Ligation of intersphincteric fistula tract (LIFT) to treat anal fistula: systematic review and meta-analysis

Failure rates and complications of four sphincter-sparing techniques for the treatment of fistula-in-ano: a systematic review and network meta-analysis

BACKGROUND

Several techniques are available to reduce the risk of sphincter injury when treating anal fistula, such as ligation of the intersphincteric fistula tract (LIFT), video-assisted anal fistula treatment (VAAFT), fistula laser closure (FiLaC) and endoanal flap (EAF). The aim of this meta-analysis is to provide data on the safety, complications and failure of these techniques.

METHODS

Studies published after 2017, with patients undergoing at least one among LIFT, VAAFT, FiLaC and EAF for perianal fistula and providing data regarding failure, were retrieved from PubMed and EMBASE. Primary outcome was failure; other outcomes included continence disturbance and complications.

RESULTS

Forty-nine articles with 3520 patients were included. The failure rates were 28.6% (range 3.8-75) for LIFT, 22.3% (6.2-65.2) for VAAFT, 43.9% (11.1-80) for FiLaC and 25.9% (4.7-100) for EAF, with a mean follow-up of 35.4 (6-80.4), 32.4 (6-48), 31.6(6.3-60) and 42.4 (12-155) months. The available network meta-analysis on failure showed RD of -0.08 (95% CI - 0.58 to 0.42) comparing LIFT vs VAAFT and 0.30 (95% CI 0.03 to 0.58) comparing LIFT vs EAF. No patients undergoing VAAFT or FiLaC reported worsening continence, while for LIFT and EAF, the continence disturbance rate was 1.5% and 7.3%, respectively. No major complications were observed. The most common minor complications were pain (1.4%), bleeding (1.1%) and wound infection (1.2%). Overall, minor complication rates were 4.3% for LIFT, 7.2% for VAAFT, 10.2% for FiLaC and 6.2% for EAF. Crohn's disease was associated with a higher failure rate (39.5% vs 31.4%).

CONCLUSIONS

FiLaC, VAAFT, LIFT and EAF may represent a valid option in the treatment of anal fistula. VAAFT showed the lowest rate of failure but with no differences from network metanalysis. Wider homogeneous studies with long-term follow-up are necessary to obtain more robust data.

PROSPERO NUMBER

CRD42022375600.

Mid- and long-term functional outcomes of advancement flap for cryptoglandular perianal fistulas

BACKGROUND

Surgical treatment for perianal fistulas requires balancing fistula closure with the risk of complications such as incontinence. The advancement flap (AF) is a widely used sphincter-sparing technique, yet it appears to offer only marginally better outcomes compared to alternative techniques, with a notable incontinence rate. This study aimed to evaluate the success rate and long-term functional outcomes of AF at our tertiary referral center.

METHODS

This retrospective cohort study analyzed prospectively collected data from electronic medical records and questionnaires distributed in December 2023. Patients aged 18 or older with primary or recurrent perianal fistulas treated with AF between 2013 and 2023 were included. Fistulas of non-cryptoglandular origin and rectovaginal fistulas were excluded. The primary outcome was fecal incontinence. Secondary outcomes included disease burden, fistula closure, and risk factors for recurrence.

RESULTS

Eighty-one patients were included; 37 (46%) were women, mean age was 45 years, and 93% had a complex fistula. The median follow-up was 27 months (IQR 15.5-64). Before AF, 36% reported some degree of incontinence, increasing to 80% at long-term follow-up after AF. Specifically, 20 out of 26 (77%) preoperative fully continent patients reported incontinence issues at long-term follow-up. Fistula disease impact on daily life was higher for those who failed AF repair. Primary fistula closure was achieved in 35 patients (43%). No risk factors for AF failure could be identified.

CONCLUSIONS

Advancement flap repair of perianal fistulas is challenging and can lead to fecal incontinence, so thorough preoperative counseling, consistent long-term follow-up, and further research comparing alternative sphincter-sparing techniques are warranted.

Sphincter-preserving total fistulectomy with resection of the anoderm and skin and intersphincteric space closure for anal fistula

Non-cure, recurrence and faecal incontinence have often been a major challenge in patients after surgical treatment for anal fistula. To overcome these problems, we have developed a sphincter-preserving total fistulectomy procedure involving resection of the anoderm and skin with intersphincteric space closure (TFRAS). The purpose of the present study was to evaluate this TFRAS technique. TFRAS was performed in 618 patients. The method involved excision of the anoderm and skin, including the internal opening, total removal of the fistula tract while preserving the sphincter, closure of the resulting intersphincteric space and open wound. The Parks classification was used, and subcutaneous, supralevatoric, and unclassifiable fistulas not included in this classification were newly defined and evaluated. The postoperative cure rate was 97.7% and the recurrence rate was 0.7%. The non-cure rate was significantly higher for supralevatoric fistulas and the recurrence rate was significantly higher for unclassifiable fistulas. No cases of postoperative solid faecal incontinence were observed, and the faecal incontinence rate was 0.7%. The mean postoperative Cleveland Clinic Faecal Incontinence (CCFI) score was 0.9, and the highest value of 8 was observed in only one case. No significant differences were found between the classifications based on faecal incontinence rates and the CCFI score. There was no significant difference in CCFI score between patients who underwent TFRAS at only one site and those who did so at two or more sites. TFRAS is considered a useful technique for anal fistulas, offering a high cure rate, a low recurrence rate, and no severe postoperative faecal incontinence.

Is the ligation of the intersphincteric fistula tract (LIFT) procedure truly a sphincter preserving procedure for anal fistula? A scoping review of the literature

INTRODUCTION

The ligation of the intersphincteric fistula tract (LIFT) procedure has garnered popularity with its success rates and purported sphincter-continence preservation. However, there remains a paucity in the literature on the objective evaluation of sphincter integrity and fecal continence after the LIFT procedure.

OBJECTIVES

The present study undertakes a scoping review to systematically explore and map the published literature, to evaluate the sufficiency of data on the impact on continence in patients after the LIFT procedure.

DESIGN

A systematic search of MEDLINE, PubMed, EMBASe, CINAHL was performed from January 2007 to April 2020 and 597 publications were identified. Forty-two satisfied the inclusion and exclusion criteria. We performed a scoping review in accordance to the PRISMA-ScR guidelines.

RESULTS

Only 3 (7.1%) of publications were randomized controlled trials, of which just 1 (2.4%) measured incontinence as a primary outcome. Continence was measured both pre- and post-LIFT in 30 (71.4%), of which 19 (45.2%) had a fixed protocol for continence assessment, which was heterogeneous between the studies. Continence was assessed using subjective scoring systems in 27 (64.3%) and objective measurement was performed in just 6 (14.3%). No studies performed post-operative anatomical assessment of the anal sphincter complex.

CONCLUSIONS

Long-term continence in post-LIFT patients is not supported with adequately powered prospective longitudinal trials using rigorously protocoled pre- and post-operative assessment of continence. Future research that focuses on a combination of objective assessment using anal manometry as well as anatomical assessment of the sphincter complex on top of subjective evaluation is needed before we can be certain if LIFT is indeed a sphincter and continence preserving technique.

Preclinical testing of a new radiofrequency ablation device in a porcine perianal fistula model

PURPOSE

Anorectal fistulas present a treatment challenge, with conventional surgical methods potentially resulting in complications such as fecal incontinence. To improve patient outcomes, more effective and minimally invasive therapies are critically needed. In this study, an optimal porcine model for the creation of anorectal fistulas was developed and used to evaluate the efficacy of radiofrequency ablation (RFA) therapy.

METHODS

Two distinct but related experiments were conducted. In the first experiment, a reliable and standardized porcine anorectal fistula model was developed. In the second, the healing process was assessed, and outcomes were compared between the RFA-treated group and the control group using the established porcine model.

RESULTS

The results indicated that a 3.5-cm fistula tract length and a 14-day evaluation period following seton removal are optimal for the porcine anorectal fistula model. In the second experiment, the RFA group tended to exhibit better outcomes regarding fistula closure, although the differences were not statistically significant. Histopathologically, no significant difference in inflammation grade was observed between groups; however, scar tissue was more predominant in the RFA group.

CONCLUSIONS

The findings suggest that RFA therapy may offer potential benefits in the treatment of anorectal fistulas, as demonstrated using a porcine model. To validate these results and explore the mechanisms of action underlying RFA therapy for anorectal fistulas, further research involving larger sample sizes and a more robust study design is required.

Closed trans-intersphincteric fistulotomy: a new modified sphincter-sparing technique for high transsphincteric anal fistula

BACKGROUND

The main goals of surgery for fistula-in-ano are to completely resolve the condition and maintain optimal anal function. Effective management of the internal opening during and proper postoperative drainage of the intersphincter plane are crucial for achieving successful outcomes. This study evaluated the clinical efficacy of a novel sphincter-sparing technique for treating high transsphincteric anal fistula (HTAF).

METHODS

This prospective study included 55 patients with HTAF who underwent closed trans-intersphincteric fistulotomy (CTiF) between July 2021 and April 2022 at our institution. Preoperative anorectal magnetic resonance imaging was performed for all patients. The primary outcome measures assessed the rate of fistula healing while the secondary outcome measures evaluated healing time, Cleveland Clinic Florida fecal incontinence score (CCF-FIS), 11-point visual analog scale (VAS) pain score and postoperative complications.

RESULTS

We included 55 patients with HTAF in this study. During a mean follow-up period of 9.3 months, CTiF achieved a healing rate of 90.91% (50/55). The mean time to recovery was 7.09 ± 1.94 weeks. Four (7.27%) patients developed postoperative urinary retention. At the 6-month follow-up, the CCF-FIS and VAS score were 0 [(0,0) range, 0-3] and 0 [(0,1); range, 0-4], respectively. Two patients with recurrent HTAF recovered after treatment with a transanal opening of intersphincteric space procedure, and three recovered after seton placement.

CONCLUSIONS

CTiF is a promising and effective sphincter-sparing technique for treating HTAF. To confirm long-term outcomes, larger sample size prospective randomized controlled trials are required.

Use of 3D Anorectal Ultrasonography in the Preoperative Assessment of Complex Anal Fistulas and Patterns of Healing, Failure, and Recurrence After Ligation of the Intersphincteric Fistula Tract (LIFT)

OBJECTIVES

To use three-dimensional anorectal ultrasonography (3D-US) to evaluate the outcome of ligation of the intersphincteric fistula tract (LIFT) in patients with crypto-glandular transsphincteric fistula and describing the patterns of healing, failure, and recurrence rate.

METHODS

After classifying the fistula and determining the length of the sphincter muscle to be transected, the patients were submitted to LIFT. The accuracy of pre- and postoperative 3D-US with 360° endoprobe (16 MHz) with automatic scanning and clinical findings was evaluated against surgical findings. Three outcomes were considered: healing, failure (persistent anal fistula through the original external opening or intersphincteric), and recurrence (reappearance of the anal fistula).

RESULTS

Sixty-three patients of both sexes were evaluated. The 3D-US assessment revealed primary healing in 50 (79.3%) patients, although in 6 (9.5%) cases healing was delayed and the cavity was without communication with the anal canal. The procedure failed in 9 (15.9%) and fistula recurred in 4 (6.3%), all of whom underwent a second surgery based on a new 3D-US, resulting in a 92.3% (12/13) healing rate on 3D-US.

CONCLUSIONS

A 3D-US was found to be useful in the preoperative assessment of fistulas by quantifying the percentage of muscle to be transected, and in the postoperative assessment by identifying healing, types of failure, and recurrence. The 3D-US was accurate and consistent with surgical findings.

Structured magnetic resonance imaging and endoanal ultrasound anal fistulas reporting template (SMART): An interdisciplinary Delphi consensus

BACKGROUND

There is still considerable heterogeneity regarding which features of cryptoglandular anal fistula on magnetic resonance imaging (MRI) and endoanal ultrasound (EAUS) are relevant to surgical decision-making. As a consequence, the quality and completeness of the report are highly dependent on the training and experience of the examiners.

AIM

To develop a structured MRI and EAUS template (SMART) reporting the minimum dataset of information for the treatment of anal fistulas.

METHODS

This modified Delphi survey based on the RAND-UCLA appropriateness for consensus-building was conducted between May and August 2023. One hundred and fifty-one articles selected from a systematic review of the literature formed the database to generate the evidence-based statements for the Delphi study. Fourteen questions were anonymously voted by an interdisciplinary multidisciplinary group for a maximum of three iterative rounds. The degree of agreement was scored on a numeric 0–10 scale. Group consensus was defined as a score ≥ 8 for ≥ 80% of the panelists.

RESULTS

Eleven scientific societies (3 radiological and 8 surgical) endorsed the study. After three rounds of voting, the experts (69 colorectal surgeons, 23 radiologists, 2 anatomists, and 1 gastroenterologist) achieved consensus for 12 of 14 statements (85.7%). Based on the results of the Delphi process, the six following features of anal fistulas were included in the SMART: Primary tract, secondary extension, internal opening, presence of collection, coexisting lesions, and sphincters morphology.

CONCLUSION

A structured template, SMART, was developed to standardize imaging reporting of fistula-in-ano in a simple, systematic, time-efficient way, providing the minimum dataset of information and visual diagram useful to referring physicians.

LIFT procedure: postoperative outcomes, risk factors for fistula recurrence and continence impairment

Ligation of the intersphincteric fistula tract has been recently employed as definitive treatment of anal fistulas. However, it carries a potential risk of continence impairment, fistula recurrence, and repeated operations. This study aimed to assess postoperative outcomes related to this procedure and evaluate the potential influence of preoperative and intraoperative features. Patients who underwent LIFT procedure between June 2012 and September 2021 were retrospectively analyzed. Patients were divided according to whether they developed fistula recurrence and on the history of a surgery prior to the LIFT. Preoperative features, postoperative outcomes, and risk factors adverse outcomes were analyzed. Forty-eight patients were included, of which 25 received primary LIFT, being the high transsphincteric fistula pattern the most frequent (62.5%). The median follow-up was 13.3 months, with a recurrence rate of 20.8%, of which the majority presented an intersphincteric fistula pattern (50%); and continence impairment rate of 16.7%. A higher prevalence of diabetes (p = 0.026) and a trend towards a higher prevalence of patients with a history of high transsphincteric fistula (0.052) were observed in the group with fistula recurrence. The history of diabetes and the operation time with a cut-off value ≥ 69 min showed a trend as a risk factors for developing fistula recurrence (0.06) and postoperative continence impairment (0.07), respectively. The LIFT procedure seems to be safe in terms of morbidity, with a reasonable incidence of recurrences, showing better results when it is primarily performed. Preoperative characteristics should be considered as they may impact outcomes.

Subtotal fistulectomy and sliding anoderm flap: A new sphincter-sparing technique for anal fistula

AIM

The underlying causes of failure or recurrence after ligation of the intersphincteric fistula tract are postulated to be refistulization, breakdown of the closure wound in the intersphincteric plane and faecal contents entering the internal opening, thereby causing recurrent infection. The aim of this study is to demonstrate the outcomes of subtotal fistulectomy with sliding anoderm flaps to prevent refistulization.

METHOD

This retrospective study used prospectively collected data. Patients with transsphincteric or intersphincteric fistulas were enrolled between August 2021 and July 2023. An anal manometric study was performed before and after surgery. Faecal incontinence was evaluated using the faecal incontinence severity index (FISI). Failure was defined as nonhealing of the surgical wound or fistula.

RESULTS

Fifty-one patients who underwent subtotal fistulectomy with a sliding anoderm flap were included. After a median follow-up of 12 months (range 4-27 months), primary healing was achieved in 49 patients (96%). Two patients experienced treatment failure, while none developed postoperative recurrence. The median healing time was 10 weeks (range 6-24 weeks). The FISI scores did not change significantly after the surgery. The median resting pressure significantly reduced after surgery [125 cmH2O (range 59-204 cmH2O) vs. 99 cmH2O (range 36-176 cmH2O); p = 0.0001]. The median squeeze pressure significantly decreased after surgery [356 cmH2O (range 137-579 cmH2O) vs. 329 cmH2O (range 72-594 cmH2O; p = 0.005)].

CONCLUSION

Subtotal fistulectomy with a sliding anoderm flap showed excellent healing rates with no postoperative deterioration of anal function.

Ligation of intersphincteric fistula tract (LIFT) for trans-sphincteric cryptoglandular anal fistula: long-term impact on faecal continence

BACKGROUND

The ligation of intersphincteric fistula tract is a surgical technique designed to treat trans-sphincteric anal fistulas aiming to preserve sphincter integrity. Recent studies suggest its efficacy in short-term fistula healing with limited impact on continence. However, comprehensive prospective data on long-term outcomes, including recurrence and bowel continence, are limited. The present study aims to report on the long-term functional outcomes.

METHODS

Patients who underwent the ligation of intersphincteric fistula tract procedure for trans-sphincteric cryptoglandular anal fistulas between July 2012 and October 2018 at two Dutch referral centres were retrospectively reviewed. The primary outcome of interest was the long-term bowel continence after the ligation of intersphincteric fistula tract procedure, using the faecal incontinence severity index. Short-term data (collected in 2018) and long-term data (collected in 2023) on bowel continence, healing rates and recurrences were obtained through electronic records and Rockwood questionnaires. Sankey diagrams were used to visually represent individual variations in continence status (preoperative versus follow-up).

RESULTS

Among 110 patients included (50% female, median follow-up 92 months), 101 patients (92%) were treated with previous surgeries (median 2, range 0-6) and 80% had previous seton drainage. Preligation of intersphincteric fistula tract, 16% of the patients reported incontinence (mean(s.d.) faecal incontinence severity index: 2.4(7.5), increasing to 18% after ligation of intersphincteric fistula tract at short-term follow-up, including 11% newly induced cases. Long-term follow-up collected using Rockwood questionnaires (63% response rate) in 69 patients uncovered a 74% incontinency rate (mean(s.d.) faecal incontinence severity index: 9.22(9.5). In those patients without subsequent surgery 49% (17 of 35) reported incontinence at long-term follow-up. Primary fistula healing after ligation of intersphincteric fistula tract was 28%. Preoperative seton drainage significantly improved healing rates (33% versus 9%). Notably, 43% (34 of 79) of unhealed fistulas transitioned into intersphincteric tracts; in these patients, 19 were treated with subsequent fistulotomy achieving cure in 18 cases.

CONCLUSIONS

Ligation of intersphincteric fistula tract healing rates fell below recent literature standards. Although the immediate impact on postoperative continence appears minimal, long-term incontinence rates are concerning. In recognizing the deterioration of individual continence, we advocate for a patient-centered approach and urge fellow researchers and clinicians to collect comprehensive prospective continence data.

Efficacy of different surgical treatments for management of anal fistula: a network meta-analysis

PURPOSE

Currently, the anal fistula treatment which optimises healing and preserves bowel continence remains unclear. The aim of our study was to compare the relative efficacy of different surgical treatments for AF through a network meta-analysis.

METHODS

Systematic searches of MEDLINE, EMBASE and CENTRAL databases up to October 2022 identified randomised controlled trials (RCTs) comparing surgical treatments for anal fistulae. Fistulae were classified as simple (inter-sphincteric or low trans-sphincteric fistulae crossing less than 30% of the external anal sphincter (EAS)) and complex (high trans-sphincteric fistulae involving more than 30% of the EAS). Treatments evaluated in only one trial were excluded from the primary analyses to minimise bias. The primary outcomes were rates of success in achieving AF healing and bowel incontinence.

RESULTS

Fifty-two RCTs were included. Of the 14 treatments considered, there were no significant differences regarding short-term (6 months or less postoperatively) and long-term (more than 6 months postoperatively) success rates between any of the treatments in patients with both simple and complex anal fistula. Ligation of the inter-sphincteric fistula tract (LIFT) ranked best for minimising bowel incontinence in simple (99.1% of comparisons; 3 trials, n = 70 patients) and complex anal fistula (86.2% of comparisons; 3 trials, n = 102 patients).

CONCLUSIONS

There is insufficient evidence in existing RCTs to recommend one treatment over another regarding their short and long-term efficacy in successfully facilitating healing of both simple and complex anal fistulae. However, LIFT appears to be associated with the least impairment of bowel continence, irrespective of AF classification.

Surgical treatment trends and outcomes for anal fistula: fistulotomy is still accurate and safe. Results from a nationwide observational study

PURPOSE

The aim of the present study was to analyse current surgical treatment preferences for anal fistula (AF) and its subtypes and nationwide results in terms of success and complications.

METHODS

A retrospective multicentre observational cohort study was conducted. The study period was 1 year (2019), with a follow-up period of at least 1 year. A descriptive analysis of patient characteristics and trends regarding technical options was performed. Univariate and multivariate Cox regression models were used to analyse factors associated with healing and faecal incontinence (FI).

RESULTS

Fifty-one hospitals were involved, providing data on 1628 patients with AF. At a median follow-up of 18.3 (9.9-28.3) months, 1231 (75.9%) patients achieved healing, while 390 (24.1%) did not; failure was catalogued as persistence in 279 (17.2.0%) patients and as recurrence in 111 (6.8%). On multivariate analysis, factors associated with healing were fistulotomy (OR 5.5; 95% CI 3.8-7.9; p < 0.001), simple fistula (OR 2.1; 95% CI 1.5-2.8; p < 0.001), single tract (HR 1.9; 95% CI 1.3-2.8; p < 0.001) and number of preparatory surgeries (none vs. 3; HR 1.8; 95% CI 1.2-2.8; p = 0.006). Regarding de novo FI, in the multivariate analysis previous anal surgery (OR 1.5, 95% CI 1.0-2.4, p = 0.037), age (OR 1.02, 95% CI 1.00-1.04, p = 0.002) and being female (OR 1.7, 95% CI 1.1-2.5, p = 0.008) were statistically related.

CONCLUSIONS

Anal fistulotomy is the most used procedure for AF, especially for simple AF, with a favourable overall balance between healing and continence impairment. Sphincter-sparing or minimally invasive sphincter-sparing techniques resulted in lower rates of healing. In spite of their intended sphincter-sparing design, a certain degree of FI was observed for several of these techniques.

Comparison of BioLIFT versus LIFT for the treatment of trans-sphincteric anal fistula: a protocol for systematic review and meta-analysis

INTRODUCTION

Identifying the optimal treatment for anal fistula has been challenging. Since first reported in 2007, the ligation of the intersphincteric fistula tract (LIFT) procedure has reported healing rates between 40% and 95% and is being increasingly adopted. The BioLIFT is an augmentation of the LIFT with an intersphincteric bioprosthetic mesh and has reported healing rates between 69% and 94%. Despite increased costs and potential complications associated with mesh, the evidence comparing healing rates between BioLIFT and LIFT is unknown. This study details the protocol for a systematic review and meta-analysis of BioLIFT and LIFT to compare outcomes associated with each procedure.

METHODS AND ANALYSIS

MEDLINE, EMBASE and the Cochrane Database will be searched from inception using a search strategy designed by an information specialist. Randomised controlled trials, prospective and retrospective cohort studies, consecutive series, cross-sectional studies and case series with more than five patients will be included. Both comparative and single group studies will be included. The eligible population will be adult patients undergoing BioLIFT or LIFT for trans-sphincteric anal fistula. The primary outcome will be primary healing rate. Secondary outcomes will capture secondary healing rate and complications. Abstract, full text and data extraction will be completed independently and in duplicate by two reviewers. Study risk of bias will be assessed using Risk of Bias In Non-randomized Studies - of Interventions and the Risk of Bias (RoB 2.0) tool. Quality of evidence for outcomes will be evaluated using Grading of Recommendations, Assessment, Development and Evaluations criteria. A meta-analysis will be performed using a random-effects inverse variance model. Subgroup and sensitivity analyses will be explored in relation to complex fistula characteristics and patients who have undergone previous LIFT. Heterogeneity will be assessed using the I2 statistic.

ETHICS AND DISSEMINATION

This review does not require research ethics board approval. This study will be completed in September 2022. The findings of this study will be disseminated through peer-reviewed international conferences and journals.

PROSPERO REGISTRATION NUMBER

CRD42020127996.

Current Therapy of Cryptoglandular Anal Fistula: Gold Standards and Alternative Methods

Cryptoglandular anal fistulas are one of the most common colorectal diseases and occur with an incidence of about 20/100,000. Anal fistulas are defined as an inflammatory junction between the anal canal and the perianal skin. They develop from an abscess or chronic infection of the anorectum. Surgical treatment of the disease is the method of choice. Even when treating an acute abscess, its cause should be sought at the same time. If there is a connection to the anal canal without affecting relevant parts of the sphincter muscles, primary fistulotomy should be performed. If larger parts of the sphincter muscle are involved, the insertion of a seton drain is usually useful. There are essentially two recommendations for the elective treatment of cryptoglandular anal fistulas. Distal fistulas should be excised, with the proviso that as little sphincter muscle as possible is sacrificed. In the case of highly proximally located and complex fistulas, sphincter-preserving surgical techniques should be used. In this case, the method of choice is the mucosal or advancement flap. Alternatively, clips, fibrin injections, fistula plugs, fistula ligatures, or laser-based procedures are described in the literature. In the case of intermediate fistulas, a fistulectomy with primary sphincter reconstruction can be useful. Every operation is carried out as a compromise between definitive healing of the fistula and a potential risk to the patient's continence. It is often difficult to make a reliable prognosis about the continence function to be expected postoperatively. In addition to the fistula morphology, particular attention should be paid to whether previous proctological operations have already been performed, the gender of the patient, and whether there are pre-existing sphincter dysfunctions. Since the surgeon's expertise plays a decisive role in the success of the treatment, the procedure should be carried out in a specialist proctological centre, especially in the case of complex fistulas or in the case of a condition after previous operations. In addition to the classic procedures, such as fistulectomy or the plastic fistula closure, this article examines alternative methods and their areas of application.

The efficacy of Ksharsutra, Fistulectomy and Ligation of Intersphincteric Fistula Tract (LIFT) procedure in management of Fistula in ano a prospective observational study

BACKGROUND

Fistula in ano is always a troublesome condition for the clinician and the patients owing to its complexity, recurrences, and high morbidity since ancient times. There is no gold standard treatment modality to date documented in the literature for complex fistula in ano.

MATERIAL AND METHODS

We enrolled 60 consecutive adult patients attending the surgical outpatient department of a tertiary care centre in India, diagnosed with complex fistula in ano. Among them, 20 each in the Ligation of intersphincteric fistula tract (LIFT), Fistulectomy andKsharsutra(Special medicated seton) group were respectively recruited randomly. A prospective observational study was conducted. The primary outcomes were postoperative recurrence and morbidity. Post-operative morbidity is measured in terms of postoperative pain, postoperative bleeding, pus discharge and post-operative incontinence. The result of the study were analysed after 6 months of follow-up by clinical examination at outpatient department and at 18 months follow up done telephonically.

RESULTS

At 6 months of follow-up, 2 patients (10%) had a recurrence in the Ligation of intersphincteric fistula tract procedure group, 3 patients (15%) in the fistulectomy group and 6 patients (30%) in Ksharsutra group, however 3(15%), 4(20%) and 9(45%) patients developed recurrence in Ligation of Intersphincteric fistula tract, Fistulectomy and Ksharsutra group respectively at 18 month of follow-up. The differences in the recurrence were not statistically significant.The mean Visual analogue score for postoperative pain after 24 h as well as after 48 h were statistically significant in Ligation of intersphincteric fistula tract versus Ksharsutra group (p < 0.05). The Visual analogue score for post-operative pain was also significant in the Ligation of the intersphincteric fistula tract versus the Fistulectomy group (p < 0.05). The patients treated via Fistulectomy and Ksharsutra had a higher proportion of bleeding (15%) as compared to the Ligation of intersphincteric fistula tract procedure. Postoperative morbidity was statistically significant between the Ligation of intersphincteric fistula tract versus the Ksharsutra and the Ligation of intersphincteric fistula tract versus Fistulectomy.

CONCLUSION

Ligation of intersphincteric fistula tract had less postoperative morbidity compared to Fistulectomy and Ksharsutra procedure; although recurrence was less compared to other methods it was statistically not significant.

Ligation of Intersphincteric Fistulous Tract vs Endorectal Advancement Flap for High-Type Fistula in Ano: A Randomized Controlled Trial

BACKGROUND

This study aimed to compare the postoperative outcomes and success rate of the endorectal advancement flap and ligation of intersphincteric fistulous tract (LIFT) in high-type fistula in ano.

STUDY DESIGN

This randomized control trial included patients with high-type fistula in ano of cryptoglandular origin. The primary endpoint was complete fistula healing at the end of 6 months. However, the patients were followed up for 2 years. Other parameters studied were perioperative complications, duration of surgery, postoperative pain, hospital stay in hours, continence, and quality of life at 6 months.

RESULTS

A total of 84 patients were recruited (42 in each group). The healing rate in the LIFT arm was better than that in the endorectal advancement flap arm (76.2.% vs 54.7%, p = 0.039). Four patients in the endorectal advancement flap group and two in the LIFT group had flatus incontinence at the end of 6 months, but all were continent at 2 years. At the end of the first week, the Visual Analog Scale score and quality of life at 6 months were better in the LIFT arm (3.7 ± 1.16 vs 4.7 ± 0.81 and 0.7 vs 0.6, p < 0.05). The mean duration of surgery was significantly less in the LIFT group (46.43 ± 9.32 vs 89.29 ± 10.90 minutes). None had any postoperative complications, and >80% were discharged within 24 hours.

CONCLUSIONS

The shorter operative duration, better quality of life at 6 months, and higher healing rate make LIFT a superior treatment option for high fistula in ano. However, studies with a large sample size will be needed to verify these results.

Trends in Treatment for Hemorrhoids, Fistula, and Anal Fissure: Go Along the Current Trends

Recent trends in benign anal disease treatment are minimizing surgery to preserve normal anorectal anatomical unit and its functions. However, some surgeons still prefer and are confident with the use of conventional solid surgical methods. In this report, we will investigate the recent trends in the treatment for hemorrhoids, fistula, and anal fissure. The practice guidelines of advanced countries, including UK, Italy, France, USA, Japan, and ESCP, are referred to in this review. Opinions suggested in international meetings were also added. In the management of hemorrhoids, surgical treatments and office procedures were recommended according to a patient's status and preference. For the management of complex anal fistula, novel sphincter-preserving surgical techniques are more widely accepted than a sphincter-dividing procedure of immediate repair following fistulectomy. The treatment of anal fissures is well covered in the guidelines of the ASCRS.

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.

A pilot randomized controlled trial on ligation of intersphincteric fistula tract (LIFT) versus modified parks technique and two-stage seton in treatment of complex anal fistula

Complex anal fistula (CAF) is a challenging condition for surgeons. This randomized trial aimed to compare ligation of the intersphincteric fistula tract (LIFT), modified Parks technique, and two-stage seton in the treatment of complex anal fistula in terms of the success of treatment and complications. This was a pilot randomized trial conducted in the period of January 2019 to December 2019 on adult patients with CAF who were allocated to one of three groups: LIFT, modified Parks technique, and two-stage seton. The main outcome measures were healing rates, time to healing, complications, operation time, and quality of life. Sixty-six patients (75.7% males) of a mean age of 45.2 years were included. Mean operation time of LIFT was significantly shorter than the other two procedures (p < 0.0001). There was a significant difference between the three groups in terms of success rate (p = 0.04) but not in regard to complications (p = 0.59). The modified Parks technique had a significantly higher success rate than LIFT (95.2% vs 68.1%, p = 0.045) whereas the success rates of two-stage seton and LIFT were not significantly different (86.9% vs 68.1%, p = 0.16). The average time to healing after LIFT was significantly shorter than the other two procedures. The quality-of-life scores were comparable among the three groups. There was a significant difference in healing rates after the three procedures as the modified Parks technique achieved the highest success rate followed by two-stage seton and then the LIFT procedure. Time to complete healing after LIFT was significantly shorter than the other two procedures. The three procedures achieved similar quality of life and complication rates.

Efficacy and Safety of Sphincter-Preserving Surgery in the Treatment of Complex Anal Fistula: A Network Meta-Analysis

Background

There are many surgical methods of sphincter preservation in treating complex anal fistula, but the therapeutic effects of each operation are different. Therefore, this study aimed to compare the impact of other treatment methods through a network meta-analysis to evaluate the best sphincter preservation method for treating complex anal fistula.

Methods

We searched PubMed, Embase, Cochrane Library, China National Knowledge Infrastructure, Chinese Biomedical Literature Database, VIP Journal Database, and the Wanfang Database to collate randomized controlled trials on sphincter-preserving surgery for complex anal fistula.

Results

A total of 29 articles were included in this meta-analysis. The cure rates showed no statistically significant differences between any two interventions (P > 0.05). The recurrence rate results showed that the rate of patients after Fistulectomy was higher than others (P < 0.05). The incidence rate of complications showed that the incidence rate after fistulectomy treatment was higher than that of others (P < 0.05). The surface under the cumulative ranking (SUCRA) was used to arrange their advantages and disadvantages, and a larger SUCRA value indicates that the intervention may be more effective. The results showed that TROPIS may have the highest cure rate (SUCRA = 78.6%), stem cell transplantation (SCT) may have the lowest recurrence rate (SUCRA = 85.5%), and imLIFT may have the least complications (SUCRA = 88.2%).

Conclusion

According to the existing literature data, for patients with complex anal fistula, TROPIS may be the surgical method with the highest cure rate, SCT may be the treatment method with the lowest recurrence rate, and imLIFT may be the surgical method with the lowest incidence of postoperative complications.

Systematic Review Registration

PROSPERO, identifier: CRD42020221907.

'Bumps down under:' hemorrhoids, skin tags and all things perianal

PURPOSE OF REVIEW

There continues to be a concentrated effort to improve treatment options readily available for some of the most common perianal diseases: hemorrhoids, anal fissure and anal fistula. The emphasis remains on therapies that definitively address the underlying pathology yet minimize pain and risk of incontinence, have a short recovery period, and are cost-effective. In this analysis, recent developments in the literature are reviewed.

RECENT FINDINGS

Treatment of early stage hemorrhoidal disease remains the same. For grades II-IV disease, hemorrhoidal vessel ligation/obliteration with laser or bipolar energy are reported. For more advanced diseases, modifying the technique for hemorrhoidectomy to improve postoperative complications and pain is described. For anal fissure, a stepwise method continues to be the mainstay of treatment (initiating with vasodilators, followed by botox, and ultimately sphincterotomy), which decreases the risk of incontinence with proper patient selection and technique. Management of anal fistula continues to be challenging, balancing cure vs. risk of harm. Recent developments include modifications to ligation of intersphincteric fistula tract procedure and use of laser to obliterate the tract.

SUMMARY

Advancements in managing benign anorectal disease are ongoing. Several reports are novel, whereas others involve enhancing well-established treatment options by either operative technique or patient selection.

External sphincter-sparing anal fistulotomy (ESSAF): a simplified technique for the treatment of fistula-in-ano

BACKGROUND

Fistula-in-ano due to cryptoglandular disease is a common condition. While a simple anal fistula can be treated successfully by a fistulotomy, the risk of potential damage to the anal sphincters and subsequent poor functional outcomes persist in a large portion of patients with complex fistulae. Several sphincter-preserving treatment procedures have been described for complex fistulae over the past 3 decades, with variable results and complication rates, and no procedure is proven to be superior to the others. We developed external sphincter-sparing anal fistulotomy (ESSAF), a reproducible simple modification of the ligation of intersphincteric fistula tract (LIFT) technique for the treatment of complex fistula-in-ano.. The aim of the present study was to describe the technique and our outcomes.

METHODS

This was a retrospective review of all patients who underwent ESSAF for a complex anal fistula at our institution from January 2014 to December 2019. The primary outcome measure of this study was the primary fistula healing rate. Secondary outcome measures included fecal and/or gas incontinence and postoperative complications. During the ESSAF procedure, the mucosa and skin overlying the fistula tract are incised to allow complete exposure of the sphincter complex. Then the internal sphincter muscle fibers overlying the tract are divided and the tract is meticulously curetted and debrided. Next, the internal opening of the tract traversing the external sphincter muscle is suture-ligated with absorbable sutures. Then, a minimal amount of mucosa is advanced and the incision is partially closed with absorbable sutures, while its external portion is left open for drainage.

RESULTS

Fifty-nine patients [43 males, median age was 50 years (range 36-63 years)] underwent ESSAF for complex anal fistula during the study period. Mean follow-up was 12 ± 14.7 months. Of the 59 patients, 42 (71.2%) experienced fistula closure, with a median healing time of 8 weeks (IQR 4-16 weeks). None of the patients developed significant anal incontinence following the procedure. One patient (1.7%) suffered from soiling and another patient (1.7%) developed postoperative bleeding. There were no infectious complications. Of the 17 patients (28.8%) who failed to heal successfully, 9 (15.2%) did not heal primarily and 8 (16%) experienced recurrence after complete healing. Thirteen (76%) of these patients underwent reoperation with complete recovery after ESSAF (n = 4), fistulotomy (n = 8) or endorectal advancement flap (ERAF) (n = 1). Overall ESSAF initiated recovery in 93.2% of the patients.

CONCLUSIONS

ESSAF is a feasible, safe, reproducible and effective sphincter-sparing procedure for the treatment of complex anal fistulae.

Extreme horseshoe and circumanal anal fistulas-challenges in diagnosis and management

OBJECTIVES

Extreme horseshoe anal fistulas are rare, and there are little data on the diagnosis and management of these fistulas.

MATERIALS AND METHODS

Patients with horseshoe anal fistula, in which the fistula tract encircled more than 75% of the anal circumference were included in the study. All patients were assessed by a preoperative magnetic resonance imaging (MRI). The patients were managed by a sphincter-sparing procedure. The continence was evaluated by an objective continence scoring system (Vaizey's scores).

RESULTS

1059 anal fistula patients were operated on over 7-years with a median follow-up of 36 months (range: 5-79 months). There were 47/1059 (4.4%) patients with extreme horseshoe anal fistulas. In 4/47 patients, the fistulas were complete circumanal (encircling anal canal completely). The mean age was 39.5 ± 10.9 years, M/F-41/6. The fistula was supralevator in 12/47 (25.5%), had an associated abscess in 28/47 (59.6%), and was recurrent in 33/47 (70.2%) patients. The tracts were intersphincteric in 27/47, transsphincteric in 2/47, and both (intersphincteric and transsphincteric) in 18/47 patients. All patients (n = 47) were managed by a sphincter-sparing procedure. Four patients were lost to follow-up. The fistula healed completely in 34/43 (79%) patients. There was no significant difference between preoperative and postoperative Vaizey's continence scores 0.031 ± 0.17 and 0.033 ± 0.18 respectively (P=0.90, Mann-Whitney U-test).

CONCLUSION

Extreme horseshoe fistulas are rare, with an incidence of about 4% (in a referral practice). The missed diagnosis of circumferential tracts could lead to a recurrence. MRI was pivotal to confirm the diagnosis. Proper identification and management of internal opening and adequate drainage of all tracts were crucial for successfully treating extreme horseshoe fistulas.

Long-term outcomes after seton placement for perianal fistulas with and without Crohn's disease

AIM

Perianal sepsis in Crohn's disease (CD) fistulas is managed with antibiotics and surgical drainage; a noncutting seton is used for an identified transsphincteric fistula tract. The optimal management following seton placement for initial control of perianal sepsis remains to be determined. Our main aim was to assess the success rates of curative surgery, seton removal or long-term indwelling seton in patients with and without CD.

METHOD

This was a retrospective cohort of consecutive patients with a perianal fistula treated with a noncutting seton between 2010 and 2019, including 83 CD patients and 94 patients without CD. Initial control of symptomatic perianal infection with a seton and subsequent healing and reintervention rates were compared between the three postseton management strategies.

RESULTS

A total of 177 patients, 61% male and 83.1% with complex fistulas, were followed for a median of 23 months (interquartile range 11-40 months). Immunomodulatory treatment was used in 90.4% of CD patients after seton placement. Good initial control of perianal infection was achieved with a seton in CD and non-CD patients, at 92.9% and 96.7%, respectively (p = 0.11). Overall fistula healing or control for CD and non-CD patients was, respectively, 64% and 86% (p = 0.1) after curative surgery, 49% and 71% after seton removal (p = 0.21) and 58% and 50% with long-term seton placement (p = 0.72). Overall reintervention for recurrence was 83% in CD versus 53.1% in non-CD patients during the follow-up period (p = 0.002).

CONCLUSION

Definitive surgery was possible in only a minority of CD patients. Long-term seton management was an effective option in patients with CD with acceptable improvement and recurrence rates.

The new pathways of spread of anal fistula and the pivotal role of MRI in discovering them

Conventionally, in the pathophysiology of anal fistulas, there is only one space considered significant for the spread of pus in the sphincter complex: the intersphincteric space. However, with increasing experience in the high-resolution MRI, and more focus being given on managing fistulas through the intersphincteric space, two additional pathways of fistula spread have been identified. First is a newly described space labelled as the outer-sphincteric space. Second is a known anatomical space (inner intersphincteric space), but this space was considered as irrelevant from the point of view of fistula spread. The conventional intersphincteric space is present in between these two spaces and is referred as 'middle intersphincteric space' in this paper. These three distinct spaces have significant clinical implications as the pattern of spread of pus is quite different in each space, and the management also differs for fistula tract in each of these spaces.

Ligation of intersphincteric fistula tract (LIFT) with or without injection of platelet-rich plasma (PRP) in management of high trans-sphincteric fistula-in-ano: Short-term outcomes of a prospective, randomized trial

BACKGROUND

Success rate after ligation of the inter-sphincteric fistula tract ranges from 40% to 75%. Platelet-rich plasma is hypothesized to improve healing by slowly releasing growth factors. The objective of the study was to compare the efficacy and outcome of ligation of the inter-sphincteric fistula tract plus platelet-rich plasma local injection versus ligation of the inter-sphincteric fistula tract alone in the management of high trans-sphincteric anal fistula in regards to postoperative pain, time for healing, morbidity, fistula closure rate, recurrence, and quality of life.

METHODS

This was a prospective randomized trial. Patients with trans-sphincteric anal fistulas involving >50% of anal sphincters were included. Patients were randomly assigned to either ligation of the inter-sphincteric fistula tract plus platelet-rich plasma or ligation of the inter-sphincteric fistula tract (49 in each group). The primary endpoints were successful complete fistula closure and duration needed for healing. Secondary endpoints were morbidity, recurrence after 1 year of follow-up, postoperative pain, and quality of life.

RESULTS

Complete primary healing was recorded in 42 patients in the ligation of the inter-sphincteric fistula tract plus platelet-rich plasma group and 32 patients in the ligation of the inter-sphincteric fistula tract group, and the difference was statistically significant (P = .03). The mean time to complete healing after ligation of the inter-sphincteric fistula tract plus platelet-rich plasma was significantly shorter than after ligation of the inter-sphincteric fistula tract alone (15.7 ± 4 days vs 21.6 ± 5.4 days; P = .03). One year after complete healing of anal fistula, recurrence was recorded in 4/42 patients in the ligation of the inter-sphincteric fistula tract plus platelet-rich plasma group and 3/32 patients in the ligation of the inter-sphincteric fistula tract group with no statistically significant difference (P = .99). Patients in the ligation of the inter-sphincteric fistula tract plus platelet-rich plasma group had significantly lower pain scores after both 1 and 7 days. Quality of life and level of happiness were significantly better 1 month after ligation of the inter-sphincteric fistula tract plus platelet-rich plasma.

CONCLUSION

Ligation of the inter-sphincteric fistula tract plus platelet-rich plasma for the treatment of high trans-sphincteric fistula-in-ano is a safe modality with significantly higher successful healing rate, shorter healing time, and less postoperative pain compared with ligation of the inter-sphincteric fistula tract alone. Ligation of the inter-sphincteric fistula tract plus platelet-rich plasma does not improve the rate of recurrence; however, it results in significantly higher short-term quality of life.

Transanal opening of the intersphincteric space: a novel sphincter-sparing procedure to treat 325 high complex anal fistulas with long-term follow-up

AIM

Sepsis in the intersphincteric plane behaves like an abscess in a closed space and is present in most complex fistulas. Ignoring this sepsis is a cause of recurrence. Complex fistulas can be successfully managed by transanal opening of the intersphincteric space (TROPIS) into the anal canal. The long-term efficacy of the TROPIS procedure was analysed in an exclusive cohort of high complex anal fistulas.

METHODS

All consecutive patients operated for a high complex fistula-in-ano were included prospectively. Preoperative MRI scans were obtained for all the patients. The intersphincteric space and internal opening was laid open into the anal canal while preserving the external sphincter. The external tracts were thoroughly curetted and cleaned. Fistula healing rate and objective incontinence scores (preoperatively and during long-term follow-up) were analysed.

RESULTS

A total of 325 patients (age 39.9 ± 10.9 years, 292 men) were operated with TROPIS and had a follow-up of 7-67 months (median 36 months). In the cohort, 67.4% (219) had recurrent fistulas, 82.8% (269) had multiple tracts, 36.3% (118) had horseshoe tracts, 37.5% (122) had associated abscesses and 24% (78) were supralevator fistulas. Nineteen patients were excluded. Fistulas healed completely in 78.4% (240/306) of patients and did not heal in 21.6% (66/306) of patients. 36/66 of these patients were operated again and the fistulas healed in 28 patients. Thus, the overall healing rate was 87.6% (268/306). The mean preoperative and postoperative incontinence scores were 0.085 ± 0.35 and 0.119 ± 0.48 respectively (P = 0.38). The healing rate of fistulas with associated acute abscesses was similar to the fistulas without abscesses (87% vs. 88%, P = 0.85).

CONCLUSION

Transanal opening of the intersphincteric space is a safe and highly effective sphincter-sparing procedure to manage high complex fistulas-in-ano.

SURGICAL TREATMENT OF IATROGENIC COMPLEX RECURRENT EXTRASPHINCTER ANORECTAL FISTULA: A CLINICAL CASE

Background: Anorectal fistula is a benign disease with an average prevalence of 1.69/10,000 population. The disease significantly reduces the life quality and has a tendency to relapse. Repeated surgical treatment can lead to anal sphincter impairment. Paraproctitis is the main anorectal fistulas cause. However, there are also iatrogenic traumatic fistulas that occur after various anorectal surgical interventions.Clinical case: A 44-year old female patient applied to the MSU University clinic in March 2020 with perineal wound with permanent purulent discharge. During examination perianal soft tissue defect was determined, the external fistula opening (40x25x25cm) was visualized at the wound bottom, the internal fistula opening (2x3mm) was visualized at 12h of the clock dial. The perianal area is deformed due to scarring. In 2016 the patient underwent surgical «rectocele elimination, posterior colporaphy, levatoroplasty, plastic surgery of the anterior rectal wall». Obstructive defecation syndrome developed during postoperative period, and repeated surgical treatment was performed – anterior anosfincterolevatoroplasty, Milligan-Morgan hemorrhoidectomy.On the 9th day, there was a «perianal soft tissue rupture» with bleeding and «local anterior rectal wall damage in the suprasphincter zone». Then «the rectal defect suturing» was performed. The perineal wound was left open. The patient was reoperated in 3 months due to a rectovaginal fistula with no effect. A fistulectomy was performed at the Moscow State University Medical Center with the removal of the anal canal defect by mucosal-submucosal flap. The surgical wound heals by secondary tension.Conclusion: The current studies describe a small number of cases of anorectal fistulas secondary to anorectal surgery. At the same time, there is no data on the further surgical management of such patients. It is important to present the iatrogenic anorectal fistulas cases, not only to analyze the fistula cause, but also to describe the surgical treatment method and its efficacy.

Management of cryptoglandular fistula-in-ano among gastrointestinal surgeons in the Netherlands

BACKGROUND

Management of cryptoglandular fistula-in-ano (FIA) can be challenging. Despite Dutch and international guidelines determining optimal therapy is still quite difficult. The aim of this study was to report current practices in the management of cryptoglandular FIA among gastrointestinal surgeons in the Netherlands.

METHODS

Dutch surgeons and residents who are treating FIA regularly were sent a survey invitation by email. The survey was available online from September 19 to December 1 2019. The questionnaire consisted of 28 questions concerning diagnostic and surgical techniques in the treatment of intersphincteric and transsphincteric FIA.

RESULTS

In total, 147 (43%) surgeons responded and completed the survey. Magnetic resonance imaging was the preferred diagnostic imaging modality (97%) followed by the endo-anal ultrasound (12%). In case of a high FIA, 86% used a non-cutting seton. Most respondents removed a seton between 6 weeks and 3 months (n = 84, 58%). Fistulotomy was the procedure of preference in low transsphincteric (86%) and low intersphincteric FIA (92%). Mucosal advancement flap (MAF) and ligation of intersphincteric fistula tract (LIFT), with 78% and 46%, respectively, were the procedures that were applied most often in high transsphincteric FIA. In high intersphincteric FIA 67% performed a MAF and 33% a fistulotomy. Thirty-three percent of all respondents stated that they habitually closed the internal fistula opening, half of them used a Z-plasty. For debridement of the fistula tract the preferred method was curettage (78%).

CONCLUSIONS

Dutch gastrointestinal surgeons use various techniques in the management of FIA. Novel promising techniques should be investigated adequately in sufficient large trials to increase consensus. A core outcome measurement and a prospective international database would help in comparing results. Until then, treatment should be adjusted to the individual patient, governed by fistula characteristics and patient choice.

High failure rates following ligation of the intersphincteric fistula tract for transsphincteric anal fistulas: are preoperative MRI measurements of the fistula tract predictive of outcome?

AIM

Treatment of transsphincteric fistulas (TSFs) with fistulotomy after an indwelling seton is tempered by risks of incontinence and litigation. Thus, ligation of the TSF tract has been popularized as an alternative option. We previously reported on 107 patients who underwent ligation of the intersphincteric fistula tract (LIFT), with a 46% failure rate. Posterior fistula was the only predictor of recurrence. The aim of the present work was to investigate whether the length, width or depth of the fistula measured on preoperative MRI was correlated with recurrence.

METHOD

Following institutional review board approval, a retrospective analysis of our prospective Complex Anal Fistula Database from 1 January 2011 to 31 August 2019 was performed. Patients with TSF who underwent preoperative MRI and LIFT were included. Fistula location was classified as anterior, posterior or lateral. MRI measurements of fistula length, width and depth (in the intersphincteric groove) were performed. The type and rate of postoperative recurrence were analysed.

RESULTS

173 patients underwent MRI for an anal fistula; of these 40 underwent LIFT and 22/40 (55%) had preoperative MRI. There was no difference in the length, width or depth of anterior (n = 9), posterior (n = 7) or lateral (n = 6) fistula tracts. The overall recurrence rate was 9/22 (41%). Posterior TSFs had the highest recurrence rate (5/7, 71%).

CONCLUSION

The mean length, width, and depth of the fistula tract, measured at the preoperative site of LIFT in the intersphincteric groove, did not correlate with recurrence regardless of fistula location.

A Multicenter Randomized Controlled Trial Comparing Safety, Efficacy, and Cost-effectiveness of the Surgisis Anal Fistula Plug Versus Surgeon's Preference for Transsphincteric Fistula-in-Ano: The FIAT Trial

OBJECTIVE

To undertake a randomized comparison of the Biodesign Surgisis anal fistula plug against surgeon's preference in treating cryptoglandular transsphincteric fistula-in-ano.

SUMMARY BACKGROUND DATA

The efficacy of the Biodesign Surgisis anal fistula plug in healing anal fistulae is uncertain.

METHODS

Participants were randomized to the fistula plug with surgeon's preference (advancement flap, cutting seton, fistulotomy, Ligation of the Intersphincteric Fistula Tract procedure). The primary outcome was faecal incontinence quality of life (FIQoL) at 12-months. Secondary outcomes were fistula healing, incontinence rates, and complication and reintervention rates.

RESULTS

Between May 2011 and March 2016, 304 participants were randomized to fistula plug or surgeon's preference. No differences were seen in FIQoL between the 2 groups at 12 months. Clinical fistula healing was reported in 66/122 (54%) of the fistula plug and 66/119 (55%) of the surgeon's preference groups at 12 months. Fecal incontinence rates improved marginally in both the groups. Complications and reinterventions were frequent, with significantly more complications in the fistula plug group at 6-weeks (49/142, 35% vs 25/137, 18%; P=0.002). The mean total costs were £2738 (s.d. £1151) for the fistula plug and £2308 (s.d. £1228) for the surgeon's preference group (mean difference +£430, P=0.0174). The average total quality adjusted life years (QALYs) gained was marginally higher in the fistula plug group. The fistula plug was 35% to 45% likely to be cost-effective across a willingness to pay threshold of £20,000 to £30,000 / QALY.

CONCLUSIONS

The Biodesign Surgisis anal fistula plug is associated with similar FIQoL and healing rates to surgeon's preference at 12 months. Higher costs and highly uncertain gains in QALYs mean that the fistula plug may not be considered as a cost-effective treatment in the UK NHS.

Evaluation of the inflammatory response induced by different materials in the treatment of perianal fistulas: experimental study in rats

The medical literature has no study evaluating the effectiveness of different materials used as setons in the treatment of perianal fistulas; therefore, there is no evidence of availability of a more effective material than others for this purpose.

Objective To evaluate the inflammatory response induced by different materials used as seton in perianal fistulas in rats.

Method Thirty Wistar rats, which were initially submitted for the construction of a perianal fistula by passing transfixing steel wire into the anal canal, were used. The rats were kept for 30 days; after this period, and with confirmation of the formation of the perianal fistula, the setons were introduced (10 rats – cotton thread #0; 10 rats – rubber; and 10 rats – silastic); after 30 days the animals were euthanized, and then the area of the fistula repaired by the seton was resected, and the material retrieved was submitted to histological analysis. The results were analyzed statistically.

Results The mean degree of inflammatory process observed by histological analysis after 30 days was 2.3 for the cotton group; 1 for the rubber group; and 1.2 for the silastic group.

Conclusion A greater inflammatory response was observed in the group treated with a cotton seton. In the remaining groups, a lower inflammatory response, with equal intensity for rubber and silastic-treated rats, was noted.

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.

Assessing Surgeons' Preferences in the Management of Fistula In Ano

Background

Fistula in ano is a common condition treated by surgeons worldwide. Despite this, there is a paucity of high-quality data to aid decision-making. Hence, management presents a difficult and frustrating dilemma for the treating surgeon.

Methods

A prospective regional survey was sent to all members of General Surgeons Australia. Questions regarding surgeon demographics, patient evaluation, perianal abscess, and simple and complex fistula in ano were presented.

Results

Equipoise exists in the management of fistula in ano among general surgeons. This was noted in the management of simple and complex fistula in ano.

Conclusion

Because of the uncertainty in certain clinical scenarios and a paucity of high-quality randomized controlled trials on the management of fistula in ano, evidence-based practice is a challenge to the treating surgeon.

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.

Could FiLaC™ be effective in the treatment of anal fistulas? A systematic review of observational studies and proportional meta-analysis

AIM

Fistula Laser Closure (FiLaC™) is a novel sphincter-preserving technique that is based on new technologies and shows promising results in repairing anal fistulas whilst maintaining external sphincter function. The aim of the present meta-analysis is to present the efficacy and the safety of FiLaC™ in the management of anal fistula disease.

METHOD

The present proportional meta-analysis was designed using the PRISMA and AMSTAR guidelines. We searched MEDLINE, Scopus, clinicaltrials.gov, Embase, Cochrane Central Register of Controlled Trials CENTRAL and Google Scholar databases from inception until November 2019.

RESULTS

Overall, eight studies were included that recruited 476 patients. The pooled success rate of the technique was 63% (95% CI 50%-75%). The pooled complication rate was 8% (95% CI 1%-18%). Sixty-six per cent of patients had a transsphincteric fistula and 60% had undergone a previous surgical intervention, mainly the insertion of a seton (54%). The majority had a cryptoglandular fistula. Operation time and follow-up period were described for each study.

CONCLUSION

FiLaC™ seems to be an efficient therapeutic option for perianal fistula disease with an adequate level of safety that preserves quality of life. Nevertheless, randomized trials need to be designed to compare FiLaC™ with other procedures for the management of anal fistulas such as ligation of intersphincteric fistula tract, anal advancement flaps, fibrin glue, collagen paste, autologous adipose tissue, fistula plug and video-assisted anal fistula treatment.

A prospective evaluation of the outcome of submucosal ligation of fistula tract

AIM

Fistula-in-ano (FIA) is an anomalous passage between perianal skin and the anal canal or the rectum that presents many management difficulties. Ligation of intersphincteric fistula tract (LIFT) was introduced as a cost-effective sphincter-saving procedure with a reported success rate of 94.4%. Unfortunately, this procedure is technically challenging, and recently submucosal ligation of fistula tract (SLOFT), a simplification of LIFT, was proposed. Our aim was to assess the SLOFT technique over a longer follow-up period to determine its effectiveness.

METHOD

A prospective observational study was performed in 47 patients with FIA treated by SLOFT from September 2017 to February 2019.

RESULTS

There were 47 patients, of whom 33(70.2%) were men. The median age was 39 years (range 30-50 years). All the patients had primary FIA of cryptoglandular origin. The patients were followed up for 1 year and were postoperatively assessed at 2, 4, 12 and 24 weeks and 1 year. The median body mass index was 27.3 kg/m² (range 24.3-29.4 kg/m² ) and the median duration of surgery was 15 min (range 13-20 min). Most (83.0%) of the fistulas were trans-sphincteric. The success rates at the end of 24 weeks and 1 year were 87.2% and 80.9%, respectively. No postoperative incontinence was recorded.

CONCLUSION

In our series the success rate of SLOFT was 80.9%. There were no sphincter-related complications. Repeat SLOFT was feasible for cases of recurrence. Therefore, SLOFT should be considered an alternative sphincter-saving procedure to LIFT for the management of FIA.

Management of Complex Cryptoglandular Anal Fistula: Challenges and Solutions

Anal fistulae can be a very difficult disease to manage. The management of complex fistulae is even more challenging. The risk to the fecal continence mechanism due to damage to the anal sphincters and refractoriness to the treatment (high recurrence rate) pose the two biggest challenges in the management of this disease. Apart from these, there are several other challenges in the treatment of complex fistulae. The intriguing and uphill task is that satisfactory solutions to most of these challenges are still not known, and there is hardly any consensus on whatever treatment solutions are available. To summarize, there is no gold-standard treatment available for treating complex anal fistulae, and the search for a satisfactory treatment option is still on. In this review, the endeavor has been to discuss and highlight recent path-breaking updates in the management of complex anal fistulae.

Video-Assisted Ligation of Intersphincteric Fistula Tract for Complex Anal Fistula: Technique and Preliminary Outcomes

BACKGROUND

Sphincter-preserving operations have been increasingly used for treating anal fistula. However, their success rates remain modest in complex anal fistulas.

OBJECTIVE

This study aimed to report outcomes of video-assisted ligation of intersphincteric fistula tract (a procedure combining video-assisted anal fistula treatment and ligation of intersphincteric fistula tract) for treating complex anal fistulas and to compare its results with conventional ligation of intersphincteric fistula tract.

DESIGN

A review of prospectively collected data from October 2014 to December 2017 was performed.

SETTINGS

The study was conducted at a large tertiary hospital in Thailand.

PATIENTS

All patients with primary or recurrent complex anal fistulas undergoing video-assisted ligation of intersphincteric fistula tract were included. Patients with anal fistula related to malignancy, Crohn's disease, tuberculosis, or acute abscess were excluded.

MAIN OUTCOME MEASURES

Healing as defined by an absence of fistula or drainage from an external opening and complete epithelialization of the external opening were measured.

RESULTS

This study included 103 patients with a median age of 47 years. The primary healing rate was 84.5% at a median follow-up of 28 months (range, 15-38 mo). Primary healing rates of anterior high transsphincteric fistula, semi-horseshoe fistula, and horseshoe fistula were 88% (44 of 50 cases), 77% (30 of 39 cases), and 93% (13 of 14 cases). Median time to healing was 4 weeks (range, 4-8 wk). Accordingly, the overall failure rate was 15.5%. None reported worse fecal incontinence postoperatively. Video-assisted ligation of intersphincteric fistula tract had a higher rate of primary healing for complex anal fistula than ligation of intersphincteric fistula tract (84.5% vs 63.4%; p < 0.001).

LIMITATIONS

This study is limited by its small sample size.

CONCLUSIONS

The outcomes of video-assisted ligation of intersphincteric fistula tract for complex anal fistulas are quite good. This technique has the potential to become another viable option of sphincter-preserving operation for complex anal fistulas. See Video Abstract at http://links.lww.com/DCR/B373. LIGADURA ASISTIDA POR VIDEO DEL TRACTO DE LA FÍSTULA INTERESFINTÉRICA PARA LA FÍSTULA ANAL COMPLEJA: TÉCNICA Y RESULTADOS PRELIMINARIES: Las operaciones de preservación del esfínter se han utilizado cada vez más para tratar la fístula anal. Sin embargo, sus tasas de éxito siguen siendo modestas en las fístulas anales complejas.Este estudio tuvo como objetivo informar los resultados de la ligadura asistida por video del tracto de la fístula interesfintérica (un procedimiento que combina el tratamiento de la fístula anal asistida por video y la ligadura del tracto de la fístula interesfintérica) para el tratamiento de las fístulas anales complejas y comparar sus resultados con la ligadura convencional de la fístula interesfintérica tracto.Se realizó una revisión de los datos recolectados prospectivamente desde Octubre de 2014 hasta Diciembre de 2017.El estudio se realizó en un gran hospital terciario en Tailandia.Se incluyeron todos los pacientes con fístulas anales complejas primarias o recurrentes sometidas a ligadura asistida por video del tracto de la fístula interesfintérica. Se excluyeron los pacientes con fístula anal relacionada con malignidad, enfermedad de Crohn, tuberculosis o absceso agudo.Curación definida por la ausencia de fístula o drenaje de la abertura externa y la epitelización completa de la abertura externa.Este estudio incluyó 103 pacientes con una mediana de edad de 47 años. La tasa de curación primaria fue del 84,5% con una mediana de seguimiento de 28 meses (rango 15-38). La tasa de curación primaria de la fístula transesfintérica alta anterior, la fístula semi-herradura y la fístula de herradura fue del 88% (44 de 50 casos), 77% (30 de 39 casos) y 93% (13 de 14 casos), respectivamente. El tiempo mediano hasta la curación fue de 4 semanas (rango 4-8). En consecuencia, la tasa de fracaso general fue del 15,5%. Ninguno informó peor incontinencia fecal después de la operación. La ligadura asistida por video del tracto de la fístula interesfintérica tuvo una mayor tasa de curación primaria para la fístula anal compleja que la ligadura del tracto de la fístula interesfintérica (84.5% vs 63.4%; p <0.001).Este estudio está limitado por su pequeño tamaño de muestra.Los resultados de la ligadura asistida por video del tracto de la fístula interesfintérica para fístulas anales complejas son bastante buenos. Esta técnica tiene el potencial de convertirse en otra opción viable de operación de preservación del esfínter para fístulas anales complejas. Consulte Video Resumen en http://links.lww.com/DCR/B373. (Traducción-Dr Yesenia Rojas-Khalil).

Anal fistula plug versus surgeon's preference for surgery for trans-sphincteric anal fistula: the FIAT RCT

BACKGROUND

The aim of fistula surgery is to eradicate the disease while preserving anal sphincter function. The efficacy of the Surgisis^® anal fistula plug (Cook Medical, Bloomington, IN, USA) in the treatment of trans-sphincteric fistula-in-ano has been variably reported.

OBJECTIVES

To undertake a randomised comparison of the safety and efficacy of the Surgisis anal fistula plug in comparison with surgeon's preference for the treatment of trans-sphincteric anal fistulas.

DESIGN

A randomised, unblinded, parallel-arm, prospective, multicentre clinical trial.

SETTING

Hospitals in the UK NHS involving colorectal surgeons accredited by the Association of Coloproctology of Great Britain and Ireland.

PARTICIPANTS

Adult patients suffering from trans-sphincteric fistula-in-ano of cryptoglandular origin.

INTERVENTIONS

Patients were randomised on a 1 : 1 basis to either the fistula plug or the surgeon's preference [e.g. fistulotomy, cutting seton, advancement flap or ligation of intersphincteric fistula tract (LIFT) procedure].

MAIN OUTCOME MEASURES

The primary outcome measure was quality of life as measured by the Faecal Incontinence Quality of Life (FIQoL) questionnaire at 12-month follow-up. Secondary outcome measures included clinical and radiological fistula healing rates, faecal incontinence rates, complications rates, reintervention rates and cost-effectiveness.

RESULTS

Between May 2011 and March 2016, 304 participants were recruited (152 fistula plug vs. 152 surgeon's preference). No difference in FIQoL score between the two trial groups was seen at the 6-week, 6-month or 12-month follow-up. Clinical evidence of fistula healing was reported in 66 of 122 (54%) participants in the fistula plug group and in 66 of 119 (55%) participants in the surgeon's preference group at 12 months. Magnetic resonance imaging (MRI) showed fistula healing in 54 of 110 (49%) participants in the fistula plug group and in 63 of 112 (56%) participants in the surgeon's preference group. Variation in 12-month clinical healing rates was observed: 55%, 64%, 75%, 53% and 42% for fistula plug, cutting seton, fistulotomy, advancement flap and LIFT procedure, respectively. Faecal incontinence rates were low at baseline, with small improvement in both groups post treatment. Complications and reinterventions were frequent. The mean total costs were £2738 [standard deviation (SD) £1151] in the fistula plug group and £2308 (SD £1228) in the surgeon's preference group. The average total quality-adjusted life-years (QALYs) gain was much smaller in the fistula plug group (0.829, SD 0.174) than in the surgeon's preference group (0.790, SD 0.212). Using multiple imputation and probabilistic sensitivity analysis, and adjusting for differences in baseline EuroQol-5 Dimensions, three-level version utility, there was a 35-45% chance that the fistula plug was as cost-effective as surgeon's preference over a range of thresholds of willingness to pay for a single QALY of £20,000-30,000.

LIMITATIONS

Limitations include a smaller sample size than originally calculated, a lack of blinding that perhaps biased patient-reported outcomes and a lower compliance rate with MRI at 12-month follow-up.

CONCLUSIONS

The Surgisis anal fistula plug is associated with similar FIQoL score to surgeon's preference at 12-month follow-up. The higher costs and highly uncertain and small gains in QALYs associated with the fistula plug mean that this technology is unlikely to be considered a cost-effective use of resources in the UK NHS.

FUTURE WORK

Further in-depth analysis should consider the clinical and MRI characteristics of fistula-in-ano in an attempt to identify predictors of fistula response to treatment.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN78352529.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 23, No. 21. See the NIHR Journals Library website for further project information.

Complex Anal Fistula: Long-Term Results of Modified Ligation of Intersphincteric Fistula Tract=LIFT

Objectives:

The anal fistula is a permanent infectious tunnel formed between the anal canal and skin in the perianal region. Fistulas are treated by surgery at any stage. Many surgical methods have been reported to treat anal fistula. One of the promising surgical methods with a high success rate is ligation of the intersphincteric fistula tract, which is performed in anatomical spaces without damage to the internal and external sphincters. We evaluated the success rate of a modified ligation of the intersphincteric fistula tract procedure for complex anal fistulas in which the technical differences were minimized by the surgery being performed by the same surgical team.

Methods:

In this study, Data of the 56 patients were retrospectively collected. Data regarding patient history, visual and digital anal examination, Cleveland Clinic Florida Fecal Incontinence (CCF-FI) score, anal-phase pelvic magnetic resonance imaging (MRI), rectosigmoidoscopy or colonoscopy and anal manometry were recorded. The changes in data recorded during the preoperative and postoperative periods were compared in each other.

Results:

The mean age of the patients was 41±15.5 years. The number of patients for each fistula type compromised in this study was as follows in accordance with frequency: high transsphincteric fistula, high intersphincteric fistula, and horseshoe abscess. The fistula recurred in seven patients during postoperative follow-up and the success rate of modified LIFT was calculated as 87.5%. The change in the mean±SD preoperative and postoperative CCF-FI scores and anal pressure was not statistically significant.

Conclusion:

One promising advantage of the ligation of the intersphincteric fistula tract procedure is that it turns a complex fistula into a simple fistula that can be treated with minimal risk of sphincter damage.

Porcine dermal collagen mesh (Permacol™) as a bioprosthesis in the ligation of intersphincteric tract (BioLIFT) procedure

BACKGROUND

Ligation of intersphincteric tract (LIFT) is a sphincter-saving technique used to treat anal fistulas. Incorporation of a bioprosthesis in LIFT (BioLIFT) aims to improve healing. The use of cross-linked porcine dermal collagen mesh Permacol™ in BioLIFT has never been investigated. The aim of this study was to compare the healing rates and outcome of LIFT and BioLIFT for complex anal fistulas using the Permacol™ biological mesh.

METHODS

A retrospective analysis of all patients having LIFT or BioLIFT for complex fistulas from January 2010 to November 2019 was performed in a tertiary referral centre. Patient data from a prospectively collected database of all patients having LIFT or BioLIFT were analyzed.

RESULTS

LIFT and BioLIFT were performed in 48 (82.8%) and 10 (17.2%) patients, respectively. All BioLIFT patients had previous interventions for their fistulas compared to 30 (62.5%) of patients who had LIFT, p = 0.023. The primary healing rate for LIFT was 87.5% (42/48) compared to 80% (8/10) in BioLIFT, (p = 0.42). Eight (13.8%) patients developed complications, 6 (12.5%) in the LIFT group vs 2 (20%) in the BioLIFT group (p = 0.62). On univariate analysis, the number of previous operations was predictive of complications (p = 0.03). BioLIFT was not associated with complication (OR = 1.75, 95% CI: 0.30-10.3, p = 0.54) or primary healing (OR = 0.57, 95% CI: 0.97-3.36, p = 0.54). There was no significant difference in recurrence (LIFT 12.5% vs BioLIFT 0%, p = 0.58). Kaplan-Meier analysis found no difference in time to recurrence between the two groups (p = 0.65).

CONCLUSION

Permacol™ mesh in BioLIFT is feasible and achieves a high primary healing rate of 80%. Prospective evidence is needed to establish the benefits of BioLIFT and determine whether Permacol™ is superior to the non-cross-linked porcine submucosal mesh.

Lift and VAAFT for high trans-sphincteric anal fistula: a single center retrospective analysis

PURPOSE

The management of complex anal fistulas remains a challenge, mainly due to the considerable risk of incontinence. We compared LIFT and VAAFT in the treatment of complex anal fistulas in terms of healing time, recurrence, continence, morbidity, and postoperative pain, focusing also on patients with local abscess at the time of surgery.

METHODS

We include all patients with high trans-sphincteric anal fistula even with abscess at the time of surgery. Anorectal manometry, endoanal ultrasound, Cleveland Clinic fecal incontinence score, VAS score, and number of previous fistula treatment were recorded. The clinical examination defined healing, insufficiency or recurrence of the fistula.

RESULTS

Fifty-four consecutive patients are undergoing surgery: 26 patients underwent LIFT and 28 underwent VAAFT. During the 18 months of follow-up there were no differences in terms of AM, CCFIS and VAS scores. Days of healing, failure, and recurrence rate were comparable in both groups. The subgroup of patients with local abscess undergoing LIFT showed worse results in terms of failure and recurrence rate (p < 0.05).

CONCLUSIONS

Both techniques are safe and effective and can offer long-term benefits. LIFT should not be used as a first treatment in high trans-sphincteric fistula with perianal abscess.

Initial Experience With Video-Assisted Anal Fistula Treatment in the Philippines

PURPOSE

We determined the outcomes of patients undergoing video-assisted anal fistula treatment (VAAFT) for fistulain-ano at the Philippine General Hospital.

METHODS

Twenty consecutive adult patients who underwent the VAAFT procedure from 2016-2018 were included in this investigation. Information detailing baseline demographic and clinical data, fistula type and classification, and previous surgeries were retrieved from in-hospital and operative records. Operative time, identification of the internal opening, method of internal opening closure, and occurrence of immediate postoperative complications were determined. The status of the fistula was assessed at one month, 3 months, and 6 months postoperatively based on outpatient follow-up records. The primary outcomes were healing rate and recurrence rate. Secondary outcomes were 30-day morbidity, postoperative complications, and incontinence using the Wexner score.

RESULTS

Eighteen patients (90%) had a preoperative diagnosis of complex fistula, and 13 patients (65%) had undergone a previous fistula surgery. Primary healing rate was 55% at 1 month, 63.16% at 3 months, and 78.95% at 6 months postoperatively. Eighteen patients (94.74%) maintained continence (Wexner score = 0) at 6 months.

CONCLUSION

Our study results suggest that VAAFT is a safe, minimally invasive technique for treatment of anal fistula and can preserve anal sphincter function. The technique has an acceptable healing rate with minimal complications.

Comparison of Ligation of the Intersphincteric Fistula Tract and BioLIFT for the Treatment of Transsphincteric Anal Fistula: A Retrospective Analysis

BACKGROUND

Ligation of the intersphincteric fistula tract is a sphincter-preserving technique for the treatment of anal fistulas. The BioLIFT modification involves the placement of a biologic mesh in the intersphincteric plane. Advocates of this modification state improved healing rates, however evidence for this is lacking, and this approach costs significantly more.

OBJECTIVE

The purpose of this study was to compare the healing rates of the ligation of the intersphincteric fistula tract with the BioLIFT.

DESIGN

This was a retrospective cohort study.

SETTINGS

The study was conducted at a tertiary care hospital from April 2008 to April 2018.

PATIENTS

All adult patients with transsphincteric anal fistulas were included. Patients were excluded if they had IBD, more than 1 fistula tract operated on simultaneously, or a previous attempt at repair.

MAIN OUTCOME MEASURES

The primary outcome was primary healing of the fistula tract, and secondary outcomes included overall success, complications, and time to recurrence.

RESULTS

There were 119 cases (75 ligation of the intersphincteric fistula tract and 44 BioLIFTs). One surgeon performed 84% of the BioLIFT cases. The primary healing rate was 75.0% versus 58.7% (p = 0.08), and the complication rate was 22.7% versus 17.3% (p = 0.48; BioLIFT vs ligation of intersphincteric fistula tract). After multivariate logistic regression, the BioLIFT had a significantly better healing rate (OR = 2.38 (95% CI, 1.01-5.62); p = 0.048). Median follow-up was 9 versus 29 weeks (BioLIFT vs ligation of intersphincteric fistula tract). Kaplan-Meier analysis demonstrated no difference in the time to recurrence (p = 0.48).

LIMITATIONS

This study was limited by the retrospective nature, different lengths of follow-up, and varying case numbers between the surgeons.

CONCLUSIONS

The BioLIFT modification is safe and effective for the treatment of anal fistulas but has a higher cost. This modification warrants additional prospective studies to establish its benefits over the ligation of the intersphincteric fistula tract procedure. See Video Abstract at http://links.lww.com/DCR/B139. COMPARACIÓN DE LIFT VERSUS BIOLIFT PARA EL TRATAMIENTO DE LA FÍSTULA ANAL TRANSFINTERÉRICA: UN ANÁLISIS RETROSPECTIVO: Ligadura del tracto de la fístula interesfintérica es una técnica para preservación del esfínter en el tratamiento de las fístulas anales. La modificación BioLIFT implica la colocación de una malla biológica en el plano interesfintérico. Protagonistas de la modificación mejoraron las tasas de curación, sin embargo, carecen evidencias definitivas y la técnica eleva costos significativamente.Comparar las tasas de curación de ligadura del tracto de la fístula interesfintérica con el BioLIFT.Estudio de cohorte retrospectivo.Hospital de atención de tercer nivel desde abril de 2008 hasta abril de 2018.Se incluyeron todos los pacientes adultos con fístulas anales transfinteréricas. Los pacientes fueron excluidos si tenían enfermedad inflamatoria intestinal, más de un tracto fistuloso operado simultáneamente o con un intento previo de reparación.El resultado principal fue la curación primaria del tracto fistuloso y los resultados secundarios incluyeron el éxito en general, las complicaciones y tiempo hasta recurrencia.Se registraron 119 casos (75 ligaduras del tracto de la fístula interesfintérica y 44 BioLIFT). Un cirujano realizó el 84% de los casos de BioLIFT. La tasa de curación primaria fue del 75.0% vs 58.7%, p = 0.08, y la tasa de complicaciones fue del 22.7% vs 17.3%, p = 0.48 comparando BioLIFT vs ligadura del tracto de la fístula interesfintérica. Después de la regresión logística multivariada, el BioLIFT tuvo una tasa de curación significativamente mejor (OR 2.38 [IC 95% 1.01-5.62], p = 0.048). La mediana de seguimiento fue de 9 vs 29 semanas (BioLIFT vs ligadura del tracto de la fístula interesfintérica). El análisis de Kaplan-Meier no demostró diferencias en el tiempo hasta la recurrencia (p = 0,48).Este estudio estuvo limitado por ser retrospectivo, las diferentes duraciones de seguimiento y el número variable de casos entre los cirujanos.La modificación BioLIFT es segura y efectiva para el tratamiento de las fístulas anales pero tiene un costo más alto. Esta modificación amerita más estudios prospectivos para establecer los beneficios sobre ligadura del tracto de la fístula interesfintérica. Consulte Video Resumen en hhttp://links.lww.com/DCR/B139.

LIFT and BioLIFT: a 10-Year Single-Centre Experience of Treating Complex Fistula-In-Ano With Ligation of Intersphincteric Fistula Tract Procedure With or Without Bio-prosthetic Reinforcement (BioLIFT)

PURPOSE

To assess the outcome of ligation of intersphincteric fistula tract (LIFT) and bioprosthetic graft (BioLIFT) in the management of transsphincteric perianal fistula.

METHODS

A single-institution retrospective analysis of all patients undergoing LIFT and BioLIFT from January 2009 to June 2018 was performed. Only patients who had LIFTs and BioLIFT performed as their primary sphincter-preserving procedure was included. Primary outcome measured was primary healing. Secondary outcomes measured were secondary healing, morbidity, time to recurrence, and pre- and post-operative anorectal manometry. Chi-square analysis was used to determine predictive factors.

RESULTS

A total of 116 patients were identified. One hundred five had LIFT and 11 had BioLIFT. The total primary healing rate was 60.3% (62.9% and 34.9% for LIFT and BioLIFT respectively). The overall secondary healing rate was 80.2% (80.0% and 81.9% for LIFT and BioLIFT respectively). There was no inpatient morbidity or post-procedural faecal incontinence reported. There was no significant change in the pre- and post-operative manometries in either group (P = 0.417 and P = 0.834 for LIFT and BioLIFT respectively). The only predictor for primary failure identified was anteriorly located fistula.

CONCLUSION

LIFT and BioLIFT compare favourably with other sphincter-preserving procedures. LIFT and BioLIFT can be performed safely, with minimal morbidity and with no reported loss of sphincteric function.

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.