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Wang Y, Wu Y, Wang Y, Jiang B, Zhou C, Zhang Y. A Disposable Nitinol Memory Alloy Anal Fistula Clip (AFC) for the Treatment of Cryptoglandular Fistula-In-Ano: a Prospective, Randomized, Controlled Study With Short-Term Follow-Up. J Gastrointest Surg 2022; 26:2224-6. [PMID: 35614286 DOI: 10.1007/s11605-022-05355-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Accepted: 04/30/2022] [Indexed: 01/31/2023]
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Studniarek A, Abcarian A, Pan J, Wang H, Gantt G, Abcarian H. What is the best method of rectovaginal fistula repair? A 25-year single-center experience. Tech Coloproctol 2021; 25:1037-1044. [PMID: 34101044 DOI: 10.1007/s10151-021-02475-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Accepted: 05/30/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND The surgical treatment of rectovaginal fistula (RVF) remains challenging and there is a lack of data to demonstrate the best, single procedure. The aim of this study was to assess the results of different surgical operations for rectovaginal fistula. METHODS Patients with RVF who underwent surgical repair between 1992 and 2017 at a single, tertiary care center were included. Twenty different procedures were performed including: primary closure, closure with sphincter repair, flap repairs, plug/fibrin/mesh repair, examination under anesthesia (EUA) ± seton placement, abdominal resections with and without diversion and ileostomy takedown, gracilis muscle transposition, fistulotomy/ligation of intersphincteric fistula tract. All patients with RVF due to diverticulitis and patients without complete data from paper charting were excluded. Success was defined based on the absence of symptoms related to RVF and absence of diverting stoma at 6 months. RESULTS One hundred twenty-four women were analyzed. The median age was 45 (range 18-84) years. Median follow-up time from the last procedure was 6 months (range 0-203 months). The total number of patients considered successfully treated at the end of their treatment was 91 (91/124, 73.4%). When considering all procedures (n = 255), the success rate for flap procedures was 57.9% (22/38), followed by abdominal resections with and without proximal diversion and ileostomy takedown (16/29, 55.2%) and primary closure with sphincter repair (17/32, 53.1%) while fistula plug, and fibrin glue had among the lowest success rates (4/22, 18.2%). The highest success rate was observed among patients whose RVF etiology was due to malignancy (11/16, 68.8%) followed by unknown (8/14, 57%) and iatrogenic (21/48, 43.8%) causes. CONCLUSIONS Local procedures such as mucosal flap or primary closure and sphincteroplasty are associated with a high success rate should be considered in patients with low-lying, simple RVF. Abdominal resections with and without proximal diversions and ileostomy takedown have a relatively high success rate in selected patients. The low success rate of fibrin glue and fistula plugs demonstrates their low efficacy in RVF; thus, these procedures should be avoided in the treatment algorithm.
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Affiliation(s)
- A Studniarek
- Division of Colon and Rectal Surgery, University of Illinois at Chicago, 840 S. Wood St., Suite 518E CSB (MC 958), Chicago, USA.
| | - A Abcarian
- Cook County Health and Hospitals Systems, Chicago, IL, USA
| | - J Pan
- Division of Colon and Rectal Surgery, University of Illinois at Chicago, 840 S. Wood St., Suite 518E CSB (MC 958), Chicago, USA
| | - H Wang
- Division of Epidemiology and Biostatistics, and Center for Clinical and Translational Science, University of Illinois at Chicago, Chicago, IL, USA
| | - G Gantt
- Division of Colon and Rectal Surgery, University of Illinois at Chicago, 840 S. Wood St., Suite 518E CSB (MC 958), Chicago, USA
| | - H Abcarian
- Division of Colon and Rectal Surgery, University of Illinois at Chicago, 840 S. Wood St., Suite 518E CSB (MC 958), Chicago, USA.,Cook County Health and Hospitals Systems, Chicago, IL, USA
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Zhang Y, Ni M, Zhou C, Wang Y, Wang Y, Shi Y, Jin J, Zhang R, Jiang B. Autologous adipose-derived stem cells for the treatment of complex cryptoglandular perianal fistula: a prospective case-control study. Stem Cell Res Ther 2020; 11:475. [PMID: 33168077 PMCID: PMC7653893 DOI: 10.1186/s13287-020-01995-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Accepted: 10/24/2020] [Indexed: 12/16/2022] Open
Abstract
Background Complex cryptoglandular perianal fistula (CPAF) is a kind of anal fistula that may cause anal incontinence after surgery. Minimally invasive surgery of anal fistula is constantly emerging. Over the past 20 years, there are several sphincter-sparing surgeries, one of which is autologous adipose-derived stem cell (ADSC) transplantation. However, to date, there is no study regarding the treatment of complex CPAF with ADSC in China. This is the first study in China on the treatment of complex CPAF with ADSC to evaluate its safety and efficacy. Methods Totally, 24 patients with complex CPAF were enrolled in this prospective case-control study from January 2018 to December 2019 in the National Colorectal Disease Center of Nanjing Hospital of Chinese Medicine Affiliated to Nanjing University of Chinese Medicine. Patients were divided into ADSC group and endorectal advancement flap (ERAF) group according to their desire. The healing of fistulas (healing of all treated fistulas at baseline, confirmed by doctor’s clinical assessment and magnetic resonance imaging or transrectal ultrasonography) was evaluated at week 12 after treatment. In addition to their safety evaluation based on adverse events monitored at each follow-up, the patients were also asked to complete some scoring scales at each follow-up including pain score with visual analog score (VAS) and anal incontinence score with Wexner score. Results The closure rates within ADSC group and ERAF group at week 12 were 54.55% (6/11) and 53.85% (7/13), respectively, without significant difference between them. VAS score in ADSC group was significantly lower than that in ERAF group at the 5th day postoperatively [1(0,2) VS 2(2,4), p = 0.011], but no differences were observed at the other time. Wexner score of all patients was not increased with no significant differences between the two groups. Adverse events were observed fewer in ADSC group (27.27%) than that in ERAF group (53.85%), but there was no significant difference between them. Conclusion This study indicated safety and efficiency of ADSC for the treatment of complex CPAF in the short term, which is not inferior to that of ERAF. ADSC may provide a promised and potential treatment for complex CPAF conforming to the future of the treatment, which is reconstruction and regeneration. Trail registration ChiCTR, ChiCTR1800014599. Registered 23 January 2018—retrospectively registered, http://www.chictr.org.cn/showproj.aspx?proj=24548
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Affiliation(s)
- Yang Zhang
- National Colorectal Disease Center of Nanjing Hospital of Chinese Medicine Affiliated to Nanjing University of Chinese Medicine, Nanjing, 210022, Jiangsu Province, China.,Graduate School of Nanjing University of Chinese Medicine, Nanjing, 210029, Jiangsu Province, China
| | - Min Ni
- National Colorectal Disease Center of Nanjing Hospital of Chinese Medicine Affiliated to Nanjing University of Chinese Medicine, Nanjing, 210022, Jiangsu Province, China
| | - Chungen Zhou
- Graduate School of Nanjing University of Chinese Medicine, Nanjing, 210029, Jiangsu Province, China
| | - Yehuang Wang
- National Colorectal Disease Center of Nanjing Hospital of Chinese Medicine Affiliated to Nanjing University of Chinese Medicine, Nanjing, 210022, Jiangsu Province, China
| | - Yaxian Wang
- Graduate School of Nanjing University of Chinese Medicine, Nanjing, 210029, Jiangsu Province, China
| | - Yang Shi
- Research Institute of Jiangsu Decon Bio-science Technologies Company Ltd., Nanjing, 210000, Jiangsu Province, China
| | - Jing Jin
- Research Institute of Jiangsu Decon Bio-science Technologies Company Ltd., Nanjing, 210000, Jiangsu Province, China
| | - Rui Zhang
- Graduate School of Nanjing University of Chinese Medicine, Nanjing, 210029, Jiangsu Province, China
| | - Bin Jiang
- National Colorectal Disease Center of Nanjing Hospital of Chinese Medicine Affiliated to Nanjing University of Chinese Medicine, Nanjing, 210022, Jiangsu Province, China.
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Egal A, Etienney I, Atienza P. Endorectal Advancement Flap With Muscular Plication in Anovaginal and Anterior Perineal Fistulas. Ann Coloproctol 2020; 37:141-145. [PMID: 32674556 PMCID: PMC8273710 DOI: 10.3393/ac.2020.04.10.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Accepted: 04/10/2020] [Indexed: 01/09/2023] Open
Abstract
Purpose Endorectal mucosal advancement flap with muscular plication can ensure complete closure of anovaginal fistulas and preserve continence. The aim of this retrospective study was to show indications might be broadened to include anoperineal fistulas. Methods This retrospective study gathered all available data from patients with anovaginal or anterior perineal fistulas who underwent transanal advancement flap repair with muscular plication. A loose seton was passed in the fistula track prior to surgery in all patients. Fistula healing was defined as fistula closure during proctological examination associated with complete resolution of symptoms. Results Thirty-five patients were included from January 2011 to March 2017. Causes of fistula were various, mostly post-operative (34.3%, n = 12), obstetrical (17.1%, n = 6) and inflammatory (14.3%, n = 5). Success rate was 65.2%. Fistula healing was obtained in 60.0% of patients with Crohn disease in remission. Closure rate was higher in anterior perineal fistulas (89.0%) than in anovaginal fistulas (63.6%) even if it did not reach statistical significance. Slight fecal continence disorders were noted in 2 women (5.7%). Conclusion This study demonstrates the efficacy of transanal advancement flap repair with muscular plication for anovaginal and anterior perineal fistulas. Similar closure rates and smaller postoperative incontinence rates compared to the classical technique make this surgery an optimal solution whose efficacy appears to be sustainable over time.
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Affiliation(s)
- Axel Egal
- Department of Proctology, Groupe Hospitalier Diaconesses Croix Saint-Simon, Paris, France
| | - Isabelle Etienney
- Department of Proctology, Groupe Hospitalier Diaconesses Croix Saint-Simon, Paris, France
| | - Patrick Atienza
- Department of Proctology, Groupe Hospitalier Diaconesses Croix Saint-Simon, Paris, France
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Yellinek S, Krizzuk D, Moreno Djadou T, Lavy D, Wexner SD. Endorectal advancement flap for complex anal fistula: does flap configuration matter? Colorectal Dis 2019; 21:581-587. [PMID: 30673146 DOI: 10.1111/codi.14564] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2018] [Accepted: 01/08/2019] [Indexed: 12/23/2022]
Abstract
AIM Treatment of complex anal fistula (CAF) is challenging, often requiring multiple operations due to a high failure rate. The plethora of options attests to the lack of a panacea. Endorectal advancement flap (ERAF) carries the advantages of no sphincter division, no contour defect to the anal canal and no perineal wound. The failure rate of this procedure ranges between 15% and 60%. Although the procedure traditionally described a rhomboid (tongue-shaped) flap, an elliptical (curvilinear) flap was introduced to try to improve the results. This study aimed to describe the elliptical-shaped ERAF performed by the senior authors and others and compare failure rates between elliptical and rhomboid ERAFs for CAF. METHOD A retrospective review of all patients who underwent ERAF for CAF between 2011 and 2017 was undertaken. Patients were divided into two groups based on the type of flap: rhomboid or elliptical. The main outcomes measures were postoperative persistent or recurrent fistula. RESULTS Seventy-six ERAF procedures for CAF were identified in 71 patients; 39 had a classic rhomboid flap and 37 had an elliptical configuration with mean follow-up of 13.8 and 13.9 months, respectively. The groups were similar for demographic parameters and preoperative fistula characteristics. The overall failure rate was 37%, with a success rate of 64% in the rhomboid and 62% in the elliptical group. CONCLUSION The shape of the ERAF for treatment of CAF does not appear to influence failure rate.
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Affiliation(s)
- S Yellinek
- Department of Colorectal Surgery, Cleveland Clinic Florida, Weston, Florida, USA
| | - D Krizzuk
- Department of Colorectal Surgery, Cleveland Clinic Florida, Weston, Florida, USA
| | - T Moreno Djadou
- Department of Colorectal Surgery, Cleveland Clinic Florida, Weston, Florida, USA
| | - D Lavy
- Department of Colorectal Surgery, Cleveland Clinic Florida, Weston, Florida, USA
| | - S D Wexner
- Department of Colorectal Surgery, Cleveland Clinic Florida, Weston, Florida, USA
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Turner JS, Okonkwo A, Chase A, Clark CE. Early outcomes of fluorescence angiography in the setting of endorectal mucosa advancement flaps. Tech Coloproctol 2017; 22:25-30. [PMID: 29256139 DOI: 10.1007/s10151-017-1732-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2017] [Accepted: 09/10/2017] [Indexed: 10/18/2022]
Abstract
BACKGROUND Fistula-in-ano has a reported incidence of 31-34%. Besides fistulotomy, options for fistula repair are seton placement, endorectal advancement flap (ERAF), fibrin sealant, anal fistula plug and ligation of the intersphincteric fistula tract. Despite having a reported success rate as high as 75-98%, ERAF is not without complications, including flap breakdown, recurrence and fecal incontinence. Traditionally, maintaining a broad base to preserve blood supply has been advocated to reduce flap failure. And the aim of the present study was to evaluate outcomes of adult patients who underwent ERAF for complex fistula-in-ano with the use of intraoperative fluorescence angiography (FA) at our institution between July 2014 and July 2016. METHODS We retrospectively reviewed consecutive cases of complex fistula-in-ano repair with ERAF and FA from a prospectively maintained dataset of adult patients with complex fistula-in-ano. Demographics, intraoperative data and 60-day outcomes were recorded and reviewed. RESULTS Six patients [five males and one female with a mean age of 40 years (range 25-46 years)], with a total of seven fistulas, were identified. Six (85.7%) of these patients had undergone prior surgery for fistula-in-ano. No recurrences or complications of any type were noted at 2-week and 8-week follow-up. The majority of patients (71.4%) required flap revision based on intraoperative FA prior to flap fixation. CONCLUSIONS FA is safe and offers real-time assessment of flap perfusion prior to and after fixation in anal fistula repair. The rate of flap ischemia may be underestimated, and therefore, to improve outcomes in ERAF, intraoperative FA should be included in the surgical armamentarium.
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Affiliation(s)
- J S Turner
- Division of Colon and Rectal Surgery, Department of Surgery, Morehouse School of Medicine, 720 Westview Dr., Atlanta, GA, 30310, USA.
| | - A Okonkwo
- Department of Surgery, Morehouse School of Medicine, Atlanta, GA, USA
| | - A Chase
- Division of Colon and Rectal Surgery, Department of Surgery, Morehouse School of Medicine, 720 Westview Dr., Atlanta, GA, 30310, USA
| | - C E Clark
- Division of Colon and Rectal Surgery, Department of Surgery, Morehouse School of Medicine, 720 Westview Dr., Atlanta, GA, 30310, USA
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Kobayashi H, Sugihara K. Successful management of rectovaginal fistula treated by endorectal advancement flap: report of two cases and literature review. Springerplus 2015; 4:21. [PMID: 25694858 PMCID: PMC4325007 DOI: 10.1186/s40064-015-0799-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/10/2014] [Accepted: 01/06/2015] [Indexed: 01/15/2023]
Abstract
Introduction Rectovaginal fistula (RVF) sometimes has a difficulty in treatment. This report describes two patients who suffered from RVF. Case descriptions One patient was a 76-year-old woman who had a RVF over 30 years after the 3rd childbirth. She underwent endorectal advancement flap (ERAF). She had a nighttime soiling after ERAF once a month, which disappeared one year after surgery. Second patient was a 23-year-old woman who had a RVF one month after the first childbirth. She underwent ERAF, and did not have any complications. Discussion and evaluation Both patients did not develop recurrence for four years. Quality of life after ERAF was satisfactory in both patients. ERAF is a safe procedure in terms of both short and long outcomes. We also present a review of the literature concerning ERAF for RVF. Conclusions ERAF can be a potential option as a treatment for RVF.
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Affiliation(s)
- Hirotoshi Kobayashi
- Center for Minimally Invasive Surgery, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo 113-8519 Japan
| | - Kenichi Sugihara
- Department of Surgical Oncology, Graduate School, Tokyo Medical and Dental University, Tokyo, Japan
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Abstract
Benign anorectal diseases, such as anal abscesses and fistula, are commonly seen by primary care physicians, gastroenterologists, emergency physicians, general surgeons, and colorectal surgeons. It is important to have a thorough understanding of the complexity of these 2 disease processes so as to provide appropriate and timely treatment. We review the pathophysiology, presentation, diagnosis, and treatment options for both anal abscesses and fistulas.
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