Prevalence of anal fistula in the United Kingdom

Early diagnosis of Crohn's disease in patients presenting with a perianal fistula: systematic review and development of a perianal red flags index

BACKGROUND

Delay in diagnosing Crohn's disease (CD) in patients presenting with perianal abscess (PAA) and/or fistula (PAF) is common. The aim of this study was to identify red flags suggestive of CD.

METHODS

A systematic literature review was conducted to identify symptoms associated with CD in patients presenting with PAA/PAF. A questionnaire including those symptoms, supplemented with items from the International Organization for the Study of Inflammatory Bowel Diseases (IO-IBD) red flags index for luminal CD, was administered to all adult patients presenting with a PAF and eventually diagnosed with CD and matched patients (1:3) from the same study period with a cryptoglandular PAF (2012-2023) at a single non-academic teaching hospital. All patients were asked to recall symptoms/signs experienced during their first PAF.

RESULTS

The systematic review identified 8 articles reporting on 15 clinical characteristics in patients presenting with PAA (n = 2)/PAF (n = 6), supplemented with 13 items from the IO-IBD red flags index (28 items in total). A total of 25 patients with CD and 75 patients with PAF without CD answered the questionnaire. Univariate analysis identified seven items associated with CD (age, family history, > 2 perianal interventions, weight loss, abdominal pain, diarrhoea and fatigue), and four items remained significant in multivariate analysis: age (OR 3.4 [1.0-11.5]), > 2 previous perianal interventions (OR 3.4 [1.0-10.1]), weight loss (OR 14.4 [3.7-55.6]) and abdominal pain (OR 9.8 [1.9-49.8]). Receiver-operating characteristic curve (ROC) analysis showed that a combination of these red flags was associated with good discrimination of CD versus non-CD (AUC 0.83 [0.72-0.94]).

CONCLUSIONS

The perianal red flags index has a good predictive value for early identification of patients with PAF at risk for underlying CD.

Silk fibroin/chitosan-based anal fistula scaffolds loaded with curcumin and 5-aminosalicylic acid

The present work describes the development of silk fibroin (SF)/chitosan (CS)-based porous composite anal fistula scaffold (SCAFS) with anti-inflammatory and healing functions. The SCAFS comprises an inner layer made from degummed silk fiber using a vertical braiding machine, and an outer layer created by freeze-drying a mixture of short SF fibers and curcumin (CUR)/5-aminosalicylic acid (5-ASA) loaded SF/CS solution. Results revealed that the SCAFS has high porosity of 42.4 %, remarkable water absorption rate of 370.5 %, robust dry/wet compression resistance of 12.28 ± 2.61 N/3.08 ± 0.43 N. The in vitro & in vivo biocompatibility and anti-inflammatory effect of SCAFS were further examined. The expression of pro-inflammatory cytokine TNF-α, anti-inflammatory cytokine IL-10, CD31 and CD68 was determined by immunohistochemistry (IHC) staining, H&E staining, Immunofluorescence (IF) staining and Masson assay. The results showed that the scaffolds possess a sustainable drug release above 400 h, better biocompatibility and anti-inflammatory effect than the control groups (p < 0.05). Thus, the SCAFS has potential application in the treatment of Crohn's disease.

Evaluating the Change in 18F-Fluorodeoxyglucose Uptake in Perianal Fistulas on PET/CT over Time: A Serial Retrospective Analysis

RATIONALE AND OBJECTIVES

Perianal fistulas on18F-fluorodeoxyglucose positron emission tomography-computed tomography (FDG-PET/CT) can be an incidental site of FDG uptake in patients undergoing PET for other indications. There are no longitudinal studies describing FDG uptake patterns in perianal fistulas. Therefore, we aimed to analyze changes in FDG uptake over time in patients with incidental perianal fistulas.

PATIENTS AND METHODS

Patients who underwent at least two FDG-PET/CTs between January 2011 and May 2023, with incidental perianal fistula, were retrospectively identified. We analyzed all sequential PET/CTs to determine the presence of a perianal fistula and recorded the fistula's maximum standardized uptake value (SUVmax). Statistical analysis compared fistula FDG-avidity in the initial versus final PET/CT examinations and assessed the correlation between initial fistula SUVmax and percent change over time.

RESULTS

The study included 15 fistulas in 14 patients, with an average of 5 PET/CT examinations per patient. The average interval between the first and last PET/CT was 24 months (range: 6-64). The average initial fistula SUVmax (11.28 ± 3.81) was significantly higher than the final fistula SUVmax (7.22 ± 3.99) (p = 0.0067). The fistula SUVmax declined by an average of 32.01 ± 35.33% with no significant correlation between initial fistula SUVmax and percent change over time (r = -0.213, p = 0.443, 95% CI -0.66-0.35).

CONCLUSION

FDG uptake in perianal fistulas shows temporal fluctuations but follows a decreasing SUVmax trend, possibly indicating a relationship with inflammatory activity. Further studies with larger cohorts paired with perianal fistula pelvic MR imaging are needed to validate these observations and their utility in guiding further management.

Perianal Fistula; from Etiology to Treatment - A Review

Anal fistula has been a challenging clinical issue for years due to its complex pathogenesis. The risk of frequent recurrence and incontinence complicates long-term treatment. Recent scientific literature has reviewed new techniques used for anal fistula treatment in recent years, assessing the advantages and disadvantages of each based on clinical outcomes. Although surgery is the main method used to treat anal fistula, there is no simple technique that can completely heal complex anal fistula. The surgical treatment should consider the healing outcome and the protection of anal function comprehensively. Several innovative techniques have emerged in recent years, such as combined techniques based on drainage seton and LIFT-plug, which appear to be relatively effective therapies. However, more multi-center prospective trials with long-term follow-up are needed to validate their effectiveness. In some situations, medical treatment may also be considered.

Clinical characterization of patients with anal fistula during follow-up of anorectal abscess: a large population-based study

PURPOSE

Approximately 15-50% of patients with an anorectal abscess will develop an anal fistula, but the true incidence of this entity is currently unknown. The aim of the study was to determine the incidence of anorectal abscess and development of a fistula in a specific population area and to identify potential risk factors associated with demographic, socioeconomic and pre-existing disease (e.g. diabetes and inflammatory bowel disease).

METHODS

A longitudinal observational study was designed including a large cohort study in an area with 7,553,650 inhabitants in Spain 1st january 2014 to 31st december 2019. Adults who attended for the first time with an anorectal abscess and had a minimum of 1-year follow-up were included. The diagnosis was made using ICD-10 codes for anorectal abscess and anal fistula.

RESULTS

During the study period, we included 27,821 patients with anorectal abscess. There was a predominance of men (70%) and an overall incidence of 596 per million population. The overall incidence of anal fistula developing from abscesses was 20%, with predominance in men, and a lower incidence in the lowest income level. The cumulative incidence of fistula was higher in men and in younger patients (p < 0.0001). On multivariate analysis, patients aged 60-69 years (hazard ratio 2.0) and those with inflammatory bowel disease (hazard ratio 1.8-2.0) had a strong association with fistula development (hazard ratio 2.0).

CONCLUSIONS

One in five patients with an anorectal abscess will develop a fistula, with a higher likelihood in men. Fistula formation was strongly associated with inflammatory bowel disease.

A Systematic Review of Epidemiology and Outcomes Associated with Local Surgical and Intersphincteric Ligation Procedures for Complex Cryptoglandular Fistulas

INTRODUCTION

This systematic literature review (SLR) assessed incidence/prevalence of cryptoglandular fistulas (CCF) and outcomes associated with local surgical and intersphincteric ligation procedures for CCFs.

METHODS

Two trained reviewers searched PubMed and Embase for observational studies evaluating the incidence/prevalence of cryptoglandular fistula and clinical outcomes of treatments for CCF after local surgical and intersphincteric ligation procedures for CCF.

RESULTS

In total 148 studies met a priori eligibility criteria for all cryptoglandular fistulas and all intervention types. Of those, two assessed incidence/prevalence of cryptoglandular fistulas. Eighteen reported clinical outcomes of surgeries of interest in CCF and were published in the past 5 years. Prevalence was reported as 1.35/10,000 non-Crohn's patients, and 52.6% of non-IBD patients were found to progress from anorectal abscess to fistula over 12 months. Primary healing rates ranged from 57.1% to 100%; recurrence occurred in a range of 4.9-60.7% and failure in 2.8-18.0% of patients. Limited published evidence suggests postoperative fecal incontinence and long-term postoperative pain were rare. Several of the studies were limited by single-center design with small sample sizes and short follow-up durations.

DISCUSSION

This SLR summarizes outcomes from specific surgical procedures for the treatment of CCF. Healing rates vary according to procedure and clinical factors. Differences in study design, outcome definition, and length of follow-up prevent direct comparison. Overall, published studies offer a wide range of findings with respect to recurrence. Postsurgical incontinence and long-term postoperative pain were rare in the included studies, but more research is needed to confirm rates of these conditions following CCF treatments.

CONCLUSION

Published studies on the epidemiology of CCF are rare and limited. Outcomes of local surgical and intersphincteric ligation procedures show differing success and failure rates, and more research is needed to compare outcomes across various procedures. (PROSPERO; registration number CRD42020177732).

Clinical features and independent predictors of postoperative refractory trauma to anal fistula combined with T2DM: A propensity score-matched analysis-retrospective cohort study

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.

Efficacy and safety of traditional Chinese medicine external washing in the treatment of postoperative wound of diabetes complicated with anal fistula: Study protocol of a randomized, double-blind, placebo-controlled, multi-center clinical trial

Introduction: Anal fistula is one of the commonest ailments seen by anorectal surgeons as surgery is currently the preferred treatment for it. Diabetes mellitus is a risk factor that can lead to slow wound healing after anal fistula surgery. Because of the large postoperative wound surface of anal fistula, patients with diabetes can have an increased probability of wound infection, which makes it hard to heal. There is an extensive clinical experience for wound healing in traditional Chinese medicine (TCM). The Jiedu Shengji decoction (JSD) is a widely used external washing decoction in clinical practice. However, the current evidence on it is still insufficient. Therefore, we report this carefully designed clinical trial to assess the efficacy and safety of JSD in the treatment of postoperative wounds in diabetic patients with anal fistula. Methods and analysis: This study was designed to be a randomized, double-blind, placebo-controlled, multi-center clinical trial. There were 60 eligible participants who were randomized at a 1:1 ratio to the intervention and placebo groups. Both groups received the same standard treatment. The intervention group was given external washing decoction of TCM (JSD), while the placebo group was given the placebo made of excipients and flavoring agents. The main outcome measures include wound healing, distribution of wound pathogens, levels of inflammatory mediators, and blood glucose. The secondary outcome measures included lipids, the quality of the life evaluation scale (Short-Form Health Survey 36). Assessments were performed before the start of the study, at 1st, 2nd, 3rd, and 4th weeks after the intervention, and at 8th, 12th, and 16th follow-up weeks. Discussion: The clinical study we proposed will be the first randomized, double-blind, placebo-controlled, multi-center clinical trial study to assess the efficacy and safety of TCM external washing (JSD) in the treatment of postoperative wounds in diabetic patients with anal fistula. Ethics and dissemination: The Medical Ethics Committee of Hospital of Chengdu University of Traditional Chinese Medicine has reviewed this study protocol and gave its approval and consent on 17 March, 2022 (Ethical Review Number: 2022KL-018).

Anti TNF treatment of complex perianal fistulas in children without luminal Crohn's disease: Is it an option?

OBJECTIVES

Complex perianal fistulas (CPFs) in children even in the absence of luminal symptoms prompt evaluation for Crohn's disease (CD). Reports of isolated CPF in children, however, are sparse. In perianal CD, antitumor necrosis factor α (anti TNF) therapy is recommended. We aimed to describe our experience with anti TNF therapy in children with isolated CPF without evidence of luminal CD.

METHODS

We retrospectively reviewed charts of patients with isolated CPF who were treated with anti TNF agents between 2011 and 2019 in a tertiary center. MRI pelvis findings at baseline versus end of follow up were scored using MAGNIFI-CD. Outcomes included clinical remission, radiological response and radiological remission based on MAGNIFI-CD score at end of follow up.

RESULTS

Overall, 17 patients were identified, [10 males (59%), mean age at anti TNF initiation 13.4 ± 2.9 years]. Median time from perianal disease onset to anti TNF was 16.5 months (IQR 9.4-36.4). None of the patients had luminal inflammation. Prior to anti TNF, all patients had been treated with antibiotics without sufficient improvement, and 9/17 with abscess drainage and or Seton insertion. Nine patients (53%) were treated with infliximab while 8 (47%) received adalimumab. Median duration of follow up was 30.7 months (IQR = 12.7-44.8). At the end of follow up 9 patients (53%) achieved clinical remission. When comparing MRI prior to and after anti TNF, 36% (5/14) had radiologic response, of whom 2 (14%) achieved radiologic resolution.

CONCLUSION

Anti TNF agents may be an effective treatment option for children with isolated CPF. Whether these patients should be considered part of the CD phenotypic spectrum or a distinct entity is unclear.

LEVELS OF EVIDENCE

Therapeutic.

Clinicopathological determinants of recurrence after surgical treatment of fistula-in-ano in a Ghanaian teaching hospital

AIM

The aim of this work is to describe the clinicopathological and surgical aspects of fistula-in-ano and assess the risks associated with recurrence of the disease in a Ghanaian teaching hospital.

METHOD

This was a retrospective observational study assessing all fistula-in-ano surgeries performed at the Korle Bu Teaching hospital from January 2014 to January 2021 that had completed follow up of at least 3 months after wound healing. Demographic, clinical, pathological and surgical data were extracted from patient records. Logistic regression analysis was used to test for association between these variables and recurrence.

RESULTS

A total of 105 patients underwent 124 fistula surgeries. Their median age was 41 years, the male:female ratio was 4:1 and 12 had comorbidities including human immunodeficiency virus infection and diabetes mellitus. Thirty-one per cent (39/124) of fistulas had previously been operated on. At surgery, 51% (64/124) of fistulas followed a single straight tract, 30% (37/124) a single curved tract and 19% (23/124) had multiple curved tracts. More than half (65/124) were trans-sphincteric, 35% (44/124) suprasphincteric, 10% (12/124) subsphincteric and 2% (3/124) were intersphincteric. Sixty per cent of fistulas were treated with a ligation of intersphincteric fistula tract (74/124), 35% (44/124) a fistulectomy and 5% a fistulotomy. Recurrence after surgery was 22.5% (28/124); this was significantly higher for fistulas with multiple curved tracts (OR 4.153, 95% CI 1.431-12.054, p = 0.012) and fistulas with comorbidities (OR 3.222, 95% CI 1.076-9.647, p = 0.037).

CONCLUSION

There was high recurrence after fistula surgery with increased risk for fistulas with multiple tracts and the presence of comorbidities.

A Comparison of Different Surgical Treatments for Complex Anal Fistula: A Systematic Review

Fistula-in-ano is a common proctological condition that primarily affects younger people and leads to chronic morbidity. An anal fistula is divided into simple and complex fistulas. A complex fistula is a challenging problem due to higher recurrence rates and incontinence associated with surgery. Many new methods have been developed for the closure of complex fistula-in-ano, but there is no single best method. The aim of this study is to identify a superior surgical technique for treating complex/high cryptoglandular perianal fistulas (HCPFs). A literature search was done using PubMed and Google Scholar for the period of 2012-2021. Articles that contain surgical treatment for complex anal fistula in the English language published in the last 10 years were included. The types of studies included were randomized controlled trials (RCTs), meta-analyses, systematic reviews, cohort studies, and traditional reviews. Articles excluded were those done more than 10 years ago, in other languages, and containing simple fistula management only. Nine studies were included in the review; a systematic review and meta-analysis concluded that no single method is effective. The ligation of the intersphincteric fistula tract (LIFT) procedure seems to be a promising and effective technique as it has a low rate of fecal incontinence as compared to other methods. Biological techniques give variable success rates so does fistula plug (FP). Mucosal advancement flap (MAF) and rerouting seton give good results according to one study. Fistula plug gives variable results and is not a preferred method. Ligation of the intersphincteric fistula tract (LIFT) seems to be a promising new technique for complex anal fistulas, but the data available is not enough to determine the best method. More randomized trials are required to compare traditional techniques and emerging new biological methods to see the best technique available.

Risk of Anorectal Cancer Associated with Benign Anal Inflammatory Diseases: A Retrospective Matched Cohort Study

Purpose: The purpose of our study was to evaluate the relationship between benign anal inflammatory diseases and anorectal cancer and assess its risk factors. Methods: A retrospective matched cohort study was conducted that included data from 2002 to 2013. The National Health Insurance Service National Sample Cohort data from 2002 to 2013 was used for the study. Of a total study population of 143,884 individuals, 28,110 individuals with anal fissures were assigned to the case group, while 115,774 individuals without anal fissures were assigned to the control group based on the 1:4 propensity score matching age, sex, and year (case: diagnosed year, control: health service received year). Results: The risk of anorectal cancer was higher in the case group (hazard ratio [HR]: 1.95, 95% confidence interval [CI]: 1.51–2.53) compared to the control group. After grouping anorectal cancers into anal cancer and rectal cancer, the risk remained higher in the case group (anal cancer HR: 2.79, 95% CI: 1.48–5.27; rectal cancer HR: 1.82, 95% CI; 1.37–2.42). The case group was further categorized into patients with fissures and patients with fistulas; patients with fissures showed a higher risk of developing anorectal cancer than patients with fistulas (HR: 2.05, 95% CI: 1.53–2.73 vs. HR: 1.73, 95% CI: 1.13–2.66). Study participants in their 30s and 40s had a 4.19- and 7.39-times higher risk of anorectal cancer compared to those in the higher age groups (0.64–1.84), while patients who did not have inflammatory bowel disease (IBD) had a higher risk of developing anorectal cancer (HR: 2.09, 95% CI: 1.56–2.80). Conclusions and Relevance: Patients with anal fistulas or fissures have an increased risk of being diagnosed with anorectal cancer, especially at a young age and even without IBD.

Long term efficacy of Video-Assisted Anal Fistula Treatment (VAAFT) for complex fistula-in-ano: a single-centre Australian experience

BACKGROUND

Video-Assisted Anal Fistula Treatment (VAAFT) is a novel minimally invasive & sphincter-saving technique for treating complex fistula-in-ano involving endoscopic assessment & treatment of perianal fistula. This retrospective, non-randomized, observational study is the first Australian study of VAAFT. It is also the longest study of VAAFT to-date.

METHODS

From January 2014 to September 2019, 59 patients with a complex anal fistula were identified via MRI & underwent VAAFT. Fourteen patients had undergone previous definitive surgery for anal fistula. Specialized Karl Storz video equipment (fistuloscope) was used in the procedure. The rigid fistuloscope was used to directly visualize the fistula tract/s & internal opening. Closure of the internal opening was then performed. The fistula tract/s were then treated via fulguration. The external opening was kept patent & dressed. Patients were then followed up for a mean 59.5 months.

RESULTS

67.9% (n = 38) of patients achieved primary healing (needing nil further intervention) at a median of 13 weeks. 12.5% (n = 7) experienced healing followed by recurrence while 19.6% (n = 11) experienced non-healing. Of the recurrence/non-healing groups, 11/18 underwent repeat VAAFT with healing occurring in 10/11 patients at a median of 7 weeks. The mean operating time was 41.1 min. There were no major complications & continence scores were not affected. Three patients were lost to follow up.

CONCLUSION

VAAFT is both effective & safe for the treatment of complex fistula-in-ano. Its minimally invasive nature means that in the instance of recurrence or persistence, VAAFT can be repeated with minimal morbidity & reasonable likelihood of success.

Prevalence of anal fistulas: a systematic review and meta-analysis

Anal fistula refers to a clinical condition with local pain and inflammation associated with purulent discharge that affects the quality of life. Due to the lack of studies, the presence of bias, and high heterogeneity in the studies, the present systematic review is the first to be performed on the population-based database in this field. The present systematic review and meta-analysis was performed according to MOOSE guidelines. After systematic searching in electronic databases, only four articles met the inclusion criteria. After preparing a checklist and extracting data from the relevant articles, a meta-analysis was performed. All studies on the prevalence of anal fistula are related to Europe, and so far, no study has been conducted on other continents. The overall prevalence of anal fistula in European countries was 18.37 (95% CI: 18.20-18.55%) per 100,000 individuals, and the highest prevalence was reported for Italy (23.20 (95% CI: 22.82 to 23.59) per 100,000 people). From the present population-based (224,097,362) study results, it can be concluded that there is a prominent knowledge gap in this context. Because all the studies included in the current study relate only to Europe, the need for further research in this field in other countries is inevitably sensible.

LIFT: a feasible option for primary and recurrent fistulas

BACKGROUND

The development of a surgical solution for anal fistulas with minimal recurrence and morbidity remains a challenge. Ligation of the intersphincteric fistula tract (LIFT), however, is a sphincter sparing technique that provides complete resolution of the transsphincteric fistula as well as minimizing recurrence and fecal incontinence. Our goal is to evaluate the efficacy of fistula tract ligation for primary and recurrent fistulas.

METHODS

A retrospective single-center case study was conducted from data between 2015 and 2019 in a large district hospital in Antwerp, Belgium. Patients who underwent LIFT were included. Demographic patient data as well as primary outcome during the follow-up period were collected. A systematic literature review and analysis was conducted with terms [ANAL FISTULA] [TREATMENT] [LIFT] [LIGATION OF INTERSPHINCTERIC FISTULA]. Primary healing and recurrence associated with surgical modifications were investigated.

RESULTS

4 out of 25 patients presented with early failure (84% primary success rate) after a median follow-up period of 7 months. The median time until recurrence was 105 days. The success rate after a redo ligation was 100%. Twenty-eight studies were included for review and divided into three groups depending on the technical variation of the used technique. The success rate was 74.2% for the LIFT group, 72.9% in the LIFT + group, and 77.5% in the mLIFT group p = .92.

CONCLUSION

LIFT is a feasible treatment option for primary and recurrent fistulas, with excellent success rates where fistula characteristics rather than chosen technique dictate the surgical outcome.

Long-term outcomes after seton placement for perianal fistulas with and without Crohn's disease

AIM

Perianal sepsis in Crohn's disease (CD) fistulas is managed with antibiotics and surgical drainage; a noncutting seton is used for an identified transsphincteric fistula tract. The optimal management following seton placement for initial control of perianal sepsis remains to be determined. Our main aim was to assess the success rates of curative surgery, seton removal or long-term indwelling seton in patients with and without CD.

METHOD

This was a retrospective cohort of consecutive patients with a perianal fistula treated with a noncutting seton between 2010 and 2019, including 83 CD patients and 94 patients without CD. Initial control of symptomatic perianal infection with a seton and subsequent healing and reintervention rates were compared between the three postseton management strategies.

RESULTS

A total of 177 patients, 61% male and 83.1% with complex fistulas, were followed for a median of 23 months (interquartile range 11-40 months). Immunomodulatory treatment was used in 90.4% of CD patients after seton placement. Good initial control of perianal infection was achieved with a seton in CD and non-CD patients, at 92.9% and 96.7%, respectively (p = 0.11). Overall fistula healing or control for CD and non-CD patients was, respectively, 64% and 86% (p = 0.1) after curative surgery, 49% and 71% after seton removal (p = 0.21) and 58% and 50% with long-term seton placement (p = 0.72). Overall reintervention for recurrence was 83% in CD versus 53.1% in non-CD patients during the follow-up period (p = 0.002).

CONCLUSION

Definitive surgery was possible in only a minority of CD patients. Long-term seton management was an effective option in patients with CD with acceptable improvement and recurrence rates.

Diagnostic Features of Perianal Fistula in Patients With Crohn's Disease: Analysis of a Japanese Claims Database

Background

Perianal fistula (PAF) is a disabling complication of Crohn's disease (CD) which greatly impacts the quality of life. To address a scarcity of data in Asian populations, we determined the prevalence of CD-associated PAF in Japan, the order of diagnosis, and medical history of patients.

Methods

A retrospective, longitudinal, observational cohort study was conducted, using an employer-based health insurance claims database. The study included patients diagnosed with CD and/or PAF from October 2013 to September 2019.

Results

The age- and gender-adjusted prevalence rates of CD-associated PAF increased from 10.33 per 100 000 in 2014, to 13.68 per 100 000 in 2019. Among patients with CD-associated PAF, 15.7% were diagnosed with PAF after diagnosis of CD, 68.6% were diagnosed with PAF before diagnosis with CD, and 15.7% were diagnosed with CD and PAF within the same month. Of the patients diagnosed with CD after PAF, approximately 30% were diagnosed with PAF by the age of 20 years, whereas less than 10% of PAF patients without CD were diagnosed with PAF by the age of 20 years.

Conclusions

The study reveals the prevalence of CD-associated PAF in Japan and that most individuals were diagnosed with CD after the diagnosis of PAF. Crohn's disease may be underdiagnosed in patients with PAF; patients diagnosed with PAF at a young age should be monitored to allow timely diagnosis of CD.

Does Proctologic Surgery Really Influence Sexual Behaviors?

INTRODUCTION

The percentage of the heterosexual population that has experienced and regularly has anal intercourse ranges from 20% to 35% in the USA. This practice increases to 95% in certain populations, including lesbian, gay, bisexual, and transgender people. Due to the lack of data in the literature about the effect of proctologic surgery on anal intercourse, this study aimed to assess the impact of this surgery on sexual behavior in both genders.

MATERIALS AND METHODS

From March 2016 to February 2018, an anonymous questionnaire was submitted to all patients aged >18 who had undergone proctologic surgery in one of two surgical units at tertiary referral centers and was assessed independently of gender. The exclusion criteria were incomplete healing and <3 months follow-up.

RESULTS

In total, 929 patients answered the questionnaire in full. The overall prevalence of preoperative anal intercourse was 22.5%. The rate of anal intercourse among men was 16.7%, while among women, it was 28.9%. The overall postoperative rate of anal intercourse was 11.8%. The rate of postoperative anal intercourse among those who regularly engaged in anal intercourse preoperatively was 52.6%, with a 47.4% rate of non-completion (p <0.0001). The experiences reported during intercourse after surgery were mainly pain, stiffness, and partner discomfort.

CONCLUSION

Considering the statistically significant postoperative AI abandonment rate following all types of proctologic surgery, the surgeon has a duty to both treat the disease and to inform the patient about the possible consequences regarding its influence on anal intercourse.

Lymphogranuloma venereum mimicking rectal cancer (T3 N2) and causing a rectovesical fistula

We present the case of a 66-year-old bisexual patient suffering from painful bloody defecation, linked to rectal thickening, rectovesical fistula and enlarged lymph nodes in the mesorectal area. The patient was misdiagnosed with rectal cancer (T3 N2) on MRI but the symptoms of the patient were due to lymphogranuloma venereum. After adequate treatment with doxycycline, symptoms faded within days; a control MRI showed complete regression of all pathologic alterations.

Surgical treatment for cryptoglandular and Crohn's perianal fistulas: Protocol of an umbrella review

INTRODUCTION

A high prevalence of cryptoglandular and Crohn's perianal fistulas has been reported worldwide, and several surgical options are available for the management of anal fistula, with varying clinical efficacy. However, currently, the available evidence for the effectiveness of these surgical approaches are lacking and of concern in terms of the credibility and strength. The purpose of this study is to evaluate the credibility of the published systematic reviews and meta-analyses that assess the efficacy and safety of the surgical options for cryptoglandular and Crohn's perianal fistulas through an umbrella review.

METHODS AND ANALYSIS

A systematic search in PubMed, Embase and Cochrane library will be performed from inception to December 2020 without any language restriction. We will include systematic reviews and meta-analyses that investigate the efficacy and safety of surgical approaches in the management of cryptoglandular and Crohn's perianal fistulas. Two reviewers will independently screen search results through reading the titles or abstracts. Relevant information will be extracted from each eligible systematic review or meta-analysis. Based on random effects model summary estimates along with their p values, 95% prediction intervals, between-study heterogeneity, small-study effects and excess significance, we will classify the evidence from convincing (class I) to weak (class IV). Findings will be summarized using quantitative synthesis combined with a narrative approach. Cryptoglandular and Crohn's perianal fistulas will be summarized separately. Two authors will independently perform the literature search, data extraction, and quality assessment of each included systematic review and meta-analysis. Any unresolved conflicts or doubts will be resolved by discussion or by consulting a senior author. The risk of bias of the systematic reviews will be assessed using a 16-item Assessment of Multiple Systematic Reviews 2 (AMSTAR2) checklist. The strength of evidence for the included systematic reviews will be classified as "high", "moderate", "low", or "critically low" quality.

ETHICS AND DISSEMINATION

Ethics approval is not required as we will collect data from the published systematic reviews and meta-analyses without using individual patient data. The results of this umbrella review will be published in a peer-reviewed journal and will be presented at an anorectal disease conference.

PROSPERO REGISTRATION NUMBER

CRD42020200754.

Fistulectomy and endorectal advancement flap repair for cryptoglandular anal fistula: recurrence and functional outcome over 10 years of follow-up

PURPOSE

To examine long-term recurrence and anal continence of patients with anal fistula treated by fistulectomy and endorectal advancement flap repair.

METHOD

Retrospective analysis of a prospective cohort of 115 patients (77.4% males, mean age 48.9 years) requiring 130 procedures, with a minimum follow-up of 10 years. Recurrence included reappearance of fistula after wound healing or presence of an abscess or chronic suppuration in the operated area at follow-up. Fecal incontinence was evaluated by the Cleveland Clinic Florida (CCF-FI) fecal incontinence scoring system.

RESULTS

The mean and SD duration of the follow-up period was 155.5 (21.7) months. Recurrence developed in 31 (23.8%) cases, 28 (90.3%) of which within the first year, with a mean time to recurrence of 4.9 (2.9) months. The success rate was 76.2%. Anal continence was normal in 80% of patients before surgery, 63.8% at 1-year follow-up, and 71.5% at the end of follow-up (p < 0.001). Overall, continence worsened in 16.9% of cases. The mean (95% CI) CCF-FI score was 0.78 (0.35-1.21) preoperatively, 1.04 (0.64-1.43) at 1 year after surgery, 0.90 (0.52-1.29) at 5 years, and 1.16 (0.66-1.67) at the end of the study (p < 0.05). Neither recurrence nor continence was significantly associated with previous anal or fistula surgical procedures or complexity of the fistula.

CONCLUSION

In this study, fistulectomy and endorectal advancement flap repair was associated with a long-term high rate of success. Most recurrences occurred within the first year and continence showed a mild deterioration over time.

CLINICAL TRIAL REGISTRATION

Not applicable.

Advances in the Treatment of Anal Fistula: A Mini-Review of Recent Five-Year Clinical Studies

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.

Efficacy and safety of ligation of intersphincteric fistula tract in the treatment of anal fistula: A protocol for systematic review and meta-analysis

BACKGROUND

Anal fistula is characterized with perianal cellulitis, anorectal pain, smelly or bloody drainage of pus, and difficulty in controlling bowel movements. Ligation of intersphincteric fistula tract (LIFT) technique is a recently developed approach against anal fistula, and it could alleviate the pain of the patient, with little postoperative trauma, which can greatly shorten the wound healing time and hospitalization stay. We conduct the meta-analysis and systematic review to systematically evaluate the clinical efficacy and safety of LIFT in the treatment of anal fistula.

METHODS

Randomized controlled trials of LIFT against anal fistula will be searched in several Chinese and English databases. Two reviewers will independently conduct the literature extraction and risk of bias assessment. Statistical analysis will be conducted in RevMan 5.3.

RESULTS AND CONCLUSIONS

The study will help to systematically evaluate the clinical efficacy and safety of LIFT in the treatment of anal fistula.

OSF REGISTRATION NUMBER

DOI 10.17605/OSF.IO/T4FUH.

[Hidradenitis suppurativa/acne inversa in the genitoanal region]

Hidradenitis suppurativa/acne inversa (HS/AI) is a chronic inflammatory skin disease. Several studies showed that perianal, perineal and gluteal involvement is more common in men. Axillary, submammary and inguinal localizations seem to be more prevalent in women. Involvement of the genitoanal region is associated with a higher reduced quality of live and sexual health compared to other locations. Moreover HS/AI in the genitoanal region can lead to serious complications. The knowledge of perianal fistula formation, pubogenital lymphedema and squamous cell carcinoma, which are three of the most severe complications, is critical for adequate treatment.

The development of a cryptoglandular Anal Fistula Core Outcome Set (AFCOS): an international Delphi study protocol

PURPOSE

Cryptoglandular anal fistula is a disorder with an incidence of around 1 per 5,000 people per year in European countries. Many studies have been conducted to evaluate the effectiveness of interventions for anal fistula. However, there is considerable heterogeneity in the outcomes assessed and reported in these studies. This limits research quality and complicates evidence synthesis. A solution for heterogeneity in outcome reporting is the development of a Core Outcome Set (COS). This paper describes the protocol for the development of a European COS for Anal Fistula (AFCOS).

METHODS

The first step will be a systematic review of the literature to identify potential outcomes that may be included in the COS. Patient interviews will be conducted in The United Kingdom and The Netherlands to ensure that both clinician-important and patient-important outcomes are captured. The outcomes will be categorized using the COMET taxonomy and taken forward to a Delphi consensus exercise. In up to three web-based Delphi surveys the outcomes will be prioritized by patients, clinicians (surgeons, gastroenterologists, and radiologists), and (clinical) researchers. The responses will be summarized and reported anonymously in subsequent round(s) facilitating convergence to a consensus opinion. The final COS will be decided during a face-to-face consensus meeting with patients, clinicians, and (clinical) researchers.

DISCUSSION

This study protocol describes the development of a European COS for anal fistula to improve research quality, evidence synthesis, and patient care.