Total sphincter conservation in high fistula in ano: results of a new approach

Predictors of Perianal Fistula Healing in Children With Newly Diagnosed Crohn Disease

OBJECTIVES

Perianal fistulas are among the most severe complications of Crohn disease, but limited data regarding their outcomes are available in children. Our objective was to determine predictors of perianal fistula healing among pediatric patients newly diagnosed with Crohn disease.

METHODS

This single-center retrospective study followed patients with perianal fistulas at Crohn disease diagnosis until fistula healing. Time to healing was analyzed using Cox proportional hazard regression models considering relevant covariates including patient demographics, disease characteristics, medical therapies [no anti-tumor necrosis factor (TNF)α therapy, anti-TNFα therapy ±therapeutic drug monitoring], and perianal surgical procedures including fistulotomy, fistulectomy, removal of perianal lesions, seton placement, and incision and drainage.

RESULTS

Of 485 patients identified, 107 (22%) had a perianal fistula at Crohn disease diagnosis. Multivariate analysis identified that perianal fistulotomy, fistulectomy, and lesion removal [hazard ratio (HR) 0.46; P = 0.028], non-White race (HR 0.30, P < 0.01), and male sex (HR 0.42; P = 0.02) were associated with delayed fistula healing. Faster fistula healing was associated with treatment with anti-TNFα with therapeutic drug monitoring (HR 1.78, P = 0.009). There were no other differences in healing by treatment.

CONCLUSIONS

Fistulotomy, fistulectomy, and perianal lesion removal as well as non-White race were associated with delayed fistula healing. Anti-TNFα therapy was associated with faster fistula healing when combined with therapeutic drug monitoring, compared to all other medical treatment groups, including anti-TNFα therapy without therapeutic drug monitoring.

Efficacy of Kegel exercises in preventing incontinence after partial division of internal anal sphincter during anal fistula surgery

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 10^th 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).

Comparison between recent sphincter-sparing procedures for complex anal fistulas-ligation of intersphincteric tract vs transanal opening of intersphincteric space

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.

Lessons learned from an audit of 1250 anal fistula patients operated at a single center: A retrospective review

BACKGROUND

A complex anal fistula is a challenging disease to manage.

AIM

To review the experience and insights gained in treating a large cohort of patients at an exclusive fistula center.

METHODS

Anal fistulas operated on by a single surgeon over 14 years were analyzed. Preoperative magnetic resonance imaging was done in all patients. Four procedures were performed: fistulotomy; two novel sphincter-saving procedures, proximal superficial cauterization of the internal opening and regular emptying and curettage of fistula tracts (PERFACT) and transanal opening of intersphincteric space (TROPIS), and anal fistula plug. PERFACT was initiated before TROPIS. As per the institutional GFRI algorithm, fistulotomy was done in simple fistulas, and TROPIS was done in complex fistulas. Fistulas with associated abscesses were treated by definitive surgery. Incontinence was evaluated objectively by Vaizey incontinence scores.

RESULTS

A total of 1351 anal fistula operations were performed in 1250 patients. The overall fistula healing rate was 19.4% in anal fistula plug (n = 56), 50.3% in PERFACT (n = 175), 86% in TROPIS (n = 408), and 98.6% in fistulotomy (n = 611) patients. Continence did not change significantly after surgery in any group. As per the new algorithm, 1019 patients were operated with either the fistulotomy or TROPIS procedure. The overall success rate was 93.5% in those patients. In a subgroup analysis, the overall healing rate in supralevator, horseshoe, and fistulas with an associated abscess was 82%, 85.8%, and 90.6%, respectively. The 90.6% healing rate in fistulas with an associated abscess was comparable to that of fistulas with no abscess (94.5%, P = 0.057, not significant).

CONCLUSION

Fistulotomy had a high 98.6% healing rate in simple fistulas without deterioration of continence if the patient selection was done judiciously. The sphincter-sparing procedure, TROPIS, was safe, with a satisfactory 86% healing rate for complex fistulas. This is the largest anal fistula series to date.

Transanal Opening of Intersphincteric Space for Fistula-in-Ano

BACKGROUND

The role of the intersphincteric space in the pathogenesis of fistula-in-ano is being increasingly recognized. Submucosal and intersphincteric rectal abscesses have been surgically managed by laying open and draining the intersphincteric space as well as by the modified ligation of intersphincteric fistula tract (LIFT) procedure. In 2017, the transanal opening of intersphincteric space (TROPIS) technique was reported for the treatment of high, complex anal fistulae.

AIM

We aim to investigate the advantages of performing the TROPIS procedure in patients with fistula-in-ano.

METHODS

This was a prospective cohort study investigating the outcomes in patients who had undergone a procedure using the TROPIS technique for the treatment of fistula-in-ano. Preoperative magnetic resonance imaging scans and electronic colonoscopies were performed on all patients. A clinical database evaluating the following variables was constructed: age, gender, body mass index (BMI), previous fistula surgery, type of fistula, postoperative complications, duration of follow-up, success rate, and incontinence scores pre- and postoperatively.

RESULTS

The TROPIS procedure was performed on 41 patients with fistula-in-ano with a follow-up time of 6-23 months. The characteristics of the patients were as follows: 36 males, 6 females, mean age 38.6±13.2 years, and mean BMI 23.5±3.9 kg·m^-2. All patients (41) had transsphincteric fistulae, and 90.2% (37) had high fistula. Of the 41 patients, 22% (9) had recurrent fistulae, 29.27% (12) had horseshoe fistulae, 7.3% (3) had supralevator fistulae, and 14.6% (6) had an associated abscess. The fistula healed completely in 85.3% (35) of patients and failed to heal in 14.7% (6) of patients, and the healing of high fistula was 86.5% (32). Of those patients who had not healed completely, 2 were found to have contracted iatrogenic infections due to foreign residues and underwent surgery with the passing of a loose seton. The additional 4 patients who had not healed underwent a fistulotomy and healed completely thereafter. There were no significant changes in incontinence scores. The incontinence scores were .15 ± .36 preoperatively and .22 ± .47 3 months postoperatively (t = -1.438, P = .16).

CONCLUSIONS

The TROPIS technique is a novel sphincter-preserving procedure, which can be effectively used in treating fistula-in-ano.

LIFT procedure for posterior fistula-in-ano. Are outcomes good enough? A systematic review and meta-analysisis of observational studies

INTRODUCTION

Efficacy of the ligation of intersphincteric fistula tract (LIFT) procedure for posterior fistula-in-ano remains under debate. However, there is scarcity of quality evidence analysing this issue. Thus, the aim of this study is to evaluate outcomes of LIFT surgery in patients with posterior anal fistula.

MATERIAL AND METHODS

Systematic review and meta-analysis to evaluate efficacy of LIFT procedure for posterior anal fistula. MEDLINE (PubMed), EMBASE, Scopus, Web of Science, Cochrane Library and Google Scholar data sources were searched for key-words (MeSH terms): "LIFT" OR "Ligation of the intersphincteric fistula tract" AND "posterior anal fistula" OR "posterior fistula-in-ano". Original, observational and experimental, non-language restriction studies published from January 2000 to March 2020 and reporting outcomes on LIFT procedure for posterior anal fistula were reviewed. Quality and potential biases were assessed using Newcastle-Ottawa scale, following AHRQ recommendations. Additional sensitivity analysis and publication bias evaluation (Beg and Egger's tets) were performed.

RESULTS

No significant differences were found in recurrence rate among patients undergoing LIFT procedure for posterior fistula-in-ano in contrast to other locations (OR 1.36 [IC 95% 0.60-3.07]; p=.46). I² test value was 77%, expressing a fair heterogeneity among included studies. The weighed median for overall recurrence was 37.8% (RI 18.3-47.7%); with a weighed median of 47.1% (RI 30.7 - 63.7%) and 36.3% (RI 15.8-51.3%) (p=.436) respectively for recurrence after LIFT for posterior fistula and fistula in other locations. There was not clear evidence about the sample size ("n") of included studies nor the disparities in quality assessment of those, could justify the observed heterogeneity. No significant publication bias was found.

CONCLUSION

This systematic review and meta-analysis suggests that there are no clear data in the literature for not performing the LIFT procedure in posteriorly located fistulas.

Contemporary surgical practice in the management of anal fistula: results from an international survey

Background

Management of anal fistula (AF) remains challenging with many controversies. The purpose of this study was to explore current surgical practice in the management of AF with a focus on technical variations among surgeons.

Methods

An online survey was conducted by inviting all surgeons and physicians on the membership directory of European Society of Coloproctology and American Society of Colon and Rectal Surgeons. An invitation was extended to others via social media. The survey had 74 questions exploring diagnostic and surgical techniques.

Results

In March 2018, 3572 physicians on membership directory were invited to take part in the study 510 of whom (14%) responded to the survey. Of these respondents, 492 (96%) were surgeons. Respondents were mostly colorectal surgeons (84%) at consultant level (84%), age ≥ 40 years (64%), practicing in academic (53%) or teaching (30%) hospitals, from the USA (36%) and Europe (34%). About 80% considered fistulotomy as the gold standard treatment for simple fistulas. Endorectal advancement flap was performed using partial- (42%) or full-thickness (44%) flaps. Up to 38% of surgeons performed ligation of the intersphincteric fistula tract (LIFT) sometimes with technical variations. Geographic and demographic differences were found in both the diagnostic and therapeutic approaches to AF. Declared rates of recurrence and fecal incontinence with these techniques were variable and did not correlate with surgeons’ experience. Only 1–4% of surgeons were confident in performing the most novel sphincter-preserving techniques in patients with Crohn’s disease.

Conclusions

Profound technical variations exist in surgical management of AF, making it difficult to reproduce and compare treatment outcomes among different centers.

Electronic supplementary material

The online version of this article (10.1007/s10151-019-02051-5) contains supplementary material, which is available to authorized users.

Review article: pathogenesis of Crohn's perianal fistula-understanding factors impacting on success and failure of treatment strategies

BACKGROUND

Evidence from groups who have studied fistula aetiology and extrapolation from interventional studies supports a multifactorial hypothesis of Crohn's perianal fistula, with several pathophysiological elements that may contribute to fistula formation, persistence and resistance to treatment.

AIM

An evidence synthesis of current understanding of pathophysiological factors underlying Crohn's perianal fistula is presented, exploring the fundamental reasons why some treatments succeed and others fail, as a means of focussing clinical knowledge on improving treatment of Crohn's perianal fistula.

METHODS

Evidence to support this review was gathered via the Pubmed database. Studies discussing pathophysiological factors underpinning perianal fistula, particularly in Crohn's disease, were reviewed and cross-referenced for additional reports.

RESULTS

Pathophysiological factors that impact on success or failure of interventions for Crohn's perianal fistulae include the high-pressure zone, obliterating the dead space, disconnecting the track from the anus, removing epithelialisation, eradicating sepsis and by-products of bacterial colonisation, correcting abnormalities in wound repair and removing the pro-inflammatory environment which allows fistula persistence. Most current interventions for Crohn's perianal fistulae tend to focus on a single, or at best two, aspects of the pathophysiology of Crohn's anal fistulae; as a result, failure to heal fully is common.

CONCLUSIONS

For an intervention or combination of interventions to succeed, multiple factors must be addressed. We hypothesise that correct, timely and complete attention to all of these factors in a multimodal approach represents a new direction that may enable the creation of an effective treatment algorithm for Crohn's anal fistula.

Sphincter-Sparing Anal Fistula Repair: Are We Getting Better?

BACKGROUND

Sphincter-sparing repairs are commonly used to treat anal fistulas with significant muscle involvement.

OBJECTIVE

The current study evaluates the trends and efficacy of sphincter-sparing repairs and determines risk factors for fistula recurrence.

DESIGN AND SETTINGS

A retrospective review was performed at 3 university-affiliated teaching hospitals.

PATIENTS

All 462 patients with cryptoglandular anal fistulas who underwent 573 sphincter-sparing repairs between 2005 and 2015 were included. Patients with Crohn's disease were excluded.

MAIN OUTCOME MEASURES

The primary outcome was the rate of fistula healing defined as cessation of drainage with closure of the external opening. Risk factors for nonhealing were also analyzed.

RESULTS

Five hundred three sphincter-sparing repairs were analyzed, whereas 70 were lost to follow-up. Two hundred twenty sphincter-sparing repairs (44%) resulted in healing, 283 (56%) resulted in nonhealing with a median follow-up of 9 (range, 1-125) months. The median time to fistula recurrence was 3 (range, 0-75) months with 79% and 91% of recurrences noted within 6 and 12 months. Patients treated with a dermal advancement flap, rectal advancement flap, or ligation of the intersphincteric tract procedure were less likely to have a recurrence than patients treated with a fistula plug or fibrin glue (p < 0.001). Over time, there was a significantly increased use of the ligation of the intersphincteric tract procedure (p < 0.001) and a significantly decreased use of fistula plugs and fibrin glue (p < 0.001); healing rates improved accordingly. There were no significant differences in healing rates with respect to patient demographics, comorbidities, or fistula characteristics.

LIMITATIONS

This study was limited by its retrospective design.

CONCLUSIONS

Healing rates following sphincter-sparing repairs of cryptoglandular anal fistulas are modest, but have improved over time with the use of better surgical techniques. In this study, ligation of the intersphincteric fistula tract and flaps were superior to fistula plugs and fibrin glue; the former procedures are therefore favored. See Video Abstract at http://links.lww.com/DCR/A391.

Management of Complex Anal Fistulas

Complex anal fistulas require careful evaluation. Prior to any attempts at definitive repair, the anatomy must be well defined and the sepsis resolved. Several muscle-sparing approaches to anal fistula are appropriate, and are often catered to the patient based on their presentation and previous repairs. Emerging technologies show promise for fistula repair, but lack long-term data.

Innovation in income-poor environments

Background

At the core of surgical development in any economic environment lies innovation. Innovation in high-income countries (HICs) often derives from research, whereas innovation in low- and middle-income countries (LMICs) may be spontaneous owing to a desperate drive to meet a local need. The local needs are substantial because of the unequal access to healthcare in LMICs.

Methods

The experience of the author in working in LMICs through Operation Hernia, a medical charity, provides a backdrop for this review. Other published innovative devices and models are discussed.

Results

Innovation in income-poor countries has provided cost-effective but efficient solutions to local health needs. Some innovations have been enhanced and adopted worldwide.

Conclusion

HICs can learn more from innovative strategies adopted in LMICs.

Ligation of intersphincteric fistula tract: What is the evidence in a review?

Broadly, complex fistulas are those that are not low transsphincteric or intersphincteric. The objectives of surgical management are to achieve fistula healing, prevent recurrences and maintain continence. The risk of incontinence associated with treatment ranges from 10% to 57%. The objective of this manuscript is to review the current literature to date on the ligation of the intersphincteric fistula tract procedure (LIFT procedure) as a treatment option in these types of fistula. A search was conducted in Medline, PUBMED, EMBASE and ISI Web of Knowledge, and studies published from January 2009 to May 2013 were included. The primary outcomes were fistula healing rates, mean healing time and patient satisfaction with this surgical technique. Eighteen studies were included in this review. The total number of patients included was 592 (65% male). The median age reported was 42.8 years. The most common type of fistula included was transsphincteric (73.3% of cases). The mean healing rate reported was 74.6%. The risk factors for failure discovered were obesity, smoking, multiple previous surgeries and the length of the fistula tract. The mean healing time was 5.5 wk, and the mean follow-up period was 42.3 wk. The patient satisfaction rates ranged from 72% to 100%. No de novo incontinence developed secondary to the LIFT procedure. There is not enough evidence that variants in the surgical technique achieve better outcomes (Bio-LIFT, LIFT-Plug, LIFT-Plus). This review indicates that the LIFT procedure is primarily effective for transsphincteric fistulas with an overall fistula closure of 74.6% and has a low impact on fecal continence. This procedure produces better outcomes at the first surgical attempt.

Imaging techniques and combined medical and surgical treatment of perianal Crohn's disease

Crohn's disease is a chronic inflammatory disease which may involve any segment of the gastrointestinal tract, most frequently the terminal ileum, the large intestine, and the perianal region. The symptoms of perianal Crohn's disease include skin disorders, hemorrhoids, anal ulcers, anorectal stenosis, perianal abscesses and fistulas, rectovaginal fistulas and carcinoma of the perianal region. The perianal manifestations of Crohn's disease cause great discomfort to the patient and are among the most difficult aspects to treat. Management of perianal disease requires a combination of different imaging modalities and a close cooperation between gastroenterologists and dedicated surgeons.

Surgical treatment of anorectal crohn disease

Crohn disease involves the perineum and rectum in approximately one-third of patients. Symptoms can range from mild, including skin tags and hemorrhoids, to unremitting and severe, requiring a proctectomy in a small, but significant, portion. Fistula-in-ano and perineal sepsis are the most frequent manifestation seen on presentation. Careful diagnosis, including magnetic resonance imaging or endorectal ultrasound with examination under anesthesia and aggressive medical management, usually with a tumor necrosis factor-alpha, is critical to success. Several options for definitive surgical repair are discussed, including fistulotomy, fibrin glue, anal fistula plug, endorectal advancement flap, and ligation of intersphincteric fistula tract procedure. All suffer from decreased efficacy in patients with Crohn disease. In the presence of active proctitis or perineal disease, no surgical therapy other than drainage of abscesses and loose seton placement is recommended, as iatrogenic injury and poor wound healing are common in that scenario.

Ligation of the intersphincteric fistula tract plus a bioprosthetic anal fistula plug (LIFT-Plug): a new technique for fistula-in-ano

AIM

Ligation of the intersphincteric fistula tract and reinforcement with a bioprosthetic graft are two recently reported procedures that have shown promise in the treatment of anal fistula. This study was undertaken to validate combining ligation of the intersphincteric fistula tract plus bioprosthetic anal fistula plug and report our preliminary results and experience.

METHOD

Twenty-one patients with transsphincteric anal fistula were treated with ligation of the intersphincteric fistula tract plus concurrent bioprosthetic plug of the anal fistula. We evaluated healing time, fistula closure rate and postoperative anal function according to the Wexner continence score.

RESULTS

No mortality or major complications were observed. Median operative time was 20 (range 15-40) min. After a median follow-up of 14 (range 12-15) months, the overall success rate was 95% (20/21), with a median healing time of 2 (range 2-3) weeks for external anal fistula opening and 4 (range 3-7) weeks for intersphincteric groove incision. Only 1 (5%) patient reported rare incontinence for gas postoperatively (Wexner score 1).

CONCLUSIONS

Ligation of the intersphincteric fistula tract plus a bioprosthetic anal fistula plug is an easy, safe, effective and useful alternative in the management of anal fistula. Further randomized controlled studies are necessary to better evaluate long-term results.

Efficacy of LIFT for recurrent anal fistula

AIM

Ligation of the intersphincteric fistula tract (LIFT) is a novel sphincter-preserving technique for anal fistula. This pilot study was designed to evaluate the results in patients with a recurrent fistula.

METHOD

Seventeen patients [nine men; median age 49 (range, 30-76) years] with a recurrent trans-sphincteric fistula were treated with a LIFT procedure between June 2008 and February 2011. All were followed prospectively for a median of 16 (range, 5-27) weeks with clinical examination. Fifteen followed for 13.5 (range, 8-26) months by clinical examination also had three-dimensional (3D) anal ultrasound.

RESULTS

The duration of the procedure was 35 (range, 18-70) min. One patient developed a small local haematoma and one had a subcutaneous infection, but otherwise there was no morbidity. At follow up, 11 (65%) patients had a successful closure, two (12%) had a remaining sinus and four (23%) had a persistent fistula. The incidence of persistent or recurrent fistulae at 13.5 months was six (40%) of 15 patients. No de novo faecal incontinence was reported.

CONCLUSION

LIFT is a safe procedure for patients with recurrent anal fistula, with healing at short-term and medium-term follow-up comparable with or superior to that of other sphincter-preserving techniques. Larger studies with a longer follow up are needed to define the ultimate role of LIFT in patients with recurrence.

Ligation of the intersphincteric fistula tract in the management of anal fistula. A systematic review

AIM

Over the last 5 years, the ligation of the intersphincteric fistula tract (LIFT) procedure has become increasingly popular as a sphincter-preserving technique for the treatment of anal fistula. The aim of this article was to review the published literature on the LIFT procedure.

METHOD

The Cochrane database and EMBASE were searched from January 1980 to November 2012, and PubMed from January 1966 to November 2012. All peer-reviewed studies that investigated the LIFT procedure for the treatment of anal fistula were eligible for inclusion. Technical notes, commentaries, letters and meeting abstracts were excluded. The primary outcome measured was the overall fistula closure rate in relation to the length of follow-up.

RESULTS

Twenty-nine articles were originally identified using the search criteria. Thirteen were finally included for analysis. Sample sizes ranged from 18 to 93 patients, with a pooled total of 498. Most fistulae, 494 (99%), were of cryptoglandular aetiology, of which 470 (94%) were transsphincteric. Overall success rates ranged from 40 to 95%, with a pooled success of 71% (352 of 495 patients; 3 of 498 were lost to follow-up). Follow-up ranged from 1 to 55 months, with a reported mean or median of 4 to 19.5 months. One hundred and eighty-three patients were formally assessed for continence, out of whom 11 (6%) had a minor disturbance.

CONCLUSION

Overall the systematic review shows that the LIFT procedure appears to be an effective sphincter-conserving approach for the treatment of transsphincteric anal fistula with a pooled healing rate of 71% over a mean or median follow-up period ranging from 4 to 19.5 months.

Does ligation of the intersphincteric fistula tract raise the bar in fistula surgery?

BACKGROUND

The ligation of the intersphincteric fistula tract procedure has been reported to have high cure rates, with minimal impairment of continence.

OBJECTIVE

The aim of this study was to evaluate the success rates and functional outcome after the ligation of the intersphincteric fistula tract procedure.

DESIGN

This study was performed as a retrospective review.

SETTINGS

The study was conducted at the Division of Colon and Rectal Surgery, University of Minnesota and at affiliated hospitals in Minneapolis and St. Paul, Minnesota, between March 2007 and September 2011.

PATIENTS

Ninety-three patients with transsphincteric cryptoglandular anal fistula were included.

INTERVENTIONS

Ligation of the intersphincteric fistula tract procedure was performed.

MAIN OUTCOME MEASURES

Failure was defined as persistent or recurrent drainage, air leakage from a patent external opening, or intersphincteric incision or reoperation for recurrent fistula. Success was defined as healing of the external fistula opening and intersphincteric incision. Patients were followed up with a questionnaire to assess the recurrence rate and the Wexner incontinence score.

RESULTS

The median follow-up time for was 19 months (range, 4-55). Thirty patients (32%) had a history of previous surgery for their fistula. The success rate of fistula healing was 40% after the first ligation of the intersphincteric fistula tract procedure. When including patients with repeat ligation of the intersphincteric fistula tract and subsequent intersphincteric fistulotomy after ligation of the intersphincteric fistula tract repair, the success rates were 47% and 57%. Patients with successful fistula closure reported a mean Cleveland Clinic Florida Fecal Incontinence score of 1.0 (SD 2.3). No predictor for successful fistula closure was found.

LIMITATIONS

Retrospective design, limited accuracy of diagnosing fistula failure, and lack of baseline continence were limitations of this study.

CONCLUSION

The present study indicates that the ligation of the intersphincteric fistula tract procedure for transsphincteric fistulas has a significant risk for failure but good functional outcome in patients with no recurrence.

Managing fistula-in-ano with ligation of the intersphincteric fistula tract procedure: the Western Hospital experience

AIM

To review the preliminary results of the ligation of the intersphincteric fistula tract (LIFT) technique in treating complex anal fistulas at our hospital.

METHOD

Between March and November 2010, patients with cryptoglandular anal fistulas were recruited prospectively from the colorectal clinic and treated using the LIFT procedure. A database was set up to collect information on demographics, past surgical treatments, fistula characteristics, MRI scan results, operative data and follow-up findings. The primary end-point measured was cure of the disease. The secondary end-point was the degree of postoperative continence. Preoperative and postoperative incontinence rates were recorded using Wexner's Incontinence Scale.

RESULTS

Twenty-five patients (eight women and 17 men; median age, 40 years) underwent the LIFT procedure. Ten patients had recurrent fistulas and previous fistula surgery. The median operating time was 39 min. No intraoperative complications were documented. The median follow-up duration was 22 (3-43) weeks. Primary healing was observed in 17 (68.0%) patients and the median healing time was 6 weeks; one wound remained incompletely healed. Seven patients (28.0%) had disease recurrence presenting between 7 and 20 weeks postoperatively. No patients reported any incontinence postoperatively.

CONCLUSION

The LIFT procedure has favourable healing rates with little or no risk of incontinence. This operation is safe and easy to learn. The early results from this pilot study show promise and affirm some of the findings of other researchers. These results will suggest opportunities to conduct further controlled studies comparing the LIFT procedure with standard therapies.

New techniques for treating an anal fistula

Surgery for an anal fistula may result in recurrence or impairment of continence. The ideal treatment for an anal fistula should be associated with low recurrence rates, minimal incontinence and good quality of life. Because of the risk of a change in continence with conventional techniques, sphincter-preserving techniques for the management complex anal fistulae have been evaluated. First, the anal fistula plug is made of lyophilized porcine intestinal submucosa. The anal fistula plug is expected to provide a collagen scaffold to promote tissue in growth and fistula healing. Another addition to the sphincter-preserving options is the ligation of intersphincteric fistula tract procedure. This technique is based on the concept of secure closure of the internal opening and concomitant removal of infected cryptoglandular tissue in the intersphincteric plane. Recently, cell therapy for an anal fistula has been described. Adipose-derived stem cells have two biologic properties, namely, ability to suppress inflammation and differentiation potential. These properties are useful for the regeneration or the repair of damaged tissues. This article discusses the rationales for, the estimated efficacies of, and the limitations of new sphincter-preserving techniques for the treatment of anal fistulae.

Ligation of the intersphincteric fistula tract (LIFT) to treat anal fistula: early results from a prospective observational study

BACKGROUND

Ligation of the intersphincteric tract (LIFT), a novel sphincter-saving technique, has been recently described with promising results. Literature data are still scant. In this prospective observational study, we present our experience with this technique.

METHODS

Between October 2010 and April 2011, 18 patients with 'complex' fistulas underwent LIFT. All patients were enrolled in the study after a physical examination including digital examination and proctoscopy. For the purpose of this pilot study, fistulas were classified as complex if any of the following conditions were present: tract crossing more than 30% of the external sphincter, anterior fistula in a woman, recurrent fistula or pre-existing incontinence. Endpoints were healing time, presence of recurrence, faecal incontinence and surgical complications.

RESULTS

Ten patients were men and 8 were women; mean age was 39 years; minimum follow-up was 4 months. Three patients required drainage seton insertion and delayed LIFT. After LIFT, 1 patient experienced haemorrhoidal thrombosis. At the end of the follow-up, 15 patients (83%) healed with no recurrence. Three patients had persistent symptoms and required further surgical treatment. We did not observe postoperative worsening of continence.

CONCLUSIONS

Results from our pilot study indicate that this novel sphincter-saving approach is effective and safe for treating complex anal fistula.

Why do we have to review our experience in managing cases with idiopathic fistula-in-ano regularly?

“Why do we have to review our experience in managing idiopathic fistula-in-ano regularly?” In order to answer this apparently simple question, we reviewed our clinical and surgical cases and most important relevant literature to find a rational and scientific answer. It would appear that whatever method you adopt in fistula management, there is a price to pay regarding either rate of recurrence (higher with conservative methods) or impairment of continence (higher with traditional surgery). Since, at the moment, reliable data to identify a treatment as a gold standard in the management of anal fistulas are lacking, the correct approach to this condition must consider all the anatomic and clinicopathological aspects of the disease; this knowledge joined to an eclectic attitude of the surgeon, who should be familiar with different types of treatment, is the only guarantee for a satisfactory treatment. As a conclusion, it is worthwhile to remember that adequate initial treatment significantly reduces recurrence, which, when it occurs, is usually due to failure to recognise the tract and primary opening at the initial operation.

Sphincter-saving surgery for complex anal fistula

At present, the treatments for complex anal fistula are often associated with high recurrence and insufficient protection of anal function. Fistulotomy and cutting seton often lead to damage to the anal sphincters, increasing the risk of incontinence. Recently, they have been replaced gradually by sphincter-saving measures, such as advancement flap, anal fistula plug and ligation of intersphincteric fistula tract. In this article, we will review the recent advances in sphincter-saving surgical treatment of complex anal fistula.

Anorectal Crohn's disease

Crohn's disease manifests with perianal or rectal symptoms in approximately one-third of patients, and is associated with a more aggressive natural history. Due to the chronic relapsing nature of the disease, surgery has been traditionally avoided. However, combined medical and surgical intervention when treating perianal fistulae has been shown to offer the best chance for success. Endoanal ultrasound examination or pelvic magnetic resonance imaging should be done in conjunction with an examination under anesthesia to characterize the disease. Any abscess should be drained and setons placed if there is active rectal inflammation or complex fistulae. Antibiotics and immunosuppressive therapy (especially with infliximab) should also be initiated. Simple fistulae can be treated surgically by fistulotomy or anal fistula plug. Complex fistulae can be closed with either an anal fistula plug or covered with flaps. Up to 20% of patients anorectal Crohn's disease require proctectomy for persistent and disabling disease.

Anti-TNF-alpha (infliximab) used as induction treatment in case of active proctitis in a multistep strategy followed by definitive surgery of complex anal fistulas in Crohn's disease: a preliminary report

PURPOSE

This study was designed to assess the healing rate of complex perianal fistulas in Crohn's disease after a multistep strategy, including induction treatment with Infliximab in case of active proctitis, followed by definitive surgery.

METHODS

From 2000 to 2003, all consecutive patients with complex fistulas and Crohn's disease underwent pretreatment with noncutting setons and, in case of severe recurrent fistulas or abscesses, a diverting stoma. Infliximab was added in cases of active proctitis. After definitive surgical treatment, patients were examined.

RESULTS

Seventeen patients were included (median age, 34 (range, 22-58) years). Seven patients were treated by surgery only, and in ten patients Infliximab was added. After a median follow-up of 19 (range, 8-40) months, fistula healing was observed in 17 patients (100 percent). One patient of the Infliximab group developed a recurrent fistula (10 percent) after 24 months, and in one patient (10 percent) soiling occurred. Two patients of the surgical group developed a recurrent fistula (29 percent) and soiling occurred in two patients (29 percent).

CONCLUSIONS

A multistep strategy followed by definitive surgery for the treatment of complex perianal fistulas in patients with Crohn's disease is a promising treatment modality. The preliminary results of this study suggest that Infliximab treatment has a beneficial additive effect in the multistep treatment followed by definitive surgery of complex anal fistulas and active proctitis in Crohn's disease.

Treatment of fistulizing Crohn's disease

The primary goals of the clinician in the treatment of fistulizing Crohn's disease (CD) include (1) defining the anatomy of the fistula, (2) draining any associated infectious material, (3) eradicating the fistulous tract through medical or surgical therapies, and (4) preventing recurrence of fistulas. Evaluation and therapeutic decisions require close collaboration between the gastroenterologist and surgeon. Appropriate evaluation should include identification of septic complications, delineation of the fistulous tract including the origin and terminus of the fistula, and determination of the extent of bowel involvement with active CD. Drainage of abscesses and control of septic complications through the placement of drains or setons is essential. Conservative therapy with avoidance of sphincter muscle-cutting procedures is the standard approach. The appropriate approach to asymptomatic patients is uncertain because there are little data to indicate if treatment alters the natural course of disease.

Treatment of fistulizing Crohn's disease

The appropriate treatment of patients with fistulas in the setting of Crohn's disease requires a knowledge of the specific medical and surgical literature of fistulizing Crohn's. The patient with symptomatic fistulizing Crohn's disease may respond differently to specific medical therapy than a patient with symptomatic obstructing Crohn's disease. Certain medications that are useful for the treatment of patients with obstructive Crohn's disease may not be helpful in the treatment of fistulas in patients with fistulizing Crohn's disease (e.g., corticosteroids and mesalamine); in fact, some medications are believed to be detrimental (e.g., corticosteroids). Few studies have been performed to assess the efficacy of specific medications on fistulas directly. To date, there has been only one published prospective randomized controlled trial that was designed to assess the efficacy and safety of a specific medication on fistulas in patients with Crohn's disease; it showed clinical efficacy over placebo in a statistically significant manner. The judicious use of surgery remains an integral part of the management of certain presentations of fistulizing Crohn's disease, and the appropriate integration of surgical and medical therapy is of paramount importance in the management of these patients. This review provides an overview of pertinent medical and surgical literature as it pertains to management of patients with fistulizing Crohn's disease.

Anal fistula surgery. Factors associated with recurrence and incontinence

PURPOSE

This study was undertaken to assess results of surgery for fistula-in-ano and identify risk factors for fistula recurrence and impaired continence.

METHODS

We reviewed the records of 624 patients who underwent surgery for fistula-in-ano between 1988 and 1992. Follow-up was by mailed questionnaire, with 375 patients (60 percent) responding. Mean follow-up was 29 months. Fistulas were intersphincteric in 180 patients, transsphincteric in 108, suprasphincteric in 6, extrasphincteric in 6, and unclassified in 75. Procedures included fistulotomy and marsupialization (n = 300), seton placement (n = 63), endorectal advancement flap (n = 3), and other (n = 9). Factors associated with recurrence and incontinence were analyzed by univariate and multivariate regression analysis.

RESULTS

The fistula recurred in 31 patients (8 percent), and 45 percent complained of some degree of postoperative incontinence. Factors associated with recurrence included complex type of fistula, horseshoe extension, lack of identification or lateral location of the internal fistulous opening, previous fistula surgery, and the surgeon performing the procedure. Incontinence was associated with female sex, high anal fistula, type of surgery, and previous fistula surgery.

CONCLUSIONS

Surgical treatment of fistula-in-ano is associated with a significant risk of recurrence and a high risk of impaired continence. Degree of risk varies with identifiable factors.

Long-term seton drainage for high anal fistulas in Crohn's disease--a sphincter-saving operation?

METHODS

Forty-one consecutive patients with Crohn's disease who underwent long-term seton drainage for high transsphincteric, suprasphincteric, or extrasphincteric anal fistula from 1985 to 1993 were reviewed. The subsequent associated procedure was simple seton removal (18), secondary fistulotomy (7), rectal flap advancement (3), and proctectomy (2). Eleven patients still had the seton in place.

RESULTS

Recurrence developed in seven patients (39 percent) undergoing simple seton removal and in one patient undergoing rectal flap advancement. None of the patients treated by secondary fistulotomy developed a recurrence. At the end of follow-up, five patients (12 percent) required proctectomy mainly for severe proctitis, and five patients (12 percent) developed anal incontinence, which was severe in two.

CONCLUSION

Long-term seton drainage for high and fistula in Crohn's disease is efficacious in both treating sepsis and preserving anal sphincter function.

Cutting seton without preliminary internal sphincterotomy in management of complex high fistula-in-ano

PURPOSE

The traditional treatment of a complex high fistula-in-ano by internal sphincterotomy and insertion of a cutting seton carries a risk of fecal incontinence. We have assessed the functional impact of treating patients with a complex fistula-in-ano by a cutting seton fistulotomy technique that preserves the internal sphincter.

METHODS

The operative steps consisted of initial eradication of sepsis, identification of the internal and external openings of the fistula tract, excision of the fistula tract with anal canal mucosa, and insertion of a cutting silk seton around both the internal and external sphincters. In this way open drainage of the intersphincteric space was avoided, and integrity of the internal sphincter was maintained. Functional outcome following treatment with this technique, with regard to fistula eradication and effect on fecal continence was assessed in 27 patients (15 males) who were treated during a six-year period. Twenty-three patients (85 percent) had a history of previous fistula surgery.

RESULTS

The fistula was cured in 26 patients (96 percent) with no reports of altered continence at the time of discharge from outpatient review. Recurrence developed in one patient (4 percent) in whom hidradenitis suppurativa was subsequently diagnosed. All four patients with Crohn's disease had their fistulas eradicated; three (75 percent) have subsequently undergone proctectomy for severe perianal and rectal Crohn's involvement. Long-term follow-up revealed three patients (19 percent, all rectovaginal fistulas) who experienced a deterioration in continence after discharge.

CONCLUSIONS

Although this procedure may not be appropriate for rectovaginal fistulas, the data suggest that cutting setons are effective in treating complex fistula-in-ano, including those that have failed to respond to other forms of surgery. Avoidance of preliminary internal sphincterotomy may prevent deterioration in continence.

Factors affecting continence after surgery for anal fistula

Anorectal physiology and continence were assessed prospectively before and after surgery in 50 patients with chronic perianal sepsis. Functional and physiological parameters were unchanged after surgery in 13 control patients who had sepsis but who did not undergo division of the anal sphincter. Group 1 comprised 22 patients with internal sphincter division alone (15 intersphincteric, seven trans-sphincteric treated by a loose seton technique) and group 2 consisted of 15 patients with a trans-sphincteric fistula laid completely open. In group 1 the median (interquartile range (i.q.r.)) resting pressure in the distal 1 cm of the anal canal was reduced from 68 (60-90) cmH2O before surgery to 44 (35-60) cmH2O after operation (P < 0.001); squeeze pressure was less affected, but function deteriorated in 11 of the 22 patients. The median (i.q.r.) resting pressure in group 2 patients also fell, from 68 (34-84) cmH2O before operation to 28 (20-54) cmH2O afterwards (P = 0.003); median (i.q.r.) maximum squeeze pressure decreased more, from 124 (76-170) cmH2O to 72 (48-112) cmH2O (P = 0.002). Functional deficit occurred in eight of the 15 patients. Incontinence was related to low resting pressure, reflecting internal sphincter integrity, and to local epithelial electrosensitivity (reflecting scarring), but not to squeeze pressure, fistula type or surgical treatment.