end of the fistula extended more than 4 cm from the anal orifice, the skin and subcutaneous tissue were dissected along the outer edge of the anal sphincter to divide the fistulous tract into two portions. One seton encircled the sphincter from the primary opening throughout the anal canal (medial seton), and the other was inserted through the distal tract outside the sphincter (lateral seton). A BIO was then introduced immediately. When discharge ceased, the Penrose tube or vessel loop was replaced sequentially with a rubber band, which was tied fittingly and subsequently removed in medial to lateral order. RESULTS The mean interval between fistula onset and CD diagnosis was 2.1 years, and that between CD diagnosis and introduction of BIOs was 0.5 years. The mean follow-up duration was 4 years. The BIOs currently used were infliximab in 10 patients, adalimumab in 7, and ustekinumab in 1. The overall success rate was 94.4%, including unproductive fistulas in 10 (55.6%) patients and fistula disappearance in 7 (38.9%). CONCLUSIONS Our seton drainage techniques via the "top-down" approach represent a promising avenue for treating perianal fistulas in patients with CD.
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Affiliation(s)
- Naoto Saigusa
- Department of Surgery, Yokoyama Memorial Hospital, Nagoya City, Japan
- Saigusa Coloproctological Clinic, Shizuoka City, Japan
| | | | - Masaru Shinozaki
- Department of Surgery, Research Hospital, Institute of Medical Science, University of Tokyo, Tokyo, Japan
| | | | - Yoshihiro Yokoi
- Department of Surgery, Shinshiro Municipal Hospital, Shinshiro City, Japan
| | - Hideki Takami
- Department of Gastroenterological Surgery (Surgery II), Nagoya University Graduate School of Medicine, Nagoya City, Japan
| | - Ryoji Miyahara
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Nagoya City, Japan
| | - Yasuhisa Yokoyama
- Department of Surgery, Yokoyama Memorial Hospital, Nagoya City, Japan
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Abstract
INTRODUCTION Misconceptions exist about the proper way to use draining setons in the management of anal fistulas. This technical note lays out the principles for their use. TECHNIQUE Insertion of draining setons is a prerequisite to successful management of anal fistulas. The correct technique involves identification of the correct track and internal opening and drainage of the track with a silastic seton. This sets the stage for definitive repair after the inflammation subsides. RESULTS Three cases are presented to illustrate common errors made during the insertion of draining setons. CONCLUSIONS Appropriate seton drainage of an anorectal fistula is an important part of the ultimate repair. Correct use of setons minimizes symptoms from the seton itself and optimizes its effectiveness.
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Yamana T. Japanese Practice Guidelines for Anal Disorders II. Anal fistula. J Anus Rectum Colon 2018; 2:103-109. [PMID: 31559351 PMCID: PMC6752149 DOI: 10.23922/jarc.2018-009] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2018] [Accepted: 06/13/2018] [Indexed: 12/21/2022] Open
Abstract
Anal fistulas usually result from an anal gland infection in the intersphincteric space, which is caused by bacteria entering through the anal crypt (cryoptglandular infection). Reports of anal fistulas have been as high as 21 people in 100,000. Anal fistulas are 2-6 times more prevalent in males than females, with the condition occurring most frequently in patients in their 30s and 40s. Anal abscess symptoms include sudden onset of anal pain, swelling, redness, and fever. Purulent discharge or intermittent perianal swelling and pain are most often consistent with anal fistula symptoms. Methods for diagnosing anal fistulas include visual inspection, palpation, digital examination, anoscopic examination, barium enema, fistulography, as well as imaging, such as ultrasound, CT, and MRI. Parks classification is widely adapted in the West; however, Japan usually employs Sumikoshi classification. Antibiotics should be administered in cases of perianal abscess with surrounding cellulitis, or concomitant systemic disease, or those not alleviated by incision and drainage. The site and size of incision and drainage depend upon the abscess type and location. Incisions should be performed taking care not to damage the sphincter muscles and with possible future fistula surgery in mind. As spontaneous recovery is rare, except in the case of children, surgery is the principle approach to anal fistulas. Several approaches are utilized for anal fistulas. A specific procedure may be chosen depending upon curability and anal function. Postsurgical outcomes vary from study to study. Fecal incontinence may occur after fistula surgery, but reports vary.
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Affiliation(s)
- Tetsuo Yamana
- Department of Coloproctology, Tokyo Yamate Medical Center
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Abstract
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.
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Kammann S, Menias C, Hara A, Moshiri M, Siegel C, Safar B, Brandes S, Shaaban A, Sandrasegaran K. Genital and reproductive organ complications of Crohn disease: technical considerations as it relates to perianal disease, imaging features, and implications on management. Abdom Radiol (NY) 2017; 42:1752-1761. [PMID: 28194515 DOI: 10.1007/s00261-017-1073-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE A relatively large proportion of patients with Crohn disease (CD) develop complications including abscess formation, stricture, and penetrating disease. A subset of patients will have genital and reproductive organ involvement of CD, resulting in significant morbidity. These special circumstances create unique management challenges that must be tailored to the activity, location, and extent of disease. Familiarity with the epidemiology, pathogenesis, imaging features, and treatment strategies for patients with genital CD can aid imaging diagnoses and guide appropriate patient management. The purpose of this study is to illustrate the spectrum of CD in the genital tract and reproductive organs and discuss the complex management strategies in these patients as it relates to imaging. CONCLUSION Given the impact on patient outcome and treatment planning, familiarity with the epidemiology, pathogenesis, imaging features, and treatment of patients with genital Crohn disease can aid radiologic diagnoses and guide appropriate patient management.
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Affiliation(s)
- Steven Kammann
- Department of Radiology, Dartmouth-Hitchcock Medical Center, 100 Hitchcock Way, Manchester, NH, 03104, USA.
| | - Christine Menias
- Department of Radiology, Mayo Clinic-Arizona, 13400 E. Shea Blvd., Scottsdale, AZ, 85259, USA
| | - Amy Hara
- Department of Radiology, Mayo Clinic-Arizona, 13400 E. Shea Blvd., Scottsdale, AZ, 85259, USA
| | - Mariam Moshiri
- Department of Radiology, University of Washington Medical Center, 1959 NE Pacific St., Seattle, WA, 98195, USA
| | - Cary Siegel
- Mallinkrodt Institute of Radiology, 510 S Kingshighway Blvd, St. Louis, MO, 63110, USA
| | - Bashar Safar
- Department of Surgery, John Hopkins School of Medicine, 600 N. Wolfe Street, Sheikh Zayed Tower, Baltimore, MD, 21287, USA
| | - Steven Brandes
- Department of Urology, Columbia University Medical Center, 161 Fort Washington Avenue, 11thFloor, New York, NY, 10032, USA
| | - Akram Shaaban
- Department of Radiology, University Hospital Radiology, University of Utah, 50 N Medical Dr., Salt Lake City, UT, 84132, USA
| | - Kumar Sandrasegaran
- Department of Radiology, Indiana University, 550 N. University Blvd. Rm 0663, Indianapolis, IN, 46202, USA
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Emile SH, Elfeki H, Thabet W, Sakr A, Magdy A, El-Hamed TMA, Omar W, Khafagy W. Predictive factors for recurrence of high transsphincteric anal fistula after placement of seton. J Surg Res 2017; 213:261-268. [PMID: 28601324 DOI: 10.1016/j.jss.2017.02.053] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2017] [Revised: 02/05/2017] [Accepted: 02/24/2017] [Indexed: 02/07/2023]
Abstract
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.
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Affiliation(s)
- Sameh Hany Emile
- Department of General Surgery, Mansoura Faculty of Medicine, Mansoura, Egypt.
| | - Hossam Elfeki
- Department of General Surgery, Mansoura Faculty of Medicine, Mansoura, Egypt
| | - Waleed Thabet
- Department of General Surgery, Mansoura Faculty of Medicine, Mansoura, Egypt
| | - Ahmed Sakr
- Department of General Surgery, Mansoura Faculty of Medicine, Mansoura, Egypt
| | - Alaa Magdy
- Department of General Surgery, Mansoura Faculty of Medicine, Mansoura, Egypt
| | - Tito M Abd El-Hamed
- Department of General Surgery, Mansoura Faculty of Medicine, Mansoura, Egypt
| | - Waleed Omar
- Department of General Surgery, Mansoura Faculty of Medicine, Mansoura, Egypt
| | - Wael Khafagy
- Department of General Surgery, Mansoura Faculty of Medicine, Mansoura, Egypt
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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]
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Kristo I, Stift A, Staud C, Kainz A, Bachleitner-Hofmann T, Chitsabesan P, Riss S. The type of loose seton for complex anal fistula is essential to improve perianal comfort and quality of life. Colorectal Dis 2016; 18:O194-8. [PMID: 26999764 DOI: 10.1111/codi.13335] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2015] [Accepted: 01/28/2016] [Indexed: 02/08/2023]
Abstract
AIM The use of a loose seton for complex anal fistulae can cause perianal discomfort and reduced quality of life. The aim of this study was to assess the impact of the novel knot-free Comfort Drain on quality of life, perianal comfort and faecal continence compared to conventional loose setons. METHOD Forty-four patients treated for complex anal fistula at a single institution between July 2013 and September 2014 were included in the study. A matched-pair analysis was performed to compare patients with a knot-free Comfort Drain and controls who were managed by conventional knotted setons. The 12-item Short Form survey (SF-12) questionnaire was used to assess quality of life. Additionally, patients reported perianal comfort and faecal incontinence using a Visual Analog Scale (VAS) and the St Mark's Incontinence Score. RESULTS The Comfort Drain was associated with improved quality of life with significant higher median physical (P = 0.001) and mental (P = 0.04) health scores compared with a conventional loose seton. According to the VAS, patients with a Comfort Drain in situ reported greater perianal comfort with significantly less burning sensation (P < 0.001) and pruritus (P < 0.001). Faecal continence was similar in each group. CONCLUSION The Comfort Drain offers improved perianal comfort and better quality of life compared with a conventional loose seton and therefore facilitates long-term therapy in patients with complex fistula-in-ano.
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Affiliation(s)
- I Kristo
- Department of Surgery, Medical University of Vienna, Vienna, Austria
| | - A Stift
- Department of Surgery, Medical University of Vienna, Vienna, Austria
| | - C Staud
- Department of Surgery, Medical University of Vienna, Vienna, Austria
| | - A Kainz
- Department of Nephrology, Medical University of Vienna, Vienna, Austria
| | | | - P Chitsabesan
- York Teaching Hospital, NHS Foundation Trust, York, UK
| | - S Riss
- Department of Surgery, Medical University of Vienna, Vienna, Austria
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Rosen DR, Kaiser AM. Definitive seton management for transsphincteric fistula-in-ano: harm or charm? Colorectal Dis 2016; 18:488-95. [PMID: 26382283 DOI: 10.1111/codi.13120] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2015] [Accepted: 07/15/2015] [Indexed: 02/08/2023]
Abstract
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.
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Affiliation(s)
- D R Rosen
- Department of Colorectal Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - A M Kaiser
- Department of Colorectal Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
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Abstract
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.
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Affiliation(s)
- Salah M Raslan
- Dr. Salah M. Raslan, Department of General Surgery,, Ain Shams University,, Abbassia, Cairo, Egypt, F: 0020226837673 , ORCID ID: orcid.org/0000-0002-9897-9717
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Izadpanah A, Rezazadehkermani M, Hosseiniasl SM, Farghadin A, Ghahramani L, Bananzadeh A, Roshanravan R, Izadpanah A. Pulling Seton: Combination of mechanisms. Adv Biomed Res 2016; 5:68. [PMID: 27169099 PMCID: PMC4854033 DOI: 10.4103/2277-9175.180637] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2014] [Accepted: 02/02/2015] [Indexed: 01/15/2023] Open
Abstract
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.
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Affiliation(s)
- Ahmad Izadpanah
- Department of Surgery, Colorectal Research Center, Shiraz, Iran
| | | | | | | | | | | | | | - Ahad Izadpanah
- Department of Surgery, Shiraz University of Medical Sciences, Shiraz, Iran
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Operative Verfahren bei hohen kryptoglandulären Analfisteln: Systematische Übersicht und Metaanalyse. COLOPROCTOLOGY 2016. [DOI: 10.1007/s00053-015-0069-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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Göttgens KWA, Smeets RR, Stassen LPS, Beets G, Breukink SO. Systematic review and meta-analysis of surgical interventions for high cryptoglandular perianal fistula. Int J Colorectal Dis 2015; 30:583-93. [PMID: 25487858 DOI: 10.1007/s00384-014-2091-8] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/01/2014] [Indexed: 02/04/2023]
Abstract
PURPOSE Perianal fistulas, and specifically high perianal fistulas, remain a surgical treatment challenge. Many techniques have, and still are, being developed to improve outcome after surgery. A systematic review and meta-analysis was performed for surgical treatments for high cryptoglandular perianal fistulas. METHODS Medline (Pubmed, Ovid), Embase and The Cochrane Library databases were searched for relevant randomized controlled trials on surgical treatments for high cryptoglandular perianal fistulas. Two independent reviewers selected articles for inclusion based on title, abstract and outcomes described. The main outcome measurement was the recurrence/healing rate. Secondary outcomes were continence status, quality of life and complications. RESULTS The number of randomized trials available was low. Fourteen studies could be included in the review. A meta-analysis could only be performed for the mucosa advancement flap versus the fistula plug, and did not show a result in favour of either technique in recurrence or complication rate. The mucosa advancement flap was the most investigated technique, but did not show an advantage over any other technique. Other techniques identified in randomized studies were seton treatment, medicated seton treatment, fibrin glue, autologous stem cells, island flap anoplasty, rectal wall advancement flap, ligation of intersphincteric fistula tract, sphincter reconstruction, sphincter-preserving seton and techniques combined with antibiotics. None of these techniques seem superior to each other. CONCLUSIONS The best surgical treatment for high cryptoglandular perianal fistulas could not be identified. More randomized controlled trials are needed to find the best treatment. The mucosa advancement flap is the most investigated technique available.
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Affiliation(s)
- K W A Göttgens
- Department of Surgery, Maastricht University Medical Centre, Post box 5800, 6202 AZ, Maastricht, The Netherlands,
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Riss S, Bachleitner-Hofmann T, Stift A. The Comfort Drain: a new device for treating complex anal fistula. Tech Coloproctol 2014; 18:1133-5. [DOI: 10.1007/s10151-014-1216-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2014] [Accepted: 08/11/2014] [Indexed: 12/20/2022]
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Blom J, Husberg-Sellberg B, Lindelius A, Gustafsson UM, Carlens S, Oppelstrup H, Bragmark M, Yin L, Nyström PO. Results of collagen plug occlusion of anal fistula: a multicentre study of 126 patients. Colorectal Dis 2014; 16:626-30. [PMID: 24506192 DOI: 10.1111/codi.12585] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2013] [Accepted: 12/13/2013] [Indexed: 02/08/2023]
Abstract
AIM The Biodesign(®) anal fistula plug was introduced as a means of obliterating the fistula tract and promoting healing through biocompatibility. The results demonstrated unexplained variations from good to bad. This report analysed the results of a retrospective multicentre study. METHOD All plug procedures performed in four Stockholm hospitals between June 2006 and June 2010 were identified and studied using a common protocol. The outcome after the first plug-insertion procedure was assessed by chart review performed a minimum of 8 months after plug insertion. Cox proportional-hazards models were used to assess the associations of various factors with fistula healing. RESULTS One-hundred and twenty-six patients (mean age 47 years) were deemed suitable for the plug procedure. Eighty-five per cent of fistulae were cryptoglandular, 64% of patients were male and a mean of 2.9 previous fistulae procedures had been performed. All patients, except four, had an indwelling seton at the time of the plug procedure, which was performed in accordance with previously established principles of day surgery. After a median of 13 months, 30 (24%) fistulae had closed with no discomfort or secretion reported. The outcome in the four hospitals varied from 13% to 33% with similar numbers of patients in each hospital. A success rate of 12% was observed for patients with anterior fistula compared with 32% for those with posterior tracks [hazard ratio (HR) for successful healing = 2.98; 95% CI: 1.01-8.78) and 41% for those with a lateral internal opening (HR = 3.76; 95% CI: 1.03-13.75). Age, sex and number of previous procedures were not associated with healing. CONCLUSION Four independent patient groups showed low success rates after the first plug-insertion procedure. Anterior fistulae were much less likely to heal compared with fistulae in other locations.
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Affiliation(s)
- J Blom
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
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The role of loose seton in the management of anal fistula: a multicenter study of 200 patients. Tech Coloproctol 2014; 18:915-9. [PMID: 24989839 DOI: 10.1007/s10151-014-1186-0] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2013] [Accepted: 04/17/2014] [Indexed: 02/06/2023]
Abstract
BACKGROUND Perianal abscesses and fistulae-in-ano are a common anorectal complaint causing significant distress to patients, and present a considerable treatment challenge. Principal of treatment is achieving closure of the fistula while maintaining continence. There are numerous treatment approaches with large debate about which method is "ideal." Our aim was to assess the tolerance and efficacy of loose seton placement in the treatment for fistula-in-ano. METHODS We performed a retrospective multicenter review of the management of anal fistulae with loose seton placement over a three-year period. All patients underwent a standardized procedure, and were rescheduled for an elective change of seton until fistula resolution. Patients' demographics, medical history, comorbidities, overall number and time interval between seton placements, tolerance, and morbidity of the procedure were recorded. RESULTS A total of 200 consecutive patients had loose seton placement. 69.5 % (n = 139) were males, and mean age was 42.6 years. The median number of setons required for each patient was 3 (range 1-8; mean 2.84). The mean interval between changes was 3.08 months (range 2-4 months). All patients had successful clearance of fistula. The procedure was well tolerated in 96 % of patients (n = 187). Only 1 % (n = 2) could not tolerate the presence of seton due to significant discomfort. Fistula recurrence rate was 6 % (n = 12). CONCLUSIONS Recently, newer treatment modalities have been reported with enthusiasm. However, there remains a lack of strong statistical evidence of efficacy to support their use. Overall, loose seton placement remains a well-tolerated, pragmatic low-cost solution to this common and difficult condition as evident by our study.
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Torkzad MR, Ahlström H, Karlbom U. Comparison of different magnetic resonance imaging sequences for assessment of fistula-in-ano. World J Radiol 2014; 6:203-209. [PMID: 24876924 PMCID: PMC4037546 DOI: 10.4329/wjr.v6.i5.203] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2013] [Revised: 01/27/2014] [Accepted: 04/17/2014] [Indexed: 02/06/2023] Open
Abstract
AIM: To assess agreement between different forms of T2 weighted imaging (T2WI), and post-contrast T1WI in the depiction of fistula tracts, inflammation, and internal openings with that of a reference test.
METHODS: Thirty-nine consecutive prospective cases were enrolled. The following sequences were used for T2WI: 2D turbo-spin-echo (2D T2 TSE); 3D T2 TSE; short tau inversion recovery (STIR); 2D T2 TSE with fat saturation performed in all patients. T1WI were either a 3D T1-weighted prepared gradient echo sequence with fat saturation or a 2D T1 fat saturation [Spectral presaturation with inversion (SPIR)]. Agreement for each sequence for determination of fistula extension, internal openings, and the presence of active inflammation was assessed separately and blindly against a reference test comprised of follow-up, surgery, endoscopic ultrasound, and assessment by an independent experienced radiologist with access to all images.
RESULTS: Fifty-six fistula tracts were found: 2 inter-sphincteric, 13 trans-sphincteric, and 24 with additional tracts. The best T2 weighted sequence for depiction of fistula tracts was 2D T2 TSE (Cohen’s kappa = 1.0), followed by 3D T2 TSE (0.88), T2 with fat saturation (0.54), and STIR (0.19). Internal openings were best seen on 2D T2 TSE (Cohen’s kappa = 0.88), followed by 3D T2 TSE (0.70), T2 with fat saturation (0.54), and STIR (0.31). Detection of inflammation showed Cohen’s kappa of 0.88 with 2D T2 TSE, 0.62 with 3D T2 TSE, 0.63 with STIR, and 0.54 with T2 with fat saturation. STIR, 3D T2 TSE, and T2 with fat saturation did not make any contributions compared to 2D T2 TSE. Post-contrast 3D T1 weighted prepared gradient echo sequence with fat saturation showed better agreement in the depiction of fistulae (Cohen’s kappa = 0.94), finding internal openings (Cohen’s kappa = 0.97), and evaluating inflammation (Cohen’s kappa = 0.94) compared to post-contrast 2D T1 fat saturation or SPIR where the corresponding figures were 0.71, 0.66, and 0.87, respectively. Comparing the best T1 and T2 sequences showed that, for best results, both sequences were necessary.
CONCLUSION: 3D T1 weighted sequences were best for the depiction of internal openings and active inflammatory components, while 2D T2 TSE provided the best assessment of fistula extension.
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How to place a seton and prevent it slipping: mission impossible? Tech Coloproctol 2014; 18:603. [PMID: 24526396 DOI: 10.1007/s10151-013-1118-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2013] [Accepted: 12/31/2013] [Indexed: 10/25/2022]
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Köckerling F, Köckerling D, Lomas C. Cornelius Celsus--ancient encyclopedist, surgeon-scientist, or master of surgery? Langenbecks Arch Surg 2013; 398:609-16. [PMID: 23344725 PMCID: PMC3627856 DOI: 10.1007/s00423-013-1050-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2012] [Accepted: 01/13/2013] [Indexed: 01/31/2023]
Abstract
PURPOSE The Roman nobleman Cornelius Celsus (25 BC-AD 50) wrote a general encyclopedia (De Artibus) dealing with several subjects, among which some had medical content (De Medicina), an eight-volume compendium, including two books about surgery (VII + VIII). It is the most significant medical document following the Hippocratic writings. In 1443, Pope Nicolas V rediscovered the work of Cornelius Celsus, despite it having been forgotten for several centuries, and it was the first medical and surgical book to be printed (AD 1478). Up until the nineteenth century, 60 editions were published in Latin as well as numerous translations in European languages, the last of which was a French translation in 1876. While Celsus' work is the best account of Roman medicine as practiced in the first century of the Christian era and its influence persisted until the nineteenth century, there is controversy as to whether Cornelius Celsus himself actually practiced as a surgeon or was only an encyclopedist who collected in the Latin language the medical knowledge available at that time. METHODS The detailed analysis of the surgical techniques described by Celsus, the modifications tailored to the findings, possible complications, detailed description of pre- and postsurgical activities, give the general impression that he himself practiced surgery at least within his family and among his dependents. In addition, his descriptions give a clear insight into the astonishingly high standard of surgical knowledge available at the time of Celsus. RESULTS His work thus reflects the state of knowledge of his time, which is why he also assumed the role of teacher and scientist. As such, his meets the modern criteria addressed to a surgeon-scientist, who apart from the practical surgical activity, also had a role as teacher of surgery and scientist. Whether Cornelius Celsus had inaugurated a new surgical technique and was the first to describe that, and as such can be described as a master of surgery, cannot be corroborated. CONCLUSION Cornelius Celsus deserves a firm place in the history of surgery because with his publication De Medicina, Book VII + VIII, he has preserved Roman surgical knowledge in the first century of the Christian era and, thanks to the use of Latin in medicine and surgery, this continues to be retained up till the present day.
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Affiliation(s)
- F Köckerling
- Department of Surgery, Vivantes Hospital Spandau, Neue Bergstraße 6, 13585 Berlin, Germany.
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Esmaeili M, Najarian S, Kashani MT. A New Surgical Device for Minimally Invasive “Core-Out” Excision of High Fistula-in-Ano. J Med Device 2013. [DOI: 10.1115/1.4023130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
Core fistulectomy with endorectal advancement flap repair has been reported as a safe and effective technique for treatment of high fistula-in-ano. A number of rigid and flexible fistulectomy sets have already been fabricated pursuing the objectives of facilitating the procedure of this conservative surgical technique and reducing its risks of continence impairment. Two different methods (the method of scraping the granulation tissue of fistula and the method of separating and removing a thin layer from inside of tract) have been served in these sets for obliterating the abnormalities. In this work, with the aim of minimizing invasion to healthy tissue encircling the fistula, specially sphincter muscles, we designed and fabricated a new flexible fistulectomy device, which uses the second mentioned method. The new set separates an approximately 2.5-mm-thick layer from inside of the fistulous tract, by rotating a special tubular blade around its axis and moving the blade along the fistulous tract from external orifice toward the internal orifice. At the same time, the separated tissue may be removed from the fistulectomy lumen by rotating a special cannulated screw embedded coaxially inside the tubular blade. A flexible guidewire was used for identifying the tract path and guiding the device along it. We used the new set for excising 10 curved fistula models of approximately 16 cm length and 1.5 mm diameter, which were created in cubic pieces of fresh cow muscle as test specimens. After removing the device, each specimen was left with a smooth-walled lumen of approximately 9 mm diameter. The tubular blade works very well in separating a thin layer from inside of the fistula models and the cannulated screw is capable of easily removing the separated tissue. The removed tissue could be used as a sample of the whole tract for histopathological examinations. The screw and flexible guidewire lead the blade along the tract in a good manner and ensure circumferential separation of the fistula. With regard to the results of our tests, it is anticipated that the new set is an efficient instrument for easy, safe and fast core-out excision of high anal fistulas and is able to reduce the risk of injuries to healthy tissue encircling the fistulous tract.
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Affiliation(s)
| | - Siamak Najarian
- e-mail: Artificial Tactile Sensing and Robotic Surgery Lab, Faculty of Biomedical Engineering, Amirkabir University of Technology, No. 424, Hafez Avenue, Tehran, Iran 1591634311
| | - Mohsen T. Kashani
- Department of Surgery, Baqiyatallah University of Medical Sciences, No. 261, Sheikhbahaei Avenue, Tehran, Iran 1435915371 e-mail:
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