The best surgical strategy for anal fistula based on a network meta-analysis

Efficacy and safety of 13 surgical techniques for the treatment of complex anal fistula, non-Crohn CAF: a systematic review and network meta-analysis

BACKGROUND

Considering the difficulty of treating complex anal fistula (CAF), various surgical techniques exist in clinical work. However, none are ideal. Evidence on the efficacy and safety of different surgical treatments is scarce. The authors aimed to compare the outcomes of the 13 surgical techniques and tried to find the best surgical method for treating CAF.

MATERIALS AND METHODS

The authors searched worldwide databases, including Pubmed, Embase, Cochrane Library, Web of Science, CNKI, WanFang, VIP, and SinoMed, from inception to March 2023. All randomized controlled trials comparing the outcomes of 13 surgical techniques were included according to the PICO principles. The indicators of the cure rate, the recurrence rate, the complication rate, the operating time, the postoperative pain on day 1 (VAS), and the postoperative incontinence in month 1 (Wexner) were extracted and analyzed using STATA software 15.1, Review Manager 5.4, and GeMTC14.3.

RESULTS

Twenty-eight randomized controlled trials with a total of 2274 patients were included in the network meta-analysis. There was no statistically significant difference in the comparison among any surgical interventions in terms of the cure rate ( P >0.05 Table 2) and recurrence rate ( P >0.05 Table 3). However, in terms of complication rate, fistulectomy was lower than FPS (Median: 0.14; 95% CI: 0.02-0.70) or fistulotomy (Median: 0.09; 95% CI: 0.01-0.55), and fistulotomy was lower than EAFR (Median: 0.24; 95% CI: 0.05-0.84), LIFT (Median: 0.17; 95% CI: 0.02-0.66) or LIFT-EAFR (Median: 0.11; 95% CI: 0.01-0.69) ( P >0.05 Table 4). The surface estimated the advantages and disadvantages under the cumulative ranking (SUCRA). The ranking results indicated that fistulectomy might have the lowest complication rate (SUCRA=7.9%). Because the network results of the operating time, the postoperative pain, and the postoperative incontinence contained no closed loops, the results of their probability ranking could only be referenced, demonstrating that fistulectomy might have the shortest operating time (SUCRA=23.4%), video-assisted modified ligation of the intersphincteric fistula tract (VAMLIFT) might have the lowest postoperative pain on day 1 (VAS) (SUCRA=0.4%) and LIFT might have the lowest postoperative incontinence in month 1(Wexner) (SUCRA=16.2%).

CONCLUSION

Fistulectomy might have the lowest complication rate, which might be the relatively superior surgical technique for treating CAF.

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.

Translation, cross-cultural adaptation, and psychometric evaluation of the Persian (Farsi) version of the QoLAF (quality of life in patients with anal fistula) questionnaire

INTRODUCTION

The effective treatment of anal fistulas almost always requires surgical intervention, which could be accompanied by post-operative complications, and affect the quality of life of patients. This study aimed to cross-culturally adapt the Persian version of the Quality of Life in patients with Anal Fistula questionnaire and evaluate its validity and reliability.

MATERIALS AND METHODS

Sixty patients with a mean age of 44 years ranging from 21 to 72 years entered the study. Forty-seven participants were men, and thirteen were women. After performing a scientific translation of the questionnaire based on Beaton's guidelines for cross-cultural adaptation and after extensive reviews by experts and specialists, the final version of the questionnaire was obtained. Then, 60 questionnaires (100%) were filled out by the participants (n = 60) and retrieved during a 7 to 21-day period. Data were collected and analyzed. Finally, according to the obtained data, the validity and reliability of the questionnaire were calculated.

RESULTS

Cross-cultural adaptation of the translated questionnaire was verified by the expert committee. The results showed perfect internal consistency (Cronbach alpha = 0.842), and external consistency (intraclass correlation coefficient = 0.800; P<0.001). Spearman correlation coefficient between test and retest was reported to be 0.980 (P-value <0.01), confirming the temporal stability of the translated questionnaire. The interrater reliability based on Cohen's kappa coefficient also demonstrated a perfect degree of agreement between two peer variables (Kappa = 0.889; P<0.001).

CONCLUSION

The Persian translation of the Quality of Life in patients with the Anal Fistula questionnaire was proven to be valid and reliable for the evaluation of the QoL of patients with anal fistula.

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.

Time-scheduled dotted and solid thread-ligating therapy combined with vacuum sealing drainage for treating high complex anal fistula

OBJECTIVE

To investigate the treatment of high complex anal fistula with time-scheduled dotted and solid thread-ligating therapy combined with vacuum sealing drainage.

METHODS

A retrospective cohort study of 80 patients with high complex anal fistula admitted to the anorectal department of our hospital was conducted. The patients in the control group (n=40) were treated with traditional incision thread-ligating therapy, while the patients in the observation group (n=40) were treated with time-scheduled dotted and solid thread-ligating therapy combined with vacuum sealing drainage. The postoperative wound healing time, clinical efficacy, postoperative pain scores as well as pre- and postoperative anal function and anorectal pressure of patients in the two groups were observed.

RESULTS

The observation group had a shorter wound healing time (P<0.001), lower postoperative pain scores (P<0.05), a lower increase of Wexner score (P<0.001), a higher total effective rate (97.50% vs. 90.00%; P>0.05), a higher anal maximal contraction pressure and a larger high pressure zone than the control group (P<0.05). Compared with those before operation, the Wexner scores of patients in the two groups after operation were increased, while the anal maximal contraction pressure and high pressure zone in the control group were decreased (P<0.001).

CONCLUSION

The treatment of complex high anal fistula with time-scheduled dotted and solid thread-ligating combined with vacuum sealing drainage has short wound healing time, high efficiency, and little influence on the postoperative function of anal sphincter. It is worthy to be popularized in clinic.

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.

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.

Epidemiological profile of patients with fistula in ano

Rationale There is a lack of consistent national data on the evaluation of the epidemiological profile of patients with anal fistula.

Objective To evaluate the epidemiological profile of patients with anal fistula at a center specialized in coloproctology.

Method A cross-sectional, retrospective study was carried out between 2016 and 2018 of patients who underwent surgical procedures for the treatment of fistula in ano by the Department of Coloproctology of the Regional Hospital of Mato Grosso do Sul. Age, gender, disease duration, number of procedures, association with Crohn's disease and other comorbidities were evaluated. The data were tabulated and submitted to statistical treatment considering p < 0.05.

Results 93.2% of the patients were less than 60 years old, 66.7% were male, 88.9% had the disease less than one year, the most frequent procedures were fistulotomy (55.6%) and fistulectomy (36.8%), with a greater percentage of patients having undergone only one procedure (74.4%), 8.5% had Crohn’s disease, 7.7% systemic hypertension and 3.4% had diabetes mellitus.

Conclusion In the studied group, there was a predominance of anal fistulae in men under 60 years old and without comorbidities, diagnosed for up to one year, most of them submitted to fistulotomy or fistulectomy at one time. Patients operated after one year of illness and also those with Crohn’s disease were submitted mainly to curettage + seton and multiple procedures.

Evaluation of polypropylene and polyglactin sutures in primary sphincteroplasty for the treatment of anal fistula in rats

Rationale Fistulotomy followed by primary sphincteroplasty is one of the therapeutic options in transsphincteric fistulae; however, it was not known which suture would present a better result.

Objective To compare polypropylene and polyglactin sutures in primary sphincteroplasty in rats subjected to fistulotomy.

Method Thirty Wistar rats were subjected to peritoneal anesthesia with ketamine and xylazine, followed by transfixation of the anal sphincter with steel thread, which remained for 30 days to develop the anal fistula. After this period, the steel thread was removed and four groups were formed: A – Control (n = 5), without treatment; B – Fistulotomy (n = 5), performed fistulotomy only; C – Polypropylene (n = 10), in which fistulotomy was performed followed by primary sphincteroplasty with polypropylene suture; D – Polyglactin (n = 10), in which fistulotomy was performed followed by primary sphincteroplasty with polyglactin suture; after 30 days the animals were anesthetized again and submitted to euthanasia by deepening the anesthetic plane to remove the specimens, analyzing fistula closure, muscle fiber distance, and inflammatory process.

Results The fistula persisted in all animals of the control group and in none of the other groups; the distances between the muscle fibers were 1620 μm, 4665 μm, and 2520 μm, respectively in Groups B, C, and D (p = 0.067); in relation to fibrosis, the means were 2.4, 2.8, and 3.6, respectively in Groups B, C, and D, showing greater fibrosis in the latter group (p = 0.041).

Conclusion There was no persistence of the fistula in any of the treated animals; there was no difference in the distance between the muscle fibers between the groups subjected to primary sphincteroplasty with polypropylene or polyglactin, or between these groups and the one treated only by fistulotomy. There was greater fibrosis in animals treated with primary sphincteroplasty with polyglactin.

Could FiLaC™ be effective in the treatment of anal fistulas? A systematic review of observational studies and proportional meta-analysis

AIM

Fistula Laser Closure (FiLaC™) is a novel sphincter-preserving technique that is based on new technologies and shows promising results in repairing anal fistulas whilst maintaining external sphincter function. The aim of the present meta-analysis is to present the efficacy and the safety of FiLaC™ in the management of anal fistula disease.

METHOD

The present proportional meta-analysis was designed using the PRISMA and AMSTAR guidelines. We searched MEDLINE, Scopus, clinicaltrials.gov, Embase, Cochrane Central Register of Controlled Trials CENTRAL and Google Scholar databases from inception until November 2019.

RESULTS

Overall, eight studies were included that recruited 476 patients. The pooled success rate of the technique was 63% (95% CI 50%-75%). The pooled complication rate was 8% (95% CI 1%-18%). Sixty-six per cent of patients had a transsphincteric fistula and 60% had undergone a previous surgical intervention, mainly the insertion of a seton (54%). The majority had a cryptoglandular fistula. Operation time and follow-up period were described for each study.

CONCLUSION

FiLaC™ seems to be an efficient therapeutic option for perianal fistula disease with an adequate level of safety that preserves quality of life. Nevertheless, randomized trials need to be designed to compare FiLaC™ with other procedures for the management of anal fistulas such as ligation of intersphincteric fistula tract, anal advancement flaps, fibrin glue, collagen paste, autologous adipose tissue, fistula plug and video-assisted anal fistula treatment.