Recurrent anal fistulas: When, why, and how to manage?

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Role of Adipose Tissue Hormones in Pathogenesis of Cryptoglandular Anal Fistula

The cryptoglandular perianal fistula is a common benign anorectal disorder that is managed mainly with surgery and in some cases may be an extremely challenging condition. Perianal fistulas are often characterized by significantly decreased patient quality of life. Lack of fully recognized pathogenesis of this disease makes it difficult to treat it properly. Recently, adipose tissue hormones have been proposed to play a role in the genesis of cryptoglandular anal fistulas. The expression of adipose tissue hormones and epithelial-to-mesenchymal transition (EMT) factors were characterized based on 30 samples from simple fistulas and 30 samples from complex cryptoglandular perianal fistulas harvested during surgery. Tissue levels of leptin, resistin, MMP2, and MMP9 were significantly elevated in patients who underwent operations due to complex cryptoglandular perianal fistulas compared to patients with simple fistulas. Adiponectin and E-cadherin were significantly lowered in samples from complex perianal fistulas in comparison to simple fistulas. A negative correlation between leptin and E-cadherin levels was observed. Resistin and MMP2 levels, as well as adiponectin and E-cadherin levels, were positively correlated. Complex perianal cryptoglandular fistulas have a reduced level of the anti-inflammatory adipokine adiponectin and have an increase in the levels of proinflammatory resistin and leptin. Abnormal secretion of these adipokines may affect the integrity of the EMT in the fistula tract. E-cadherin, MMP2, and MMP9 expression levels were shifted in patients with more advanced and complex perianal fistulas. Our results supporting the idea of using mesenchymal stem cells in the treatment of cryptoglandular perianal fistulas seem reasonable, but further studies are warranted.

Simplified dressing change after surgery for high anal fistula: A prospective, single centre randomized controlled study on loose combined cutting seton (LCCS) technique

BACKGROUND

Dressing change is the most important part of postoperative wound care. The aim of this study was to evaluate whether a more effective, simple and less painful method of dressing change for anal fistulas could be found without the need for debridement and packing. Data related to postoperative recovery were recorded at postoperative days 3, 7, 14, 21 and 180.

METHODS

In this experiment, 76 subjects diagnosed with high anal fistula were randomly divided into a simplified dressing change (SDC) group and a traditional debridement dressing change(TDDC) group according to a ratio of 1:1.

RESULTS

The SDC group had significantly fewer pain scores, bleeding rates, dressing change times, inpatient days and lower average inpatient costs than the TDDC group. There were no significant differences in wound healing time, area and depth and Wexner score between the two groups.

CONCLUSIONS

Studies have shown that the use of simplified dressing changes does not affect cure or recurrence rates, but significantly reduces dressing change times and pain during changes, reducing patient inpatient length of stay and costs.

Cutting seton for the treatment of cryptoglandular fistula-in-ano: a systematic review and meta-analysis

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.

Impact of Preoperative Three-Dimensional Endoanal Ultrasound on the Surgical Outcome of Primary Fistula in Ano. A Multi-Center Observational Study of 253 Patients

PURPOSE

To evaluate the impact of preoperative three-dimensional endoanal ultrasound (3D-EAUS) on the clinical outcome of anal fistula surgery.

METHODS

The research consisted of multi-center retrospective case-control study including 253 consecutive adult patients undergoing surgery for confirmed or suspected primary fistula in ano who had undergone preoperative 3D-EAUS evaluation between January 2011 and January 2021. Main outcome measures were the concordance (K value) between ultrasound results and surgery in the identification of fistulas internal openings, primary tracts and secondary extensions and the 6 and 12 months success rate in patients with concordant and discordant findings.

RESULTS

A good agreement in the identification of the main fistulas characteristics between ultrasound results and operative findings was found. A significant difference (P < .0001; Fisher's exact test) in the success rate was found between patients with concordant and discordant ultrasound results and operative findings in identification or location of internal opening. Particularly, all the 11 (4.8%) patients with discordant results experimented a failure of the surgical procedure at 6 months follow-up. At re-operation, the shift from discordant to concordant results was associated with an 81.8% 12 months success-rate.

CONCLUSION

The three-dimensional endoanal ultrasound preoperative evaluation may have a relevant impact on the outcome of a defined group of patients undergoing surgery for anal fistula, since the careful evaluation of ultrasound results could simplify the internal orifice intra-operative detection and improve the success rate.

Outcomes of gracilis muscle interposition for rectourethral fistulas caused by treatment of prostate cancer

BACKGROUND

Gracilis muscle interposition (GMI) has been associated with favorable outcomes in treating complex perianal fistulas. Outcomes of GMI may vary according to the fistula etiology, particularly between rectovaginal fistulas in women and rectourethral fistulas (RUF) in men. The aim of this study was to assess the outcome of GMI to treat RUF acquired after prostate cancer treatment.

METHODS

This retrospective cohort study included male patients treated with GMI for RUF acquired after prostate cancer treatment between January 2000 and December 2018 in the Department of Colorectal Surgery, Cleveland Clinic Florida. The primary outcome was the success of GMI, defined as complete healing of RUF without recurrence. Secondary outcomes were length of hospital stay and postoperative complications.

RESULTS

This study included 53 male patients with a median age of 68 (range, 46-85) years. Patients developed RUF after treatment of prostate cancer with radiation (52.8%), surgery (34%), or transurethral resection of the prostate (TURP) (13.2%). Median hospital stay was 5 (IQR, 4-7) days. Twenty (37.7%) patients experienced 25 complications, the most common being wound infection and dehiscence. Primary healing after GMI was achieved in 28 (52.8%) patients. Fifteen additional patients experienced successful healing of RUF after additional procedures, for a total success rate of 81.1%. Median time to complete healing was 8 (range, 4-56) weeks. The only significant factor associated with outcome of GMI was wound dehiscence (p = 0.008).

CONCLUSIONS

Although the initial success rate of GMI was approximately 53%, it increased to 81% after additional procedures. Complications after GMI were mostly minor, with wound complications being the most common. Perianal wound dehiscence was significantly associated with failure of healing of RUF after GMI.

Preoperative Assessment of Perianal Fistulas with Combined Magnetic Resonance and Tridimensional Endoanal Ultrasound: A Prospective Study

BACKGROUND

we designed a prospective study of diagnostic accuracy that compared pelvic MRI and 3D-EAUS with pelvic MRI alone in the preoperative evaluation and postoperative outcomes of patients with perianal fistulas.

METHODS

the sample size was 72 patients and this was divided into two imaging groups. MRI alone was performed on the first group. Both MRI and 3D-EAUS were performed in parallel on the second group. Surgical exploration took place after two weeks and was the standard reference. Park's classification, the presence of a concomitant abscess or a secondary tract, and the location of the internal opening were recorded. All patients were re-evaluated for complete fistula healing and fecal incontinence six months postoperatively. All of the collected data were subjected to statistical analysis.

RESULTS

the MRI group included 36 patients with 42 fistulas. The MRI + 3D-EAUS group included 36 patients with 46 fistulas. The adjusted sensitivity and negative predictive value were 1.00 for most fistula types in the group that underwent combined imaging. The adjusted specificity improved for intersphincteric fistulas in the same group. The adjusted balanced accuracy improved for all fistula types except rectovaginal. The combination of imaging methods showed improved diagnostic accuracy only in the detection of a secondary tract. The healing rate at six months was 100%. Fecal incontinence at six months did not present a statistically significant difference between the two groups (Fisher's exact test p-value > 0.9). Patients with complex perianal fistulas had a statistically significant higher probability of undergoing a second surgery (x2 test p-value = 0.019).

CONCLUSIONS

the combination of pelvic MRI and 3D-EAUS showed improved metrics of diagnostic accuracy and should be used in the preoperative evaluation of all patients with perianal fistulas, especially those with complex types.

A complex presentation and successful management of fistulizing perianal Crohn's disease extending to the mid-back

Fistulizing perianal disease is a debilitating complication present in nearly half of all patients diagnosed with Crohn's disease. The majority of anal fistulas arising in these patients are complex. Treatment can be challenging with therapy often requiring both medical and surgical interventions with differing levels of symptomatic relief. Fecal diversion is an option after medical and surgical modalities have been exhausted but demonstrates limited efficacy. Complex perianal fistulizing Crohn's disease is inherently morbid and can be difficult to manage. We present a case of a young male with Crohn's, severe malnutrition and multiple perianal abscess with extensive fistula tracts up to his back; a planned fecal diversion was instituted to control sepsis and allow for wound healing and optimize medical therapy.

Endorectal advancement flap compared to ligation of inter-sphincteric fistula tract in the treatment of complex anal fistulas: A meta-analysis of randomized clinical trials

BACKGROUND

Rectal advancement flap and ligation of intersphincteric fistula tract are common procedures for treating complex anal fistula. The present meta-analysis aimed to compare the surgical outcomes of advancement flap and ligation of intersphincteric fistula tract.

METHODS

A Preferred Reporting Items for Systematic Reviews and Meta-Analyses-compliant systematic review of randomized clinical trials comparing the ligation of intersphincteric fistula tract and advancement flap was conducted. PubMed, Scopus, and Web of Science were searched through January 2023. The risk of bias was assessed using the Risk of Bias 2 tool and certainty of evidence with the Grading of Recommendations Assessment, Development and Evaluation approach. The primary outcomes were healing and recurrence of anal fistulas, and secondary outcomes were operative time, complications, fecal incontinence, and early pain.

RESULTS

Three randomized clinical trials (193 patients, 74.6% male) were included. The median follow-up was 19.2 months. Two trials had a low risk of bias, and 1 had some risk of bias. The odds of healing (odds ratio: 1.363, 95% confidence interval: 0.373-4.972, P = .639), recurrence (odds ratio: 0.525, 95% confidence interval: 0.263-1.047, P = .067), and complications (odds ratio: 0.356, 95% confidence interval: 0.085-1.487, P = .157) were similar between the 2 procedures. Ligation of intersphincteric fistula tract was associated with a significantly shorter operation time (weighted mean difference: -4.876, 95% confidence interval: -7.988 to -1.764, P = .002) and less postoperative pain (weighted mean difference: -1.030, 95% confidence interval: -1.418 to -0.641, 0.198, P < .001, I² = 3.85%) than advancement flap. Ligation of intersphincteric fistula tract was associated with marginally lower odds of fecal incontinence than advancement flap (odds ratio: 0.27, 95% confidence interval: 0.069-1.06, P = .06).

CONCLUSION

Ligation of intersphincteric fistula tract and advancement flap had similar odds of healing, recurrence, and complications. The odds of fecal incontinence and extent of pain after ligation of intersphincteric fistula tract were lower than after advancement flap.

Three-dimensional pelvic ultrasound is a practical tool for the assessment of anal fistula

OBJECTIVE

This study aims to investigate the diagnostic value of three-dimensional pelvic ultrasound in the preoperative assessment of anal fistula compared with findings of MRI and surgery.

METHODS

A total of 67 patients (62 males) with suspected anal fistula were analyzed retrospectively. Preoperative three-dimensional pelvic ultrasound and magnetic resonance imaging were performed in all patients. The number of internal openings and the type of fistula were recorded. The accuracy of three-dimensional pelvic ultrasound was determined by comparing these parameters with surgical outcomes.

RESULTS

At surgery, 5 (6%) were extrasphincteric, 10 (12%) were suprasphincteric, 11 (14%) were intersphincteric, and 55 (68%) were transsphincteric. There was no significant difference in the accuracy of pelvic 3D US and MRI, based on internal openings (97.92%, 94.79%), anal fistulas (97.01%, 94.03%), and those under Parks classification (97.53%, 93.83%).

CONCLUSION

Three-dimensional pelvic ultrasound is a reproducible and accurate method for determining the type of fistula and detecting internal openings and anal fistulas.

Introducing 3D modelling of MRI in the preoperative mapping of perianal fistula: How it could help the surgeons?

Background

Surgeons find treating perianal fistula difficult because insufficient drainage and failure to eradicate perianal sepsis could increase the risk of recurrence and postoperative complications. For better planning of the most suitable surgical technique, surgeons must consider the risk factors of recurrence with an accurate pre-operative assessment of perianal fistulae. The most common imaging method for grading primary perianal fistulas, identifying their complications, and locating occult extensions is magnetic resonance imaging (MRI). However, surgeons may find it challenging to read the lengthy reports of complex tracts, particularly for complicated patients. The creation of three-dimensional (3D) models has gained traction recently as a genuinely useful diagnostic tool for pre-operative planning. The authors evaluated the value of these surgical models. Inspecting the 3D models in addition to the routine two-dimensional study caused four out of five skilled colorectal surgeons to re-evaluate how far the fistulae extended. This made promise that 3D models would be helpful, simple to understand, and quick to interpret for colorectal surgeons. The purpose of the study is to assess the value of adding 3D modelling of MRI to standard two-dimensional MRI protocol for more accurate delineation of perianal fistula and its complications aiming at better surgical outcomes.

Results

Regarding 3D models, the highest degree of accuracy was in detecting supra-levator extension (100%) by both the third radiologist and the surgeon. There was a statistically high diagnostic inter-observer agreement between both, with a p-value < 0.0001. The highest inter-observer agreement was in the supra-levator extension (50/50, 100%), and the lowest agreement was in the side branches detection (44/50, 88%).

Conclusions

Pre-operative 3D MRI modelling provided the surgeon with a pre- and intra-operative road map that improved the surgeon’s orientation and ability to see complex perianal fistulas and their consequences, especially those with supra levator extension, thus helping the surgeon achieve better surgical results and decrease the preoperative risk factors of recurrence. Surgeons should utilise it in complex and recurrent cases reducing preoperative risk factors and improving outcomes. Although this technique is expensive, its cost–benefit ratio is low relative to recurrent hospitalisation and complications.

Complex Anal fistula treated with IFTAK (Interception of fistulous track with application of ksharsutra) technique- A case report

BACKGROUND

An anal fistula is a common benign anorectal disease that tends to reoccur simple or low-type fistulas can be treated without affecting the sphincter mechanism; however, repairing a complex ano fistula without compromising anal continence can be difficult for a surgeon.

CASE PRESENTATION

Here, we present an anal fistula of complex clinical appearance managed successfully by the IFTAK (Interception of fistulous track with application of ksharsutra) technique practiced at Banaras Hindu University, Varanasi, India. The diagnosis was made via visual and bi-manual digital rectal examination then confirmed by Endoanal ultrasonography (EAUS). The patient showed remarkable improvement and the fistula healed completely in due course of time without impairing the anal continence status of the patient. At four months of follow-up the patient was healthy and no recurrence was found.

CONCLUSION

IFTAK is a minimally invasive technique and very effective in managing complex fistula in ano of cryptoglandular origin. The main cause of recurrence in complex anal fistula is non-identification of an infected anal crypt, secondary extensions, associated sepsis, or abscess at the time of examination or surgery. So, precise diagnosis and appropriate surgical measures play an equal role in the successful outcome of anal fistula treatment, failure to either will result in non-healing or recurrence.

MRI of Recurrent Fistula-in-Ano: Is it Different from Treatment-Naïve Fistula-in-Ano and How Does it Correlate with Anal Sphincter Morphology?

Objectives  The main aim of this study was to compare magnetic resonance imaging (MRI) findings of recurrent and treatment-naïve fistula-in-ano and to correlate imaging findings with anal sphincter morphology in recurrent fistula-in-ano. Methods  This is a retrospective study of adult patients who underwent MRI for suspected fistula-in-ano in 2018. After excluding patients with alternative diagnosis, patients were stratified into recurrent ( n  = 103) and treatment-naïve ( n  = 106) fistula-in-ano groups. Two blinded radiologists reread MRI scans in consensus for fistula characteristics and anal sphincter morphology. We compared imaging features of recurrent and treatment-naïve fistula-in-ano, assessed the incidence of anal sphincter scarring among patients with recurrent fistula-in-ano, and studied its association with fistula features. Results  Two-hundred nine patients (187 males) with mean age of 40.6 (standard deviation: 12.2) years were included. Trans-sphincteric, inter-sphincteric, extra-sphincteric, and supra-sphincteric fistula-in-ano were seen in 63.6, 33, 2.9, and 0.5%, respectively. There were secondary tracts, supralevator extension, and secondary cause for fistula in 49.3, 12.9, and 14.8%, respectively. There was no difference between the fistula features of recurrent and treatment-naïve fistula-in-ano, except for significantly fewer external openings among recurrent fistula-in-ano ( p  = 0.005). Among patients with recurrent fistula-in-ano, MRI detected anal sphincter defect/scarring was seen in 53.4% ( n  = 55) and was significantly associated with posterior fistula-in-ano ( p  = 0.031), collections and/or supralevator extension ( p  = 0.010), and secondary tracts ( p  = 0.015). Conclusion  Fistula features of recurrent and treatment-naïve patients were mostly similar. There was high incidence (53.4%) of MRI-identified anal sphincter scarring/defect among recurrent fistula-in-ano, which was significantly associated with posterior fistula, collections, supra or translevator extension, and secondary tracts. Key Points MRI-identified anal sphincter scarring is very common among patients with recurrent fistula-in-ano and seen in more than half of them.There was significantly higher incidence of sphincter scarring among patients who had posterior fistula, collections, supralevator/translevator extension, and secondary tracts.

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

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.

Polyherbal formulation Anoac‑H suppresses the expression of RANTES and VEGF for the management of bleeding hemorrhoids and fistula

Hemorrhoids and fistula are considered the most common anorectal conditions in the general population. These conditions affect the quality of a patient's life by causing pain and bleeding during defecation or even in the resting state. Lower grades of hemorrhoids may be controlled by traditional measures. However, surgery is an effective treatment option in recurrent-lower and higher-grade hemorrhoids. Surgical procedures are associated with various complications, including pain and delayed wound healing. Recurrence of hemorrhoids is also a major concern in the post-operative period. An anal fistula is the connection between the anus and the skin and causes severe pain, swelling, as well as blood and pus discharge. Fistula has serious social and economic consequences. Hence, it is important to understand the pathophysiology and molecular pathology of hemorrhoids and fistula, to identify the molecular targets and to develop pharmacological-interventions. In a previous study by our group, the polyherbal formulation Anoac-H was developed for the treatment of different stages of hemorrhoids and fistula, and it was demonstrated that Anoac-H is an effective formulation for treating hemorrhoids. However, the molecular mode of action of Anoac-H on hemorrhoids and fistula had remained elusive. In the present study, it was determined that this formulation reduces the migration of mesenchymal (fibroblasts) and immune (RAW 264.7) cells without affecting their viability. It was also observed that Anoac-H suppresses the expression of regulated upon activation, normal T cell expressed and presumably secreted (RANTES) and VEGF in fibroblasts and macrophages. Inflammation and elevated expression of RANTES and VEGF were observed in hemorrhoids and fistula. However, inflammation, as well as the expression of RANTES and VEGF, were significantly reduced in treated human hemorrhoid and fistula tissues as compared to untreated ones, confirming the in vitro results.

Long-term Outcomes After Anal Fistula Surgery: Results From Two University Hospitals in Thailand

Purpose

This study aimed to evaluate long-term outcomes after anal fistula surgery from university hospitals in Thailand.

Methods

A prospectively collected database of patients with cryptoglandular anal fistula undergoing surgery from 2011 to 2017 in 2 university hospitals was reviewed. Outcomes were treatment failure (persistent or recurrent fistula), fecal continence status, and chronic postsurgical pain.

Results

This study included 247 patients; 178 (72.1%) with new anal fistula and 69 (27.9%) with recurrent fistula. One hundred twenty-one patients (49.0%) had complex fistula; 53 semi-horseshoe (21.5%), 41 high transsphincteric (16.6%), 24 horseshoe (9.7%), and 3 suprasphincteric (1.2%). Ligation of intersphincteric fistula tract (LIFT) was the most common operation performed (n = 88, 35.6%) followed by fistulotomy (n = 79, 32.0%). With a median follow-up of 23 months (interquartile range, 12–45 months), there were 18 persistent fistulas (7.3%) and 33 recurrent fistulae (13.4%)—accounting for 20.6% overall failure. All recurrence occurred within 24 months postoperatively. Complex fistula was the only significant predictor for recurrent fistula with a hazard ratio of 4.81 (95% confidence interval, 1.82–12.71). There was no significant difference in healing rates of complex fistulas among seton staged fistulotomy (85.0%), endorectal advancement flap (72.7%), and LIFT (65.9%) (P = 0.239). Four patients (1.6%) experienced chronic postsurgical pain. Seventeen patients (6.9%) reported worse fecal continence.

Conclusion

Overall failure for anal fistula surgery was 20.6%. Complex fistula was the only predictor for recurrent fistula. At least 2-year period of follow-up is suggested for detecting recurrent diseases and assessing patient-reported outcomes such as chronic pain and continence status.

Impact of number of previous surgeries on the continence state and healing after repeat surgery for recurrent anal fistula

BACKGROUND

The management of recurrent anal fistulas after previous surgery is usually challenging. The present study aimed to review the characteristics and treatment outcomes of recurrent anal fistulas as compared to primary anal fistulas.

METHODS

The records of patients with anal fistula who underwent surgery were reviewed. Characteristics and treatment outcomes of patients with recurrent anal fistulas were compared to those of patients with primary anal fistula without a history of surgery.

RESULTS

The study included 138 patients with recurrent anal fistulas, 76.8% of which were complex. Failure of healing was recorded in 25 (18.1%) patients and fecal incontinence (FI) in 9 (6.5%). Patients with recurrent anal fistulas had significantly higher percentage of anterior, complex, and horseshoe fistulas than patients with primary fistulas. Surgery for recurrent anal fistulas was followed by a significantly higher rate of failure of healing than primary fistulas (18.1% vs. 9.8%, P=0.011), whereas the rates of FI were comparable amongst the two groups (6.5% vs. 2.8%, P=0.07). Patients who had more than two previous operations for anal fistula had a significantly higher rate of FI than patients who underwent one or two previous surgeries (20% vs. 3.7% vs. 14.3%, P=0.04), yet healing rates were comparable.

CONCLUSION

Recurrent anal fistulas were more complex than primary fistulas. Surgical treatment of recurrent anal fistula was followed by a significantly higher rate of failure of healing and similar rate of FI as compared to primary anal fistulas. The number of previous fistula surgeries had a significant effect on postoperative continence state.

SURGICAL TREATMENT OF IATROGENIC COMPLEX RECURRENT EXTRASPHINCTER ANORECTAL FISTULA: A CLINICAL CASE

Background: Anorectal fistula is a benign disease with an average prevalence of 1.69/10,000 population. The disease significantly reduces the life quality and has a tendency to relapse. Repeated surgical treatment can lead to anal sphincter impairment. Paraproctitis is the main anorectal fistulas cause. However, there are also iatrogenic traumatic fistulas that occur after various anorectal surgical interventions.Clinical case: A 44-year old female patient applied to the MSU University clinic in March 2020 with perineal wound with permanent purulent discharge. During examination perianal soft tissue defect was determined, the external fistula opening (40x25x25cm) was visualized at the wound bottom, the internal fistula opening (2x3mm) was visualized at 12h of the clock dial. The perianal area is deformed due to scarring. In 2016 the patient underwent surgical «rectocele elimination, posterior colporaphy, levatoroplasty, plastic surgery of the anterior rectal wall». Obstructive defecation syndrome developed during postoperative period, and repeated surgical treatment was performed – anterior anosfincterolevatoroplasty, Milligan-Morgan hemorrhoidectomy.On the 9th day, there was a «perianal soft tissue rupture» with bleeding and «local anterior rectal wall damage in the suprasphincter zone». Then «the rectal defect suturing» was performed. The perineal wound was left open. The patient was reoperated in 3 months due to a rectovaginal fistula with no effect. A fistulectomy was performed at the Moscow State University Medical Center with the removal of the anal canal defect by mucosal-submucosal flap. The surgical wound heals by secondary tension.Conclusion: The current studies describe a small number of cases of anorectal fistulas secondary to anorectal surgery. At the same time, there is no data on the further surgical management of such patients. It is important to present the iatrogenic anorectal fistulas cases, not only to analyze the fistula cause, but also to describe the surgical treatment method and its efficacy.

Modification of Parks Classification of Cryptoglandular Anal Fistula

BACKGROUND

The Parks classification has been used for the classification of anal fistula for several years, but it does not allow for risk factors for failure after surgery.

OBJECTIVE

This study aimed to describe a modification of the Parks classification of anal fistula and examine its predictive validity in the assessment of the outcome of anal fistula in terms of failure of healing and fecal incontinence.

DESIGN

This is a retrospective review of a prospective database.

SETTING

This study was conducted in the Colorectal Surgery Unit, Mansoura University Hospitals.

PATIENTS

Adult patients with anal fistula who underwent surgery were included.

INTERVENTIONS

Five risk factors for failure after fistula surgery were identified from the literature and were examined by multivariate analysis of our patients. Four risk factors proved to be significant independent predictors of failure: secondary extensions, horseshoe fistula, previous fistula surgery, and anterior anal fistula in women. We modified the Parks classification by dividing the transsphincteric type into high and low and by grouping supra- and extrasphincteric anal fistulas into 1 group. The first 3 stages were subdivided according to the absence or presence of predictors of failure.

MAIN OUTCOME MEASURES

The primary outcome measured was the validity of the modified Parks classification with regard to the rates of failure and fecal incontinence after surgical treatment of each stage of anal fistula.

RESULTS

A total of 665 patients with cryptoglandular anal fistula were included. Failure rates increased from 2.3% (95% CI, 0.9%-4.7%), to 17.4% (95% CI, 10.8%-25.9%), 19.5% (95% CI, 15%-24.6%), and 30.7% (95% CI, 9.1%-61.4%) across the 4 stages. The area under the receiver operating characteristic curve was 0.90 (95% CI, 0.85-0.94) indicating the strong discriminative ability of the final multivariable predictive model. The increase in failure and incontinence rates across the fistula stages was significant.

LIMITATIONS

This is a retrospective, single-center study.

CONCLUSION

Inclusion of predictors of poor outcome into the modified classification helped differentiate simple and complex fistulas within each stage and between the different stages, which can help in assessment and decision making for anal fistula. See Video Abstract at http://links.lww.com/DCR/B441.

MODIFICACIN DE LA CLASIFICACIN DE PARKS DE LA FSTULA ANAL CRIPTOGLANDULAR

ANTECEDENTES:La clasificación de Parks se ha utilizado para la clasificación de la fístula anal durante varios años, sin embargo, no tuvo en cuenta los factores de riesgo de fracaso después de la cirugía.OBJETIVO:Describir una modificación de la clasificación de Parks de fístula anal y examinar su validez predictiva en la evaluación de los resultados de la fístula anal en términos de fracaso de la cicatrización e incontinencia fecal.DISEÑO:Revisión retrospectiva de la base de datos prospectiva.AJUSTE:Unidad de Cirugía Colorrectal, Hospital Universitario de Mansoura.PACIENTES:Pacientes adultos con fístula anal intervenidos quirúgicamente.INTERVENCIONES:Se identificaron cinco factores de riesgo de fracaso después de la cirugía de fístula de la literatura y se examinaron mediante análisis multivariante de nuestros pacientes. Cuatro factores de riesgo demostraron ser importantes predictores independientes de fracaso: extensiones secundarias, fístula en herradura, cirugía de fístula previa y fístula anal anterior en mujeres. Modificamos la clasificación de Parks dividiendo el tipo transesfinteriano en alto y bajo y agrupando la fístula anal supraesfinteriana y extraesfinteriana en un grupo. Las tres primeras etapas se subdividieron según la ausencia o presencia de predictores de fracaso.PRINCIPALES MEDIDAS DE RESULTADO:Validez de la clasificación de Parks modificada con respecto a las tasas de fracaso e incontinencia fecal después del tratamiento quirúrgico de cada etapa de la fístula anal.RESULTADOS:Se incluyeron 665 pacientes con fístula anal criptoglandular. Las tasas de fracaso aumentaron del 2,3% (IC del 95%: 0,9-4,7%), al 17,4% (IC del 95%: 10,8 al 25,9%), 19,5% (IC del 95%: 15-24,6%) y 30,7% (95% IC: 9,1- 61,4%) en las cuatro etapas. El área bajo la curva característica operativa del receptor fue 0,90 (IC del 95%: 0,85-0,94), lo que indica una fuerte capacidad discriminativa del modelo predictivo multivariable final. El aumento en las tasas de fracaso e incontinencia en las etapas de la fístula fue significativo.LIMITACIONES:Estudio retrospectivo, unicéntrico.CONCLUSIÓN:La inclusión de predictores de mal resultado en la clasificación modificada ayudó a diferenciar las fístulas simples y complejas dentro de cada etapa y entre las diferentes etapas, lo que puede ayudar en la evaluación y toma de decisiones para la fístula anal. Consulte Video Resumen en http://links.lww.com/DCR/B441.

Evaluating postoperative anal fistula prognosis by diffusion-weighted MRI

PURPOSE

The purpose of this study was to explore whether preoperative diffusion-weighted magnetic resonance imaging (DW-MRI) can be used to evaluate the prognosis of anal fistula and identify the influence factors of postoperative recurrence.

METHODS

This is a retrospective study of 117 patients with anal fistula who have undergone preoperative DW-MRI and surgery. All patients were followed up by telephone or reexamination within 2 years after surgery. Of the 117 patients, 35 were excluded due to loss of follow-up and only 82 were included in this study. MRI fistula imaging-related data were analyzed, and fistula severity was scored using criteria of both local extension of fistulas and active inflammation for a total maximum score of 22. The apparent diffusion coefficient (ADC) value of the fistula in patients with anal fistula during preoperative MRI examination was measured. According to whether anal fistula patients are accompanied by perianal abscess, they are divided into two groups, namely anal fistula group and anal fistula with abscess group. Based on whether patients with anal fistula recur after surgery, they were further divided into recurrent group and non-recurrent group.

RESULTS

82 patients with anal fistula were included in this analysis, 23 of them recurred and 59 were cured. Among patients with perianal abscess, the mean ADC value of the recurrent group was (1.19 ± 0.21)×10^-3 mm²/s, which is significantly lower than that of the non-recurrent group (1.36 ± 0.19)×10^-3 mm²/s. There were significant statistical differences in ADC values between the two groups (p = 0.03). Among patients with anal fistulas without abscesses, 15 patients recurred after surgery, with a mean ADC value of (1.45 ± 0.27) ×10^-3 mm²/s, and 33 patients didn't occur, with a mean ADC value of (1.44 ± 0.31)×10^-3 mm²/s. The ADC value of preoperative fistula in patients was negative significant correlation with MRI findings score (r= -0.332, P = 0.002). Risk factors for the recurrence after anal fistula surgery include the time interval between MRI and operation, multiple fistula tracks. Fatigue, excessive intake of spicy or greasy food and diarrhea may also be external risk factors for postoperative recurrence of patients with anal fistula.

CONCLUSIONS

DW-MRI has important application value for the prognosis evaluation of anal fistula. Complex type of anal fistula and improper lifestyle are the main risk factors affecting the recurrence after anal fistula surgery.