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

Efficacy of anal duct ligation and muscle closure: A novel sphincter-preserving surgical technique for fistula-in-ano

AIM

Although various sphincter-preserving techniques exist for treating anal fistulas, none have demonstrated clear superiority. Therefore, the aim of this study was to introduce a novel sphincter-preserving technique for anal duct ligation and muscle closure (ALMC) and analyse its perioperative outcomes.

METHOD

The data for patients who underwent ALMC for fistula-in-ano at Seoul Song Do Hospital between 2009 and 2023 were retrospectively reviewed. Patient demographics, intraoperative information and postoperative outcomes were assessed. The main outcomes were recurrence and wound healing. Recurrence was defined as the presence of a fistula tract or discharge more than 12 weeks after the primary surgery after achieving complete healing. Faecal incontinence was also investigated clinically.

RESULTS

Overall, 556 patients (84.0% male; mean age 41.7 ± 12.3 years) underwent ALMC. Among these, 152 (27.3%) had a history of fistula surgery and 261 (46.9%) had suprasphincteric fistulas. Fistula-in-ano recurred in 33 patients (5.9%), wound healing was delayed in 97 (17.4%) and faecal incontinence was observed in 12 (2.2%). The mean follow-up duration was 10.0 ± 16.0 months, and the average duration until recurrence was 13.8 ± 10.7 months. The proportion of suprasphincteric fistulas was similar in those who experienced recurrence and those who did not (57.6% vs. 46.3%, respectively; p = 0.239). The proportion of suprasphincteric fistulas in the delayed wound healing group was slightly higher, although the differences were not statistically significant (56.7% vs. 44.9%, respectively; p = 0.054).

CONCLUSION

ALMC appeared to be a safe and feasible option for treating anal fistulas, providing good perioperative outcomes, particularly when sphincter preservation was crucial.

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.