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

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

Objectives

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

Methods

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

Results

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

Conclusions

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

Evaluating the predictive superiority of Garg's classification for surgical decision-making in perianal fistula management

Background: Managing perianal fistulae involves balancing the risks of incontinence and recurrence, with existing classification systems offering limited guidance for surgical decision-making. Garg's classification provides a detailed assessment of fistula anatomy, aiding the choice between fistulotomy and sphincter-sparing procedures. This study evaluates its predictive accuracy.

Antibiotic use during the first episode of acute perianal sepsis: a still-open question

PURPOSE

The role of antibiotics in preventing fistula formation following an initial abscess remains a subject of debate. This study compared the incidence of fistula in ano in patients experiencing their first episode of acute perianal sepsis, with and without antibiotic therapy, and evaluated the prevalence of fistula in ano necessitating surgical intervention at 1 year.

METHODS

This retrospective cohort study was conducted at a tertiary care hospital with a dedicated proctology department. All patients who presented to the emergency proctology unit with a first episode of acute perianal sepsis were eligible for inclusion.

RESULTS

This study included 276 patients. At 1 year, fistula formation was identified in 65.6% of all patients, 54.0% of those who had received antibiotics, and 75.0% of those who had not (P<0.001). This finding remained significant after weighted propensity analysis (odds ratio, 0.53; 95% confidence interval, 0.31-0.92; P=0.025).

CONCLUSIONS

The rate of fistula formation was relatively high in this study. However, it was lower among patients with perianal sepsis who were treated with antibiotics, although a causal relationship could not be established. Prolonged follow-up is needed to clarify the role of antibiotic therapy in preventing or delaying fistula development in patients with acute perianal sepsis.

Curing cryptoglandular anal fistulas-Is it possible without surgery?

BACKGROUND

Empirical reviews suggested that cryptoglandular anal fistulas require surgical resolution. However, some reports have indicated the possibility of nonsurgical and conservative treatment, which is discussed in this review.

METHODS

This review explores the potential of nonsurgical approaches for curing anal fistulas through bacterial inhibition and immunomodulation. The longstanding cryptoglandular theory has been a subject of controversy, prompting the reevaluation of conventional surgical interventions for anal fistulas. The review was conducted through database searches, including Medline, EMBASE, PubMed, and the Cochrane Library.

RESULTS

Emerging evidence suggests that targeting the anaerobic environments present in anal fistulas and perianal abscesses and eradicating bacteria and their by-products may be critical for successful treatment. Immunomodulatory strategies show promise as a potential avenue for the nonsurgical management of anal fistulas.

CONCLUSIONS

Ongoing developments in pharmacological research offer opportunities for alternative treatment options, shedding light on the prospects of noninvasive anal fistula management.

Management of Complex Perianal Fistulas Using Platelet-Rich Plasma and Adipose-Derived Mesenchymal Stem Cells: A Case Series

Perianal fistulas have posed a medical and surgical problem since ancient times. The plethora of surgical operations described nowadays for anal fistula treatment is real proof that there is no ideal therapeutic procedure. The cornerstone of all approaches is the equilibrium between the definitive treatment of the fistula with the maintenance of the anal continence mechanism, i.e., anal sphincters. Especially complex anal fistulas (multiple tracts, high transphincteric fistulas, rectovaginal and Crohn disease-associated anal fistulas) are difficult to deal with to preserve this therapeutic balance. Contemporary experimental procedures include the use of autologous biological products such as platelet-rich plasma (PRP) and mesenchymal stem cells (MSCs), either in their "raw" matrix (stromal vascular fraction, SVF) or after isolation and cultivation before delivered to the patient. Herein, we present a new experimental procedure that we implemented for four patients with perianal fistulas, which is safe and effective, easily reproduced, and cheap. It is a one-stage procedure that requires only simple means and could serve as a first-line approach in complex anal fistulas. In this article, we will present four indicative cases treated with this method, using different syringes for various patient conditions, while analyzing the corresponding clinical and imaging results.

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

BACKGROUND

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

AIM

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

METHODS

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

RESULTS

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

CONCLUSION

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

Recent advances in the diagnosis and treatment of complex anal fistula

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

Computed tomography imaging and clinical significance of bacterium-positive pulmonary tuberculosis complicated with diabetes

BACKGROUND

The increasing prevalence of tuberculosis (TB) and diabetes on a global scale poses a significant health challenge, particularly due to their co-occurrence, which amplifies the severity, recurrence and mortality rates associated with both conditions. This highlights the need for further investigation into their inter-relationship.

AIM

To explore the computed tomography (CT) imaging and clinical significance of bacterium-positive pulmonary TB (PTB) combined with diabetes.

METHODS

There were 50 patients with bacterium-positive PTB and diabetes, and 50 with only bacterium-positive PTB. The latter were designated as the control group. The CT imaging of the two groups of patients was compared, including lesion range, shape, density and calcification.

RESULTS

No significant differences were observed in age, gender, smoking and drinking history, high blood pressure, hyperlipidemia and family genetic factors between the groups. However, compared to the patients diagnosed solely with simple bacterium-positive PTB, those with concurrent diabetes showed a wider range of lesions and more complex and diverse morphology on CT images. Among them, intrapulmonary tuberculosis lesions were often accompanied by manifestations of pulmonary infection, such as cavity formation and bronchiectasis. At the same time, diabetes-related signs were often seen on CT images, such as pulmonary infection combined with diabetic pulmonary lesions. Logistic regression analysis identified age and medical history as significant factors influencing the degree of pulmonary infection and CT imaging outcomes in patients with both TB and diabetes. This suggests that older age and specific medical histories may increase the risk or severity of pulmonary damage in these patients.

CONCLUSION

CT imaging reveals more complex lesions in PTB patients with diabetes, emphasizing the need for careful evaluation and comprehensive analysis to enhance diagnostic accuracy.

Dynamic contrast-enhanced MR imaging in identifying active anal fistula after surgery

BACKGROUND

It is challenging to identify residual or recurrent fistulas from the surgical region, while MR imaging is feasible. The aim was to use dynamic contrast-enhanced MR imaging (DCE-MRI) technology to distinguish between active anal fistula and postoperative healing (granulation) tissue.

METHODS

Thirty-six patients following idiopathic anal fistula underwent DCE-MRI. Subjects were divided into Group I (active fistula) and Group IV (postoperative healing tissue), with the latter divided into Group II (≤ 75 days) and Group III (> 75 days) according to the 75-day interval from surgery to postoperative MRI reexamination. MRI classification and quantitative analysis were performed. Correlation between postoperative time intervals and parameters was analyzed. The difference of parameters between the four groups was analyzed, and diagnostic efficiency was tested by receiver operating characteristic curve.

RESULTS

Wash-in rate (WI) and peak enhancement intensity (PEI) were significantly higher in Group I than in Group II (p = 0.003, p = 0.040), while wash-out rate (WO), time to peak (TTP), and normalized signal intensity (NSI) were opposite (p = 0.031, p = 0.007, p = 0.010). Area under curves for discriminating active fistula from healing tissue within 75 days were 0.810 in WI, 0.708 in PEI, 0.719 in WO, 0.783 in TTP, 0.779 in NSI. All MRI parameters were significantly different between Group I and Group IV, but not between Group II and Group III, and not related to time intervals.

CONCLUSION

In early postoperative period, DCE-MRI can be used to identify active anal fistula in the surgical area.

TRIAL REGISTRATION

Chinese Clinical Trial Registry: ChiCTR2000033072.

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.

Clinical value of combined serum MMP-2, MMP-9 and TIMP-1 for the prognosis of perianal fistula patients who received minimally invasive surgery

OBJECTIVE

This study aimed to investigate the clinical value of combined serum matrix metalloproteinases (MMPs) and tissue inhibitors of metalloproteinases (TIMPs) for the prognosis of perianal fistula patients.

METHODS

Patients diagnosed and treated for perianal fistula by minimally invasive surgery (MIS) were enrolled. The concentrations of serum MMP-2, MMP-9 and TIMP-1 were measured at 24 h after surgery. Different levels of wound secretion, growth of granulation tissue and wound pain were used as criteria to evaluate surgical incision healing. The receiver operating characteristic curve was used to analyze the predicted assessment value.

RESULTS

The concentrations of serum MMP-2 and MMP-9 were significantly higher, while the concentrations of serum TIMP-1 at 24 h after surgery were significantly lower in the poor healing group than in the good healing group. It was further found that high levels of serum MMP-2 and MMP-9 were risk factors for poor healing, while high concentrations of serum TIMP-1 at 24 h after surgery were protective factors for poor healing.

CONCLUSION

High concentrations of serum MMP-2 and MMP-9 and low concentrations of serum TIMP at 24 h after surgery are risk factors for poor healing in perianal fistula patients who receive MIS, and the combined test has a higher predictive value.

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

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

[Perianal Fistula: An Overview]

Perianal fistula is a common inflammatory condition in the general population and affects the area around the anal canal. Although most cases are benign, they cause serious morbidity and require surgical treatment due to a high risk of recurrence. MR imaging is a gold standard technique for the evaluation of perianal fistulas and provides accurate information on the anatomy of the anal canal, its relationship to the anal sphincter complex, accurate identification of secondary tracts or abscesses, and reporting associated complications. MR imaging can help monitor treatment effects and determine treatment methods. Crohn's disease-related fistulas often require medical rather than surgical treatment. The radiologist is required to know the anatomy and MR imaging findings of the perianal fistula to present an accurate diagnosis to the clinician.

Surgery of Simple and Complex Anal Fistulae in Adults: A Review of the Literature for Optimal Surgical Outcomes

Anal fistulas are common anorectal conditions, and surgery is the primary treatment option. In the last 20 years of literature, there exist a large number of surgical procedures, especially for the treatment of complex anal fistulas, as they present more recurrences and continence problems than simple anal fistulas. To date, there are no guidelines for choosing the best technique. We conducted a recent literature review, mainly the last 20 years, based on the PubMed and Google Scholar medical databases, with the goal of identifying the surgical procedures with the highest success rates, lowest recurrence rates, and best safety profiles. Clinical trials, retrospective studies, review articles, comparative studies, recent systematic reviews, and meta-analyses for various surgical techniques, as well as the latest guidelines of the American Society of Colon and Rectal Surgeons, the Association of Coloproctology of Great Britain and Ireland, and the German S3 guidelines on simple and complex fistulas were reviewed. According to the literature, there is no recommendation for the optimal surgical technique. The etiology, complexity, and many other factors affect the outcome. In simple intersphincteric anal fistulas, fistulotomy is the procedure of choice. In simple low transsphincteric fistulas, the patient's selection is crucial in order to perform a safe fistulotomy or another sphincter-saving technique. The healing rate in simple anal fistulas is higher than 95% with low recurrence and without significant postoperative complications. In complex anal fistulas, only sphincter-saving techniques should be used; the optimal outcomes are obtained by the ligation of the intersphincteric fistulous tract (LIFT) and rectal advancement flaps. Those techniques assure high healing rates of 60-90%. The novel technique of the transanal opening of the intersphincteric space (TROPIS) is under evaluation. The novel sphincter-saving techniques of fistula laser closure (FiLac) and video-assisted anal fistula treatment (VAAFT) are safe, with reported healing rates ranging from 65% to 90%. Surgeons should be familiar with all sphincter-saving techniques in order to face the variability of the fistulas-in-ano. Currently, there is no universally superior technique that can treat all fistulas.

Crohn's Disease-Associated and Cryptoglandular Fistulas: Differences and Similarities

Perianal fistulas are defined as pathological connections between the anorectal canal and the perianal skin. Most perianal fistulas are cryptoglandular fistulas, which are thought to originate from infected anal glands. The remainder of the fistulas mainly arises as complications of Crohn's disease (CD), trauma, or as a result of malignancies. Fistulas in CD are considered as a consequence of a chronic and transmural inflammatory process in the distal bowel and can, in some cases, even precede the diagnosis of CD. Although both cryptoglandular and CD-associated fistulas might look similar macroscopically, they differ considerably in their complexity, treatment options, and healing rate. Therefore, it is of crucial importance to differentiate between these two types of fistulas. In this review, the differences between CD-associated and cryptoglandular perianal fistulas in epidemiology, pathogenesis, and clinical management are discussed. Finally, a flow chart is provided for physicians to guide them when dealing with patients displaying their first episode of perianal fistulas.

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

BACKGROUND

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

STUDY DESIGN

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

RESULTS

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

CONCLUSIONS

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

Comparison of contrast-enhanced fat-suppressed T1-3D-VIBE and T1-TSE MRI in evaluating anal fistula

OBJECTIVE

To evaluate the accuracy of contrast-enhanced (CE) fat-suppressed three-dimensional (3D) T1-weighted imaging with volumetric interpolated breath-hold examination (FS-T1-3D-VIBE) and fat-suppressed T1-weighted turbo spin echo (FS-T1-TSE) sequence in characteristics of anal fistula.

METHODS

One hundred and two patients underwent perianal CE-MRI examination on a 3T scanner including FS-T1-3D-VIBE and FS-T1-TSE sequences before surgery. The performance of each sequence was evaluated in terms of fistula classification, clarity of internal opening, number and position of internal openings including the distance between internal opening and anal verge, presence of secondary tracts and blind-ending sinus tracts. MRI findings were compared with surgical findings. Signal-to-noise ratios (SNRs) and contrast-to-noise ratios (CNRs) of fistula, gluteus maximus, and subcutaneous fat were compared between CE FS-T1-TSE and CE FS-T1-3D-VIBE.

RESULTS

Compared with CE FS-T1-TSE, CE FS-T1-3D-VIBE displayed more accurate in secondary tract, lithotomy position of the internal opening and the distance between internal opening and anal verge (P < 0.05). CE FS-T1-3D-VIBE was found superior to CE FS-T1-TSE in the clarity of the internal openings and in the diagnostic accuracy of blind-ending sinus tracts and complex fistulas in Standard Practice Task Force classification (P < 0.05). CE FS-T1-3D-VIBE achieved higher SNRs and CNRs in fistula and gluteus maximus than CE FS-T1-TSE (P ≤ 0.001).

CONCLUSION

CE-MRI of FS-T1-3D-VIBE might be a more valuable noninvasive technique than FS-T1-TSE to evaluate the anal fistula on evaluating the lithotomy position of internal opening, distance between internal opening and anal verge, clarity of internal opening, secondary tract, blind-ending sinus tract and classification of the complex fistula. The trial registration number for this prospective trial was Chi-TR1800020206 and the trial registration date was December 20, 2018.

Incontinence after fistulotomy in low anal fistula: Can Kegel exercises help improve postoperative incontinence?

AimFistulotomy is the commonest procedure performed for low anal fistulas. The incidence of gas and urge incontinence after fistulotomy and whether Kegel exercises (KE) could help recover sphincter function after fistulotomy has not been studied before. Methods Patients operated by fistulotomy for low fistulas were recommended KE (pelvic contraction exercises) 50 times/day for one year postoperatively. Incontinence (solid, liquid, gas and urge) was evaluated objectively (Vaizeys scores) preoperatively [Pre-op Group], in the immediate postoperative period [Pre-KE Group] and at 6-months follow-up [Post-KE Group]. Incontinence scores in all three groups were compared to evaluate the efficacy of KE. Results101 MRI-documented low anal-fistula patients were included. There were 79 males (mean age 39.412.9 years) and median follow-up was 12 months (6-18months). Two patients were lost to follow-up. Fistulas healed in all the patients. Incontinence was present in 5/99 patients (mean incontinence scores-0.130.63) preoperatively and occurred in 20/99 (mean incontinence scores-1.032.18) patients postoperatively (Pre-KE Group). With KE, the incontinence improved completely in 10 and partially improved in other 10 (mean incontinence scores-0.311.09). Urge and gas incontinence accounted for most cases (80%). The mean incontinence scores deteriorated significantly after fistulotomy (pre-op vs pre-KE, p=0.000059, significant) but continence improved significantly with KE, thus the scores between pre-op and post-KE became comparable (pre-op vs post-KE, p=0.07, not significant).ConclusionsFistulotomy, even in low fistulas, can lead to significant increase in gas and urge incontinence. Regular Kegel exercises postoperatively can help recover lost sphincter function and can bring back continence comparable to preoperative levels.

Perianal fistulas: A review with emphasis on preoperative imaging

PURPOSE

We aim to present a comprehensive literature review which focuses on the preoperative imaging of perianal fistulas.

MATERIAL/METHODS

Pelvic magnetic resonance imaging (MRI) and endoanal ultrasound (EAUS) are the two first-line imaging modalities for the preoperative evaluation of patients with perianal fistulas. We conducted a search in PubMed, Scopus and Google Scholar concerning articles comparing pelvic MRI with EAUS, which were published from 1994 until 2019.

RESULTS

In most articles, pelvic MRI is superior to EAUS for the evaluation of perianal fistulas (especially for supralevator and extrasphincteric ones). Preoperative pelvic MRI is associated with statistically significant better results and prognosis after surgical treatment of the disease. Preoperative EAUS poses high sensitivity and specificity in identifying intersphincteric and transsphincteric perianal fistulas, as well as the internal opening of a fistula-in-ano. There is only one meta-analysis which compares the diagnostic accuracy of the two mentioned imaging modalities in preoperative fistula detection. Sensitivity of both - pelvic MRI and EAUS, is acceptably high (0.87). Specificity of pelvic MRI is 0.69 in comparison to EAUS (0.43), but both values are considered low.

CONCLUSIONS

Future well-designed prospective studies are needed to investigate the diagnostic accuracy of pelvic MRI and EAUS in the preoperative assessment of patients with perianal fistulas. Moreover, the combination of pelvic MRI and EAUS should also be studied, since several published articles suggest that it could lead to improved diagnostic accuracy. A novel treatment algorithm for perianal fistulas could arise from this study.

Treating highly complex anal fistula with a new method of combined intraoperative endoanal ultrasonography (IOEAUS) and transanal opening of intersphincteric space (TROPIS)

Introduction

Treatment of highly complex anal fistula is still a profound test for a specialist colorectal surgeon. The reasons are directly related to recurrence and incontinence.

Aim

To evaluate the clinical results of a combined method of intraoperative endoanal ultrasonography (IOEAUS) and transanal opening of the intersphincteric space (TROPIS).

Material and methods

This study retrospectively included 48 patients with complex anal fistula, all of whom underwent new surgical methods. This operation mainly consists of two steps. Firstly, the type of anal fistula was determined by endoanal ultrasonography (EAUS) or magnetic resonance imaging (MRI) before the operation. Then the TROPIS procedure was performed with the help of EAUS, and the decision on whether a drainage seton should be placed depended on the condition of the tract. If there were secondary tracts, they were found and the same was done.

Results

The median follow-up was 12 months. Two (4.1%) patients experienced recurrence. Four (8.3%) patients did not have primary healing. All 6 patients underwent the same procedure again, and three recovered completely. So total successful fistula healing was observed in 45 (93.7%). There were no major complications and no significant deterioration in anal function and incontinence postoperatively.

Conclusions

Combined IOEAUS and TROPIS is an effective procedure in the treatment of highly complex anal fistula, and it may offer a new means for other operations.

A Novel Modification of the Endorectal Advancement Flap for Complex Anal Fistulas: Surgical Technique and Outcomes

Objective

A modification of the endorectal advancement flap (EAF) procedure is described with outcomes in a single-center, large retrospective cohort study.

Summary of background data

Fistula-in-ano is a common problem encountered by surgeons that can be classified as either simple or complex. Complex fistulas (CFs) cause higher morbidity and are much more challenging to treat. Although numerous treatment options are available for CF, none are proven to be 100% effective. The endorectal advancement flap (EAF) procedure was developed as an alternative to conventional surgical treatments for CF.

Methods

Charts were reviewed of patients with CF who underwent EAF between 2004 and 2019. The conventional EAF procedure was modified by performing transverse imbrication of the internal sphincter over the internal fistula opening. The incidence of new-onset fecal incontinence and recurrence were analyzed at the last available date of in-person follow-up.

Results

With a median follow-up of 6.6 months (range, 3.3–24 months), 99 patients with CFs underwent a modified EAF. Of these, 93% (92 of 99) had resolution of fistula without adverse outcomes, 7% (7 of 99) experienced recurrence, and 1% (1 of 99) experienced new-onset fecal incontinence. Systemic steroid or immunomodulatory therapy use (P = 0.001) and patients with diagnosed inflammatory bowel disease (P &lt; 0.0001) were associated with increased rate of recurrence.

Conclusions

EAF with transverse imbrication of the internal opening using interrupted, absorbable suture is an effective technique to treat complex or recurrent anal fistulas. It is associated with a low risk of recurrence (7%) and fecal incontinence (1%) and is a valid treatment option for CFs.

Current concepts in the pathogenesis of cryptoglandular perianal fistula

Cryptoglandular perianal fistula is a common benign anorectal disorder that is managed mainly with surgery. A fistula is typically defined as a pathological communication between two epithelialized surfaces. More specifically, perianal fistula manifests as an abnormal tract between the anorectal canal and the perianal skin. Perianal fistulas are often characterized by significantly decreased patient quality of life. The cryptoglandular theory of perianal fistulas suggests their development from the proctodeal glands, which originate from the intersphincteric plane and perforate the internal sphincter with their ducts. Involvement of proctodeal glands in the inflammatory process could play a primary role in the formation of cryptoglandular perianal fistula. The objective of this narrative review was to investigate the current knowledge of the pathogenesis of cryptoglandular perianal fistula with the specific aims of characterizing the potential role of proinflammatory factors responsible for the development of chronic inflammation. Further studies are crucial to improve the therapeutic management of cryptoglandular perianal fistulas.

Assessing validity of existing fistula-in-ano classifications in a cohort of 848 operated and MRI-assessed anal fistula patients - Cohort study

AIM/BACKGROUND

The commonly used fistula-in-ano classifications, Park or St. James's University hospital(SJUH), neither grade fistulas as per their severity nor guide regarding their management. A new classification(NC), published in 2017, proposed to classify fistulas as per their severity and also guided in its management. The early grades (NC grade I & II) were simple fistulas and were amenable to fistulotomy whereas higher grades (NC grade III-V) were complex fistulas and were not amenable to fistulotomy.

METHODS

Lower grades of all the three classifications were classified as simple (Parks: I, SJUH:I-II, NC:I-II) whereas higher grades were classified as complex (Parks: II-IV, SJUH: III-V, NC: III-V) fistulas. Fistulotomy should be possible in simple fistulas but not in complex fistulas. This was analysed for all these classifications. The long-term follow-up of continence was done by an objective scoring system (Vaizey's scores).

RESULTS

The SJUH & Parks classifications categorized 504/828 fistulas as 'complex' which was quite inaccurate as 42.7%(215/504) of these fistulas were safely amenable to fistulotomy. On the other hand, the New classification (NC) classified 282/828 fistulas as 'complex' which was very accurate as 99% (279/282) of these were actually complex and were not amenable to fistulotomy. The change in the preoperative and the postoperative continence scores in the patients who underwent fistulotomy, as per these classifications, Parks & SJUH vs NC, was 0.064 ± 0.62 and 0.089 ± 0.85 respectively and was not significantly different(p = 0.80, Mann-Whitney U test).

CONCLUSIONS

The New classification(NC) seems better than the existing classifications for grading the disease as well as in guiding the management of the disease.

Magnetic resonance imaging findings in patients with initial manifestations of perianal fistulas

BACKGROUND

Crohn's disease (CD) is a serious cause of perianal disease and the incidence is increasing in Saudi Arabia. MR imaging may document specific features that may help to foresee Crohn's disease in patients making an initial presentation.

OBJECTIVE

Present MR imaging findings of perianal fistulas in patients making an initial presentation.

DESIGN

Retrospective, observational.

SETTING

Radiology clinic in in Dhahran.

PATIENTS AND METHODS

All previously undiagnosed and untreated patients who presented for the first time to the outpatient clinics from September 2015-2018 with perianal fistulas were retrospectively evaluated. Previously diagnosed CD patients, post-surgical or intervention cases were excluded. Fistulas were categorized as low or high anal, simple or complex, and were graded per St. James University Hospital Classification. Imaging was interpreted by two experienced readers based on the Van Assche score.

MAIN OUTCOME MEASURES

Fistula features on MR imaging and diagnosis of CD.

SAMPLE SIZE

171 patients.

RESULTS

Of 171 patients, 139 (81.3%) were males with mean age of 37.2 (12.7) years; the 32 females had a mean age of 35.8 (10.6) years. Twenty-one patients (12.3%) had CD. Fourteen (40.4%) patients with complex fistulas had CD in comparison to only 5 (4.8%) simple fistula patients ( P=.0005). More than half of patients with complex and high anal fistulas had CD ( P=.0005). Females were more affected than males ( P=.0005).

CONCLUSION

Complex or high anal fistula on MR imaging may be the initial presentation of CD and warrant further work up to establish the diagnosis.

LIMITATIONS

Retrospective, small sample, single center, and short duration study.

CONFLICT OF INTEREST

None.

Perianal Tuberculosis: Lessons Learned in 57 Patients From 743 Samples of Histopathology and Polymerase Chain Reaction and a Systematic Review of Literature

BACKGROUND

Few data are published on perianal tuberculosis.

OBJECTIVE

This study aimed to determine the best method to diagnose tuberculosis in patients with fistula-in-ano and to conduct a systematic review to determine the incidence and characteristics of tuberculosis fistula-in-ano.

DATA SOURCES

The prospective study data and existing literature were derived from PubMed, Google scholar, and Scopus STUDY SELECTION:: Prospective analysis of patients with tuberculous fistula-in-ano treated between 2014 and 2018 was conducted, and a systematic review of studies describing ≥3 patients with tuberculosis fistula-in-ano was completed.

INTERVENTION

Testing of tuberculosis was performed by histopathology or polymerase chain reaction of tissue or pus from the fistula tract.

MAIN OUTCOME MEASURES

The primary outcomes measured were the detection rate of various tests to detect tuberculosis in fistula-in-ano and the prevalence rate of tuberculosis in simple versus complex fistulas.

RESULTS

In 637 samples (410 patients) tested, tuberculosis was detected in 49 samples (43 patients). Additional samples (n = 106) sent in patients with a high index of suspicion tested positive in 14 more patients. Thus, overall, 63 samples tested positive in 57 patients (total: 743 samples in 410 patients were tested). Tuberculosis was detected in 2 of 181 patients (1.1%) in tissue (histopathology), in 28 of 341 patients (8.2%) in tissue (polymerase chain reaction), and in 19 of 115 patients (16.5%) in pus (polymerase chain reaction) samples. To detect tuberculosis, tissue (polymerase chain reaction) was significantly better than tissue (histopathology) (28/341 vs 2/181, p < 0.00001) and pus (polymerase chain reaction) was significantly better than tissue (polymerase chain reaction) (19/115 vs 28/341, p < 0.0009). Tuberculosis was significantly more common in complex fistulas than in simple fistulas (20.3% vs 7.2%, p = 0.0002). The systematic review (n = 199) highlighted that tubercular fistulas are more common in recurrent and complex fistulas and in tuberculosis endemic regions.

LIMITATIONS

The true sensitivity and specificity of each testing modality could not be determined because not all patients with tuberculosis fistula-in-ano were tested by every diagnostic modality studied.

CONCLUSIONS

The tuberculosis detection rate of polymerase chain reaction was significantly higher than histopathology. Among polymerase chain reaction, pus had higher detection rate than tissue. Tuberculosis was associated with more complex and recurrent fistulas.

Anal fistula and pilonidal sinus disease coexisting simultaneously: An audit in a cohort of 1284 patients

Fistula-in-ano and pilonidal disease are not known to occur together. In a retrospective study, all patients having fistula-pilonidal disease coexisting simultaneously were included. Out of 1284 patients, 933 were operated (fistula-in-ano, 849; pilonidal disease, 77; and coexisting fistula-pilonidal, 7). A total of 351 patients did not undergo any surgery (two patients had coexisting fistula-pilonidal). Thus, a total of nine patients having coexisting fistula-pilonidal sinus were included in the study (mean age 35.8 ± 19.9 years, M/F 7/2). pIn 6/9 patients, the pilonidal tract was communicating with fistula-in-ano, and in 3/9 patients, they were not communicating/connected. The connection could be established preoperatively with the help of MRI. In all patients with communicating fistula-pilonidal sinus (n=6), the fistula was posterior. 6/9 patients had recurrent fistula and all (9/9) had multiple tracts. The fistula was high and complex in 8/9 patients (grade IV-7, grade V-1). 4/9 patients tested positive for tuberculosis while one patient was suffering from hidradenitis suppurativa. The latter improved on medical treatment. One patient did not agree for surgery and seven were operated. The disease healed in four patients, the disease did not heal in one patient, and two patients were in the convalescent stage. Anal fistula and pilonidal disease can coexist in a same patient and can even be connected. Such diseases are more complex and have a higher incidence of associated diseases like tuberculosis. Magnetic resonance imaging plays a pivotal role in diagnosis. If the connection is missed, the disease treatment becomes difficult.

Comparison of Preoperative and Postoperative MRI After Fistula-in-Ano Surgery: Lessons Learnt from An Audit of 1323 MRI At a Single Centre

AIM

Several studies have evaluated the efficacy of preoperative MRI in fistula-in-ano. However, the evaluation of MRI after fistula-in-ano surgery has never been done. The aim was to evaluate the utility of MRI in postoperative period after fistula-in-ano surgery.

METHODS

Preoperative MRI was done in all the patients presenting with fistula-in-ano. Postoperative MRI was done to check radiological healing in clinically healed fistulas or when postoperative complication/healing problem was seen. The postoperative MRI was compared with preoperative MRI and correlated with the clinical picture.

RESULTS

A total of 1323 MRI were done in 1003 fistula-in-ano patients, out of which 702 patients underwent surgery. In 702 patients, there were 361 recurrent fistulas, 153 had associated abscess, 388 had multiple tracts, 146 had horseshoe tract, and 76 had supralevator fistula. In total, 320 postoperative MRI scans were done in 180/702 patients. The requirement of postoperative MRI was significantly higher in complex (grades III-V) than simple fistulas (grades I-II) [43.5% (136/313) vs. 11.3% (44/389), respectively, P < 0.0001]. In early postoperative period (8 weeks), healing (granulation) tissue was difficult to differentiate from active fistula tract/pus. The complete radiological healing took at least 10-12 weeks. So getting MRI scan for the assessment of healing was more accurate after 12 weeks. MRI was very accurate to identify postoperative complications like abscess, missed tract or non-healing of a tract. MRI detected such complications even in apparently clinically healed tracts. Closure/healing of internal opening and intersphincteric tract was assessed accurately by MRI and correlated well with the fistula healing.

CONCLUSIONS

MRI is highly useful to assess healing and detect complications after fistula surgery.

Is fistulotomy still the gold standard in present era and is it highly underutilized?: An audit of 675 operated cases

AIM

Due to fear of incontinence, fistulotomy perhaps remains highly underutilized. The aim was to analyze the efficacy of fistulotomy in a large cohort, to assess the magnitude of underutilization of fistulotomy by current classifications and to identify the subgroup in whom the fistulotomy should be done.

METHODS

All consecutive operated patients of fistula-in-ano were included in the study retrospectively. The fistulas were classified as per existing classifications-Parks, St James University Hospital (SJUH) and Garg classification. Smaller grades of each classification (Parks I, SJUH I-II, Garg I-II) were expected to be simple fistulas and thus amenable to fistulotomy. Objective incontinence scores were done preoperatively and postoperatively.

RESULTS

675 patients were operated over a 5.5 year period (median-27 months). 25 patients were excluded. Fistulotomy was done in 353/650 (54.3%) patients and sphincter-saving procedures (SSP) performed in 297/650 (45.7%) patients. After fistulotomy, 346/353 (98%) fistulas healed after the first operation. Seven patients with recurrent fistula were cured after a repeat fistulotomy surgery. Thus the overall healing rate was 353/353 (100%). There was no significant change in continence scores. The 353 fistulotomy patients were classified as per different classifications- Parks (I-225,II-112,III-16,IV-0), SJUH(I-138,II-87,III-47,IV-65,V-16) and Garg (I-188,II-165,III-0,IV-0,V-0). 123 (36.3%) patients who could undergo fistulotomy successful were erroneously classified as complex fistula by Parks and SJUH classifications. Garg classification accurately identified all 353/353 (100%) patients were amenable to fistulotomy.

CONCLUSIONS

Fistulotomy is a safe procedure with remarkably high success rate (100%) and is gold-standard in majority of patients (>50%). Parks and SJUH classifications are inaccurate in selecting patients for fistulotomy. Garg classification predicts amenability to fistulotomy with very high accuracy.