Application of advancement flap after loose seton placement: a modified two-stage surgical repair of a transsphincteric anal fistula

Evaluation of the inflammatory response induced by different materials in the treatment of perianal fistulas: experimental study in rats

The medical literature has no study evaluating the effectiveness of different materials used as setons in the treatment of perianal fistulas; therefore, there is no evidence of availability of a more effective material than others for this purpose.

Objective To evaluate the inflammatory response induced by different materials used as seton in perianal fistulas in rats.

Method Thirty Wistar rats, which were initially submitted for the construction of a perianal fistula by passing transfixing steel wire into the anal canal, were used. The rats were kept for 30 days; after this period, and with confirmation of the formation of the perianal fistula, the setons were introduced (10 rats – cotton thread #0; 10 rats – rubber; and 10 rats – silastic); after 30 days the animals were euthanized, and then the area of the fistula repaired by the seton was resected, and the material retrieved was submitted to histological analysis. The results were analyzed statistically.

Results The mean degree of inflammatory process observed by histological analysis after 30 days was 2.3 for the cotton group; 1 for the rubber group; and 1.2 for the silastic group.

Conclusion A greater inflammatory response was observed in the group treated with a cotton seton. In the remaining groups, a lower inflammatory response, with equal intensity for rubber and silastic-treated rats, was noted.

Loss of seton in patients with complex anal fistula: a retrospective comparison of conventional knotted loose seton and knot-free seton

BACKGROUND

Loose setons are often utilized. Replacements after seton loss are frequent, but the exact incidence of this loss of seton (LOS) in patients is unknown. The aim of the present study was to assess the incidence of LOS in a population with complex anal fistula, comparing the knot-free loose seton with the conventional knotted loose seton.

METHODS

All consecutive patients treated with a loose seton for complex anal fistula in two large teaching hospitals in the Netherlands between January 2017 and December 2019 were included in the present study. The incidence of loss of a conventional knotted loose seton was compared with the loss of commercially available knot-free setons.

RESULTS

There were 212 patients. Fifty-two patients were included in the knotted loose group and 160 patients were included in the knot-free seton group. Sixteen patients who were treated with both a knotted and a knot-free loose seton were included in both groups. The incidence of LOS was 12% in the knotted seton group and 28% in the knot-free loose seton group (p = 0.02). Median time to LOS was 36 days for the knotted loose seton and 89 days for the knot-free loose seton (p = 0.36). Sex (p = 0.61), age at the time of seton placement (p = 0.60), and presence of inflammatory bowel disease (p = 0.28) were not significantly associated with LOS.

CONCLUSIONS

LOS occurs frequently in patients treated for complex anal fistulas. The incidence of LOS is significantly higher in patients treated with a knot-free loose seton. Further developments in seton manufacturing should be focussed on optimisation of the closure mechanism.

A comparative study on the effectiveness of rectal advancement flap and seton placement surgeries in patients with anal fistula on the rate of recurrence, incontinence and infection

Introduction:

Due to the high prevalence of anal fistulas and the recurrence of the disease following surgery, different methods have been suggested for appropriate treatment of this disease. In this study, the effects of rectal advancement flap surgery and seton placement on the recurrence rate, incontinence and wound infection were compared.

Methods:

In this interventional, prospective and quasi-experimental study, 45 patients with anal fistulas including 28 males and 17 females were studied for 2 years (2015-2017). Patients were divided into two groups and mucosal advancement flap and seton placement techniques were used for each of them. Descriptive analysis of data was performed by SPSS software.

Results:

24 patients (54%) had seton placement surgery and 21 patients (46%) underwent rectal advancement flap surgery. Recurrence was significantly higher in patients who underwent seton placement surgery than the group that underwent rectal advancement flap surgery. Twelve patients (57%) who underwent rectal advancement flap surgery showed improvement in sphincter tone while 11 patients (45%) showed improvements with seton placement.

Conclusion:

The overall results of this study showed that rectal advancement flap surgery reduces recurrence and wound infection more significantly than seton placement in patients with anal fistula.

Anal fistula plug vs rectal advancement flap for the treatment of complex cryptoglandular anal fistulas: a systematic review and meta-analysis of studies with long-term follow-up

AIM

The aim was to compare the effectiveness of the anal fistula plug (AFP) with the rectal advancement flap (RAF) for complex cryptoglandular anal fistulas.

METHODS

We conducted a literature search to identify relevant available articles published without language restriction from Embase and PubMed databases and the Cochrane Library. Studies comparing outcomes with the AFP vs RAF for complex cryptoglandular anal fistulas were eligible for inclusion.

RESULTS

A total of 11 articles with 810 patients were included in this meta-analysis. Four RCTs and one observational clinical study provided long-term follow-up. The pooled analysis of all 11 studies indicated that there was no significant difference between the AFP and RAF in terms of healing rate, recurrence rate and incidence of fistula complications. However, the pooled results of studies with long-term follow-up revealed that the RAF group had a significantly higher healing rate (OR 0.32, 95% CI 0.13, 0.78, P = 0.01) and lower recurrence rate (OR 4.45, 95% CI 1.45, 13.65, P = 0.009) than the AFP group.

CONCLUSIONS

For the treatment of complex cryptoglandular anal fistulas, the RAF was superior to the AFP in terms of healing and recurrence rate after pooling of randomized controlled trials with long-term follow-up, even though a comparison based on the pooling of all studies showed no significant difference.

[Seton drainage in sphincter-sparing treatment of rectal fistulas]

Sphincter-sparing procedures for rectal fistulas are becoming more popular among coloproctologists. However, the outcomes are not optimal that forces surgeons to seek new approaches in order to improve results. Seton drainage prior to radical stage is one of these methods. The effect of seton drainage on the outcomes is reviewed in the article. Elibrary, Pubmed and Google Scholar databases were analyzed. We have assessed 14 out of 151 trials for the period 1984 - 2017. There were no significant advantages of seton drainage compared with single-stage approach (χ² = 3.84, p> 0.05, RR = 0.95, CI 95% 0.84 - 1.08). The same situation is observed for mucomuscular flap bringing down to close internal fistula. Fistula healing was more common after seton drainage deployment within 4 - 8 weeks. Bringing down of the flap to anal canal should be preferred after drainage due to less incidence of recurrences. Further trials are necessary to determine advisability of seton drainage and optimal surgical approach.

Analysis and description of disease-specific quality of life in patients with anal fistula

INTRODUCTION

In patients diagnosed with anal fistula, knowing the quality of life specifically related to the disease can help coloproctology specialists to choose the most appropriate therapeutic strategy for each case. The aim of our study is to analyzse and describe the factors related to the specific quality of life in a consecutive series of patients diagnosed with anal fistula.

METHODS

Observational, cross-sectional study carried out from March 2015 to February 2017. All patients were assessed in the colorectal surgery unit of a hospital in southeast of Spain. After performing an initial anamnesis and a physical examination, patients diagnosed with anal fistula completed the Quality of Life in Ppatients with Anal Fistula Questionnaire (QoLAF-Q). This questionnaire specifically measures quality of life in people with anal fistula and its score range is the following: zero impact = 14 points, limited impact = 15 to 28 points, moderate impact = 29 to 42 points, high impact = 43 to 56 points, and very high impact = 57 to 70 points.

RESULTS

A total of 80 patients were included. The median score obtained in the questionnaire for the sample studied was 34.00 (range=14-68). Statistically significant differences between patients with "primary anal fistula" (n=65) and "recurrent anal fistula" (n=15) were observed (mean rank=42.96 vs. mean rank=29.83, p=0.048). Furthermore, an inverse proportion (P=.016) between "time with clinical symptoms" and "impact on quality of life" was found (<6 months: mean rank = 45.55; 6-12 months: mean rank = 44.39; 1-2 years: mean rank = 37.83; 2-5 years: mean rank = 22; >5 years: mean rank = 19.00). There were no statistically significant differences (P=.149) between quality of life amongst patients diagnosed with complex (mean rank = 36.13) and simple fistulae (mean rank = 43.59).

CONCLUSIONS

Anal fistulae exert moderate-high impact on patients' quality of life. "Shorter time experiencing clinical symptoms" and the "presence of primary fistula" are factors that can be associated with worse quality of life.

Adoption and success rates of perineal procedures for fistula-in-ano: a systematic review

AIM

Several sphincter-preserving techniques have been described with extremely encouraging initial reports. However, more recent studies have failed to confirm the positive early results. We evaluate the adoption and success rates of advancement flap procedures (AFP), fibrin glue sealant (FGS), anal collagen plug (ACP) and ligation of intersphincteric fistula tract (LIFT) procedures based on their evolution in time for the management of anal fistula.

METHOD

A PubMed search from 1992 to 2015. An assessment of adoption, duration of study and success rate was undertaken.

RESULTS

We found 133 studies (5604 patients): AFP (40 studies, 2333 patients), FGS (31 studies, 871 patients), LIFT (19 studies, 759 patients), ACP (43 studies, 1641 patients). Success rates ranged from 0% to 100%. Study duration was significantly associated with success rates in AFP (P = 0.01) and FGS (P = 0.02) but not in LIFT or ACP. The duration of use of individual procedures since first publication was associated with success rate only in AFP (P = 0.027). There were no statistically significant differences in success rates relative to the number of the patients included in each study.

CONCLUSION

Success and adoption rates tend to decrease with time. Differences in patient selection, duration of follow-up, length of availability of the individual procedure and heterogeneity of treatment protocols contribute to the diverse results in the literature. Differences in success rates over time were evident, suggesting that both international trials and global best practice consensus are desirable. Further prospective randomized controlled trials with homogeneity and clear objective parameters would be needed to substantiate these findings.