Treatment of anal fistulas with high intersphincteric extension

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.

Surgical management of complex perianal fistula revisited in a systematic review: a critical view of available scientific evidence

BACKGROUND

Treating complex perianal fistulas in Crohn's disease patients remains a challenge. Classical surgical treatments for Crohn's disease fistulas have been extrapolated from cryptoglandular fistulas treatment, which have different etiology, and this might interfere with its effectiveness, in addition, they increase fecal incontinence risk. Recently, new surgical techniques with support from biological approaches, like stem cells, have been developed to preserve the function of the sphincter. We have performed a systematic literature review to compare the results of these different techniques in the treatment of Crohn's or Cryptoglandular fistula.

METHODS

PubMed, EMBASE, Database of Abstracts of Reviews of Effectiveness, Cochrane Central Register of Controlled Trials were searched systematically for relevant articles. We included randomized controlled trials and observational studies that referred to humans, were written in English, included adults 18+ years old, and were published during the 10-year period from 2/01/2010 to 2/29/2020. Evidence level was assigned as designated by the Scottish Intercollegiate Guidelines Network.

RESULTS

Of the 577 citations screened, a total of 79 were ultimately included in our review. In Crohn's disease patients, classical techniques such as primarily seton, Ligation of Intersphincteric Fistula Tracks, or lay open, healing rates were approximately 50-60%, while in cryptoglandular fistula were around, 70-80% for setons or flaps. In Crohn's disease patients, new surgical techniques using derivatives of adipose tissue reported healing rates exceeding 70%, stem cells-treated patients achieved higher combined remission versus controls (56.3% vs 38.6%, p = 0.010), mesenchymal cells reported a healing rate of 80% at week 12. In patients with cryptoglandular fistulas, a healing rate of 70% using derivatives of adipose tissue or platelets was achieved, and a healing rate of 80% was achieved using laser technology. Fecal incontinence was improved after the use of autologous platelet growth factors and Nitinol Clips.

CONCLUSION

New surgical techniques showed better healing rates in Crohn's disease patients than classical techniques, which have better results in cryptoglandular fistula than in Crohn's disease. Healing rates for complex cryptoglandular fistulas were similar between the classic and new techniques, being the new techniques less invasive; the incontinence rate improved with the current techniques.

Comparison of different methods to manage supralevator rectal opening in anal fistulas: A retrospective cohort study

INTRODUCTION

Supralevator fistula-in-ano are difficult to manage. If these fistulas have an additional supralevator internal-opening in rectum apart from the primary internal-opening at the dentate line, then the management becomes even more difficult. There is no literature/guidelines available on the management of supralevator rectal opening (SRO).

METHODS

All consecutive supralevator fistula-in-ano patients having a SRO were retrospectively analyzed. The operative management of SRO in these fistulas was reviewed. All the fistulas were managed by the same procedure, transanal opening of intersphincteric space (TROPIS). The latter was a modification of LIFT (ligation of intersphincteric tract) procedure in which the intersphincteric tract was opened-up in the rectum rather than ligated (as is done in LIFT). The SRO was managed in three ways, group-1:SRO was laid-open into the rectum in continuity with the primary opening at dentate line, group-2:the mucosa around SRO was cauterized, group-3:nothing could be done to SRO.

RESULTS

Out of 836 patients operated between 2015 and 2020, 138 patients (16.5%) had supralevator extension. Amongst these, 23/138 (16.6%) patients had a SRO. 2 patients were excluded (short follow-up) and 21 patients were included in the analysis. 12/13(92%) patients in group-1, 4/5 (80%) patients in group-2 and 2/3(67%) patients in group-3 got healed (p=0.47, Chi-square test). The overall healing rate was 18/21(86%).

CONCLUSIONS

The supralevator rectal opening (SRO) heals well irrespective of the method utilized. Thus, proper management of the primary opening at the dentate line holds the key to fistula healing and SRO is perhaps not much responsible for persistence of the fistula. However, more studies are needed to corroborate these findings.

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

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

Comparison of different methods to manage supralevator rectal opening in anal fistulas: A retrospective cohort study

INTRODUCTION

Supralevator fistula-in-ano are difficult to manage. If these fistulas have an additional supralevator internal-opening in rectum apart from the primary internal-opening at the dentate line, then the management becomes even more difficult. There is no literature/guidelines available on the management of supralevator rectal opening (SRO).

METHODS

All consecutive supralevator fistula-in-ano patients having a SRO were retrospectively analyzed. The operative management of SRO in these fistulas was reviewed. All the fistulas were managed by the same procedure, transanal opening of intersphincteric space (TROPIS). The latter was a modification of LIFT (ligation of intersphincteric tract) procedure in which the intersphincteric tract was opened-up in the rectum rather than ligated (as is done in LIFT). The SRO was managed in three ways, group-1:SRO was laid-open into the rectum in continuity with the primary opening at dentate line, group-2:the mucosa around SRO was cauterized, group-3:nothing could be done to SRO.

RESULTS

Out of 836 patients operated between 2015 and 2020, 138 patients (16.5%) had supralevator extension. Amongst these, 23/138 (16.6%) patients had a SRO. 2 patients were excluded (short follow-up) and 21 patients were included in the analysis. 12/13(92%) patients in group-1, 4/5 (80%) patients in group-2 and 2/3(67%) patients in group-3 got healed (p=0.47, Chi-square test). The overall healing rate was 18/21(86%).

CONCLUSIONS

The supralevator rectal opening (SRO) heals well irrespective of the method utilized. Thus, proper management of the primary opening at the dentate line holds the key to fistula healing and SRO is perhaps not much responsible for persistence of the fistula. However, more studies are needed to corroborate these findings.

Modification of Parks Classification of Cryptoglandular Anal Fistula

BACKGROUND

The Parks classification has been used for the classification of anal fistula for several years, but it does not allow for risk factors for failure after surgery.

OBJECTIVE

This study aimed to describe a modification of the Parks classification of anal fistula and examine its predictive validity in the assessment of the outcome of anal fistula in terms of failure of healing and fecal incontinence.

DESIGN

This is a retrospective review of a prospective database.

SETTING

This study was conducted in the Colorectal Surgery Unit, Mansoura University Hospitals.

PATIENTS

Adult patients with anal fistula who underwent surgery were included.

INTERVENTIONS

Five risk factors for failure after fistula surgery were identified from the literature and were examined by multivariate analysis of our patients. Four risk factors proved to be significant independent predictors of failure: secondary extensions, horseshoe fistula, previous fistula surgery, and anterior anal fistula in women. We modified the Parks classification by dividing the transsphincteric type into high and low and by grouping supra- and extrasphincteric anal fistulas into 1 group. The first 3 stages were subdivided according to the absence or presence of predictors of failure.

MAIN OUTCOME MEASURES

The primary outcome measured was the validity of the modified Parks classification with regard to the rates of failure and fecal incontinence after surgical treatment of each stage of anal fistula.

RESULTS

A total of 665 patients with cryptoglandular anal fistula were included. Failure rates increased from 2.3% (95% CI, 0.9%-4.7%), to 17.4% (95% CI, 10.8%-25.9%), 19.5% (95% CI, 15%-24.6%), and 30.7% (95% CI, 9.1%-61.4%) across the 4 stages. The area under the receiver operating characteristic curve was 0.90 (95% CI, 0.85-0.94) indicating the strong discriminative ability of the final multivariable predictive model. The increase in failure and incontinence rates across the fistula stages was significant.

LIMITATIONS

This is a retrospective, single-center study.

CONCLUSION

Inclusion of predictors of poor outcome into the modified classification helped differentiate simple and complex fistulas within each stage and between the different stages, which can help in assessment and decision making for anal fistula. See Video Abstract at http://links.lww.com/DCR/B441.

MODIFICACIN DE LA CLASIFICACIN DE PARKS DE LA FSTULA ANAL CRIPTOGLANDULAR

ANTECEDENTES:La clasificación de Parks se ha utilizado para la clasificación de la fístula anal durante varios años, sin embargo, no tuvo en cuenta los factores de riesgo de fracaso después de la cirugía.OBJETIVO:Describir una modificación de la clasificación de Parks de fístula anal y examinar su validez predictiva en la evaluación de los resultados de la fístula anal en términos de fracaso de la cicatrización e incontinencia fecal.DISEÑO:Revisión retrospectiva de la base de datos prospectiva.AJUSTE:Unidad de Cirugía Colorrectal, Hospital Universitario de Mansoura.PACIENTES:Pacientes adultos con fístula anal intervenidos quirúgicamente.INTERVENCIONES:Se identificaron cinco factores de riesgo de fracaso después de la cirugía de fístula de la literatura y se examinaron mediante análisis multivariante de nuestros pacientes. Cuatro factores de riesgo demostraron ser importantes predictores independientes de fracaso: extensiones secundarias, fístula en herradura, cirugía de fístula previa y fístula anal anterior en mujeres. Modificamos la clasificación de Parks dividiendo el tipo transesfinteriano en alto y bajo y agrupando la fístula anal supraesfinteriana y extraesfinteriana en un grupo. Las tres primeras etapas se subdividieron según la ausencia o presencia de predictores de fracaso.PRINCIPALES MEDIDAS DE RESULTADO:Validez de la clasificación de Parks modificada con respecto a las tasas de fracaso e incontinencia fecal después del tratamiento quirúrgico de cada etapa de la fístula anal.RESULTADOS:Se incluyeron 665 pacientes con fístula anal criptoglandular. Las tasas de fracaso aumentaron del 2,3% (IC del 95%: 0,9-4,7%), al 17,4% (IC del 95%: 10,8 al 25,9%), 19,5% (IC del 95%: 15-24,6%) y 30,7% (95% IC: 9,1- 61,4%) en las cuatro etapas. El área bajo la curva característica operativa del receptor fue 0,90 (IC del 95%: 0,85-0,94), lo que indica una fuerte capacidad discriminativa del modelo predictivo multivariable final. El aumento en las tasas de fracaso e incontinencia en las etapas de la fístula fue significativo.LIMITACIONES:Estudio retrospectivo, unicéntrico.CONCLUSIÓN:La inclusión de predictores de mal resultado en la clasificación modificada ayudó a diferenciar las fístulas simples y complejas dentro de cada etapa y entre las diferentes etapas, lo que puede ayudar en la evaluación y toma de decisiones para la fístula anal. Consulte Video Resumen en http://links.lww.com/DCR/B441.

Video-Assisted Modified Ligation of the Intersphincteric Fistula Tract, an Integration of 2 Minimally Invasive Techniques for the Treatment of Parks Type II Anal Fistulas

Introduction. Complex anal fistula (CAF) is a challenging anorectal condition. Although numerous treatments for its management have been proposed, none is ideal. Herein, we investigated the clinical efficacy of video-assisted modified ligation of the intersphincteric fistula tract (LIFT) in comparison with the incision-thread-drawing procedure for Parks type II anal fistulas. Methods. Male and female adult patients with Parks type II anal fistula who were randomized to receive one of two procedures in the Anorectal Surgery Unit of the Affiliated People's Hospital of Ningbo University: video-assisted modified LIFT (test group, 30 cases) or incision thread drawing (control group, 30 cases). Healing and recurrence, postoperative pain, and postoperative autonomous anal control ability were compared. Results. In the test group, the pain scores were significantly lower (P = .001) and wound healing was faster (P = .001). However, there were no marked differences between groups in operative efficacy or postoperative infection rate (all P > .05). We followed all the patients for more than 18 months, with the test group having lower Jorge-Wexner incontinence (P = .005) and fecal incontinence (FI) severity index (P = .000) scores. No significant difference in recurrence (χ² = .351, P = .554) or healing (χ² = 1.071, P = .301) rate was found between the 2 groups. Conclusions. We established that video-assisted modified LIFT is superior in repairing Parks type II anal fistulas, with less trauma, quicker recovery, and better anal function.

Tools for fecal incontinence assessment: lessons for inflammatory bowel disease trials based on a systematic review

BACKGROUND

Fecal incontinence is a disabling condition affecting up to 20% of women.

OBJECTIVE

We investigated fecal incontinence assessment in both inflammatory bowel disease and non-inflammatory bowel disease patients to propose a diagnostic approach for inflammatory bowel disease trials.

METHODS

We searched on Pubmed, Embase and Cochrane Library for all studies on adult inflammatory bowel disease and non-inflammatory bowel disease patients reporting data on fecal incontinence assessment from January 2009 to December 2019.

RESULTS

In total, 328 studies were included; 306 studies enrolled non-inflammatory bowel disease patients and 22 studies enrolled inflammatory bowel disease patients. In non-inflammatory bowel disease trials the most used tools were the Wexner score, fecal incontinence quality of life questionnaire, Vaizey score and fecal incontinence severity index (in 187, 91, 62 and 33 studies). Anal manometry was adopted in 41.2% and endoanal ultrasonography in 34.0% of the studies. In 142 studies (46.4%) fecal incontinence evaluation was performed with a single instrument, while in 64 (20.9%) and 100 (32.7%) studies two or more instruments were used. In inflammatory bowel disease studies the Wexner score, Vaizey score and inflammatory bowel disease quality of life questionnaire were the most commonly adopted tools (in five (22.7%), five (22.7%) and four (18.2%) studies). Anal manometry and endoanal ultrasonography were performed in 45.4% and 18.2% of the studies.

CONCLUSION

Based on prior validation and experience, we propose to use the Wexner score as the first step for fecal incontinence assessment in inflammatory bowel disease trials. Anal manometry and/or endoanal ultrasonography should be taken into account in the case of positive questionnaires.

Recurrent anal fistulas: When, why, and how to manage?

Anal fistula is a commonly encountered anal condition in the surgical practice. Despite being a benign condition, anal fistula remains to represent a surgical challenge, particularly the complex type of fistulas. One of the common complications of anal fistula surgery is the persistence or recurrence of the pathology, both defined as failure of surgery. Recurrent anal fistulas after previous surgery represent an even more challenging problem since they are usually associated with a higher risk of re-recurrence and continence disturbance. The present review aimed to shed light on various aspects of recurrent anal fistulas, including the different definitions of failure after surgery, risk factors of recurrence, problems associated with management of recurrent fistulas, and assessment and treatment of recurrent anal fistulas.

Drained mucosal advancement flap versus rerouting Seton around the internal anal sphincter in treatment of high trans-sphincteric anal fistula: A randomized trial

BACKGROUND

Several sphincter saving techniques have been described for complex anal fistula (CAF) with variable outcomes. The present trial aimed to compare two techniques for CAF; the drained mucosal flap technique and rerouting Seton around the internal anal sphincter (IAS).

METHODS

Adult patients with high trans-sphincteric anal fistula were randomly assigned to one of two groups: group I underwent mucosal advancement flap with drainage Seton rerouted around the external anal sphincter, and group II underwent rerouting Seton around the IAS. The two groups were compared in terms of the incidence of postoperative fecal incontinence (FI), healing of fistula, complications, and changes in anal pressures.

RESULTS

97 patients (80 male) of a mean age of 39.5 years were included. One patient developed FI in group I versus 7 in group II (p = 0.03). Failure of healing occurred in 2 patients in group I and 4 in group II (p = 0.43). In group II, the average time for spontaneous fall of Seton was 14 ± 2.8 days whereas in group I the average time for removal of Seton was 40 ± 14.9 days (p < 0.0001). There were no significant differences between the two groups in complication rate. Postoperatively, the decrease in resting anal pressure was significant in Group II but not group I.

CONCLUSION

The drained mucosal flap technique was associated with significantly lower incidence of FI, yet longer operative time and longer time to complete healing compared to rerouting Seton around the IAS. The success rates of both techniques was comparable.

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

BACKGROUND

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

OBJECTIVE

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

DESIGN

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

SETTINGS

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

PATIENTS

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

INTERVENTIONS

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

MAIN OUTCOME MEASURES

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

RESULTS

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

LIMITATIONS

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

CONCLUSIONS

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

TRIAL REGISTRATION

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

Supralevator abscess: New treatment for an uncommon aetiology: Case report

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Proper drainage of supralevantor abscess should be achieved for the fistulae path.

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After supralevator abscess resolution the drain should be taken off and marsupialization with ENDO GIA® should be performed.

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It is possible to adapt the length of ENDO GIA® to the length of the fistulae tract.

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This treatment is a safe method for definitive treatment of traumatic supralevator abscess with intersphincteric fistulae.

Introduction

Supralevator abscess is the least common type of anorectal abscess. Its diagnosis can be hard and treatment difficult.

Presentation of the case

A 48-year-old men was diagnosed in the emergency department with a supralevantor abscess. Under general anaesthesia, the abscess drainage was accomplished after removal of a fish bone, who was perforating the rectum. Due to persistent rectal purulent discharge, a pelvic Magnetic Resonance (MRI) was performed: a supralevator abscess adjacent to the internal obturator muscle and an inter-sphincteric fistulae from the inferior margin of this collection were identified. A Pezzer® drain was placed through the fistula tract. After radiological resolution, under general anaesthesia, the patient was submitted to extraction of the drain and marsupialization of the path left using an ENDO GIA®. At two year follow up he remained asymptomatic.

Discussion

Despite of the abscess aetiology, the principles of treatment are the same: good radiological characterization and proper drainage. An adequate radiological characterization is important to avoid iatrogenic creation of a complex fistulae.

Conclusion

If a supralevator abscess diagnosis is made, fistulae trajectory should be studied. If no clear internal opening is evident, a pelvic MRI should be done followed by drainage of the abscess. After resolution the drain should be taken off and marsupialization with ENDO GIA® should be performed.

Japanese Practice Guidelines for Anal Disorders II. Anal fistula

Anal fistulas usually result from an anal gland infection in the intersphincteric space, which is caused by bacteria entering through the anal crypt (cryoptglandular infection). Reports of anal fistulas have been as high as 21 people in 100,000. Anal fistulas are 2-6 times more prevalent in males than females, with the condition occurring most frequently in patients in their 30s and 40s. Anal abscess symptoms include sudden onset of anal pain, swelling, redness, and fever. Purulent discharge or intermittent perianal swelling and pain are most often consistent with anal fistula symptoms. Methods for diagnosing anal fistulas include visual inspection, palpation, digital examination, anoscopic examination, barium enema, fistulography, as well as imaging, such as ultrasound, CT, and MRI. Parks classification is widely adapted in the West; however, Japan usually employs Sumikoshi classification. Antibiotics should be administered in cases of perianal abscess with surrounding cellulitis, or concomitant systemic disease, or those not alleviated by incision and drainage. The site and size of incision and drainage depend upon the abscess type and location. Incisions should be performed taking care not to damage the sphincter muscles and with possible future fistula surgery in mind. As spontaneous recovery is rare, except in the case of children, surgery is the principle approach to anal fistulas. Several approaches are utilized for anal fistulas. A specific procedure may be chosen depending upon curability and anal function. Postsurgical outcomes vary from study to study. Fecal incontinence may occur after fistula surgery, but reports vary.

Understanding and Treating Supralevator Fistula-in-Ano: MRI Analysis of 51 Cases and a Review of Literature

BACKGROUND

Supralevator fistulas are highly complex. The delineation of the supralevator fistula has become accurate because of MRI.

OBJECTIVE

The aim of the study was to analyze the pathophysiology and treatment of different types of supralevator fistulas.

DESIGN

This was a prospective study.

SETTINGS

The study was conducted at a specialized fistula treatment center in North India.

PATIENTS

All of the patients with fistula-in-ano who presented in the outpatient department were assessed with a physical examination and MRI scan. The patients in whom the supralevator extension was confirmed on MRI were included in the study.

MAIN OUTCOME MEASURES

The MRI scans of patients included in the study were analyzed in detail to assess the types of supralevator fistulas and other characteristics of these fistulas. The patients who were operated on were followed for cure rate and deterioration in incontinence.

RESULTS

Of 702 patients with fistula-in-ano who were analyzed by MRI over a period of 3 years, 51 patients with supralevator fistula-in-ano were identified. The mean age was 44.3 ± 12.1 years and the male:female ratio was 16:1. The incidence of supralevator fistulas was 7.26% (51 of 702). In supralevator fistulas, the supralevator extension (upper part) was found to be in the intersphincteric plane in all of the patients. This upper part could be successfully managed by laying it open through the transanal route. The infralevator (lower) part could be of 3 types: intersphincteric (n = 13), low transsphincteric (n = 3), or high transsphincteric (n = 35). The lower part could be managed conventionally. There were no extrasphincteric fistulas. An extensive review of the literature revealed only 2 studies (total fistulas = 16) in which supralevator fistula was studied.

LIMITATIONS

This was a retrospective study.

CONCLUSIONS

The upper supralevator extension in all of the supralevator fistulas is almost always in the intersphincteric plane. This upper part could be laid open through the transanal route. The lower infralevator part could be of 3 types, intersphincteric, low transsphincteric, or high transsphincteric, which could be managed conventionally. Thus, supralevator fistulas could be managed successfully and easily. See Video Abstract at http://links.lww.com/DCR/A630.

A new minimally invasive treatment for anal fistula

In colorectal surgery, eradicating the fistula and maintaining continence are still complex challenges for a colorectal surgeon. A minimally invasive method using a novel device was performed to consecutively treat 14 patients with anal fistula from August 2008 to November 2009. After a follow-up period of 36 months, 13 patients achieved successful closure of their fistula tracts, and recurrence occurred only in one patient. Recurrence was due to the delay of dressing change. No patient had interference with continence, and no major intra- and postoperative complications were identified. Using the novel device with invasive methods can be a promising alternative for managing anal fistulas.

The use of an endostapler in the treatment of supralevator abscess of intersphincteric origin

AIM

This technical note describes the use of an endostapler for the definitive treatment of supralevator abscess upward from an intersphincteric origin.

METHOD

A two-stage treatment was performed. First an endoanal drainage was performed by inserting a mushroom catheter in the supralevator abscess cavity. In the second stage transanal unroofing of the fistula was performed with an endostapler.

RESULTS

Since 2011, three patients have been treated in this way. After 2 years of follow up, none of the patients had recurrence of the abscess or been referred for anal incontinence.

CONCLUSION

The use of an endostapler in the treatment of supralevator abscess of intersphincteric origin may be an alternative to decrease the risk of recurrence and incontinence.