Cellular angiofibroma arising from the rectocutaneous fistula in an adult: A case report

BACKGROUND

Rectocutaneous fistulae are common. The infection originates within the anal glands and subsequently extends into adjacent regions, ultimately resulting in fistula development. Cellular angiofibroma (CAF), also known as an angiomyofibroblastoma-like tumor, is a rare benign soft tissue neoplasm predominantly observed in the scrotum, perineum, and inguinal area in males and in the vulva in females. We describe the first documented case CAF that developed within a rectocutaneous fistula and manifested as a perineal mass.

CASE SUMMARY

In the outpatient setting, a 52-year-old male patient presented with a 2-year history of a growing perineal mass, accompanied by throbbing pain and minor scrotal abrasion. Physical examination revealed a soft, well-defined, non-tender mass at the left buttock that extended towards the perineum, without a visible opening. The initial assessment identified a soft tissue tumor, and the laboratory data were within normal ranges. Abdominal and pelvic computed tomography (CT) revealed swelling of the abscess cavity that was linked to a rectal cutaneous fistula, with a track-like lesion measuring 6 cm × 0.7 cm in the left perineal region and attached to the left rectum. Rectoscope examination found no significant inner orifices. A left medial gluteal incision revealed a thick-walled mass, which was excised along with the extending tract, and curettage was performed. Histopathological examination confirmed CAF diagnosis. The patient achieved total resolution during follow-up assessments and did not require additional hospitalization.

CONCLUSION

CT imaging supports perineal lesion diagnosis and management. Perineal angiofibromas, even with a cutaneous fistula, can be excised transperineally.

LIFT procedure: postoperative outcomes, risk factors for fistula recurrence and continence impairment

Ligation of the intersphincteric fistula tract has been recently employed as definitive treatment of anal fistulas. However, it carries a potential risk of continence impairment, fistula recurrence, and repeated operations. This study aimed to assess postoperative outcomes related to this procedure and evaluate the potential influence of preoperative and intraoperative features. Patients who underwent LIFT procedure between June 2012 and September 2021 were retrospectively analyzed. Patients were divided according to whether they developed fistula recurrence and on the history of a surgery prior to the LIFT. Preoperative features, postoperative outcomes, and risk factors adverse outcomes were analyzed. Forty-eight patients were included, of which 25 received primary LIFT, being the high transsphincteric fistula pattern the most frequent (62.5%). The median follow-up was 13.3 months, with a recurrence rate of 20.8%, of which the majority presented an intersphincteric fistula pattern (50%); and continence impairment rate of 16.7%. A higher prevalence of diabetes (p = 0.026) and a trend towards a higher prevalence of patients with a history of high transsphincteric fistula (0.052) were observed in the group with fistula recurrence. The history of diabetes and the operation time with a cut-off value ≥ 69 min showed a trend as a risk factors for developing fistula recurrence (0.06) and postoperative continence impairment (0.07), respectively. The LIFT procedure seems to be safe in terms of morbidity, with a reasonable incidence of recurrences, showing better results when it is primarily performed. Preoperative characteristics should be considered as they may impact outcomes.

Video-assisted anal fistula treatment (VAAFT) combined with ozonide oil dressing: standardization of technique in pediatric patients

BACKGROUND

Anal fistula and perianal abscess are commonly acquired anorectal pathologies in children. Surgical treatment options commonly adopted are fistulotomy, fistulectomy, cutting seton placement, and more recently video-assisted anal fistula treatment (VAAFT). Optimal postoperative wound dressing remains debated. This study aimed to report our series of pediatric patients, who received VAAFT and postoperative wound dressing using ozonide oil.

METHODS

All patients who underwent VAAFT between August 2018 and May 2023 were included in the study. Demographics, clinical features, pre-operative imaging, surgical details, outcome, and mid-term outcome data were retrospectively reviewed for each patient. All VAAFT procedures were performed under general anesthesia and using a 10-Ch fistuloscope.

RESULTS

Thirty-three VAAFT procedures were performed in 30 patients over the study period. The median patient age was 5.7 years (range 1.75-14). Anal fistula was idiopathic in 26/30 (86.6%), iatrogenic in 2/30 (6.7%), and secondary to Crohn's disease in 2/30 (6.7%). The median duration of surgery was 23 min (range 18-40). All patients received ozonide oil dressing twice a day for 5 weeks postoperatively. The median hospital stay was 24 h (range 9-36). The median healing time was 28 days (range 17-39). With a median follow-up of 2 years (range 0.5-5), disease recurrence occurred in 3/30 (10%) patients with idiopathic fistula, who were re-operated using the same technique, with no further recurrence. No fecal incontinence or soiling was observed.

CONCLUSION

Our series confirmed that VAAFT is a safe and effective technique to treat children with perianal fistula. The technique is versatile, allowing to treat fistulae of different etiologies. Postoperative course was painless and fast. Future comparative prospective studies are needed to better establish these conclusions.

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.

Which magnetic resonance imaging feature is associated with treatment response in perianal fistulizing Crohn's disease?

PURPOSE

Perianal fistulae are disabling complications of Crohn's Disease. Magnetic resonance imaging features could predict treatment response. This study aimed to determine which magnetic resonance imaging features were predictive of long-term clinical outcome in real life.

METHODS

Consecutive patients with magnetic resonance imaging performed in a tertiary center were retrospectively analyzed. Clinical outcome was defined as a need for surgical drainage of perianal fistulae or hospitalization. Clinical data and magnetic resonance imaging features (MAGNIFI-CD and Van Assche indices, degree of fibrosis) were studied.

RESULTS

Fifty-two patients were included between 2016 and 2019 with a mean follow-up of 38 months [29;48]. A higher MAGNIFI-CD index (17/25 versus 11/25; p < 0.01) was associated with an unfavorable long-term clinical outcome. The MAGNIFI-CD index showed an area under the curve of 0.74 (p = 0.006) to predict the clinical outcome of perianal Crohn's disease, compared to 0.67 (p < 0.05) for the Van Assche index. At a threshold of 13 for the MAGNIFI-CD index, sensitivity was 75% (CI95% [59%; 86%]) and specificity was 69% (CI95% [44%; 86%]). No association was found between the degree of fibrosis and clinical outcome, but the association of a high degree of fibrosis (≥ 80%) and of a low MAGNIFI-CD index (≤ 13) was predictive of clinical outcome (p < 0.01).

CONCLUSION

The MAGNIFI-CD index could be used to predict clinical outcome in perianal Crohn's disease. In combination with a high degree of fibrosis, a low MAGNIFI-CD index, may help to identify patients with the best prognosis.

[On fistulas and threads : Sense and nonsense of seton drainage]

BACKGROUND

In the daily practice of a large proctological center numerous wrong or misplaced fistula threads are encountered. This indicates that there are misconceptions and knowledge gaps in this surgical field in nonspecialized general surgeons.

MATERIAL AND METHODS

Comprehensive footage of own experiences in a proctological center shows faulty threads and correct loop placement.

RESULTS

In fistula treatment there is still a distinct need for improvement. This synopsis is an educational contribution.

CONCLUSION

In the case of a lack of experience in proctological surgery, education and training has to be provided for the decent management of anal fistulas with correct threads.

National observational study about the surgical treatment of anal fistula: Does the kind of hospital modify the results?

INTRODUCTION

Performing the surgical procedure in a high-volume center has been seen to be important for some surgical procedures. However, this issue has not been studied for patients with an anal fistula (AF).

MATERIAL AND METHODS

A retrospective multicentric study was performed including the patients who underwent AF surgery in 2019 in 56 Spanish hospitals. A univariate and multivariate analysis was performed to analyse the relationship between hospital volume and AF cure and fecal incontinence (FI).

RESULTS

1809 patients were include. Surgery was performed in a low, middle, and high-volume hospitals in 127 (7.0%), 571 (31.6%) y 1111 (61.4%) patients respectively. After a mean follow-up of 18.9 months 72.3% (1303) patients were cured and 132 (7.6%) developed FI. The percentage of patients cured was 74.8%, 75.8% and 70.3% (p = 0.045) for low, middle, and high-volume hospitals. Regarding FI, no statistically significant differences were observed depending on the hospital volume (4.8%, 8.0% and 7.7% respectively, p = 0.473). Multivariate analysis didńt observe a relationship between AF cure and FI.

CONCLUSION

Cure and FI in patients who underwent AF surgery were independent from hospital volume.

Transanal opening of the intersphincteric space (TROPIS): a novel procedure on the horizon to effectively manage high complex anal fistulas

Anal fistulas, especially complex and high fistulas, are difficult to manage. The transanal opening of the intersphincteric space (TROPIS) procedure was first described in 2017, and a high success rate of over 90% was reported in high complex fistulas. Since then, more studies and even a meta-analysis have corroborated the high efficacy of this procedure in high fistulas. Conventionally, the main focus was to close the internal (primary) opening for the fistula to heal. However, most complex fistulas have a component of the fistula tract in the intersphincteric plane. This component is like an abscess (sepsis) in a closed space (2 muscle layers). It is a well-known fact that in the presence of sepsis, healing by secondary intention leads to better results than attempting to heal by primary intention. Therefore, TROPIS is the first procedure in which, instead of closing the internal opening, the opening is widened by laying open the fistula tract in the intersphincteric plane so that healing can occur by secondary intention. Although the drainage of high intersphincteric abscesses through the transanal route was described 5 decades ago, the routine utilization of TROPIS for the definitive management of high complex fistulas was first described in 2017. The external anal sphincter (EAS) is completely spared in TROPIS, as the fistula tract on either side of the EAS is managed separately-inner (medial) to the EAS by laying open the intersphincteric space and outer (lateral) to the EAS by curettage or excision.

An applicability study of rapid artificial intelligence-assisted compressed sensing (ACS) in anal fistula magnetic resonance imaging

Objective

To evaluate the applicability of artificial intelligence-assisted compressed sensing (ACS) to anal fistula magnetic resonance imaging (MRI).

Methods

51 patients were included in this study and underwent T2-weighted sequence of MRI examinations both with ACS and without ACS technology in a 3.0 T MR scanner. Subjective image quality scores, and objective image quality-related metrics including scanning time, signal-to-noise ratio (SNR), and contrast-to-noise ratio (CNR), were evaluated and statistically compared between the images collected with and without ACS.

Results

No significant difference in the subjective image quality of lesion conspicuity was observed between the two groups. However, ACS MRI decreased the acquisition time with regard to control group (74.00 s vs. 156.00 s). Besides, SNR of perianal and muscle in the ACS group was significantly higher than that of the control group (164.07 ± 33.35 vs 130.81 ± 29.10, p < 0.001; 109.87 ± 22.01 vs 87.61 ± 17.95, p < 0.001; respectively). The CNR was significantly higher in the ACS group than in the control group (54.02 ± 23.98 vs 43.20 ± 21.00; p < 0.001). Moreover, the accuracy rate of the ACS groups in evaluating the direction and internal opening of the fistula was 88.89 %, exactly the same as that of the control group.

Conclusion

We demonstrated the applicability of using ACS to accelerate MR of anal fistulas with improved SNR and CNR. Meanwhile, the accuracy rates of the ACS group and the control were equivalent in evaluating the direction and internal opening of the fistula, based on the results of surgical exploration.

The management of low trans-sphincteric anal fistula during the COVID-19 pandemic: revisiting the role of the seton

The management of trans-sphincteric anal fistula (TAF) includes several surgical options; however, during the COVID-19 pandemic, the access to the operating rooms was severely limited, leaving only the choice of minimally invasive procedures. This study aimed to evaluate the safety and effectiveness of the slow cutting seton technique for TAF performed in an outpatient setting during the COVID-19 pandemic.Patients treated for TAF between January 2020 and July 2022 and followed-up for at least 12 months were retrospectively evaluated. A vascular silicone tie used as seton was positioned in the fistula tract using a Lockhart-Mummery fistula probe. The seton was maintained in moderate tension until the sphincter muscle was passed. Percentage and time for healing, recurrence, SF-36, VAS and Vaizey's Score were recorded.Fifty-eight patients [36 male/22 female, median age 56.5 years (IQR 41.25-65.75) [with TAF were included. After a median time of 4 months, complete healing occurred in 53 cases (91.5%), the anal pain VAS decreased from 6 to 0, the anal incontinence scores did not change significantly and the QoL improved significantly in all the SF36 domains. No complications were recorded, but the fistula recurred in five cases (8.5%). Two of them had additional seton treatment, and three underwent other surgical procedures after the COVID-19 emergency.The slow cutting seton technique is a safe and effective treatment for outpatient procedure with minimal patient discomfort. This treatment option in healthcare delivery for TAF should be reconsidered, even outside the limited in-hospital access during the COVID-19 pandemic.

Enhancing surgical precision: unveiling the impact of preoperative colonoscopy in anal fistula patients

BACKGROUND

Anal fistula is a common benign anorectal disease that often requires surgical intervention for effective treatment. In recent years, preoperative colonoscopy as a diagnostic tool in patients with anal fistula has garnered increasing attention due to its potential clinical application value. By investigating underlying inflammatory bowel disease (IBD), polyps, and other abnormalities, preoperative colonoscopy can offer insights to refine surgical strategies and improve patient outcomes.

METHODS

This retrospective study focused on 1796 patients with various benign anorectal diseases who underwent preoperative intestinal endoscopy and met surgical criteria within the preceding three years at the First Affiliated Hospital of Guizhou University of Traditional Chinese Medicine. Among these patients, 949 diagnosed with anal fistula comprised group A, while 847 patients without anal fistula were assigned to group B for comparison. The investigation encompassed an analysis of general patient information, endoscopic findings, polyp histopathology, distribution of bowel inflammation sites, and results of inflammatory bowel disease assessments between the two patient cohorts. A subgroup analysis was also conducted on 2275 anal fistula patients with no surgical contraindications. This subgroup was categorized into Group A (949 patients who underwent preoperative intestinal endoscopy) and Group C (1326 patients who did not undergo preoperative colonoscopy). The study compared the rates of detecting endoscopic lesions and IBD-related findings between the two subgroups.

RESULTS

The study initially confirmed the comparability of general patient information between groups A and B. Notably, the abnormal detection rate in group A was significantly higher than in group B (P < 0.01). In terms of endoscopic findings, the anal fistula group (group A) exhibited higher rates of detecting bowel inflammation, inflammatory bowel disease, and polyps compared to the non-anal fistula group (group B) (P < 0.05). The distribution of inflammation locations indicated higher detection rates in the terminal ileum, ileocecal region, and ascending colon for group A compared to group B (P < 0.05). Although the incidence of IBD in group A was higher than in group B, this difference did not reach statistical significance (P > 0.05). Subsequently, the analysis of the subgroup (groups A and C) revealed a significant disparity in intestinal endoscopic detection rates (P < 0.01) and statistically significant differences in detecting IBD (P < 0.05) and Crohn's disease (P < 0.05) between the two anal fistula subgroups.

CONCLUSIONS

The findings of this study underscore the substantial clinical value of preoperative colonoscopy in the comprehensive evaluation of patients with anal fistula. Preoperative colonoscopy aids in ruling out localized perianal lesions caused by underlying inflammatory bowel disease, thereby mitigating the likelihood of missed diagnoses and enhancing treatment outcomes. This research highlights the importance of incorporating preoperative colonoscopy as a valuable diagnostic tool in managing anal fistula patients.

Effectiveness and safety of ultra-low-dose spinal anesthesia versus perineal blocks in hemorroidectomy and anal fistula surgery: a randomized controlled trial

BACKGROUND

Ultra-low-dose Spinal Anesthesia (SA) is the practice of employing minimal doses of intrathecal agents so that only the roots that supply a specific area are anesthetized. The aim of this study was to compare the effectiveness and safety of ultra-low-dose spinal anesthesia with that of Perineal Blocks (PB).

METHODS

A two-arm, parallel, double-blind randomized controlled trial comparing two anesthetic techniques (SA and PB) for hemorrhoidectomy and anal fistula surgery was performed. The primary outcomes were postoperative pain, complementation and/or conversion of anesthesia, and hemodynamic changes.

RESULTS

Fifty-nine patients were included in the final analysis. The mean pain values were similar in the first 48 h in both groups (p > 0.05). The individuals allocated to the SA group did not need anesthetic complementation; however, those in the PB group required it considerably (SA group, 0% vs. PB group, 25%; p = 0.005). Hemodynamic changes were more pronounced after PB: during all surgical times, the PB group showed lower MAP values and higher HR values (p < 0.05). Postoperative urinary retention rates were similar between both groups (SA group 0% vs. PB group 3.1%, p = 0.354).

CONCLUSION

SA and PB are similarly effective in pain control during the first 48 h after hemorrhoidectomy and anal fistula surgery. Although surgical time was shorter among patients in the PB group, the SA technique may be preferable as it avoids the need for additional anesthesia. Furthermore, the group that received perineal blocks was under sedation with a considerable dose of propofol.

Efficacy of cx601 (darvadstrocel) for the treatment of perianal fistulizing Crohn's disease-A prospective nationwide multicenter cohort study

BACKGROUND

The use of mesenchymal stem cells is considered a novel and promising therapeutic option for patients with perianal fistulizing Crohn's disease; however, data on its clinical application remain scarce. This multicenter nationwide study aimed to assess the clinical efficacy of mesenchymal stem cells in closing complex anal fistulas.

METHODS

In this study 14 Crohn's disease patients (3 males, 11 females) with complex anal fistulas treated in 3 tertiary hospitals in Austria were included between October 2018 and April 2021. Injection of 120 million allogeneic expanded adipose-derived mesenchymal stem cells (Cx601-darvadstrocel) was performed in each patient. Closure of the external fistula opening without secretion by external manual compression was defined as treatment success.

RESULTS

The median age of the patient population at the time of surgery was 32 years (range 26-53 years) with a median body mass index of 21.7 kg/m2 (range 16.7-26.6 kg/m2). Of the patients 12 (86%) received monoclonal antibodies (infliximab, adalimumab, ustekinumab, vedolizumab) at the time of surgery. The median number of complex fistulas was 1.4 (range 1-2), The median operative time was 20 min (range 6-50 min) with no perioperative complications. After a median follow-up of 92 weeks, we found successful fistula closure in 57.1% (n = 8) of treated patients. The perianal disease activity index did not improve significantly from initially 7 to a median of 6 after 52 weeks (p = 0.495).

CONCLUSION

Darvadstrocel is a safe, minimally invasive surgical technique without significant perioperative complications. Clinical success can be expected in about half of the treated patients.

Clinical characterization of patients with anal fistula during follow-up of anorectal abscess: a large population-based study

PURPOSE

Approximately 15-50% of patients with an anorectal abscess will develop an anal fistula, but the true incidence of this entity is currently unknown. The aim of the study was to determine the incidence of anorectal abscess and development of a fistula in a specific population area and to identify potential risk factors associated with demographic, socioeconomic and pre-existing disease (e.g. diabetes and inflammatory bowel disease).

METHODS

A longitudinal observational study was designed including a large cohort study in an area with 7,553,650 inhabitants in Spain 1st january 2014 to 31st december 2019. Adults who attended for the first time with an anorectal abscess and had a minimum of 1-year follow-up were included. The diagnosis was made using ICD-10 codes for anorectal abscess and anal fistula.

RESULTS

During the study period, we included 27,821 patients with anorectal abscess. There was a predominance of men (70%) and an overall incidence of 596 per million population. The overall incidence of anal fistula developing from abscesses was 20%, with predominance in men, and a lower incidence in the lowest income level. The cumulative incidence of fistula was higher in men and in younger patients (p < 0.0001). On multivariate analysis, patients aged 60-69 years (hazard ratio 2.0) and those with inflammatory bowel disease (hazard ratio 1.8-2.0) had a strong association with fistula development (hazard ratio 2.0).

CONCLUSIONS

One in five patients with an anorectal abscess will develop a fistula, with a higher likelihood in men. Fistula formation was strongly associated with inflammatory bowel disease.

Results from a nationwide observational study

PURPOSE

The aim of the present study was to analyse current surgical treatment preferences for anal fistula (AF) and its subtypes and nationwide results in terms of success and complications.

METHODS

A retrospective multicentre observational cohort study was conducted. The study period was 1 year (2019), with a follow-up period of at least 1 year. A descriptive analysis of patient characteristics and trends regarding technical options was performed. Univariate and multivariate Cox regression models were used to analyse factors associated with healing and faecal incontinence (FI).

RESULTS

Fifty-one hospitals were involved, providing data on 1628 patients with AF. At a median follow-up of 18.3 (9.9-28.3) months, 1231 (75.9%) patients achieved healing, while 390 (24.1%) did not; failure was catalogued as persistence in 279 (17.2.0%) patients and as recurrence in 111 (6.8%). On multivariate analysis, factors associated with healing were fistulotomy (OR 5.5; 95% CI 3.8-7.9; p < 0.001), simple fistula (OR 2.1; 95% CI 1.5-2.8; p < 0.001), single tract (HR 1.9; 95% CI 1.3-2.8; p < 0.001) and number of preparatory surgeries (none vs. 3; HR 1.8; 95% CI 1.2-2.8; p = 0.006). Regarding de novo FI, in the multivariate analysis previous anal surgery (OR 1.5, 95% CI 1.0-2.4, p = 0.037), age (OR 1.02, 95% CI 1.00-1.04, p = 0.002) and being female (OR 1.7, 95% CI 1.1-2.5, p = 0.008) were statistically related.

CONCLUSIONS

Anal fistulotomy is the most used procedure for AF, especially for simple AF, with a favourable overall balance between healing and continence impairment. Sphincter-sparing or minimally invasive sphincter-sparing techniques resulted in lower rates of healing. In spite of their intended sphincter-sparing design, a certain degree of FI was observed for several of these techniques.

Study on the factors influencing the prognosis after perianal abscess surgery

OBJECTIVE

To study the influence of clinical characteristics and diagnosis and treatment methods of perianal abscess on postoperative recurrence or formation of anal fistula to provide a basis for selecting appropriate surgical and inspection methods for clinical treatment of perianal abscess in the future.

METHODS

The clinical data of 394 patients with perianal abscesses were collected, the influencing factors were investigated, and univariate analysis and multivariate logistic regression analysis were performed to further determine the risk factors affecting the prognosis of perianal abscess.

RESULTS

The results showed that the rate of preoperative blood routine results in the uncured group was higher (51.16%) than in the cured group (35.61%); the rate of high abscess space in the uncured group (23.26%) was higher than in the cured group (9.11%); the proportion of patients in the uncured group who underwent magnetic resonance imaging (MRI) before surgery (27.90%) was lower than in the cured group (45.30%); the proportion of patients in the uncured group who underwent simple drainage (51.16%) was higher than in the cured group (28.49%). The two groups had significant differences in perineal MRI examination, surgical method, preoperative blood routine, and abscess space (p = 0.030, p = 0.002, p = 0.047 and p = 0.010, respectively). Based on the results of univariate analysis and multivariate logistic regression analysis, the extent of the abscess cavity (OR = 2.544, 95%CI = 1.087-5.954, p = 0.031) and the surgical method (OR = 2.180, 95%CI = 1.091-4.357, p = 0.027) were independent influencing factors for postoperative recurrence of perianal abscess or anal fistula.

CONCLUSION

Preoperative assessment of the abscess range and precise intraoperative methods to resolve the infection of the abscess glands in the internal mouth can effectively improve the cure rate.

A case report of anal fistula-associated mucinous adenocarcinoma developing 3 years after treatment of perianal abscess

BACKGROUND

A long-standing (over 10 years) anal fistula is considered a fundamental cause of fistula-associated mucinous adenocarcinoma (FAMC). Perianal abscesses and anal fistulas are two sequential phases of the same anorectal infectious process. We experienced a case of FAMC which developed 3 years after the treatment of a perianal abscess.

CASE PRESENTATION

A 68-year-old woman was admitted to our hospital because of progressive anal pain and a palpable tumor. She had a history of undergoing a drainage operation for a perianal abscess 3 years previously. A 15 × 15-mm tumor at the former drainage site was identified; transanal ultrasonography showed an intersphincteric fistula connecting to the tumor. A biopsy taken from the tumor demonstrated mucinous adenocarcinoma; the tumor was diagnosed as FAMC. Laparoscopic abdominoperineal resection was performed. Histopathology showed highly dysplastic cells lining the lumen of the anal fistula and poorly differentiated mucinous adenocarcinoma proliferating in the dermis and epidermis in the distal aspect of the fistula.

CONCLUSIONS

FAMC can develop within fewer than 3 years after the development of a perianal abscess and anal fistula.

Characteristics and post-operative outcomes of surgery for fistula-in-ano managed at a tertiary care hospital in Sri Lanka: a retrospective study

OBJECTIVES

Management of fistula-in-ano is associated with recurrence and, occasionally, with anal incontinence. We investigated the clinical characteristics and outcomes of fistula-in-ano.

METHODS

We included patients with fistula-in-ano managed at a tertiary care center (2016-2021). We collected clinical characteristics and 1-year outcomes using questionnaires. The chi-square test was used in statistical analysis.

RESULTS

In total, 284 patients (231 men, 81.3%; median age 39.5 [range: 7-73] years) were included. Most patients had simple fistulae (n = 191, 67.3%). Transphincteric (n = 110, 38.7%) fistulae were the most common type, followed by intersphinteric fistulae (n = 103, 36.6%). Fistulotomy (n = 157, 55.3%) was the most common procedure. Follow-up details were traceable in 157 (55.3%) patients. At 1 year, the overall healing rate was 88.5% (n = 136). There was no association between type of surgical procedure and incontinence. The mean Vaizey score, used to assess anal incontinence, was 0.84 (range: 0-14). Incontinence was observed in 32 patients (20.9%), and flatus incontinence was the most common type (n = 17, 53.1%). Complex fistulae were associated with higher recurrence rates than simple fistulae (32.6% vs. 2.8%).

CONCLUSION

The healing rate in surgical treatment of fistula-in-ano was 88.5%, with acceptable complication rates. There was no association between surgical procedure type and incontinence.

Surgical management of perianal fistula using an ovine forestomach matrix implant

PURPOSE

Invasive surgical management of cryptoglandular perianal fistulas (PF) is challenging because of high recurrence rates and the potential for injury to the sphincter complex. In the present technical note, we introduce a minimally invasive treatment for PF using a perianal fistula implant (PAFI) comprising ovine forestomach matrix (OFM).

METHODS

This retrospective observational case series highlights 14 patients who had undergone a PAFI procedure at a single center between 2020 and 2023. During the procedure, previously deployed setons were removed and tracts were de-epithelialized with curettage. OFM was rehydrated, rolled, passed through the debrided tract, and secured in place at both openings with absorbable suture. Primary outcome was fistula healing at 8 weeks, and secondary outcomes included recurrence or postoperative adverse events.

RESULTS

Fourteen patients underwent PAFI using OFM with a mean follow-up period of 37.6 ± 20.1 weeks. In follow-up, 64% (n = 9/14) had complete healing at 8 weeks and all remained healed, except one at last follow-up visit. Two patients underwent a second PAFI procedure and were healed with no recurrence at the last follow-up visit. Of all patients that healed during the study period (n = 11), the median time to healing was 3.6 (IQR 2.9-6.0) weeks. No postprocedural infections nor adverse events were noted.

CONCLUSIONS

The minimally invasive OFM-based PAFI technique for PF treatment was demonstrated to be a safe and feasible option for patients with trans-sphincteric PF of cryptoglandular origin.

Anal fistulotomy with one-stage shaped skin grafting for intersphincter anal fistulas: study protocol on a multicentre randomised controlled trial

BACKGROUND

Anal fistulas are mainly treated via surgery. They can be difficult to treat without surgical intervention. Numerous procedures, such as fistulectomy and fistulotomy, are performed to treat anal fistulas and achieve good effects. However, the wounds created through fistulectomy and fistulotomy take a long time to heal. Therefore, a multicentre randomised controlled trial (RCT) is proposed to study the efficacy of one-stage shaped skin grafting at the surgical wound to heal low simple intersphincter anal fistulas.

METHODS

This study is a multicentre, hospital-based RCT. It will be performed at three hospitals. A total of 104 patients with low simple intersphincter anal fistulas who meet the inclusion criteria will be included in this trial and will be allocated randomly to two groups (test and control groups). The patients in the test group will receive one-stage anal fistulotomy surgery combined with shaped skin grafting, and those in the control group will undergo anal fistulotomy only. All the operations will be performed by attending colorectal surgeons or surgeons of a higher level. Effectiveness and safety indicators will be observed, recorded and analysed.

DISCUSSION

Anal fistulotomy can heal low simple intersphincter anal fistulas effectively and safely with a low recurrence rate. Skin grafts promote wound epithelisation significantly. We believe that skin grafting can treat low simple intersphincter fistulas with a short healing time.

TRIAL REGISTRATION

Chinese Clinical Trial Register, ChiCTR2000039174. Registered on 28 October 2020.

Postoperative three-dimensional endoanal ultrasound findings and relation to anal fistula plug failure

OBJECTIVES

To explore the utilization of three-dimensional (3D) endoanal ultrasound (EAUS) for the follow-up of the anal fistula plug (AFP), describe morphological findings in postoperative 3D EAUS, and evaluate if postoperative 3D EAUS combined with clinical symptoms can predict AFP failure.

MATERIALS AND METHODS

A retrospective analysis of 3D EAUS examinations performed during a single-centre study of prospectively included consecutive patients treated with the AFP between May 2006 and October 2009. Postoperative assessment by clinical examination and 3D EAUS was performed at 2 weeks, 3 months and 6-12 months ("late control"). Long-term follow-up was carried out in 2017. The 3D EAUS examinations were blinded and analysed by two observers using a protocol with defined relevant findings for different follow-up time points.

RESULTS

A total of 95 patients with a total of 151 AFP procedures were included. Long-term follow-up was completed in 90 (95%) patients. Inflammation at 3 months, gas in fistula and visible fistula at 3 months and at late control, were statistically significant 3D EAUS findings for AFP failure. The combination of gas in fistula and clinical finding of fluid discharge through the external fistula opening 3 months postoperatively was statistically significant (p < 0.001) for AFP failure with 91% sensitivity and 79% specificity. The positive predictive value was 91%, while the negative predictive value was 79%.

CONCLUSIONS

3D EAUS may be utilized for the follow-up of AFP treatment. Postoperative 3D EAUS at 3 months or later, especially if combined with clinical symptoms, can be used to predict long-term AFP failure.ClinicalTrials.gov identifier NCT03961984.

Perianal mucinous adenocarcinoma: A case report

INTRODUCTION

Perianal mucinous adenocarcinoma is a tumor that is rarely seen by colorectal or even general surgeons.

CASE PRESENTATION

Here we report a case of mucinous adenocarcinoma associated with chronic anal fistula in a 43 years old male patient. He underwent laparoscopic abdominoperineal resection and coverage with myocutaneous pedicled gracilis muscle flap.

DISCUSSION

Most cases are related to chronic anal pathologies, such as anal fistulae; however, further studies are needed for a causation link to be made between the two conditions. Available literature shows that the optimal treatment of perianal mucinous adenocarcinoma is radical surgical resection combined with pre- or postoperative chemoradiotherapy.

CONCLUSION

This case report is to highlight the rare incidence of mucinous adenocarcinoma in the perianal region.

Repeat operations in patients with anal fistula, a retrospective study across England and Wales

AIM

This article reports the frequency of repeat operations including waiting times within the National Health Service (NHS) of England and Wales.

METHODS

Retrospective study on repeat operations for anal fistula (AF) performed between 1st January 2010 and 31st December 2016. Data were extracted from the national registry of data entered into Hospital Episode Statistics (HES). Patient factors (age, sex, self-declared ethnicity) and geographical location were tested for association with repeat operations and time to the second operation.

RESULTS

We analysed 36,223 patients that had an operation for AF within 148 NHS trusts. The median follow-up time was 28 months. The majority of patients (67.4%) had only one operation. Eighty-five per cent of them remained under the care of a single consultant. Six per cent of the repeat surgeries occurred in at least three different treatment sites. Young age and female sex were associated with higher rates of repeat operations. Non-declared and Black or Black British ethnicity were associated with fewer operations. The median waiting time between the first and second operations was 27.4 weeks (IQR: 14.7-55.3); between the second and third 28.0 weeks (IQR: 14.7-57.0); between the third and fourth 29.0 weeks.

CONCLUSION

This large real world population-based study shows that the majority of patients with AF undergo only one operation. Patients requiring multiple procedures tend to stay under the care of a small number of consultants but waiting times between operations are long. There is a geographical variation in the number of operations and the time between them.

The potential roles of gut microbiome in anal fistula

Anal fistula is a common proctological disease, but the thorough mechanisms of the anal fistula formation are still unclear. An increasing number of studies have revealed the crucial role of gut microbiota in intestinal diseases. We used 16S rRNA gene sequencing to analyze the intestinal microbiome in order to determine whether there are differences in the microbiome between anal fistula patients and healthy individuals. The microbiome samples were extracted by repeatedly wiping the rectal wall with intestinal swab. Before this operation, the whole intestine of all participants was irrigated and the score of the Boston bowel preparation scale reached 9. The biodiversity of gut microbiome of rectum revealed significant difference between anal fistula patients and healthy individuals. 36 discriminative taxa were identified by LEfSe analysis between two groups. At the phylum level, Synergistetes was enriched in anal fistula patients, while Proteobacteria was higher in healthy individuals. We also found that at the genus level, Blautia, Faecalibacterium, Ruminococcus, Coprococcus, Bacteroides, Clostridium, Megamonas and Anaerotruncus were highly enriched in anal fistula patients, while the microbiome of healthy individuals was enriched with Peptoniphilus and Corynebacterium. Spearman correlations showed the extensive and close association among genera and species. Finally, a diagnostic prediction model was constructed by random forest classifier, and the area under curve (AUC) reached 0.990. This study gave an important hint for analyzing gut microbiome of rectum in anal fistula patient.Keypoints.We use the 16S rRNA gene sequencing to test the microbiome samples extracted from the intestinal swab. This is the first study to explore the gut microbiome of rectum using this workflow. We also found the distinct gut microbiome of rectum differences between anal fistula patients and healthy individuals.

Synchronous anal mucinous adenocarcinoma and anal tuberculosis presenting as chronic anal fistula: Challenging management

Metachronous anal tuberculosis to an anal adenocarcinoma is an exceptional condition. The aim of our study was to report management of the first case of synchronized anal canal adenocarcinoma and anal canal tuberculosis and report our multidisciplinary approach. A 71-year-old man was admitted for non-healing anal fistula. Rectal examination at supine position showed an ulcerative growth at the medio-superior quadrant on a radius of 2cm from the anal verge. Digital rectal examination assessed no tumor in the anorectum. Biopsy of fistulae confirmed diagnosis of anal mucinous adenocarcinoma with coexisting anal tuberculosis. Further exploration confirmed diagnosis with no distal metastasis, no active pulmonary tuberculosis and no immunodepression. Adjuvant anti-bacillary chemotherapy was initiated 1 month prior to adjuvant radio-chemotherapy. Patient was re-admitted at the 6th week following the last dose of radio-chemotherapy for surgery. On long-term evaluation at 10 months, the patient reported absence of symptoms with weight gain. Association of both entities is rare. Chronic inflammatory damage may possibly initiate a sequence of metaplasia and dysplasia, resulting in neoplastic transformation. Anal canal adenocarcinoma treatment follows same guidelines as rectal cancer. Extra-pulmonary tuberculosis treatment follows anti-bacillary protocol with consequent side effects. Therefore, our case is a unique clinical challenge for physicians. Management decision was multidisciplinary process. Their pathophysiology relationship is yet to be understood. Moreover, each entity has defined and individual therapeutic protocols and indications. All this taken into consideration, such case presents a clinical and therapeutic challenge for physicians.

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.

Diagnostic performance of texture analysis in the differential diagnosis of perianal fistulising Crohn’s disease and glandular anal fistula

BACKGROUND

Perianal fistulising Crohn's disease (PFCD) and glandular anal fistula have many similarities on conventional magnetic resonance imaging. However, many patients with PFCD show concomitant active proctitis, but only few patients with glandular anal fistula have active proctitis.

AIM

To explore the value of differential diagnosis of PFCD and glandular anal fistula by comparing the textural feature parameters of the rectum and anal canal in fat suppression T2-weighted imaging (FS-T2WI).

METHODS

Patients with rectal water sac implantation were screened from the first part of this study (48 patients with PFCD and 22 patients with glandular anal fistula). Open-source software ITK-SNAP (Version 3.6.0, http://www.itksnap.org/) was used to delineate the region of interest (ROI) of the entire rectum and anal canal wall on every axial section, and then the ROIs were input in the Analysis Kit software (version V3.0.0.R, GE Healthcare) to calculate the textural feature parameters. Textural feature parameter differences of the rectum and anal canal wall between the PFCD group vs the glandular anal fistula group were analyzed using Mann-Whitney U test. The redundant textural parameters were screened by bivariate Spearman correlation analysis, and binary logistic regression analysis was used to establish the model of textural feature parameters. Finally, diagnostic accuracy was assessed by receiver operating characteristic-area under the curve (AUC) analysis.

RESULTS

In all, 385 textural parameters were obtained, including 37 parameters with statistically significant differences between the PFCD and glandular anal fistula groups. Then, 16 texture feature parameters remained after bivariate Spearman correlation analysis, including one histogram parameter (Histogram energy); four grey level co-occurrence matrix (GLCM) parameters (GLCM energy_all direction_offset1_SD, GLCM entropy_all direction_ offset4_SD, GLCM entropy_all direction_offset7_SD, and Haralick correlation_all direction_ offset7_SD); four texture parameters (Correlation_all direction_offset1_SD, cluster prominence _angle 90_offset4, Inertia_all direction_offset7_SD, and cluster shade_angle 45_offset7); five grey level run-length matrix parameters (grey level nonuniformity_angle 90_offset1, grey level nonuniformity_all direction_offset4_SD, long run high grey level emphasis_all direction_offset1_SD, long run emphasis_all direction_ offset4_ SD, and long run high grey level emphasis_all direction_offset4_SD); and two form factor parameters (surface area and maximum 3D diameter). The AUC, sensitivity, and specificity of the model of textural feature parameters were 0.917, 85.42%, and 86.36%, respectively.

CONCLUSION

The model of textural feature parameters showed good diagnostic performance for PFCD. The texture feature parameters of the rectum and anal canal in FS-T2WI are helpful to distinguish PFCD from glandular anal fistula.

A Systematic Review of Epidemiology and Outcomes Associated with Local Surgical and Intersphincteric Ligation Procedures for Complex Cryptoglandular Fistulas

INTRODUCTION

This systematic literature review (SLR) assessed incidence/prevalence of cryptoglandular fistulas (CCF) and outcomes associated with local surgical and intersphincteric ligation procedures for CCFs.

METHODS

Two trained reviewers searched PubMed and Embase for observational studies evaluating the incidence/prevalence of cryptoglandular fistula and clinical outcomes of treatments for CCF after local surgical and intersphincteric ligation procedures for CCF.

RESULTS

In total 148 studies met a priori eligibility criteria for all cryptoglandular fistulas and all intervention types. Of those, two assessed incidence/prevalence of cryptoglandular fistulas. Eighteen reported clinical outcomes of surgeries of interest in CCF and were published in the past 5 years. Prevalence was reported as 1.35/10,000 non-Crohn's patients, and 52.6% of non-IBD patients were found to progress from anorectal abscess to fistula over 12 months. Primary healing rates ranged from 57.1% to 100%; recurrence occurred in a range of 4.9-60.7% and failure in 2.8-18.0% of patients. Limited published evidence suggests postoperative fecal incontinence and long-term postoperative pain were rare. Several of the studies were limited by single-center design with small sample sizes and short follow-up durations.

DISCUSSION

This SLR summarizes outcomes from specific surgical procedures for the treatment of CCF. Healing rates vary according to procedure and clinical factors. Differences in study design, outcome definition, and length of follow-up prevent direct comparison. Overall, published studies offer a wide range of findings with respect to recurrence. Postsurgical incontinence and long-term postoperative pain were rare in the included studies, but more research is needed to confirm rates of these conditions following CCF treatments.

CONCLUSION

Published studies on the epidemiology of CCF are rare and limited. Outcomes of local surgical and intersphincteric ligation procedures show differing success and failure rates, and more research is needed to compare outcomes across various procedures. (PROSPERO; registration number CRD42020177732).

Three-dimensional pelvic ultrasound is a practical tool for the assessment of anal fistula

OBJECTIVE

This study aims to investigate the diagnostic value of three-dimensional pelvic ultrasound in the preoperative assessment of anal fistula compared with findings of MRI and surgery.

METHODS

A total of 67 patients (62 males) with suspected anal fistula were analyzed retrospectively. Preoperative three-dimensional pelvic ultrasound and magnetic resonance imaging were performed in all patients. The number of internal openings and the type of fistula were recorded. The accuracy of three-dimensional pelvic ultrasound was determined by comparing these parameters with surgical outcomes.

RESULTS

At surgery, 5 (6%) were extrasphincteric, 10 (12%) were suprasphincteric, 11 (14%) were intersphincteric, and 55 (68%) were transsphincteric. There was no significant difference in the accuracy of pelvic 3D US and MRI, based on internal openings (97.92%, 94.79%), anal fistulas (97.01%, 94.03%), and those under Parks classification (97.53%, 93.83%).

CONCLUSION

Three-dimensional pelvic ultrasound is a reproducible and accurate method for determining the type of fistula and detecting internal openings and anal fistulas.

[Current WSES-AAST guidelines on anorectal emergencies-Summary and comments]

In 2019, the World Society of Emergency Surgery (WSES) and the American Association for the Surgery of Trauma (AAST) generated consensus recommendations for the treatment of anorectal emergencies in Parma, Italy, and published a guideline in 2021. This is the first global guideline dealing with this important topic for surgeons' everyday work. Seven anorectal emergencies were discussed and the guideline recommendations were given according to the GRADE (Grading of Recommendations Assessment, Development and Evaluation) system.

Platelet-rich plasma in the treatment of anal fistula: a systematic review and meta-analysis

OBJECTIVE

To analyse the safety and effectiveness of platelet-rich plasma (PRP) in anal fistula patients.

METHODS

Online databases including PubMed, Embase, Cochrane Library, and Web of Science were searched from inception to December 5, 2022, for eligible studies about evaluating the efficacy of platelet-rich plasma (PRP) in treating anal fistula. Literature search, screening, data extraction, and quality assessment were carried out by two independent investigators. The overall cure rate, the complete cure rate, the recurrence rate, and the adverse event rate with their 95% confidence intervals (95% CI) were the primary calculation indexes. Subgroup analyses were conducted primarily according to whether PRP was combined with other treatments. Softwares of MedCalc 18.2 and Review Manager 5.3 were used for meta-analysis.

RESULTS

A total of 14 studies with 514 patients were included in the meta-analysis. The overall cure rate of 14 studies was 72.11% (95% CI 0.64-0.79). The cure rate of PRP alone was 62.39% (95% CI 0.55-0.69). The combined cure rate of PRP with other treatments was 83.12% (95% CI 0.77-0.88). The cure rate of interventions involving PRP were superior to the cure rate of surgery methods without using PRP significantly in the 4 randomized controlled studies (RR = 1.30, 95% CI 1.10-1.54, p = 0.002). The complete cure rate of the 8 studies was 66.37% (95% CI 0.52-0.79). The recurrence rate of the 12 studies was 14.84% (95% CI 0.08-0.24). The adverse event rate of the 12 studies was 6.31% (95% CI 0.02-0.12).

CONCLUSION

PRP showed favorable safety and effectiveness in the treatment of anal fistula, especially combined with other treatment procedures.

The optimal primary treatment for pediatric perianal abscess and anal fistula: A systemic review and meta-analysis

BACKGROUND

Perianal abscesses and anal fistulas are common. The principle of intention-to-treat has not been considered in previous systemic reviews. Thus, the comparison between primary and post-recurrence management was confused, and the recommendation of primary treatment is obscure. The current study aims to identify the optimal initial treatment for pediatric patients.

METHODS

Using PRISMA guidelines, studies were identified from MEDLINE, EMBASE, PubMed, Cochrane Library, and Google Scholar without any language or study design restriction. The inclusion criteria include original articles or articles with original data, studies of management for a perianal abscess with or without anal fistula, and patient age of <18 years. Patients with local malignancy, Crohn's disease, or other underlying predisposing conditions were excluded. Studies without analyzing recurrence, case series of <5, and irrelevant articles were excluded in the screening stage. Of the 124 screened articles, 14 articles had no full texts or detailed information. Articles written in a language other than English or Mandarin were translated by Google Translation first and confirmed with native speakers. After the eligibility process, studies that compared identified primary managements were then included in the qualitative synthesis.

RESULTS

Thirty-one studies involving 2507 pediatric patients met the inclusion criteria. The study design consisted of two prospective case series of 47 patients and retrospective cohort studies. No randomized control trials were identified. Meta-analyses for recurrence after initial management were performed with a random-effects model. Conservative treatment and drainage revealed no difference (Odds ratio [OR], 1.222; 95% Confidential interval [CI]: 0.615-2.427, p = 0.567). Conservative management had a higher risk of recurrence than surgery without statistical significance (OR 0.278, 95% CI: 0.109-0.707, p = 0.007). Compared with incision/drainage, surgery can prevent recurrence remarkably (OR 4.360, 95% CI: 1.761-10.792, p = 0.001). Subgroup analysis of different approaches within conservative treatment and operation was not performed for lacking information.

CONCLUSION

Strong recommendations cannot be made due to the lack of prospective or randomized controlled studies. However, the current study based on real primary management supports initial surgical intervention for pediatric patients with perianal abscesses and anal fistula to prevent recurrence.

LEVEL OF EVIDENCE

Type of study: Systemic review; Evidence level: Level II.

Clinical application of self-adjustable seton in high complex anal fistula

BACKGROUND

Cutting seton is still one of the main methods for the treatment of high complex anal fistula at present. During the treatment, the thread should be tightened many times until it falls off. The traditional thread tightening method is not only complicated in operation and painful for patients, but also requires specialized equipment and doctors to operate, which is very inconvenient. The above problems can be solved by self-adjusting seton.

AIM

To explore the clinical feasibility of self-adjustable seton in the treatment of high complex anal fistula.

METHODS

Sixty-one patients with anal fistula who met the inclusion criteria at the Department of Anorectal Surgery of Yuyao People's Hospital from July 2019 to June 2022 were selected and randomly divided into an experimental group (n = 29) with self-adjustable seton and a control group (n = 32) with traditional cutting seton (tightening the seton by stages). There was no significant difference between the two groups in terms of age, gender, body mass index, educational level, or the nature of disease (P > 0.05). The main pipe of the anal fistula was all treated with cutting and seton, but the postoperative tightening methods were different: A self-adjustable seton was used in the experimental group, while a traditional cutting seton in the control group. Tightening-falling off time, total tightening times, outpatient tightening times, the degree of tightening-related pain, wound healing time, and efficacy were compared between the two groups.

RESULTS

One patient in the experimental group and two in the control group were intraoperatively treated with drainage and seton, which was removed after surgery. There was no significant difference between the experimental group and the control group in terms of the time of thread tightening off, total thread tightening times, wound healing time, or efficacy (P > 0.05). Outpatient tightening times were less, and the average degree of tightening-related pain was lower in the experimental group than in the control group (P < 0.001).

CONCLUSION

Self-adjustable seton can achieve the effect of traditional cutting seton in tightening-falling off time, wound healing time, and efficacy. However, it is more convenient than traditional seton tightening, and can be adjusted at home to reduce outpatient tightening times, with less cutting pain and lower medical costs. Therefore, it is a relatively suitable tightening method at present and can be popularized and applied in the medical service community and other grass-roots hospitals as a suitable technology in the future.

Gracilis muscle transposition in complex anorectal fistulas of diverse types and etiologies: long-term results of 60 cases

PURPOSE

Complex fistulas often require several attempts at repair and continue to be a challenging task for the surgeon, but above all, a major burden for the affected patient. This study is aimed at evaluating the potential of gracilis muscle transposition (GMT) as a therapeutic option for complex fistulas of diverse etiologies.

METHODS

A retrospective study was conducted over a period of 16 years with a total of 60 patients (mean age 50 years). All were treated for complex fistula with GMT at St. Josef's Hospital in Regensburg, Germany. Follow-up data were collected and analyzed using a prospective database and telephone interview. Success was defined as the absence of fistula.

RESULTS

A total of 60 patients (44 women, 16 men; mean age 50 years, range 24-82 years) were reviewed from January 2005 to June 2021. Primary fistula closure after GMT was achieved in 20 patients (33%) and 19 required further interventions for final healing. Overall healing rate was 65%. Fistula type was heterogeneous, with a dominant subgroup of 35 rectovaginal fistulas. Etiologies of the fistulas were irradiation, abscesses, obstetric injury, and iatrogenic/unknown, and 98% of patients had had previous unsuccessful repair attempts (mean 3.6, range 1-15). In 60% of patients with a stoma (all patients had a stoma, 60/60), stoma closure could be performed after successful fistula closure. Mean follow-up after surgery was 35.9 months (range 1-187 months). No severe intraoperative complications occurred. Postoperative complications were observed in 25%: wound healing disorders (n = 6), gracilis necroses (n = 3), incisional hernia (n = 2), scar tissue pain (n = 2), suture granuloma (n = 1), and osteomyelitis (n = 1). In 3 patients, a second gracilis transposition was performed due to fistula recurrence (n = 2) or fecal incontinence (n = 1).

CONCLUSION

Based on the authors' experience, GMT is an effective therapeutic option for the treatment of complex fistulas when other therapeutic attempts have failed and should therefore be considered earlier in the treatment process. It should be seen as the main but not the only step, as additional procedures may be required for complete closure in some cases.

Autologous platelet-rich-plasma injection and platelet-rich fibrin glue interposition for treatment of anal fistula resistant to surgery

Aim

The current study purposed to evaluate the autologous platelet-rich plasma (PRP), and platelet-rich fibrin glue (PRFG) effect on the treatment of complex, and recalcitrant anal fistula (AF) which was not cured by several surgeries.

Background

AF has remained one of difficult challenges for centuries. Surgery is the common treatment method for it, but the risk of fecal incontinence and recurrence is still a distressing complication for patients and surgeons. New procedures were published in the scientific literature, each with advantages and disadvantages. According to reports, an effective therapy option is the autologous fibrin glue that is rich in platelets.

Methods

Autologous PRP and PRFG were prepared from 10 patients' own blood. The surgeon curetted the tract of anal fistula for the deepithelialisation till hemorrhage occurred; PRP was injected around the fistula into the tissue, and PRFG was interpositioned in the tract. Age, number of previous surgeries, complications, number of PRP and PRFG administrations, and duration of halting the discharge were among the information gathered. Patients were followed up between 10 months to 84 months after treatment.

Results

No complications were observed during and after the injection. During the period of follow-up, AF leakage was stopped for 6 patients, but not for 4 patients.

Conclusion

Since autologous PRP injection, and PRFG interposition is a safe, effective, and minimally invasive procedure for resistant AF to surgeries; it can be used, along with surgery to increase the healing rate of complex anal fistula.

Complex Anal fistula treated with IFTAK (Interception of fistulous track with application of ksharsutra) technique- A case report

BACKGROUND

An anal fistula is a common benign anorectal disease that tends to reoccur simple or low-type fistulas can be treated without affecting the sphincter mechanism; however, repairing a complex ano fistula without compromising anal continence can be difficult for a surgeon.

CASE PRESENTATION

Here, we present an anal fistula of complex clinical appearance managed successfully by the IFTAK (Interception of fistulous track with application of ksharsutra) technique practiced at Banaras Hindu University, Varanasi, India. The diagnosis was made via visual and bi-manual digital rectal examination then confirmed by Endoanal ultrasonography (EAUS). The patient showed remarkable improvement and the fistula healed completely in due course of time without impairing the anal continence status of the patient. At four months of follow-up the patient was healthy and no recurrence was found.

CONCLUSION

IFTAK is a minimally invasive technique and very effective in managing complex fistula in ano of cryptoglandular origin. The main cause of recurrence in complex anal fistula is non-identification of an infected anal crypt, secondary extensions, associated sepsis, or abscess at the time of examination or surgery. So, precise diagnosis and appropriate surgical measures play an equal role in the successful outcome of anal fistula treatment, failure to either will result in non-healing or recurrence.

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.

Laser ablation of anal fistulae: a 6-year experience in a tertiary teaching hospital in Malaysia

BACKGROUND

Several studies have investigated the role of laser ablation of anal fistulae in the European setting. However, long-term follow-up results following laser fistula ablations are not widely investigated and no study was performed in the Asia-Pacific, a region with a distinctive prevalence of tuberculosis. The primary objective of this study is to report a single-centre experience with laser ablation of anal fistulae in Malaysia over a period of 6 years.

METHOD

This was a retrospective observational study assessing the outcomes following 70 laser ablations of anal fistulae from February 2014 till December 2019. All cases were assessed using endoanal ultrasound. The laser ablation procedures were performed using laser systems and fibres from Endoteq Medizinische Laser GmBH, Germany, and Biolitec AG, Jena, Germany. Laser fibres were introduced into the fistula tract and laser energy was emitted radially in continuous mode when activated during the procedure. Pre-defined post-procedural outcomes (primary healing, healing failure or recurrence) were recorded as either present or absent during subsequent follow-up appointments and the data was analysed.

RESULTS

Over a median follow-up period of 10 months, primary healing was reported following 42 procedures (60.0%). Healing failure was reported following 28 procedures (40.0%) whilst recurrence was seen after 16 procedures (22.86%). No new cases of incontinence were reported following the procedure.

CONCLUSION

The reported primary healing rate following laser ablation of anal fistulae in this study appears consistent with existing literature published by other international centres. The most apparent clinical advantage of this procedure is sphincter-function preservation. However, the primary healing rate after isolated laser fistula ablation is still suboptimal. Judicious patient selection and application in anal fistulae with suitable characteristics could potentially improve the post-procedural outcomes.

Efficacy of Kegel exercises in preventing incontinence after partial division of internal anal sphincter during anal fistula surgery

BACKGROUND

The transanal opening of intersphincteric space (TROPIS) procedure, performed to treat complex anal fistulas, preserves the external anal sphincter (EAS) but involves partial incision of the internal anal sphincter (IAS).

AIM

To ascertain the incidence of incontinence after the division of the IAS as is done in TROPIS and to evaluate whether regular Kegel exercises (KE) in the postoperative period can prevent incontinence due to IAS division.

METHODS

Patients operated on for high complex fistulas and having no preoperative continence problem (score = 0) were included in the study. All patients were operated on by the TROPIS procedure and were recommended KE (pelvic contraction exercises) 50 times/day. KE were commenced on the 10^th postoperative day and continued for 1 year. Incontinence was evaluated objectively (by modified Vaizey’s scores) in the immediate postoperative period (Pre-KE group) and on long-term follow-up (Post-KE group). The incontinence scores in both groups were compared to evaluate the efficacy of KE.

RESULTS

Of 102 anal fistula patients operated on between July 2018 and July 2020 were included in this study. There were 90 males, the mean age was 42.3 ± 12.8, and the median follow-up was 30 mo (18-42 mo). Three patients were lost to follow-up. There were 65 recurrent fistulas, 92 had multiple tracts, 42 had associated abscess, 46 had horseshoe fistula and 34 were supralevator fistulas. All were magnetic resonance imaging-documented high fistulas (> 1/3 EAS involved). Overall incontinence occurred in 31% patients (Pre-KE group) with urge and gas incontinence accounting for the majority of cases (28.3%). The mean incontinence scores in the Pre-KE group were 1.19 ± 1.96 (in 31 patients, solid = 0, liquid = 7, gas = 8, urge = 24) and in the Post-KE group were 0.26 ± 0.77 (in 13 patients, solid = 0, liquid = 2, gas = 3, urge = 10) (P = 0.00001, t-test).

CONCLUSION

Division of the IAS led to incontinence, mainly urge incontinence, and also to a mild degree of gas and liquid incontinence. However, regular KE led to a significant reduction in incontinence (both in the number of affected patients and the severity of scores in these patients).

Treatment of cryptoglandular fistulas with the fistula tract laser closure (FiLaC™) method in comparison with standard methods: first results of a multicenter retrospective comparative study in the Netherlands

BACKGROUND

Current surgical closure techniques for sphincter-sparing treatment of high cryptoglandular fistulas in the Netherlands include the mucosal advancement flap procedure (MAF) and ligation of the intersphincteric fistula tract (LIFT). A relatively novel treatment is the fistula tract laser closure (FiLaC™) method. The aim of this study was to investigate the differences in healing and recurrence rates between FiLaC™ and current standard practices.

METHODS

This multicenter retrospective cohort study included both primary and recurrent high cryptoglandular anorectal fistulas, treated with either FiLaC™ or standard methods (MAF or LIFT) between September 2015 and July 2020. Patients with extrasphincteric fistulas, Crohn's disease, multiple fistulas, age < 18 years or missing data regarding healing time or recurrence were excluded. The primary outcomes were the clinical primary and secondary healing and recurrence rates. Primary healing was defined as a closed external opening without fluid discharge within 6 months of treatment on examination, while secondary healing was the same endpoint after secondary treatment. Secondary outcomes included healing time and complaints.

RESULTS

A total of 162 high fistulas from 3 Dutch hospitals were included. Ninety-nine high fistulas were treated with FiLaC™ and 63 with either MAF or LIFT. There were no significant differences between FiLaC™ and MAF/LIFT in terms of clinical healing (55.6% versus 58.7%, p = .601), secondary healing (70.0% versus 69.2%, p = .950) or recurrence rates (49.5% versus 54%, p = .420), respectively. Median follow-up duration was 7.1 months in the FiLaC™ group (interquartile range [IQR] 4.1-14.4 months) versus 6 months in the control group (IQR 3.5-8.1 months).

CONCLUSIONS

FiLaC™ treatment of high anorectal fistulas does not appear to be inferior to MAF or LIFT. Based on these preliminary results, FiLaC™ can be considered as a worthwhile treatment option for high cryptoglandular fistulas. Prospective studies with a longer follow-up period and well-determined postoperative parameters such as complication rates, magnetic resonance imaging for confirmation of fistula healing, incontinence and quality of life are warranted.

The development of a minimum dataset for MRI reporting of anorectal fistula: a multi-disciplinary, expert consensus process

There are a range of sphincter-preserving procedures available to treat anorectal fistula, some of which can be precluded, or rendered more optimal by specific features of fistula anatomy. Magnetic resonance imaging (MRI) is the gold standard modality for assessing anorectal fistula. To maximise clinical utility, the MRI report should accurately describe these clinically relevant features. We aimed to develop a minimum dataset for reporting MRI of anorectal fistula, in order to improve the assessment and management of these patients. A longlist of 70 potential items for the minimum dataset was generated through systematic review of the literature. This longlist was presented to radiologists, surgeons and gastroenterologists in an online survey to understand the features that shape current clinical practice. The longlist and survey results were then presented to an expert consensus panel to generate the final minimum dataset through discussion and anonymous voting. The final minimum dataset details the general characteristics, features of the internal and external openings, path of the fistula through the sphincters and any associated extensions and collections that should be described in all MRI reports for anal fistula. Additional surgical and perianal Crohn's disease subsets were developed to indicate the features that aid decision-making for these patients, in addition to a minimum dataset for the clinical request. This study represents a multi-disciplinary approach to developing a minimum dataset for MRI reporting of anal fistula, highlighting the most important features to report that can assist in clinical decision-making. KEY POINTS: • This paper recommends the minimum features that should be included in all MRI reports for the assessment of anal fistula, including Parks classification, number of tracts, features of the internal and external opening, path of the tract through the sphincters, the presence and features of extensions and collections. • Additional features that aid decision-making for surgery or in the presence of Crohn's disease have been identified. • The items that should be included when requesting an MRI are specified.

Comparison between recent sphincter-sparing procedures for complex anal fistulas-ligation of intersphincteric tract vs transanal opening of intersphincteric space

Complex anal fistulas are difficult to treat. The main reasons for this are a higher recurrence rate and the risk of disrupting the continence mechanism because of sphincter involvement. Due to this, several sphincter-sparing procedures have been developed in the last two decades. Though moderately successful in simple fistulas (50%-75% healing rate), the healing rates in complex fistulas for most of these procedures has been dismal. Only two procedures, ligation of intersphincteric fistula tract and transanal opening of intersphincteric space have been shown to have good success rates in complex fistulas (60%-95%). Both of these procedures preserve continence while achieving high success rates. In this opinion review, I shall outline the history, compare the pros and cons, indications and contraindications and future application of both these procedures for the management of complex anal fistulas.

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.

Including video and novel parameter-height of penetration of external anal sphincter-in magnetic resonance imaging reporting of anal fistula

The main purpose of a radiologist’s expertise in evaluation of anal fistula magnetic resonance imaging (MRI) is to benefit patients by decreasing the incontinence rate and increasing the healing rate. Any loss of vital information during the transfer of this data from the radiologist to the operating surgeon is unwarranted and is best prevented. In this regard, two methods are suggested. First, a short video to be attached with the standardized written report highlighting the vital parameters of the fistula. This would ensure minimum loss of information when it is conveyed from the radiologist to the operating surgeon. Second, inclusion of a new parameter, the amount of external sphincter involvement by the anal fistula. This parameter is usually not included in the MRI report. This can be evaluated as the height of penetration of the external anal sphincter (HOPE) by the fistula. The external anal sphincter plays a pivotal role in maintaining continence. This parameter (HOPE) is distinct from the ‘height of internal opening’ and assumes immense importance as its knowledge is paramount to prevent damage to the external anal sphincter by the surgeon during surgery.

Anal fistula metastasis of rectal cancer after neoadjuvant therapy: a case report

BACKGROUND

Anal metastasis of colorectal cancer is very rare and may present synchronously or metachronously, regardless of pre-existing anal diseases. We report a case of anal fistula metastasis after completion of neoadjuvant therapy for rectal cancer, followed by surgical resection of the primary tumor and metastatic lesion.

CASE PRESENTATION

A 50-year-old man was diagnosed with rectal cancer located 5 cm from the anal verge, with a clinical stage of cT3N0M0. He denied any medical or surgical history, and physical examination revealed no perianal disease. He underwent preoperative chemoradiation therapy (CRT) consisting of a tegafur/gimeracil/oteracil potassium (S-1)-based regimen with 45 Gy of radiation. After completion of CRT, computed tomography (CT) revealed the primary tumor's partial response, but a liver mass highly suggestive of metastasis was detected. This mass was later diagnosed as cavernous hemangioma 3 months after CRT initiation. He then underwent and completed six cycles of consolidation chemotherapy with a capecitabine-based regimen. Subsequent colonoscopy revealed the complete response of the primary tumor, but CT showed thickening of the edematous rectal wall. Therefore, we planned to perform low anterior resection as a radical surgery. However, he presented with persistent anal pain after the last chemotherapy, and magnetic resonance imaging revealed a high-intensity mass behind the anus, suggestive of an anal fistula. We considered the differential diagnosis of a benign anal fistula or implantation metastasis into the anal fistula. Fistulectomy was performed, and a pathological diagnosis of tubular adenocarcinoma, suggestive of implantation metastasis, was made. Thereafter, we performed laparoscopic abdominoperineal resection. Histopathological examination revealed well-differentiated adenocarcinoma, ypT2N0, with a grade 2 therapeutic effect. Subsequent immunohistochemistry of the resected anal fistula showed a CDX-2-positive, CK20-positive, CK7-negative, and GCDFP-15 negative tumor, with implantation metastasis. There was no cancer recurrence 21 months after the radical surgery.

CONCLUSIONS

This is the first report of anal fistula metastasis after neoadjuvant therapy for rectal cancer in a patient without a previous history of anal disease. If an anal fistula is suspected during or after neoadjuvant therapy, physical and radiological assessment, differential diagnosis, and surgical intervention timing for fistula must be carefully discussed.

Three-dimensional endoanal ultrasound to assess the validity of Goodsall's Rule and the Midline Rule in predicting the path of perianal fistula-in-ano and the location of the internal opening

BACKGROUND

Correct identification of the internal opening is essential in the management of perianal fistulae. The aim of this study was to assess the validity of Goodsall's Law and the Midline Rule in predicting the path of perianal fistula-in-ano and the location of the internal opening using 3-dimensional endoanal ultrasound.

METHODS

An observational study including patients diagnosed with fistula-in-ano, at our institution from January 2006 to December 2020 was performed. Location and distance from the anal verge of the external opening, internal opening, and the path of the fistulous tract were recorded during physical examination and endoanal ultrasound. Goodsall's and Midline rules were applied to all fistulae according to the location of the external opening. The location of the internal opening as predicted by either rule was then compared to the real location of the internal opening identified during endoanal ultrasound examination.

RESULTS

Nine hundred and nine patients [657 (72.3%) males, mean age 50.78 (49.84-51.72) years] were included. 665 (73.2%) of fistulae were transsphinteric. Concordance between predicted internal opening site and the true internal opening location was 0.601 (good match) for Goodsall's rule, and 0.416 (moderate match) for the Midline rule. Goodsall's rule proved to be more predictive in the anterior plane (p < 0.001). Both rules were more likely to make a correct diagnosis in posterior fistulae located 4.5-7.5 mm from the anal verge.

CONCLUSIONS

Both Midline and Goodsall's rules are highly predictive of the course of fistula tracts located in the posterior plane, and are lower for anterior located fistulae, female patients and when the external opening is located further from the anal verge.

Living with cryptoglandular anal fistula: a qualitative investigation of the patient's experience through semi-structured patient interviews

Purpose

Cryptoglandular anal fistula continues to be a subject of extensive surgical research due to the lack of effective and enduring treatments, some of which incur risks to continence and quality of life. However, the patient experience of disease has seldom been reported. The aims of this study are to understand the impact of living with a fistula and the treatment outcomes that are valued by patients.

Methods

Patients with cryptoglandular anal fistula were recruited using purposive sampling from two tertiary referral centres in the UK and the Netherlands. Patients underwent semi-structured interviews that were audio-recorded and transcribed verbatim. Dutch transcripts were translated into English and underwent independent, thematic analysis using open coding by two study team members to identify common themes and sub-themes.

Results

Twenty interviews were conducted before saturation was reached (11 male, median age 49, Interquartile range 39–55 years). Four broad themes emerged, covering the physical symptoms of fistula, the patient journey towards understanding the condition, life impact, and treatment. Several inter-related sub-themes were found, reflecting the extensive impact and adjustment that the disease entails.

Conclusion

The impact of cryptoglandular anal fistula extends beyond the physical symptoms of pain and discharge, requires significant readjustment, and often negatively impacts psycho-social wellbeing. These aspects of disease should receive greater attention in future assessment of treatment and quality of life.

Supplementary Information

The online version contains supplementary material available at 10.1007/s11136-022-03098-y.

Increasing experience with the LIFT procedure in Crohn's disease patients with complex anal fistula

BACKGROUND

Surgical management of anal fistulas in Crohn's disease (CD) is associated with high failure rates, and treatment options are limited due to ongoing proctitis, multiple tracts, and concern for incontinence and non-healing wounds. The aim of this study was to investigate the healing rate of ligation of the inters-sphincteric fistula tract (LIFT) for anal fistulas in Crohn's disease and identify prognostic factors for healing.

METHODS

This prospective analysis compared long-term healing rates of CD patients undergoing LIFT for anal fistulas. Consecutive patients with CD who underwent LIFT procedure at our institution, in the period from March 2012 to September 2019 were included. The main outcome was anal fistula healing rate.

RESULTS

The study cohort of 46 patients (mean age of 34.2 ± 13.0 years, 18 (40%) males). After a mean follow-up time of 33 ± 28 months, fistula healing was seen in 30 (65%) patients. A total of 8 patients were noted to have inter-sphincteric recurrence and 8 patients had trans-sphincteric recurrence. Smoking at the time of surgery was significantly associated with LIFT failure (HR 3.18, 95% CI 1.18-8.61, p = 0.02). Other factors, such as age, sex, race, disease duration and location, type of fistula history of proctitis, preoperatively use of biologics or a seton, and previous repair attempts, did not appear to influence LIFT healing. Although not statistically significant, there was a trend toward increase in failure among patients with active proctitis at the time of surgery (HR 1.97, 95% CI 0.71-5.42, p = 0.19).

CONCLUSION

Our increasing experience with LIFT for anal fistula in CD demonstrates a higher rate of healing (65%) than previously reported (48%). Smoking appears to negatively influence healing of LIFT in CD.