1
|
Li L, Yao ZC, Parian A, Yang YH, Chao J, Yin J, Salimian KJ, Reddy SK, Zaheer A, Gearhart SL, Mao HQ, Selaru FM. A nanofiber-hydrogel composite improves tissue repair in a rat model of Crohn's disease perianal fistulas. SCIENCE ADVANCES 2023; 9:eade1067. [PMID: 36598982 PMCID: PMC9812382 DOI: 10.1126/sciadv.ade1067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Accepted: 11/23/2022] [Indexed: 06/17/2023]
Abstract
Perianal fistulas (PAFs) represent a severe complication of Crohn's disease (CD). Despite the advent of biologic and small-molecule therapeutics for luminal disease, PAFs in CD (CD-PAF) are relatively resistant to treatment, with less than 50% responding to any therapy. We report an injectable, biodegradable, mechanically fragmented nanofiber-hydrogel composite (mfNHC) loaded with adipose-derived stem cells (ADSCs) for the treatment of fistulas in a rat model of CD-PAF. The ADSC-loaded mfNHC results in a higher degree of healing when compared to surgical treatment of fistulas, which is a standard treatment. The volume of fistulas treated with mfNHC is decreased sixfold compared to the surgical treatment control. Molecular studies reveal that utilization of mfNHC reduced local inflammation and improved tissue regeneration. This study demonstrates that ADSC-loaded mfNHC is a promising therapy for CD-PAF, and warrants further studies to advance mfNHC toward clinical translation.
Collapse
Affiliation(s)
- Ling Li
- Division of Gastroenterology and Hepatology, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Zhi-Cheng Yao
- Institute for NanoBioTechnology, Johns Hopkins University, Baltimore, MD, USA
- Department of Materials Science and Engineering, Whiting School of Engineering, Johns Hopkins University, Baltimore, MD, USA
- Translational Tissue Engineering Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Alyssa Parian
- Division of Gastroenterology and Hepatology, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Yueh-Hsun Yang
- Institute for NanoBioTechnology, Johns Hopkins University, Baltimore, MD, USA
- Translational Tissue Engineering Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Department of Plastic and Reconstructive Surgery, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Jeffrey Chao
- Institute for NanoBioTechnology, Johns Hopkins University, Baltimore, MD, USA
- Translational Tissue Engineering Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Department of Public Health Studies, Krieger School of Arts and Sciences, Johns Hopkins University, Baltimore, MD, USA
| | - Jason Yin
- Institute for NanoBioTechnology, Johns Hopkins University, Baltimore, MD, USA
- Department of Materials Science and Engineering, Whiting School of Engineering, Johns Hopkins University, Baltimore, MD, USA
- Translational Tissue Engineering Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Kevan J. Salimian
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Sashank K. Reddy
- Institute for NanoBioTechnology, Johns Hopkins University, Baltimore, MD, USA
- Department of Plastic and Reconstructive Surgery, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Atif Zaheer
- Division of Radiology and Radiological Sciences, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Susan L. Gearhart
- Division of Colorectal Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Hai-Quan Mao
- Institute for NanoBioTechnology, Johns Hopkins University, Baltimore, MD, USA
- Department of Materials Science and Engineering, Whiting School of Engineering, Johns Hopkins University, Baltimore, MD, USA
- Translational Tissue Engineering Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Department of Biomedical Engineering, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Florin M. Selaru
- Division of Gastroenterology and Hepatology, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
- Department of Oncology, Sidney Kimmel Cancer Center, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| |
Collapse
|
2
|
Tang X, He T, Li X, Liu Y, Wu Y, You G, Li J, Yun Y, Wu L, Li L, Kang J. Clinical features and independent predictors of postoperative refractory trauma to anal fistula combined with T2DM: A propensity score-matched analysis-retrospective cohort study. Front Surg 2023; 10:1119113. [PMID: 36911620 PMCID: PMC9998506 DOI: 10.3389/fsurg.2023.1119113] [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: 12/14/2022] [Accepted: 01/31/2023] [Indexed: 02/26/2023] Open
Abstract
Background Refractory wound is a common postoperative complication in anal fistula surgery, when combined with type 2 diabetes mellitus (T2DM) it presents a slower recovery time and more complex wound physiology. The study aims to investigate factors associated with wound healing in patients with T2DM. Materials and methods 365 T2DM patients who underwent anal fistula surgery at our institution were recruited from June 2017 to May 2022. Through propensity score-matched (PSM) analysis, multivariate logistic regression analysis was applied to determine independent risk factors affecting wound healing. Results 122 pairs of patients with no significant differences were successfully established in matched variables. Multivariate logistic regression analysis revealed that uric acid (OR: 1.008, 95% CI: 1.002-1.015, p = 0.012), maximal fasting blood glucose (FBG) (OR: 1.489, 95% CI: 1.028-2.157, p = 0.035) and random intravenous blood glucose (OR: 1.130, 95% CI: 1.008-1.267, p = 0.037) elevation and the incision at 5 o'clock under the lithotomy position (OR: 3.510, 95% CI: 1.214-10.146, p = 0.020) were independent risk factors for impeding wound healing. However, neutrophil percentage fluctuating within the normal range can be considered as an independent protective factor (OR: 0.906, 95% CI: 0.856-0.958, p = 0.001). After executing the receiver operating characteristic (ROC) curve analysis, it was found that the maximum FBG expressed the largest under curve area (AUC), glycosylated hemoglobin (HbA1c) showed the strongest sensitivity at the critical value and maximum postprandial blood glucose (PBG) had the highest specificity at the critical value. To promote high-quality healing of anal wounds in diabetic patients, clinicians should not only pay attention to surgical procedures but also take above-mentioned indicators into consideration.
Collapse
Affiliation(s)
- Xiao Tang
- Department of Proctology, Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, China.,School of Clinical Medicine, Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Taohong He
- Department of Proctology, Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Xinyi Li
- Department of Proctology, Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, China.,School of Clinical Medicine, Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Ya Liu
- Department of Endocrinology, Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Yuqi Wu
- Department of Proctology, Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, China.,School of Clinical Medicine, Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Gehang You
- Department of Proctology, Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, China.,School of Clinical Medicine, Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Jie Li
- Department of Proctology, Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, China.,School of Clinical Medicine, Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Yu Yun
- Department of Proctology, Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, China.,School of Clinical Medicine, Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Lei Wu
- Department of Proctology, Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, China.,School of Clinical Medicine, Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Li Li
- Department of Proctology, Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, China.,School of Clinical Medicine, Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Jian Kang
- Department of Proctology, Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, China
| |
Collapse
|
3
|
Beaman HT, Howes B, Ganesh P, Monroe MBB. Shape memory polymer hydrogels with cell-responsive degradation mechanisms for Crohn's fistula closure. J Biomed Mater Res A 2022; 110:1329-1340. [PMID: 35218140 DOI: 10.1002/jbm.a.37376] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Revised: 01/28/2022] [Accepted: 02/17/2022] [Indexed: 11/11/2022]
Abstract
Crohn's disease, a form of inflammatory bowel disease, commonly results in fistulas, tunneling wounds between portions of the urinary, reproductive, and/or digestive systems. These tunneling wounds cause pain, infection, and abscess formation. Of Crohn's patients with fistula formation, 83% undergo surgical intervention to either drain or bypass the fistula openings, and ~23% of these patients ultimately require bowel resections. Current treatment options, such as setons, fibrin glues, and bioprosthetic plugs, are prone to infection, dislodging, and/or require a secondary removal surgery. Thus, there is a need for fistula filling material that can be easily and stably implanted and then degraded during fistula healing to eliminate the need for removal. Here, the development of a shape memory polymer hydrogel foam containing polyvinyl alcohol (PVA) and cornstarch (CS) with a disulfide polyurethane crosslinker is presented. These materials undergo controlled degradation by amylase, which is present in the digestive tract, and by reducing thiol species such as glutathione/dithiothreitol. Increasing CS content and using lower molecular weight PVA can be used to increase the degradation rate of the materials while maintaining shape memory properties that could be utilized for easy implantation. This material platform is based on low-cost and easily accessible components and provides a biomaterial scaffold with cell-responsive degradation mechanisms for future potential use in Crohn's fistula treatment.
Collapse
Affiliation(s)
- Henry T Beaman
- Department of Biomedical and Chemical Engineering, Syracuse BioInspired Institute, Syracuse University, Syracuse, New York, USA
| | - Bryanna Howes
- Department of Chemistry, LeMoyne College, Syracuse, New York, USA
| | - Priya Ganesh
- Department of Biomedical and Chemical Engineering, Syracuse BioInspired Institute, Syracuse University, Syracuse, New York, USA
| | - Mary Beth Browning Monroe
- Department of Biomedical and Chemical Engineering, Syracuse BioInspired Institute, Syracuse University, Syracuse, New York, USA
| |
Collapse
|
4
|
Treating highly complex anal fistula with a new method of combined intraoperative endoanal ultrasonography (IOEAUS) and transanal opening of intersphincteric space (TROPIS). Wideochir Inne Tech Maloinwazyjne 2021; 16:697-703. [PMID: 34950264 PMCID: PMC8669985 DOI: 10.5114/wiitm.2021.104368] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2020] [Accepted: 01/26/2021] [Indexed: 02/07/2023] Open
Abstract
Introduction Treatment of highly complex anal fistula is still a profound test for a specialist colorectal surgeon. The reasons are directly related to recurrence and incontinence. Aim To evaluate the clinical results of a combined method of intraoperative endoanal ultrasonography (IOEAUS) and transanal opening of the intersphincteric space (TROPIS). Material and methods This study retrospectively included 48 patients with complex anal fistula, all of whom underwent new surgical methods. This operation mainly consists of two steps. Firstly, the type of anal fistula was determined by endoanal ultrasonography (EAUS) or magnetic resonance imaging (MRI) before the operation. Then the TROPIS procedure was performed with the help of EAUS, and the decision on whether a drainage seton should be placed depended on the condition of the tract. If there were secondary tracts, they were found and the same was done. Results The median follow-up was 12 months. Two (4.1%) patients experienced recurrence. Four (8.3%) patients did not have primary healing. All 6 patients underwent the same procedure again, and three recovered completely. So total successful fistula healing was observed in 45 (93.7%). There were no major complications and no significant deterioration in anal function and incontinence postoperatively. Conclusions Combined IOEAUS and TROPIS is an effective procedure in the treatment of highly complex anal fistula, and it may offer a new means for other operations.
Collapse
|
5
|
Garg P, Dawka S, Yagnik VD, Kaur B, Menon GR. Anal fistula at roof of ischiorectal fossa inside levator-ani muscle (RIFIL): a new highly complex anal fistula diagnosed on MRI. Abdom Radiol (NY) 2021; 46:5550-5563. [PMID: 34455464 DOI: 10.1007/s00261-021-03261-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Revised: 08/21/2021] [Accepted: 08/23/2021] [Indexed: 12/14/2022]
Abstract
BACKGROUND As experience with anal fistula imaging (MRI) has increased, new pathways of fistula extension have been identified. A recently described pathway is the 'outer-sphincteric space' present between the external anal sphincter and its covering outer fascia. A new type of complex fistula is being described which is present in the outer-sphincteric space and continues superiorly along the lateral border of the external anal sphincter to the infero-lateral surface of the puborectalis and levator-ani. In effect, these outer-sphincteric fistulas are at the roof of the ischiorectal fossa inside the levator muscle (RIFIL). These fistulas are not transsphincteric fistulas as they remain inside the levator muscle and do not enter the ischiorectal fossa. METHODS The MRI scans of consecutive anal fistula patients operated over the last two years were analyzed retrospectively. RESULTS Of 419 operated fistula patients analyzed, 42(10%) had RIFIL and 377 non-RIFIL fistulas. Compared to non-RIFIL fistulas, there were significantly more recurrent, multiple tracts, horseshoe, supralevator, and suprasphincteric fistulas in the RIFIL group. RIFIL fistulas were significantly more complex than non-RIFIL fistulas(85.7% vs 38.5%, p < 0.00001) and the surgery failure rate was also significantly higher in the RIFIL group (30.6%) than in the non-RIFIL fistula (7.2%) group(p = 0.0001). CONCLUSION RIFIL are highly complex fistulas. Proper diagnosis by MRI, surgical access, and subsequent management of these fistulas is quite challenging and they are associated with poor prognosis. Missing their diagnosis would lead to higher recurrence rate. These have not been described previously and were perhaps confused with high transsphincteric infralevator fistulas in ischiorectal fossa.
Collapse
|
6
|
Garg P, Kaur B, Yagnik VD, Menon GR. Extreme horseshoe and circumanal anal fistulas-challenges in diagnosis and management. Tzu Chi Med J 2021; 33:374-379. [PMID: 34760634 PMCID: PMC8532580 DOI: 10.4103/tcmj.tcmj_287_20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Revised: 02/04/2021] [Accepted: 02/09/2021] [Indexed: 12/19/2022] Open
Abstract
Objectives: Extreme horseshoe anal fistulas are rare, and there are little data on the diagnosis and management of these fistulas. Materials and Methods: Patients with horseshoe anal fistula, in which the fistula tract encircled more than 75% of the anal circumference were included in the study. All patients were assessed by a preoperative magnetic resonance imaging (MRI). The patients were managed by a sphincter-sparing procedure. The continence was evaluated by an objective continence scoring system (Vaizey's scores). Results: 1059 anal fistula patients were operated on over 7-years with a median follow-up of 36 months (range: 5–79 months). There were 47/1059 (4.4%) patients with extreme horseshoe anal fistulas. In 4/47 patients, the fistulas were complete circumanal (encircling anal canal completely). The mean age was 39.5 ± 10.9 years, M/F-41/6. The fistula was supralevator in 12/47 (25.5%), had an associated abscess in 28/47 (59.6%), and was recurrent in 33/47 (70.2%) patients. The tracts were intersphincteric in 27/47, transsphincteric in 2/47, and both (intersphincteric and transsphincteric) in 18/47 patients. All patients (n = 47) were managed by a sphincter-sparing procedure. Four patients were lost to follow-up. The fistula healed completely in 34/43 (79%) patients. There was no significant difference between preoperative and postoperative Vaizey's continence scores 0.031 ± 0.17 and 0.033 ± 0.18 respectively (P=0.90, Mann–Whitney U-test). Conclusion: Extreme horseshoe fistulas are rare, with an incidence of about 4% (in a referral practice). The missed diagnosis of circumferential tracts could lead to a recurrence. MRI was pivotal to confirm the diagnosis. Proper identification and management of internal opening and adequate drainage of all tracts were crucial for successfully treating extreme horseshoe fistulas.
Collapse
Affiliation(s)
- Pankaj Garg
- Department of Colorectal Surgery, Indus International Hospital, Mohali, Punjab, India
| | - Baljit Kaur
- Department of Radiodiagnosis, SSRD Imaging Centre, Chandigarh, India
| | - Vipul D Yagnik
- Department of Surgical Gastroenterology, Nishtha Surgical Hospital and Research Centre, Patan, Gujarat, India
| | - Geetha R Menon
- Indian Council of Medical Research, National Institute of Medical Statistics, New Delhi, India
| |
Collapse
|
7
|
Gao H, Cheng X, Gao L, Wang W, Wang X, Gong F, Zhang M, Hu J. Time-scheduled dotted and solid thread-ligating therapy combined with vacuum sealing drainage for treating high complex anal fistula. Am J Transl Res 2021; 13:11737-11744. [PMID: 34786101 PMCID: PMC8581849] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Accepted: 08/10/2021] [Indexed: 06/13/2023]
Abstract
OBJECTIVE To investigate the treatment of high complex anal fistula with time-scheduled dotted and solid thread-ligating therapy combined with vacuum sealing drainage. METHODS A retrospective cohort study of 80 patients with high complex anal fistula admitted to the anorectal department of our hospital was conducted. The patients in the control group (n=40) were treated with traditional incision thread-ligating therapy, while the patients in the observation group (n=40) were treated with time-scheduled dotted and solid thread-ligating therapy combined with vacuum sealing drainage. The postoperative wound healing time, clinical efficacy, postoperative pain scores as well as pre- and postoperative anal function and anorectal pressure of patients in the two groups were observed. RESULTS The observation group had a shorter wound healing time (P<0.001), lower postoperative pain scores (P<0.05), a lower increase of Wexner score (P<0.001), a higher total effective rate (97.50% vs. 90.00%; P>0.05), a higher anal maximal contraction pressure and a larger high pressure zone than the control group (P<0.05). Compared with those before operation, the Wexner scores of patients in the two groups after operation were increased, while the anal maximal contraction pressure and high pressure zone in the control group were decreased (P<0.001). CONCLUSION The treatment of complex high anal fistula with time-scheduled dotted and solid thread-ligating combined with vacuum sealing drainage has short wound healing time, high efficiency, and little influence on the postoperative function of anal sphincter. It is worthy to be popularized in clinic.
Collapse
Affiliation(s)
- Hengqing Gao
- Department of Anorectal, Zigong Hospital of Chinese Traditional MedicineZigong 643010, Sichuan Province, China
| | - Xiaohong Cheng
- Department of Pharmacy Zigong Hospital of Chinese Traditional MedicineZigong 643010, Sichuan Province, China
| | - Lijuan Gao
- Department of Anorectal, Zigong Hospital of Chinese Traditional MedicineZigong 643010, Sichuan Province, China
| | - Wei Wang
- Department of Anorectal, Zigong Hospital of Chinese Traditional MedicineZigong 643010, Sichuan Province, China
| | - Xiaoqiang Wang
- Department of Anorectal, Zigong Hospital of Chinese Traditional MedicineZigong 643010, Sichuan Province, China
| | - Furao Gong
- Department of Anorectal, Zigong Hospital of Chinese Traditional MedicineZigong 643010, Sichuan Province, China
| | - Mengmeng Zhang
- Graduate School of Chengdu University of Traditional Chinese MedicineChengdu 610072, Sichuan Province, China
| | - Jing Hu
- Department of Science and Education, Zigong Hospital of Chinese Traditional MedicineZigong 643010, Sichuan Province, China
| |
Collapse
|
8
|
Ji L, Zhang Y, Xu L, Wei J, Weng L, Jiang J. Advances in the Treatment of Anal Fistula: A Mini-Review of Recent Five-Year Clinical Studies. Front Surg 2021; 7:586891. [PMID: 33644110 PMCID: PMC7905164 DOI: 10.3389/fsurg.2020.586891] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Accepted: 12/15/2020] [Indexed: 12/16/2022] Open
Abstract
Anal fistula, with its complicated pathogenesis, has been considered as a clinical challenge for centuries. The risk of frequent recurrence and incontinence constitutes a considerable threat in the long-term treatment of anal fistula. In this work, we narratively reviewed the scientific literature of new techniques that have been used for anal fistula treatment over the recent 5 years, objectively evaluated the pros and cons of each technique on the basis of clinical outcomes, and tried to disclose the effective strategies for anal fistula treatment. Up to date, surgery is the main method used for treating anal fistula, but there is no simple technique that can completely heal complex anal fistula. In the course of surgery treatment, the healing outcome, and the protection of anal function should be weighed comprehensively. Among the innovative techniques that have emerged in recent years, combined techniques based on drainage Seton and LIFT-plug seem to be the relatively effective therapies, but their effectiveness requires more multi-center prospective randomized controlled trials with large sample size and long-term follow-up to be validated.
Collapse
Affiliation(s)
- Lijiang Ji
- Department of Anorectal Surgery, Changshu Hospital Affiliated to Nanjing University of Chinese Medicine, Changshu, China
| | - Yang Zhang
- Colorectal Disease Center, Nanjing Hospital of Chinese Medicine Affiliated to Nanjing University of Chinese Medicine, Nanjing, China
| | - Liang Xu
- Department of General Surgery, Changshu Hospital Affiliated to Nanjing University of Chinese Medicine, Changshu, China
| | - Jun Wei
- Department of Anorectal Surgery, Changshu Hospital Affiliated to Nanjing University of Chinese Medicine, Changshu, China
| | - Liping Weng
- Department of Anorectal Surgery, Changshu Hospital Affiliated to Nanjing University of Chinese Medicine, Changshu, China
| | - Jie Jiang
- Department of Anorectal Surgery, Changshu Hospital Affiliated to Nanjing University of Chinese Medicine, Changshu, China
| |
Collapse
|
9
|
Garg P, Kaur B, Singla K, Menon GR, Yagnik VD. A Simple Protocol to Effectively Manage Anal Fistulas with No Obvious Internal Opening. Clin Exp Gastroenterol 2021; 14:33-44. [PMID: 33564257 PMCID: PMC7866917 DOI: 10.2147/ceg.s291909] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Accepted: 01/20/2021] [Indexed: 12/19/2022] Open
Abstract
Purpose In some anal fistulas, the internal/primary opening cannot be located even after examination and assessment on MRI or transrectal ultrasound. The efficacy of a simple new protocol to manage such therapeutically challenging fistulas was tested. Patients and Methods All anal fistula patients operated consecutively over 7 years were included in the study. A simple two-step protocol was followed for fistulas in which the internal opening was not locatable after clinical examination and MRI assessment. First, the MRI was reassessed. The site where the fistula was closest to the internal sphincter was noted. It was assumed that the internal-opening was located at that position and the fistula was treated accordingly. Second, in horseshoe anal fistulas with no apparent internal opening, it was assumed that the internal opening was located in the midline. Low fistulas were treated by fistulotomy and high fistulas by a sphincter-sparing procedure. Incontinence was evaluated by objective incontinence scores (Vaizey scores). Results A total of 757 patients were operated (median follow-up-33 months). Of these, 57 patients were excluded due to short or inadequate follow-up. In 154/700 (22%) patients, the internal opening could not be located while in 546/700 (78%), the internal opening was found. Both the groups were similar in all parameters. In the "internal-opening found" group, the fistula healed completely in 486/546 (89%) and in the 'internal-opening not found group', the fistula healed in 140/156 (90.9%) (p=1.01). The objective continence scores did not change significantly after surgery in both the groups. Conclusion This new protocol seems effective as a high cure rate could be achieved in 'internal-opening not found' fistulas which was comparable to fistula healing in the 'internal-opening found' group.
Collapse
Affiliation(s)
- Pankaj Garg
- Department of Colorectal Surgery, Indus International Hospital, Mohali, India.,Department of Colorectal Surgery, Garg Fistula Research Institute (GFRI), Haryana, India
| | - Baljit Kaur
- Department of Radiology, SSRD Imaging Centre, Chandigarh, India
| | - Konica Singla
- Department of Colorectal Surgery, Garg Fistula Research Institute (GFRI), Haryana, India
| | - Geetha R Menon
- Department of Biostatistics, Indian Council of Medical Research, New Delhi, India
| | - Vipul D Yagnik
- Department of Surgical Gastroenterology, Nishtha Surgical Hospital and Research Centre, Patan, Gujarat, India
| |
Collapse
|
10
|
Tao Y, Zheng Y, Han JG, Wang ZJ, Cui JJ, Zhao BC, Yang XQ. Effects of an anal fistula plug on anal function after surgery for treatment of a trans-sphincteric anal fistula. Langenbecks Arch Surg 2020; 406:855-861. [PMID: 33174168 DOI: 10.1007/s00423-020-02024-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Accepted: 11/03/2020] [Indexed: 12/12/2022]
Abstract
PURPOSE The aim of this study was to evaluate the anal function in patients with trans-sphincteric anal fistulas who underwent an anal fistula plug procedure, and analyze risk factors that might affect post-operative anal function. METHODS This was an observational, retrospective study of patients diagnosed with trans-sphincteric anal fistulas and initially underwent anal fistula plug procedures between August 2008 and September 2012 at our institute. The analysis includes clinical characteristics, anal fistula healing, and the Wexner score for pre- and post-operative anal function (0 = no incontinence to 20 = complete incontinence). RESULTS A total of 123 patients who had an adequate follow-up in the end were included. The median duration of follow-up was 8 years (range 72-121 months). The overall healing rate was 56% (69/123), and 33 (26.8%) patients had decreased anal function after surgery. The post-operative Wexner score on anal function was significantly higher than that before the operation (p < 0.001), as well as scores of gas, liquid stool, solid stool incontinence, and alteration in lifestyle (p < 0.05). Based on multiple logistic regression analysis, a high body mass index (p < 0.001) and long distance between the external opening and anal verge (p = 0.003) were significantly associated with a decline in post-operative anal function. CONCLUSIONS As a sphincter-preserving technique for the treatment of anal fistulas, the anal fistula plug procedure might impair the anal function. Especially for patients with obesity or long distance between the external opening of anal fistula and anal verge, the reduced anal function is more likely to occur after treatment with anal fistula plug therapy.
Collapse
Affiliation(s)
- Yu Tao
- Department of General Surgery, Beijing Chaoyang Hospital, Capital Medical University, No. 8 Gongtinan Road, Chaoyang District, Beijing, 100020, People's Republic of China
| | - Yi Zheng
- Department of General Surgery, Beijing Chaoyang Hospital, Capital Medical University, No. 8 Gongtinan Road, Chaoyang District, Beijing, 100020, People's Republic of China
| | - Jia Gang Han
- Department of General Surgery, Beijing Chaoyang Hospital, Capital Medical University, No. 8 Gongtinan Road, Chaoyang District, Beijing, 100020, People's Republic of China.
| | - Zhen Jun Wang
- Department of General Surgery, Beijing Chaoyang Hospital, Capital Medical University, No. 8 Gongtinan Road, Chaoyang District, Beijing, 100020, People's Republic of China.
| | - Jin Jie Cui
- Department of General Surgery, Beijing Chaoyang Hospital, Capital Medical University, No. 8 Gongtinan Road, Chaoyang District, Beijing, 100020, People's Republic of China
| | - Bao Cheng Zhao
- Department of General Surgery, Beijing Chaoyang Hospital, Capital Medical University, No. 8 Gongtinan Road, Chaoyang District, Beijing, 100020, People's Republic of China
| | - Xin Qing Yang
- Department of General Surgery, Beijing Chaoyang Hospital, Capital Medical University, No. 8 Gongtinan Road, Chaoyang District, Beijing, 100020, People's Republic of China
| |
Collapse
|
11
|
Garg P, Sodhi SS, Garg N. Management of Complex Cryptoglandular Anal Fistula: Challenges and Solutions. Clin Exp Gastroenterol 2020; 13:555-567. [PMID: 33204136 PMCID: PMC7667587 DOI: 10.2147/ceg.s198796] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2020] [Accepted: 10/15/2020] [Indexed: 12/16/2022] Open
Abstract
Anal fistulae can be a very difficult disease to manage. The management of complex fistulae is even more challenging. The risk to the fecal continence mechanism due to damage to the anal sphincters and refractoriness to the treatment (high recurrence rate) pose the two biggest challenges in the management of this disease. Apart from these, there are several other challenges in the treatment of complex fistulae. The intriguing and uphill task is that satisfactory solutions to most of these challenges are still not known, and there is hardly any consensus on whatever treatment solutions are available. To summarize, there is no gold-standard treatment available for treating complex anal fistulae, and the search for a satisfactory treatment option is still on. In this review, the endeavor has been to discuss and highlight recent path-breaking updates in the management of complex anal fistulae.
Collapse
Affiliation(s)
- Pankaj Garg
- Department of Colorectal Surgery, Garg Fistula Research Institute, Panchkula, Haryana, India
| | - Sohail Singh Sodhi
- Department of General Surgery, Dayanand Medical College and Hospital, Ludhiana, Punjab, India
| | - Navdeep Garg
- Department of General Surgery, Government Medical College and Hospital, Chandigarh, India
| |
Collapse
|
12
|
Video-Assisted Ligation of Intersphincteric Fistula Tract for Complex Anal Fistula: Technique and Preliminary Outcomes. Dis Colon Rectum 2020; 63:1534-1540. [PMID: 33044294 DOI: 10.1097/dcr.0000000000001691] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Sphincter-preserving operations have been increasingly used for treating anal fistula. However, their success rates remain modest in complex anal fistulas. OBJECTIVE This study aimed to report outcomes of video-assisted ligation of intersphincteric fistula tract (a procedure combining video-assisted anal fistula treatment and ligation of intersphincteric fistula tract) for treating complex anal fistulas and to compare its results with conventional ligation of intersphincteric fistula tract. DESIGN A review of prospectively collected data from October 2014 to December 2017 was performed. SETTINGS The study was conducted at a large tertiary hospital in Thailand. PATIENTS All patients with primary or recurrent complex anal fistulas undergoing video-assisted ligation of intersphincteric fistula tract were included. Patients with anal fistula related to malignancy, Crohn's disease, tuberculosis, or acute abscess were excluded. MAIN OUTCOME MEASURES Healing as defined by an absence of fistula or drainage from an external opening and complete epithelialization of the external opening were measured. RESULTS This study included 103 patients with a median age of 47 years. The primary healing rate was 84.5% at a median follow-up of 28 months (range, 15-38 mo). Primary healing rates of anterior high transsphincteric fistula, semi-horseshoe fistula, and horseshoe fistula were 88% (44 of 50 cases), 77% (30 of 39 cases), and 93% (13 of 14 cases). Median time to healing was 4 weeks (range, 4-8 wk). Accordingly, the overall failure rate was 15.5%. None reported worse fecal incontinence postoperatively. Video-assisted ligation of intersphincteric fistula tract had a higher rate of primary healing for complex anal fistula than ligation of intersphincteric fistula tract (84.5% vs 63.4%; p < 0.001). LIMITATIONS This study is limited by its small sample size. CONCLUSIONS The outcomes of video-assisted ligation of intersphincteric fistula tract for complex anal fistulas are quite good. This technique has the potential to become another viable option of sphincter-preserving operation for complex anal fistulas. See Video Abstract at http://links.lww.com/DCR/B373. LIGADURA ASISTIDA POR VIDEO DEL TRACTO DE LA FÍSTULA INTERESFINTÉRICA PARA LA FÍSTULA ANAL COMPLEJA: TÉCNICA Y RESULTADOS PRELIMINARIES: Las operaciones de preservación del esfínter se han utilizado cada vez más para tratar la fístula anal. Sin embargo, sus tasas de éxito siguen siendo modestas en las fístulas anales complejas.Este estudio tuvo como objetivo informar los resultados de la ligadura asistida por video del tracto de la fístula interesfintérica (un procedimiento que combina el tratamiento de la fístula anal asistida por video y la ligadura del tracto de la fístula interesfintérica) para el tratamiento de las fístulas anales complejas y comparar sus resultados con la ligadura convencional de la fístula interesfintérica tracto.Se realizó una revisión de los datos recolectados prospectivamente desde Octubre de 2014 hasta Diciembre de 2017.El estudio se realizó en un gran hospital terciario en Tailandia.Se incluyeron todos los pacientes con fístulas anales complejas primarias o recurrentes sometidas a ligadura asistida por video del tracto de la fístula interesfintérica. Se excluyeron los pacientes con fístula anal relacionada con malignidad, enfermedad de Crohn, tuberculosis o absceso agudo.Curación definida por la ausencia de fístula o drenaje de la abertura externa y la epitelización completa de la abertura externa.Este estudio incluyó 103 pacientes con una mediana de edad de 47 años. La tasa de curación primaria fue del 84,5% con una mediana de seguimiento de 28 meses (rango 15-38). La tasa de curación primaria de la fístula transesfintérica alta anterior, la fístula semi-herradura y la fístula de herradura fue del 88% (44 de 50 casos), 77% (30 de 39 casos) y 93% (13 de 14 casos), respectivamente. El tiempo mediano hasta la curación fue de 4 semanas (rango 4-8). En consecuencia, la tasa de fracaso general fue del 15,5%. Ninguno informó peor incontinencia fecal después de la operación. La ligadura asistida por video del tracto de la fístula interesfintérica tuvo una mayor tasa de curación primaria para la fístula anal compleja que la ligadura del tracto de la fístula interesfintérica (84.5% vs 63.4%; p <0.001).Este estudio está limitado por su pequeño tamaño de muestra.Los resultados de la ligadura asistida por video del tracto de la fístula interesfintérica para fístulas anales complejas son bastante buenos. Esta técnica tiene el potencial de convertirse en otra opción viable de operación de preservación del esfínter para fístulas anales complejas. Consulte Video Resumen en http://links.lww.com/DCR/B373. (Traducción-Dr Yesenia Rojas-Khalil).
Collapse
|
13
|
|