Fistulotomy with or without marsupialisation of wound edges in treatment of simple anal fistula: a randomised controlled trial

European Society of Coloproctology: Guidelines for diagnosis and treatment of cryptoglandular anal fistula

AIM

The primary aim of the European Society of Coloproctology (ESCP) Guideline Development Group (GDG) was to produce high-quality, evidence-based guidelines for the management of cryptoglandular anal fistula with input from a multidisciplinary group and using transparent, reproducible methodology.

METHODS

Previously published methodology in guideline development by the ESCP has been replicated in this project. The guideline development process followed the requirements of the AGREE-S tool kit. Six phases can be identified in the methodology. Phase one sets the scope of the guideline, which addresses the diagnostic and therapeutic management of perianal abscess and cryptoglandular anal fistula in adult patients presenting to secondary care. The target population for this guideline are healthcare practitioners in secondary care and patients interested in understanding the clinical evidence available for various surgical interventions for anal fistula. Phase two involved formulation of the GDG. The GDG consisted of 21 coloproctologists, three research fellows, a radiologist and a methodologist. Stakeholders were chosen for their clinical and academic involvement in the management of anal fistula as well as being representative of the geographical variation among the ESCP membership. Five patients were recruited from patient groups to review the draft guideline. These patients attended two virtual meetings to discuss the evidence and suggest amendments. In phase three, patient/population, intervention, comparison and outcomes questions were formulated by the GDG. The GDG ratified 250 questions and chose 45 for inclusion in the guideline. In phase four, critical and important outcomes were confirmed for inclusion. Important outcomes were pain and wound healing. Critical outcomes were fistula healing, fistula recurrence and incontinence. These outcomes formed part of the inclusion criteria for the literature search. In phase five, a literature search was performed of MEDLINE (Ovid), PubMed, Embase (Ovid) and the Cochrane Database of Systematic Reviews by eight teams of the GDG. Data were extracted and submitted for review by the GDG in a draft guideline. The most recent systematic reviews were prioritized for inclusion. Studies published since the most recent systematic review were included in our analysis by conducting a new meta-analysis using Review manager. In phase six, recommendations were formulated, using grading of recommendations, assessment, development, and evaluations, in three virtual meetings of the GDG.

RESULTS

In seven sections covering the diagnostic and therapeutic management of perianal abscess and cryptoglandular anal fistula, there are 42 recommendations.

CONCLUSION

This is an up-to-date international guideline on the management of cryptoglandular anal fistula using methodology prescribed by the AGREE enterprise.

Efficacy of different surgical treatments for management of anal fistula: a network meta-analysis

PURPOSE

Currently, the anal fistula treatment which optimises healing and preserves bowel continence remains unclear. The aim of our study was to compare the relative efficacy of different surgical treatments for AF through a network meta-analysis.

METHODS

Systematic searches of MEDLINE, EMBASE and CENTRAL databases up to October 2022 identified randomised controlled trials (RCTs) comparing surgical treatments for anal fistulae. Fistulae were classified as simple (inter-sphincteric or low trans-sphincteric fistulae crossing less than 30% of the external anal sphincter (EAS)) and complex (high trans-sphincteric fistulae involving more than 30% of the EAS). Treatments evaluated in only one trial were excluded from the primary analyses to minimise bias. The primary outcomes were rates of success in achieving AF healing and bowel incontinence.

RESULTS

Fifty-two RCTs were included. Of the 14 treatments considered, there were no significant differences regarding short-term (6 months or less postoperatively) and long-term (more than 6 months postoperatively) success rates between any of the treatments in patients with both simple and complex anal fistula. Ligation of the inter-sphincteric fistula tract (LIFT) ranked best for minimising bowel incontinence in simple (99.1% of comparisons; 3 trials, n = 70 patients) and complex anal fistula (86.2% of comparisons; 3 trials, n = 102 patients).

CONCLUSIONS

There is insufficient evidence in existing RCTs to recommend one treatment over another regarding their short and long-term efficacy in successfully facilitating healing of both simple and complex anal fistulae. However, LIFT appears to be associated with the least impairment of bowel continence, irrespective of AF classification.

Treating highly complex anal fistula with a new method of combined intraoperative endoanal ultrasonography (IOEAUS) and transanal opening of intersphincteric space (TROPIS)

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.

Is Fistulotomy with Marsipulization more Effective than Fistulectomy alone for Low Fistula in Ano?

Background Fistula in ano is a very common perianal condition seen in outpatient departments. Fistulotomy and fistulectomy are two conventional options of surgery. The present study is designed to observe wound healing time and mean postoperative pain score in the comparison of outcome of the fistulectomy to fistulotomy with marsupialization.

Methods This prospective randomized trial was conducted in the surgical department of the Civil Hospital Karachi for a period of 12 months, in which 60 patients with low anal fistula were divided into 2 groups. Thirty patients in group A were treated with fistulectomy, and 30 in group B were treated with fistulotomy with marsupialization. The postoperative pain severity was assessed after 24 hrs through a visual analogue scale and on weekly and fortnightly follow-ups for 6 weeks. Wound healing was assessed by clinical examination on weekly and fortnightly follow-ups for 6 weeks to estimate the mean healing time.

Results The mean pain score was significantly lower in group B in comparison to group A (3.6 ± 1.99 versus 2.40 ± 1.52; p = 0.01). The mean wound healing time was shorter in group B in comparison to group A (4.23 ± 0.77 versus 5.80 ± 0.41 weeks; p = 0.0005).

Conclusion Fistulotomy with marsupialization is a simple, easy, and more effective method than fistulectomy for the treatment of simple perianal fistula.

Simple fistula-in-ano: is it all simple? A systematic review

BACKGROUND

Simple anal fistula is one of the most common causes of proctological surgery and fistulotomy is considered the gold standard. This procedure, however, may cause complications. The aim of this systematic review was to assess the surgical treatment of simple anal fistula with traditional and sphincter-sparing techniques.

METHODS

A literature research was performed using PubMed, Cochrane, and Google Scholar to identify studies on the surgical treatment of simple anal fistulas. Observational studies and randomized clinical trials were included. We assessed the risk of bias of included studies using the Jadad scale for randomized controlled trials, and the MINORS Scale for the remaining studies.

RESULTS

The search returned 456 records, and 66 studies were found to be eligible. The quality of the studies was generally low. A total of 4883 patients with a simple anal fistula underwent a sphincter-cutting procedure, mainly fistulotomy, with a weighted average healing rate of 93.7%, while any postoperative continence impairment was reported in 12.7% of patients. Sphincter-sparing techniques were adopted to treat 602 patients affected by simple anal fistula, reaching a weighted average success rate of 77.7%, with no study reporting a significant postoperative incontinence rate. The postoperative onset of fecal incontinence and the recurrence of the disease reduced patients' quality of life and satisfaction.

CONCLUSIONS

Surgical treatment of simple anal fistulas with sphincter-cutting procedures provides excellent cure rates, even if postoperative fecal incontinence is not a negligible risk. A sphincter-sparing procedure could be useful in selected patients.

A meta-analysis of marsupialisation versus none in the treatment of simple fistula-in-ano

INTRODUCTION

Marsupialisation of post-fistulotomy wounds results in a smaller raw surface area and may improve postoperative outcomes. However, it remains a variable practice. We performed a systematic review and meta-analysis to evaluate the effectiveness of marsupialisation in the treatment of simple fistula-in-ano.

MATERIALS AND METHODS

PubMed, EMBASE and Cochrane databases were searched for relevant articles from inception until April 2020. All trials that reported on marsupialisation in anal fistula treatment were included. The primary outcome measure was time to complete healing, while secondary outcomes included recurrence, pain scores and incontinence. Random effects models were used to calculate pooled effect size estimates. A sensitivity analysis was performed.

RESULTS

Six randomised controlled trials were included capturing 461 patients. The mean (SD) age of the cohort was 39.31 (± 8.71) years. There were 395 males (85.7%). All fistulae were of the cryptoglandular aetiology. On random effects analysis, marsupialisation was associated with a significantly shorter time to healing compared with no marsupialisation (SMD - 0.97 weeks, 95% CI = - 1.36 to - 0.58, p < 0.00001). However, there was no difference in recurrence (RD = - 0.00, 95% CI = - 0.02 to 0.02, p = 0.72), pain scores at 24 h (SMD - 0.03, 95% CI = - 0.56 to 0.50, p = 0.91) or incontinence (RD = - 0.01, 95% CI = - 0.05 to 0.02, p = 0.42). On sensitivity analysis, focusing exclusively on fistulotomy for simple fistula-in-ano, the results for time to healing, recurrence and incontinence remained similar.

CONCLUSIONS

Marsupialisation of fistulotomy wounds for simple fistula-in-ano is associated with a significantly shorter healing time, but similar recurrence, pain scores at 24 h and incontinence rates, compared with omitting marsupialisation.

Video-assisted anal fistula treatment for complex anal fistula: a long-term follow-up study

AIM

This prospective study aimed to evaluate the safety and efficacy of video-assisted anal fistula treatment (VAAFT) in complex fistula-in-ano (FIA).

METHOD

Consecutive patients presenting with complex FIA were recruited between November 2012 and November 2018. The primary outcome was healing of the fistula.

RESULTS

Seventy-two patients were included, 39 (54%) of whom were men, with a mean age of 46 (±11) years. The mean follow-up was 32 (±18) months. Complete healing was achieved in 64 (89%) patients. When persistent and recurrent cases were considered together, the failure rate was 21% and the success rate 79%. When patients failed, they were offered VAAFT again, after which there was an in increase in the healing rate, which overall (primary and secondary) was 86%. There was no statistically significant deterioration in continence. Eight (11%) patients experienced postoperative complications which required no additional surgical intervention.

CONCLUSION

VAAFT represents a promising, sphincter-saving technique for the treatment of complex FIA. It has proved efficacious, with 79% of patients achieving complete healing after its primary application. After a second use, this reached 86%. The main advantage of VAAFT compared with other sphincter-saving techniques is working under direct vision. VAAFT has a good safety profile with 11% of patients experiencing minor complications, and there is no effect on continence.