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Wang C, Huang T, Wang X. Efficacy and safety of transanal opening of intersphincteric space in the treatment of high complex anal fistula: A meta‑analysis. Exp Ther Med 2024; 28:306. [PMID: 38873039 PMCID: PMC11170326 DOI: 10.3892/etm.2024.12595] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Accepted: 05/01/2024] [Indexed: 06/15/2024] Open
Abstract
The best treatment of high complex anal fistula (HCAF) is to avoid anal incontinence while improving the cure rate. On this basis, several surgical procedures for preserving the anal sphincter have been proposed. The purpose of the present study was to evaluate the efficacy and safety of transanal opening of intersphincteric space for treating HCAF. PubMed, Cochrane Library, China National Knowledge Infrastructure and the Wanfang databases were searched to collate all the articles on transanal opening of intersphincteric space for treating HCAF. A total of two researchers independently completed the whole process, from screening and inclusion to data extraction and the data was included in the RevMan 5.3 software for analysis. The main outcomes included the patients' essential characteristics, primary healing rate, management after recurrence, final healing rate, anal incontinence score before and after surgery, postoperative complication rate and types of complications. A total of six articles were included in this meta-analysis. The results showed that the weighted final healing rate of patients following transanal opening of intersphincteric space was 89% [risk differences (RD)=0.89; 95% confidence interval (CI)=0.86-0.92; I2=0%; P<0.00001]. The results of the anal incontinence score showed that there was no significant difference between the results before and after transanal opening of intersphincteric space surgery mean differences [(MD)=-0.04, Cl=-0.10-0.02, I2=0%; P=0.21]. Only 11 patients were reported to have complications, including urinary retention and bleeding following transanal opening of intersphincteric space with a complication rate of 8% (11/138) and the weighted average complication rate was 6% (RD=0.06,95% CI=0.02-0.10; I2=9%; P=0.003). Transanal opening of intersphincteric space has a high cure rate, a favorable anal incontinence score, fewer types of postoperative complications and a low complication rate; it can be used as a minimally invasive and sphincter-preserving surgical method for treating HCAF and is worthy of further promotion and research in clinical practice.
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Affiliation(s)
- Chunqiang Wang
- Department of Anorectal Surgery, Affiliated Xiaoshan Hospital, Hangzhou Normal University, Hangzhou, Zhejiang 311200, P.R. China
| | - Tianye Huang
- Department of Anorectal Surgery, Linyi Central Hospital, Linyi, Shandong 276401, P.R. China
| | - Xuebing Wang
- Department of Anorectal Surgery, Taian Municipal Hospital, Taian, Shandong 271021, P.R. China
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Garg P, Garg PK, Sodhi GS. Cutting seton is an inferior version of fistulotomy and is associated with increased morbidity in the management of anal fistulas. Tech Coloproctol 2024; 28:57. [PMID: 38789585 DOI: 10.1007/s10151-024-02929-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Accepted: 04/03/2024] [Indexed: 05/26/2024]
Affiliation(s)
- P Garg
- Garg Fistula Research Institute, 1042, Sector-15, Panchkula, 134113, Haryana, India.
| | - P K Garg
- Department of Surgery, Civil Hospital, Panchkula, India
| | - G S Sodhi
- Government Medical College and Hospital, Chandigarh, India
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Dawoud C, Widmann KM, Czipin S, Pramhas M, Scharitzer M, Stift A, Harpain F, Riss S. Efficacy of cx601 (darvadstrocel) for the treatment of perianal fistulizing Crohn's disease-A prospective nationwide multicenter cohort study. Wien Klin Wochenschr 2024; 136:289-294. [PMID: 37823920 PMCID: PMC11078846 DOI: 10.1007/s00508-023-02283-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Accepted: 09/09/2023] [Indexed: 10/13/2023]
Abstract
BACKGROUND The use of mesenchymal stem cells is considered a novel and promising therapeutic option for patients with perianal fistulizing Crohn's disease; however, data on its clinical application remain scarce. This multicenter nationwide study aimed to assess the clinical efficacy of mesenchymal stem cells in closing complex anal fistulas. METHODS In this study 14 Crohn's disease patients (3 males, 11 females) with complex anal fistulas treated in 3 tertiary hospitals in Austria were included between October 2018 and April 2021. Injection of 120 million allogeneic expanded adipose-derived mesenchymal stem cells (Cx601-darvadstrocel) was performed in each patient. Closure of the external fistula opening without secretion by external manual compression was defined as treatment success. RESULTS The median age of the patient population at the time of surgery was 32 years (range 26-53 years) with a median body mass index of 21.7 kg/m2 (range 16.7-26.6 kg/m2). Of the patients 12 (86%) received monoclonal antibodies (infliximab, adalimumab, ustekinumab, vedolizumab) at the time of surgery. The median number of complex fistulas was 1.4 (range 1-2), The median operative time was 20 min (range 6-50 min) with no perioperative complications. After a median follow-up of 92 weeks, we found successful fistula closure in 57.1% (n = 8) of treated patients. The perianal disease activity index did not improve significantly from initially 7 to a median of 6 after 52 weeks (p = 0.495). CONCLUSION Darvadstrocel is a safe, minimally invasive surgical technique without significant perioperative complications. Clinical success can be expected in about half of the treated patients.
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Affiliation(s)
- Christopher Dawoud
- Department of General Surgery, Division of Visceral Surgery, Medical University Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Kerstin Melanie Widmann
- Department of General Surgery, Division of Visceral Surgery, Medical University Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Sascha Czipin
- Department of Visceral, Transplant and Thoracic Surgery, Centre for Operative Medicine, Medical University of Innsbruck, Innsbruck, Austria
| | - Michael Pramhas
- First Surgical Department, Klinik Landstraße, Vienna, Austria
| | - Martina Scharitzer
- Department of Biomedical Imaging and Image-Guided Therapy, Medical University Vienna, Vienna, Austria
| | - Anton Stift
- Department of General Surgery, Division of Visceral Surgery, Medical University Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Felix Harpain
- Department of General Surgery, Division of Visceral Surgery, Medical University Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Stefan Riss
- Department of General Surgery, Division of Visceral Surgery, Medical University Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria.
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Yagnik VD, Kumar S, Thakur A, Bhattacharya K, Dawka S, Garg P. Recent Advances in the Understanding and Management of Anal Fistula from India. Indian J Surg 2024. [DOI: 10.1007/s12262-024-04050-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2023] [Accepted: 02/05/2024] [Indexed: 07/26/2024] Open
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Varsamis N, Kosmidis C, Chatzimavroudis G, Apostolidou Kiouti F, Efthymiadis C, Lalas V, Mystakidou CM, Sevva C, Papadopoulos K, Anthimidis G, Koulouris C, Karakousis AV, Sapalidis K, Kesisoglou I. Preoperative Assessment of Perianal Fistulas with Combined Magnetic Resonance and Tridimensional Endoanal Ultrasound: A Prospective Study. Diagnostics (Basel) 2023; 13:2851. [PMID: 37685389 PMCID: PMC10486944 DOI: 10.3390/diagnostics13172851] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2023] [Revised: 08/29/2023] [Accepted: 08/31/2023] [Indexed: 09/10/2023] Open
Abstract
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.
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Affiliation(s)
- Nikolaos Varsamis
- Third Surgical Department, “AHEPA” University Hospital, Medical Faculty, Aristotle University of Thessaloniki, 1 Kiriakidi Street, 54636 Thessaloniki, Greece; (C.K.); (C.S.); (K.P.); (C.K.); (A.V.K.); (K.S.); (I.K.)
| | - Christoforos Kosmidis
- Third Surgical Department, “AHEPA” University Hospital, Medical Faculty, Aristotle University of Thessaloniki, 1 Kiriakidi Street, 54636 Thessaloniki, Greece; (C.K.); (C.S.); (K.P.); (C.K.); (A.V.K.); (K.S.); (I.K.)
| | - Grigorios Chatzimavroudis
- Second Surgical Department, “G. Gennimatas” University Hospital, Medical Faculty, Aristotle University of Thessaloniki, 41 Eth. Aminis Steet, 54635 Thessaloniki, Greece;
| | - Fani Apostolidou Kiouti
- Biostatistics Unit, Medical Faculty, Aristotle University of Thessaloniki, 54124 Thessaloniki, Greece;
| | | | - Vasilis Lalas
- Radiology Department, “Euromedica” Diagnostic Center, 35 Gr. Lampraki & Ag. Dimitriou Street, 54638 Thessaloniki, Greece;
| | | | - Christina Sevva
- Third Surgical Department, “AHEPA” University Hospital, Medical Faculty, Aristotle University of Thessaloniki, 1 Kiriakidi Street, 54636 Thessaloniki, Greece; (C.K.); (C.S.); (K.P.); (C.K.); (A.V.K.); (K.S.); (I.K.)
| | - Konstantinos Papadopoulos
- Third Surgical Department, “AHEPA” University Hospital, Medical Faculty, Aristotle University of Thessaloniki, 1 Kiriakidi Street, 54636 Thessaloniki, Greece; (C.K.); (C.S.); (K.P.); (C.K.); (A.V.K.); (K.S.); (I.K.)
| | - George Anthimidis
- Surgical Department, European Interbalkan Medical Center, 10 Asklipiou Street, 55535 Thessaloniki, Greece;
| | - Charilaos Koulouris
- Third Surgical Department, “AHEPA” University Hospital, Medical Faculty, Aristotle University of Thessaloniki, 1 Kiriakidi Street, 54636 Thessaloniki, Greece; (C.K.); (C.S.); (K.P.); (C.K.); (A.V.K.); (K.S.); (I.K.)
| | - Alexandros Vasileios Karakousis
- Third Surgical Department, “AHEPA” University Hospital, Medical Faculty, Aristotle University of Thessaloniki, 1 Kiriakidi Street, 54636 Thessaloniki, Greece; (C.K.); (C.S.); (K.P.); (C.K.); (A.V.K.); (K.S.); (I.K.)
| | - Konstantinos Sapalidis
- Third Surgical Department, “AHEPA” University Hospital, Medical Faculty, Aristotle University of Thessaloniki, 1 Kiriakidi Street, 54636 Thessaloniki, Greece; (C.K.); (C.S.); (K.P.); (C.K.); (A.V.K.); (K.S.); (I.K.)
| | - Isaak Kesisoglou
- Third Surgical Department, “AHEPA” University Hospital, Medical Faculty, Aristotle University of Thessaloniki, 1 Kiriakidi Street, 54636 Thessaloniki, Greece; (C.K.); (C.S.); (K.P.); (C.K.); (A.V.K.); (K.S.); (I.K.)
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Shivakumar V, Jayarajah U, Samarasekera DN. Characteristics and post-operative outcomes of surgery for fistula-in-ano managed at a tertiary care hospital in Sri Lanka: a retrospective study. J Int Med Res 2023; 51:3000605231194516. [PMID: 37706483 PMCID: PMC10503298 DOI: 10.1177/03000605231194516] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2023] [Accepted: 07/27/2023] [Indexed: 09/15/2023] Open
Abstract
OBJECTIVES Management of fistula-in-ano is associated with recurrence and, occasionally, with anal incontinence. We investigated the clinical characteristics and outcomes of fistula-in-ano. METHODS We included patients with fistula-in-ano managed at a tertiary care center (2016-2021). We collected clinical characteristics and 1-year outcomes using questionnaires. The chi-square test was used in statistical analysis. RESULTS In total, 284 patients (231 men, 81.3%; median age 39.5 [range: 7-73] years) were included. Most patients had simple fistulae (n = 191, 67.3%). Transphincteric (n = 110, 38.7%) fistulae were the most common type, followed by intersphinteric fistulae (n = 103, 36.6%). Fistulotomy (n = 157, 55.3%) was the most common procedure. Follow-up details were traceable in 157 (55.3%) patients. At 1 year, the overall healing rate was 88.5% (n = 136). There was no association between type of surgical procedure and incontinence. The mean Vaizey score, used to assess anal incontinence, was 0.84 (range: 0-14). Incontinence was observed in 32 patients (20.9%), and flatus incontinence was the most common type (n = 17, 53.1%). Complex fistulae were associated with higher recurrence rates than simple fistulae (32.6% vs. 2.8%). CONCLUSION The healing rate in surgical treatment of fistula-in-ano was 88.5%, with acceptable complication rates. There was no association between surgical procedure type and incontinence.
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Affiliation(s)
| | - Umesh Jayarajah
- Department of Surgery, Faculty of Medicine, University of Colombo, Sri Lanka
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Garg P, Kaur B. Transanal Opening of Intersphincteric Space: A Novel Procedure to Manage Highly Complex Anal Fistulas. Dis Colon Rectum 2023; 66:e292-e293. [PMID: 36892493 DOI: 10.1097/dcr.0000000000002612] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/10/2023]
Affiliation(s)
- Pankaj Garg
- Department of Colorectal Surgery, Indus Super Specialty Hospital, Mohali, India
- Department of Colorectal Surgery, Garg Fistula Research Institute, Panchkula, India
| | - Baljit Kaur
- Department of MRI, SSRD MRI Imaging Center, Chandigarh, India
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Teymouri A, Keshvari A, Ashjaei A, Ahmadi Tafti SM, Salahshour F, Khorasanizadeh F, Naseri A. Predictors of outcome in cryptoglandular anal fistula according to magnetic resonance imaging: A systematic review. Health Sci Rep 2023; 6:e1354. [PMID: 37359408 PMCID: PMC10286857 DOI: 10.1002/hsr2.1354] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Revised: 05/27/2023] [Accepted: 06/07/2023] [Indexed: 06/28/2023] Open
Abstract
Background and Aims Anal fistula (AF) with cryptoglandular origin tends to recur, and multiple risk factors are implicated. Recently, some magnetic resonance imaging (MRI) findings with predictive value for disease outcomes have been proposed. These intrinsic anatomic features include those of the AF and its surrounding structures. This study aims to clarify the prognostic role of MRI in AF. Methods We performed a systematic search of PubMed, Embase, and EBSCO databases. Two independent reviewers conducted the search and screened the articles. We selected studies that used MRI to assess AF and reported its relationship to disease outcome. We extracted data regarding the study design, type of intervention, outcome, MRI-measured items, and their significance. Results Out of 1230 retrieved articles, 18 were eligible for final inclusion, and a total of 4026 patients were enrolled in the selected studies. For preoperative MRI, the significant items affecting the outcome were the length of the fistula, horseshoe type, presence of multiple tracts, supralevator extension, and apparent diffusion coefficient (ADC) value. Other studies investigated the healing process using postoperative MRI. Conclusion This review found that MRI can be useful in the management of AF, both preoperatively and postoperatively. Factors, such as fistula length, horseshoe type, presence of multiple tracts, supralevator extension, and ADC value were found to be significantly associated with treatment outcomes. The presence of the fistula tract and the development of new abscesses on postoperative MRI was found to hinder the healing process. Further studies are needed to confirm these findings.
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Affiliation(s)
- Alireza Teymouri
- Department of Colorectal SurgeryImam Reza HospitalAja University of Medical SciencesTehranIran
| | - Amir Keshvari
- Department of SurgeryColorectal Research Center, Imam Hospital ComplexTehran University of Medical SciencesTehranIran
| | - Ali Ashjaei
- Department of SurgeryBesat HospitalAja University of Medical SciencesTehranIran
| | - Seyed Mohsen Ahmadi Tafti
- Department of SurgeryColorectal Research Center, Imam Hospital ComplexTehran University of Medical SciencesTehranIran
| | - Faeze Salahshour
- Department of RadiologyAdvanced Diagnostic and Interventional Radiology Research Center (ADIR)Tehran University of Medical SciencesTehranIran
| | - Faezeh Khorasanizadeh
- Department of RadiologyAdvanced Diagnostic and Interventional Radiology Research Center (ADIR)Tehran University of Medical SciencesTehranIran
| | - Amirhosein Naseri
- Department of Colorectal SurgeryImam Reza HospitalAja University of Medical SciencesTehranIran
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Yagnik VD, Kaur B, Dawka S, Sohal A, Menon GR, Garg P. Non-Locatable Internal Opening in Anal Fistula Associated with Acute Abscess and Its Definitive Management by Garg Protocol. Clin Exp Gastroenterol 2022; 15:189-198. [PMID: 36186926 PMCID: PMC9525211 DOI: 10.2147/ceg.s374848] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Accepted: 09/20/2022] [Indexed: 11/23/2022] Open
Abstract
Background Definitive management of acute fistula-abscess (anal fistulas associated with acute abscess) is gaining popularity against the two-staged approach (early abscess drainage with deferred fistula management). However, locating an internal opening (IO) in acute fistula-abscess can be difficult. A recent protocol (Garg protocol) has been shown to be effective in managing anal fistulas with non-locatable IO. Purpose To test the efficacy of the Garg protocol in managing acute fistula-abscess with non-locatable IO. Methods Patients with acute fistula-abscess operated by a definitive procedure were included. A preoperative MRI was done in all patients. Patients in whom the IO was non-locatable after clinical, MRI, and intraoperative examination were managed by the three-step Garg protocol. Garg protocol: 1) Reassessment of MRI; 2) In non-horseshoe fistulas, the IO was assumed to be at the point where the fistula tract reached closest to the sphincter-complex; 3) In horseshoe fistulas, the IO was assumed to be located in the midline (anterior or posterior as per the horseshoe location). Low fistulas were treated by fistulotomy and high fistulas by a sphincter-sparing procedure. The long-term healing rate and change in continence (Vaizey scores) were evaluated. Results A total of 201 patients with acute fistula-abscess were operated over six years, and 19 were lost to follow-up. A total of 182 patients (154-males) were followed up (median-37 months). The IO was locatable in 133/182 (73.1%) (control group) and was non-locatable in 49/182 (26.9%) (study group). The study group was managed as per the Garg protocol. The age, sex-ratio, and fistula parameters were comparable in both groups. The long-term healing rate was 112/133(84.2%) in the IO-locatable group and 43/49 (87.8%) in the IO-non-locatable group (p=0.64, not-significant). The objective continence scores did not change significantly after surgery in both groups. Conclusion Acute fistula-abscess with non-locatable IO can be managed successfully by the Garg protocol without any risk of incontinence.
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Affiliation(s)
- Vipul D Yagnik
- Department of Surgical Gastroenterology, Nishtha Surgical Hospital and Research Center, Patan, Gujarat, India
| | - Baljit Kaur
- Department of Radiology, SSRD Magnetic Resonance Imaging Institute, Chandigarh, India
| | - Sushil Dawka
- Department of Surgery, SSR Medical College, Belle Rive, Mauritius
| | - Aalam Sohal
- Department of Internal Medicine, University of California San Francisco (UCSF), Fresno, CA, USA
| | - Geetha R Menon
- Department of Statistics, Indian Council of Medical Research, New Delhi, India
| | - Pankaj Garg
- Department of Colorectal Surgery, Indus International Hospital, Mohali, Punjab, India.,Department of Colorectal Surgery, Garg Fistula Research Institute, Panchkula, Haryana, India
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Garg P, Sachdeva M, Yagnik VD. TROPIS (Transanal Opening of Intersphincteric Space) Procedure for the Treatment of Horseshoe Anal Fistulas. J Gastrointest Surg 2022; 26:1814-1815. [PMID: 35710960 DOI: 10.1007/s11605-022-05384-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Accepted: 06/01/2022] [Indexed: 01/31/2023]
Affiliation(s)
- Pankaj Garg
- Department of Colorectal Surgery, Garg Fistula Research Institute, 1042 Sector-15, Panchkula, Haryana, India, 134113.
| | - Mehak Sachdeva
- Department of Surgery, Government Medical College, Patiala, India
| | - Vipul D Yagnik
- Department of General Surgery, Nishtha Surgical Hospital and Research Centre, Patan, Gujarat, India
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Garg P, Yagnik VD, Kaur B, Menon GR, Dawka S. Efficacy of Kegel exercises in preventing incontinence after partial division of internal anal sphincter during anal fistula surgery. World J Clin Cases 2022; 10:6845-6854. [PMID: 36051110 PMCID: PMC9297395 DOI: 10.12998/wjcc.v10.i20.6845] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Revised: 05/12/2022] [Accepted: 06/17/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND The transanal opening of intersphincteric space (TROPIS) procedure, performed to treat complex anal fistulas, preserves the external anal sphincter (EAS) but involves partial incision of the internal anal sphincter (IAS).
AIM To ascertain the incidence of incontinence after the division of the IAS as is done in TROPIS and to evaluate whether regular Kegel exercises (KE) in the postoperative period can prevent incontinence due to IAS division.
METHODS Patients operated on for high complex fistulas and having no preoperative continence problem (score = 0) were included in the study. All patients were operated on by the TROPIS procedure and were recommended KE (pelvic contraction exercises) 50 times/day. KE were commenced on the 10th postoperative day and continued for 1 year. Incontinence was evaluated objectively (by modified Vaizey’s scores) in the immediate postoperative period (Pre-KE group) and on long-term follow-up (Post-KE group). The incontinence scores in both groups were compared to evaluate the efficacy of KE.
RESULTS Of 102 anal fistula patients operated on between July 2018 and July 2020 were included in this study. There were 90 males, the mean age was 42.3 ± 12.8, and the median follow-up was 30 mo (18-42 mo). Three patients were lost to follow-up. There were 65 recurrent fistulas, 92 had multiple tracts, 42 had associated abscess, 46 had horseshoe fistula and 34 were supralevator fistulas. All were magnetic resonance imaging-documented high fistulas (> 1/3 EAS involved). Overall incontinence occurred in 31% patients (Pre-KE group) with urge and gas incontinence accounting for the majority of cases (28.3%). The mean incontinence scores in the Pre-KE group were 1.19 ± 1.96 (in 31 patients, solid = 0, liquid = 7, gas = 8, urge = 24) and in the Post-KE group were 0.26 ± 0.77 (in 13 patients, solid = 0, liquid = 2, gas = 3, urge = 10) (P = 0.00001, t-test).
CONCLUSION Division of the IAS led to incontinence, mainly urge incontinence, and also to a mild degree of gas and liquid incontinence. However, regular KE led to a significant reduction in incontinence (both in the number of affected patients and the severity of scores in these patients).
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Affiliation(s)
- Pankaj Garg
- Department of Colorectal Surgery, Garg Fistula Research Institute, Panchkula 134113, Haryana, India
- Department of Colorectal Surgery, Indus International Hospital, Mohali 140507, Punjab, India
| | - Vipul D Yagnik
- Department of Surgical Gastroenterology, Nishtha Surgical Hospital and Research Center, Patan 384265, Gujarat, India
| | - Baljit Kaur
- Department of Radiology, SSRD Magnetic Resonance Imaging Institute, Chandigarh 160011, India
| | - Geetha R Menon
- Department of Statistics, Indian Council of Medical Research, New Delhi 110029, India
| | - Sushil Dawka
- Department of Surgery, SSR Medical College, Belle Rive 744101, Mauritius
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Garg P. Comparison between recent sphincter-sparing procedures for complex anal fistulas-ligation of intersphincteric tract vs transanal opening of intersphincteric space. World J Gastrointest Surg 2022; 14:374-382. [PMID: 35734614 PMCID: PMC9160686 DOI: 10.4240/wjgs.v14.i5.374] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2021] [Revised: 01/29/2022] [Accepted: 04/26/2022] [Indexed: 02/06/2023] Open
Abstract
Complex anal fistulas are difficult to treat. The main reasons for this are a higher recurrence rate and the risk of disrupting the continence mechanism because of sphincter involvement. Due to this, several sphincter-sparing procedures have been developed in the last two decades. Though moderately successful in simple fistulas (50%-75% healing rate), the healing rates in complex fistulas for most of these procedures has been dismal. Only two procedures, ligation of intersphincteric fistula tract and transanal opening of intersphincteric space have been shown to have good success rates in complex fistulas (60%-95%). Both of these procedures preserve continence while achieving high success rates. In this opinion review, I shall outline the history, compare the pros and cons, indications and contraindications and future application of both these procedures for the management of complex anal fistulas.
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Affiliation(s)
- Pankaj Garg
- Department of Colorectal Surgery, Garg Fistula Research Institute, Panchkula 134113, India
- Department of Colorectal Surgery, Indus International Hospital, Mohali 140507, India
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Garg P, Yagnik VD, Dawka S, Kaur B, Menon GR. Guidelines to diagnose and treat peri-levator high-5 anal fistulas: Supralevator, suprasphincteric, extrasphincteric, high outersphincteric, and high intrarectal fistulas. World J Gastroenterol 2022; 28:1608-1624. [PMID: 35581966 PMCID: PMC9048780 DOI: 10.3748/wjg.v28.i16.1608] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Revised: 10/06/2021] [Accepted: 03/16/2022] [Indexed: 02/06/2023] Open
Abstract
Supralevator, suprasphincteric, extrasphincteric, and high intrarectal fistulas (high fistulas in muscle layers of the rectal wall) are well-known high anal fistulas which are considered the most complex and extremely challenging fistulas to manage. Magnetic resonance imaging has brought more clarity to the pathophysiology of these fistulas. Along with these fistulas, a new type of complex fistula in high outersphincteric space, a fistula at the roof of ischiorectal fossa inside the levator ani muscle (RIFIL), has been described. The diagnosis, management, and prognosis of RIFIL fistulas is reported to be even worse than supralevator and suprasphincteric fistulas. There is a lot of confusion regarding the anatomy, diagnosis, and management of these five types of fistulas. The main reason for this is the paucity of literature about these fistulas. The common feature of all these fistulas is their complete involvement of the external anal sphincter. Therefore, fistulotomy, the simplest and most commonly performed procedure, is practically ruled out in these fistulas and a sphincter-saving procedure needs to be performed. Recent advances have provided new insights into the anatomy, radiological modalities, diagnosis, and management of these five types of high fistulas. These have been discussed and guidelines formulated for the diagnosis and treatment of these fistulas for the first time in this paper.
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Affiliation(s)
- Pankaj Garg
- Department of Colorectal Surgery, Garg Fistula Research Institute,Panchkula 134113, Haryana, India
- Department of Colorectal Surgery, Indus International Hospital,Mohali 140201, Punjab, India
| | - Vipul D Yagnik
- Department of Surgical Gastroenterology, Nishtha Surgical Hospital and Research Center, Patan 384265, Gujarat, India
| | - Sushil Dawka
- Department of Surgery, SSR Medical College, Belle Rive 744101,Mauritius
| | - Baljit Kaur
- Department of Radiology, SSRD Magnetic Resonance Imaging Institute, Chandigarh 160011, India
| | - Geetha R Menon
- Department of Statistics, Indian Council of Medical Research,New Delhi 110029, India
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Garg P, Kaur B, Yagnik VD, Dawka S. Including video and novel parameter-height of penetration of external anal sphincter-in magnetic resonance imaging reporting of anal fistula. World J Gastrointest Surg 2022; 14:271-275. [PMID: 35664366 PMCID: PMC9131832 DOI: 10.4240/wjgs.v14.i4.271] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Revised: 12/28/2021] [Accepted: 04/04/2022] [Indexed: 02/06/2023] Open
Abstract
The main purpose of a radiologist’s expertise in evaluation of anal fistula magnetic resonance imaging (MRI) is to benefit patients by decreasing the incontinence rate and increasing the healing rate. Any loss of vital information during the transfer of this data from the radiologist to the operating surgeon is unwarranted and is best prevented. In this regard, two methods are suggested. First, a short video to be attached with the standardized written report highlighting the vital parameters of the fistula. This would ensure minimum loss of information when it is conveyed from the radiologist to the operating surgeon. Second, inclusion of a new parameter, the amount of external sphincter involvement by the anal fistula. This parameter is usually not included in the MRI report. This can be evaluated as the height of penetration of the external anal sphincter (HOPE) by the fistula. The external anal sphincter plays a pivotal role in maintaining continence. This parameter (HOPE) is distinct from the ‘height of internal opening’ and assumes immense importance as its knowledge is paramount to prevent damage to the external anal sphincter by the surgeon during surgery.
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Affiliation(s)
- Pankaj Garg
- Department of Colorectal Surgery, Garg Fistula Research Institute, Panchkula 134113, Haryana, India
- Department of Colorectal Surgery, Indus International Hospital, Mohali 140507, Punjab, India
| | - Baljit Kaur
- Department of Radiology, SSRD Magnetic Resonance Imaging Institute, Chandigarh 160011, Chandigarh, India
| | - Vipul D Yagnik
- Department of Surgical Gastroenterology, Nishtha Surgical Hospital and Research Center, Patan 384265, Gujarat, India
| | - Sushil Dawka
- Department of Surgery, SSR Medical College, Belle Rive 744101, Belle Rive, Mauritius
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Perianal fistulas: A review with emphasis on preoperative imaging. Adv Med Sci 2022; 67:114-122. [PMID: 35134600 DOI: 10.1016/j.advms.2022.01.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2021] [Revised: 11/24/2021] [Accepted: 01/14/2022] [Indexed: 02/06/2023]
Abstract
PURPOSE We aim to present a comprehensive literature review which focuses on the preoperative imaging of perianal fistulas. MATERIAL/METHODS Pelvic magnetic resonance imaging (MRI) and endoanal ultrasound (EAUS) are the two first-line imaging modalities for the preoperative evaluation of patients with perianal fistulas. We conducted a search in PubMed, Scopus and Google Scholar concerning articles comparing pelvic MRI with EAUS, which were published from 1994 until 2019. RESULTS In most articles, pelvic MRI is superior to EAUS for the evaluation of perianal fistulas (especially for supralevator and extrasphincteric ones). Preoperative pelvic MRI is associated with statistically significant better results and prognosis after surgical treatment of the disease. Preoperative EAUS poses high sensitivity and specificity in identifying intersphincteric and transsphincteric perianal fistulas, as well as the internal opening of a fistula-in-ano. There is only one meta-analysis which compares the diagnostic accuracy of the two mentioned imaging modalities in preoperative fistula detection. Sensitivity of both - pelvic MRI and EAUS, is acceptably high (0.87). Specificity of pelvic MRI is 0.69 in comparison to EAUS (0.43), but both values are considered low. CONCLUSIONS Future well-designed prospective studies are needed to investigate the diagnostic accuracy of pelvic MRI and EAUS in the preoperative assessment of patients with perianal fistulas. Moreover, the combination of pelvic MRI and EAUS should also be studied, since several published articles suggest that it could lead to improved diagnostic accuracy. A novel treatment algorithm for perianal fistulas could arise from this study.
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Garg P, Yagnik VD, Dawka S, Kaur B, Menon GR. A Novel MRI and Clinical-Based Scoring System to Assess Post-Surgery Healing and to Predict Long-Term Healing in Cryptoglandular Anal Fistulas. Clin Exp Gastroenterol 2022; 15:27-40. [PMID: 35210804 PMCID: PMC8860728 DOI: 10.2147/ceg.s343254] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Accepted: 02/07/2022] [Indexed: 12/12/2022] Open
Abstract
Background Anal fistulas cause great uncertainty and anxiety in patients and surgeons alike. This is largely because of the inability to accurately confirm postoperative fistula healing, especially long-term healing. There is no scoring system available that can objectively assess cryptoglandular anal fistulas for postoperative healing and can also accurately predict long-term healing. Methods Several parameters that could indicate anal fistula healing were assessed. Out of these, six parameters (four MRI-based and two clinical) were finalized, and a weighted score was given to each parameter. A novel scoring system (NSS) was developed. A minimum possible score (zero) indicated complete healing whereas the maximum weighted score (n = 20) indicated confirmed non-healing. Scoring was done with postoperative MRI (at least 3 months post-surgery), then compared with the actual healing status, and subsequently correlated with the final long-term clinical outcome. Results The NSS was validated in 183 operated cryptoglandular fistula-in-ano patients over a 3-year period in whom 283 MRIs (preoperative plus postoperative) were performed. The postoperative follow-up was 12–48 months (median-30 months). The NSS was found to have a very high positive predictive value (98.2%) and moderately high negative predictive value (83.7%) for long-term fistula healing. Additionally, its sensitivity and specificity in predicting healing were 93.9% and 94.7%, respectively. Conclusion Thus, this new scoring system is highly accurate and would be a useful tool for surgeons and radiologists managing anal fistulas. By objectivizing the assessment of postoperative healing, it can both ease and streamline management. Moreover, reliable prediction of recurrence-free long-term healing will greatly allay the apprehensions associated with this dreaded disease.
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Affiliation(s)
- Pankaj Garg
- Department of Colorectal Surgery, Indus Super Specialty Hospital, Mohali, Punjab, India
- Department of Colorectal Surgery, Garg Fistula Research Institute Surgery, Panchkula, Haryana, India
- Correspondence: Pankaj Garg, Department of Colorectal Surgery, Indus Super Specialty Hospital, Mohali, Punjab, 140507, India, Fax +91 9501011000, Email
| | - Vipul D Yagnik
- Department of Surgical Gastroenterology, Nishtha Surgical Hospital and Research Centre, Patan, Gujarat, India
| | - Sushil Dawka
- Department of Surgery, SSR Medical College, Belle Rive, Mauritius
| | - Baljit Kaur
- Department of Radiology, SSRD MRI Imaging Centre, Chandigarh, Haryana, India
| | - Geetha R Menon
- National Institute of Medical Statistics, Indian Council of Medical Research, New Delhi, India
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Garg P, Yagnik VD, Dawka S. Spontaneous involvement of penile shaft (corpora cavernosa) by anal fistula. ANZ J Surg 2022; 92:2353-2355. [PMID: 35044034 DOI: 10.1111/ans.17479] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2022] [Accepted: 01/08/2022] [Indexed: 11/29/2022]
Affiliation(s)
- Pankaj Garg
- Department of General Surgery, Indus Super Specialty Hospital, Mohali, India.,Department of Colorectal Surgery, Garg Fistula Research Institute, Panchkula, India
| | - Vipul D Yagnik
- Department of General Surgery, Nishtha Surgical Hospital and Research Center, Patan, Gujarat, India
| | - Sushil Dawka
- Department of General Surgery, SSR Medical College, Belle Rive, Mauritius
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Hinksman M, Naidu S, Loon K, Grundy J. Long term efficacy of Video-Assisted Anal Fistula Treatment (VAAFT) for complex fistula-in-ano: a single-centre Australian experience. ANZ J Surg 2022; 92:1132-1136. [PMID: 35014148 DOI: 10.1111/ans.17451] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Revised: 12/08/2021] [Accepted: 12/21/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Video-Assisted Anal Fistula Treatment (VAAFT) is a novel minimally invasive & sphincter-saving technique for treating complex fistula-in-ano involving endoscopic assessment & treatment of perianal fistula. This retrospective, non-randomized, observational study is the first Australian study of VAAFT. It is also the longest study of VAAFT to-date. METHODS From January 2014 to September 2019, 59 patients with a complex anal fistula were identified via MRI & underwent VAAFT. Fourteen patients had undergone previous definitive surgery for anal fistula. Specialized Karl Storz video equipment (fistuloscope) was used in the procedure. The rigid fistuloscope was used to directly visualize the fistula tract/s & internal opening. Closure of the internal opening was then performed. The fistula tract/s were then treated via fulguration. The external opening was kept patent & dressed. Patients were then followed up for a mean 59.5 months. RESULTS 67.9% (n = 38) of patients achieved primary healing (needing nil further intervention) at a median of 13 weeks. 12.5% (n = 7) experienced healing followed by recurrence while 19.6% (n = 11) experienced non-healing. Of the recurrence/non-healing groups, 11/18 underwent repeat VAAFT with healing occurring in 10/11 patients at a median of 7 weeks. The mean operating time was 41.1 min. There were no major complications & continence scores were not affected. Three patients were lost to follow up. CONCLUSION VAAFT is both effective & safe for the treatment of complex fistula-in-ano. Its minimally invasive nature means that in the instance of recurrence or persistence, VAAFT can be repeated with minimal morbidity & reasonable likelihood of success.
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Affiliation(s)
- Mat Hinksman
- Department of General Surgery, Queen Elizabeth II Jubilee Hospital, Brisbane, Queensland, Australia
| | - Sanjeev Naidu
- Department of General Surgery, Queen Elizabeth II Jubilee Hospital, Brisbane, Queensland, Australia
| | - Kenneth Loon
- Department of General Surgery, Queen Elizabeth II Jubilee Hospital, Brisbane, Queensland, Australia
| | - Joshua Grundy
- Department of General Surgery, Queen Elizabeth II Jubilee Hospital, Brisbane, Queensland, Australia
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Garg P, Dawka S, Yagnik VD, Kaur B, Menon GR. Anal fistula at roof of ischiorectal fossa inside levator-ani muscle (RIFIL): a new highly complex anal fistula diagnosed on MRI. Abdom Radiol (NY) 2021; 46:5550-5563. [PMID: 34455464 DOI: 10.1007/s00261-021-03261-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Revised: 08/21/2021] [Accepted: 08/23/2021] [Indexed: 12/14/2022]
Abstract
BACKGROUND As experience with anal fistula imaging (MRI) has increased, new pathways of fistula extension have been identified. A recently described pathway is the 'outer-sphincteric space' present between the external anal sphincter and its covering outer fascia. A new type of complex fistula is being described which is present in the outer-sphincteric space and continues superiorly along the lateral border of the external anal sphincter to the infero-lateral surface of the puborectalis and levator-ani. In effect, these outer-sphincteric fistulas are at the roof of the ischiorectal fossa inside the levator muscle (RIFIL). These fistulas are not transsphincteric fistulas as they remain inside the levator muscle and do not enter the ischiorectal fossa. METHODS The MRI scans of consecutive anal fistula patients operated over the last two years were analyzed retrospectively. RESULTS Of 419 operated fistula patients analyzed, 42(10%) had RIFIL and 377 non-RIFIL fistulas. Compared to non-RIFIL fistulas, there were significantly more recurrent, multiple tracts, horseshoe, supralevator, and suprasphincteric fistulas in the RIFIL group. RIFIL fistulas were significantly more complex than non-RIFIL fistulas(85.7% vs 38.5%, p < 0.00001) and the surgery failure rate was also significantly higher in the RIFIL group (30.6%) than in the non-RIFIL fistula (7.2%) group(p = 0.0001). CONCLUSION RIFIL are highly complex fistulas. Proper diagnosis by MRI, surgical access, and subsequent management of these fistulas is quite challenging and they are associated with poor prognosis. Missing their diagnosis would lead to higher recurrence rate. These have not been described previously and were perhaps confused with high transsphincteric infralevator fistulas in ischiorectal fossa.
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Garg P, Kaur B, Yagnik VD, Dawka S. A New Anatomical Pathway of Spread of Pus/Sepsis in Anal Fistulas Discovered on MRI and Its Clinical Implications. Clin Exp Gastroenterol 2021; 14:397-404. [PMID: 34675587 PMCID: PMC8504714 DOI: 10.2147/ceg.s335703] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Accepted: 10/03/2021] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND In the anal sphincter complex, the intersphincteric space between the internal and external sphincters is the only conventionally recognized pathway for the spread of sepsis. However, there is another unrecognized space discovered on MRI, the "outer-sphincteric space", between the external anal sphincter and its lateral fascia along which pus can spread. An abscess in the intersphincteric space is easily drained into the rectum via the transanal route and is more likely to spread into the supralevator space. Conversely, an abscess in the outer-sphincteric space is difficult to drain transanally into the rectum and is more likely to become a transsphincteric abscess/fistula. METHODS The MRIs of anal fistula patients operated over four years on intersphincteric abscesses were analyzed. The pattern of spread into the ischiorectal fossa and/or supralevator space and ease of drainage into the rectum through the transanal route were studied. RESULTS Thirty-six patients were operated on to drain their intersphincteric abscesses through the anal canal. Two distinct patterns were noted. Twenty patients had abscesses in the intersphincteric space, which were easily drained into the rectum. Of them, 6/20 had supralevator extension, while only 1/20 had spread to the ischiorectal fossa. In 16/36 patients, the abscess was in the outer-sphincteric space and could not be drained into the rectum. In 9/16 of these patients, pus spread into the ischiorectal fossa but supralevator spread did not happen in any patient. CONCLUSION Apart from the intersphincteric space, there is perhaps another unrecognized anatomical space - the outer-sphincteric space - discovered on MRI, through which pus can spread in anal fistulas or abscesses.
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Affiliation(s)
- Pankaj Garg
- Indus Super Specialty Hospital, Mohali, India
| | - Baljit Kaur
- Department of Radiology, SSRD MRI Centre, Chandigarh, India
| | - Vipul D Yagnik
- Nishtha Surgical Hospital and Research Centre, Patan, Gujarat, India
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Garg P, Kaur B, Yagnik VD, Dawka S, Menon GR. Guidelines on postoperative magnetic resonance imaging in patients operated for cryptoglandular anal fistula: Experience from 2404 scans. World J Gastroenterol 2021; 27:5460-5473. [PMID: 34588745 PMCID: PMC8433608 DOI: 10.3748/wjg.v27.i33.5460] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2021] [Revised: 06/12/2021] [Accepted: 08/05/2021] [Indexed: 02/06/2023] Open
Abstract
Magnetic resonance imaging (MRI) is considered the gold standard for the evaluation of anal fistulas. There is sufficient literature available outlining the interpretation of fistula MRI before performing surgery. However, the interpretation of MRI becomes quite challenging in the postoperative period after the surgery of fistula has been undertaken. Incidentally, there are scarce data and no set guidelines regarding analysis of fistula MRI in the postoperative period. In this article, we discuss the challenges faced while interpreting the postoperative MRI, the timing of the postoperative MRI, the utility of MRI in the postoperative period for the management of anal fistulas, the importance of the active involvement and experience of the treating clinician in interpreting MRI scans, and the latest advancements in the field.
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Affiliation(s)
- Pankaj Garg
- Department of Colorectal Surgery, Garg Fistula Research Institute, Panchkula 134113, Haryana, India
- Department of Colorectal Surgery, Indus International Hospital, Mohali 140201, Punjab, India
| | - Baljit Kaur
- Department of Radiology, SSRD Magnetic Resonance Imaging Institute, Chandigarh 160011, Chandigarh, India
| | - Vipul D Yagnik
- Department of Surgical Gastroenterology, Nishtha Surgical Hospital and Research Center, Patan 384265, Gujarat, India
| | - Sushil Dawka
- Department of Surgery, SSR Medical College, Belle Rive, Mauritius
| | - Geetha R Menon
- Department of Statistics, Indian Council of Medical Research, New Delhi 110029, New Delhi, India
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Garg P, Yagnik VD, Dawka S. Fecal diversion in complex anal fistulas: Is there a way to avoid it? World J Clin Cases 2021; 9:7306-7310. [PMID: 34616796 PMCID: PMC8464477 DOI: 10.12998/wjcc.v9.i25.7306] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Revised: 06/23/2021] [Accepted: 07/16/2021] [Indexed: 02/06/2023] Open
Abstract
Temporary fecal diversion by a diverting colostomy or ileostomy is occasionally performed for serious complex fistulas. The main indications are highly complex and extensive cryptoglandular anal fistula, anal fistula associated with severe anorectal Crohn’s disease, recurrent rectovaginal fistula, radiation-induced fistula and anal fistula with associated necrotizing fasciitis. The purpose of stoma formation is to divert the fecal stream away from the anorectum and the perianal region so as to control the infective process and prevent trauma to the operated repaired tissues. Once the fistula has healed, the diverting stoma is closed. However, two questions are relevant. First, is it certain that the same disease would not relapse (or the fistula would not recur) once the colostomy is closed? Second, is there a non-surgical method which can obviate the need for a diverting colostomy? An attempt is made to answer both these questions in this review.
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Affiliation(s)
- Pankaj Garg
- Colorectal Surgery,Garg Fistula Research Institute, Panchkula 134113, Haryana, India
- Colorectal Surgery, Indus International Hospital, Mohali 140201, Punjab, India
| | - Vipul D Yagnik
- Surgical Gastroenterology, Nishtha Surgical Hospital and Research Center, Patan 384265, Gujarat, India
| | - Sushil Dawka
- Surgery, SSR Medical College, Belle Rive 744101, Mauritius
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Garg P, Yagnik VD. The Efficacy of Transanal Opening of Intersphincteric Space Procedure in High Complex Anal Fistulas on Long-term Follow-up. Am Surg 2021; 88:319-320. [PMID: 33847169 DOI: 10.1177/00031348211011092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Pankaj Garg
- Department of Colorectal Surgery, Garg Fistula Research Institute, Panchkula, Haryana, India
| | - Vipul D Yagnik
- Department of General Surgery, 552925Nishtha Surgical Hospital and Research Centre, Patan, Gujarat, India
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