Sphincter-sparing surgery for complex anal fistulas: radiofrequency thermocoagulation of the tract is of no help

Prospective and multicentre study of radiofrequency treatment in anal fistula

BACKGROUND

The most effective treatment for anal fistula is fistulotomy, but it involves a risk of anal incontinence. To reduce this morbidity, sphincter-sparing treatments have been developed, but their success in real life is often less than 50%. The aim is to determine the clinical healing rate 6 months after radiofrequency treatment.

METHODS

We planned to evaluate 50 patients from three French proctology centres. Treatment efficacy was evaluated at 6 and 12 months by means of clinical and magnetic resonance imaging examination. We evaluated morbidity and healing prognostic factors.

RESULTS

Fifty patients with a mean age of 51 years (22-82) were included. Eleven patients had a low trans-sphincteric fistula (LTS), 21 patients had a high trans-sphincteric fistula (HTS), eight had a complex fistula and nine had Crohn's disease fistula. After 6 months, 17 patients (34.7%) had a clinically healed fistula, including five (45.5%) with LTS fistula, seven (33.3%) with HTS fistula, one (12.5%) with complex fistula, four (44.4%) with Crohn's disease, with no significant difference between these fistula types (p: 0.142). At 12 months, the healing rate was identical. MRI in 15 out of 17 clinically healed patients showed a deep remission of 73.3% at 12 months. Energy power was associated with the success of the treatment. There was an 8.2% incidence of post-surgical complications with 4.1% being abscesses (one required surgical management). Postoperative pain was minor. No new cases or deterioration of continence have been shown.

CONCLUSION

Radiofrequency is effective in 34.7% of the cases as an anal fistula treatment in this first prospective study, with low morbidity and no effect on continence. Clinical healing was deep (MRI) in three-quarters at 1 year. The increase in energy power during the procedure seems to be a key point to be analysed to optimise results.

Risk factors for postoperative recurrence of anal fistula identified by an international, evidence-based Delphi consultation survey of surgical specialists

BACKGROUND

Despite the emerging knowledge about postoperative anal fistula recurrence (AFR) and the increasing number of clinical studies, there is no better understanding or consensus regarding the risk factors for AFR. The aim of this study was to generate international consensus guidance statements focusing on AFR.

METHODS

A two-round modified Delphi process was conducted among international surgical specialists via an online survey delivered by email with a secure link created with Google Forms. Surgeons were asked to use a 9-point Likert scale to rate the importance of patient-, fistula-, and surgery-related statements developed based on our previous systematic review. Consensus was reached when at least 70% of panel members rated a statement as being of critical importance (ratings of 7-9).

RESULTS

Of a total of 60 experts invited, 38 experts representing 13 countries from four continents agreed to participate in the first round of the Delphi process and 31 in the second round. In total, consensus was reached on 14 statements on the risk factors for AFR in three domains: patient-related risk factors included comorbid colitis, inflammatory bowel disease and use of immunosuppressants; fistula-related factors included transsphincteric fistula, number of fistula, horseshoe extension, undetected internal opening, location of anal fistula, recurrent fistula, suprasphincteric fistula, and height of the internal opening; and surgery-related factors included type of surgery, previous fistula surgery and surgeon.

CONCLUSION

This Delphi study provides an evidence-based profile of risk factors for AFR in the patient-, surgery- and fistula-related domains from a global perspective. Clinically, these indicators can be incorporated to develop risk calculation tools for the early detection of AFR in high-risk patients, allowing early prevention and intervention.

The management of cryptoglandular fistula-in-ano

Idiopathic cryptoglandular fistula-in-ano is a common pathological condition. Fistula-in-ano has been managed by a number of surgical techniques, and there is still no consensus regarding the management of this condition. Surgical techniques aim to treat and cure the fistula-in-ano with minimal risk of recurrence or complications, and to maintain patient continence. This article discusses the evidence available to inform the management of idiopathic cryptoglandular fistula-in-ano, and problems that surgeons face because of the lack of high-quality evidence.