Fistulotomy or fistulectomy and primary sphincteroplasty for anal fistula (FIPS): a systematic review

Prevalence and Characteristics of Transsphincteric Anal Fistulas Unclassifiable by the Sumikoshi Classification: A Single-center Retrospective Study

Objectives

The Sumikoshi classification for anal fistulas is widely used in Japan; however, it does not include a category for transsphincteric fistulas. Therefore, low transsphincteric fistulas were included in type IIL (low intersphincteric) for convenience; however, high transsphincteric fistulas have not been properly classified. We defined high transsphincteric fistulas as type IIT and investigated their prevalence and clinical characteristics.

Methods

Consecutive patients who underwent fistula surgery at our hospital were included. The operative and endoanal ultrasonography records were retrospectively reviewed, and the following cases were reclassified as type IIT: cases documented as transsphincteric fistulas or cases with written records and/or illustrations indicating that the fistula tract penetrated the upper two-thirds of the external anal sphincter.

Results

Of the 1,069 eligible patients, 895 (83.7%) had type II (intersphincteric) fistulas. Among the type II subtypes, type IIL was the most common with 771 (86.1%) patients, whereas type IIT accounted for 54 (6.0%) patients. The direction of the primary opening was more posterior (62.2%) in patients with type II fistulas other than type IIT, but it was more anterolateral (55.6%) in patients with type IIT fistulas. Patients with type IIT fistulas were more likely to undergo sphincter-sparing surgery than patients with other type II fistulas (37.0 vs. 3.7%, p<0.001).

Conclusions

Type IIT is not rare (6.0%) and should be treated as a complex fistula because of the greater involvement of the external anal sphincter. Surgeons may benefit by including type IIT as a new type II subclass in the Sumikoshi classification system.

Fistulectomy and primary sphincter reconstruction for high cryptoglandular anal fistula: a retrospective cohort study with long-term results

BACKGROUND

Surgical repair for high anal fistulas is challenging and can be associated with impaired functional outcomes. This study evaluated the long-term results of transsphincteric fistulectomy with primary sphincter repair for high anal fistulas in terms of recurrence, wound healing, fecal incontinence, and quality of life.

METHOD

This retrospective cohort study included patients who underwent surgical repair for high anal fistulas between 2006 and 2015. Data were collected by reviewing patients' electronic hospital records, including demographic characteristics, medical conditions, surgical findings, performed procedures, and follow-up data until the last recorded visit. Functional outcomes were assessed using self-reported online questionnaires for quality of life (RAND SF-36) and fecal incontinence (Wexner score).

RESULTS

Fifty-five patients were included. Primary healing was achieved in 42 (76%) patients, while 13 (24%) experienced recurrence. Following reoperations for recurrence, an additional 12 patients achieved healing, resulting in an overall healing rate of 98%. The median Wexner score was significantly higher in reoperated patients, and the median scores across all eight parameters of the RAND SF-36 were lower. None of the patients required proctectomy, and two ended with permanent stomas.

CONCLUSION

Surgery for high anal fistulas is associated with a high success rate, but reoperations for recurrence are linked to considerable impairment in functional outcomes.

Preliminary results of a novel sphincter-sparing technique-fistula occlusion with the internal sphincter flap (FOISF)-for high complex anal fistulas

Background and aim

High complex anal fistula is a clinical challenge for proctologists and a nightmare for patients. Although the sphincter-sparing approach seems an ideal surgical intervention, there remains room for improvement in treatment efficacy. Herein, we introduce an enhanced sphincter-sparing approach, namely the fistula occlusion with the internal sphincter flap (FOISF), for treating high complex anal fistulas.

Methods

This study evaluated 15 patients with high complex anal fistulas who underwent FOISF between October 2021 and December 2022 in the Sixth Affiliated Hospital, Sun Yat-sen University (Guangzhou, P. R. China). Data on success rates, anal function, and various surgical characteristics were subjected to rigorous analysis.

Results

All patients underwent the FOISF procedure, with a median operation time of 53 min. Fourteen patients achieved primary intention healing, while one patient healed by second intention. No recurrence was observed over a follow-up period of 14-30 months. All patients exhibited satisfactory anal continence, with no statistically significant difference observed between preoperative and postoperative Wexner scores (P = 0.331). A significant improvement in the quality of life was observed when compared with the preoperative assessment (P < 0.001).

Conclusion

The preliminary results of the FOISF procedure present an effective approach to treat high complex anal fistula.

Perineal Disintegration Syndrome (PDS) in Children With Human Immunodeficiency Virus (HIV) Infection: A Scoping Review

BACKGROUND

Paediatric healthcare for children with HIV involves managing complex challenges, including severe perineal issues that significantly affect their quality of life. We introduce the term "perineal disintegration syndrome" (PDS) to describe conditions characterised by abscesses and various fistulae involving the anus, rectum, urethra, or reproductive tracts. The literature on PDS is limited and lacks a standardised treatment approach and universally accepted terminology. Our proposal for a new term aims to standardise nomenclature and stimulate targeted research to improve management and outcomes for this vulnerable group.

OBJECTIVES

The aim of the study was to conduct a comprehensive analysis of the existing literature on PDS in paediatric HIV patients to uncover key findings, identify knowledge gaps, and outline practical implications and recommendations for clinical care and future research.

METHODS

A systematic search across databases with comprehensive keywords identified relevant articles on PDS in paediatric HIV patients was conducted.

RESULTS

The review emphasises the focus of PDS literature in African nations, highlighting the urgent need for research and clinical attention in HIV/AIDS-burdened regions. Challenges in diagnosing and managing PDS, uncertainties in its causes, and the lack of standardised management approaches in resource-constrained settings were revealed.

CONCLUSION

This review emphasises the importance of prospective research, standardised protocols and patient-centred multidisciplinary care in managing PDS in paediatric HIV patients to improve care and outcomes of this population.

LEVEL OF EVIDENCE

I.

Evaluating the efficacy of multi-incision and tube-dragging therapy combined with laser closure for high horseshoe-shaped anal fistula: Protocol of a prospective, randomized, controlled trial

INTRODUCTION

High horseshoe-shaped anal fistula (HHAF) is a complicated and challenging condition that presents considerable obstacles in treatment. We are presently investigating a novel surgical technique involving a combination of multi-incision and tube-dragging therapy, and laser closure (MITD-LaC) for the management of HHAF. Due to the current scarcity of rigorous evidence evaluating this approach, it is essential to perform a well-designed randomized controlled trial to compare the effectiveness of this new method with incision and thread-drawing therapy.

METHODS AND ANALYSIS

This trial is a prospective, randomized, controlled and interventional study. After preliminary screening of qualified outpatients, a total of 64 adult patients will be enrolled in the trial and randomly allocated to either the MITD-LaC group or the control group (n = 32 per group). These patients will receive either MITD-LaC or incision and thread-drawing therapy. The design aims to allow for a robust comparison between the two treatment modalities. The primary endpoint is the wound healing time, while secondary endpoints include postoperative anal pain at 1, 3, and 5 days (measured with visual analogue scale), fecal incontinence score within 30 days after operation (measured with Cleveland Clinic Florida incontinence score), and the occurrence of postoperative complications within 1 month after surgery, and quality of life up to six months postoperatively (evaluated by The Quality of Life in patients with Anal Fistula Questionnaire Score).

DISCUSSION

This study represents the first randomized controlled trial evaluating the short-term outcomes of MITD-LaC, thereby aiming to contribute high-quality evidence to guide clinical practice. Moreover, this trial incorporates comprehensive outcome measures assessing both subjective and objective dimensions. Because of this multidimensional assessment, MITD-LaC offers a promising potential for broader application in the treatment of HHAF. Consequently, obtaining more definitive and authoritative evidence through scientifically rigorous clinical trials is of utmost importance in further validating this treatment approach.

ETHICS AND DISSEMINATION

We have submitted the clinical study protocol to the Ethics Committee, and it has been approved under ethical approval number 2021-1036-111-01. The results of the trial will be disseminated through peer-reviewed academic journals and presentations at professional conferences.

REGISTRATION NUMBER

ChiCTR2100053556.

Recent advances in the diagnosis and treatment of complex anal fistula

Anal fistula can be a challenging condition to manage, with complex fistulas presenting even greater difficulties. The primary concerns in treating this condition are a risk of damage to the anal sphincters, which can compromise fecal continence, and refractoriness to treatment, as evidenced by a high recurrence rate. Furthermore, the treatment of complex anal fistula involves several additional challenges. Satisfactory solutions to many of these obstacles remain elusive, and no consensus has been established regarding the available treatment options. In summary, complex anal fistula has no established gold-standard treatment, and the quest for effective therapies continues. This review discusses and highlights groundbreaking advances in the management of complex anal fistula over the past decade.

Tsay A, Abbass M. Immediate sphincter repair following fistulotomy for anal fistula: does it impact the healing rate and septic complications?

PURPOSE

Fistulotomy is considered the most effective treatment for anal fistula; however, it carries a risk of incontinence. Sphincteroplasty in the setting of fistulotomy is not standard practice due to concerns regarding healing and potential infectious complications. We aimed to compare the outcomes of patients who underwent fistulotomy with primary sphincteroplasty to those who did not undergo repair.

METHODS

This was a retrospective review of consecutive patients who underwent fistulotomy for cryptoglandular anal fistula. All operations were performed by one colorectal surgeon. Sphincteroplasty was performed for patients perceived to be at higher risk for continence disturbance. The main outcome measures were the healing rate and postoperative septic complications.

RESULTS

In total, 152 patients were analyzed. Group A (fistulotomy with sphincteroplasty) consisted of 45 patients and group B (fistulotomy alone) included 107 patients. Both groups were similar in age (P=0.16) and sex (P=0.20). Group A had higher proportions of multiple fistulas (26.7% vs. 6.5%, P<0.01) and complex fistulas (mid to high transsphincteric, 37.8% vs. 10.3%; P<0.01) than group B. The median follow-up time was 8 weeks. The overall healing rate was similar in both groups (93.3% vs. 90.6%, P=0.76). No significant difference between the 2 groups was noted in septic complications (6.7% vs. 3.7%, P=0.42).

CONCLUSION

Fistulotomy with primary sphincter repair demonstrated a comparable healing rate to fistulotomy alone, without an increased risk of postoperative septic complications. Further prospective randomized studies are needed to confirm these findings and to explore the functional outcomes of patients who undergo sphincteroplasty.

A comparative study between high ligation of the inter-sphincteric fistula tract via lateral Approach Versus Fistulotomy and primary sphincteroplasty in High Trans-Sphincteric Fistula-in-Ano: a randomized clinical trial

BACKGROUND

Trans-sphincteric fistula management is very challenging and everyday new techniques are introduced to reach the safest and the most effective technique. In this study two of the most effective techniques are compared based on their post-operative outcomes.

OBJECTIVE

To compare the efficacy of high ligation of the inter-sphincteric fistula tract by lateral approach (modified LIFT) and Fistulotomy and primary sphincteroplasty (FIPS) in the management of high trans-sphincteric fistula regarding their post-operative outcomes in the form of post-operative pain, time of wound healing in weeks, wound infection, incontinence and recurrence within one year.

PATIENTS AND METHODS

The current study is single-blind, prospective, randomized, controlled, single-center trial conducted from June 2020 to June 2022 in the colorectal surgical unit of Ain Shams University Hospitals, which included 80 patients presented with high trans-sphincteric perianal fistula 55 (68.75%) males and 25 (31.25%) including a one-year follow-up postoperative.

RESULTS

There were 80 patients in our study 40 patients in each group. The mean age of group (I) is 46.65 with standard deviation 6.6. while, in group (II) the mean age is 45.85 with standard deviation 6.07 (p = 0.576). From the included 80 patients 55(68.7%) were males and 25 (31.25%) were females (p = 0.469). Regarding, postoperative wound infection occurred in 2(5%) Patients in group (I) and 7(17.5%) patients in group (II) (p = 0.154). There were no cases of incontinence in group I. However, there were 6(15%) cases of incontinence to gases only scored by Wexner score 3/20 in group II (p = 0.026) and its significant difference between the two techniques. Postoperative pain was assessed for one week duration by the visual analogue score (VAS) from 0 to 10 in which, zero is the least and 10 is the maximum. In group (I) 18(45%) patients scored their pain mild from 1 to 3, 20(50%) patients scored their pain moderate from 4 to 6 and 2(5%) patients scored severe pain from 7 to 9. While, in group (II) 14(35%) patients scored their pain mild from 1 to 3, 22(55%) patients their pain moderate from 4 to 6 and 4(10%) patients scored their pain severe from 7 to 9 (p = 0.275). Recurrence in one-year follow-up occurred in 13(32.5%) patients in group (I) about 7 patients had recurrence in the form of inter-sphincteric fistula and 6 patients in the form of trans-sphincteric fistula. While, in group II recurrence occurred in 1 (2.5%) patient in the form of subcutaneous fistula at the healing site (p = 0.001).

CONCLUSION

Fistulotomy and primary sphincteroplasty is an effective and preferred technique for the trans-sphincteric fistula repair with high statistically significant lower incidence of recurrence in one-year follow-up as compared to modified LIFT technique. Although, there is higher incidence regarding incontinence to gases only post-operative. This work recommends fistulotomy and primary sphincter reconstruction procedure in high trans-sphincteric perianal fistulas to be more popular, to be implemented as a corner stone procedure along various and classic operations for such cases as it's easy, feasible.

A Comparison of Laser and Fistulotomy Techniques in the Treatment of Fistula-in-Ano

Background Anal fistulas are a common complication of perianal abscesses. The treatment of anal fistulas is challenging, with persistent and high recurrence rates. The aim of this study was to evaluate the efficacy and cost-effectiveness of laser ablation compared to fistulotomy in the treatment of anal fistulas. Materials and methods The patients were examined for external and internal openings of the fistula, its number, length, type, relationship with the sphincters, and any previous history of abscess or proctological surgery. The surgical procedures, complications, incontinence, recurrence, and recovery time were evaluated and compared between the two groups. The laser ablation group received an intermittent laser application at a wavelength of 1470 nm and 10 watts for three seconds, while the fistulotomy group underwent cutting of the fistula tract with electrocautery while keeping a stylet in place. Results A total of 253 patients were included in this retrospective study, with 149 patients undergoing fistulotomy and 104 patients undergoing laser ablation. The patients were evaluated based on the type, number, and location of internal and external openings, and the length of the fistula tract according to the Parks classification. The mean follow-up period was 9.0±4.3 months. The results showed that the laser group had a shorter time to return to work and less postoperative pain compared to the fistulotomy group. However, the recurrence rate was higher in the laser group. The recurrence rate was also found to be higher in patients with low transsphincteric fistulas and in patients with diabetes mellitus. Conclusion Our study findings indicate that while laser ablation may be associated with less pain and quicker recovery time, it may also have a higher recurrence rate compared to fistulotomy. We believe that laser ablation is a valuable option for surgeons to consider early on in the treatment process, especially in cases where fistulotomy is not suitable.

Cohort study of fistulotomy with external tract fistulectomy and primary sphincter reconstruction in high trans-sphincteric fistula-in-ano

AIM

Treatment of complex fistula-in-ano is challenging and there is no consensus on the optimal treatment that can provide complete healing and preserve sphincter function. The aim of this study was to evaluate fistulotomy with external tract fistulectomy and primary sphincter reconstruction (FFSR) in the treatment of high trans-sphincteric fistula.

METHOD

This is a prospective single-centre study including patients with a high trans-sphincteric fistula who underwent FFSR from June 2017 to June 2018. All patients were evaluated preoperatively by pelvic MRI and clinical examination. Other types of complex fistula were excluded. All patients were followed up for 1 year for recurrence and incontinence.

RESULTS

Forty patients underwent FFSR during the study period, 62.5% were men and the mean age was 37.45 (range 20-60) years. The mean time to achieve complete healing was 8.4 weeks, 35 (87.5%) patients achieved primary healing within 8 weeks and 5 (12.5%) patients required more time to achieve delayed healing. Four (10%) patients developed recurrence with a mean time for recurrence of 20 weeks. Only four (10%) patients developed incontinence; one to liquid stools and three patients only to gas.

CONCLUSION

Fistulotomy with external tract fistulectomy and primary sphincter reconstruction is a safe option in the treatment of high trans-sphincteric fistula in selected patients. This showed an acceptable recurrence rate when compared with other procedures with comparable sphincter function outcomes.

Fistulectomy and primary sphincteroplasty in complex anal fistula treatment: a hospital-based long-term follow-up study

BACKGROUND

Currently, there is no agreement on the best treatment for complex anal fistulas with the least recurrence and lowest complication rate. The aim of this study was to evaluate the long-term recurrence and incontinence after fistulectomy and primary sphincteroplasty (FIPS) in a group of patients with complex perianal fistula.

METHODS

This prospective observational study was done at the colorectal ward of Taleghani Hospital of Tehran from January 2010 to December 2020. Patients with anal fistula who underwent FIPS were studied. After surgery, patients were evaluated regularly by a colorectal surgeon for fistula recurrence and incontinence. Recurrence was described as a new fistula tract formation after the initial cure and failure of healing in the operation site or any purulent discharge from the fistula tract and openings. In addition, the patient's continence was assessed based on the Wexner score.

RESULTS

There were 335 patients (66 men and 269 women, mean age 42.74 ± 12.44 years), 191 of them with low fistula and 144 with high fistula. Thirteen patients (3.90%) experienced recurrence (all had a low fistula). Thirty-nine patients (11.64%), 19 patients with high and 20 patients with low fistula, had a Wexner score ≥ 3 during the follow-up. Fifteen patients were lost to follow-up. Male patients (OR = 2.67, 95% CI 0.84, 8.45, p = 0.094, adjusted OR = 4.41, 95% CI 1.05, 18.48, p = 0.042), patients with low fistula (p = 0.001), and recurrent cases had a significantly higher rate of recurrence (OR = 10.38, 95% CI 3.24-33.20 p ≤ 0.001, adjusted OR = 23.36, 95% CI 4.35-125.39, p ≤ 0.001). A significant correlation between body mass index > 35 kg/m² and incontinence was found (OR = 4.40, 95% CI 1.35, 14.33, p = 0.014).

CONCLUSIONS

In the present study, an acceptable healing rate and a low percentage of complications following FIPS were seen in patients with complex anal fistula. Randomized clinical trials with appropriate follow-up duration and sample size comparing different surgical methods in these patients are needed to confirm these results.

Fistulotomy versus Fistulectomy for Fistula-in-Ano: A Randomized Prospective Study

Background  Fistula-in-ano is common surgical ailment yet challenging to treat. Current management remains majorly dependent on two conventional surgical options (fistulotomy and fistulectomy), surgeon's preference, and their experience.

Methods  This prospective, randomized study was conducted to compare fistulotomy with fistulectomy in the management of patients with simple fistula-in-ano. Fifty patients were recruited and randomized into two groups each containing 25 patients: group I was managed by fistulotomy and group II was managed by fistulectomy. The outcomes of the study include operating time, postsurgery hospital stay, wound healing time, postoperative pain, and postoperative complications.

Results  Of the 50 patients, 11 (22%) were female and 39 (78%) were male with a mean age of 40.62 ± 12.86 years. The operating time in patients in the fistulotomy group was 21.96 ± 1.90 minutes and in the fistulectomy group was 31.32 ± 2.99 minutes ( p ≤ 0.001). The mean postsurgical hospital stay in the fistulotomy group was 1.32 ± 0.47 days and in the fistulectomy group was 2.32 ± 0.69 days ( p ≤ 0.001), respectively. Mean Visual Analog Scale score was higher in fistulectomy when compared with the fistulotomy at 6 hours and at discharge ( p ≤ 0.05). Postoperative complications were also found to be less in fistulotomy patients compared with patients who underwent fistulectomy.

Conclusion  In comparison to a fistulectomy, fistulotomy has a slight edge in terms of operating time, postsurgery hospital stay, wound healing time, postoperative pain, and postoperative complications. Fistulotomy yielded better results than fistulectomy and we recommend fistulotomy procedure as a treatment of choice in patients with simple low lying fistula-in-ano.

Development of a decision analytical framework to prioritise operating room capacity: lessons learnt from an empirical example on delayed elective surgeries during the COVID-19 pandemic in a hospital in the Netherlands

OBJECTIVE

To develop a prioritisation framework to support priority setting for elective surgeries after COVID-19 based on the impact on patient well-being and cost.

DESIGN

We developed decision analytical models to estimate the consequences of delayed elective surgical procedures (eg, total hip replacement, bariatric surgery or septoplasty).

SETTING

The framework was applied to a large hospital in the Netherlands.

OUTCOME MEASURES

Quality measures impacts on quality of life and costs were taken into account and combined to calculate net monetary losses per week delay, which quantifies the total loss for society expressed in monetary terms. Net monetary losses were weighted by operating times.

RESULTS

We studied 13 common elective procedures from four specialties. Highest loss in quality of life due to delayed surgery was found for total hip replacement (utility loss of 0.27, ie, 99 days lost in perfect health); the lowest for arthroscopic partial meniscectomy (utility loss of 0.05, ie, 18 days lost in perfect health). Costs of surgical delay per patient were highest for bariatric surgery (€31/pp per week) and lowest for arthroscopic partial meniscectomy (-€2/pp per week). Weighted by operating room (OR) time bariatric surgery provides most value (€1.19/pp per OR minute) and arthroscopic partial meniscectomy provides the least value (€0.34/pp per OR minute). In a large hospital the net monetary loss due to prolonged waiting times was €700 840 after the first COVID-19 wave, an increase of 506% compared with the year before.

CONCLUSIONS

This surgical prioritisation framework can be tailored to specific centres and countries to support priority setting for delayed elective operations during and after the COVID-19 pandemic, both in and between surgical disciplines. In the long-term, the framework can contribute to the efficient distribution of OR time and will therefore add to the discussion on appropriate use of healthcare budgets. The online framework can be accessed via: https://stanwijn.shinyapps.io/priORitize/.

Video-assisted anal fistula treatment for complex anorectal fistulas in adults: a systematic review and meta-analysis

BACKGROUND

Video-assisted anal fistula treatment (VAAFT) has gained increasing acceptance as a sphincter-sparing procedure for treating complex anorectal fistulas (CAF), but no unequivocal conclusions can yet be drawn regarding its ultimate effectiveness. We reviewed the literature and performed a meta-analysis to evaluate the efficacy and safety of VAAFT in CAF patients.

METHODS

The study protocol was registered with the PROSPERO database (CRD42021279085). A systematic literature search was performed in the PubMed, Embase, and Cochrane Library databases up to June 2021 with no restriction on language based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We used the keywords video-assisted surgery, video-assisted anal fistula treatment, and complex anorectal fistula to identify relevant studies.

RESULTS

Fourteen trials (7 prospective and 7 retrospective) with a total of 1201 patients (mean age 43.5 years) were included. The median follow-up duration was 16.5(8-48) months. Pooled analysis showed that the rates of success, recurrence and postoperative complication across the studies were 83% (95% CI 81-85%, I² = 37.9%), 16% (95% CI 14-18%, I² = 4.8%), 11% (95% CI 7-15%, I² = 72.1%), respectively. The postoperative Jorge-Wexner score used to assess the level of anal incontinence was 1.09 (95% CI, 0.9-1.27, I² = 74.6%). The internal opening detection rate was 97.6% (95% CI 96.1-99.6%, I² = 48.2%). Recurrence rates varied according to the closure method of internal opening from 21.4% after using staplers, 18.7% after suturing, to 23.5% after advancement flap. The hospital stay was 3.15 days (95% CI 2.96-3.35, I² = 49.7%). Subgroup analysis indicated that the risk of heterogeneity in the urine retention group was higher  compared with that of the overall group and that retrospective studies may be the source of heterogeneity for postoperative anal incontinence. r . Sensitivity analysis confirmed the stability of the pooled results. Begg's and Egger's tests showed no evidence of publication bias.

CONCLUSIONS

According to the available evidence, VAAFT may be a valuable alternative to fistulotomy or seton in treating CAF and has the additional long-term benefits of reducing anal incontinence and surgical morbidity, permitting earlier healing and accelerated rehabilitation.

Mesenchymal Stem Cells for Cryptoglandular Anal Fistula: Current State of Art

Anal fistula is a common disease that needs surgical treatment to be resolved. Despite a variety of surgical options, the major problem is still to cure complex fistulas without any recurrence in the long-term follow-up but, at the same time, to avoid an impairment of continence. In recent years, one solution has been the application of mesenchymal stem cells derived from adipose tissue, especially in association with other treatments, such as the use of fibrin glue or the previous application of a seton. Their initial use in fistulas associated with Crohn's disease has shown encouraging results. In this non-systematic review our aim is to analyze the use in cryptoglandular fistulas: the rate of healing is not so high, and the number of studies is limited. Therefore, further randomized controlled trials are needed to establish their efficacy in the case of complex cryptoglandular anal fistulas and their possible complications.

OPTIMIZATION OF PARARECTAL FISTULA SURGICAL TREATMENT

OBJECTIVE

The aim: To improve the results of treatment of complex PF by the ligation of the intersphincteric fistula tract (LIFT).

PATIENTS AND METHODS

Materials and methods: 27 patients with transsphincteric fistulas of the rectum of different complexity have been operated by two methods: by ligature method ("cutting seton") and by the ligation of the intersphincteric fistula tract (LIFT).

RESULTS

Results: No early complications were noticed in patients who had been applied the technique of fistula ligation in the postoperative period. The pain syndrome was expressed insignificantly. The rehabilitation period was less than 12 days. Having analyzed the long-term results of the observation period lasting up to 26 months, we arrived at the conclusion that the choice of surgical treatment had little effect on the recurrence rate of pararectal fistula (21.4 and 15.38%, respectively). However, one LIFT patient had gas incontinence within 1 year of surgery in contrast to 4 patients who had had a cutting ligature method having anal incontinence for 1 year and 1 patient - during the observation period.

CONCLUSION

Conclusions: Ligation of the fistula in the intersphincter tract is an effective sphincter-preserving operation, does not require additional equipment and expensive consumables, is characterized by minimal damage to the anal sphincter and a high percentage of closure of PF (84.6%). The recurrence rate does not exceed 15.38%.

Is fistulotomy with immediate sphincter reconstruction (FISR) a sphincter preserving procedure for high anal fistula? A systematic review and meta-analysis

AIM

This systematic review aimed to assess the outcomes of fistulotomy or fistulectomy and immediate sphincter repair (FISR) in relation to healing, incontinence and sphincter dehiscence both overall and in patients with high anal fistulae.

METHODS

Medline, Embase and The Cochrane library were searched for studies of patients undergoing FISR for anal fistula. Data regarding healing, continence and sphincter dehiscence were extracted overall and for high anal fistulae. The DerSimonian-Laird random-effects method was used for pooled analysis, heterogeneity between studies was assessed based on the significance of between-study heterogeneity, and on the size of the I²  value. Risk of bias was assessed using the Cochrane risk of bias tool and the Newcastle-Ottawa scale.

RESULTS

We identified 21 studies evaluating 1700 patients. Pooled analysis of healing reached 93% (95% CI: 91%-95%, I²  = 51% p-value for heterogeneity = 0.004), with continence disturbance and worsening continence reaching 11% (95% CI: 6%-18%, I²  = 87% p < 0.001) and 8% (95% CI: 4%-13%, I²  = 74% p < 0.001), respectively. Subgroup analysis according to fistula height could only be conducted on limited data. Pooled healing in high anal fistulae was 89% (95% CI: 84%-94%, I²  = 76% p < 0.001), 16% suffered disturbance of continence (95% CI: 7%-27%, I²  = 89% p < 0.001), 8% worsening continence from baseline (95% CI: 2%-16%, I²  = 80% p < 0.001) and 2% suffered sphincter dehiscence (95% CI: 0%-10%, I²  = 89% p < 0.001).

CONCLUSION

The evidence suggests FISR is a safe, effective procedure. However, data are limited by inconsistencies in reporting of continence and definition of fistula height, particularly high anal fistulae. Significant heterogeneity means that outcomes in high fistulae remain uncertain.

Long-term Evaluation of Fistulotomy and Immediate Sphincteroplasty as a Treatment for Complex Anal Fistula

BACKGROUND

Fistulotomy with immediate sphincteroplasty is a technique that can heal fistulas and decrease fecal incontinence more effectively than fistulotomy alone, in selected patients.

OBJECTIVE

We aimed to perform a long-term evaluation of fecal incontinence after fistulotomy and immediate sphincteroplasty in patients with complex anal fistula.

DESIGN

This prospective study included patients undergoing fistulotomy and immediate sphincteroplasty for complex anal fistula from January 2000 to December 2010.

SETTINGS

The study was conducted by 2 colorectal surgeons in the coloproctology unit of the General Hospital of Elche.

PATIENTS

We included patients aged ≥18 years with complex anal fistulas of cryptoglandular origin.

MAIN OUTCOME MEASURES

Main outcomes were recurrence and continence after fistulotomy and immediate sphincteroplasty, according to fistula tract height and preoperative continence status.

RESULTS

A total of 107 patients were included; 68.2% were men, with a mean age of 48 years and mean fistula duration of 12.8 months. The range and median follow-up period were 84 to 204 and 96 months. Thirty-seven fistulas were not primary. The overall healing rate was 84.1%. Primary fistulas healed by the end of follow-up in 58 (82.9%) of 70 patients; recurrent fistulas healed in 32 (86.5%) of 37; high tracts healed in 31 (83.8%) of 37, and nonhigh fistulas healed in 59 (84.3%) of 70. Male sex (OR = 0.66 (95% CI, 0.20-2.13); p > 0.05) and recurrent fistulas (OR = 0.43 (95% CI, 0.11-1.68); p > 0.05) could have a protective effect against postoperative fecal incontinence; however, more studies with larger sample sizes are necessary to confirm this result, whereas high fistulas showed a 4-fold increased risk of incontinence (range, 1.22-13.06; p < 0.01). One in 5 high-tracts patients experienced continence deterioration.

LIMITATIONS

This was a prospective study, and randomized clinical trials with more patients and longer follow-up are needed to compare fistulotomy and immediate sphincteroplasty with other sphincter-preserving techniques.

CONCLUSIONS

Fistulotomy and immediate sphincteroplasty are good options for treating complex anal fistulas, especially for recurrent fistulas, men, and patients with nonhigh tracts, with acceptable recurrence and incontinence rates. See Video Abstract at http://links.lww.com/DCR/B498.

EVALUACIN A LARGO PLAZO DE LA FISTULOTOMA Y LA ESFINTEROPLASTIA INMEDIATA COMO TRATAMIENTO PARA LA FSTULA ANAL COMPLEJA

ANTECEDENTES:La fistulotomía y la esfinteroplastia inmediata es una técnica que puede curar las fístulas y disminuir la incontinencia fecal de manera más efectiva que la fistulotomía sola, en pacientes seleccionados.OBJETIVO:Nuestro objetivo fue realizar una evaluación a largo plazo de la incontinencia fecal después de la fistulotomía y la esfinteroplastia inmediata en pacientes con fístula anal compleja.DISEÑO:Este estudio prospectivo incluyó pacientes sometidos a fistulotomía y esfinteroplastia inmediata por fístula anal compleja, desde enero de 2000 hasta diciembre de 2010.ENTORNO CLINICO:El estudio fue realizado por dos cirujanos colorrectales de la Unidad de Coloproctología del Hospital General de Elche.PACIENTES:Se incluyeron pacientes ≥ 18 años con fístulas anales complejas de origen criptoglandular.PRINCIPALES MEDIDAS DE VALORACION:Los principales resultados fueron la recurrencia y la continencia después de la fistulotomía y la esfinteroplastia inmediata, de acuerdo con la altura del trayecto de la fístula y el estado de continencia preoperatoria.RESULTADOS:Se incluyeron un total de 107 pacientes; El 68,2% eran varones, con una edad media de 48 años y una duración media de la fístula de 12,8 meses. El rango y la mediana del período de seguimiento fue de 84-204 y 96 meses, respectivamente. Treinta y siete fístulas no fueron primarias. La tasa de curación general fue del 84,1%. Las fístulas primarias cicatrizaron al final del seguimiento en 58/70 (82,9%) pacientes; las fístulas recurrentes cicatrizaron en 32/37 (86,5%); los tractos altos cicatrizaron en 31/37 (83,8%) y las fístulas no altas cicatrizaron en 59/70 (84,3%). El sexo masculino (razón de posibilidades: 0,66 [0,20-2,13], p > 0,05) y las fístulas recurrentes (razón de posibilidades: 0,43 [0,11-1,68], p > 0,05) podrían tener un efecto protector contra la incontinencia fecal postoperatoria, sin embargo, más estudios con una muestra más grande son necesarios para confirmar este resultado. Fistulas altas mostraron un riesgo cuatro veces mayor de incontinencia ([1.22-13.06], p < 0.01). Uno de cada cinco pacientes con tractos altos experimentó un deterioro de la continencia.LIMITACIONES:Este fue un estudio prospectivo y se necesitan ensayos clínicos aleatorios con más pacientes y un seguimiento más prolongado para comparar la fistulotomía y la esfinteroplastia inmediata con otras técnicas de preservación del esfínter.CONCLUSIÓN:La fistulotomía y la esfinteroplastia inmediata son buenas opciones para el tratamiento de fístulas anales complejas, especialmente para fístulas recurrentes, varones y pacientes con tractos no altos, con tasas aceptables de recurrencia e incontinencia. Consulte Video Resumen en http://links.lww.com/DCR/B498.

Fistulectomy and primary sphincteroplasty (FIPS) to prevent keyhole deformity in simple anal fistula: a single-center retrospective cohort study

OBJECTIVE

Fistulotomy remains the gold standard for the surgical treatment of simple anal fistula, but may cause fecal incontinence and a characteristic anal 'keyhole' deformity. Although seemingly trivial, keyhole deformity may lead to bothersome symptoms such as anal pruritus and fecal soiling. This study aims to evaluate the efficacy of fistulectomy and primary sphincteroplasty (FIPS), a technique with immediate sphincter reconstruction, in the treatment of simple anal fistula and the prevention of keyhole deformity created by simple fistulotomy.

METHODS

A retrospective study was performed on all consecutive patients who underwent FIPS for a simple anal fistula at our institution between January 2015 and August 2019. The primary outcome of the study was the rate of early postoperative wound dehiscence, which essentially transforms a FIPS into a simple fistulotomy and may lead to keyhole deformity. All patients received follow-up at regular intervals to evaluate fistula healing and the presence of keyhole deformity.

RESULTS

FIPS was performed in 24 patients (median age: 52.8 years). After a median follow-up time of 3.0 (2.0, 6.3) months, the overall healing rate was 95.8% (23/24 patients). Six (25%) patients experienced early postoperative wound dehiscence resulting in the development of a keyhole deformity. Five of them were symptomatic (mainly soiling). Keyhole deformity was diagnosed at a median time of 6.0 (3.8, 7.5) months postoperatively. The occurrence of early wound dehiscence and subsequent keyhole deformity was associated with a posteriorly located fistula (p = .02).

CONCLUSION

FIPS avoids the development of keyhole deformity in the majority of patients with simple anal fistula, but is less successful in posterior fistulas. Since FIPS is a very effective, fast and simple procedure, it should be considered a valid alternative for the treatment of every simple anal fistula.

Surgery for anal fistulae: state of the art

BACKGROUND AND AIM

Anal fistulae (AF) are considered a challenge for colorectal surgeons, as they recur if not properly operated. Being a septic disease, they are correlated with immunodeficiency and surgery may be followed by anal incontinence (AI). The aim of this paper is to suggest a state-of-the-art treatment of AF.

METHODS

Pathogenesis, classification, diagnostic tools, intraoperative assessment, and surgeries proposed for AF have been reviewed, together with the results following conventional surgery and innovations aimed at sphincters' preservation.

RESULTS

Stress causes immunodepression and favors anal sepsis, and heavy smoking facilitates AF recurrences. Evacuation fistulography, MRI, and transanal ultrasound may help the diagnosis. Fistulotomy allows high cure rate, up to 96.4%, but may cause up to 64% of AI in transsphincteric AF. Fistulectomy with rectal advancement flap is effective in 80% of these cases and avoids AI. Other options are either suturing of AF internal orifice or positioning a cutting seton. Ligation of intersphincteric fistula track (LIFT) is a costless alternative carrying a success of 57-99% with 0-23% AI. Costly innovations, i.e., autologous stem cells, porcine derma sheet (Permacol), video-assisted fistula excision (VAAFT), porcine matrix (PLUG), and laser closure (FiLaC), minimize AI, but may carry AF recurrence. Their grades of recommendation range between 2B and 2C in the Guidelines of the Italian Society of Colorectal Surgery.

CONCLUSION

Postoperative incontinence in transsphincteric AF may be minimized by both costless and costly sphincter-saving procedures, the latter carrying higher recurrence rate. The success of surgery may be increased by a different lifestyle.

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.

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

BACKGROUND

A complex anal fistula is a challenging disease to manage.

AIM

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

METHODS

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

RESULTS

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

CONCLUSION

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

Evaluation of polypropylene and polyglactin sutures in primary sphincteroplasty for the treatment of anal fistula in rats

Rationale Fistulotomy followed by primary sphincteroplasty is one of the therapeutic options in transsphincteric fistulae; however, it was not known which suture would present a better result.

Objective To compare polypropylene and polyglactin sutures in primary sphincteroplasty in rats subjected to fistulotomy.

Method Thirty Wistar rats were subjected to peritoneal anesthesia with ketamine and xylazine, followed by transfixation of the anal sphincter with steel thread, which remained for 30 days to develop the anal fistula. After this period, the steel thread was removed and four groups were formed: A – Control (n = 5), without treatment; B – Fistulotomy (n = 5), performed fistulotomy only; C – Polypropylene (n = 10), in which fistulotomy was performed followed by primary sphincteroplasty with polypropylene suture; D – Polyglactin (n = 10), in which fistulotomy was performed followed by primary sphincteroplasty with polyglactin suture; after 30 days the animals were anesthetized again and submitted to euthanasia by deepening the anesthetic plane to remove the specimens, analyzing fistula closure, muscle fiber distance, and inflammatory process.

Results The fistula persisted in all animals of the control group and in none of the other groups; the distances between the muscle fibers were 1620 μm, 4665 μm, and 2520 μm, respectively in Groups B, C, and D (p = 0.067); in relation to fibrosis, the means were 2.4, 2.8, and 3.6, respectively in Groups B, C, and D, showing greater fibrosis in the latter group (p = 0.041).

Conclusion There was no persistence of the fistula in any of the treated animals; there was no difference in the distance between the muscle fibers between the groups subjected to primary sphincteroplasty with polypropylene or polyglactin, or between these groups and the one treated only by fistulotomy. There was greater fibrosis in animals treated with primary sphincteroplasty with polyglactin.

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.

Longterm outcome of anal fistula - A retrospective study

This retrospective observational study analyses the outcomes of patients undergoing surgery for anal fistula at a single centre in order to assess recurrence and re-operation rates after different surgical techniques. During January 2005 and May 2013, all patients with anal fistula were included. Baseline characteristics, details of presentation, fistula anatomy, type of surgery, post-surgical outcomes and follow-up data were collected. The primary endpoints were long-term closure rate and recurrence rate after 2 years. Secondary endpoints were persistent pain, postoperative complications and continence status. A total of 65 patients were included. From a total amount of 93 operations, 65 were fistulotomies, 13 mucosal advancement flaps, 7 anal fistula plugs and 8 cutting-setons. The mean follow up was 80 months. Healing was achieved in 85%. The highest recurrence rate was seen in anal fistula plug with 42%. On the other hand, no recurrence was observed in the cutting-seton procedures. For all included operation no persistent postoperative pain nor incontinence was observed. In conclusion, despite all existing anal fistula operations up to date, the optimal technique with low recurrence rate and assured safety for the anal sphincter is still lacking. Nonetheless, according to our promising results for the cutting-seton technique, this technique, otherwise considered obsolete, should be further evaluated in a prospective study.

Fistelchirurgie und primäre Sphinkterrekonstruktion

Die operative Therapie transsphinktärer Fisteln zeichnet sich durch eine variantenreiche Methodik aus. Die zumeist durchgeführten Techniken sind wohl die Fistulektomie mit Lappenplastik, die Fistulotomie mit oder ohne Sphinkterrepair und die (modifizierte) LIFT-Technik (Ligatur des intersphinktären Fisteltrakts). Ungeklärt aber ist die genaue Definition der Indikation einer Technik zu allen definierten Fisteltypen, was zum Teil dem Studiendesign anzuschulden ist und zu einer Variabilität der Auswertungen führt. Im vorliegenden Beitrag wird der Frage nach bisher vorhandenen Erfahrungen und Studien zur operativen Technik mit primärem Sphinkterrepair bei bestimmten Fisteltypen nachgegangen. In den letzten Jahrzehnten sind randomisierte Studien zu hoch- und suprasphinktären sowie zu rezidivierenden Fisteln mit guten Heilungs- und postoperativen Inkontinenzraten zur Technik der Fistulotomie mit Exzision des Fistelgewebes und primärem Sphinkterrepair erschienen. Die Technik wird in großen retrospektiven Studien jedoch bei allen transsphinktären Fisteln als erfolgreiche Therapieoption mit guter Kontinenzerhaltung beschrieben.

Fistulotomy and primary sphincteroplasty for anal fistula: long-term data on continence and patient satisfaction

BACKGROUND

The aim of this study was to evaluate the safety and long-term efficacy of fistulotomy and primary sphincteroplasty (FIPS). Secondary endpoints were its impact on postoperative continence status and patients' satisfaction.

METHODS

A retrospective study was conducted on patients with cryptoglandular anal fistula (AF) who had FIPS between June 2006 and May 2017. Patients were evaluated with standardized telephone interviews and clinical/instrumental assessment. Main outcome measures included fistula healing rate, continence status, and patient satisfaction. Incontinence was defined as an inability to hold either gas, liquid, or solid stools, as well as postdefecation soiling, and was measured by the Cleveland Clinic fecal incontinence score. Patient satisfaction was evaluated by an 11-point numeric rating scale.

RESULTS

There were 203 patients (139 males; mean age: 48.7 years) who had FIPS. The overall healing rate was 93% (188 patients) with a mean follow-up period of 56 ± 31 months. Half of the total cohort (51%) had a complex fistula. Preoperatively, 8 (4%) patients complained of postdefecation soiling and 2 (1%) of gas incontinence. Postoperatively, 26 (13%) patients had continence impairment (de novo n = 24), mainly consisting of postdefecation soiling (10%). In univariate analysis, patients with recurrent (RR 6.153 95% CI 2.097-18.048; p = 0.002) or complex (RR 3.005 95% CI 1.203-7.506; p = 0.012) AF and those with secondary tracts (RR 8.190 95% CI 2.188-30.654; p = 0.004) or previous set on drainage (RR 5.286 95% CI 2.235-12.503; p = 0.0001) were at higher risk of incontinence. In multivariate analysis, no significant predictors were found, although fistula complexity approached statistical significance (RR 5.464 95% CI 0.944-31.623; p = 0.050). The mean patient satisfaction numeric rating scale was 9.3 ± 1.6. Lower satisfaction rates were found in patients with transphincteric (p = 0.011) or complex (p = 0.0001) AF, with secondary tracts (p = 0.041) or previous seton drainage (p = 0.008), and in those with postoperative continence impairment (p = 0.0001). Postoperative onset of incontinence was the only significant factor in multivariate analysis (p = 0.0001).

CONCLUSIONS

FIPS should be considered a valid therapeutic option for selected AF. However, the risk of postoperative minor fecal incontinence exists, and should be discussed during preoperative patient counselling.

Perianal fistulas and the lift procedure: results, predictive factors for success, and long-term results with subsequent treatment

Background

Treatment of a perianal fistula is difficult due to the risk of fecal incontinence and recurrence. The ligation of intersphincteric tract (LIFT) procedure is a sphincter-saving procedure associated with success rates ranging from 57 to 94%. The aim of our study was to find predictors for a favorable outcome of the LIFT procedure, evaluation of postoperative fecal incontinence, quality of life, and subsequent treatment with long-term follow-up.

Methods

This study was performed in patients who underwent LIFT between 2013 and 2015 at our institution. Their medical data were retrieved from the electronic patient files. The fistula characteristics were described by physical examination, three-dimensional endoanal ultrasound, and perioperative evaluation. Recurrence rate, postoperative fecal incontinence, and quality of life were assessed with the Patient-Reported Outcome Measurement (PROM). Thirty-two months later, long-term follow-up including subsequent procedures was evaluated.

Results

Forty-five patients [17 men, mean age 40 years (range 24–67 years)] were included. In 41 (84%) patients, the fistula was classified as complex; 32 (71%) were referrals with a history of previous fistula surgery. The initial success rate was 18 (40%). Only the height of the internal fistula opening (≥ 15 mm p < 0.03) was associated with recurrence. The LIFT procedure did not affect the occurrence of fecal incontinence or soiling. Recurrence showed a trend with a lower PROM (p = 0.07). Twenty-four months later, further surgery leads to cure in 34 (75%), asymptomatic fistulas in 7 (16%), and persisting active fistulas in 4 (9%) patients.

Conclusions

Initial LIFT had a success rate of 40% and with subsequent surgical treatment 75%. Recurrence after LIFT is related to the height of the internal fistula opening and is associated with diminished quality of life. Continence was not affected by initial LIFT.

[Quality indicators in the treatment of anal fistulas]

Anal fistulas are a common anorectal disease and are frequently associated with a perianal abscess. The etiology is based on a cryptoglandular infection in the intersphincteric space. Surgery remains the only definitive therapy. The primary goal of definitive fistula surgery is healing; however, success of fistula surgery is influenced by a variety of factors including the surgeon's experience, type of fistula, involvement of sphincter muscles, type of surgical procedure and patient-related factors. For the surgical treatment of a complex anal fistula, a variety of operative procedures have been described including fistulectomy with sphincterotomy, different flap procedures (e.g. mucosal flap and advancement flap) and finally so-called sphincter-preserving techniques, such as LIFT (ligation of intersphincteric fistula tract), VAAFT (video-assisted anal fistula treatment), the use of plugs of collagen or fibrin glue sealants as well as laser procedures or the clip. In the search for suitable quality indicators in anal fistula surgery there is a conflict between healing and preservation of continence. If potential quality indicators are identified the principles of anal fistula surgery must be adhered to and the appropriate selection of patients and procedures is of crucial importance to achieve high healing rates without compromising continence or inducing surgical revision due to abscesses or recurrence. Based on the available literature and guidelines, in the assessment of quality indicators considerable differences exist with respect to patient selection, etiology of anal fistulas and length of follow-up. Heterogeneity of treatment protocols lead to difficulties in a definitive assessment of which surgical treatment is the best option for complex anal fistulas.

Fistulectomy with primary sphincter reconstruction

AIM

Despite modern medical techniques, anatomically proximal (high) anal fistulas are still a challenge in colorectal surgery. In previous years, the standard of care was complete fistulectomy with a high rate of continence disorders. Over the past 20 to 30 years, sphincter-saving procedures have gained wide acceptance. They represent the technique used in these cases. Additionally, many patients received indefinite treatment, namely the placement of a seton to maintain surgical drainage. The main problem with all fistula surgical possibilities is the high recurrence rate of 30 to 50% in flap procedures and 100% persistence in seton treatments. In recent years, a direct repair (primary reconstruction) in distal fistulas was instigated and shows excellent results. It allowed our technique for proximal (high) anal fistulas to evolve.

METHOD

All patients who underwent surgery at the University Medical Center Mannheim, Department of Colo-proctology (from 06/2003 to 11/2015), were retrospectively evaluated using a prospective database. Patients who underwent fistulectomy with primary sphincter reconstruction were all included.

RESULTS

The primary healing rate, after a mean follow-up of 11 months (7 to 200 months), was 88.2% (374 of 424). Taking into account revisionary surgeries with secondary sphincter repair, this rate reaches 95.8% (406 of 424). Factors such as gender and fistula location as related to the sphincter had significant influence on the study outcome, whereas variables such as the amount of reconstructed muscle (in mm), number of revisions, patient age, other anal operations, and concomitant medication did not. The incontinence of a subgroup of 148 patients was evaluated in detail by way of a questionnaire. Even at a preoperative baseline, 9.6% of those patients reported some minor degree of continence disorders. After the procedure, incontinence disorders were observed in 34 patients (23.0%), with 23 of these patients suffering from flatus incontinence (15.5%), 10 patients from liquid incontinence (6.8%), and 1 patient from solid fecal incontinence.

CONCLUSION

Fistulectomy with primary sphincter reconstruction is a feasible procedure resulting in a low recurrence rate. No other procedure has shown better results in transsphincteric fistulas. Continence disorders seem to be of minor relevance/consequence for these patients.

Treatment of Rectovaginal Fistula Using Sphincteroplasty and Fistulectomy

Aim

To assess the results of the treatment of rectovaginal fistulas with incontinence and impaired anal tonus.

Materials and Methods

This study comprised three rectovaginal fistula groups that were treated using sphincteroplasty and fistulectomy: group 1: eight women with simple rectovaginal fistula due to birth trauma; group 2: six rectovaginal fistula cases that were associated with chronic inflammatory diseases; and group 3: five cases with at least one failed repair attempt. In the second step, operations that took place before the year 2000 were compared to the operations that took place after the year 2000 in terms of demographic and clinical characteristics.

Results

All of the simple rectovaginal fistula cases healed after the operation. Five of the group 2 patients healed after the operation. However, 1 patient with Crohn's disease needed to undergo reoperation, but successfully healed after 6 months. On the contrary, 3 patients in group 3 healed (60%) whereas 2 of them failed to heal. Clinical characteristics of the patients were different between the groups (before and after the year 2000).

Conclusion

The choice of operation must be done according to the patient's underlying pathology. Proper management of associated inflammatory diseases and systemic disorders is recommended for necessary complex cases.

Post-surgical fecal incontinence

The primary endpoint of this work was to understand the pathophysiology of fecal incontinence manifested after rectal and anal surgery. A retrospective cohort study with negative colonoscopy patients was created and 169 postoperative incontinent patients were analyzed (114 women and 55 men: mean age 58.9 ± 6.3): clinical evaluation, endoanal ultrasound and anorectal manometry reports were scanned. The duration of incontinence was very long, with a mean of 21.7 months. The mean number of bowel movements/week was 18.2 ± 7.2. Urge incontinence was present in 82.2% of patients, mixed with passive incontinence in 44 patients. Patients' Fecal Incontinence Severity Index (FISI) score was 27.0 ± 6.6. Operated patients had significantly lower anal resting pressure (P < 0.01) than controls while patients with colo-anal anastomosis and those who underwent Delorme operation had lowest values (P < 0.01). Maximal tolerated volume and rectal compliance were significantly impaired in operated patients with rectum involvement (colo-anal anastomosis, Delorme, restorative procto-colectomy and STARR). External anal sphincter (EAS) defects were present in 33.1% of all patients and internal anal sphincter (IAS) was damaged in 44.3%: a combined lesion of anal sphincters was detected in 39 patients (23.0%). A positive correlation was found between patients' FISI score and thickness of both sphincters (EAS: ρ_{s =} 73; IAS: ρ_s = 81). Malfunctioning continence factors may induce fecal incontinence involving each time, in a different way, the volumetric capacity and/or the motility of the rectum, the perception of the fecal bolus and anal sphincter contraction.

Comparing existing classifications of fistula-in-ano in 440 operated patients: Is it time for a new classification? A Retrospective Cohort Study

BACKGROUND

Fistula-in-ano are classified so as to grade them according to increasing complexity which can help guide their management. The classifications used are Parks, St James Hospital University (SJHU) and Standard Practice Task Force (SPTF). Laying open (fistulotomy) of the fistula tract is the most commonly done procedure for fistula-in-ano and has high success rate. The lower grade fistulas are supposed to have low risk of incontinence when laid open and vice-versa. The objective of the study was to evaluate the efficacy of the existing classifications.

MATERIALS & METHODS

440 consecutive fistula-in-ano patients operated over four years were analyzed on the basis of preoperative MRI scan and operative findings. It was assessed whether the amenability to fistulotomy (measurement of fistula simplicity) correlated with the fistula-in-ano grades in different classifications.

RESULTS

Out of 440 patients operated, 242 underwent fistulotomy whereas 198 underwent sphincter-sparing procedures for complex fistula. As per SJHU classification, the amenability to fistulotomy was 99.1% in Grade-I, 82.1% in Grade-II, 46.2% in Grade-III, 29.0% in Grade-IV and 5.4% in Grade-V. In Park's classification, the amenability to fistulotomy was 93.5% in Grade-I, 34.8% in Grade-II, 5.4% in Grade-III and 0% in Grade-IV. As per SPTF classification, 99.3% of simple and 32.1% of complex fistulas underwent fistulotomy. Even the higher grade fistula-in-ano in all three classifications had high rate of amenability to fistulotomy. Therefore none of the above classifications were accurate. A new classification is being proposed which divides fistula-in-ano in 5 grades in order of increasing complexity. Grade I & II are simple fistulas (fistulotomy be done conveniently) and Grade III-V are high complex fistulas (fistulotomy should not be attempted). The data was analyzed as per new classification and found it to be highly accurate.

CONCLUSIONS

None of the existing classifications accurately correlated between the grade and the complexity of fistula. A new classification is being proposed.

German S3 guidelines: anal abscess and fistula (second revised version)

BACKGROUND

The incidence of anal abscess and fistula is relatively high, and the condition is most common in young men.

METHODS

This is a revised version of the German S3 guidelines first published in 2011. It is based on a systematic review of pertinent literature.

RESULTS

Cryptoglandular abscesses and fistulas usually originate in the proctodeal glands of the intersphincteric space. Classification depends on their relation to the anal sphincter. Patient history and clinical examination are diagnostically sufficient in order to establish the indication for surgery. Further examinations (endosonography, MRI) should be considered in complex abscesses or fistulas. The goal of surgery for an abscess is thorough drainage of the focus of infection while preserving the sphincter muscles. The risk of abscess recurrence or secondary fistula formation is low overall. However, they may result from insufficient drainage. Primary fistulotomy should only be performed in case of superficial fistulas. Moreover, it should be done by experienced surgeons. In case of unclear findings or high fistulas, repair should take place in a second procedure. Anal fistulas can be treated only by surgical intervention with one of the following operations: laying open, seton drainage, plastic surgical reconstruction with suturing of the sphincter (flap, sphincter repair, LIFT), and occlusion with biomaterials. Only superficial fistulas should be laid open. The risk of postoperative incontinence is directly related to the thickness of the sphincter muscle that is divided. All high anal fistulas should be treated with a sphincter-saving procedure. The various plastic surgical reconstructive procedures all yield roughly the same results. Occlusion with biomaterial results in lower cure rate.

CONCLUSION

In this revision of the German S3 guidelines, instructions for diagnosis and treatment of anal abscess and fistula are described based on a review of current literature.

Total fistulectomy, sphincteroplasty and closure of the residual cavity for trans-sphincteric perianal fistula in the elderly patient

BACKGROUND

Perianal fistula is a complex and frequent disease. At present, no treatment nor technique has shown an absolute superiority in terms of efficacy and recurrence rate. The technique has to be chosen considering the balance between faecal continence preservation and disease eradication. Rarely concomitant perianal abscess and fistula are treated at the same time, and often time to complete recovery is long.

AIMS

The aim of this study was to evaluate the possibility of treating the abscess and the fistula tract in one procedure with total fistulectomy, sphincteroplasty and an almost complete closure of the residual cavity, thus reducing the healing time in older patients.

METHODS

A non-randomized single-centre series of 86 patients from 2007 to 2012 with low-medium trans-sphincteric perianal fistula (< 30% of external sphincter involvement) with or without synchronous perianal abscess were treated with total fistulectomy, sphincteroplasty and closure of the residual cavity technique.

RESULTS

Success rate was 97.7% with a healing time of 4 weeks; overall morbidity was 16.2%; recurrence rate was 2.3%; no major alterations of continence were observed.

DISCUSSION

Fistulectomy, sphincteroplasty and closure of the residual cavity are associated with a low rate of recurrence and good faecal continence preservation in older patients. This technique can be safely used even with a concomitant perianal abscess, with reduction in healing time and in the number of surgical procedures needed.

CONCLUSIONS

Total fistulectomy with sphincteroplasty and partial closure of the residual cavity, as described, is a safe procedure but has to be performed by dedicated colorectal surgeons.

Meta-analysis of randomized clinical trials comparing fistulectomy versus fistulotomy for low anal fistula

Objective

We evaluated the efficacy of fistulectomy compared to fistulotomy, and which procedure was the best procedure for patients with low anal fistula.

Methods

The literature search included PubMed, EMBASE, Cochrane library, Google original studies and a manual search of reference on the topic of fistulectomy compared to fistulotomy for anal fistula that had a deadline for publication by June 2016. Randomized controlled trials studies were included in the review. The outcome variables were analyzed which including operative time, healing time, postoperative complications, recurrence and incontinence.

Results

Six randomized controlled trials (fistulectomy = 280, fistulotomy = 285) were considered suitable for the meta-analysis, with a total of 565 patients. The result of meta-analysis indicated no statistically significant difference in operative time [OR 4.74, 95 % CI −2.74, 12.23, p = 0.21] and healing time [OR −3.32, 95 % CI −19.86, 13.23, p = 0.69] between the fistulectomy and fistulotomy procedures. Three main postoperative complications were included, and the combined result indicated no statistically significant difference in overall complications [OR 1.39, 95 % CI 0.51, 3.78, p = 0.52] and subgroup complication. At the end of follow up, two kinds of surgical methods have the same low recurrence rate and faecal incontinence. The result revealed that there was no significant difference in rate of fistula recurrence between the fistulectomy and the fistulotomy [OR 1.39, 95 % CI 0.70, 2.73, p = 0.34].

Conclusion

The meta-analysis indicates that there is no conclusive evidence if fistulectomy or fistulotomy procedure is better in the treatment of low anal fistula.

Prospective evaluation of a new device for the treatment of anal fistulas

AIM

To evaluate the safety of the implantation of a new device for the treatment of anal fistulas. The short-term clinical efficacy was also assessed.

METHODS

This study took place at a tertiary care university hospital. Patients with a complex anal fistula of cryptoglandular origin were enrolled in the study and were treated with insertion of the new device. All patients were evaluated by clinical and physical examination, including an endoanal ultrasound at the baseline, and then at the 2 wk and 1, 2, 3 and 6-mo follow-up visits.

RESULTS

Morbidity, continence status, and success rate were the main outcome measures. Ten patients underwent the placement of the new device. The fistulas were transphincteric in eight patients and extrasphincteric in the remaining two. The median duration of the surgical procedure was 34.5 (range, 27-42) min. Neither intra- nor postoperative complications occurred, and all patients were discharged the day after the procedure. At the 6-mo follow-up evaluation, the final success rate was 70%. Three failures were registered: a device expulsion (on the 10(th) postoperative day), the persistence of inflammatory tissue around the fistula tract (at the 2-mo follow up), and the persistence of serum discharge (at the 6-mo follow up). No patient experienced any change incontinence, as assessed by the Cleveland Clinic Fecal Incontinence score.

CONCLUSION

The technical procedure is simple and has low risk of perioperative morbidity. The pre- and post-operative continence status did not change in any of the patients. The initial results at the 6-mo follow up seem to be promising. However, a longer follow-up period and a larger sample size are needed to confirm these preliminary results.

Therapeutic management of complex anal fistulas by installing a nitinol closure clip: study protocol of a multicentric randomised controlled trial--FISCLOSE

INTRODUCTION

Complex anal fistulas are responsible for pain, faecal incontinence and impaired quality of life. The rectal mucosa advancement flap (RMAF) procedure to cover the internal opening of the fistula remains a strategy of choice. However, a new procedure for closing anal fistulas is now available with the use of a nitinol closure clip (OTSC Proctology, OVESCO), which should ensure a better healing rate. This procedure is currently becoming more widespread, though without robust scientific validation, and it is therefore essential to carry out a prospective evaluation in order to determine the efficacy and safety of this new medical device for complex anal fistulas.

METHODS AND ANALYSIS

The FISCLOSE trial is aimed at evaluating the efficacy and safety of a nitinol closure clip compared to the RMAF procedure for the management of complex anal fistulas. This trial is a prospective, randomised, controlled, single-blind, bicentre and interventional study. Patients (n=46 per group) will be randomly assigned for management with either a closure clip or RMAF. The main objectives are to improve the healing rate of the anal fistula, lessen the postoperative pain and faecal incontinency, enhance the quality of life, and lower the number of reinterventions and therapeutic management costs. The primary outcome is the proportion of patients with a healed fistula at 3 months. The secondary outcomes are anal fistula healing (6 and 12 months), proctological pain (visual analogue scale), the faecal incontinence score (Jorge and Wexner questionnaire), digestive disorders and quality of life (Gastrointestinal Quality of Life Index and Euroqol EQ5D-3 L) up to 1 year.

ETHICS AND DISSEMINATION

The study was approved by an independent medical ethics committee 1 (IRB00008526, CPP Sud-Est 6, Clermont-Ferrand, France) and registered by the competent French authority (ANSM, Saint Denis, France). The results will be disseminated in a peer-reviewed journal and presented at international congresses.

TRIAL REGISTRATION NUMBER

NCT02336867; pre-result.