Ustekinumab for Perianal Crohn's Disease: The BioLAP Multicenter Study From the GETAID

INTRODUCTION

New therapeutic options for patients with Crohn's disease (CD) with perianal lesions failing anti-tumor necrosis factor (TNF) agents are needed. We aimed to assess the effectiveness of ustekinumab in perianal CD (pCD) and predictors of clinical success in a real-life multicenter cohort.

METHODS

We conducted a national multicenter retrospective cohort study in patients with either active or inactive pCD who received ustekinumab. In patients with active pCD at treatment initiation, the success of ustekinumab was defined by clinical success at 6 months assessed by the physician's judgment without additional medical or surgical treatment for pCD. Univariate and multivariable logistic regression analyses were performed to identify predictors of success. In patients with inactive pCD at ustekinumab initiation, the pCD recurrence-free survival was calculated using the Kaplan-Meier method.

RESULTS

Two hundred seven patients were included, the mean age was 37.7 years, the mean duration of CD was 14.3 years, and the mean number of prior perianal surgeries was 2.8. Two hundred five (99%) patients had previously been exposed to at least 1 anti-TNF and 58 (28%) to vedolizumab. The median follow-up time was 48 weeks; 56/207 (27%) patients discontinued therapy after a median time of 43 weeks. In patients with active pCD, success was reached in 57/148 (38.5%) patients. Among patients with setons at initiation, 29/88 (33%) had a successful removal. The absence of optimization was associated with treatment success (P = 0.044, odds ratio 2.74; 95% confidence interval: 0.96-7.82). In multivariable analysis, the number of prior anti-TNF agents (≥3) was borderline significant (P = 0.056, odds ratio 0.4; 95% confidence interval: 0.15-1.08). In patients with inactive pCD at initiation, the probability of recurrence-free survival was 86.2% and 75.1% at weeks 26 and 52, respectively.

DISCUSSION

Ustekinumab appears as a potential effective therapeutic option in perianal refractory CD. Further prospective studies are warranted.

Anorectal malformation with rectobladder neck fistula: A distinct and challenging malformation

BACKGROUND

Rectobladder neck fistula is the highest and most complex anorectal malformation in boys and the only one that requires an abdominal approach, open or laparoscopic, for repair. The aim of this study was to describe the unique characteristics of rectobladder neck fistulas that warrant special attention and to describe the associated anatomic variants in the genitourinary tract.

METHODS

The database of a tertiary medical center was retrospectively reviewed for all patients treated for rectobladder neck fistula, by our team in 1980-2011. Data on surgical history, associated and functional defects, treatment and outcome were collected by chart review.

RESULTS

The study group included 111 patients. The most common anatomic urologic defect was a single kidney in 37 patients (33.3%) and the most common functional urologic defect was vesicoureteral reflux in 40 patients (36%), including 11/37 patients with a single kidney (29.7%). Of the 40 patients who underwent cystoscopy, 16 (40%) had a higher than normal location of the verumontanum. Follow-up ranged from 2 to 290months (median 59). Urinary continence was achieved in 40 of the 61 patients (65.5%) for whom data were available, and fecal continence was achieved in 9 of the 69 patients (13%) for whom data were available. A sacral ratio of 0.4 or less was associated with lower rates of urinary control (23%) and fecal control (0%), relative to higher ratios. Twenty stomas (18%) were found to be located too distally, limiting the availability of the bowel for a pull through.

CONCLUSIONS

Rectobladder neck fistula carries a poor prognosis for bowel control and is associated with a high rate of urinary malformations that require long-term care. Pediatric surgeons need to be aware of these complications in order to provide proper treatment and parental counseling. Intra-vesical verumontanum is found in a surprisingly high percentage of patients. The combination of a single kidney with vesicoureteral reflux is common and should be closely followed to avoid renal deterioration. Special attention should be given to colostomy construction to avoid complications and unnecessary procedures. A sacral ratio of 0.4 or less is an indicator of poor fecal and urinary control.

Quality of life with anal fistula

INTRODUCTION

Anal fistula affects people of working age. Symptoms include abscess, pain, discharge of pus and blood. Treatment of this benign disease can affect faecal continence, which may, in turn, impair quality of life (QOL). We assessed the QOL of patients with cryptoglandular anal fistula.

METHODS

Newly referred patients with anal fistula completed the St Mark's Incontinence Score, which ranges from 0 (perfect continence) to 24 (totally incontinent), and Short form 36 (SF-36) questionnaire at two institutions with an interest in anal fistula. The data were examined to identify factors affecting QOL.

RESULTS

Data were available for 146 patients (47 women), with a median age of 44 years (range 18-82 years) and a median continence score of 0 (range 0-23). Versus population norms, patients had an overall reduction in QOL. While those with recurrent disease had no difference on continence scores, QOL was worse on two of eight SF-36 domains (p<0.05). Patients with secondary extensions had reduced QOL in two domains (p<0.05), while urgency was associated with reduced QOL on five domains (p<0.05). Patients with loose seton had the same QOL as those without seton. No difference in urgency was found between patients with and without loose seton. In primary fistula patients, 19.4% of patients experienced urgency versus 36.3% of those with recurrent fistulas.

CONCLUSIONS

Patients with anal fistula had a reduced QOL, which was worse in those with recurrent disease, secondary extensions and urgency. Loose seton had no impact on QOL.

Modern management of anal fistula

Ideal surgical treatment for anal fistula should aim to eradicate sepsis and promote healing of the tract, whilst preserving the sphincters and the mechanism of continence. For the simple and most distal fistulae, conventional surgical options such as laying open of the fistula tract seem to be relatively safe and therefore, well accepted in clinical practise. However, for the more complex fistulae where a significant proportion of the anal sphincter is involved, great concern remains about damaging the sphincter and subsequent poor functional outcome, which is quite inevitable following conventional surgical treatment. For this reason, over the last two decades, many sphincter-preserving procedures for the treatment of anal fistula have been introduced with the common goal of minimising the injury to the anal sphincters and preserving optimal function. Among them, the ligation of intersphincteric fistula tract procedure appears to be safe and effective and may be routinely considered for complex anal fistula. Another technique, the anal fistula plug, derived from porcine small intestinal submucosa, is safe but modestly effective in long-term follow-up, with success rates varying from 24%-88%. The failure rate may be due to its extrusion from the fistula tract. To obviate that, a new designed plug (GORE BioA^®) was introduced, but long term data regarding its efficacy are scant. Fibrin glue showed poor and variable healing rate (14%-74%). FiLaC and video-assisted anal fistula treatment procedures, respectively using laser and electrode energy, are expensive and yet to be thoroughly assessed in clinical practise. Recently, a therapy using autologous adipose-derived stem cells has been described. Their properties of regenerating tissues and suppressing inflammatory response must be better investigated on anal fistulae, and studies remain in progress. The aim of this present article is to review the pertinent literature, describing the advantages and limitations of new sphincter-preserving techniques.

Treatment of peri-anal fistula in Crohn's disease

Anal fistulas are a common manifestation of Crohn’s disease (CD). The first manifestation of the disease is often in the peri-anal region, which can occur years before a diagnosis, particularly in CD affecting the colon and rectum. The treatment of peri-anal fistulas is difficult and always multidisciplinary. The European guidelines recommend combined surgical and medical treatment with biologic drugs to achieve best results. Several different surgical techniques are currently employed. However, at the moment, none of these techniques appear superior to the others in terms of healing rate. Surgery is always indicated to treat symptomatic, simple, low intersphincteric fistulas refractory to medical therapy and those causing disabling symptoms. Utmost attention should be paid to correcting the balance between eradication of the fistula and the preservation of fecal continence.

Salvage irrigation-suction in gracilis muscle repair of complex rectovaginal and rectourethral fistulas

AIM: To evaluate the efficacy of gracilis muscle transposition and postoperative salvage irrigation-suction in the treatment of complex rectovaginal fistulas (RVFs) and rectourethral fistulas (RUFs).

METHODS: Between May 2009 and March 2012, 11 female patients with complex RVFs and 8 male patients with RUFs were prospectively enrolled. Gracilis muscle transposition was undertaken in all patients and postoperative wound irrigation-suction was performed in patients with early leakage. Efficacy was assessed in terms of the success rate and surgical complications. SF-36 quality of life (QOL) scores and Wexner fecal incontinence scores were compared before and after surgery.

RESULTS: The fistulas healed in 14 patients after gracilis muscle transposition; the initial healing rate was 73.7%. Postoperative leakage occurred and continuous irrigation-suction of wounds was undertaken in 5 patients: 4 healed and 1 failed, and postoperative fecal diversions were performed for the patient whose treatment failed. At a median follow-up of 17 mo, the overall healing rate was 94.7%. Postoperative complications occurred in 4 cases. Significant improvement was observed in the quality outcomes framework scores (P < 0.001) and Wexner fecal incontinence scores (P = 0.002) after the successful healing of complex RVFs or RUFs. There was no significant difference in SF-36 QOL scores between the initial healing group and irrigation-suction-assisted healing group.

CONCLUSION: Gracilis muscle transposition and postoperative salvage wound irrigation-suction gained a high success rate in the treatment of complex RVFs and RUFs. QOL and fecal incontinence were significantly improved after the successful healing of RVFs and RUFs.

[The ethiology, pathogenesis, diagnostics and clinical features of the complicated posttraumatic rectal fistulae]

The ethiology, pathogenesis, diagnostics, clinical features and the capabilities of modern instrumental methods in the diagnosis of 134 patients with posttraumatic rectal fistulaes. The main causes of the rectal fistulae formation was the mechanism of the forecoming trauma, late hospital admission and postoperative complications. The use of modern diagnostic facilities allows to know the anatomic features of the fistulae, the presence of the septic cavities of the pararectal tissue, the involvement of sphincter muscles to the inflammatory process and their functional state. All the listed above facilitate the efficacy of the surgical treatment.

[Results of one-stage reconstruction of anal sphincter in surgical treatment of fistulas-in-ano combined with fecal incontinence]

The investigation included 20 patients. Mean index of the severity of incontinence before operation by the Wexner scale was 9.3+/-2.4 scores. After radical dissection of the fistula and sphincter plasty in 7 patients (the first group) the wound of the rectum mucosa was sutured in longitudinal direction, in 13 patients (the second group) the rectum wall graft was brought down to the edge of the created anal canal. Uncomplicated post-operative period was noted in 15 (75%) patients. Suppuration of the wound developed in 3 (42.9%) patients of the first group and in 2 (15.3%) patients of the second group. The index of incontinence severity decreased to 2.4+/-1.1% scores (reduction of 4.5 scores in the first group and 7.7 scores in the second group).

[Application of anocutaneous flap in surgical treatment of complex fistulas-in-ano]

The author makes an assessment of results of treatment of recurrent pararectal fistulas of extrasphincteric pararectal fistulas with liquidation of internal opening of the fistula using a combination of bringing down the mucous-muscular coat of the rectum and transfer of the anocutaneous island flap on the feeding pedicle from the subcutaneous fat. After operation the superficial inflammation of the wound of the perianal area was noted in 9 patients, primary wound healing at the place of connection of the cutaneous and mucous-muscular flap was observed in 28 patients. Recurrent fistula was noted in 2 patients, one of them having Crohn's disease. The holding function of the rectum sphincter apparatus after operation was saved.

Myocutaneous flaps and proctocolectomy in severe perianal Crohn's disease--a single stage procedure

BACKGROUND

Complex perianal wounds can be extremely difficult to treat and primary closure of these defects can be a challenge even for experienced surgeons. So far, myocutaneous flaps for wound closure after removal of malignant tumors are a well-accepted option, but there are only a few reports focusing on the primary closure of the perineal wound after proctocolectomy for Crohn's disease. We describe our experience with wide excision of the diseased perineum using a combined abdominoperineal two-team approach.

MATERIALS AND METHODS

We performed proctocolectomy with permanent ileostomy in five patients with longstanding extensive Crohn's disease. All five patients had fistulizing perineal Crohn's disease combined with Crohn's colitis. Each patient received at least one flap for primary wound closure, either a rectus abdominis myocutaneous flap or a gracilis flap.

RESULTS

Indication for surgical intervention included anal or bowel stenosis, septic condition, fecal incontinence, or a combination of these features. One patient had a simultaneous adenocarcinoma of the sigmoid colon. Five patients underwent a total of seven flaps. Three months after surgery, complete healing was achieved in all patients; one patient suffered recurrence in the region of his right thigh. Mean follow up was 19.6 months (range-12-43 months).

CONCLUSIONS

Myocutaneous flaps are a promising therapeutic option in patients with chronic perianal disease. With the transposition of well-vascularized tissue into the perineal defect, complete healing and control of sepsis can be achieved in the majority of patients.

Factors affecting continence after fistulotomy for intersphincteric fistula-in-ano

BACKGROUND AND AIMS

This study was undertaken to determine the incidence of and risk factors for anal incontinence after fistulotomy for intersphincteric fistula-in-ano. We also evaluated the role of anal manometry in preoperative assessment of intersphincteric fistula.

MATERIALS AND METHODS

A prospective, observational study was undertaken in 148 patients who underwent fistulotomy for intersphincteric fistula between January and December 2004. Functional results were assessed by standard questionnaire and anal manometry. Possible factors predicting postoperative incontinence were examined by univariate and multivariate regression analyses.

RESULTS

The mean follow-up period was 12 months. Postoperative anal incontinence occurred in 30 patients (20.3%), i.e., soiling in 6, incontinence for flatus in 27, and incontinence for liquid stool in 4. Fistulotomy significantly decreased maximum resting pressure (85.9 +/- 20.4 to 60.2 +/- 18.4 mmHg, P < 0.0001) and length of the high pressure zone (3.92 +/- 0.69 to 3.82 +/- 0.77 cm, P = 0.035), but it did not affect voluntary contraction pressure (164.7 +/- 85.2 to 160.3 +/- 84.8 mmHg, P = 0.2792). Multivariate analysis showed low voluntary contraction pressure and multiple previous drainage surgeries to be independent risk factors for postoperative incontinence.

CONCLUSION

Fistulotomy produces a satisfactory outcome in terms of eradicating sepsis and preserving function in the vast majority of patients with intersphincteric fistula with intact sphincters. However, sphincter-preserving treatment may be advocated for patients with low preoperative voluntary contraction pressure or those who have undergone multiple drainage surgeries. Preoperative anal manometry is useful in determining the proper surgical procedure.

Non-sphincter splitting fistulectomy vs conventional fistulotomy for high trans-sphincteric fistula-in-ano: a prospective functional and manometric study

PURPOSE

This study compared the clinical and physiological results of non-sphincter splitting fistulectomy (N-SSF) with those of sphincter splitting fistulotomy (SSF) for treatment of high trans-sphincteric fistula-in-ano.

MATERIALS AND METHODS

A prospective, observational study was undertaken in 70 consecutive patients with high trans-sphincteric fistula treated by SSF (n = 35) or N-SSF (n = 35). Anal manometry was performed before and 3 months after surgery. Anal continence was assessed using the Cleveland Clinic Florida Incontinence Score.

RESULTS

There was no difference between the two groups in age, gender, presence of horseshoe extension, preoperative incontinence score and manometric values. The incidence of recurrence was similar between the two groups. The postoperative incontinence score of the SSF group was significantly higher than that of the N-SSF group (1.9 +/- 2.9 vs 1.1 +/- 2.9, P = 0.0347). Maximum resting pressure showed significant decrease after surgery in both groups (83.2 to 56.1 mmHg, P = 0.0001 and 85.1 to 58.4 mmHg, P = 0.0001). Voluntary contraction pressure and functional anal canal length did not change after N-SSF (137.6 to 138.2 mmHg, P = 0.9524 and 4.06 to 4.07 cm, P = 0.9524), but significantly decreased after SSF (120.2 to 96.7 mmHg, P = 0.0085 and 4.12 to 3.74 cm, P = 0.0183).

CONCLUSION

Non-sphincter splitting fistulectomy for high trans-sphincteric fistula provided better functional results than fistulotomy. Less impairment of anal continence was achieved possibly not only by maintenance of the external anal sphincter function but also by preservation of the length of the high-pressure zone.

Clinical and manometric results of endorectal advancement flaps for complex anal fistula

BACKGROUNDS AND AIM

Endorectal advancement flap repair is a well-recognized method for the treatment of complex anorectal fistula. The purpose of this study was to prospectively assess the clinical and functional results of endorectal advancement flaps for complex anorectal fistula and to identify factors that affect outcome.

MATERIALS AND METHODS

A prospective study of 56 patients was performed. Clinical and functional results were studied using the Wexner continence scale and anal manometry before and after surgery. Factors associated with recurrence and incontinence were analyzed by univariate and multivariate regression analysis.

RESULTS

Sixty endorectal flaps were constructed in 56 patients. Mean age was 49 years (range 24-74). The fistula was of cryptoglandular origin in 91.1% cases. Mean follow-up was 43.8 months. The technique was repeated in four patients because of recurrence (7.1%), with subsequent healing in all cases. There were significant reductions in maximum resting pressure 3 months after surgery (83.6+/-33.2 vs 45.6+/-18.3, p<0.001) and maximum squeeze pressure (208.8+/-91.5 vs 169.5+/-75, p<0.001). Before surgery, five patients (8.9%) reported incontinence symptoms. After surgery, 78.6% patients had normal continence, seven patients (12.5%) complained of minor incontinence, and five (9%) had major continence disturbances. None of the variables studied (age, sex, previous fistula surgery, rectovaginal fistula, and Crohn's disease) affected the outcome of the procedure in multivariate analysis.

CONCLUSIONS

Endorectal advancement flap repair is an effective technique for complex anal fistula, with a low recurrence rate (7.1%). Patients (21.4%) reported disturbed anal continence. It is still not possible to identify factors that are predictive of failure or incontinence.

Prospective clinical and manometric study of fistulotomy with primary sphincter reconstruction in the management of recurrent complex fistula-in-ano

BACKGROUND AND AIMS

The aim of this study was to assess the results of fistulotomy with sphincter reconstruction in the management of recurrent complex fistula-in-ano in terms of recurrence and continence.

PATIENTS AND METHODS

Prospective study of 16 patients undergoing fistulotomy with sphincter reconstruction for recurrent complex fistula-in-ano was done. Preoperative and postoperative evaluation included physical examination, anal ultrasonography and anal manometry, with a 40-month follow-up. The Wexner Continence Grading Scale (0-20) was used to assess faecal continence.

RESULTS

Fistulas were classified as high transsphincteric in 13 patients (81.3%), suprasphincteric in 2 (12.5%) and extrasphincteric in 1 patient (6.2%). Four patients (25%) had recurred twice or more. Eight patients (50%) complained of varying degrees of prior faecal incontinence. Their mean score decreased from 8.5 to 1.875 after surgery, and all the patients improved except for one whose score remained the same. On anal manometry, the differences between continent and incontinent patients before surgery [maximum resting pressure (MRP) 86.3 vs 57.6 mmHg, maximum squeeze pressure (MSP) 196.5 vs 138.6 mmHg] decreased after surgery (MRP 81.9 vs 63.7 mmHg, MSP 179.8 vs 159.3 mmHg). In fully continent patients, both the clinical score and manometric values were quite similar after surgery. Two fully continent patients (25%) developed occasional flatus incontinence and soiling, scoring two and three points, respectively. One patient recurred (6.25%) 6 months after surgery.

CONCLUSION

Fistulotomy with sphincter reconstruction seems to be an effective resource in the management of recurrent complex fistula-in-ano. It improves both anal continence and manometric values in incontinent patients without compromising them in fully continent ones.

Randomized clinical and manometric study of advancement flap versus fistulotomy with sphincter reconstruction in the management of complex fistula-in-ano

BACKGROUND

The goal of this study was to compare the outcomes of advancement flap (AF) versus fistulotomy with sphincter reconstruction (FSR) for primary complex fistula-in-ano in terms of recurrence and anal function.

METHODS

A randomized clinical trial was conducted to compare AF with FSR. Preoperative and postoperative evaluation included physical examination, anal ultrasonography, and anal manometry, with a minimum follow-up period of 24 months. Anal continence was evaluated using the Wexner Continence Grading Scale (scale, 0-20).

RESULTS

Sixty patients were randomized to AF (group 1, N = 30) or FSR (group 2, N = 30). Three patients from group 1 and 2 patients from group 2 were excluded from the study because of active sepsis at surgery. Fistulas were classified as high transsphincteric in 44 patients (80%) and suprasphincteric in 11 patients (20%). Demographic and clinical features showed no differences between the 2 groups. The mean Wexner Continence Grading Scale did not vary significantly after surgery in either group, and there was no difference between the groups. On anal manometry there was a significant decrease in the maximum resting pressure after surgery in both groups, and in the maximum squeeze pressure in the AF group, but neither the maximum resting pressure nor the maximum squeeze pressure differed significantly between groups, either before or after surgery. Two fistulas from each group recurred after surgery (7.4% and 7.1%, respectively). The mean follow-up period was 36 months (range, 24-52 mo).

CONCLUSIONS

FSR compares with AF in terms of postoperative continence and recurrence. Anal continence and manometric values are not jeopardized in either technique.

[Transrectal ultrasonography by rotating feeler in the perianal fistulae/abscesses surgery. Anatomo-functional description]

INTRODUCTION

Anal fistula represents a big topically subject above all as regards the complex correlated surgical implications. The transectal ultrasonography (TUS) is the first help for a careful, cheep, poorly invasive diagnosis.

MATERIALS AND METHODS

From September 2002 to December 2003 we submitted TUS 53 patient with clinical diagnosis of perianal fistula abscesses and 27 patients, already subordinates to surgical intervention for perianal fistulae/abscesses, which only presented perianal pain without clear signs of perianal pathology (48 males and 15 females).

RESULTS

TUS diagnosis and surgical confirmation of abscess and/or anal fistulae in all the patients; in the 27 patients, in whom at clinician exam was not clear an abscess, it was diagnosed in 21 patients (6 positive-false).

DISCUSSION

The obtained data show the validity of this methodical diagnostics and its importance for a correct surgical management. The 7.2% of discovered positive-false (surgical response: scary tissue), they are to charge to the objective technical dfficulty with discriminating scary outcomes; in confirmation of that the datum that in all these cases the patients had already been submitted to previous ano-rectal surgery.

CONCLUSIONS

Surgery of the anal abscesses and fistulas, for effective being, must stay in balance between aggressiveness and safeguards surgery. Surgery, to be correct, cannot leave out of consideration TUS: a valid tool in the Pre-operatory diagnosis, but also in the Post-operatory phase to highlight possible recidivisms.

[Clinical research of thread-dragging through fistula method in treating patients with simple anorectal fistula]

OBJECTIVE

To evaluate the efficacy and safety of thread-dragging through fistula method in treating patients with simple anorectal fistula.

METHODS

In this multi-centered, prospective, and randomized controlled clinical trial, 244 patients with simple low or high anorectal fistula were randomly divided into study group (with the method of thread-dragging through fistula) and control group (with the method of incision or thread-drawing). The healing time and curative rate of anorectal fistula, and the integral calculus of clinical symptom and life quality evaluations before and after treatment were all examined. The maximal anal canal squeeze pressure was measured to compare the therapeutic safety between these two groups. The health economical benefits were also assessed to determine which therapeutic method was more economical.

RESULTS

The curative rate of simple low and high anorectal fistula were of no significant differences between the study group and the control group. The healing time of simple low anorectal fistula in the study group and the control group were (22.26+/-8.67) d and (31.41+/-11.39) d respectively, while the healing time of simple high anorectal fistula in the study group and the control group were (24.73+/-8.15) d and (32.20+/-12.60) d respectively, and there revealed significant differences between these two groups. Each integral calculus of clinical symptom evaluation in the study group was not obviously different from those in the control group besides the integral calculus of anal sphincter function. The integral calculus of life quality between the study group and the control group of simple low anorectal fistula had no significant differences. The integral calculus of anal sphincter function and confidence in treatment in the study group of high anorectal fistula were better than those in the control group. The hospitalization expense of the study group was remarkably lower than that of the control group. The maximal anal canal squeeze pressure in the study group after treatment was not reduced obviously as compared with that in the same group before treatment, while it was decreased significantly in the control group after treatment as compared with those in the same group before treatment and in the study group after treatment.

CONCLUSION

The method of thread-dragging through fistula in treating simple low and high anorectal fistula can shorten the course of the disease, save the hospitalization expenses, improve the life quality of the patients, and protect the anal sphincter function.

Smoking impairs rectal mucosal bloodflow--a pilot study: possible implications for transanal advancement flap repair

Transanal advancement flap repair has been advocated as the treatment of choice for trans-sphincteric perianal fistulas, because it enables the healing of almost all fistulas without sphincter damage and consequent continence disturbance. After initial promising reports, recently less favorable results have been reported. It remains unclear why there is such a large variety in the reported healing rates. Recently, it has been suggested that impaired wound healing caused by a diminished rectal mucosal perfusion in patients who smoke may lead to the breakdown of the advancement flap in patients undergoing flap repair for perianal fistulas. This study was designed to investigate the difference in blood flow in rectal mucosa between patients who smoke and those who do not smoke. Furthermore, we assessed the impact of the creation of a mucosa advancement flap and the difference in blood flow in the flap between smoking and nonsmoking patients. Between July 2001 and July 2002, 23 consecutive patients (19 males; median age, 46 (range, 26-69) years) with a perianal fistula of cryptoglandular origin underwent surgery for a perianal fistula. Among them were 13 patients who smoked cigarettes. All patients underwent intraoperative laser Doppler flowmetry. Median blood flow before transanal advancement flap repair was 35 (range, 8-70) volts in patients who did not smoke. In patients who smoked the median blood flow before transanal advancement flap repair was 18 (range, 7-35) volts. Blood flow was significantly lower in patients who smoked (P = 0.018; Mann-Whitney). In conclusion, it seems likely that impaired wound healing caused by a diminished rectal mucosal perfusion is a contributing factor in the breakdown of advancement flaps in patients who smoke cigarettes.

Fistulotomy with Primary Sphincter Reconstruction in the Management of Complex Fistula-in-Ano: Prospective Study of Clinical and Manometric Results

BACKGROUND

Complex fistula-in-ano is a frequent source of concern for both patients and surgeons, because of its high rate of recurrence and postoperative anal incontinence. The objective of this study was to assess the results of fistulotomy with sphincter reconstruction in terms of recurrence and anal function.

STUDY DESIGN

We conducted a prospective study of 35 patients undergoing fistulotomy with sphincter reconstruction for complex fistula-in-ano. Preoperative and postoperative evaluation included physical examination, anal ultrasonography, and anal manometry, with a 32-month followup. Fecal continence was assessed using the Wexner Continence Grading Scale (0 to 20).

RESULTS

Fistulas were classified as high trans-sphincteric in 30 patients (85.7%), suprasphincteric in 4 patients (11.4%), and extrasphincteric in 1 patient (2.9%). Eleven patients (31.4%) reported varying degrees of earlier fecal incontinence. Their mean continence scores decreased from 7.2 to 2.0 (p=0.008) after operation, and all patients improved except for 2, whose scores remained unchanged. On anal manometry, there were significant differences between continent and incontinent patients before operation (maximum resting pressure: 89.2 versus 65.5 mmHg, p=0.013; maximum squeeze pressure: 203.6 versus 148 mmHg, p=0.008) that disappeared after operation (maximum resting pressure: 81.9 versus 70.6 mmHg, p=0.21; maximum squeeze pressure: 199.1 versus 154.8 mmHg, p=0.052). There were neither clinical nor manometric differences between pre- and postoperative values in fully continent patients, although 3 patients (12.5%) reported minor alterations of continence (Wexner<4). Two female patients had recurrences (5.7%), 3 and 6 months after operation, respectively.

CONCLUSIONS

Fistulotomy with sphincter reconstruction is an effective resource in the management of complex fistula-in-ano. It improves both anal continence and manometric values in incontinent patients without compromising them in fully continent ones.

Acquired rectal fistula in human immunodeficiency virus-positive children: a causal or casual relationship?

Acquired rectal fistula in human immunodeficiency virus (HIV)-positive children is a new and worrisome entity. The aim of this paper is to highlight the relationship between HIV infection and acquired rectal fistula (RF) in children in order to create awareness among clinicians who attend to children. Over a 1-year period, 11 girls aged 4 weeks-11 months (median 5 months) with acquired RF were managed at our institution. Ten were HIV-positive by enzyme-linked immunosorbent assay and confirmed by Western blot test. One child defaulted before the test. All the mothers and three fathers of the 10 children were seropositive for HIV. Bronchopneumonia, otitis media, oral thrush, diarrhoea, and lymphadenopathy were common associations. Treatment was essentially conservative because the result of surgical intervention was disappointing. Two of the infants and one of the fathers are now dead from full-blown acquired immunodeficiency syndrome. Acquired RF seems to be a sign of HIV infection in children. It will be necessary to screen any child presenting with acquired RF for HIV infection.

Treatment for horseshoe fistulas-in-ano with primary closure of the internal fistula opening: a clinical and manometric study

INTRODUCTION

We report on a patient cohort with dorsal horseshoe fistulas-in-ano. We sought to answer the question of whether these fistulas can be operatively treated, implementing a sphincter-preserving fistulectomy with primary closure of the internal opening, as is done when treating transsphincteric anal fistulas. Long-term clinical. course is examined here and operative methods are discussed.

METHODS

During the time period from 1985 to 2000, 42 patients (29 men, 13 women) with an average age of 44 +/- 11 years were operatively treated for horseshoe fistulas-in-ano originating in cryptoglandular regions. Twenty patients originally had an abscess, which was surgically drained and then a seton was placed in the tract of the fistula. Later, a fistulectomy or curettage of the fistula tract with primary closure of the internal fistula opening was performed in all patients without severing the sphincter muscle. We implemented four different surgical techniques to facilitate this closure: the mucosa-submucosa advancement flap, the rectal wall advancement flap (part or full thickness), the anocutaneous advancement flap, and direct closure without any further mobilization. The follow-up averaged 58 months (1-14 years).

RESULTS

Thirty-seven of the 42 fistulas (88 percent) healed. In 31 patients, restitution occurred after the first operation, in 4 patients after the second operation and in 2 patients after the third operation. One patient developed a recurrence after the first operation and died from secondary causes before a second operation was performed. The other four patients were listed as unclear, because the time of observation was less than one year. The total recurrence rate of flap procedures is 23 percent (mucosa-submucosa advancement flap, 25 percent; rectal wall advancement flap, 35 percent; anocutaneous advancement flap, 25 percent; direct closure, 0 percent; not significant). Thirty-four (81 percent) of the 42 patients had previously been operatively treated on an average of three times. Twelve patients developed deficits in continence. Eight patients developed minor deficits, which included incontinence for flatus and problems with staining. Four patients became incontinent for liquid stools. There was a significant decrease in manometric resting pressure of 25 percent (from 123 +/- 40 cm H2O to 91 +/- 29 cm H2O) and in squeeze pressure of 21 percent (from 262 +/- 70 cm H2O to 207 +/- 66 cm H2O).

CONCLUSIONS

As in other high anal fistulas, horseshoe-shaped anal fistulas can be operatively treated implementing a fistulectomy combined with any of the above-mentioned forms of closure of the internal fistula opening, with good success rates and acceptable postoperative continence. Sufficient drainage of the retroanal region is of utmost importance. Through these measures, it is possible to avoid severing the sphincter muscle and to prevent an anal canal deformation (keyhole deformity).

The direct closure of the internal fistula opening without advancement flap for transsphincteric fistulas-in-ano

PURPOSE

The recommended closure techniques for transsphincteric fistulas demonstrate divergent results for postoperative continence and recurrence rates. An incontinence rate of 35 percent and a recurrence rate of up to 54 percent has been reported after transanal advancement techniques. The authors hypothesize that a direct closure of the internal fistula opening without tissue mobilization is easier to facilitate and generally leads to better clinical and functional results.

METHODS

A prospective, observational study between 1995 and 1999 was undertaken in 90 patients with transsphincteric fistulas. A direct closure of the internal fistula opening without a flap was performed in all patients. A three-layer, nonstaggered closure of mucosa, submucosa, internal, and external anal sphincters was performed. The follow-up time periods ranged from one-half to six (median, 2.6) years and included assessment of fistula recurrence and continence using patients' histories, physical examinations, proctoscopy, and continence scores. Statistical analysis was performed using Student's t-test or chi-squared test.

RESULTS

Data from 90 patients with a total of 106 operations were analyzed (65 males and 41 females; average age 46 (range, 22-78) years). Sixty-six patients had previous anorectal abscess surgery, and 41 had a previous fistula operation. The mean number of previous fistula operations was 1.7. All patients were continent before surgery. Mean elapsed operative time period was 37 +/- 11 minutes, and the mean anal retraction time was 20 +/- 7 minutes. Suture line dehiscence was the main postoperative complication. It was found to occur between the fourth and tenth postoperative days in 15 patients (14 percent). In 12 of 15 patients (80 percent), the fistula persisted and operative treatment was necessary. In three patients (20 percent), spontaneous closure took place. A recurrent fistula after wound healing was observed in seven patients (6.6 percent). The risk of developing a suture line dehiscence leading to a persistent fistula or a recurrent fistula was 22.5 percent. Ninety-four percent of the patients were continent (continence score 0), 6 percent had a minimal disorder of continence (score 4). A continence level for all patients was determined by the international classification of continence disorders.

CONCLUSIONS

Direct closure for the treatment of transsphincteric fistulas is a safe and effective approach and achieves a good functional outcome; a small risk of suture line dehiscence, which may lead to a recurrent or persistent fistula, remains.

Increased anal resting pressure and rectal sensitivity in Crohn's disease

PURPOSE

Anal pathology occurs in 20 to 80 percent of patients with Crohn's disease in which abscesses, fistulas, and fissures account for considerable morbidity. The etiology is not clearly defined, but altered anorectal pressures may play a role. This study was designed to investigate anorectal physiologic conditions in patients with Crohn's disease compared with healthy controls.

METHODS

Twenty patients with Crohn's disease located in the ileum (n = 9) or the colon (n = 11) without macroscopic proctitis or perianal disease were included. All were subjected to rectal examination, anorectal manometry, manovolumetry, and rectoscopy. Comparison was made with a reference group of 173 healthy controls of whom 128 underwent anorectal manometry, 29 manovolumetry, and 16 both examinations.

RESULTS

Maximum resting pressure and resting pressure area were higher in patients than in controls (P = 0.017 and P = 0.011, respectively), whereas maximum squeeze pressure and squeeze pressure area were similar. Rectal sensitivity was increased in patients expressed as lower values both for volume and pressure for urge (P = 0.013 and P = 0.014, respectively) as well as maximum tolerable pressure (P = 0.025).

CONCLUSIONS

This study demonstrates how patients with Crohn's disease without macroscopic proctitis have increased anal pressures in conjunction with increased rectal sensitivity. This may contribute to later development of anal pathology, because increased intra-anal pressures may compromise anal circulation, causing fissures, and also discharging of fecal matter into the perirectal tracts, which may have a role in infection and fistula development.

Efficacy of fibrin sealant in the management of complex anal fistula: a prospective trial

PURPOSE

A prospective trial was conducted to establish long-term healing of complex idiopathic anorectal fistula, without extension, after fibrin glue treatment, with clinical assessment and magnetic resonance imaging to determine tract healing.

METHODS

Twenty-two patients undergoing glue instillation after fistula curettage and irrigation were followed up for a median of 14 months. Clinical assessment, short tau inversion recovery sequence magnetic resonance imaging, and combined short tau inversion recovery and dynamic contrast-enhanced magnetic resonance imaging were performed at a median of three months postoperatively, and their ability to predict outcome in the presence of early skin healing was determined.

RESULTS

Of 22 patients, 19 (86.5 percent) had transsphincteric fistulas, 1 (4.5 percent) had a suprasphincteric fistula, 1 (4.5 percent) had an extrasphincteric fistula, and 1 (4.5 percent) had a rectovaginal fistula. None had clinical or radiologic evidence of secondary extension. Despite skin healing in 17 (77 percent) of 22 patients at a median of 14 days after treatment, only 3 (14 percent) remained healed at 16 months. Magnetic resonance imaging with short tau inversion recovery sequences in combination with dynamic contrast-enhanced magnetic resonance imaging predicted outcome in all 10 assessments (100 percent), compared with short tau inversion recovery sequence alone in 16 (94 percent) of 17 assessments or clinical examination in 12 (71 percent) of 17 (P = 0.02).

CONCLUSIONS

The success rate of fibrin glue application for complex anorectal fistulas without extension is 14 percent. Magnetic resonance imaging predicts outcome at an earlier stage than clinical examination.

Long-term results of seton drainage on complex anal fistulae in patients with Crohn's disease

BACKGROUND

The aim of this study was to assess the long-term (greater than 2 years) results of seton drainage on anal fistulae in patients with Crohn's disease.

METHODS

Between September 1990 and September 1999, 32 patients with Crohn's disease underwent seton drainage for complex anal fistulae. The median follow-up time in these patients was 62 months (range, 25-133 months). In 10 patients (31.3%), recurrent perineal abscesses occurred with inlying seton drainage, and these were drained by re-insertion of the seton. A Malecot catheter was also inserted in 8 patients with recurrence.

RESULTS

The overall success rate of long-term seton usage was 87.5%. The subsequent associated procedure was simple seton removal ( n = 9), secondary core-out fistulectomy ( n = 7), or lay-open fistulotomy ( n = 4). Eleven patients still had the seton in place. Recurrence developed in 3 patients (33%) who underwent simple seton removal and in 2 patients (18.2%) who underwent the secondary core-out procedure or fistulotomy. At the last follow-up examination, continence had not changed in 28 (87.5%) of the 32 patients. No change in continence was experienced by 10 of the 11 patients who underwent secondary fistulotomy or the secondary core-out procedure.

CONCLUSIONS

Long-term seton drainage for complex anal fistula in Crohn's disease is efficacious in both treating sepsis and preserving anal sphincter function. A relatively good result was achieved by the secondary core-out procedure or fistulotomy at the time of seton removal.

Change in anal continence after surgery for intersphincteral anal fistula: a functional and manometric study

BACKGROUND AND AIMS

Dividing or "laying open" of the tract for intersphincteral type anal fistula is simple and effective and entails low risk of complication, but little is known of the functional and manometric results. This study assessed the clinical and manometric effect of this surgery on anal sphincter function.

PATIENTS AND METHODS

The study examined 45 adults undergoing surgical treatment for intersphincteral fistula. We administered the questionnaire for continence score and performed anorectal manometry before the operation and at least 6 months after the operation. The operative method was laying open of the fistula tract and trimming the redundant anoderm for adequate drainage of the wound in all cases.

RESULTS

There was a significant decrease in maximal resting anal pressure and in resting pressure throughout the distal 2 cm of the anal canal after operation. The maximal contractile pressure after operation was similar to that before operation. Continence control was significantly poorer in women and patients who had lower preoperative resting pressure. Multivariate analysis showed lower preoperative resting pressure to be the only independent factor for impaired continence control after fistula surgery.

CONCLUSION

Although laying open of the fistula tract is a simple and effective therapy for intersphincteral type anal fistula, it should be more conservative for patients with low resting anal pressure.

[Anal fistulae and abscesses: diagnostic and therapeutic aspects, excepting Crohn's disease]

Anal fistulae are an often neglected and underevaluated disease. They are painful and invalidating. Surgeons must be aware of the pathophysiological aspects to achieve successful treatment. The anatomical classification is established to better understand anal anatomy and physiology of anal abscessess and fistulae. The Diagnosis of a perianal abscess is usually easy except in case of deep abscess. Clinical signs of chronic fisula may be misleading. Modern imaging (MRI and endoscopic ultrasonography) may be useful to detail the fistular anatomy in difficult cases. Several operative procedures have been proposed to treat anal fistulae and abscesses. Besides old procedures such as fistulotomy, cutting or draining, seton, we can also mention recently proposed preservative sphincter surgery. This new concept is believed to improve wound healing and decrease functional deficiency. Particularly, the rectal flap seems to be attractive but its superiority has not been proven with a randomized trial. So far, our preference goes to the well-known procedures such as prolonged seton drainage and/or slow cutting seton.

Ileo-rectal fistula complicating advanced ovarian carcinoma

Fistula between the bowels and an ovarian carcinoma is recognized but rare complication. Internal malignant fistula of the gastrointestinal tract involving two or more loops of different segments of the bowel and genitourinary structure are rare. The colon is frequently one of the participating loops. In reviewing the literature, however, we were unable to find a previous report of ileo-rectal fistula as a complication of an ovarian carcinoma. A case report and review of the English medical literature are presented with emphasis on the cause, clinical presentation, and management of advanced ovarian cancer with ileo-rectal involvement.

Laser ablation of complex perianal fistulas preserves continence and is a rectum-sparing alternative in Crohn's disease patients

A 20-year review of the inflammatory bowel disease surgical database of the author was analyzed for Crohn's disease (CD) patients who had a surgical approach to perianal fistula disease (PAD). Of 333 patients with CD operated between July 1977 and February 1997, 51 had procedures for PAD (15.3%), and 7 of these patients had laser ablation of severe, debilitating complex PAD (13.7%). These patients have traditionally been treated by diverting ileostomy or proctectomy with permanent diversion. Others have advocated conservative management with long-term antibiotics, staged operations, and insertion of multiple loose setons to promote drainage. This technique was adapted from the laser procedure now advocated for severe hydradenitis suppurativa. The hand-held CO2 laser was used to unroof all fistulas external to the external sphincter. Fistulas were identified by probing. Infected granulation tissue was removed by laser ablation until normal fat or muscle was revealed. Intersphincteric abscesses were unroofed, and a single seton was placed around the external sphincter for all but submucous fistulas. Patients were usually operated as outpatients with pain control effected with oral and transnasal agents. A laparoscopically performed temporary diverting ileostomy was used in one early patient in the series. Patients were followed, and progress was documented by physical examination and photographs. Quality of life was assessed. All patients improved remarkably from their preoperative state. The 4 patients in the group operated more than 1 year before this review have all demonstrated complete healing. The three more recent patients are in various stages of healing. Continence was preserved in 7 of 7 patients. No patient has required rectal excision. Recurrence thought to be related to associated hydradenitis has occurred in 1 patient. Laser ablation is a valuable technique in the management of patients with severe, debilitating complex PAD complicating CD. It effectively eradicates the septic tracks and pockets while preserving sphincter function. It obviates the need for diversion with or without proctectomy.

Functional results after transanal rectal advancement flap repair of trans-sphincteric fistula

BACKGROUND

Transanal rectal advancement flap repair is an operation to treat trans-sphincteric fistula which leaves the external sphincter muscle essentially untouched. Anal sphincter function was evaluated prospectively before and after this procedure.

METHODS

Anorectal manometry was performed in 24 patients before operation and 3 months after surgery. A detailed standardized questionnaire on faecal continence was answered before surgery, then at 3 and 48 months after surgery.

RESULTS

No significant differences were seen between mean(s.e.m.) preoperative and postoperative values for maximum squeeze pressure (100.0(9.7) versus 118.0(12.7) mmHg), maximum resting pressure (56.6(4.3) versus 52.8(4.1) mmHg), rectal compliance (4.4(0.6) versus 3.5(0.5) ml/mmHg) or any other parameter of anorectal manometry. The questionnaire revealed the occurrence of minor incontinence in two patients following surgery, which remained unchanged for 4 years. Three other patients had continence disturbances 4 years after surgery which were probably unrelated to the procedure.

CONCLUSION

In addition to high success rates, transanal rectal advancement flap repair also yields excellent functional results. This procedure should be performed for trans-sphincteric fistula in place of alternative treatments whenever feasible.

Cutting seton versus two-stage seton fistulotomy in the surgical management of high anal fistula

BACKGROUND

The aim of this study was to compare the clinical results obtained with the cutting seton and the two-stage seton fistulotomy (TSSF) in the surgical management of high anal fistula.

METHODS

The case records of 59 patients with high anal fistula of cryptoglandular origin treated with cutting seton (n = 12) or TSSF (n = 47) over a 5-year period were retrospectively reviewed. There was no difference between the groups in age, sex distribution, or estimated percentage of anal sphincter involved by the fistula. Follow-up was by a mailed questionnaire inquiring about fistula recurrence, incontinence, and degree of satisfaction. Mean follow-up was similar in both groups (27 months for cutting seton versus 33 months for TSSF). Comparisons were made by Student t and chi 2 tests, as required.

RESULTS

There were no differences in the rate of fistula recurrence between the groups treated with cutting seton or TSSF (one of 12 versus four of 47), difficulty holding gas (six of 12 versus 25 of 47), underwear staining (six of 12 versus 18 of 47), stool incontinence (three of 12 versus 12 of 27), overall incontinence (eight of 12 versus 31 of 47) and mean incontinence score (4.9 versus 4.2). The fistula healing time and degree of satisfaction with the operation were not significantly different between the groups. One-half of the patients treated by TSSF had the seton removed under general or epidural anaesthesia.

CONCLUSION

Both techniques are equally effective in eradicating the fistula, and both are associated with a similar rate of incontinence.

Healing after anal fistulotomy: comparative study between HIV+ and HIV- patients

PURPOSE

The aim of this work was to compare wound-healing after anal fistulotomy in human immunodeficiency virus (HIV)+ and HIV- patients and to recognize healing parameters in HIV+ patients.

METHODS

Sixty patients were treated with fistulotomy for intersphincteric anal fistula. For each patient, we evaluated white blood cell count values, T CD4 counts, Centers for Disease Control and Prevention classification, and healing duration. There were 31 HIV+ patients (7 A2; 1 A3; 7 C1; 6 C2; 10 C3).

RESULTS

Seven C3 patients had incomplete healing. Statistically, there was no difference in the healing duration in HIV+ A2, C1, C2, and HIV-negative patients. C3 patients who did heal took longer than other HIV+ patients. T CD4 counts were similar to healed and not healed C3 patients, although healed C3 values of white blood cell counts were higher than not healed C3 values (4,450 and 2,380/mm3).

CONCLUSION

After anal fistulotomy, HIV+ C3 patients either had retarded healing or no healing at all. Therefore, we feel that surgery should be done only in emergency cases of anorectal diseases or in patients with more than 3,000 white blood cells/mm3.

Randomized controlled trial of primary fistulotomy with drainage alone for perianal abscesses

PURPOSE

Primary fistulotomy may be advantageous for perianal abscesses because unlike ischiorectal abscesses, fistulas are more commonly found and can be laid open with full preservation of the external anal sphincters. Therefore, a randomized, controlled trial was conducted to compare primary fistulotomy with incision and drainage alone, specifically for perianal abscesses.

METHODS

Fifty-two consecutive patients (43 males; mean age, 40 (standard error of mean, 2) years) with perianal abscesses were randomized to treatment by either incision and drainage (controls; N = 28) or fistulotomy (N = 24). Patients were followed up clinically for a mean of 15.5 (standard error of the mean, 0.7) months. Anorectal manometry was also performed before, six weeks, and three months after surgery.

RESULTS

Persistent fistulas developing after surgery were significantly more common after incision and drainage (N = 7; 25 percent) than after fistulotomy (N = 0; P = 0.009). One patient in each group was also found to have a residual abscess, which required repeat drainage. All patients remained fully continent. The anal pressures after incision and drainage and fistulotomy were not significantly different. Operative time, hospital stay, and time for the wound to heal completely were the same in both groups.

CONCLUSIONS

Primary fistulotomy at the time of drainage for perianal abscesses results in fewer persistent fistulas and no added risk of fecal incontinence.

Cutting seton for anal fistulas: high risk of minor control defects

PURPOSE

Long-term results of cutting seton in the treatment of anal fistulas were studied.

METHODS

Of the 44 patients with anal fistulas, mainly of the high variety, managed with this method, 35 (25 men) attended a clinical and manometric follow-up examination on average 70 (range, 28-184) months after operation. Fistula distribution was high transsphincteric (25), low transsphincteric (5), extrasphincteric (3), and suprasphincteric (2). The seton was tightened at one-week to two-week intervals to achieve gradual sphincter division.

RESULTS

Time required to achieve complete fistula healing ranged from 37 to 557 (mean, 151) days. Two (6 percent) of the 35 patients re-examined had recurrence of fistula and 22 (63 percent) reported symptoms of minor impairment in anal control, which in four patients had existed already before operation. Anal resting pressures were similar for defective and normal control, but other manometric variables were inferior in incontinence, although total squeeze pressure only showed statistically significant difference from normal continence (P = 0.0345). Incontinence was likely associated with hard and gutter-shaped operation scars in the anal canal, but the difference from normal continence was not statistically significant.

CONCLUSION

Cutting seton yields fairly good results in regard to cure of fistula, but the risk of anal incontinence, despite its minor degree, seems to be too high to recommend its routine use for all high fistulas. The suprasphincteric fistulas and some extrasphincteric fistulas are difficult to treat otherwise, but especially for high transsphincteric fistulas, other methods of treatment (preferably those in which sphincter division can be avoided and the risk of anal canal deformity and incontinence are minimized) are advocated.

Urologic problems in anorectal malformations. Part 2: functional urologic sequelae

A consecutive series of 90 children with anorectal malformations was reviewed for urologic problems related to lower urinary tract dysfunction. Neurogenic bladder-sphincter dysfunction was seen in 22 patients (24%), all but one of whom had sacral agenesis. Vesicoureteral reflux was present in 60% of the patients with dysfunction, and 32% had reflux nephropathy. Urinary incontinence was present in 91% of the patients who had bladder-sphincter dysfunction. However, the management of bladder-sphincter dysfunction and urinary incontinence was not as straightforward as for patients with myelodysplasia because the parents were more reluctant to accept the therapeutic measures. It was particularly difficult to introduce clean intermittent catheterization (CIC), especially in older patients, because genital and urethral sensation often was undisturbed. Only if CIC had been started in the neonatal period or early infancy were there no problems with acceptance and parental compliance. The authors emphasize the importance of urodynamic testing of neonates and infants who have an anorectal malformation and associated sacral agenesis in identifying those who have neurogenic bladder-sphincter dysfunction. Consequently, patients with lower urinary tract dysfunction should receive prompt treatment, including CIC if necessary, to prevent or reduce secondary urologic morbidity, especially loss of renal function.

The rectoanal relaxation reflex and continence in repaired anorectal malformations with and without an internal sphincter-saving procedure

From 1985 to 1994, 27 patients with high- or intermediate type imperforate anus who underwent anorectoplasty were studied for postoperative function, particularly with respect to the rectoanal relaxation reflex and continence. Fourteen of the patients had a rectourogenital fistula and were treated with posterior sagittal anorectoplasty using the fistular end as the neoanus (internal sphincter-saving). Nine patients had a blind rectal pouch and received posterior sagittal anorectoplasty using the trimmed bowel end for reconstruction of the neoanus (incomplete internal sphincter-saving). The other four had Rehbein's mucosa-stripping endorectal pull-through combined with anterior sagittal anorectoplasty (none internal sphincter-saving). A positive rectoanal relaxation reflex was found in 8 of 14 (57.1%), 7 of 9 (77.8%), and 3 of 4 (75%), respectively. It appears that the internal sphincter-saving procedure is not essential for the development of the rectoanal relaxation reflex. Compensation or adaptation most likely contributes to the presence of the rectoanal relaxation reflex, and perhaps to postoperative continence.

What is new in the treatment of perianal fistulae in Crohn's disease?

Perianal fistulae in Crohn's disease occur frequently and are the most difficult perianal manifestation of the disease to treat. The relation between the fistula and the sphincter apparatus and pelvic floor forms the basis for the surgical problems. Simple lower fistulae with regard to the anal sphincters can be treated as any other perianal fistula with a technique in which the fistulous tract is layed open with only a minor division of sphincter muscle. Complex high-situated fistulae require another treatment approach in order not to render the patient incontinent. Therefore, it is of prime importance to be informed about the nature of the fistula before operation. Magnetic resonance imaging seems to give all the information needed on complex fistulae that was not available previously. It allows a thorough surgical planning of the procedure in which all the fistulous tissue is removed with primary repair of the pelvic floor and sphincters if necessary. Our first results are promising.

Posterior sagittal anorectoplasty: functional results of primary and secondary operations in comparison to the pull-through method in anorectal malformations

BACKGROUND

Control of defaecation after surgical correction of high and intermediate types of congenital anorectal malformations is difficult. The posterior sagittal approach with careful reconstruction of the external sphincter is postulated to give a better outcome than the pull-through operation. The functional results of these procedures performed in one centre were evaluated in order to identify prognostic factors.

MATERIAL AND METHODS

Between 1979 and 1992 66 patients with high or intermediate congenital anorectal anomalies were treated in our centre. In 16 patients a pull-through operation (Kĩesewetter-Rehbein) was performed. After 1984, the posterior sagittal anorectoplasty (PSARP) (Peña and deVries) was used in 35 patients as the primary operation. In 22 patients a PSARP operation was done as a secondary procedure, in one third of these patients after a previous pull-through operation in our centre. The functional results were analysed in retrospect.

RESULTS

Sixty operations in 53 patients could be evaluated. The overall continence rate was 34%. After the pull-through operation six out of 15 patients (40%) were continent, after a primary PSARP 10 out of 25 (40%) and after a secondary PSARP operation five out of 20 patients (25%). Patients with a sacral defect were continent only in 16% as compared to 44% of the patients with a normal sacrum. Sex was also relevant: 67% of the girls were continent, compared to 30% of the boys. Ten out of 11 girls (90%) with a normal sacrum became continent.

CONCLUSION

The PSARP for high and intermediate anorectal malformations does not give better functional results than the pull-through operation. The prognosis is determined by other factors than the type of operation, notably sex and the presence or absence of sacral defects.

Clinical course after transanal advancement flap repair of perianal fistula in patients with Crohn's disease

A total of 36 rectal advancement flap repairs were performed in 32 patients with perianal Crohn's disease. There were 12 anovaginal and 20 trans-sphincteric fistulas. Patients were followed prospectively for a mean of 19.5 months to evaluate postoperative recurrence rate. The prognostic influence of fistula type, rectal disease, intestinal disease and faecal diversion on recurrence was assessed. Four of 36 repairs showed primary failure, the operated fistula recurred in 11 patients after a median of 7 months, and a new fistula developed in six patients. The fistula recurrence rate was higher in patients with anovaginal fistula or Crohn's colitis but did not correlate with disease activity. Transitory mild incontinence of stool was observed in one patient only. Although rectal advancement flap repair does not cure perianal fistulas in most patients with Crohn's disease, those without Crohn's colitis may have long-term benefit. Short-term improvement of symptoms justifies this simple procedure even in patients with anovaginal fistula.

Twenty-year review of the surgical management of perianal Crohn's disease

PURPOSE

A retrospective analysis of 48 patients treated over a 20-year period (March 1973-April 1993) was undertaken to assess the results of our practice of early surgical intervention in suppurative complications of perianal Crohn's disease.

METHODS

All patients were either seen in the office within the last six months or contacted by phone.

RESULTS

The average age of our patients was 30 years at initial diagnosis. Thirty-four patients (71 percent) initially presented with intestinal disease and four (8 percent) with only perianal disease. Thirteen patients (27 percent) initially presented with simultaneous intestinal and perianal disease. The various fistulas at initial presentation included 8 intersphincteric (17 percent), 14 transphincteric (29 percent), 11 complex or multiple (23 percent), 5 rectovaginal (10 percent), and 2 unclassified, for a total of 40 patients. Eight patients (17 percent) presented with only an abscess. Eighty five percent of our patients healed after their first procedure, with an average time to heal of 2.8 months. Thirteen (27 percent) patients had recurrences after initial healing of their wounds. The mean time to recurrence after healing was 5.25 years. Fifty-four percent of our recurrences (7 patients) were treated by incision and drainage of an abscess only. Seven of 13 recurrences healed after the second procedure (54 percent), and 5 of 6 healed after a third procedure (83 percent). Only seven (14 percent) of our patients underwent a proctocolectomy during the study period, through September, 1993. Our overall probability of avoiding proctectomy and healing perineal wounds of 86 percent is consistent with published literature.

CONCLUSIONS

Early aggressive surgical management of suppurative complications of perianal Crohn's disease before complex management problems ensue results in a high incidence of healing and a low risk of subsequent proctectomy.

Anorectal malformations

The posterior sagittal approach was used to treat 792 patients with anorectal malformations. From these, 387 cases were evaluated 6 months to 13 years later. Voluntary bowel movements were present in 74.3% of the entire series. When distributed by diagnosis, the percentages varied: 100% in patients with rectal atresia and perineal fistula; 93.2% in those with vestibular fistula; 80.9% in those with bulbar fistula; 71.1% in those with cloacas; 66.7% in those with prostatic fistula, and 15.8% in those with bladder-neck fistula. Soiling was present in 57% of all cases. Patients with voluntary bowel movements and no soiling were classified as totally continent; 40.8% of the series belong to this group. Distributed by diagnosis, it varied from 100% in cases with rectal atresia or perineal fistula, 65.9% in those with vestibular fistula, 34% in those with bulbar fistula, 31.6% in those with cloacas, 26.3% in those with prostatic fistula; none of the patients with vaginal fistula or bladder-neck fistula was totally continent. Constipation was detected in 43.1% of all patients, and was more frequent in those with simple defects. Urinary incontinence was found in 19% of patients with cloacas who had a common channel shorter than 3 cm, and in 68.8% of the patients who had longer common channels. Other patients suffered from urinary incontinence only when they had an absent sacrum or other severe bladder or urethral congenital defects. An accurate diagnosis and evaluation of the sacrum allows us to establish, with reasonable accuracy, functional prognosis in most children. Those with functional disorders must be treated properly medically, to improve their quality of life.

Clinical results and manometric studies after rectal flap advancement for infra-levator trans-sphincteric fistula-in-ano

Eleven patients with infra-levator trans-sphincteric fistula-in-ano underwent fistula excision with rectal flap advancement. The clinical results were assessed by interview and the physiological function determined by ano-rectal manometry. Nine patients underwent paired studies before and 5 (range 2 to 6) months after operation. Median maximum resting anal pressure was 84 (48-135) cm water before operation and 76 (29-139) cm water after operation (P = N.S.). Median maximum squeeze pressure was 112 (64-290) cm water before operation and 88 (44-316) cm water after operation (P = N.S.). The median sphincter length was preserved after operation. There was one clinical failure following the development of an abscess under the flap. All patients are continent and there have been no recurrences. We conclude that rectal flap advancement is an acceptable way to cure more complex fistula-in-ano. Good functional results are achieved by maintaining anal sphincter function together with preservation of the integrity of the anal margin.

Factors affecting continence after surgery for anal fistula

Anorectal physiology and continence were assessed prospectively before and after surgery in 50 patients with chronic perianal sepsis. Functional and physiological parameters were unchanged after surgery in 13 control patients who had sepsis but who did not undergo division of the anal sphincter. Group 1 comprised 22 patients with internal sphincter division alone (15 intersphincteric, seven trans-sphincteric treated by a loose seton technique) and group 2 consisted of 15 patients with a trans-sphincteric fistula laid completely open. In group 1 the median (interquartile range (i.q.r.)) resting pressure in the distal 1 cm of the anal canal was reduced from 68 (60-90) cmH2O before surgery to 44 (35-60) cmH2O after operation (P < 0.001); squeeze pressure was less affected, but function deteriorated in 11 of the 22 patients. The median (i.q.r.) resting pressure in group 2 patients also fell, from 68 (34-84) cmH2O before operation to 28 (20-54) cmH2O afterwards (P = 0.003); median (i.q.r.) maximum squeeze pressure decreased more, from 124 (76-170) cmH2O to 72 (48-112) cmH2O (P = 0.002). Functional deficit occurred in eight of the 15 patients. Incontinence was related to low resting pressure, reflecting internal sphincter integrity, and to local epithelial electrosensitivity (reflecting scarring), but not to squeeze pressure, fistula type or surgical treatment.

Treatment of high anal fistulae by primary occlusion of the internal ostium, drainage of the intersphincteric space, and mucosal advancement flap

In a prospective study on 224 patients with so-called high-fistula in ano (189 transsphincteric, 35 suprasphincteric) the long-term results of a sphincter-saving operation technique were assessed. The follow-up period was 1 to 7.5 years. This technique consists of one-stage fistulectomy as well as of drainage of the intersphincteric space by internal sphincterotomy. The site of the former primary orifice of the fistula is adapted by multiple peranally performed single stitches, including mucosal advancement flap distal to the original fistulous opening. Postoperatively, 24 cases of suture leakage occurred (9% with the transsphincteric and 20% with the suprasphincteric fistula). 27 patients developed late complications like fistula recurrences or combinations of fistula and anal abscess (10.7% with the transsphincteric and 19.9% with the suprasphincteric fistula). Anal manometry was carried out preoperatively as well as postoperatively. A significant decrease in the postoperative resting pressure compared to the preoperative value was determined. The two fistula groups differed statistically both with regard to the resting pressure and the contraction pressure. Significant impairment of continence developed in 21% of patients with transsphincteric fistula but in 43% of patients with suprasphincteric fistula (intermittent fecal spoiling/use of perineal pads). The total percentage of complications rose with the number of previous fistula operations.