Efficacy of amoxicillin/clavulanic acid after surgical drainage of perianal abscess in the prevention of the development of anal fistula (PERIQxA study): study protocol for a multicenter randomized, double-blind clinical trial

BACKGROUND

Anorectal fistula, which is a relatively common pathology, is the chronic manifestation of the acute perirectal process that forms an anal abscess. The development of a fistula after incision and drainage of an anal abscess is seen in approximately 26-37%. Its treatment is a relevant topic, and the role of the use of antibiotic therapy in its prevention remains controversial, after the publication of several studies with contradictory results and several methodological limitations. Our hypothesis is that the combination of amoxicillin and clavulanic acid will reduce the incidence of anal fistula.

METHOD

The aim of this study is to evaluate the efficacy of antibiotherapy after surgical drainage of perianal abscess in the development of perianal fistula. The PERIQxA study is a multicenter, randomized, double-blind controlled trial. The study has been designed to include 286 adult patients who will be randomly (1:1) assigned to either the experimental (amoxicillin/clavulanic acid 875/125 mg TDS for 7 days) or the control arm (placebo). The primary outcome measure is the percentage of patients that develop perianal fistula after surgery and during follow-up (6 months).

DISCUSSION

This clinical trial is designed to evaluate the efficacy and safety of amoxicillin/clavulanic in the prevention of perianal fistula. The results of this study are expected to contribute to stablish the potential role of antibiotherapy in the therapeutics for anal abscess.

TRIAL REGISTRATION

EudraCT Number: 2021-003376-14. Registered on November 26, 2021.

Preventing Rectourethral Fistula Recurrence With Gracilis Flap

BACKGROUND

Rectourethral fistula (RUF) is an uncommon serious condition with various etiologies including neoplasm, radiation therapy, and surgery. Treatment for RUF remains problematic with a high recurrence rate. Although studies have suggested the recurrence rate of RUF is lower after surgical repair using a gracilis flap, outcomes have varied and the studies were small and inadequately controlled. Here, we compare outcomes of RUF repair with and without gracilis flap to evaluate its efficacy in preventing fistula recurrence and identify risk factors for recurrence.

METHODS

We retrospectively reviewed patients who had undergone surgical repair for RUF between 2007 and 2018 at our institution and had at least 30 days of follow-up. Patient demographics, comorbidities, and surgical outcomes were recorded and compared for patients who had gracilis flap repair and those who did not (controls). Single variable logistic regression analysis was used to identify risk factors for recurrence.

RESULTS

The gracilis group (n = 24) and control group (n = 12) had similar demographics and comorbidities. Fistula recurrence was far less frequent in the gracilis group (8% vs 50%, P = 0.009). There were no significant differences in other outcomes including length of hospitalization and surgical complications. When recurrent RUF was treated with a muscle flap (gracilis or inferior gluteus), 83% of the group had no additional fistula recurrence. In the control group, history of radiation ( P = 0.04) and urinary incontinence ( P = 0.015) were associated with fistula recurrence.

CONCLUSIONS

We recommend using a gracilis flap for RUF repair given its association with lower recurrence without increased surgical complications.

[Significance of nontraumatic anal sphincter relaxation for the success of plastic and miniinvasive interventions in coloproctology]

The investigation objective was to estimate the role of nontraumatic anal sphincter (AS) stretching, as a leading factor of success in minimally invasive and/or plastic proctological interventions. One-centre randomized investigation was performed in 83 patients: In 22 of them the AS fissura was revealed (in 16), suprasphincteric fistula (in 3) and coexistent rectocele 2-3 Ap (according to POP-Q classification) with thinning of the AS anterior segment, the degree III hemorrhoids and anterior AS fissure presence. Ninety units of botulotoxin preparation (Disport) were injected between internal and external AS portions 5-15 days preoperatively. The treatment results without botulotoxin injection were compared retrospectively. After botulotoxin injection performance the AS spasm elimination was noted, leading to the pain subsiding promotion before and postoperatively in all the patients observed. The spasm elimination have permitted to escape the anal high fistula recurrence as a result of the mucosal flap shift after intraluminal closure of the fistula or because of the fistula intermuscular electrowelding "suture" rupture, also have guaranteed the plastic sutures on AS, even while the stage II-III rectocele presence, not depending of performance of its simultant surgica correction.

Crypto-glandular fistulous paraproctites--is the surgical prophylaxis of reccurences imperative?

It is done an analysis of 191 patients operated on for crypto-glandular chronic fistulous paraproctitis. The age of the patients vary 21 to 76 years and the male:female proportion is 2,25 to 1. In 164 patients it was first operation for fistula-in-ano and in 27 cases it was a consecutive one for reccurence. There was intervened a concomitant other disease of the anal channel which pathogenetically predispose the development of fistula in 54 (28%) cases. The patients were discharged 1-3 days after surgery. Ambulant control and ligature procedures up to the 30th day were done. A follow up was done of 118 patients (68%) for period of 3 to 12 months. In all the followed up patients was registered full continence and good tonus of the anal sphincters. Recurrences were registered in 8 cases with fibrin glue occlusion of the fistula. There are no registered cases of recurrences by the followed up patients after fistulotomy and excision-ligature methods. The authors review in the discussion the pathogenetical predisposition for paraproctitis in consequence of other diseases of the anal channel and the necessity of surgical prophylaxis of recurrences.

Waiting for attention and care: birthing accounts of women in rural Tanzania who developed obstetric fistula as an outcome of labour

BACKGROUND

Obstetric fistula is a physically and socially disabling obstetric complication that affects about 3,000 women in Tanzania every year. The fistula, an opening that forms between the vagina and the bladder and/or the rectum, is most frequently caused by unattended prolonged labour, often associated with delays in seeking and receiving appropriate and adequate birth care. Using the availability, accessibility, acceptability and quality of care (AAAQ) concept and the three delays model, this article provides empirical knowledge on birth care experiences of women who developed fistula after prolonged labour.

METHODS

We used a mixed methods approach to explore the birthing experiences of women affected by fistula and the barriers to access adequate care during labour and delivery. Sixteen women were interviewed for the qualitative study and 151 women were included in the quantitative survey. All women were interviewed at the Comprehensive Community Based Rehabilitation Tanzania in Dar es Salaam and Bugando Medical Centre in Mwanza.

RESULTS

Women experienced delays both before and after arriving at a health facility. Decisions on where to seek care were most often taken by husbands and mothers-in-law (60%). Access to health facilities providing emergency obstetric care was inadequate and transport was a major obstacle. About 20% reported that they had walked or were carried to the health facility. More than 50% had reported to a health facility after two or more days of labour at home. After arrival at a health facility women experienced lack of supportive care, neglect, poor assessment of labour and lack of supervision. Their birth accounts suggest unskilled birth care and poor referral routines.

CONCLUSIONS

This study reveals major gaps in access to and provision of emergency obstetric care. It illustrates how poor quality of care at health facilities contributes to delays that lead to severe birth injuries, highlighting the need to ensure women's rights to accessible, acceptable and adequate quality services during labour and delivery.

Integrating women's human rights into global health research: an action framework

This article uses Scale of Change theory as a framework to guide global health researchers to synergistically target women's health outcomes in the context of improving their right to freedom, equity, and equality of opportunities. We hypothesize that health researchers can do so through six action strategies. These strategies include (1) becoming fully informed of women's human rights directives to integrate them into research, (2) mainstreaming gender in the research, (3) using the expertise of grass roots women's organizations in the setting, (4) showcasing women's equity and equality in the organizational infrastructure, (5) disseminating research findings to policymakers in the study locale to influence health priorities, and (6) publicizing the social conditions that are linked to women's diseases. We explore conceptual and logistical dilemmas in transforming a study using these principles and also provide a case study of obstetric fistula reduction in Nigeria to illustrate how these strategies can be operationalized. Our intent is to offer a feasible approach to health researchers who, conceptually, may link women's health to social and cultural conditions but are looking for practical implementation strategies to examine a women's health issue through the lens of their human rights.

Incision and drainage of perianal abscess with or without treatment of anal fistula

BACKGROUND

The perianal abscess is a common surgical problem. A third of perianal abscesses may manifest a fistula-in-ano which increases the risk of abscess recurrence requiring repeat surgical drainage. Treating the fistula at the same time as incision and drainage of the abscess may reduce the likelihood of recurrent abscess and the need for repeat surgery. However, this could affect sphincter function in some patients who may not have later developed a fistula-in-ano.

OBJECTIVES

We aimed to review the available randomised controlled trial evidence comparing incision and drainage of perianal abscess with or without fistula treatment.

SEARCH STRATEGY

Randomised trials were identified from MEDLINE, EMBASE, the Cochrane Library, and reference lists of published papers and reviews.

SELECTION CRITERIA

Trials comparing outcome after fistula surgery with drainage of perianal abscess compared with drainage alone were included in the review.

DATA COLLECTION AND ANALYSIS

The primary outcomes were recurrent or persistent abscess/fistula which may require repeat surgery and short-term and long-term incontinence. Secondary outcomes were duration of hospitalisation, duration of wound healing, postoperative pain, quality of life scores. For dichotomous variables, relative risks and their confidence intervals were calculated.

MAIN RESULTS

We identified six trials, involving 479 subjects, comparing incision and drainage of perianal abscess alone versus incision and drainage with fistula treatment. Metaanalysis showed a significant reduction in recurrence, persistent abscess/fistula or repeat surgery in favour of fistula surgery at the time of abscess incision and drainage (RR=0.13, 95% Confidence Interval of RR = 0.07-0.24). Transient manometric reduction in anal sphincter pressures, without clinical incontinence, may occur after treatment of low fistulae with abscess drainage. Incontinence at one year following drainage with fistula surgery was not statistically significant (pooled RR 3.06, 95% Confidence Interval 0.7-13.45) with heterogeneity demonstrable between the trials (Chi(2) =5.39,df=3, p=0.14, I(2) =44.4%).

AUTHORS' CONCLUSIONS

The published evidence shows fistula surgery with abscess drainage significantly reduces recurrence or persistence of abscess/fistula, or the need for repeat surgery. There was no statistically significant evidence of incontinence following fistula surgery with abscess drainage. This intervention may be recommended in carefully selected patients.

Surgical intervention for anorectal fistula

BACKGROUND

Surgery for anorectal fistula may result in recurrence, or impairment of continence. The ideal treatment for anorectal fistulae should be associated with low recurrence rates, minimal incontinence and good quality of life.

OBJECTIVES

To assess the efficacy and morbidity of operative procedures for chronic anal fistula, primary outcomes being recurrence and incontinence.

SEARCH STRATEGY

The following databases were searched: EMBASE (Webspirs 5.1, Silver Platter version 2.0, 1950-2009); Medline (Webspirs 5.1, Silver Platter version 2.0, 1950-2009); The Cochrane Central Register of Controlled Trials (2009 issue 4)and the IndMed ( Indian Medline, www.indmed.nic.in) database. We restricted our search to the English literature. The Indian Journal of Surgery was electronically searched (issues between 2003 and vol 71, Oct 2009). We also searched all primary trial registers (Indian, Australian, Chinese, WHO, ISRCTN and American).

SELECTION CRITERIA

Randomised controlled trials comparing operative procedures for anorectal fistulae were considered. Non randomised trials and cohort studies were examined where data on recurrence and function were available.

DATA COLLECTION AND ANALYSIS

Two reviewers (TJ and BP) independently selected the trials for inclusion in the review. Disagreements were solved by discussion. Where disagreement persisted and published results made data extraction difficult, we obtained clarification from the authors. REVMAN 5 was used for statistical analysis. Quality of the trials were assessed and allowances made for subgroup analysis and prevention of publication bias, using funnel plots if needed.

MAIN RESULTS

Ten randomised controlled trials were available for analysis. The quality of included studies was adequate, though in some trials the numbers were small and they were inadequately powered for equivalence or to detect significant differences. Comparisons were made between various modalities of treatments. There were no significant difference in recurrence rates or incontinence rates in any of the studied comparisons except in the case of advancement flaps. There were more recurrences in the glue plus flap group, a significant difference that favoured the flap only technique. It was also noted that Fibrin glue and advancement flap procedures report low incontinence rates.In the review of literature of non-randomised trials, most trials on fibrin glue indicate good healing in simple fistulae with low incontinence rates.

AUTHORS' CONCLUSIONS

There are very few randomized controlled trials comparing the various modalities of surgery for fistula in ano. While post operative pain, time to healing and discharge from hospital affect quality of life, recurrence and incontinence are the most important. As it turns out, there seems to be no major difference between the various techniques used as far as recurrence rates are concerned.The use of Fibrin glue and advancement flaps are associated with low incontinence rates.There is a crying need for well powered, well conducted randomised controlled trials comparing various modes of treatment of fistula in ano. Newer operations like the anal fistula plug and the LIFT procedure need to be evaluated by randomised clinical trials.

[Role of endoanal ultrasonography in reducing anal fistula recurrence]

The aim of surgical treatment of fistula-in-ano is to eradicate the suppurative process permanently without compromising faecal continence. The appearance of a recurrence of fistula-in-ano is often due to non-identification of the internal opening by the surgeon, and to the presence of complex fistulae. We evaluated the clinical course of 214 patients in a randomised. controlled trial with respect to the recurrence rate of anal fistula with or without preoperative endoanal ultrasonography. In this study we demonstrate that endoanal ultrasonography was the most accurate diagnostic modality for detecting internal opening and complex fistulae. Therefore, endoanal ultrasonography is reliable and useful in the preoperative assessment of anal fistula, and particularly for decreasing the recurrence rate of this disease.

[Brachyterapy in localized prostate cancer]

INTRODUCTION AND OBJECTIVES

Considering the high frequency of localized prostate cancer in stages, at the moment there are minimally invasive techniques that compete with the classic surgery. One of them is the Low Dose Rate (LDR) Brachytherapy with permanent implants of 1125 seeds. The objective of the present study is to expose our experience from the year 1998, when we made the first treatment, until today. The results and the morbidity of the patients over a 7 and a half years period are analyzed.

MATERIAL AND METHODS

A total of 800 patients were treated with LDR brachytherapy, with average age of 68 years and range between 48 and 83 years. In all patients the 1125 seeds were used with Rapid-Strand and peripheral load by means of intraoperative planning.

RESULTS

The urinary rate of complications was of 3% of AUR, and 0.2% of urinary incontinence. The morbidity on the digestive apparatus was of a 12% intermittent bleeding, 2% of proctitis, and a 0.3% of rectal fistulas.

Nonoperative management of perianal abscess in infants is associated with decreased risk for fistula formation

OBJECTIVE

We sought to determine the frequency of progression in infants of perianal abscess with and without surgical drainage to fistula in ano to optimize a treatment plan for these children.

METHODS

A retrospective cohort study was conducted of all patients who were < or = 1 year of age and presented with perianal abscess to 2 pediatric tertiary care institutions during a 10-year period (January 1995 to February 2005, inclusive). Patients were divided into those who underwent surgical drainage and those who did not, and the rate of subsequent fistula formation was determined.

RESULTS

Of 165 children initially identified, follow-up was available for 140. Ninety-four percent of children were male. Mean age was 4.2 +/- 3.1 months. Of the 140 patients, 83 abscesses were drained and 57 were not drained. Of patients who underwent surgical drainage, 50 developed a fistula, whereas of those who did not undergo drainage only 9 developed a fistula. Synchronous administration of antibiotics (intravenous or oral) used in 57 of 58 patients from 1 institution was associated with an even greater decrease in fistula formation (12.5%) in the undrained population.

CONCLUSIONS

Perianal abscess formation in infants who are younger than 12 months is a separate entity from abscess formation in older age groups. In this largest study to date, a combined center series of patients who presented to 2 academic pediatric hospitals with infantile perianal abscess, local hygiene and systemic antibiotics without surgical drainage minimized formation of fistula in ano.

Ultrasound probe positioning to minimize the risk of recto-urethral fistula during cryosurgical ablation of prostate cancer

OBJECTIVE

To evaluate the ability to increase the distance between the rectal mucosa and prostate, and thus decrease the risk of recto-urethral fistula, and to improve the ability to adequately freeze beyond the prostatic capsule during cryosurgical ablation for prostate cancer.

PATIENTS AND METHODS

The transrectal ultrasound probe was manipulated to increase the distance from the rectal mucosa to prostate in 28 men scheduled for cryosurgical ablation for localized prostate cancer. Ten patients were treated for local recurrence after previous definitive radiotherapy, and cryosurgery was chosen as the primary treatment for the remainder.

RESULTS

The mean (range) distance from the rectal mucosa to the prostate when the probe was securely applied to the rectal wall was 2.5 (1-7) mm, and could be extended to 9.6 (7-14) mm before the ultrasonogram quality diminished enough to impede accurate placing of the cryoprobe. The mean distance gained as a margin of error was 7.1 (4-12) mm (P < 0.001). In no patient was it felt that visualization during the freezing cycles was impaired. No recto-urethral fistula was identified.

CONCLUSION

The manoeuvres described here allow the surgeon to freeze beyond the prostatic capsule while maintaining a visible distance from rectal wall. The extra distance created by this manoeuvre might reduce the risk of recto-urethral fistula, and potentially improve tumour control in the posterior aspect of the prostate, based on the ability to freeze beyond the capsule to reach lethal temperatures in all prostatic tissue.

Effect of MRI on clinical outcome of recurrent fistula-in-ano

Recurrent fistula-in-ano is usually due to sepsis missed at surgery, which can be identified by MRI. We aimed to establish the therapeutic effect of MRI in patients with fistula-in-ano. We did MRI in 71 patients with recurrent fistula, with further surgery done at the discretion of the surgeon. Surgery and MRI agreed in 40 patients, five (13%) of whom had further recurrence, compared with 16 (52%) of 31 in whom surgery and MRI disagreed (p=0.0005). Further recurrence in all 16 was at the site predicted by MRI. For surgeons who always acted on MRI, further recurrences arose in four of 25 (16%) operations versus eight of 14 (57%) operations for those who ignored imaging (p=0.008). Surgery guided by MRI reduces further recurrence of fistula-in-ano by 75% and should be done in all patients with recurrent fistula.

[The elective use of protective colostomy in rectal resection surgery]

To clarify the indications and clinical value of "protective colostomy" in cases of low colorectal anastomoses, some recent series are analyzed and compared to the experience of the authors, which includes 65 low anterior resections of the rectum for cancer, with colorectal anastomosis at less than 10 cm from the anus. "Protective colostomy" seems not to prevent the onset of anastomotic fistulae, but appears effective in reducing its clinical effects. "Protective colostomy" seems convenient when there is an increased risk of fistulization, as indicated by a series of factors defined by the authors. In doubtful cases "protective colostomy" may be performed but not opened. So the patient will be given the maximum safety, and not submitted to the uneasiness of an open colostomy unless needed.

Long-term 6-mercaptopurine treatment in adolescents with Crohn's disease

Although 6-mercaptopurine is often used to treat adolescents with intractable Crohn's disease, its long-term efficacy has not yet been studied in this population. This study shows data derived from 36 adolescents (mean age +/- SD, 16.5 +/- 3.3 years; 27 males, 9 females) treated at least 6 months with 6-mercaptopurine (1.5 mg.kg-1.day-1, maximum of 75 mg/day). Sites of Crohn's disease at the start of 6-mercaptopurine therapy included 17 ileocolic, 9 pancolic, 7 small bowel, and 3 partial colon. All had received corticosteroids, sulfasalazine, antibiotics, and nutritional support for 5.0 +/- 3.0 years before administering 6-mercaptopurine, but intractable symptoms persisted. Disease activity lessened during the first year of 6-mercaptopurine, reflected by a higher Lloyd-Still disease activity score (pre, 64 +/- 9 vs. 6-mercaptopurine, 72 +/- 11; P less than 0.0001). General activity, physical examination, nutrition, and laboratory subscores all improved (P less than 0.004). Lessened disease activity occurred despite concomitant decrease in duration of prednisone use (pre, 9.5 +/- 4.2 vs. 6-mercaptopurine, 6.6 +/- 4.9 months/year; P less than 0.001) and cumulative annual prednisone exposure (pre, 3672 +/- 2106 vs. 6-mercaptopurine, 1964 +/- 1460 mg; P less than 0.0007). The frequency of perianal fistulae and abscesses also decreased (P less than 0.01) during treatment. Annual rates of hospitalization decreased in 44% of subjects during 6-mercaptopurine treatment, while increasing in only 22%. Follow-up beyond 1 year of 6-mercaptopurine treatment showed continued remission in 23 of 30 subjects. No serious complications were seen. 6-mercaptopurine is an effective long-term therapy for adolescents with intractable Crohn's disease. While inducing remission, it also has a significant steroid-sparing effect which may be of particular benefit to this population.

Value of pelvic suction-irrigation in reducing morbidity of low anterior resection of the rectum--a ten-year experience

Resection of the rectosigmoid colon with anastomosis below the peritoneal reflection carries appreciable mortality and morbidity rates particularly because of leakage and resulting sepsis, Protecting the anastomosis with a transverse colostomy does not prevent this complication although it does reduce the catastrophic sequelae that often occur. Anastomotic leakage rates have been reported to be as high as 69% and fecal fistula rates as high as 27% following this type of surgery. A pelvic. A pelvic hematoma may act as a culture medium should sepsis occur and may interfere with anastomotic healing. A method of removing accumulated blood and serum from the pelvis following low anterior resection has been employed with the aim of reducing anastomotic leakage, and a 10-year experience has been compiled. Sixty consecutive patients were studied from July 1970 to June 1980. All underwent barium enema examination and/or proctosigmoidoscopy following low anterior resection with concomitant or previous transverse colostomy. There were four subclinical leaks seen at 6 weeks for an incidence of 6.8%. All resolved spontaneously within 6 additional weeks. No fecal fistulas or pelvic abscesses were encountered. Contaminated blood and serum are significant contributing factors to low anterior anastomotic breakdown. By removing such material before it can become infected, this complication can be significantly reduced.

[Causes and prevention of rectal fistula recurrences]

The study of 412 patients with recidivations of rectal fistulas has shown that most frequent recidivations of extrasphincter fistulas are observed in the presence of ramified suppurative cavities in the pararectal fat. The recidivation may be caused by errors in the preoperative diagnosis and inadequate choice of the operation method, by non-radical operations and insufficient control of the postoperative wound healing.

[Prevention and treatment of horseshoe-shaped rectal fistulas]

The paper deals with a newly developed effective method of the treatment of horseshoe fistulae, which was successfully applied in 110 patients. This method is distinguished for its low traumatic effect. The closure of the internal opening is carried out by means of the plasty with a wide layer of the mucous membrane displaced laterally.

[Preoperative preparation in colorectal surgery: antibiotics (author's transl)]

Out of a total of 2727 operations of the large bowel because of tumors and inflammatory disease, performed over a 14-year period, 897 were one-stage resections of the colon and rectum without relaxing colostomy. Standard preoperative preparation of the bowel consists of a balanced diet, laxatives, and enema supplemented by 9 g Neomycin and 1.8 g Achromycin, within a 2-day period. Disturbances in wound healing occurred in 12.5%, seroma included. Anastomotic insufficiency occurred in 4%, and fatal fecal peritonitis due to tumors in 1.3% and due to diverticulitis in 1.2%. Total mortality was about 5.7%. Postoperative hospitalization after resections because of tumors was 15 days and because of diverticulitis, 19 days.

The results of colonic anastomoses at the Royal Melbourne Hospital

One hundred consecutive colocolic and colorectal anastomoses are reviewed. The operative mortality was 5%, wound infection rate 27%, and faecal fistula rate 15%. These complications are shown to double the hospital bed stay. Factors affecting their occurence are examined, and recommendations are made with a view to lower this morbidity.

Rectal impalement with perforation of the bladder

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