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

Contemporary management of anorectal fistula

Anorectal fistula is a common, chronic condition, and is primarily managed surgically. Herein, we provide a contemporary review of the relevant etiology and anatomy anorectal fistula, treatment recommendations that summarize relevant outcomes and alternative considerations, in particular when to refer to a fistula expert.

Long term results of video-assisted anal fistula treatment for complex anal fistula: another shattered dream?

AIM

Complex anal fistula represents a burden for patients, and its management is a challenge for surgeons. Video-assisted anal fistula treatment (VAAFT) is one sphincter-sparing technique. However, data on its long-term effectiveness are scant. We aimed to explore the outcomes of VAAFT in a retrospective cohort of patients referred to a tertiary centre.

METHOD

Consecutive adult patients with a minimum of 2 years' follow-up after VAAFT were reviewed. Patients were followed up to 5 years postoperatively. Failure was defined as incomplete healing of the external orifice(s) during the first 6 months. Recurrence was defined as new radiologically and/or clinically confirmed onset of the fistula after primary healing. A generalized linear model was fitted to evaluate the association between failure and sociodemographic characteristics. Predictors of recurrence were determined in a subgroup analysis of patients found to be free from disease at 6 months postoperatively.

RESULTS

Overall, 106 patients (70% male; mean age 41 years) were reviewed. Of these 86% had a previous seton placement. Fistulas were either high trans-sphincteric (74%), suprasphincteric (12%) or extrasphincteric (13%). Eight (7%) patients experienced postoperative complications, none of which required reintervention. Mean follow-up was 53 ± 13.2 months. VAAFT failed in 14 (13%) patients. The overall recurrence rate ranged from 29% at 1 year to 63% at 5 years. Multiple external orifices, suprasphincteric fistula, younger age, previous surgery and higher complexity of the fistulous tract were independent risk factors for recurrence.

CONCLUSION

VAAFT is a safe sphincter-sparing technique. The initially high success rate decreases over time and relates to a higher degree of complexity.

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

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

A Systematic Review of Epidemiology and Outcomes Associated with Local Surgical and Intersphincteric Ligation Procedures for Complex Cryptoglandular Fistulas

INTRODUCTION

This systematic literature review (SLR) assessed incidence/prevalence of cryptoglandular fistulas (CCF) and outcomes associated with local surgical and intersphincteric ligation procedures for CCFs.

METHODS

Two trained reviewers searched PubMed and Embase for observational studies evaluating the incidence/prevalence of cryptoglandular fistula and clinical outcomes of treatments for CCF after local surgical and intersphincteric ligation procedures for CCF.

RESULTS

In total 148 studies met a priori eligibility criteria for all cryptoglandular fistulas and all intervention types. Of those, two assessed incidence/prevalence of cryptoglandular fistulas. Eighteen reported clinical outcomes of surgeries of interest in CCF and were published in the past 5 years. Prevalence was reported as 1.35/10,000 non-Crohn's patients, and 52.6% of non-IBD patients were found to progress from anorectal abscess to fistula over 12 months. Primary healing rates ranged from 57.1% to 100%; recurrence occurred in a range of 4.9-60.7% and failure in 2.8-18.0% of patients. Limited published evidence suggests postoperative fecal incontinence and long-term postoperative pain were rare. Several of the studies were limited by single-center design with small sample sizes and short follow-up durations.

DISCUSSION

This SLR summarizes outcomes from specific surgical procedures for the treatment of CCF. Healing rates vary according to procedure and clinical factors. Differences in study design, outcome definition, and length of follow-up prevent direct comparison. Overall, published studies offer a wide range of findings with respect to recurrence. Postsurgical incontinence and long-term postoperative pain were rare in the included studies, but more research is needed to confirm rates of these conditions following CCF treatments.

CONCLUSION

Published studies on the epidemiology of CCF are rare and limited. Outcomes of local surgical and intersphincteric ligation procedures show differing success and failure rates, and more research is needed to compare outcomes across various procedures. (PROSPERO; registration number CRD42020177732).

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.

Guidelines to diagnose and treat peri-levator high-5 anal fistulas: Supralevator, suprasphincteric, extrasphincteric, high outersphincteric, and high intrarectal fistulas

Supralevator, suprasphincteric, extrasphincteric, and high intrarectal fistulas (high fistulas in muscle layers of the rectal wall) are well-known high anal fistulas which are considered the most complex and extremely challenging fistulas to manage. Magnetic resonance imaging has brought more clarity to the pathophysiology of these fistulas. Along with these fistulas, a new type of complex fistula in high outersphincteric space, a fistula at the roof of ischiorectal fossa inside the levator ani muscle (RIFIL), has been described. The diagnosis, management, and prognosis of RIFIL fistulas is reported to be even worse than supralevator and suprasphincteric fistulas. There is a lot of confusion regarding the anatomy, diagnosis, and management of these five types of fistulas. The main reason for this is the paucity of literature about these fistulas. The common feature of all these fistulas is their complete involvement of the external anal sphincter. Therefore, fistulotomy, the simplest and most commonly performed procedure, is practically ruled out in these fistulas and a sphincter-saving procedure needs to be performed. Recent advances have provided new insights into the anatomy, radiological modalities, diagnosis, and management of these five types of high fistulas. These have been discussed and guidelines formulated for the diagnosis and treatment of these fistulas for the first time in this paper.

Living with cryptoglandular anal fistula: a qualitative investigation of the patient's experience through semi-structured patient interviews

Purpose

Cryptoglandular anal fistula continues to be a subject of extensive surgical research due to the lack of effective and enduring treatments, some of which incur risks to continence and quality of life. However, the patient experience of disease has seldom been reported. The aims of this study are to understand the impact of living with a fistula and the treatment outcomes that are valued by patients.

Methods

Patients with cryptoglandular anal fistula were recruited using purposive sampling from two tertiary referral centres in the UK and the Netherlands. Patients underwent semi-structured interviews that were audio-recorded and transcribed verbatim. Dutch transcripts were translated into English and underwent independent, thematic analysis using open coding by two study team members to identify common themes and sub-themes.

Results

Twenty interviews were conducted before saturation was reached (11 male, median age 49, Interquartile range 39–55 years). Four broad themes emerged, covering the physical symptoms of fistula, the patient journey towards understanding the condition, life impact, and treatment. Several inter-related sub-themes were found, reflecting the extensive impact and adjustment that the disease entails.

Conclusion

The impact of cryptoglandular anal fistula extends beyond the physical symptoms of pain and discharge, requires significant readjustment, and often negatively impacts psycho-social wellbeing. These aspects of disease should receive greater attention in future assessment of treatment and quality of life.

Supplementary Information

The online version contains supplementary material available at 10.1007/s11136-022-03098-y.

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.

Evaluation of Fistulotomy with Immediate Sphincteric Reconstruction in the Treatment of High Transsphincteric Perianal Fistula

Background High perianal fistula treatment remains challenging, mainly due to the variability in success and recurrence rates as well as continence impairment risks. So far, no procedure can be considered the gold standard for surgical treatment. Yet, strong efforts to identify effective and complication-free surgical options are ongoing. Fistulotomy can be considered the best perianal fistula treatment option, providing a perfect surgical field view, allowing direct access to the source of chronic inflammation. Controversy exists concerning the risk of continence impairment associated with fistulotomy. The present study aimed to assess the outcomes of fistulotomy with immediate sphincteric reconstruction regaring fistula recurrence, incontinence, and patient satisfaction.

Methods This interventional study was performed at the General Surgery Department of Zagazig University Hospital during the period from July 2018 to December 2019 on 24 patients with a clinical diagnosis of high transsphincteric fistula-in-ano. The fistulous tract was laid open over the probe placed in the tract. After the fistula tract had been laid open, the tract was curetted and examined for secondary extensions. Then, suturing muscles to muscles, including the internal and external sphincters, by transverse mattress sutures.

Results Our study showed that 2 patients develop incontinence to flatus ∼ 8.3%.and only one patient develop incontinence to loose stool, 4.2%. Complete healing was achieved in 83% and recurrence was 16.6%.

Conclusion Fistulotomy with immediate sphincteric reconstruction is considered to be an effective option in the management of high perianal fistula, with low morbidity and high healing rate with acceptable continence state.

Video-assisted anal fistula treatment versus fistulectomy and sphincter repair in the treatment of high cryptoglandular anal fistula: a randomized clinical study

Background

Video-assisted anal fistula treatment (VAAFT) may have a recurrence rate comparable to that of fistulectomy and sphincter repair (FSR) in the treatment of high anal fistula and with potential advantages in wound healing, functional outcome and quality of life. The aim and objectives of the study are to compare the outcome of VAAFT with that of FSR for high cryptoglandular anal fistula.

Methods

This was a single-centre randomized controlled trial of adults with high anal fistula comparing FSR with VAAFT. Primary outcome was fistula recurrence. Secondary outcomes were results of anal manometry, quality of life and faecal continence. A power calculation of 33 patients in each arm (1 : 1) was based on recurrence in the FSR and VAAFT groups of 5 per cent and 30 per cent respectively. Follow-up at 6 months after surgery included physical examination, MRI, anal manometry, quality-of-life assessment (RAND SF 36 questionnaire) and faecal-continence assessment (Wexner score).

Results

The study was terminated early due to high recurrence rates in both groups. A total of 45 patients were included. Recurrence rates were 65 per cent for VAAFT and 27 per cent for FSR, with hazard ratio 4.18 (P = 0.016). Length of the fistula was a risk factor with an association with recurrence (hazard ratio 1.8, P = 0.020). There were significant differences in quality of life in favour of FSR and in anal manometry in favour of VAAFT with a significant improvement in Wexner score in both groups.

Conclusion

FSR was associated with a lower recurrence rate than VAAFT in the management of complex anal fistulae in this single-centre study but the study was terminated early due to higher than predicted recurrence rate in both groups.

Registration number

NCT02585167 (http://www.clinicaltrials.org).

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Advances in the Treatment of Anal Fistula: A Mini-Review of Recent Five-Year Clinical Studies

Anal fistula, with its complicated pathogenesis, has been considered as a clinical challenge for centuries. The risk of frequent recurrence and incontinence constitutes a considerable threat in the long-term treatment of anal fistula. In this work, we narratively reviewed the scientific literature of new techniques that have been used for anal fistula treatment over the recent 5 years, objectively evaluated the pros and cons of each technique on the basis of clinical outcomes, and tried to disclose the effective strategies for anal fistula treatment. Up to date, surgery is the main method used for treating anal fistula, but there is no simple technique that can completely heal complex anal fistula. In the course of surgery treatment, the healing outcome, and the protection of anal function should be weighed comprehensively. Among the innovative techniques that have emerged in recent years, combined techniques based on drainage Seton and LIFT-plug seem to be the relatively effective therapies, but their effectiveness requires more multi-center prospective randomized controlled trials with large sample size and long-term follow-up to be validated.

Simple fistula-in-ano: is it all simple? A systematic review

Background

Simple anal fistula is one of the most common causes of proctological surgery and fistulotomy is considered the gold standard. This procedure, however, may cause complications. The aim of this systematic review was to assess the surgical treatment of simple anal fistula with traditional and sphincter-sparing techniques.

Methods

A literature research was performed using PubMed, Cochrane, and Google Scholar to identify studies on the surgical treatment of simple anal fistulas. Observational studies and randomized clinical trials were included. We assessed the risk of bias of included studies using the Jadad scale for randomized controlled trials, and the MINORS Scale for the remaining studies.

Results

The search returned 456 records, and 66 studies were found to be eligible. The quality of the studies was generally low. A total of 4883 patients with a simple anal fistula underwent a sphincter-cutting procedure, mainly fistulotomy, with a weighted average healing rate of 93.7%, while any postoperative continence impairment was reported in 12.7% of patients. Sphincter-sparing techniques were adopted to treat 602 patients affected by simple anal fistula, reaching a weighted average success rate of 77.7%, with no study reporting a significant postoperative incontinence rate. The postoperative onset of fecal incontinence and the recurrence of the disease reduced patients’ quality of life and satisfaction.

Conclusions

Surgical treatment of simple anal fistulas with sphincter-cutting procedures provides excellent cure rates, even if postoperative fecal incontinence is not a negligible risk. A sphincter-sparing procedure could be useful in selected patients.

Long-Term Clinical Results of Use of an Anal Fistula Plug for Treatment of Low Trans-Sphincteric Anal Fistulas

BACKGROUND An anal fistula plug is a sphincter-sparing procedure that uses biological substances to close an anorectal fistula. This study aimed to evaluate the long-term therapeutic effect of an anal fistula plug procedure in patients with trans-sphincteric fistula-in-ano and to determine the risk factors affecting fistula healing. MATERIAL AND METHODS A single-center retrospective study was performed assessing long-term treatment outcomes of patients with low trans-sphincteric anal fistulas who initially underwent anal fistula plug procedures between August 2008 and September 2012. Risk factors affecting fistula healing were identified using univariate and multivariate analyses. RESULTS A total of 135 patients who had low trans-sphincteric anal fistulas and underwent anal fistula plug procedures were analysed. The overall healing rate was 56% (75/135) with a median follow-up time of 8 years (range, 72-121 months). The primary reasons for treatment failure were plug extrusion (n=12, 20%) and surgical site infection (n=9, 15%), occurring within 30 days after surgery. Multiple logistic regression analysis showed that the duration of anal fistula ≥6 months was significantly associated with treatment failure using an anal fistula plug (OR=3.187, 95% CI: 1.361-7.466, P=0.008). Of the patients who failed initial treatment with an anal fistula plug, 6 (9%) had anal fistulas that healed spontaneously after 2-3 years without additional treatment. CONCLUSIONS As a sphincter-preserving procedure, the anal fistula plug can effectively promote healing of low trans-sphincteric anal fistulas. The long-term efficacy is good and the procedure warrants wider use in clinical practice.

Factors associated with healing, reoperation and continence disturbance in patients following surgery for fistula-in-ano

AIM

Fistula-in-ano (FIA) is associated with high treatment costs and has a deleterious impact on quality of life. A wide range of healing, incontinence and recurrence rates have been reported. This study aimed to identify operative, patient and disease factors that influence these outcomes after surgery for FIA.

METHOD

An observational cohort study of consecutive patients who were managed for FIA at a tertiary colorectal practice (1999-2019) was performed. Outcome measures included healing, impaired continence and the need to reoperate. Clinico-pathological variables, including patient comorbidities, fistula anatomy and operative approach, were assessed for their association with these outcomes.

RESULTS

Some 411 procedures were performed on 263 patients [median age 41.8 years (range 17.8-79.7 years), 184 men (70.0%)]. Some 77.9% of patients achieved complete healing, 9.5% experienced some deterioration in continence postoperatively and 37.6% required reoperation at a median time of 19.0 weeks. Poorer healing was associated with Crohn's disease, high trans-sphincteric fistulas, extrasphincteric fistulas and steroid usage. Poorer continence was associated with female sex, age > 40 years, posterior location, suprasphincteric fistulas, seton insertion and having more than three subsequent procedures. The need to reoperate was associated with female sex, high trans-sphincteric fistulas, suprasphincteric fistulas, inflammatory bowel disease and previous operations for FIA.

CONCLUSION

Minimizing recurrence of FIA and preservation of continence can be competing management goals. More than one in three patients require reoperation, one in five fails to heal completely and one in ten suffers worsened continence following surgery. Awareness of the factors that contribute to these outcomes is important to the process of informed consent and managing patient expectations before surgery.