The surgical management of fistula-in-ano in a specialist colorectal unit

A systematic review of the quality of reporting of interventions in the surgical treatment of Crohn's anal fistula: an assessment using the TIDiER and Blencowe frameworks

BACKGROUND

Crohn's anal fistula is a challenging condition, and may require multiple surgical procedures. To replicate successful procedures, these must be adequately reported in the literature. The aim of this study was to review the quality of reporting of components of surgical interventions for Crohn's anal fistula.

METHODS

A systematic review was conducted. It was registered with PROSPERO (CRD:42019135157). The Medline and EMBASE databases were searched for studies reporting interventions intended to close fistula in patients with Crohn's disease, published between 1999 and August 2019. Abstracts and full texts were screened for inclusion by two reviewers. Dual extraction of data was performed to compare reporting to the TIDiER and Blencowe frameworks for reporting of interventions.

RESULTS

Initial searches identified 207 unique studies; 38 full texts were screened for inclusion and 33 were included. The most common study design was retrospective cohort (17/33), and the most frequently reported interventions were anal fistula plug (n = 8) and fibrin glue (n = 6). No studies showed coverage of all domains of TIDieR. Reporting was poor among domains related to who provided an intervention, where it was provided, and how it was tailored. Reporting of domains in the Blencowe framework was poor; the majority of studies did not report the component steps of procedures or efforts to standardise them.

CONCLUSIONS

This study demonstrates that reporting on technical aspects of interventions for Crohn's anal fistula is poor. Surgeons should aim to improve reporting to allow accurate reproduction of techniques both in clinical practice and in clinical trials.

Evaluation and management of perianal abscess and anal fistula: SICCR position statement

Perianal sepsis is a common condition ranging from acute abscess to chronic anal fistula. In most cases, the source is considered to be a non-specific cryptoglandular infection starting from the intersphincteric space. Surgery is the main treatment and several procedures have been developed, but the risks of recurrence and of impairment of continence still seem to be an unresolved issue. This statement reviews the pertinent literature and provides evidence-based recommendations to improve individualized management of patients.

Cx601 (darvadstrocel) for the treatment of perianal fistulizing Crohn's disease

Introduction: Given the well-documented difficulty to treat perianal fistulizing Crohn's disease (pCD), with 40% of patients experiencing recurrence even after reiterative surgery and advanced medical therapy, research in this field has focused on the role of mesenchymal stem cells (MSC). Areas covered: The aim of this article is to furnish an overview of the pathogenetic mechanisms, clinical applications and evidences for the use of MSC for pCD with particular focus on adipose-derived allogenic MSC including darvadstrocel. Expert Opinion: The effect of MSC on fistula healing is probably mediated by their anti-inflammatory properties more than by their ability to engraft and trans-differentiate in the healthy tissue. A holistic treatment of pCD, addressing different pathophysiological factors, may represent the key for an improvement in the healing rate. In this setting, MSC might play a role as 'augmentation' therapy in combination with more conventional treatments. Whether MSC have benefit in non-complex fistula in biological naïve patients, in complex fistula with many tracts and/or in rectovaginal fistulas, are unexplored fields that need further investigation. A central registry of pCD patients undergoing treatment with MSC should be created in order to elucidate the efficacy, safety and costs of stem cells treatment on long term follow up.

One stage fistulectomy for high anal fistula with reconstruction of anal sphincter without fecal diversion

Perianal sepsis and fistula is a troublesome disease in the field of colorectal surgery in term of recurrence and fecal incontinence. The aim of our study is to evaluate the role of 'one stage complex anal fistula excision with reconstruction of anal sphincter without stool diversion' regarding fecal incontinence and recurrence. This was prospective cohort study on 175 patients of complex high peri-anal fistulae, the patients were subjected to fistulectomy and reconstruction (primary suture repair) of anal sphincter without stool diversion, the patients were followed up 1 year postoperatively after complete healing of the wound regarding their continence to stool and gases using Wexner score and recurrence of the fistula which is examined clinically and radio-logically using MRI. Among the 175 patients only four had developed fecal incontinence with varying degrees in which 2 patients developed gas incontinence and 2 patients developed soiling, after 3 months 8 patients had recurrence and after 6-9 months 6 patients developed recurrence . Also at the end of follow up period upon performing the confirmatory MRI, 2 patients showed hidden fistulous tracts ending into a high abscess cavity. This ends up into total of 16 recurrent cases. Five patients experienced delayed wound healing. In conclusion, Compared to other treatment modalities for complex anal fistula found in literature, it had been found that one stage surgery (fistulectomy with primary sphincter repair) has good results regarding healing of the fistula with low risk of incontinence, low recurrence rate and good wound healing.

How to Insert a Draining Seton Correctly

INTRODUCTION

Misconceptions exist about the proper way to use draining setons in the management of anal fistulas. This technical note lays out the principles for their use.

TECHNIQUE

Insertion of draining setons is a prerequisite to successful management of anal fistulas. The correct technique involves identification of the correct track and internal opening and drainage of the track with a silastic seton. This sets the stage for definitive repair after the inflammation subsides.

RESULTS

Three cases are presented to illustrate common errors made during the insertion of draining setons.

CONCLUSIONS

Appropriate seton drainage of an anorectal fistula is an important part of the ultimate repair. Correct use of setons minimizes symptoms from the seton itself and optimizes its effectiveness.

CAN THREE-DIMENSIONAL ANORECTAL ULTRASONOGRAPHY BE INCLUDED AS A DIAGNOSTIC TOOL FOR THE ASSESSMENT OF ANAL FISTULA BEFORE AND AFTER SURGICAL TREATMENT?

BACKGROUND

There is no a clear knowledge concerning the division of any part of the anal sphincter complex and the effect of this procedure on the function of the anal canal during the treatment of perianal fistula.

OBJECTIVE

To evaluate the usefulness of 3D anorectal ultrasound in the assessment of anal fistula, quantifying the length of the sphincter muscle to be transected, selecting patients for different approaches and identifying healing, failure or recurrence after the surgical treatment.

METHODS

A prospective study included patients with primarily cryptogenic transsphincteric anal fistula assessed by fecal Incontinence score, tri-dimensional anorectal ultrasound and anal manometry before and after surgery. Based on 3D-AUS, patients with ≥50% external sphincter or external sphincter+puborectalis muscle involvement in males and ≥40% external sphincter or external sphincter+puborectalis muscle in females were referred for the ligation of the intersphincteric tract (LIFT) or seton placement and subsequent fistulotomy; and with <50% involvement in males and <40% in females were referred to one-stage fistulotomy. After surgery, the fibrosis (muscles divided) and residual muscles were measured and compared with the pre-operative.

RESULTS

A total of 73 patients was included. The indication for the LIFT was significantly higher in females (47%), one-stage fistulotomy was significantly higher in the males (46%) and similar in seton placement. The minor postoperative incontinence was identified in 31% of patients underwent sphincter divided and were similar in both genders. The 3D-AUS identified seven failed cases.

CONCLUSION

The 3D ultrasound was shown to be an effective method in the preoperative assessment of anal fistulas by quantifying the length of muscle to be divided, as the results were similar at the post-operative, providing a safe treatment approach according to the gender and percentage of muscle involvement. Additionally, 3D ultrasound successfully identified the healing tissue and the type of failure or recurrence.

Treatment of Perianal Fistulas in Poland

A perianal fistula is a pathological canal covered by granulation tissue connecting the anal canal and perianal area epidermis. The above-mentioned problem is the reason for the patient to visit the surgeonproctologist. Unfortunately, the disease is characterized by a high recurrence rate, even despite proper management. The aim of the study was to determine the current condition of perianal fistula treatment methods in everyday surgical practice, considering members of the Society of Polish Surgeons.

MATERIAL AND METHODS

1523 members of the Society of Polish Surgeons received an anonymous questionnaire comprising 15 questions regarding perianal fistula treatment in everyday practice.

RESULTS

Results were obtained from 807 (53%) members. After receiving answers, questionnaire results were collected, analysed, and presented in a descriptive form.

CONCLUSIONS

Study results showed that most Polish surgeons choose the fistulectomy/fistulotomy method. Considering treatment of perianal fistulas the most important issue is to find the correct, primary fistula canal. Further methods should be individually selected for each patient. One should also remember that every fistula is different. Surgical departments that operate a small number of perianal fistulas should direct such patients to reference centers.

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.

Evaluation and management of perianal abscess and anal fistula: a consensus statement developed by the Italian Society of Colorectal Surgery (SICCR)

Perianal sepsis is a common condition ranging from acute abscess to chronic fistula formation. In most cases, the source is considered to be a non-specific cryptoglandular infection starting from the intersphincteric space. The key to successful treatment is the eradication of the primary track. As surgery may lead to a disturbance of continence, several sphincter-preserving techniques have been developed. This consensus statement examines the pertinent literature and provides evidence-based recommendations to improve individualized management of patients.

The ligation of the intersphincteric fistula tract procedure for anal fistula: a mixed bag of results

BACKGROUND

The ligation of the intersphincteric fistula tract procedure, a sphincter-preserving technique, aims to obtain complete, durable healing, while preserving fecal continence in the treatment of transsphincteric anal fistulas.

OBJECTIVE

This was a systematic review to evaluate the outcomes of the originally described (classic) ligation of the intersphincteric fistula tract procedure and the identified technical variations of the procedure.

DATA SOURCES

PubMed, Web of Science, and the archive of Diseases of the Colon & Rectum were searched with the terms "ligation of intersphincteric fistula" and "ligation of intersphincteric fistula tract."

STUDY SELECTION

Original, English-language studies reporting the primary healing rate for each technical variation of the ligation of the intersphincteric fistula tract procedure were included. Studies were excluded when the technique used was unclear or when primary healing rate was reported in a pooled manner including outcomes from multiple technical variations of the ligation of the intersphincteric fistula tract procedure.

INTERVENTION

Outcomes associated with all of the technical variations of the ligation of the intersphincteric fistula tract procedure were investigated.

MAIN OUTCOME MEASURES

The main outcome measured was primary healing rate. Secondary outcome measures included time to healing, changes in continence, and risk factors for failure.

RESULTS

In all, 26 studies met criteria for review, including 1 randomized controlled trial and 25 cohort/case series. Seven technical variations of the ligation of the intersphincteric fistula tract procedure were identified and classified according to the surgical technique. Primary healing rates ranged from 47% to 95%.

LIMITATIONS

The levels of evidence available in the published works are relatively low, as indicated by the Oxford Center for Evidence-Based Medicine evidence levels.

CONCLUSIONS

The ligation of the intersphincteric fistula tract procedure is a promising treatment option for transsphincteric fistulas, with reasonable success rates and minimal impact on continence. The true efficacy of the procedure is unknown because of the number of technical variations and the pooled results reported in the literature.

Outcomes after operations for anal fistula: results of a prospective, multicenter, regional study

BACKGROUND

There are various surgical techniques used treat anal fistulas. The adoption and success rates of newer techniques have not been clearly established.

OBJECTIVE

The purpose of this study was to determine the healing rate after operations for anal fistulas in New England colorectal surgery practices.

DESIGN

We conducted a retrospective review of a prospectively collected database.

SETTINGS

The study was conducted at colorectal surgery practices in New England.

PATIENTS

A prospective, multicenter registry was created by the New England Society of Colon and Rectal Surgeons. Surgeons were invited to collect data prospectively regarding patients operated on for anal fistulas between January 1, 2011, and August 1, 2013. Fistula classification, surgical intervention, continence scores, and healing were determined by the treating surgeon.

INTERVENTION

Operation for anal fistula was performed.

MAIN OUTCOME MEASURES

We measured the proportion of patients with healed fistulas at 3 months.

RESULTS

Sixteen surgeons submitted data regarding 240 operations for fistula with curative intent. Mean patient age was 45 ± 14 years. A total of 158 patients (66%) were men, and 110 (46%) had undergone an anorectal operation. Twenty-nine (12%) had Crohn's disease. The healing rates of fistulotomy, advancement flap, and fistula plugs at 3 months were 94% (95% CI, 89-97), 60% (95% CI, 33-77), and 20% (95% CI, 5-50). The healing rate of the ligation of intersphincteric fistula tract procedure at 3 months was 79% (95% CI, 65-88). Hospital site was the only variable associated with healing (p < 0.05). Hospitals that performed more ligation of intersphincteric fistula tract procedures had higher healing rates at 3 months (p < 0.0001).

LIMITATIONS

This study was limited by selection bias and reporting bias.

CONCLUSIONS

A wide variety of techniques are used to treat anal fistulas in our region. Fistulotomy continues to have excellent results. There has been enthusiastic early adoption of the ligation of intersphincteric fistula tract technique. Early healing rates after the ligation of intersphincteric fistula tract procedure appear to be excellent.

Horseshoe tract of anal fistula: bad luck or an avoidable extension? Lessons from 82 cases

AIM

The aim of this study was to analyse the characteristics of horseshoe tract formation in anal fistula.

METHOD

We retrospectively analysed the data from all consecutive patients who underwent surgery for an anal fistula from November 2004 to March 2011. A horseshoe tract was defined as a circumferential extension connecting both sides of the anorectum.

RESULTS

During the period of analysis, 1876 patients were operated on for a fistula. Of these, 82 (4.4%) had a horseshoe extension. The majority (72%) were male and the median age was 46 (17-84) years. The primary tract was high transsphincteric in 90% of cases and the primary opening was posterior in 65% of cases. The location of the horseshoe extension was posterior in 66% of cases with spread in the deep perianal space in 62%. In all, 71% were cryptoglandular and 24% were seen in Crohn's disease (20). Of the 62 non-Crohn's patients previous treatment was common and included surgery (42), antibiotics alone (41) and non-steroidal anti-inflammatory drugs (21).

CONCLUSION

Horseshoe extension in anal fistula is uncommon. With Crohn's disease excepted, the majority had had previous treatment.

Collagen matrix injection combined with flap repair for complex anal fistula

Several biomaterials have been proposed to treat anal fistula alone or in combination with other surgical procedures aiming to reduce recurrence rates while minimizing continence impairment. More recently a porcine dermal matrix injection has been proposed as infill biomaterial to treat fistulae. We propose an approach consisting of non-cutting seton positioning followed several weeks later by flap repair associated with dermal matrix injection into the fistula tracts. We report our experience with this two-staged procedure on 24 consecutive patients with complex anal fistulae with a median follow up of > 12 months. In our experience this two-stage approach seems to be safe and effective.

Update on anal fistulae: surgical perspectives for the gastroenterologist

Anal fistulae are common and debilitating; they are characterized by severe pain and discharge. They arise following infection near the anal canal, or as a primary event from an abscess in the abdomen, fistulating into the vagina or perianal skin. The term 'cryptoglandular' is given to abscesses arising from the anal glands.For many years, the treatment of choice was to lay open the fistula; however, this risks causing incontinence with potentially devastating consequences. Alternative surgical treatments include setons, fibrin glue, collagen plugs and flaps to cover the internal fistula opening. These have achieved varying degrees of success, as will be discussed. The present review also discusses anal fistulae in light of much recently published literature. Currently, anal fistulae remain challenging and require specialist expertise; however, new treatment options are on the horizon.

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.

Porcine dermal collagen matrix injection may enhance flap repair surgery for complex anal fistula

INTRODUCTION

The use of biomaterials to treat anal fistula has drawn great interest. More recently, a porcine dermal matrix injection has been proposed as infill biomaterial to treat fistulas.

METHODS

We propose a novel approach consisting in non-cutting seton positioning followed by flap repair associated with dermal matrix injection into the fistula tracts after several weeks.

RESULTS

We report our experience with this two-staged procedure on 11 consecutive patients with recurrent high trans-sphincteric fistulas with a minimum follow-up of 6 months.

CONCLUSIONS

In our experience, this two-stage approach seems to be safe and effective.

Análise das complicações tardias em operações anorretais: experiência de um serviço de referência em coloproctologia

INTRODUÇÃO: as operações anorretais correspondem a 80% do movimento do coloproctologista. O índice de complicações tardias após estas operações é indefinido, e varia de acordo com o tipo de operação e serviço onde estas são realizadas. OBJETIVO: estabelecer a taxa de complicações tardias decorrentes das operações anorretais e fatores de risco que pudessem estar associados a estas complicações. MÉTODO: estudo retrospectivo (série de casos) dos pacientes submetidos a operações anorretais entre janeiro de 2007 e julho de 2009. Variáveis estudadas: sexo, idade, operação, sistema de saúde, técnica de anestesia, complicações tardias, além da taxa de reoperações realizadas. RESULTADOS: foram avaliados 430 pacientes (234 mulheres - 54,4%), submetidos a 453 operações anorretais. A hemorroidectomia foi o mais freqüente procedimento realizado: 50,3% das operações. Encontrou-se 102 complicações tardias pós-operatórias, representando 22,52% dos casos. A fissura anal residual foi a complicação mais freqüente (54%/ n=55). Somente 38 pacientes necessitaram de reintervenção cirúrgica (8,83%). Não houve diferença significativa em relação ao sexo, idade, sistema de saúde e ao tipo de operação realizada com as complicações encontradas. CONCLUSÕES: a taxa de complicações tardias foi de 22,52%, com reintervenções cirúrgicas em 8,83% dos pacientes. Não houve fator de risco para complicações identificado nesta série de casos.