Fibrin glue treatment of complex anal fistulas has low success rate

Ligation of the Intersphincteric Fistula Tract as an Emergency Treatment for Cryptoglandular Anal Fistula

Introduction

Ligation of the intersphincteric fistula tract (LIFT) is a sphincter-preserving procedure for treating anal fistula of cryptoglandular origin. Our prospective study aimed to determine the postoperative outcomes of patients undergoing LIFT in emergency and elective settings.

Methods

This was a single-centre prospective observational study of the LIFT procedure for the treatment of anal fistulas. The differences in the 6-month postoperative outcomes between the emergency and elective procedures were analysed, including the healing rate, healing time, recurrence rate, recurrence time, postoperative complications and length of hospital stay.

Results

Twenty-two patients were recruited for this study: 11 patients underwent LIFT as an emergency procedure (EM-LIFT), while the others underwent LIFT as an elective procedure (EL-LIFT). The healing rate for the EM-LIFT group was 90.9% (n = 10), with a median healing time of 2 months (range 0.5-4). For the EL-LIFT group, the healing rate was 100% (n = 11), with the same median healing time of 2 months (range 0.5-4). Two of the patients in the EM-LIFT group developed recurrence, with a median recurrence time of 5 months (range 4-6) and three developed recurrence in the EL-LIFT group, with the same median recurrence time of 5 months (range 4-6). There were minor postoperative complications of pain and subcutaneous infection, with no faecal incontinence. There was no statistically significant difference in postoperative outcomes between the groups.

Conclusion

EM-LIFT is a feasible and safe primary procedure for active cryptoglandular-type anal fistulas.

Novel Approach in Rectovaginal Fistula Treatment: Combination of Modified Martius Flap and Autologous Micro-Fragmented Adipose Tissue

In this paper, we introduce an innovative therapeutic approach for managing rectovaginal fistulas (RVF), by combining the modified Martius flap and micro-fragmented adipose tissue (MFAT) enriched with mesenchymal stem cells (MSC). This novel approach aims to deal with the difficulties associated with RVF, a medically complex condition with a lack of effective treatment options. We present the case of a 45-year-old female patient with a 15-year history of Crohn's disease (CD). During the preceding eight years, she had encountered substantial difficulties resulting from a rectovaginal fistula (RVF) that was active and considerable in size (measuring 3.5 cm in length and 1 cm in width). Her condition was accompanied by tissue alterations at both the vaginal and rectal openings. Following her admission to our hospital, the patient's case was discussed during both surgical and multidisciplinary hospital team (IRB) meetings. The team decided to combine a modified Martius flap with autologous MFAT containing MSCs. The results were remarkable, leading to comprehensive anatomical and clinical resolution of the RVF. Equally significant was the improvement in the patient's overall quality of life and sexual satisfaction during the one-year follow-up period. The integration of the modified Martius flap with MFAT emerges as a highly promising approach for addressing CD-related RVFs that had historically been, and still are, difficult to treat, given their often refractory nature and low healing success rates.

Predictors of outcome in cryptoglandular anal fistula according to magnetic resonance imaging: A systematic review

Background and Aims

Anal fistula (AF) with cryptoglandular origin tends to recur, and multiple risk factors are implicated. Recently, some magnetic resonance imaging (MRI) findings with predictive value for disease outcomes have been proposed. These intrinsic anatomic features include those of the AF and its surrounding structures. This study aims to clarify the prognostic role of MRI in AF.

Methods

We performed a systematic search of PubMed, Embase, and EBSCO databases. Two independent reviewers conducted the search and screened the articles. We selected studies that used MRI to assess AF and reported its relationship to disease outcome. We extracted data regarding the study design, type of intervention, outcome, MRI-measured items, and their significance.

Results

Out of 1230 retrieved articles, 18 were eligible for final inclusion, and a total of 4026 patients were enrolled in the selected studies. For preoperative MRI, the significant items affecting the outcome were the length of the fistula, horseshoe type, presence of multiple tracts, supralevator extension, and apparent diffusion coefficient (ADC) value. Other studies investigated the healing process using postoperative MRI.

Conclusion

This review found that MRI can be useful in the management of AF, both preoperatively and postoperatively. Factors, such as fistula length, horseshoe type, presence of multiple tracts, supralevator extension, and ADC value were found to be significantly associated with treatment outcomes. The presence of the fistula tract and the development of new abscesses on postoperative MRI was found to hinder the healing process. Further studies are needed to confirm these findings.

Antimicrobial PVA Hydrogels with Tunable Mechanical Properties and Antimicrobial Release Profiles

Hydrogels are broadly employed in wound healing applications due to their high water content and tissue-mimicking mechanical properties. Healing is hindered by infection in many types of wound, including Crohn's fistulas, tunneling wounds that form between different portions of the digestive system in Crohn's disease patients. Owing to the rise of drug-resistant infections, alternate approaches are required to treat wound infections beyond traditional antibiotics. To address this clinical need, we designed a water-responsive shape memory polymer (SMP) hydrogel, with natural antimicrobials in the form of phenolic acids (PAs), for potential use in wound filling and healing. The shape memory properties could allow for implantation in a low-profile shape, followed by expansion and would filling, while the PAs provide localized delivery of antimicrobials. Here, we developed a urethane-crosslinked poly(vinyl alcohol) hydrogel with cinnamic (CA), p-coumaric (PCA), and caffeic (Ca-A) acid chemically or physically incorporated at varied concentrations. We examined the effects of incorporated PAs on antimicrobial, mechanical, and shape memory properties, and on cell viability. Materials with physically incorporated PAs showed improved antibacterial properties with lower biofilm formation on hydrogel surfaces. Both modulus and elongation at break could be increased simultaneously in hydrogels after both forms of PA incorporation. Cellular response in terms of initial viability and growth over time varied based on PA structure and concentration. Shape memory properties were not negatively affected by PA incorporation. These PA-containing hydrogels with antimicrobial properties could provide a new option for wound filling, infection control, and healing. Furthermore, PA content and structure provide novel tools for tuning material properties independently of network chemistry, which could be harnessed in a range of materials systems and biomedical applications.

Endoscopic Treatment of Acute and Chronic Anastomotic Leaks from Inflammatory Bowel Disease Surgery

Acute or chronic anastomotic leak is a common complication after any gastrointestinal surgery in inflammatory bowel disease (IBD). The underlying disease of the bowel, comorbidities, malnutrition, anemia, and concurrent use of corticosteroids increase the risk for the development of anastomotic leaks. Anastomotic leak is traditionally managed with surgery. However, recent innovation has allowed the use of endoscopic methods in the management of some anastomotic leaks and their consequences. This article discusses a variety of endoscopic techniques that have either been established or are under current evaluation, for the management of anastomotic leaks in patients with IBD.

The Optimal Management of Fistulizing Crohn’s Disease: Evidence beyond Randomized Clinical Trials

Fistulizing Crohn’s disease (FCD) remains the most challenging aspect of treating patients with CD. FCD can occur in up to 30% of patients with CD and may lead to significant disability and impaired quality of life. The optimal treatment strategies for FCD require a multidisciplinary approach, including a combined medical and surgical approach. The therapeutic options for FCD are limited due to sparse evidence from randomized clinical trials (RCTs). The current recommendations are mainly based on post hoc analysis from RCTs, real-world clinical studies and expert opinion. There is variation in everyday clinical practice amongst gastroenterologists and surgeons. The evidence for anti-tumor necrosis factor therapy is the strongest in the treatment of FCD. However, long-term fistula healing can be achieved in only 30–50% of patients. In recent years, emerging data in the advent of therapeutic modalities, including the use of new biologic agents, therapeutic drug monitoring, novel surgical methods and mesenchymal stem cell therapy, have been shown to improve outcomes in achieving fistula healing. This review summarizes the existing literature on current and emerging therapies to provide guidance beyond RCTs in managing FCD.

Comprehensive literature review of the applications of surgical laser in benign anal conditions

Surgery for benign anal conditions is a common practice and is usually followed by a good outcome. The present review aimed to summarize the emergence and evolution of different laser techniques used for the treatment of benign anal conditions and report their current outcome. PubMed and Scopus were searched for studies that assessed the use of laser in benign anal conditions. Anal conditions reviewed were hemorrhoids, anal fistula, anal warts, anal stenosis, and anal fissure. The full text of the studies retrieved was summarized in a narrative and tabular form. Laser techniques used for the treatment of hemorrhoidal disease were laser open hemorrhoidectomy, laser hemorrhoidoplasty, and Doppler-guided hemorrhoidal laser dearterialization. Resolution of hemorrhoidal symptoms was reported in 72-100% of patients after laser treatment. YAG laser, fistula laser closure, and photodynamic therapy have been used for the treatment of anal fistula with success rates ranging from 20 to 92.6%. Anal warts can be treated with photodynamic therapy with or without YAG or CO² laser with a success rate up to 88%. A few studies reported the use of laser in the treatment of chronic anal fissure and anal stenosis. The use of laser in the treatment of benign anal conditions is associated with promising outcomes. Laser was most assessed in hemorrhoidal disease and anal fistula and showed more consistent success rates with hemorrhoidal disease than with anal fistula. Preliminary reports assessed the outcome of laser treatment in other conditions as anal fissure and warts with acceptable outcomes.

Shape memory polymer hydrogels with cell-responsive degradation mechanisms for Crohn's fistula closure

Crohn's disease, a form of inflammatory bowel disease, commonly results in fistulas, tunneling wounds between portions of the urinary, reproductive, and/or digestive systems. These tunneling wounds cause pain, infection, and abscess formation. Of Crohn's patients with fistula formation, 83% undergo surgical intervention to either drain or bypass the fistula openings, and ~23% of these patients ultimately require bowel resections. Current treatment options, such as setons, fibrin glues, and bioprosthetic plugs, are prone to infection, dislodging, and/or require a secondary removal surgery. Thus, there is a need for fistula filling material that can be easily and stably implanted and then degraded during fistula healing to eliminate the need for removal. Here, the development of a shape memory polymer hydrogel foam containing polyvinyl alcohol (PVA) and cornstarch (CS) with a disulfide polyurethane crosslinker is presented. These materials undergo controlled degradation by amylase, which is present in the digestive tract, and by reducing thiol species such as glutathione/dithiothreitol. Increasing CS content and using lower molecular weight PVA can be used to increase the degradation rate of the materials while maintaining shape memory properties that could be utilized for easy implantation. This material platform is based on low-cost and easily accessible components and provides a biomaterial scaffold with cell-responsive degradation mechanisms for future potential use in Crohn's fistula treatment.

Jump Technique versus Seton Method for Anal Fistula Repair: A Randomized Controlled Trial

BACKGROUND

The treatment of anal fistula has been a conundrum for surgeons over the years. Various methods such as fistulotomy, fistulectomy, seton, ligation of the intersphincteric fistula tract (LIFT), advancement flaps, fibrin glue, and plugs are well-known techniques. Yet, they may be followed by several considerable complications, including incontinency and recurrence.

METHODS

In this study, the outcomes of the "Jump" and "Seton" techniques are compared. A randomized controlled trial consisting of 130 cases with cryptoglandular anal fistula randomly sorted into two groups was conducted. Group A underwent the "Jump technique" while group B underwent the "Seton technique." Outcomes, incontinency and recurrences in particular, were evaluated after a year of treatment. Data were analyzed by Fisher Exact, Chi-Square and Mann Whitney Tests.

RESULTS

Group A with 65 cases underwent the "Jump technique" while group B with 65 cases underwent the "Seton Method." Recurrence was reported in 12 (20%) cases in group A and 10 (15.6%) cases in group B (p=0.687). Overall incontinence was reported in 3 (4.6%) cases in group A and 18 (27.7%) cases in group B (P=0.001). The total St. Mark's scores for incontinency of group A (0.092±0.52) and group B (1.8±02.47) significantly differed (p<0.001).

CONCLUSIONS

The "Jump technique", named after a runner who jumped over hurdles, has obviated these complications. The "Jump technique" had satisfactory results and can be utilized as a first-line approach for all types of fistulas. Moreover, it can be redone for cases with recurrences without affecting the continence, paving the way to change the technique during operations.

Treatments for the amelioration of persistent factors in complex anal fistula

Anal fistulae are abnormal hollow connections between the wall of the anal canal and the perianal skin around the anus that have remained a burden on the medical sector for centuries. The complexity of this disease is attributed to a number of factors such as the degree of associated sphincter muscle, concomitant illnesses, existence of multiple fistulous tracts and the number of previous interventions. Persistence of a complex anal fistula can cause a decline in patient's physical quality of life as well as impact on the psychological status of patients who often suffer from anxiety and depression. Surgical intervention remains the gold standard for treatment, however; the risk of incontinence and high recurrence potential has led to interest into developing alternative treatment approaches such as the use of biologics, bioactives and biomaterials. One potential reason for these varied outcomes could be the multifactorial interplay between genetic, immune-related, environmental, and microbial persistence factors on tissue regeneration. Recent observations have proposed that adverse inflammatory mediators may contribute more than microbial factors. The moderate to high success rates of biotechnological advances (mesenchymal stem cells and biomaterial scaffolds) show promise as therapies for the amelioration of adverse persistent factors while facilitating a means to closing the fistula tract. The purpose of this review is to outline recent advances in biologics and combination therapies to treat persistent factors associated with complex anal fistula.

Efficacy of Permacol injection for perianal fistulas in a tertiary referral population: poor outcome in patients with complex fistulas

AIM

Injection of Permacol collagen paste can be used as a sphincter-sparing treatment for perianal fistulas. In a tertiary referral population we aimed to evaluate the efficacy of Permacol injection and the clinical and fistula-related factors associated with recurrence.

METHOD

This was a retrospective analysis of consecutive patients with perianal fistulas treated with Permacol injection at a specialist centre between June 2015 and April 2019. Endoanal ultrasonography was systematically reanalysed, blinded to treatment outcome. Rectovaginal, anovaginal and Crohn's disease fistulas were excluded. Healed fistulas were defined as absent anal symptoms and a closed external opening on physical examination at a minimum follow-up of 6 months. Regression analyses were performed to identify factors associated with unhealed fistulas.

RESULTS

A total of 90 patients (51 men; median age 45 years) were analysed. Seventy-two (80.0%) patients had complex perianal fistulas (greater than one-third sphincter involvement or multiple tracts). After a single Permacol injection, fistulas were healed in 20 (22.2%) patients at 3 months follow-up and in 18 (20.0%) patients at a median follow-up of 30 months (interquartile range 17-37). Eight (11.1%) patients with unhealed fistulas had significant improvement in their symptoms. Complex fistulas were significantly associated with unhealed status [OR 3.53 (95% CI 1.12-11.09); p = 0.031]. Twenty patients underwent subsequent Permacol injections, which were successful in six (30.0%) patients after one (n = 3) or two (n = 3) additional injections.

CONCLUSION

This largest study to date in patients with mainly complex perianal fistulas, demonstrated that the efficacy of a single Permacol injection was only 20%. Complex fistulas were associated with a poor outcome.

Systematic review of efficacy of LIFT procedure in crpytoglandular fistula-in-ano

Background fistula-in-ano is a common problem. Ligation of intersphincteric fistula tract (LIFT) is a new addition to the list of operations available to deal with complex fistula-in-ano.

Objective we sought to qualitatively analyze studies describing LIFT for crpytoglandular fistula-in-ano and determine its efficacy.

Data sources MEDLINE (Pubmed, Ovid), Embase, Scopus and Cochrane Library were searched.

Study selection all clinical trials which studied LIFT or compared LIFT with other methods of treatment for anal fistulae, prospective observational studies, clinical registry data and retrospective case series which reported clinical healing of the fistula as the outcome were included. Case reports, studies reporting a combination with other technique, modified technique, abstracts, letters and comments were excluded.

Intervention the intervention was ligation of intersphincteric fistula tract in crpytoglandular fistula-in-ano.

Main outcome measure primary outcome measured was success rate (fistula healing rate) and length of follow-up.

Mesenchymal Stromal Cell Therapy in the Management of Perianal Fistulas in Crohn's Disease: An Up-To-Date Review

Crohn’s Disease (CD) is a chronic inflammatory disorder that potentially involves the entire gastrointestinal tract. Perianal fistulizing CD (pCD) is a serious and frequent complication associated with significant morbidities and a heavy negative impact on quality of life. The aim of CD treatment is to induce and maintain disease remission and to promote mucosal repair. Unfortunately, even the best therapeutic regimens in pCD do not have long-term efficacy and cause a significant number of side effects. Therefore, it is mandatory to study new therapeutical options such as the use of mesenchymal stromal cells (MSCs). These cells promote tissue repair via the induction of immunomodulation. The present review aims to analyze the existing updated scientific literature on MSCs adoption in the treatment of pCD to evaluate its efficacy and safety and to compare the use of bone marrow and adipose tissue derived MSCs, type of administration, and dose required for recovery.

Treatment of Refractory Perianal Fistulas with Ligation of the Intersphincteric Fistula Tract: Preliminary Results

Several surgical options exist for management of fistula in ano. The goal of treatment is to achieve closure of the fistula while maintaining continence. Sphincter-sparing operations to close perianal fistulas include advancement flap, anal fistula plug, fibrin glue, and fistulectomy. Variable success rates from 30 to 80 per cent have been reported. Ligation of intersphincteric fistula tract (LIFT), first described in 2007, has a reported success rate from 40 to 94 per cent. The objective of this study was to study our results of the LIFT procedure for refractory perianal fistulas. We conducted a retrospective 18-month review of consecutive patients with refractory perianal disease treated with the LIFT procedure at an academic, tertiary, colorectal practice. All patients undergoing a LIFT procedure for anal fistula from August 2010 to August 2012 were included in the study. The primary end points were success rates at 1 month and 3 months. Secondary end points were postoperative complications and maintenance of continence. Twenty patients underwent LIFT procedures of whom nine had previously failed treatments. Mean age was 45 years and included 12 male and eight female patients. Success rate at 1 month was 70 per cent (14 patients) and at 3 months was 80 per cent (16 patients). Success rates for patients with previously failed attempts were 67 per cent at 1 month and 89 per cent at 3 months. Continence was maintained in 100 per cent of patients. Our data support the use of the LIFT procedure for refractory perirectal fistulas.

Hot topics in global perianal fistula research: A scopus-based bibliometric analysis

BACKGROUND

The number of citations a scientific paper has received indicates its impact within any medical field. We performed a bibliometric analysis to highlight the key topics of the most frequently cited 100 articles on perianal fistula to determine the advances in this field.

METHODS

The Scopus database was searched from 1960 to 2018 using the search terms "perianal fistula" or "anal fistula" or "fistula in ano" or "anal fistulae" or "anorectal fistulae" including full articles. The topic, year of publication, publishing journal, country of origin, institution, and department of the first author were analyzed.

RESULTS

The median number of citations for the top 100 of 3431 eligible papers, ranked in order of the number of citations, was 100 (range: 65-811), and the number of citations per year was 7.5 (range: 3.8-40.1). The most-cited paper (by Parks et al in 1976; 811citations) focused on the classification of perianal fistula. The institution with the highest number of publications was St Mark's Hospital, London, UK. The most-studied topic was surgical management (n = 47). The country and the decade with the greatest number of publications in this field were the USA (n = 34) and the 2000s (n = 50), respectively.

CONCLUSION

The 100 most frequently cited manuscripts showed that surgical management had the greatest impact on the study of perianal fistula. This citation analysis provides a reference of what could be considered the most classic papers on perianal fistula, and may serve as a reference for researchers and clinicians as to what constitutes a citable paper in this field.

Use of the Martius advancement flap for low rectovaginal fistulas

AIM

The percentage recurrence after any surgical treatment for low rectovaginal fistula (LRVF) is unacceptably high. The aim of this study was to evaluate the short- and long-term results of the Martius procedure in a carefully selected series of patients with a LRVF of at least 1 cm diameter who had had at least two previous surgeries or in the presence of chronically inflamed local tissues.

METHOD

Between January 2009 and April 2017, 24 patients with the abovementioned features were prospectively included in this study. Success was defined both as the absence of any subjective symptoms and the fistula, as confirmed by evaluation under anaesthesia. Postoperative complications were assessed using the Clavien-Dindo classification. Quality of life (SF-12 score), quality of sexual life [Female Sexual Function Index (FSFI) score] and continence [Cleveland Clinic Incontinence Score (CCIS)] were also determined pre- and postoperatively.

RESULTS

The mean follow-up was 42 ± 29 months (range 3-101 months). The overall success rate was 91.3% (22/24 patients). The median operation time was 50 min (range 45-70 min), and the median hospital stay was 3.5 days (range 3-5 days). No major complications occurred. Pre- and postoperative CCIS did not differ [1 (range 0-3.5)]. The postoperative SF-12 score improved both in terms of the physical (33.6 ± 7.2 vs 50.8 ± 7.8; P < 0.001) and mental (32.6 ± 6.7 vs 56.3 ± 7.8; P < 0.001) components. FSFI improved from 19.5 ± 6.6 to 24.4 ± 6.3 (P < 0.001).

CONCLUSION

The Martius procedure should be considered as the first-line method of treatment in carefully selected cases of LRVF.

Risk Factors for Recurrence after anal fistula surgery: A meta-analysis

BACKGROUND

Despite a burgeoning literature during the last two decades regarding perioperative risk management of anal fistula, little is known about its risk factors that influence postoperative recurrence. We performed a meta-analysis to summarize and assess the credibility of evidence of potential risk factors for anal fistula recurrence (AFR) after surgery.

METHODS

Pubmed and EMBASE without language restriction were searched from inception to April 2018 that reported risk factors which predisposed recurrence after anal fistula surgery. We excluded studies that involved patients with anal fistula associated with Crohn's disease. MOOSE guidelines were followed when this meta-analysis was performed. We used random-effects models to pool relative risks (RRs) with 95% confidence intervals (CIs). Evidence from observational studies was graded into high-quality (Class I), moderate-quality (Class II/III) and low-quality (Class IV) based on Egger's P value, total sample size and between-study heterogeneity.

RESULTS

Of 3514 citations screened, 20 unique observational studies comprising 6168 patients were involved in data synthesis. High-quality evidence showed that AFR was associated with high transsphincteric fistula (RR, 4.77; 95% CI, 3.83 to 5.95), internal opening unidentified (RR, 8.54; 95% CI, 5.29 to 13.80), and horseshoe extensions (RR, 1.92; 95% CI, 1.43 to 2.59). Moderate-quality evidence suggested an association with prior anal surgery (RR, 1.52; 95% CI, 1.04 to 2.23), seton placement surgery (RR, 2.97; 95% CI, 1.10 to 8.06), and multiple fistula tract (RR, 4.77; 95% CI, 1.46 to 15.51). High-quality evidence demonstrated no significant association with gender or smoking; moderate-quality evidence also suggested no association with age, tertiary referral, alcohol use, diabetes mellitus, obesity, preoperative seton drainage, high internal opening, postoperative drainage, mucosal advancement flap surgery, supralevator extensions, location or type of anal fistula.

CONCLUSION

Several patient, surgery and fistula-related factors are significantly associated with postoperative AFR. These findings strengthen clinical awareness of early warning to identify patients with high-risk disease recurrence for AFR.

Advances in Perianal Disease Associated with Crohn's Disease-Evolving Approaches

Perianal diseases, common complications of Crohn's disease, are difficult to diagnose/manage. Patients with perianal Crohn's disease suffer from persistent pain and drainage, recurrent perianal sepsis, impaired quality of life, and financial burden. Conventional medical and surgical therapies carry risk of infection, myelosuppression, incontinence, disease recurrence. Although the phenotype of Crohn's disease has been extensively studied, reported outcomes are inconsistent. Endoanal ultrasonography is also becoming popular because of low cost and ability to acquire images in real time. Emerging management strategies for treatment including laser therapy, local injection of agents, use of hyperbaric oxygen, and stem cell therapy, have demonstrated efficacy.

The clinical efficacy of stem cell therapy for complex perianal fistulas: a meta-analysis

BACKGROUND

Treatment of complex anal fistulas remains difficult. However, treatment with stem cells has had an encouraging success rate when applied to complex perianal fistulas. We systematically reviewed the current evidence through meta-analysis.

METHODS

We performed an electronic literature search on PubMed, Embase, and the Cochrane Library and identified studies (published between January 1946 and August 2017) that used stem cells to treat patients with complex perianal fistula. Each paper was evaluated for treatment success rate, target patients, types of stem cells used, number of cells used, and criteria for complete healing. Potential publication bias was assessed via visual inspection of a funnel plot and Orwin's fail-safe N. Out of 171 papers, 16 were included in the meta-analysis.

RESULTS

The overall healing rate of stem cell injection therapy for patients with complex perianal fistulas was 62.8% (95% CI 53.5-71.2, I² = 54.05%), whereas those for patients with Crohn's perianal fistulas alone and complex anal fistulas not associated with Crohn's disease were 64.1% and 61.5% (p = 0.840), respectively. Healing rates for autologous and allogenic stem cell treatment were 69.4% and 50.7% (p = 0.020), respectively. Four comparative studies out of 16 studies were analyzed separately. Stem cell therapy increased the healing rate compared to the control groups (OR 0.379, 95% CI 0.152-0.947).

CONCLUSIONS

Stem cell therapy is a good treatment option for complex perianal fistulas, which cannot be healed by conventional operative procedures. However, further research for additional supportive evidence, such as a large-scale randomized controlled trial, is required.

Factors Increasing the Risk of Recurrence in Fistula-in-ano

Anal fistula, or fistula-in-ano, is a condition involving the anal region that is common yet debilitating. Surgery is the mainstay of treatment for an anal fistula and the chances of recurrence are quite high even after corrective surgical procedures. The risk factors for recurrence can be broadly classified into four categories: 1) risk factors related to the fundamental anatomy of the fistula and presence of comorbidities, 2) lack of proper preoperative assessment of the fistula, which includes failure to recognize the internal opening and overall structure of the fistula and not supplementing the proctologic examination with sufficient imaging, 3) intraoperative loopholes that include improper procedure selection, inexperience of the surgeon, and failure to get rid of the entire tract along with its ramifications, and 4) lack of proper postoperative care in the early and late periods following the surgery.

The aim of this paper, therefore, is to highlight the factors that could increase the risk of recurrence in different types of anal fistulae. Once surgeons know these risk factors, they can anticipate any complication and detect recurrence early.

Recent trends (2016-2017) in the treatment of inflammatory bowel disease

Prevalence of inflammatory bowel disease (IBD), ulcerative colitis and Crohn's disease has dramatically increased in Asian countries in the last three decades. In this period, many new medical therapies were introduced for the treatment of IBD, such as immunosuppressants, anti-tumor necrosis factor agents, leukocyte apheresis, anti-integrin antibody, and so on, which have contributed to induce remission and to reduce complications in IBD. As for surgical techniques for Crohn's disease, a stapled functional end-to-end anastomosis and conventional end-to-end anastomosis have similar perianastomotic recurrence rate and reoperation rate. Prospective randomized controlled studies which compare Kono-S anastomosis and stapled side-to-side anastomosis are ongoing. Variant two-stage ileal pouch anal anastomosis (IPAA) and transanal IPAA are new concepts for surgical treatment of ulcerative colitis. Various endoscopic procedures, such as balloon dilation for stenosis or stricture, endoscopic fistulotomy, injection of filling agents, and clipping for fistulas or perforations will be new options in the treatment of Crohn's disease. Adverse effects of preoperative treatments on postoperative complications should also be taken into account to improve surgical outcomes in IBD patients.

Closing Perianal Fistulas Using a Laser: Long-Term Results in 103 Patients

BACKGROUND

Primary closure of the fistula tract using energy emitted by a radial fiber connected to a diode laser is a novel procedure for treating perianal fistulas.

OBJECTIVE

The aim of this study was to determine the long-term effectiveness of this new technique.

DESIGN

The surgical objective was to seal the fistula tract using laser energy.

SETTINGS

The study was conducted at a single day-case surgery center.

PATIENTS

Between April 2012 and June 2016, 103 consecutive patients with primary or recurrent perianal fistula underwent a laser closure procedure using a 12-watt laser emitting at a wavelength of 1470 nm.

MAIN OUTCOME MEASURES

Patients were classified according to the Park classification, and healing was evaluated based on the perianal fistula disease severity score.

RESULTS

Among the 103 patients treated using the laser closure procedure, 82 (80%) were men and 21 (20%) were women. The median age of the patients was 43 years (range, 18-78 y). Fifty-three patients (52%) had previous perianal fistula repair surgery. Based on the Park classification, 56 patients (54%) had intersphincteric fistula, 29 (28%) had transsphincteric fistula, 11 (11%) had suprasphincteric or extrasphincteric fistula, and 7 (7%) had superficial perianal fistula. Based on the perianal disease severity score, 41 patients (40%) obtained overall complete healing, 38 (37%) had persistent symptomatic drainage, 20 (19%) had slight drainage with minimal symptoms, and 4 (4%) had painful symptomatic drainage.

LIMITATIONS

This was a retrospective analysis of noncomparative data with a lack of formal prospective continence assessment.

CONCLUSIONS

Closure of perianal fistulas using a laser should be considered as a treatment option but with modest expectations. Although our complete healing rate was not as high as in earlier studies, this technique is a reasonable option with nearly no risk of sphincter damage when treating perianal fistulas. See Video Abstract at http://links.lww.com/DCR/A545.

Perianal fistulizing Crohn's disease: pathogenesis, diagnosis and therapy

Perianal fistulizing Crohn's disease has a major negative effect on patient quality of life and is a predictor of poor long-term outcomes. Factors involved in the pathogenesis of perianal fistulizing Crohn's disease include an increased production of transforming growth factor β, TNF and IL-13 in the inflammatory infiltrate that induce epithelial-to-mesenchymal transition and upregulation of matrix metalloproteinases, leading to tissue remodelling and fistula formation. Care of patients with perianal Crohn's disease requires a multidisciplinary approach. A complete assessment of fistula characteristics is the basis for optimal management and must include the clinical evaluation of fistula openings, endoscopic assessment of the presence of proctitis, and MRI to determine the anatomy of fistula tracts and presence of abscesses. Local injection of mesenchymal stem cells can induce remission in patients not responding to medical therapies, or to avoid the exposure to systemic immunosuppression in patients naive to biologics in the absence of active luminal disease. Surgery is still required in a high proportion of patients and should not be delayed when criteria for drug failure is met. In this Review, we provide an up-to-date overview on the pathogenesis and diagnosis of fistulizing Crohn's disease, as well as therapeutic strategies.

Systematic review of surgical interventions for Crohn's anal fistula

Background

Anal fistula occurs in approximately one in three patients with Crohn's disease and is typically managed through a multimodal approach. The optimal surgical therapy is not yet clear. The aim of this systematic review was to identify and assess the literature on surgical treatments of Crohn's anal fistula.

Methods

A systematic review was conducted that analysed studies relating to surgical treatment of Crohn's anal fistula published on MEDLINE, Embase and Cochrane databases between January 1995 and March 2016. Studies reporting specific outcomes of patients treated for Crohn's anal fistula were included. The primary outcome was fistula healing rate. Bias was assessed using the Cochrane ROBINS‐I and ROB tool as appropriate.

Results

A total of 1628 citations were reviewed. Sixty‐three studies comprising 1584 patients were ultimately selected in the analyses. There was extensive reporting on the use of setons, advancement flaps and fistula plugs. Randomized trials were available only for stem cells and fistula plugs. There was inconsistency in outcome measures across studies, and a high degree of bias was noted.

Conclusion

Data describing surgical intervention for Crohn's anal fistula are heterogeneous with a high degree of bias. There is a clear need for standardization of outcomes and description of study cohorts for better understanding of treatment options.

Ligation of Intersphincteric Fistula Tract for Fistula in Ano: Lessons Learned From a Decade of Experience

BACKGROUND

Ligation of intersphincteric fistula tract is a well-described sphincter-preserving technique for the management of fistula in ano. In 2007, we reported our early experience demonstrating a primary success rate of 94.4%. These findings have since been supported by several short-term studies, but long-term results and secondary cure rates after ligation of intersphincteric fistula tract failure remain unknown.

OBJECTIVE

This study aims to report a 10-year experience of ligation of intersphincteric fistula tract with extended long-term follow-up.

DESIGN

Retrospective analysis of single-center data from May 2006 to October 2010 was performed.

SETTINGS

This study was conducted at a large tertiary hospital in Bangkok, Thailand.

PATIENTS

All patients with primary or recurrent fistula in ano who underwent a ligation of intersphincteric fistula tract procedure were included. Patients with malignancy, incontinent patients, and patients with rectovaginal fistula were excluded.

MAIN OUTCOME MEASURES

Healing as defined by the absence of symptoms with no visible external opening on clinical examination. Follow-up was continued until May 2016.

RESULTS

In total, 251 patients were identified, with a primary healing rate of 87.65% at a median follow-up of 71 months. The healing rates for low transsphincteric, intersphincteric, high transsphincteric, semihorseshoe, and horseshoe fistulas were 92.1%, 85.2%, 60.0%, 89.0%, and 40.0%. Of the 42 patients who had an unhealed fistula after previous non-ligation of intersphincteric fistula tract surgery, 38 (90.48%) healed after the first attempt at ligation of intersphincteric fistula tract. There were 31 patients with unhealed fistulas after the first ligation of intersphincteric fistula tract. Of these, 3 healed spontaneously, and the rest underwent either repeat ligation of intersphincteric fistula tract, fistulotomy (if the recurrence was intersphincteric), or simple curettage (if no internal opening was found). Ultimately, only 2 of the original 251 patients remained unhealed, and there was no change in subjective continence status after surgery.

LIMITATIONS

This study was limited by its retrospective design.

CONCLUSION

Ligation of intersphincteric fistula tract is an effective technique for the treatment of fistula in ano, including recurrent or unhealed fistula after other procedures. See Video Abstract at http://links.lww.com/DCR/A387.

Exploring endoscopic therapy for the treatment of Crohn's disease-related fistula and abscess

Fistula and abscess represent penetrating disease phenotypes of Crohn's disease (CD) and can develop in patients with or without prior history of CD-related surgery. While CD fistula and abscess have been traditionally treated with medical and surgical therapy, the role of endoscopic therapy in this particular phenotype of CD is expanding recently, thanks to advanced endoscopic techniques and a better understanding of pathogenesis and natural history of the disease and principle of treatment. The success of endoscopic treatment for inflammatory bowel disease depends on comprehension and appreciation of principles, then techniques, followed by instrument and device. Attempts should be made to temporarily or permanently close the feeding side (or the primary) orifice at the gut, by various forms of clipping. Endoscopic fistulotomy is feasible, particularly for perianal fistula and surgery-associated distal bowel fistula. Perianal abscess can be treated with endoscopic incision and drainage and even seton placement. Endoscopic treatment for fistula and abscess as well as for stricture has become an important part of the multidisciplinary approach to complex CD.

What is the optimal surgical strategy for complex perianal fistulous disease in pediatric Crohn's disease? A systematic review

PURPOSE

Perianal fistulous disease is present in 10-15% of children with Crohn's disease (CD) and is frequently complex and refractory to treatment, with one-third of patients having recurrent lesions. We conducted a systematic review of the literature to examine the best surgical strategy or strategies for pediatric complex perianal fistulous disease (CPFD) in CD.

METHODS

We searched CENTRAL, MEDLINE, EMBASE, and CINAHL for studies discussing at least one surgical strategy for the treatment of pediatric CPFD in CD. Reference lists of included studies were hand-searched. Two researchers screened all studies for inclusion, quality assessed each relevant study, and extracted data.

RESULTS

One non-randomized prospective and two retrospective studies met our inclusion criteria. Combined use of setons and infliximab therapy shows promise as a first-line treatment. A specific form of fistulectomy, "cone-like resection," also shows promise when combined with biologics. Endoscopic ultrasound to guide medical and surgical management is feasible in the pediatric population, though it is unclear if it improves outcomes.

CONCLUSION

There is a paucity of evidence regarding the treatment of CPFD in the pediatric population, and further research is required before recommendations can be made as to what, if any, surgical management is optimal.

Treatment Options in Gastrointestinal Cutaneous Fistulas

Enterocutaneous fistulas occur most commonly following surgery. A minority of them is caused by a myriad of other etiologies including infection, malignancy, and radiation. While some fistulas may close spontaneously, most patients will eventually need surgery to resolve this pathology. Successful treatment entails adoption of various methods of treatment aimed at control of sepsis, protection of surrounding skin and soft tissue, control of fistula output, and maintenance of nutrition, with eventual spontaneous or surgical closure of the fistula. The aim of this article is to review the various treatment options in their appropriate context.

Transvaginal Repair of Complex Rectovaginal Fistulas Using the Porcine Urinary Bladder Matrix as an Augmenting Graft

BACKGROUND

After the US Food and Drug Administration issued a safety warning concerning vaginal mesh implants in 2008, their use in correction of pelvic floor defects have decreased in the United States (http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm479732.htm). However, we are still treating patients who have had complications associated with their use, rectovaginal fistulas (RVFs) being one of them. Rectovaginal fistulas are considered complex if greater than 2.5 cm, recurrent, associated with inflammatory bowel disease, or if they are proximal in location. Various surgical techniques have been described for treating RVFs. Interposition grafts such as Martius, gracilis, omental J flaps, and rectus abdominis flaps have been used extensively in correcting RVFs (Am J Gastroenterol 2014;109(8):1141-1157). However, these techniques may increase morbidity or have poor cosmesis. Pelvic surgeons have chronicled the use of biologic grafts for fistula repair. Of the various biologic grafts in use, there have been no reports describing the use of porcine urinary bladder matrix (UBM) for fistula repair. We report on 2 cases of large, complex RVFs secondary to mesh erosion, which were effectively treated with transvaginal repair using the UBM.

CASES

An 80-year-old woman was referred by the colorectal service to our urogynecology service with complaints of rectal bleeding and vaginal spotting secondary to mesh erosion. Surgical history included hysterectomy with mesh augmented posterior repair with synthetic midurethral sling placement in 2002. Examination revealed a 3-cm mesh exposure located in the middle third of the posterior vaginal wall. On rectovaginal examination, a 3-cm full-thickness RVF with through-and-through mesh erosion was noted between the rectum and vagina.A 65-year-old woman presented to our service with complaints of passage of fecal material through the vagina. Surgical history was significant for hysterectomy in 1988 and prolapse repair with anterior and posterior vaginal mesh in 2009. Subsequently in 2011, she had part of the mesh removed because of exposure. Vaginal examination revealed mesh exposure at the right sulcus of the anterior wall consistent with evidence of prior sling and another mesh exposure on the posterior vaginal wall. Rectovaginal examination revealed palpable mesh in the rectovaginal septum with a 3-cm large and complex fistula. Both of our patients underwent transvaginal excision of mesh, RVF repair, and posterior repair with augmentation with UBM. At 6- and 10-month follow-up, they reported complete resolution of their symptoms with no fistula noted on physical examination.

CONCLUSIONS

Typically, traditional repair with use of muscular advancement flaps is performed for complex RVF closures. Recently, however, various biologic agents have been successfully used to augment RVF repair. In our cases, the use of UBM led to successful follow-up at 6 to 8 months. Despite existing literature, there remains a void in the depth of knowledge regarding the UBM grafts. Larger studies utilizing it for repair of RVFs are warranted to further understand the success and effectiveness of the UBM grafts for RVF repair.

Predictive factors for recurrence of high transsphincteric anal fistula after placement of seton

BACKGROUND

The optimal surgical treatment for high transsphincteric fistula-in-ano (FIA) should attain complete eradication of the fistulous track and, in the same time, not compromising the anal sphincters. The present study aimed to investigate the predictive factors for recurrence of high transsphincteric FIA after placement of draining seton and to evaluate the efficacy and complications of seton treatment for high cryptoglandular anal fistula.

MATERIALS AND METHODS

This is a retrospective case-control study of patients with high transsphincteric FIA who were treated with seton placement. Variables analyzed were the characteristics of FIA, incidence of recurrence, postoperative complications including fecal incontinence (FI), and the predictive factors for recurrence.

RESULTS

A total of 251 patients (232 males) with high transsphincteric FIA were treated with loose seton placement. Patients were followed for a median period of 16 mo. Recurrence of FIA was recorded in 26 of patients (10.3%) after a mean duration of 12.2 ± 3.9 mo of seton removal. Previously recurrent fistula (odds ratio [OR] = 2.81, P = 0.02), supralevator extension (OR = 3.19, P = 0.01) and anterior fistula (OR = 3.36, P = 0.004), and horseshoe fistula (OR = 5.66, P = 0.009) were the most significant predictors of recurrence. FI was detected in eight patients (3.2%). Female gender (OR = 15.2, P = 0.0003) and horseshoe fistula (OR = 8.66, P = 0.01) were the significant risk factors for FI after the procedure.

CONCLUSIONS

Significant risk factors for recurrence of FIA were previous fistula surgery, anterior anal fistula, and presence of secondary tracks or branches as supralevator extension, and horseshoe fistula.

Perianal Crohn's disease: challenges and solutions

Perianal Crohn’s disease affects a significant number of patients with Crohn’s disease and is associated with poor quality of life. The nature of the disease, compounded by presentation of various disease severities, has made the treatment of perianal Crohn’s disease difficult. The field continues to evolve with the use of both historical and contemporary solutions to address the challenges associated with it. The goal of this article is to review current literature regarding medical and surgical treatment, as well as the future directions of therapy.

Applications of Fibrin Sealant in Surgery

Fibrin sealant has been used with increasing frequency in a variety of surgical field for its unique hemostatic and adhesive abilities. Fibrin sealant mimics the last step of the coagulation cascade and takes place independently of the patient's coagulation status. With rapid advances in minimally invasive surgery, the potential uses for this type of biologic and synthetic material are expanding exponentially. This article reviews the data associated with the application of fibrin sealant in various surgical procedures. From reinforcing gastrointestinal anastomosis to repair perforated duodenal ulcers to mesh fixation in laparoscopic inguinal hernia repair, fibrin sealant is gaining increasing acceptance among surgeons. The applications of fibrin sealant are expanding, and new preparations of fibrin sealant are currently being evaluated.

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

AIM

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

METHOD

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

RESULTS

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

CONCLUSION

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

Ligation of the intersphincteric fistula tract for the treatment of fistula-in-ano: experience of a tertiary care centre in South India

AIM

Ligation of the intersphincteric fistula tract (LIFT) is a new sphincter-sparing surgical technique increasingly used to treat fistulae-in-ano yielding good results. The aim of this study was to evaluate its effectiveness in the treatment of complex fistulae-in-ano and to determine factors associated with recurrence and its subsequent management.

METHOD

A prospective observational study was performed of 167 patients with complex fistula-in-ano treated by LIFT from June 2013 to January 2014. In all patients a LIFT with partial core-out of the fistula tract was performed.

RESULTS

There were 167 patients of mean age 43.6 ± 12.8 years. Thirty-three fistulae were recurrent. 150 were trans-sphincteric, 16 were intersphincteric and one was a suprasphincteric fistula. The median postoperative stay was 2 (range: 1-14) days (mean = 2.4 days). At follow up there was no change in continence. The median healing time was 4 (range: 1-8) weeks. Two patients developed an intersphincteric abscess needing surgical drainage healing uneventfully. The mean follow up was 12.8 [median = 12 (range: 4-22)] months. The healing rate was 94.1%. Ten (5.9%) patients developed a recurrent fistula that was managed by a second LIFT procedure in seven, a sinus tract excision with curettage in two and seton placement in one. Recurrence was significantly associated with diabetes mellitus and perianal collections and showed an increased incidence with tract abscesses and multiple tracts.

CONCLUSION

LIFT has a high success rate in complex fistulae-in-ano. Recurrence is related to diabetes mellitus, perianal collections, tract abscesses and multiple tracts and a second LIFT procedure may be feasible and efficient.

Endoscopy in the Diagnosis and Management of Complications of Inflammatory Bowel Disease

The role of endoscopy in inflammatory bowel disease (IBD) has grown over the last decade in both diagnostic and therapeutic realms. It aids in the initial diagnosis of the disease and also in the assessment of the extent and severity of disease. IBD is associated with development of multiple complications such as strictures, fistulae, and colon cancers. Endoscopy plays a pivotal role in the diagnosis of colon cancer in patients with IBD through incorporation of chromoendoscopy for surveillance. In addition, endoscopic resection with surveillance is recommended in the management of polypoid dysplastic lesions without flat dysplasia. IBD-associated benign strictures with obstructive symptoms amenable to endoscopic intervention can be managed with endoscopic balloon dilation both in the colon and small intestine. In addition, endoscopy plays a major role in assessing the neoterminal ileum after surgery to risk-stratify patients after ileocolonic resection and assessment of a patient with ileoanal pouch anastomosis surgery and management of postsurgical complications. Our article summarizes the current evidence in the role of endoscopy in the diagnosis and management of complications of IBD.

Adoption and success rates of perineal procedures for fistula-in-ano: a systematic review

AIM

Several sphincter-preserving techniques have been described with extremely encouraging initial reports. However, more recent studies have failed to confirm the positive early results. We evaluate the adoption and success rates of advancement flap procedures (AFP), fibrin glue sealant (FGS), anal collagen plug (ACP) and ligation of intersphincteric fistula tract (LIFT) procedures based on their evolution in time for the management of anal fistula.

METHOD

A PubMed search from 1992 to 2015. An assessment of adoption, duration of study and success rate was undertaken.

RESULTS

We found 133 studies (5604 patients): AFP (40 studies, 2333 patients), FGS (31 studies, 871 patients), LIFT (19 studies, 759 patients), ACP (43 studies, 1641 patients). Success rates ranged from 0% to 100%. Study duration was significantly associated with success rates in AFP (P = 0.01) and FGS (P = 0.02) but not in LIFT or ACP. The duration of use of individual procedures since first publication was associated with success rate only in AFP (P = 0.027). There were no statistically significant differences in success rates relative to the number of the patients included in each study.

CONCLUSION

Success and adoption rates tend to decrease with time. Differences in patient selection, duration of follow-up, length of availability of the individual procedure and heterogeneity of treatment protocols contribute to the diverse results in the literature. Differences in success rates over time were evident, suggesting that both international trials and global best practice consensus are desirable. Further prospective randomized controlled trials with homogeneity and clear objective parameters would be needed to substantiate these findings.

Rectovaginal Fistulae

Rectovaginal fistulae are abnormal epithelialized connections between the rectum and vagina. Fistulae from the anorectal region to the posterior vagina are truly best characterized as anovaginal or very low rectovaginal fistulae. True rectovaginal fistulae are less common and result from inflammatory bowel disease, trauma, or iatrogenic injury. A very few patients are asymptomatic, but the symptoms of rectovaginal fistula are incredibly distressing and unacceptable. Diagnostic approach, timing, and choice of surgical intervention, including sphincteroplasty, gracilis flaps, Martius flaps, and special circumstances are discussed.

Management of Complex Anal Fistulas

Complex anal fistulas require careful evaluation. Prior to any attempts at definitive repair, the anatomy must be well defined and the sepsis resolved. Several muscle-sparing approaches to anal fistula are appropriate, and are often catered to the patient based on their presentation and previous repairs. Emerging technologies show promise for fistula repair, but lack long-term data.

Rectovaginal Fistula: What Is the Optimal Strategy?: An Analysis of 79 Patients Undergoing 286 Procedures

OBJECTIVES

The aim of this study was to assess results of surgery for rectovaginal fistula (RVF) and prognostic factors for success.

BACKGROUND DATA

Management of RVF remains challenging and numerous surgical options are available. Few large reports of RVF are available and success prognostic factors remain unknown.

METHODS

All patients operated for RVF from 1996 to 2014 were included.

RESULTS

Seventy-nine patients presented RVF due to Crohn disease in 34 (43%), postoperative in 25 (32%), obstetrical in 7 (9%), radiation proctitis in 4 (5%), and miscellaneous in 9 (11%). A total of 286 procedures (132 with associated stoma, 46%) were performed including 217 conservative (76%) [seton drainage (n = 59; 21%), vaginal (n = 49, 17%) or rectal advancement flap (n = 46; 16%), diverting stoma only (n = 27; 9%), plug (n = 15; 5%), glue (n = 13; 5%), or others (n = 8, 3%)]; and 69 major procedures (24%) [gracilis muscle interposition (n = 32; 11%), coloanal or colorectal anastomosis (n = 19; 7%) including 11 delayed anastomosis with colonic pull-through, biomesh interposition (n = 9, 3%), and abdominoperineal resection (n = 9; 3%)]. After a mean follow-up of 33 months, overall success rate was 57 of 79 (72%). Per-procedure-based multivariate analysis identified major procedure [odds ratio (OR): 6.4 (2.9-14.2); P < 0.001], diverting stoma [OR: 3.5 (1.4-8.7); P = 0.009], less than 9 months between diagnosis and first surgery [OR: 2.3 (1.1-5.3); P = 0.046], and first surgery in our institution [OR: 3.2 (1.5-6.9); P = 0.003], as independent factors for success.

CONCLUSIONS

Our study suggested that aggressive surgical treatment of RVF, including early use of temporary stoma and major procedure in case of failure of previous local treatment, leads to high success rates.

Endoscopic Therapy in Inflammatory Bowel Diseases

Background

Endoscopy is an essential diagnostic and therapeutic modality in the clinical care of inflammatory bowel disease (IBD) patients. Endoscopic therapy can be used for treatment of disease-related strictures, surveillance and resection of intraepithelial neoplasia, and treatment of fistulas or disease-related complications, and is currently being evaluated regarding its capacity in in vivo molecular imaging procedures.

Methods

A literature search using Medline and Science Citation Index was performed in March 2015. All studies on endoscopic therapy in IBD published from 1980 to 2015 (March) were reviewed. Potential studies were initially screened by title and abstract. The terms ‘endoscopy IBD’, ‘endoscopy therapy IBD’, ‘dilatation IBD’, ‘strictureplasty Crohn's disease’, ‘endoscopy therapy fistula’, ‘endoscopy toxic megacolon’, ‘endoscopy dysplasia IBD’, ‘endoscopy complications IBD’, and ‘molecular imaging IBD’ were used in the search. A total of 115 articles were studied to construct this review.

Results

Dilatation is most useful in short anastomotic strictures, but can be also undertaken in colonic strictures. Strictures in ulcerative colitis are always suspicious for neoplasia and should be evaluated carefully. Lesions with intraepithelial neoplasia can be resected when complete removal can be assured. The finding of carcinoma or high-grade dysplasia in a random biopsy is an indication for colectomy. If intraepithelial neoplasia is present in random biopsy specimens, colectomy should similarly be recommended. Endoscopic therapy of Crohn's fistulas is a possible emerging technology. In vivo molecular imaging is currently being studied in IBD patients and offers promising therapeutic opportunities.

Conclusion

Therapeutic endoscopy is indispensable in the management of IBD. It has to be carefully evaluated against alternative surgical options but often offers an effective therapeutic approach.

© 2015 S. Karger GmbH, Freiburg

Indications and Specific Surgical Techniques in Crohn's Disease

Background

Crohn's disease (CD) as one of the major entities of chronic inflammatory bowel diseases can affect all segments of the gastrointestinal tract but occurs most often in the small bowel, the terminal ileum, the colon, and the rectum. Typical symptoms include tiredness, lower abdominal pain, fever, and diarrhea, which are initially treated by conservative measures. Most patients will eventually develop complications such as fistulas, abscesses, or strictures. Surgery is often unavoidable in these cases.

Methods

This review considers studies on the treatment of CD, published from 1979 up to now. The literature regarding the course, complications, and surgical therapy of CD was reviewed. Searches were performed in PubMed, using the following key words: CD, surgery, immunosuppression, guidelines, malnutrition as well as appropriate sub-items. In most cases the literature is limited to detailed information on specific therapeutic or diagnostic topics. Moreover, many studies are designed retrospectively and with a small number of patients. Additionally, our long-standing experience with patients suffering from CD is taken into consideration in this review.

Results

There is a wide variety of indications for surgery in CD which includes complications like strictures, fistulas and abscess formation, neoplasia, or refractoriness to medical therapy. The risk of developing complications is about 33% after 5 years, and 50% after 20 years. Furthermore, one-third of CD patients need surgical therapy within the first 5 years of diagnosis. The treatment requires close cooperation between gastroenterologists and surgeons. When indicated, surgery should be performed in a ‘conservative’ fashion, i.e. as limited as possible, in order to achieve the required result and to avoid small bowel syndrome.

Conclusion

This article provides a complete overview of indications and specific surgical treatment in patients with CD. Surgery is typically indicated when complications of CD occur. An interdisciplinary collaboration is necessary in order to ensure optimal indications and timing of surgery. This is of paramount importance to achieve the ultimate goal, i.e. a good quality of life of the patients.

Managing perianal Crohn's fistula in the anti-TNFα era

Perianal fistulas in Crohn's disease are common and difficult to treat. Their aetiology is poorly understood. Assessment is clinical, endoscopic and radiological, and management is undertaken by a multidisciplinary team of gastroenterologists, surgeons and radiologists. Surgical drainage of the fistula tract system with the placement of loose setons precedes combined therapy with immunosuppressant and anti-TNFα agents in most patients. Proctitis should be rigorously eliminated where possible. Definitive surgical repair is sometimes possible and diversion or proctectomy are occasionally required. Combined medical and surgical management represents a promising avenue for the future.

Complex anal fistula remains a challenge for colorectal surgeon

AIM

Anal fistula is a common proctological problem to both patient and physician throughout surgical history. Several surgical and sphincter-sparing approaches have been described for the management of fistula-in-ano, aimed to minimize the recurrence and to preserve the continence. We aimed to systematically review the available studies relating to the surgical management of anal fistulas.

MATERIAL AND METHODS

A Medline search was performed using the PubMed, Ovid, Embase, and Cochrane databases to identify articles reporting on fistula-in-ano management, aimed to find out the current techniques available, the new technologies, and their effectiveness in order to delineate a gold standard treatment algorithm.

RESULTS

The management of low anal fistulas is usually straightforward, given that fistulotomy is quite effective, and if the fistula has been properly evaluated, continence disturbance is minimal. On the contrary, high complex fistulas are challenging, because cure and continence are directly competing priorities.

CONCLUSIONS

Conventional fistula surgery techniques have their place, but new technologies such as fibrin glues, dermal collagen injection, the anal fistula plugs, and stem cell injection offer alternative approaches whose long-term efficacy needs to be further clarified in large long-term randomized trials.