The role of loose seton in the management of anal fistula: a multicenter study of 200 patients. Tech Coloproctol. 2014;18:915-919. [PMID: 24989839 DOI: 10.1007/s10151-014-1186-0]

Treading the unusual path: a rare case of fistula-in-ano extending up to thigh

The perianal region is typically the site of a fistula-in-ano tract's opening, though this is not always the case. Complex fistulas are therefore very difficult to treat and frequently the cause of recurrence. This article describes a unique fistula-in-ano that extended posteriorly to the mid-thigh and was successfully treated with multiple modalities and secondary healing.

Evaluation surgical strategies in perianal fistulas treatment: Efficacy draining seton compared to other surgical approaches; a case-control study

Background and Aims

Perianal fistula is a prevalent anorectal condition originating from an infectious crypt extending to the external opening. Multiple surgical methods exist for treating perianal fistulas; however, selecting the appropriate options is still controversial. Our study aims to evaluate seton replacement versus other surgical methods in treating perianal fistula.

Methods

This study recruited 72 patients presenting with perianal discharge and diagnosed with perianal fistula through intra-sphincteric, trans-sphincteric, and supra-sphincteric examinations at Imam Reza and Besat Hospitals from July 2022 up to March 2023. Regarding case-control design, patients were divided into two groups: the first group (n = 36) underwent seton insertion, while the control group (n = 36) received alternative surgical methods. Follow-up was conducted for 1 month post-discharge, with monthly visits for 6 months. Patients were evaluated for fistula tract healing, seton loosening, and daily secretion rate (based on infected pads) during each visit. Finally, the two groups were compared in terms of improvement rates.

Results

In the seton group, approximately 94.4% of patients showed improvement. However, the difference between the groups was insignificant (p = 0.494). Seton replacement was performed in 52% of patients, with the majority requiring replacement twice (61%). Improvement rates were highest among cases with two seton replacements, although the difference was not statistically significant (p = 0.073). Following seton replacement, the most common treatment methods were endoanal flap and fistulotomy, with observed improvement in 10 cases for each procedure.

Conclusion

This study highlights that draining seton remains a primary choice for intermediate treatment due to its satisfactory improvement rate and lower requirement for replacement, especially up to two times.

European Society of Coloproctology: Guidelines for diagnosis and treatment of cryptoglandular anal fistula

AIM

The primary aim of the European Society of Coloproctology (ESCP) Guideline Development Group (GDG) was to produce high-quality, evidence-based guidelines for the management of cryptoglandular anal fistula with input from a multidisciplinary group and using transparent, reproducible methodology.

METHODS

Previously published methodology in guideline development by the ESCP has been replicated in this project. The guideline development process followed the requirements of the AGREE-S tool kit. Six phases can be identified in the methodology. Phase one sets the scope of the guideline, which addresses the diagnostic and therapeutic management of perianal abscess and cryptoglandular anal fistula in adult patients presenting to secondary care. The target population for this guideline are healthcare practitioners in secondary care and patients interested in understanding the clinical evidence available for various surgical interventions for anal fistula. Phase two involved formulation of the GDG. The GDG consisted of 21 coloproctologists, three research fellows, a radiologist and a methodologist. Stakeholders were chosen for their clinical and academic involvement in the management of anal fistula as well as being representative of the geographical variation among the ESCP membership. Five patients were recruited from patient groups to review the draft guideline. These patients attended two virtual meetings to discuss the evidence and suggest amendments. In phase three, patient/population, intervention, comparison and outcomes questions were formulated by the GDG. The GDG ratified 250 questions and chose 45 for inclusion in the guideline. In phase four, critical and important outcomes were confirmed for inclusion. Important outcomes were pain and wound healing. Critical outcomes were fistula healing, fistula recurrence and incontinence. These outcomes formed part of the inclusion criteria for the literature search. In phase five, a literature search was performed of MEDLINE (Ovid), PubMed, Embase (Ovid) and the Cochrane Database of Systematic Reviews by eight teams of the GDG. Data were extracted and submitted for review by the GDG in a draft guideline. The most recent systematic reviews were prioritized for inclusion. Studies published since the most recent systematic review were included in our analysis by conducting a new meta-analysis using Review manager. In phase six, recommendations were formulated, using grading of recommendations, assessment, development, and evaluations, in three virtual meetings of the GDG.

RESULTS

In seven sections covering the diagnostic and therapeutic management of perianal abscess and cryptoglandular anal fistula, there are 42 recommendations.

CONCLUSION

This is an up-to-date international guideline on the management of cryptoglandular anal fistula using methodology prescribed by the AGREE enterprise.

Slowly cutting, loose seton ligature and staged fistulotomy for healing of idiopathic perianal fistula and influence on anal continence

PURPOSE

To investigate the ability of a "slowly cutting, loose seton ligature and staged fistulotomy" to heal perianal fistulas, the time needed with the seton ligature, recurrence rate, influence on anal continence, health-related quality of life (HRQoL), and patient satisfaction.

METHODS

Observational single-center study. We reviewed the medical records of all patients with primary surgeries from January 1, 2009, to December 31, 2018. The patients answered a questionnaire pre- and postoperative on anal continence (St. Mark's incontinence score) and HRQoL (The Short Health Scale). Satisfaction with the operation was answered postoperatively.

RESULTS

Forty-three patients (37 men, 6 women) were included. Initially 41 of 43 healed (95%). Three patients (7%) had a recurrence, two healed after retreatment. The median follow-up was 55 months (IQR, 4). Thirty-four patients (79%) responded to the questionnaire. At follow-up, forty (93%) patients were healed. The median time treated with a seton ligature in the healed patients was 13 months (IQR, 14). St. Mark's incontinence score preoperative was median 2 (IQR, 9) and after the operation median 1 (IQR, 4). The Short Health Scale improved from median 20 (IQR, 5) preoperatively to 5 (IQR, 5) postoperatively, p < 0.001. Patient satisfaction was median 1 (= very satisfied) (IQR, 1).

CONCLUSION

A "slowly cutting, loose seton ligature followed by a staged fistulotomy", heals the vast majority of perianal fistulas with minor or none influence on continence and few recurrences. Patient-reported HRQoL improves greatly, and patient satisfaction is high.

Analysis of Ambulatory Proctologic Surgery for Simple Anal Fistulas in Terms of Recovery, Complications, Recurrence, and Cost

Background Ambulatory anorectal surgeries have increased in the last few years. This clinical study aimed to compare general operating room conditions with outpatient procedures for simple anal fistulas in terms of healing success, recurrence, cost, complications, and sustainability. Methodology Only primary fistulotomy and seton application for simple anal fistulas were retrospectively analyzed. Results Two-hundred fifty patients (73.7%) were male, and 89 (26.3%) were female. Sixty patients (17.7%) were treated in the operating room, and 279 (82.3%) were treated in the outpatient clinic conditions. Of the ambulatory surgeries, 160 patients underwent fistulotomy and 119 patients loose seton. On the other hand, 34 patients underwent fistulotomy and 26 patients loose seton in operating room conditions. No significant difference was found between the groups according to the distribution of age, gender, complications, and recurrence (P > 0.05). Cost-effectiveness assessment according to the place (ambulatory/operating room) and type of operation (fistulotomy/loose seton) reveals that ambulatory surgery provides significantly more savings (P < 0.001). Conclusions For simple anal fistulas, ambulatory anorectal surgery is a safe approach that can be performed at a lower cost than operating room conditions.

Treatment of pediatric fistula-in-ano-Sphincter-sparing non-cutting seton placement as the future treatment of choice?

Background

Therapeutic principles of fistula-in-ano (FIA) are lacking evidence-based consensus on treatment options. Non-cutting, sphincter-sparing options have not been published for infancy and childhood FIA.

Patients and methods

We are presenting retrospective data on FIA treatment with non-cutting seton placement between 2011 and 2020. Data were collected based on medical records and complemented by patients' contact for follow-up analyses between November 2021 and October 2022. Data were analyzed regarding the outcome variables of recurrent FIA and recurrent perianal abscess. Furthermore, outcomes in different age groups were compared (<1/1.5-12 years of age).

Results

Treatment duration with non-cutting seton was at a median of 4.6 months and was not associated with recurrent FIA (p = 0.8893). Overall recurrence rate of FIA within an observation time of 9 months postsurgically was at 7% (n = 3/42) and was only seen in infancy, whereas recurrent perianal abscess was mainly observable in children (n = 2, p = 0.2132). Comparison of age groups revealed no significant differences. Of the 42 included patients, 37 responded in the follow-up analysis, resulting in a response rate of 88% with a median follow-up time of 4.9 years. Fecal incontinence was postsurgically only seen in two patients, who were diagnosed prior to surgery and symptoms remained unchanged.

Conclusions

Non-cutting seton placement might be a promising option in the treatment of FIA in infancy and childhood. Perioperative settings like duration of placed seton and antibiotic treatment have to be discussed in further prospective, enlarged population-based studies.

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

BACKGROUND AND AIMS

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

METHODS

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

RESULTS

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

CONCLUSION

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

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.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Ambulatory seton placement followed by fistulotomy: efficacy and safety for perianal fistula treatment

PURPOSE

To evaluate the efficacy and safety of ambulatory seton placement followed by superficial fistulotomy as treatment of perianal fistula.

METHODS

Retrospective observational analysis of patients with cryptogenic perianal fistula aged 18-90 years, followed in a central hospital proctology consultation between 2006 and 2017. Data were obtained through clinical record's analysis. Fistula was characterized, using Parks Classification. A probe was passed through the fistula tract, followed by a seton, which remained in situ until superficial fistulotomy was possible.

RESULTS

Ninety-six patients were included (66.67% males, mean age 56 ± 15 years old). Nineteen patients (19.89%) had previous history of perianal fistula and 14 (14.58%) previous anorectal surgery. Seventy-four patients (78.72%) were submitted to fistulotomy, three (3.19%) had seton fistulotomy and one had no seton progression. Intention-to-treat and per-protocol efficacy analyses were 80.2 and 98.7%, respectively. Among the 74 patients who completed the procedure, type of fistula and time with seton were distributed as followed: 47 (63.51%) intersphincteric fistula (15 ± 31 weeks), 26 (35.14%) transsphincteric fistula (32 ± 47 weeks), one (1.35%) suprasphincteric fistula (11 weeks). Previous fistula was associated with a longer time with seton (P = 0.018). Incontinence was reported in two (2.7%) patients, who had previous perianal fistula or anorectal surgery. Two patients (2.7%) had recurrence after fistulotomy.

CONCLUSION

Placement of seton followed by superficial fistulotomy in an ambulatory setting is a safe and effective method for simple low perianal fistula treatment. Incontinence rate may be higher in patients with previous perianal fistula or anorectal surgery.

Long-term follow-up study of loose combined cutting seton surgery for patients with high anal fistula

BACKGROUND

The treatment of high anal fistula (HAF) is still difficult for clinical surgeons. Our previous study demonstrated the short-term benefit of loose combined cutting seton (LCCS) for patients with HAF. This study aimed to evaluate the long-term effectiveness of LCCS for treating HAF patients.

METHODS

We retrospectively enrolled consecutive HAF patients who received LCCS therapy in our hospital between March 2014 and July 2017. After enrollment, all patients were followed up by clinical review. The patients' clinical information and most recent follow-up results were collected. Pain was assessed by the visual analog scale (VAS), and the severity of fecal incontinence was assessed by the Wexner Continence Grading Scale. We also assessed the patients' quality of life (QOL) using a the MOS item short from health survey (SF-36) questionnaire. HAF healing was considered the primary outcome, while the fistula recurrence rate, severity of fecal incontinence, and QOL were the secondary outcomes.

RESULTS

In total, 22 patients (18 male, four female) were enrolled in the final analysis. The mean duration of follow-up was 3.65 years (interquartile range: 3.55-4.22; range, 3.50-5.43). All patients were cured and there was no recurrence during the follow-up period. Eight patients reported a Wexner score of 1, while the remaining patients reported a score of 0 at the final follow-up. Furthermore, one patient had a VAS score of 1, while the remaining patients had a VAS score of 0, which indicated almost no postoperative pain. The QOL of all patients improved significantly.

CONCLUSIONS

LCCS is an effective method to treat HAF patients. Large, multicenter randomized controlled trials are warranted.

Surgical Management of Idiopathic Perianal Fistulas: A Systematic Review and Meta-Analysis

BACKGROUND

Perianal fistula is a common colorectal condition with an incidence of 9 per 100,000. Many surgical treatments exist, all aiming to eliminate symptoms with minimal risk of recurrence and impact upon continence. Despite extensive evaluation of the therapeutic modalities, no clear consensus exists as to what is the gold standard approach. This systematic review aimed to examine all available evidence pertaining to the surgical management of perianal fistulas. Primary outcomes examined were recurrence and incontinence.

SUMMARY

This study was conducted according to PRISMA guidelines. Primary outcomes were analyzed for each group and expressed as pooled odds ratio with confidence intervals of 95%. 687 studies were identified from which 28 relevant studies were included. There was no significant difference in rates of incontinence identified between various surgical approaches. Glues and plugs show higher recurrence rates. Newer treatments continue to emerge with promise but lack supporting evidence of benefit over conventional therapies. Key Messages: While we await more robust randomized data, we will continue to proceed cautiously trying to offset the benefits of fistula healing against the inherent risk of altered continence.

Comparison of the Efficacy of the Various Treatment Modalities in the Management of Perianal Crohn's Fistula: A Review

Crohn's disease (CD) is a transmural inflammatory bowel disease (IBD) that can affect any part of the gastrointestinal (GI) tract. With the disease's progression, adhesions and transmural fissuring, intra-abdominal abscesses, and fistula tracts may develop. An anal fistula (or fistula-in-ano) is a chronic abnormal epithelial lined tract communicating the anorectal lumen (internal opening) to the perineal or buttock skin (external opening). The risk of fistula development varies from 14%-38%. It can cause significant morbidity, which adversely impacts the quality of life. It is mostly believed that an anal crypt gland infection causes anal abscesses, leading to fistula development. Crohn's disease's pathogenesis involves Th1 and Th17 hypersensitivity due to an unknown antigen within the intestinal mucosa.

Evidence to support this review was gathered via the Pubmed database. Search terms used were combinations of "Perianal fistula," "seton," "immunotherapy." Studies were reviewed and cross‐referenced for additional reports.

Setons are surgical thread loops passed from the external to the internal opening of the fistula tract and exteriorized through the anorectal canal, facilitating abscess drainage and inciting a local inflammatory reaction, thus promoting the resolution of the fistula. Biologicals such as anti-tumor necrosis factor (TNF) antibody (infliximab, adalimumab, certolizumab), anti-IL-12/23 (ustekinumab), and anti-α₄β₇ integrin antibody (vedolizumab) have been approved for Crohn's disease targeting the Th1/Th17-mediated inflammation. Other therapeutic modalities are fistulotomy, cyanoacrylate glue, bioprosthetic plugs, mucosal advancement flap, ligation of inter-sphincteric fistula tract (LIFT), diverting stoma, proctectomy, video-assisted anal fistula treatment (VAAFT), and fistula laser closure (FiLaC).

Our review found that chronic seton therapy should be the primary approach, especially if the patient has a perianal abscess. It has a low incidence of re-intervention, recurrent abscess formation, and side-branching of the fistulous tract, with preservation of the fistulous tract's patency and cost-effectiveness. The major disadvantage of seton therapy is the discomfort and time to achieve stability. Among the biologicals, infliximab is the only therapy which has a statistically significant effect on the healing rate of perianal Crohn's fistula compared to placebo, but the major disadvantage associated with anti-TNF as sole therapy is high re-intervention rate, prolong maintenance therapy, high recurrence rate, and severe side effects. We hypothesize that the two aspects should be addressed concurrently to increase the fistula healing or closure rate. First, the seton should be used as initial therapy to maintain tract patency to allow abscess drainage and minimize the intestinal flora colonization within the tract mucosa, thereby leukocytic infiltration and propagation of inflammation within the tract. The second aspect that has to be considered is that we should target the initial stimulation of the Th1/Th17 mediated hypersensitivity instead of a factor/cytokine involved in the inflammation mediation. Although the unknown antigen triggering such hypersensitivity is not clear, we could target the RAR-related orphan receptor γ (RORγ)-T (transcription factor involved in activation of Th17 cells) and the T-bet (transcription factor involved in activation of Th17 cells) within the GI mucosa by a novel target immune therapy.

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

Background

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

Methods

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

Results

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

Conclusions

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

Loss of seton in patients with complex anal fistula: a retrospective comparison of conventional knotted loose seton and knot-free seton

BACKGROUND

Loose setons are often utilized. Replacements after seton loss are frequent, but the exact incidence of this loss of seton (LOS) in patients is unknown. The aim of the present study was to assess the incidence of LOS in a population with complex anal fistula, comparing the knot-free loose seton with the conventional knotted loose seton.

METHODS

All consecutive patients treated with a loose seton for complex anal fistula in two large teaching hospitals in the Netherlands between January 2017 and December 2019 were included in the present study. The incidence of loss of a conventional knotted loose seton was compared with the loss of commercially available knot-free setons.

RESULTS

There were 212 patients. Fifty-two patients were included in the knotted loose group and 160 patients were included in the knot-free seton group. Sixteen patients who were treated with both a knotted and a knot-free loose seton were included in both groups. The incidence of LOS was 12% in the knotted seton group and 28% in the knot-free loose seton group (p = 0.02). Median time to LOS was 36 days for the knotted loose seton and 89 days for the knot-free loose seton (p = 0.36). Sex (p = 0.61), age at the time of seton placement (p = 0.60), and presence of inflammatory bowel disease (p = 0.28) were not significantly associated with LOS.

CONCLUSIONS

LOS occurs frequently in patients treated for complex anal fistulas. The incidence of LOS is significantly higher in patients treated with a knot-free loose seton. Further developments in seton manufacturing should be focussed on optimisation of the closure mechanism.

Drainage Seton Versus External Anal Sphincter-Sparing Seton After Rerouting of the Fistula Tract in the Treatment of Complex Anal Fistula: A Randomized Controlled Trial

BACKGROUND

Complex anal fistula is one of the challenging anorectal conditions. Several treatments have been proposed for complex anal fistula, yet none proved to be ideal.

OBJECTIVE

This randomized trial aimed to assess the efficacy of external anal sphincter-sparing seton in comparison with the conventional drainage seton in the treatment of complex anal fistula.

DESIGN

This was a prospective, randomized, single-blind controlled study.

SETTINGS

The study was conducted at the Colorectal Surgery Unit of Mansoura University Hospitals.

PATIENTS

Adult patients of both sexes with complex anal fistula were recruited and evaluated with MRI before surgery.

INTERVENTIONS

Patients were randomly divided into 2 groups; group 1 was treated with conventional drainage seton and group 2 was treated with external anal sphincter-sparing seton using a rerouting technique.

MAIN OUTCOME MEASURES

The duration of healing, incidence of recurrence or persistence, postoperative pain, and complications including fecal incontinence were measured.

RESULTS

Sixty patients (56 men) with a mean age of 43 years were included. Mean operation time in group 1 was significantly shorter than group 2 (29.8 ± 4.3 vs 43.8 ± 4.5 min; p < 0.0001). The mean pain score at 24 hours in group 1 was 8.1 ± 1.6 versus 5.3 ± 1.3 in group 2 (p < 0.0001). Five patients (17%) in group 1 experienced complications versus 2 (7%) in group 2. All of the patients in group 1 required a second-stage fistulotomy versus 2 patients (7%) in group 2 (p < 0.0001). Time to complete healing in group 1 was significantly (p < 0.0001) longer than group 2 (103 ± 47 vs 46 ± 18 d). Four patients (13%) in group 1 and 1 patient (3%) in group 2 experienced persistence or recurrence of anal fistula (p = 0.35).

LIMITATIONS

This was a single-center study with relatively small numbers in each group.

CONCLUSIONS

Patients treated with external anal sphincter-sparing seton after rerouting of the fistula tract achieved quicker healing and less postoperative pain than those with conventional drainage seton. Postoperative complication and recurrence rates were comparable in both groups. See Video Abstract at http://links.lww.com/DCR/A963.

TRIAL REGISTRATION

clinicaltrials.gov identifier: NCT03636997 (https://clinicaltrials.gov/ct2/show/NCT03636997).

Anal Fistula Laser Closure: the length of fistula is the Achilles' heel

BACKGROUND

Laser closure is a novel sphincter-saving technique for the treatment of anal fistula. The aim of this study was to report middle term results of laser treatment without closure of the internal orifice and to identify prognostic factors to improve selection criteria and maximize healing.

METHODS

A retrospective observational study was conducted on patients treated with laser for transphinteric anal fistula. A diode laser emitting laser energy of 12W at a wavelength of 1470 nm was used. The relationship between fistula healing and age, sex, previous fistula surgery, location of fistula, and length of fistula tract was investigated. A successful outcome was defined by the complete healing of the surgical wound and external opening for at least 6 months.

RESULTS

Thirty patients (16 males, median age 52 years, range 26-72 years) underwent laser fistula closure between January 2015 and December 2016. Cure was achieved in 10 patients (33.3%). The mean follow-up was 11.30 months (range 6-24 months). Patients with persistent or recurrent fistula were offered repeat surgery. Eventually 4 underwent laser treatment once more. Two patients were cured leading to an overall healing rate of 40% (12 out of 30). Only 4 minor complications occurred (13.3%). No worsening of anal continence was registered. Only fistula length had a statistically significant correlation with successful treatment. Fistula tracts shorter than 30 mm were associated with a primary healing rate of 58.3% while tracts longer than 30 mm were cured in only 16.6% of cases (p < 0.02).

CONCLUSIONS

Laser closure is a safe and effective treatment for transphinteric anal fistula. The fistula length is the only significant prognostic factor when closing anal fistulas exclusively with laser: shorter fistulas have a better outcome.

[Seton drainage in sphincter-sparing treatment of rectal fistulas]

Sphincter-sparing procedures for rectal fistulas are becoming more popular among coloproctologists. However, the outcomes are not optimal that forces surgeons to seek new approaches in order to improve results. Seton drainage prior to radical stage is one of these methods. The effect of seton drainage on the outcomes is reviewed in the article. Elibrary, Pubmed and Google Scholar databases were analyzed. We have assessed 14 out of 151 trials for the period 1984 - 2017. There were no significant advantages of seton drainage compared with single-stage approach (χ² = 3.84, p> 0.05, RR = 0.95, CI 95% 0.84 - 1.08). The same situation is observed for mucomuscular flap bringing down to close internal fistula. Fistula healing was more common after seton drainage deployment within 4 - 8 weeks. Bringing down of the flap to anal canal should be preferred after drainage due to less incidence of recurrences. Further trials are necessary to determine advisability of seton drainage and optimal surgical approach.

How to Insert a Draining Seton Correctly

INTRODUCTION

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

TECHNIQUE

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

RESULTS

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

CONCLUSIONS

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

The treatment of anal fistula: second ACPGBI Position Statement - 2018

It is over 10 years since the first ACPGBI Position Statement on the management of anal fistula was published in 2007. This second edition is the result of scrutiny of the literature published during this time; it updates the original Position Statement and reviews the published evidence surrounding treatments for anal fistula that have been developed since the original publication.

Analysis and description of disease-specific quality of life in patients with anal fistula

INTRODUCTION

In patients diagnosed with anal fistula, knowing the quality of life specifically related to the disease can help coloproctology specialists to choose the most appropriate therapeutic strategy for each case. The aim of our study is to analyzse and describe the factors related to the specific quality of life in a consecutive series of patients diagnosed with anal fistula.

METHODS

Observational, cross-sectional study carried out from March 2015 to February 2017. All patients were assessed in the colorectal surgery unit of a hospital in southeast of Spain. After performing an initial anamnesis and a physical examination, patients diagnosed with anal fistula completed the Quality of Life in Ppatients with Anal Fistula Questionnaire (QoLAF-Q). This questionnaire specifically measures quality of life in people with anal fistula and its score range is the following: zero impact = 14 points, limited impact = 15 to 28 points, moderate impact = 29 to 42 points, high impact = 43 to 56 points, and very high impact = 57 to 70 points.

RESULTS

A total of 80 patients were included. The median score obtained in the questionnaire for the sample studied was 34.00 (range=14-68). Statistically significant differences between patients with "primary anal fistula" (n=65) and "recurrent anal fistula" (n=15) were observed (mean rank=42.96 vs. mean rank=29.83, p=0.048). Furthermore, an inverse proportion (P=.016) between "time with clinical symptoms" and "impact on quality of life" was found (<6 months: mean rank = 45.55; 6-12 months: mean rank = 44.39; 1-2 years: mean rank = 37.83; 2-5 years: mean rank = 22; >5 years: mean rank = 19.00). There were no statistically significant differences (P=.149) between quality of life amongst patients diagnosed with complex (mean rank = 36.13) and simple fistulae (mean rank = 43.59).

CONCLUSIONS

Anal fistulae exert moderate-high impact on patients' quality of life. "Shorter time experiencing clinical symptoms" and the "presence of primary fistula" are factors that can be associated with worse quality of life.

The type of loose seton for complex anal fistula is essential to improve perianal comfort and quality of life

AIM

The use of a loose seton for complex anal fistulae can cause perianal discomfort and reduced quality of life. The aim of this study was to assess the impact of the novel knot-free Comfort Drain on quality of life, perianal comfort and faecal continence compared to conventional loose setons.

METHOD

Forty-four patients treated for complex anal fistula at a single institution between July 2013 and September 2014 were included in the study. A matched-pair analysis was performed to compare patients with a knot-free Comfort Drain and controls who were managed by conventional knotted setons. The 12-item Short Form survey (SF-12) questionnaire was used to assess quality of life. Additionally, patients reported perianal comfort and faecal incontinence using a Visual Analog Scale (VAS) and the St Mark's Incontinence Score.

RESULTS

The Comfort Drain was associated with improved quality of life with significant higher median physical (P = 0.001) and mental (P = 0.04) health scores compared with a conventional loose seton. According to the VAS, patients with a Comfort Drain in situ reported greater perianal comfort with significantly less burning sensation (P < 0.001) and pruritus (P < 0.001). Faecal continence was similar in each group.

CONCLUSION

The Comfort Drain offers improved perianal comfort and better quality of life compared with a conventional loose seton and therefore facilitates long-term therapy in patients with complex fistula-in-ano.

Definitive seton management for transsphincteric fistula-in-ano: harm or charm?

AIM

The treatment of transsphincteric anal fistula requires a balance between eradication of the disease and preservation of faecal control. A cutting seton is an old tool that is now out of vogue for many surgeons. We hypothesized that the concept remains reliable and safe with results that exceed those reported for many of the more recently described methods.

METHOD

A retrospective review was conducted of real-time electronic health records (single institution, single surgeon) of patients presenting during the 14 years between 2001 and 2014 with a transsphincteric anal fistula who were treated with a cutting seton. Excluded were patients with Crohn's disease, fistulae related to malignancy or a previous anastomosis and patients whose fistula was treated by another method including a loose draining seton. Data collection included demographics, duration of the disease, duration of the treatment, outcome and continence.

RESULTS

In all, 121 patients (80 men) of mean age 40.2 ± 12.2 years (range 18-76) with a mean follow-up of 5.1 ± 3.3 (1-24) months were included in the analysis. The median duration of symptoms was 6 (1-84) months; 36% had failed other fistula surgery, 12% had a complex fistula with more than one track and 35% had some form of comorbidity. The median time to healing was 3 (1-18) months; 7.4% required further surgery, but eventually 98% had complete fistula healing. The incontinence rate decreased postoperatively to 11.6% from 19% before treatment with 17/121 with pre-existing incontinence resolved and 8/107 new cases developing.

CONCLUSION

Despite its retrospective non-comparative design, the study has demonstrated that a cutting seton is a safe, well tolerated and highly successful treatment for transsphincteric anal fistula and is followed overall by improved continence. The results compare very favourably with other techniques.

Treating anal fistula with the anal fistula plug: case series report of 12 patients

Introduction

Recurrent and complex high fistulas remain a surgical challenge. This paper reports our experience with the anal fistula plug in patients with complex fistulas.

Methods

Data were collected prospectively and analyzed from consecutive patients undergoing insertion of a fistula plug from January 2011 through April 2014 at Hazrat-e-Rasoul Hospital in Tehran. We ensured that sepsis had been eradicated in all patients prior to placement of the plug. During surgery, a conical shaped collagen plug was pulled through the fistula tract.

Results

Twelve patients were included in this case study. All patients had previously undergone failed surgical therapy to cure their fistula and had previously-placed Setons. There were eight males and four females with an average age of 44 who were treated for complex fistulas. At a median time of follow-up of 22.7 months, 10 of the 12 patients had healed (83.3%). One patient developed an abscess that was noted on the sixth postoperative day, and there was one recurrence during follow-up.

Conclusions

Fistula plugs are effective for the long-term closure of complex anal fistulas. Success of treatment with the fistula plug depends on the eradication of sepsis prior to plug placement.

Novel Technique for Management of Axillary Hidradenitis Suppurativa Using Setons

Management of hidradenitis suppurativa (HS) of the axilla which is nonresponding to conservative management presents a significant therapeutic challenge. Most surgical treatment options are associated with significant morbidities and prolonged hospital stay. We present a technique of management of HS using setons which is simple and allows the ongoing treatment to be done on an outpatient basis. Given the fact that HS is a chronic relapsing condition each recurrence may again be managed using this technique. This will allow the patients to manage their recurrences with minimal impact on their activities of daily living.

Modern management of anal fistula

Ideal surgical treatment for anal fistula should aim to eradicate sepsis and promote healing of the tract, whilst preserving the sphincters and the mechanism of continence. For the simple and most distal fistulae, conventional surgical options such as laying open of the fistula tract seem to be relatively safe and therefore, well accepted in clinical practise. However, for the more complex fistulae where a significant proportion of the anal sphincter is involved, great concern remains about damaging the sphincter and subsequent poor functional outcome, which is quite inevitable following conventional surgical treatment. For this reason, over the last two decades, many sphincter-preserving procedures for the treatment of anal fistula have been introduced with the common goal of minimising the injury to the anal sphincters and preserving optimal function. Among them, the ligation of intersphincteric fistula tract procedure appears to be safe and effective and may be routinely considered for complex anal fistula. Another technique, the anal fistula plug, derived from porcine small intestinal submucosa, is safe but modestly effective in long-term follow-up, with success rates varying from 24%-88%. The failure rate may be due to its extrusion from the fistula tract. To obviate that, a new designed plug (GORE BioA^®) was introduced, but long term data regarding its efficacy are scant. Fibrin glue showed poor and variable healing rate (14%-74%). FiLaC and video-assisted anal fistula treatment procedures, respectively using laser and electrode energy, are expensive and yet to be thoroughly assessed in clinical practise. Recently, a therapy using autologous adipose-derived stem cells has been described. Their properties of regenerating tissues and suppressing inflammatory response must be better investigated on anal fistulae, and studies remain in progress. The aim of this present article is to review the pertinent literature, describing the advantages and limitations of new sphincter-preserving techniques.