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

Surgical Intervention is Effective for the Treatment of Crohn's related Rectovaginal Fistulas: Experience From A Tertiary Inflammatory Bowel Disease Practice

BACKGROUND AND AIMS

Rectovaginal fistula occurs in up to 10-20% of women with Crohn's disease, significantly affecting their quality of life. We sought to determine outcomes of single and repeat operative interventions.

METHODS

A retrospective review of all adult patients with a Crohn's related rectovaginal fistula who underwent an operation between 1995 to 2021 was performed. Data collected included patient demographics, Crohn's related medical treatment, surgical intervention, postoperative outcomes, and fistula outcomes.

RESULTS

A total of 166 patients underwent 360 operations; mean age was 42.8 (+/-13.2) years. Thirty-four (20.7%) patients were current and 58 (35.4%) former smokers. The most commonly performed procedure was a local approach (n=160, 44.5%) using fibrin glue, fistulotomy/fistulectomy or seton placement, followed by a transvaginal/transanal approach (n=113, 31.4%) with an advancement flap repair (including Martius advancement flap) and episoproctotomy, a transabdominal approach (n=98, 27.2%) including proctectomy or redo anastomosis and finally gracilis muscle interposition (n=8, 2.2%). The median number of operative interventions per patient was 2 (1.0-3.0) procedures. The overall fistula healing rate per patient was 71.7% (n=119) at a median follow-up of 5.5 (1.2-9.8) years. Factors that impaired healing included former smoking (OR 0.52 95%, CI 0.31 - 0.87, p=0.014) and seton insertion (OR 0.42 95%, CI 0.21-0.83, p=0.012).

CONCLUSION

Over two-thirds of Crohn's related rectovaginal fistulas can achieve closure with multiple surgical interventions. Smoking and seton usage negatively impact healing rates and should be avoided.

Rectovaginal fistula in Crohn's disease treatment: a low long-term success rate and a high definitive stoma risk after a conservative surgical approach

BACKGROUND

Management of rectovaginal fistula (RVF) in Crohn's disease (CD) is challenging. Available studies are heterogeneous and retrospective, with short-term follow-up. The aim of this study was to assess the overall long-term medico-surgical treatment results in women with RVF due to CD.

METHODS

A retrospective study was conducted on consecutive patients operated on for RVF in CD from September 1996 to November 2019 at a tertiary teaching hospital. All surgeries were classified as preliminary, closure, or salvage procedures. Primary outcome was fistula remission defined as the combination of fistula closure and no stoma, at least 6 months since last procedure.

RESULTS

Thirty-two patients (median age 34 [range 21-55] years), with a median follow-up of 11.3 years (0-23.7) after first surgery, were included. Altogether, 138 procedures were performed; 36 (26%) preliminary, 80 (58%) closure, and 13 (9%) salvage procedures. RVF remission was obtained in 7/32 patients (22%). At the end of follow-up, a stoma was present in 13/32 patients (41%). The percentage of time on biologics was 86% for patients in remission, versus 36% for the others (p = 0.0057). After univariate analysis, only anti-TNF-α was significantly related to successful closure techniques (p = 0.007).

CONCLUSIONS

The RVF remission rate in CD was low in the long term. However, patients underwent a succession of interventions, and the stoma rate was high. Combination of biologics with surgical management was crucial.

Surgical options for perianal fistula in patients with Crohn's disease: A comparison of seton placement, fistulotomy, and stem cell therapy

OBJECTIVE

This study was designed to assess the demographic characteristics of patients with Crohn's perianal fistula (CPF) who were treated at a tertiary referral institution. Surgical outcomes were compared in groups of patients who underwent seton placement, fistulotomy, and stem cell therapy.

METHODS

Patients who underwent surgery for CPF between 2015 and 2017 at Asan Medical Center, Seoul, Korea, were retrospectively evaluated. Patients were divided into groups who underwent seton placement, fistulotomy, and stem cell therapy. Their clinical variables and closure rates were compared.

RESULTS

This study included 156 patients who underwent a total of 209 operations. More than half of the operations consisted of seton placement (67%), followed by stem cell therapy (18%) and fistulotomy (15%) patients. Of the 209 fistulas, 153 (73%) were complex, with an overall closure rate of 38% during a median follow-up of 29 months. Closure rates following fistulotomy, stem cell therapy, and seton placement were 90%, 70%, and 18%. Seton placement was more significantly frequently used than the other procedures in patients with complex fistula and those with abscesses. Of the 79 fistulas that achieved complete closure, 11 (14%) recurred. The recurrence rates did not differ among the various techniques.

CONCLUSION

Surgical treatment of CPF is dependent on lesion type. Seton placement was the primary draining procedure for complex fistulas and abscesses, resulting in low closure rates. Fistulotomy was the definite procedure for low type and simple fistula. Stem cell therapy showed high closure rates as definitive treatment, even for complex fistulas.

Modern Management of Perianal Crohn's Disease: A Review

Perianal Crohn's disease (CD) is a complex manifestation of CD that affects approximately 10% of patients. The spectrum of disease is quite variable, ranging from relatively mild disease to severe, aggressive manifestations that result in frequent hospitalizations, multiple surgeries, and poor quality of life. Despite significant recent advances in surgical and medical management, treatment remains challenging and frequently requires a multidisciplinary medical-surgical approach. The goal of this article is to review the current literature regarding the work-up, treatment, and future directions of therapy. Crucial features of effective management include the precise identification of manifestations, control of sepsis, limiting rectal inflammation, frequently with use of antitumor necrosis factor agents, and avoidance of extensive surgery.

Loose combined cutting seton for patients with high intersphincteric fistula: a retrospective study

Background

Achieving a complete cure while maintaining continence constitutes a considerable challenge in the treatment of patients with high anal fistula. This study aimed to evaluate the effectiveness of loose combined cutting seton (LCCS) for treating patients with high intersphincteric fistula.

Methods

Consecutive patients with high intersphincteric fistula who underwent LCCS were retrospectively enrolled. Patient data including demographics, medical history, comorbidities, details of the fistula, operative procedure, and prognosis were collected. Postoperative pain was assessed using a visual analog scale (VAS), which ranged from 0 (no pain) to 10 (extremely severe pain). The severity of fecal incontinence was assessed using the Wexner Continence Grading Scale, with a total score ranging from 0 (no incontinence) to 20 (complete incontinence). The primary outcome was the healing rate of fistula. Secondary outcomes included the recurrence rate of fistula and the severity of fecal incontinence.

Results

The 22 patients (male: female =18:4) in our study had a median follow-up of 55 (range, 32–568) days. The healing rate was 100%, and none of the patients experienced fistula recurrence. At the follow-up visit, 19 patients (86.4%) reported no fecal incontinence. The median total Wexner score was 0. 95.5% patients had VAS score of 0 and only 1 patient (4.5%) had a VAS score of 1, which indicated a low level of postoperative pain.

Conclusions

LCCS achieved a high healing rate with an increased level of continence, as well as a low level of postoperative pain, in most patients with high anal fistula in our study. Further randomized controlled trials are needed to confirm the effectiveness of this novel seton-based technique.

Hot topics in global perianal fistula research: A scopus-based bibliometric analysis

BACKGROUND

The number of citations a scientific paper has received indicates its impact within any medical field. We performed a bibliometric analysis to highlight the key topics of the most frequently cited 100 articles on perianal fistula to determine the advances in this field.

METHODS

The Scopus database was searched from 1960 to 2018 using the search terms "perianal fistula" or "anal fistula" or "fistula in ano" or "anal fistulae" or "anorectal fistulae" including full articles. The topic, year of publication, publishing journal, country of origin, institution, and department of the first author were analyzed.

RESULTS

The median number of citations for the top 100 of 3431 eligible papers, ranked in order of the number of citations, was 100 (range: 65-811), and the number of citations per year was 7.5 (range: 3.8-40.1). The most-cited paper (by Parks et al in 1976; 811citations) focused on the classification of perianal fistula. The institution with the highest number of publications was St Mark's Hospital, London, UK. The most-studied topic was surgical management (n = 47). The country and the decade with the greatest number of publications in this field were the USA (n = 34) and the 2000s (n = 50), respectively.

CONCLUSION

The 100 most frequently cited manuscripts showed that surgical management had the greatest impact on the study of perianal fistula. This citation analysis provides a reference of what could be considered the most classic papers on perianal fistula, and may serve as a reference for researchers and clinicians as to what constitutes a citable paper in this field.

Efficacy of flap repair for anal fistula: study protocol for a systematic review of randomized controlled trial

BACKGROUND

Clinical trials have reported that flap repair (FR) can treat anal fistula (AF) effectively. However, no study systematically investigated its efficacy and safety for patients with AF. This study will systematically assess its efficacy and safety of AF.

METHODS

We will retrieve MEDLINE, EMBASE, Cochrane Library, Elsevier, Springer, Web of Science, Scopus, Chinese Biomedical Literature Database, China National Knowledge Infrastructure, VIP Information, and Wanfang Data from their inceptions to May 1, 2019 without any language limitations. The primary outcome is fistula cure rate. The secondary outcomes consist of fistula recurrence rate, fecal continence, quality of life, and complications. RevMan 5.3 software will be used for methodological quality assessment, data synthesis, subgroup analysis and sensitivity analysis.

RESULTS

The results of this study will summarize a high-quality synthesis of current evidence for the treatment of FR for patients with AF.

CONCLUSION

The findings of this proposed study will provide evidence for judging whether FR is an effective and safety intervention for AF or not.PROSPERO registration number: PROSPERO CRD42019135507.

Novel Approaches to Ileocolic and Perianal Fistulising Crohn's Disease

Crohn's disease (CD) is a well-known idiopathic inflammatory bowel disease characterised by transmural inflammation which can ordinarily affect all the gastrointestinal tract. Its true aetiology is unknown, and a causal therapy is not available to date. The most peculiar aspect of CD lies in its absolute heterogeneity, as we might face various scenarios, locations of the disease, pathologic behaviours, and severity of the disease itself. For these reasons, the cornerstone for the treatment of CD lies in a complex multimodal management, requiring close collaborations among surgeons, gastroenterologists, radiologists, and staff nurses. Advances in surgical and medical therapy are changing the course of the disease. Nowadays, the introduction of both laparoscopy and novel surgical techniques, the improvement of recovery pathways, and the opening of new frontiers are allowing healthcare professionals to deal with complex and recurrent scenarios, trying to spare bowel and anal function, thus ensuring a better quality of life for the patient. Given the heterogeneity and complexity of this disease, it would be impractical to encompass all the aspects of surgical management of CD. This review will address areas that are considered to be hot topics, controversies, challenges, and novelties: thus, we will focus on complex ileocecal disease, surgical strategies, and fistulising perianal conditions.

Systematic review of surgical interventions for Crohn's anal fistula

Background

Anal fistula occurs in approximately one in three patients with Crohn's disease and is typically managed through a multimodal approach. The optimal surgical therapy is not yet clear. The aim of this systematic review was to identify and assess the literature on surgical treatments of Crohn's anal fistula.

Methods

A systematic review was conducted that analysed studies relating to surgical treatment of Crohn's anal fistula published on MEDLINE, Embase and Cochrane databases between January 1995 and March 2016. Studies reporting specific outcomes of patients treated for Crohn's anal fistula were included. The primary outcome was fistula healing rate. Bias was assessed using the Cochrane ROBINS‐I and ROB tool as appropriate.

Results

A total of 1628 citations were reviewed. Sixty‐three studies comprising 1584 patients were ultimately selected in the analyses. There was extensive reporting on the use of setons, advancement flaps and fistula plugs. Randomized trials were available only for stem cells and fistula plugs. There was inconsistency in outcome measures across studies, and a high degree of bias was noted.

Conclusion

Data describing surgical intervention for Crohn's anal fistula are heterogeneous with a high degree of bias. There is a clear need for standardization of outcomes and description of study cohorts for better understanding of treatment options.

Interdisciplinary Management of Perianal Crohn's Disease

Perianal disease is a common manifestation of Crohn disease (CD) that results in significant morbidity and decreased quality of life. Despite several medical and surgical options, complex perianal CD remains difficult to treat. Before the advent of biologic therapy, antibiotics were the mainstay of medical treatment. Infliximab remains the most well-studied medical therapy for perianal disease. Surgical interventions are limited by the risk of nonhealing wounds and potential incontinence. When treatment options fail, fecal diversion or proctectomy may be necessary. Stem cell therapies may offer improved results and seem to be safe, but are not yet widely used.

Natural history of anorectal sepsis

Background

Progression from anorectal abscess to fistula is poorly described and it remains unclear which patients develop a fistula following an abscess. The aim was to assess the burden of anorectal abscess and to identify risk factors for subsequent fistula formation.

Methods

The Hospital Episode Statistics database was used to identify all patients presenting with new anorectal abscesses. Cox regression analysis was undertaken to identify factors predictive of fistula formation.

Results

A total of 165 536 patients were identified in the database as having attended a hospital in England with an abscess for the first time between 1997 and 2012. Of these, 158 713 (95·9 per cent) had complete data for all variables and were included in this study, the remaining 6823 (4·1 per cent) with incomplete data were excluded from the study. The overall incidence rate of abscess was 20·2 per 100 000. The rate of subsequent fistula formation following an abscess was 15·5 per cent (23 012 of 148 286) in idiopathic cases and 41·6 per cent (4337 of 10 427 in patients with inflammatory bowel disease (IBD) (26·7 per cent coded concurrently as ulcerative colitis; 47·2 per cent coded as Crohn's disease). Of all patients who developed a fistula, 67·5 per cent did so within the first year. Independent predictors of fistula formation were: IBD, in particular Crohn's disease (hazard ratio (HR) 3·51; P < 0·001), ulcerative colitis (HR 1·82; P < 0·001), female sex (HR 1·18; P < 0·001), age at time of first abscess 41–60 years (HR 1·85 versus less than 20 years; P < 0·001), and intersphincteric (HR 1·53; P < 0·001) or ischiorectal (HR 1·48; P < 0·001) abscess location compared with perianal. Some 2·9 per cent of all patients presenting with a new abscess were subsequently diagnosed with Crohn's disease; the median time to diagnosis was 14 months.

Conclusion

The burden of anorectal sepsis is high, with subsequent fistula formation nearly three times more common in Crohn's disease than idiopathic disease, and female sex is an independent predictor of fistula formation following abscess drainage. Most fistulas form within the first year of presentation with an abscess.

MR Imaging of Perianal Crohn Disease

Pelvic magnetic resonance (MR) imaging is currently the standard for imaging perianal Crohn disease. Perianal fistulas are a leading cause of patient morbidity because closure often requires multimodality treatments over a prolonged period of time. This review summarizes clinically relevant anal sphincter anatomy, imaging methods, classification systems, and treatment objectives. In addition, the MR appearance of healing perianal fistulas and fistula complications is described. Difficult imaging tasks including the assessment of rectovaginal fistulas and ileoanal anastomoses are highlighted, along with illustrative cases. Emerging innovative treatments for perianal Crohn disease are now available and have the promise to better control sepsis and maintain fecal continence. Different treatment modalities are selected based on fistula anatomy, patient factors, and management goals (closure versus sepsis control). Radiologists can help maximize patient care by being familiar with MR imaging features of perianal Crohn disease and knowledgeable about what features may influence therapy decisions. ^© RSNA, 2017 Online supplemental material is available for this article.

Management of rectovaginal fistulas and patient outcome

Rectovaginal fistulas are a relatively rare, but debilitating condition which pose a significant treatment challenge. Areas covered: In this manuscript we discuss the etiology, classification as well as the manifestations and evaluation of rectovaginal fistulas. We summarize the different surgical techniques and evaluate their success rates and perioperative considerations according to cited sources. Expert commentary: A deep understanding of the disease, treatment options, and familiarity with the different surgical treatment options available is mandatory for choosing the correct treatment. When the surgical treatment is tailored to the specific fistula and patient, many patients can eventually have successful resolution. This review will address the management and patient outcomes after treatment for rectovaginal fistulas.

Predictive factors for recurrence of high transsphincteric anal fistula after placement of seton

BACKGROUND

The optimal surgical treatment for high transsphincteric fistula-in-ano (FIA) should attain complete eradication of the fistulous track and, in the same time, not compromising the anal sphincters. The present study aimed to investigate the predictive factors for recurrence of high transsphincteric FIA after placement of draining seton and to evaluate the efficacy and complications of seton treatment for high cryptoglandular anal fistula.

MATERIALS AND METHODS

This is a retrospective case-control study of patients with high transsphincteric FIA who were treated with seton placement. Variables analyzed were the characteristics of FIA, incidence of recurrence, postoperative complications including fecal incontinence (FI), and the predictive factors for recurrence.

RESULTS

A total of 251 patients (232 males) with high transsphincteric FIA were treated with loose seton placement. Patients were followed for a median period of 16 mo. Recurrence of FIA was recorded in 26 of patients (10.3%) after a mean duration of 12.2 ± 3.9 mo of seton removal. Previously recurrent fistula (odds ratio [OR] = 2.81, P = 0.02), supralevator extension (OR = 3.19, P = 0.01) and anterior fistula (OR = 3.36, P = 0.004), and horseshoe fistula (OR = 5.66, P = 0.009) were the most significant predictors of recurrence. FI was detected in eight patients (3.2%). Female gender (OR = 15.2, P = 0.0003) and horseshoe fistula (OR = 8.66, P = 0.01) were the significant risk factors for FI after the procedure.

CONCLUSIONS

Significant risk factors for recurrence of FIA were previous fistula surgery, anterior anal fistula, and presence of secondary tracks or branches as supralevator extension, and horseshoe fistula.

Perianal Crohn's disease: challenges and solutions

Perianal Crohn’s disease affects a significant number of patients with Crohn’s disease and is associated with poor quality of life. The nature of the disease, compounded by presentation of various disease severities, has made the treatment of perianal Crohn’s disease difficult. The field continues to evolve with the use of both historical and contemporary solutions to address the challenges associated with it. The goal of this article is to review current literature regarding medical and surgical treatment, as well as the future directions of therapy.

Systematic review of evidence and consensus on perianal fistula: an analysis of national and international guidelines

AIM

Treatment of perianal fistula has evolved with the introduction of new techniques and biologicals in Crohn's disease (CD). Several guidelines are available worldwide, but many recommendations are controversial or lack high-quality evidence. The aim of this work was to provide an overview of the current available national and international guidelines for perianal fistula and to analyse areas of consensus and areas of conflicting recommendations, thereby identifying topics and questions for future research.

METHOD

MEDLINE, EMBASE and PubMed were systematically searched for guidelines on perianal fistula. Inclusion was limited to papers in English less than 10 years old. The included topics were classified as having consensus (unanimous recommendations in at least two-thirds of the guidelines) or controversy (fewer than three guidelines commenting on the topic or no consensus) between guidelines. The highest level of evidence was scored as sufficient (level 3a or higher of the Oxford Centre for Evidence-based Medicine Levels of Evidence 2009, http://www.cebm.net/oxford-centre-evidence-based-medicine-levels-evidence-march-2009/) or insufficient.

RESULTS

Twelve guidelines were included and topics with recommendations were compared. Overall, consensus was present in 15 topics, whereas six topics were rated as controversial. Evidence levels varied from strong to lack of evidence.

CONCLUSION

Evidence on the diagnosis and treatment of perianal fistulae (cryptoglandular or related to CD) ranged from nonexistent to strong, regardless of consensus. The most relevant research questions were identified and proposed as topics for future research.

Modern Treatments and Stem Cell Therapies for Perianal Crohn's Fistulas

Crohn's disease (CD) is a complex disorder with important incidence in North America. Perianal fistulas occur in about 20% of patients with CD and are almost always classified as complex fistulas. Conventional treatment options have shown different success rates, yet there are data indicating that these approaches cannot achieve total cure and may not improve quality of life of these patients. Fibrin glue, fistula plug, topical tacrolimus, local injection of infliximab, and use of hematopoietic stem cells (HSC) and mesenchymal stem cells (MSC) are newly suggested therapies with variable success rates. Here, we aim to review these novel therapies for the treatment of complex fistulizing CD. Although initial results are promising, randomized studies are needed to prove efficacy of these approaches in curing fistulizing perianal CD.

[Efficiency of tacrolimus therapy for perianal Crohn's disease]

AIM

To determine the efficacy of 0.1% tacrolimus ointment in patients with perianal Crohn's disease (CD).

SUBJECTS AND METHODS

This prospective randomized trial enrolled 20 patients with perianal CD as anal fissures and rectal fistulas. The inclusion criteria were rectovaginal or extrasphincteric fistulas and purulent leakages. A study group comprised 11 patients, including 9 with anal fissures and 2 with fistulas. A control group included 9 patients, including 8 with fissures and 1 with fistulas. The study group received systemic therapy with azathioprine 2 mg/kg/day and tacrolimus ointment 2 mg/day; the control group had systemic therapy with azathioprine 2 mg/kg/day, hormone ointment 1 mg/day, and metronidazole suppositories 250 mg/day. Control examination and perianal CD activity index (PCDAI) determination were done 6 and 12 weeks after therapy initiation.

RESULTS

At 6 weeks after beginning the study, local examination revealed the signs of anal fissure epithelialization in 5 (45.5%) of the 11 patients in the study group and in 3 (33.3%) of the 9 patients in the control one. At 12 weeks, fissure epithelialization and fistula obliteration were stated in 6 (54%) patients in the study group and in 3 (33%) of the 9 patients in the control group. At 12 weeks, PCDAI in the study and control groups was 2.00 and 4.44 scores (p = 0.01).

CONCLUSION

The findings suggest that topical 0.1% tacrolimus ointment versus antibacterial suppositories and hormone ointments is effective in treating patients with perianal CD. Topical 0.1% tacrolimus ointment therapy caused a reduction in PCDAI.

Contemporary surgical management of rectovaginal fistula in Crohn's disease

Rectovaginal fistula is a disastrous complication of Crohn’s disease (CD) that is exceedingly difficult to treat. It is a disabling condition that negatively impacts a women’s quality of life. Successful management is possible only after accurate and complete assessment of the entire gastrointestinal tract has been performed. Current treatment algorithms range from observation to medical management to the need for surgical intervention. A wide variety of success rates have been reported for all management options. The choice of surgical repair methods depends on various fistula and patient characteristics. Before treatment is undertaken, establishing reasonable goals and expectations of therapy is essential for both the patient and surgeon. This article aims to highlight the various surgical techniques and their outcomes for repair of CD associated rectovaginal fistula.

Multidisciplinary and evidence-based management of fistulizing perianal Crohn's disease

Perianal symptoms are common in patients with Crohn's disease and cause considerable morbidity. The etiology of these symptoms include skin tags, ulcers, fissures, abscesses, fistulas or stenoses. Fistula is the most common perianal manifestation. Multiple treatment options exist although very few are evidence-based. The phases of treatment include: drainage of infection, assessment of Crohn's disease status and fistula tracts, medical therapy, and selective operative management. The impact of biological therapy on perianal Crohn's disease is uncertain given that outcomes are conflicting. Operative treatment to eradicate the fistula tract can be attempted once infection has resolved and Crohn's disease activity is controlled. The operative approach should be tailored according to the anatomy of the fistula tract. Definitive treatment is challenging with medical and operative treatment rarely leading to true healing with frequent complications and recurrence. Treatment success must be weighed against the risk of complications, specially anal sphincter injury. A full understanding of the etiology and all potential therapeutic options is critical for success. Multidisciplinary management of fistulizing perianal Crohn's disease is crucial to improve outcomes.

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.

Setons in the treatment of anal fistula: review of variations in materials and techniques

AIM

Anorectal fistulas have been a common surgical problem since ancient times. Age-old seton techniques are still practiced successfully in the treatment of complex anal fistulas. Many variations in materials and techniques are described in the literature. The selection of a seton type and technique depends on personal preferences. Our aim was to put together all the available variations in materials and techniques for seton treatment. This comprehensive review will help the surgeon to become more familiar with the various options available with regard to materials and techniques.

METHODS

A review of the literature using Medline was done using the Key Words 'anal fistula' and 'seton'. All articles published in English were reviewed. The articles which had variations in materials and techniques for seton treatment were studied.

RESULTS

Various aspects of variations in materials, insertion techniques, maintenance of tension, mechanisms of action, drainage techniques and changing the seton have been elaborated in detail.

CONCLUSIONS

Throughout this paper we present the various available variations in setons with regard to materials, placement and maintenance techniques. This study will help clinicians in choosing a new seton variation or modifying their current method of treatment with setons.

A comprehensive review of inflammatory bowel disease focusing on surgical management

The two main diseases of inflammatory bowel disease are Crohn's disease and ulcerative colitis. The pathogenesis of inflammatory disease is that abnormal intestinal inflammations occur in genetically susceptible individuals according to various environmental factors. The consequent process results in inflammatory bowel disease. Medical treatment consists of the induction of remission in the acute phase of the disease and the maintenance of remission. Patients with Crohn's disease finally need surgical treatment in 70% of the cases. The main surgical options for Crohn's disease are divided into two surgical procedures. The first is strictureplasty, which can prevent short bowel syndrome. The second is resection of the involved intestinal segment. Simultaneous medico-surgical treatment can be a good treatment strategy. Ulcerative colitis is a diffuse nonspecific inflammatory disease that involves the colon and the rectum. Patients with ulcerative colitis need surgical treatment in 30% of the cases despite proper medical treatment. The reasons for surgical treatment are various, from life-threatening complications to growth retardation. The total proctocolectomy (TPC) with an ileal pouch anal anastomosis (IPAA) is the most common procedure for the surgical treatment of ulcerative colitis. Medical treatment for ulcerative colitis after a TPC with an IPAA is usually not necessary.

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.

Non-cutting setons for progressive migration of complex fistula tracts: a new spin on an old technique

AIM

We introduced a modification of the loose seton for high transsphincteric fistula which involved daily self-rotation of the seton by 360°, which we call the progressive migration technique. The outcomes were evaluated.

METHOD

A retrospective review was undertaken of all operations for anal fistula performed by a single colorectal surgeon from Jan. 2002-Dec. 2007. Twenty-four patients with high transsphincteric fistulas were treated with loose, 0-silk setons. Patients were asked to rotate the seton daily, one revolution in each direction, pulling the knot through the fistula tract. Follow-up was done by phone with questionnaires to address incontinence pain scores, satisfaction, and recurrence.

RESULTS

The patients' mean age was 48 years (range, 22-77 years), with M/F ratio of 3:1. The mean duration for seton in place was 14 months (range, 2-40 months). Follow-up ranged from 12-81 months (mean, 45 months). The progressive migration technique resulted in the gradual healing of the fistula tract in 75% of patients (n = 18), with no recurrence (setons completely worked their way to the surface [n = 9], or tract migration was extensive to allow a safe completion fistulotomy [n = 9]). All were fistula free. Twenty-five percent (n = 6) had Crohn's disease. Reported incontinence rates were 0% for solid and liquid stool and 8% (n = 2) for flatus. Twenty-five percent (n = 6) tolerated the setons poorly, and an alternative procedure was performed.

CONCLUSIONS

Simple daily self-rotation of a heavy silk seton, resulting in progressive migration of the fistula tract, is an alternative technique for treating complex, high transsphincteric anal fistulas.

Perianal abscess/fistula disease

Perirectal abscesses and fistulas represent the acute and chronic manifestations of the same disease process, an infected anal gland. They have beleaguered patients and physicians for millennia. A thorough understanding of the anatomy and pathophysiology of the disease process is critical for optimal diagnosis and management. Abscess management is fairly straightforward, with incision and drainage being the hallmark of therapy. Fistula management is much more complicated. It requires striking a balance between rates of healing and potential alteration of fecal continence. This, therefore, requires much more finesse. Many techniques are now available in the armamentarium of the surgeon who treats fistula-in-ano. Although no single technique is appropriate for all patients and all fistula types, appropriate selection of patients and choice of repair technique should yield higher success rates with lower associated morbidity.

Perianal fistulae in Crohn's Disease: current and future approaches to treatment

: affecting sphincter integrity and continence. Traditional surgical and medical approaches are not without their limitations and may result in either comorbidity, such as fecal incontinence, or incomplete healing of the fistulae. Over the last 2 decades these limitations have led to a paradigm shift toward the use of biomaterials, and more recently cell-based therapies, which have met with variable degrees of success. This review discusses the traditional and current methods of treatment, as well as emerging and possible alternative approaches that may improve fistula healing.

Anorectal abscess and fistula-in-ano: evidence-based management

The management of anorectal abscess and anal fistula has changed markedly with time. Invasive methods with high resulting rates of incontinence have given way to sphincter-sparing methods that have a much lower associated morbidity. There has been an increase in reports in the medical literature describing the success rates of the varying methods of dealing with this condition. This article reviews the various methods of treatment and evidence supporting their use and explores advances that may lead to new therapies.

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.

The role of pelvic MRI in assessment of combined surgical and Infliximab treatment for perianal Crohn's disease

AIM: To evaluate the role of pelvic MRI in diagnosis and assesment of combined surgical and infliximab treatment of perianal Crohn's disease (PACD). METHOD: 24 patients with signs of PACD were prospectively evaluated. They were previously treated with azathyoprin for a period of 6 months to 7 years and antibiotics and than started on Infliximab 5 mg/kg (IFX) at 0,2 and 6 weeks induction protocol. Luminal CD activity was assesed by colonoscopy. Perianal Disease Activity Index (PDAI) was calculated to evaluate perianal fistulae activity. Surgical examination under anesthesia (EUA) was performed and noncutting seton placed where appropriate. Pelvic MRI was performed in each patient before Infliximab treatment, and in half of the patients after IFX. MRI criteria were used to asses activity and remission of PACD. RESULTS: 14/24(58.5%) patients had ileocolitis, 10/24 (41.5%) colitis, and in 22/24(91.7%) rectum was affected. Median disease duration was 5.5+2.5 years. MRI revealed simple fistula in 4/24 (16.7%) and complex fistula in 20/24 (83.3%) patients. Abscess was present in 19/24(79%) patients. Enterocutaneous and recto-vaginal fistula was found in 2(8.3%) and 3(12.5%) patients, respectively. Median PDAI before and 8 weeks after IFX treatment was 8.3+2.08 and 3.5+1.03, respectively (p=0.00064). Incomplete response (reduction fistulae drainage by 50%) was found in 10/24(42%) patients, complete response (no drainage) in 11/24 (46%) patients, while in 3/24(12.5%) new fistula opened. Control pelvic MRI was performed in 13/24 (54%) patients. Of those, 9/13(69%) had complete remission according to MRI criteria. Seton was removed after second IFX dose in 15/24 (62.5%) patients and placed again in 2/24 (8%) patients 4 months after completion of IFX treatment. CONCLUSION: In patients with PACD, pelvic MRI before and after IFX treatment is an important diagnostic tool to asses fistula tract localization, reveal abscess, planning adequate treatment approach and assess the effect of treatment. Surgical decision to remove seton was in accordance with MRI criteria for remission in PACD.

Anorectal Crohn's disease: surgical and medical management

In some patients with Crohn's disease the anorectal complications are the major cause of symptoms and morbidity. Anorectal Crohn's disease may be present in patients with intestinal Crohn's disease, may be the initial manifestation of the disease, or rarely occurs without involvement of Crohn's disease elsewhere in the intestinal tract. The pathogenesis of these anorectal complications remains to be clarified. The anorectal examination is very important in the assessment of patients with suspected or documented inflammatory bowel disease. Meticulous physical examination, examination under anaesthesia and radiological imaging modalities may be utilised to specifically identify the location of abscesses and fistulae. Treatment strategy should be directed toward symptomatic relief; the most important symptom is pain. In most patients this pain will be attributable to an incompletely drained rectal abscess. Simple incision and drainage procedures are often all that is required as initial treatment of anorectal abscesses. Treatment of the anorectal fistulae that occur secondary to Crohn's disease requires combined medical and surgical therapy. Drug therapy is more often initiated for Crohn's disease that involves other areas of the gastrointestinal tract. The anorectal manifestations often respond to these same medications. Lay-open procedures (fistulotomies) are often all that is required surgically for simple (low) anorectal fistulae. High (complex) fistulae that involve large portions of the anorectal muscular ring are more difficult to treat. Patients with these fistulae must be treated on an individual basis, usually local surgical therapy combined with a medical regimen. Many surgical procedures are performed and many classes of medications are utilised on patients with these complex anorectal fistulae. Choosing the appropriate surgical and medical interventions is often quite difficult. Although sulfasalazine, mesalazine and corticosteroids have no lasting or maintenance value for fistulae, the immunosuppressive agents mercaptopurine, azathioprine and cyclosporin, the antibacterial metronidazole and the anti-tumour necrosis factor-alpha monoclonal antibody infliximab have varying degrees of effect. The goal of the combined regimen is to cure the fistula, or at least make it minimally symptomatic, without altering the patient's continence.

Surgical therapy of perianal Crohn's disease

The surgical management of perianal Crohn's disease is complex with a wide range of operations being described. The initial emergency treatment is to drain any source of underlying sepsis. A loose seton drainage or a defunctioning stoma can then be used as a 'bridge' to definitive treatment allowing both adequate assessment of the condition and preventing further sepsis. The likelihood of success of any surgical repair must be weighed against the risk of faecal incontinence. Improved results of a local surgical repair are seen with optimal surgical and medical management of perianal Crohn's disease.

Perianal Crohn's disease

Perianal Crohn's disease in children is a potentially debilitating condition that can precede or follow the intestinal disease component. The perianal abnormalities are varied and can include lesions of the perianal skin or anal canal, abscesses or fistulas, and malignancies. The appropriate management of these problems is predicated on a thorough evaluation of the perineum and anus as well as the remainder of the alimentary tract. Therapy usually includes a combination of antibiotics, immunomodulators, and biologic agents as well as conservative operative procedures. The surgical options are intended to safely ameliorate disease-related symptoms without compromising function or continence.

Bioprosthetic plugs for complex anal fistulas: an early experience

PURPOSE

The goal in the treatment of anal fistulas is to eliminate the fistula without a change in continence. No single technique exists that is appropriate for the treatment of all fistulas. Options include fistulotomy, use of setons, fibrin sealant, and advancement flaps. Recently, a bioprosthetic fistula plug has been described. The purpose of this study is to report the author's early experience with the bioprosthetic fistula plug and to compare the results of bioprosthetic plug closure of complex anal fistulas with those achieved with advancement flap repair.

METHODS

A retrospective analysis of prospectively collected data was performed for patients treated with an anal fistula. Data collected included age, gender, fistula anatomy and etiology, previous repairs, comorbidities, procedure performed, pain scores, and fistula recurrence.

RESULTS

Overall, 95 patients comprised the control group (43 men and 52 women), with transsphincteric or rectovaginal fistulas in 51 and 44 patients, respectively, managed by advancement flap repair of their fistula. The fistula recurred in 31 patients (32.6%) during a median follow-up of 10 months. Overall,18 patients had their fistula managed using the porcine fistula plug (12 men and 6 women), with transsphincteric or rectovaginal fistulas in 13 and 5 patients, respectively. The fistula recurred in 2 patients (12%) during a median follow-up of 6 months.

CONCLUSION

Use of a porcine fistula plug for the management of complex anal fistulas is a new technique that, in the early experience, seems to yield results similar to advancement flap repair.

Carcinoma arising in enterocutan fistulae of Crohn's disease patients: description of two cases

Rarely, carcinoma arises from the fistulous tract of Crohn's disease. Adequate radiological examination often produces misleading pseudonegative findings. We reported two cases of fistula cancers treated with infliximab. The short time-span between the administration of this drug and the diagnosis of cancer makes the correlation between the two unlikely.

Controversies in the treatment of common anal problems

Treating common benign anal diseases has evolved towards more outpatient procedures with better outcome. However, minimizing post-procedure morbidities such as pain and the avoidance incontinence remain the most significant concerns. We introduce some controversies and highlight the developments in current surgical practice for the treatment of common anal problems.

Staged mucosal advancement flap for the treatment of complex anal fistulas: pretreatment with noncutting Setons and in case of recurrent multiple abscesses a diverting stoma

OBJECTIVE

To assess the efficacy of a staged strategy for the treatment of complex perianal fistula.

METHODS

Between January 1999 and April 2003 all consecutive patients with complex perianal fistulas were treated according to a staged strategy. Fistula tracks originating from the middle third or upper part of the anal sphincter were included. Patients were examined for recurrent fistulas and complaints of incontinence and soiling. Initial treatment consisted of a noncutting seton with or without a diverting stoma. Definitive surgical treatment consisted of an advancement flap or fistulotomy.

RESULTS

Thirty patients were included (median age; 42 years, range 22-68 years). Seven had Crohn's disease without signs of rectal and anal involvement other than the fistula. At a median follow up of 22 months (range 8-52 months) in 29 (97%) patients, the wounds had healed completely; 7 (22%) patients subsequently developed a recurrent fistula and minor soiling occurred in 7 (23%) patients.

CONCLUSION

Initial treatment with a seton with and without a diverting stoma minimizing inflammatory activity at the fistula site before definitive surgical treatment gave good results in this difficult group of patients.

Practice parameters for the treatment of perianal abscess and fistula-in-ano (revised)

The American Society of Colon and Rectal Surgeons is dedicated to assuring high-quality patient care by advancing the science, prevention, and management of disorders and diseases of the colon, rectum, and anus. The Standards Committee is composed of Society members who are chosen because they have demonstrated expertise in the specialty of colon and rectal surgery. This Committee was created to lead international efforts in defining quality care for conditions related to the colon, rectum, and anus. This is accompanied by developing Clinical Practice Guidelines based on the best available evidence. These guidelines are inclusive, and not prescriptive. Their purpose is to provide information on which decisions can be made, rather than dictate a specific form of treatment. These guidelines are intended for the use of all practitioners, health care workers, and patients who desire information about the management of the conditions addressed by the topics covered in these guidelines. It should be recognized that these guidelines should not be deemed inclusive of all proper methods of care or exclusive of methods of care reasonably directed to obtaining the same results. The ultimate judgment regarding the propriety of any specific procedure must be made by the physician in light of all of the circumstances presented by the individual patient.

Anal abscesses and fistulas

Anal abscesses and fistulas are a common part of surgical practice. Most abscesses simply need to be drained and most fistulas can be safely laid open. Excessive probing should not be attempted when draining abscesses as this may lead to iatrogenic fistulas. A small percentage of fistulas are complex and very challenging to manage. Management involves an accurate diagnosis and a balance between eradication of the fistula and maintenance of continence. A decision should be made, based on clinical evaluation and anal ultrasound (if available), whether the fistula can be laid open. If it cannot be laid open, a loose seton is placed and the sepsis is allowed to settle. Once the sepsis is quiescent, a definitive repair can be attempted. There are various techniques available including rectal advancement flap, fibrin glue and cutaneous flaps all of which are discussed.

Management of Perianal Crohn's Disease

Perianal manifestations of Crohn's disease usually coexist with active inflammation of other primary sites of the disease. Although treatment of active proximal disease may sometimes alleviate perianal symptoms, it is reasonable to separately treat symptomatic perianal disease. The diversity of perianal manifestations in Crohn's disease mandates a tailored, individualized approach in every case. Medical therapy is the best treatment option for hemorrhoids and anal fissures. The medical management of patients with perianal Crohn's disease includes the use of systemic antibiotics, immunosuppressive agents, and infliximab. Infliximab is now recognized as a very efficacious agent for treating fistulizing Crohn's disease, including perianal fistulae. It may also reduce the need for surgical intervention in specific cases. Abscesses and fistulae are treated by control of sepsis, resolution of inflammation and optimal preservation of continence, and quality of life. Abscesses require surgical drainage that may need to be prolonged to achieve complete healing. Fistulae may be treated medically, especially in cases of concurrent proctitis. Refractory fistulae may require surgical treatment including an occasional need for fecal diversion or proctectomy. The role of new treatment options such as natalizumab and CDP571 is evolving and requires further investigation.

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.

Long-term indwelling seton for complex anal fistulas in Crohn's disease

PURPOSE

This study was designed to review the results of long-term indwelling seton or depezzar catheter in the management of perianal Crohn's disease.

METHODS

A retrospective case review from data extracted from a prospective endorectal ultrasound database was performed. All patients underwent an intraoperative endorectal ultrasound to identify the extent of the fistulas and to assess anal wall thickness. Fistulas were classified by Parks' criteria. All patients then underwent insertion of a seton or depezzar catheter under ultrasound guidance. All patients were followed clinically and with endorectal ultrasound by the senior author. Outcome measures included symptom control, number of procedures required, fecal continence, and reduction in anal wall thickness.

RESULTS

Twenty-eight patients with 43 complex perianal Crohn's fistulas were identified. Median follow-up was 13 (range, 2-81) months. Twenty-one percent of patients developed recurrent or new perianal symptoms while the seton was in situ. Eleven percent of patients required further surgical intervention. The median anal wall thickness at the time of diagnosis was 18.5 mm reducing to a median of 14 mm after seton insertion and symptom control (P < 0.02). No patient reported a deterioration in fecal continence after seton insertion. In multivariate analysis, patient age (P < 0.005), reduction in anal wall thickness after seton insertion (P < 0.04), and length of follow-up (P < 0.03) were significant predictors of long-term symptom control.

CONCLUSIONS

Long-term indwelling seton is an effective management modality for complex perianal Crohn's fistulas, which does not negatively impact fecal continence. Clinical symptoms and course are associated with anal wall thickness as measured by endorectal ultrasound.