New techniques for treating an anal fistula

A PILOT STUDY on the Clinical and Functional Outcomes of an Improvised Technique of Core-cut Fistulectomy for Fistula-in-ano

BACKGROUND

Anal fistulae are difficult to treat entities and minimally invasive procedures are evolving with promises. Our improvised technique is a simple and easy day-care procedure for simple fistulae.

AIM

To evaluate the outcomes of a technical modification in the procedure of core-cut fistulectomy in simple cryptoglandular fistula-in-ano.

METHODS

47 patients of fistula-in-ano presenting to the out-patient of the General Surgery department at All India Institute of Medical Sciences, Bhopal, from November 2018 to March 2020 were selected. A complete history, physical examination followed by relevant investigations were meticulously performed and recorded. They were operated using an improvised core-cut technique, under a pudendal nerve block. Patients were kept on follow-up for a minimum of 6 months period to note the outcome of the surgery.

RESULTS

The mean age was 37 ± 13.17 years with a male: female ratio of 5.1:1. The most common clinical presentation was perianal discharge in 96% of patients followed by pain and pruritus ani in 45% and 32%, respectively. 93.62% were inter-sphincteric, and 6.38% were trans-sphincteric. Extra-sphincteric and supra-levator fistulae were excluded from the study. The mean operative time was 17 ± 10.19 minutes. The mean healing time was 19.21 ± 5.99 days. The success rate of this novel technique of core-cut was calculated to be 89.37%. The rate of recurrence was calculated to be 10.63% (5 out of 47 patients). None of our patients developed incontinence.

CONCLUSION

Our pilot study results for simple fistulae-in-ano had less morbidity, postoperative pain, better wound healing, patient satisfaction, and compliance with low risk of recurrence, and no incontinence. It could hence be recommended for larger groups and more complicated fistulae in the future.

External sphincter-sparing anal fistulotomy (ESSAF): a simplified technique for the treatment of fistula-in-ano

BACKGROUND

Fistula-in-ano due to cryptoglandular disease is a common condition. While a simple anal fistula can be treated successfully by a fistulotomy, the risk of potential damage to the anal sphincters and subsequent poor functional outcomes persist in a large portion of patients with complex fistulae. Several sphincter-preserving treatment procedures have been described for complex fistulae over the past 3 decades, with variable results and complication rates, and no procedure is proven to be superior to the others. We developed external sphincter-sparing anal fistulotomy (ESSAF), a reproducible simple modification of the ligation of intersphincteric fistula tract (LIFT) technique for the treatment of complex fistula-in-ano.. The aim of the present study was to describe the technique and our outcomes.

METHODS

This was a retrospective review of all patients who underwent ESSAF for a complex anal fistula at our institution from January 2014 to December 2019. The primary outcome measure of this study was the primary fistula healing rate. Secondary outcome measures included fecal and/or gas incontinence and postoperative complications. During the ESSAF procedure, the mucosa and skin overlying the fistula tract are incised to allow complete exposure of the sphincter complex. Then the internal sphincter muscle fibers overlying the tract are divided and the tract is meticulously curetted and debrided. Next, the internal opening of the tract traversing the external sphincter muscle is suture-ligated with absorbable sutures. Then, a minimal amount of mucosa is advanced and the incision is partially closed with absorbable sutures, while its external portion is left open for drainage.

RESULTS

Fifty-nine patients [43 males, median age was 50 years (range 36-63 years)] underwent ESSAF for complex anal fistula during the study period. Mean follow-up was 12 ± 14.7 months. Of the 59 patients, 42 (71.2%) experienced fistula closure, with a median healing time of 8 weeks (IQR 4-16 weeks). None of the patients developed significant anal incontinence following the procedure. One patient (1.7%) suffered from soiling and another patient (1.7%) developed postoperative bleeding. There were no infectious complications. Of the 17 patients (28.8%) who failed to heal successfully, 9 (15.2%) did not heal primarily and 8 (16%) experienced recurrence after complete healing. Thirteen (76%) of these patients underwent reoperation with complete recovery after ESSAF (n = 4), fistulotomy (n = 8) or endorectal advancement flap (ERAF) (n = 1). Overall ESSAF initiated recovery in 93.2% of the patients.

CONCLUSIONS

ESSAF is a feasible, safe, reproducible and effective sphincter-sparing procedure for the treatment of complex anal fistulae.

Surgical technique: an improvisation in application of the technique of core-cut fistulectomy for fistula-in-ano

Cryptoglandular fistula-in-ano is a chronic inflammatory condition of the perianal region attributed to the obstruction of the glands, located chiefly at the dentate line and their subsequent infection. Anal fistulae are difficult to treat, and minimally invasive procedures are evolving with promises. We present an improvised application of core-cut technique of fistulectomy. It is a minimally invasive, simple, effective and easy to perform procedure with minimal risk of incontinence and recurrence in simple cryptoglandular fistulae-in-ano. We performed 47 cases with good results and present this procedure to emphasize the procedural modification used.

Ligation of the intersphincteric fistula tract procedure and its modifications

Purpose Treatment of anal fistulae is regarded as a challenge due to the diverse nature of this disease and its countless complications. Ligation of the intersphincteric fistula tract procedure and its modifications have been popularized among many surgeons worldwide due to their simplicity and promising outcomes. The main purpose of this article was to conduct a comprehensives review of the published literature on ligation of the intersphincteric fistula tract procedure and its modifications.

Method PubMed, the Cochrane database and Ovid were searched from January 2007 to June 2017. Fully published peer-reviewed studies which applied ligation of the intersphincteric fistula tract procedure and its modifications for the treatment of anal fistulae of cryptogenic origin with follow-up of median 12 months were eligible. Uncompleted studies, case reports, reviews, abstracts, letters, short communication, comments, and studies which did not fulfill inclusion criteria were excluded. The primary outcome was to measure primary healing, overall healing, failure, and recurrence of ligation of the intersphincteric fistula tract procedure and its modifications.

Results Twenty-two studies were identified with only ten studies meeting criteria of inclusion. Original ligation of the intersphincteric fistula tract was performed in five studies with a population of 199 patients while the remaining five studies showed four different modifications of the ligation of the intersphincteric fistula tract with a total number of 147 patients. Both original LIFT and its modifications have promising as well as potentially similar outcomes; primary healing in the original ligation of the intersphincteric fistula tract (73.95%) (95% CI 60.3–85.6) performed less than the modifications (82.3%) (95% CI 64.8–94.7). Overall healing in the original ligation of the intersphincteric fistula tract (78.9%) (95% CI 58.5–93.7) performed relatively less than in the modifications (93.6%) (95% CI 81.4–99.6). Failure in the original ligation of the intersphincteric fistula tract (17.9%) (95% CI 4.9–36.5) performed almost the same as the modifications (17.7%) (95% CI 5.3–35.2). Recurrence in the original ligation of the intersphincteric fistula tract was 9.7% (95% CI 1.7–23.2). However, there was no recurrence in the modifications.

Conclusion Ligation of the intersphincteric fistula tract and its modifications are effective and simple procedures in treating simple anal fistulae, especially high transsphincteric ones. However, more trials should be performed to evaluate its effectiveness regarding complex fistulae.

Video-Assisted Anal Fistula Treatment (VAAFT) for complex anorectal fistula: efficacy and risk factors for failure at 3-year follow-up

BACKGROUND

The aim of this study was to assess the 3-year objective and subjective outcomes of patients with complex anorectal fistula treated with Video-Assisted Anal Fistula Treatment (VAAFT). Furthermore, we evaluated the risk factors associated with recurrence.

METHODS

All consecutive patients with complex anorectal fistula who underwent VAAFT in Beata Vergine Hospital of Mendrisio, Switzerland, from January 2013 to January 2016, were enrolled. Patients with suspicion or diagnosis of Crohn's disease, malignancy, previous history of radiotherapy or radical pelvic surgery were excluded. Preoperative clinical assessment based upon medical history, physical examination and endosonography, was performed in all patients. Data regarding subjective outcomes (the Patient Global Impression of Improvement, patient satisfaction scores and Wexner score), objective cure rate (absence of fistula at clinical examination), and adverse events were collected during follow-up. Uni and multivariate analysis were performed to investigate outcomes.

RESULTS

One hundred and four patients had VAAFT. At 3-year follow-up, 96 patients (92.3%) were available for the evaluation. At 3 years after surgery, 81 of 96 patients (84.4%) declared themselves cured (p = 0.60). Similarly, at 3-year evaluation, 80 of 96 patients (83.3%) were objectively cured (p = 0.52). No serious intraoperative or postoperative complications were reported. All recurrences were treated with a repeat VAAFT procedure resulting in a complete healing. Uni and multivariate analysis of variables potentially involved in the failure of VAAFT showed that age ≥ 50 years was the only factor associated at risk of recurrence.

CONCLUSIONS

VAAFT is a highly effective safe procedure for the treatment of anorectal fistula, with a low recurrence rate at 3-year follow-up. However, our study demonstrated that age ≥ 50 years is a risk factor for failure of VAAFT.

Decellularized and matured esophageal scaffold for circumferential esophagus replacement: Proof of concept in a pig model

Surgical resection of the esophagus requires sacrificing a long portion of it. Its replacement by the demanding gastric pull-up or colonic interposition techniques may be avoided by using short biologic scaffolds composed of decellularized matrix (DM). The aim of this study was to prepare, characterize, and assess the in vivo remodeling of DM and its clinical impact in a preclinical model. A dynamic chemical and enzymatic decellularization protocol of porcine esophagus was set up and optimized. The resulting DM was mechanically and biologically characterized by DNA quantification, histology, and histomorphometry techniques. Then, in vitro and in vivo tests were performed, such as DM recellularization with human or porcine adipose-derived stem cells, or porcine stromal vascular fraction, and maturation in rat omentum. Finally, the DM, matured or not, was implanted as a 5-cm-long esophagus substitute in an esophagectomized pig model. The developed protocol for esophageal DM fulfilled previously established criteria of decellularization and resulted in a scaffold that maintained important biologic components and an ultrastructure consistent with a basement membrane complex. In vivo implantation was compatible with life without major clinical complications. The DM's scaffold in vitro characteristics and in vivo implantation showed a pattern of constructive remodeling mimicking major native esophageal characteristics.

What happens after a failed LIFT for anal fistula?

BACKGROUND

Ligation of the intersphincteric fistula tract (LIFT) was developed to treat transsphincteric anal fistulas. The aftermath of a failed LIFT has not been well documented.

METHODS

Retrospective chart review of LIFT procedure for transsphincteric anal fistula between March 2012 and September 2016.

RESULTS

53 patients with LIFT procedure were identified, 20 (37.7%) had persistent fistula with median followup of 4 months. Following LIFT, recurrence of fistula was transsphincteric (75%) or intersphincteric (25%) (p = NS). Persistent transsphincteric fistulas after LIFT were treated with seton (71.4%) followed by advancement flap (20%) or fistulotomy (50%). Of the recurrent intersphincteric fistulas, 50% underwent seton placement followed by fistulotomy, or advancement flap. Of the patients who underwent surgery after failed LIFT, 50% have had resolution of the fistula; 31.7% are still undergoing treatment.

CONCLUSION

Patients who underwent surgery after failed LIFT had 50% healing with placement of seton followed by fistulotomy or rectal advancement flap.

Fistula tract curettage and the use of biological dermal plugs improve high transsphincteric fistula healing in an animal model

PURPOSE

The treatment of high transsphincteric fistula is a complex procedure, which may be associated with the risk of recurrence and fecal incontinence. In this study, we used an animal model to compare different types of sphincter-preserving treatments for transsphincteric fistula.

METHODS

Sixteen female New Zealand rabbits, weighing 2.8-4.8 kg underwent a surgical creation of high transsphincteric fistula. After 6 weeks, magnetic resonance imaging (MRI) was performed in order to confirm fistula formation and measure the fistula diameter. The rabbits were divided into three groups. Group 1 received no plug treatment (control). Autologous dermal graft and acellular dermal matrix were used as a plug in groups 2 and 3, respectively. Five weeks after treatment, fistula tract healing was determined by measuring the largest fistula diameter with MRI. All rabbits were euthanized and the anorectum excised en bloc for histopathological examination.

RESULTS

According to the MRI findings, all groups showed significant healing after the treatment (p < 0.05). The healing rate of fistula diameters after treatment was 40, 66, and 29% in the control, dermal graft, and acellular dermal matrix groups, respectively. In terms of negative healing parameters such as neutrophil, eosinophil, lymphocyte, and plasmocyte accumulation, dermal graft and acellular dermal matrix groups showed significantly lower results than those in the control group (p < 0.05).

CONCLUSION

According to MRI and histopathological results, fistula tract curettage and fistula orifice closure improved transsphincteric anal fistula healing. Additionally, in this study, plug treatment favoring autologous dermal graft resulted in better healing.

VAAFT: Video Assisted Anal Fistula Treatment; Bringing revolution in Fistula treatment

Objective:

To share our findings that the new treatment modality Video Assisted Anal Fistula Treatment (VAAFT) is a better alternate to the conventional treatments of Fistula in Ano in our setup with minor changes in the initial method described by Meinero.

Methods:

Karl Storz Video equipment including Meinero Fistuloscope was used. Key steps are visualization of the fistula tract, correct localization of the internal fistula opening under direct vision and endoscopic treatment of the fistula. This is followed by an operative phase of fulguration of the fistula tract using glycine solution mixed with manitol, curetting the tract with curette and fistula brush. Internal opening is closed with a Vicryl 1 suture.

Result:

Total of 40 patients were operated using VAAFT from October 2013 to March 2014. Three were re-operated. The other 37 cases were followed up at 6 weeks, 3 months and 6 months. Primary healing took place in 20 (50%) cases at 6 weeks. In the remaining 17 (42.5%) cases, minor discharge occurred with itching which resolved till the next visit at 8 weeks and 12 weeks.

Conclusion:

As the main aim in treating fistula is proper identification of the internal opening, excision of the tract and sparing the sphincter function, VAAFT achieves all aims with additional benefits of patients’ satisfaction and negligible scaring.

Management of complex anorectal fistulas with seton drainage plus partial fistulotomy and subsequent ligation of intersphincteric fistula tract (LIFT)

BACKGROUND

Ligation of intersphincteric fistula tract (LIFT) is a relatively new technique in the treatment of complex anorectal fistulas. As it spares the anal sphincter, rates of post-operative incontinence may be lower when compared to conventional treatment. To date, there have not been enough reports of long-term fistula recurrence rates. We performed a long-term follow-up study of 75 patients who underwent LIFT following seton drainage and partial fistulotomy.

METHODS

Only patients with complex cryptogenic anorectal fistulas were included. After seton insertion and partial fistulotomy, the tract was reviewed at 4 months for the absence of anorectal sepsis. Patients then underwent LIFT in a day surgery setting. Operative time, complications, recurrences and incontinence were evaluated.

RESULTS

Between May 2008 and June 2013, 75 patients [51 men, mean age 49.5 years, standard error of the mean (SEM) 1.4 years] were treated with a LIFT protocol. The mean operating time for LIFT was 13.2 min (SEM 1.5 min). Complications included minor bleeding, superficial wound dehiscence and perianal pain. At a mean follow-up of 14.6 months (SEM 1.7 months), there were nine (12 %) recurrences, diagnosed at a mean 9.2 months (SEM 2.7 months). They were treated with seton insertion followed by LIFT with biomesh or anorectal advancement flap, and there were no subsequent recurrences. Review of preoperative and post-operative continence scores revealed only one (1.3 %) patient with minor incontinence following LIFT. Recurrences were significantly related to fistulas with multiple tracts (p < 0.001).

CONCLUSIONS

Our results suggest that the protocol of seton insertion and partial fistulotomy followed by LIFT is associated with a low recurrence rate comparing well with published results from studies involving other techniques and protocols for treating anal fistula.

Magnetic resonance imaging (MRI) evaluation of perianal fistulae with surgical correlation

AIMS

The purpose of the study was to evaluate the role of Magnetic Resonance Imaging in detection and characterization of perianal fistulae and correlating it with surgical findings.

METHODS

Fifty consecutive patients with suspected perianal fistulae having one or more external openings were prospectively selected for MRI evaluation. Previously operated or patients with recurrent perianal disease were excluded from the study. MRI findings were recorded according to "St. James's University Hospital MR Imaging Classification of Perianal Fistulae" and correlated with surgical observations. Finally, comparison between T2-weighted fat saturated and postcontrast T1-weighted fat saturated sequences was done.

RESULTS

Amongst the total of 50 patients, per-operative findings confirmed perianal fistulae in 45 patients. The sensitivity and specificity of MRI in correctly detecting and grading the primary tract was found to be 95.56% and 80% respectively; for abscess, it was 87.50% and 95.24% respectively. High sensitivity was also discerned in identification of secondary tract (93.75%), correct localization of internal opening (95.83%) and for correctly detecting the horse-shoeing (87.50%). Our assumption of null hypothesis was accepted on comparing results of T2-weighted fat saturated sequences and postcontrast T1-weighted fat saturated sequences.

CONCLUSION

Magnetic Resonance Imaging (MRI) was highly accurate in assessment of surgically important parameters (primary tract and its grading, internal opening, secondary tract, abscess, horseshoeing) of perianal fistulae. Comparison of results of imaging findings on T2-weighted and postcontrast T1-weighted fat saturated sequences were statistically similar, so contrast study can be omitted, particularly while evaluating primary / previously unoperated perianal fistulae.

Adipose-Derived Stem Cells in Tissue Regeneration: A Review

In 2001, researchers at the University of California, Los Angeles, described the isolation of a new population of adult stem cells from liposuctioned adipose tissue. These stem cells, now known as adipose-derived stem cells or ADSCs, have gone on to become one of the most popular adult stem cells populations in the fields of stem cell research and regenerative medicine. As of today, thousands of research and clinical articles have been published using ASCs, describing their possible pluripotency in vitro, their uses in regenerative animal models, and their application to the clinic. This paper outlines the progress made in the ASC field since their initial description in 2001, describing their mesodermal, ectodermal, and endodermal potentials both in vitro and in vivo, their use in mediating inflammation and vascularization during tissue regeneration, and their potential for reprogramming into induced pluripotent cells.