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Hurtado-Lorenzo A, Swantek JL. The landscape of new therapeutic opportunities for IBD. ADVANCES IN PHARMACOLOGY (SAN DIEGO, CALIF.) 2024; 101:1-83. [PMID: 39521596 DOI: 10.1016/bs.apha.2024.10.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2024]
Abstract
This chapter presents an overview of the emerging strategies to address the unmet needs in the management of inflammatory bowel diseases (IBD). IBD poses significant challenges, as over half of patients experience disease progression despite interventions, leading to irreversible complications, and a substantial proportion do not respond to existing therapies, such as biologics. To overcome these limitations, we describe a diverse array of novel therapeutic approaches. In the area of immune homeostasis restoration, the focus is on targeting cytokine networks, leukocyte trafficking, novel immune pathways, and cell therapies involving regulatory T cells and mesenchymal stem cells (MSC). Recognizing the critical role of impaired intestinal barrier integrity in IBD, we highlight therapies aimed at restoring barrier function and promoting mucosal healing, such as those targeting cell proliferation, tight junctions, and lipid mediators. Addressing the challenges posed by fibrosis and fistulas, we describe emerging targets for reversing fibrosis like kinase and cytokine inhibitors and nuclear receptor agonists, as well as the potential of MSC for fistulas. The restoration of a healthy gut microbiome, through strategies like fecal microbiota transplantation, rationally defined bacterial consortia, and targeted antimicrobials, is also highlighted. We also describe innovative approaches to gut-targeted drug delivery to enhance efficacy and minimize side effects. Reinforcing these advancements is the critical role of precision medicine, which emphasizes the use of multiomics analysis for the discovery of biomarkers to enable personalized IBD care. Overall, the emerging landscape of therapeutic opportunities for IBD holds great potential to surpass the therapeutic ceiling of current treatments.
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Affiliation(s)
- Andrés Hurtado-Lorenzo
- Translational Research & IBD Ventures, Research Department, Crohn's & Colitis Foundation, New York, NY, United States.
| | - Jennifer L Swantek
- Translational Research & IBD Ventures, Research Department, Crohn's & Colitis Foundation, New York, NY, United States
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An Y, Gao J, Xu J, Qi W, Wang L, Tian M. Efficacy and safety of 13 surgical techniques for the treatment of complex anal fistula, non-Crohn CAF: a systematic review and network meta-analysis. Int J Surg 2024; 110:441-452. [PMID: 37737881 PMCID: PMC10793738 DOI: 10.1097/js9.0000000000000776] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Accepted: 09/09/2023] [Indexed: 09/23/2023]
Abstract
BACKGROUND Considering the difficulty of treating complex anal fistula (CAF), various surgical techniques exist in clinical work. However, none are ideal. Evidence on the efficacy and safety of different surgical treatments is scarce. The authors aimed to compare the outcomes of the 13 surgical techniques and tried to find the best surgical method for treating CAF. MATERIALS AND METHODS The authors searched worldwide databases, including Pubmed, Embase, Cochrane Library, Web of Science, CNKI, WanFang, VIP, and SinoMed, from inception to March 2023. All randomized controlled trials comparing the outcomes of 13 surgical techniques were included according to the PICO principles. The indicators of the cure rate, the recurrence rate, the complication rate, the operating time, the postoperative pain on day 1 (VAS), and the postoperative incontinence in month 1 (Wexner) were extracted and analyzed using STATA software 15.1, Review Manager 5.4, and GeMTC14.3. RESULTS Twenty-eight randomized controlled trials with a total of 2274 patients were included in the network meta-analysis. There was no statistically significant difference in the comparison among any surgical interventions in terms of the cure rate ( P >0.05 Table 2) and recurrence rate ( P >0.05 Table 3). However, in terms of complication rate, fistulectomy was lower than FPS (Median: 0.14; 95% CI: 0.02-0.70) or fistulotomy (Median: 0.09; 95% CI: 0.01-0.55), and fistulotomy was lower than EAFR (Median: 0.24; 95% CI: 0.05-0.84), LIFT (Median: 0.17; 95% CI: 0.02-0.66) or LIFT-EAFR (Median: 0.11; 95% CI: 0.01-0.69) ( P >0.05 Table 4). The surface estimated the advantages and disadvantages under the cumulative ranking (SUCRA). The ranking results indicated that fistulectomy might have the lowest complication rate (SUCRA=7.9%). Because the network results of the operating time, the postoperative pain, and the postoperative incontinence contained no closed loops, the results of their probability ranking could only be referenced, demonstrating that fistulectomy might have the shortest operating time (SUCRA=23.4%), video-assisted modified ligation of the intersphincteric fistula tract (VAMLIFT) might have the lowest postoperative pain on day 1 (VAS) (SUCRA=0.4%) and LIFT might have the lowest postoperative incontinence in month 1(Wexner) (SUCRA=16.2%). CONCLUSION Fistulectomy might have the lowest complication rate, which might be the relatively superior surgical technique for treating CAF.
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Affiliation(s)
- Yongkang An
- Graduate School, Hebei University of Chinese Medicine, Shijiazhuang
- The First Affiliated Hospital of Henan University of Traditional Chinese Medicine
| | - Jihua Gao
- Anorectal Department, The First Affiliated Hospital of Hebei University of Chinese Medicine
- Key Laboratory of Integrated Chinese Medicine and Western Medicine for Gastroenterology Research (Hebei), Shijiazhuang, People’s Republic of China
| | - Jiancheng Xu
- Anorectal Department, The First Affiliated Hospital of Hebei University of Chinese Medicine
| | - Wenyue Qi
- Graduate School, Hebei University of Chinese Medicine, Shijiazhuang
| | - Linyue Wang
- Graduate School, Hebei University of Chinese Medicine, Shijiazhuang
| | - Maosheng Tian
- Anorectal Department, The First Affiliated Hospital of Hebei University of Chinese Medicine
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Bhat S, Xu W, Varghese C, Dubey N, Wells CI, Harmston C, O'Grady G, Bissett IP, Lin AY. Efficacy of different surgical treatments for management of anal fistula: a network meta-analysis. Tech Coloproctol 2023; 27:827-845. [PMID: 37460830 PMCID: PMC10485107 DOI: 10.1007/s10151-023-02845-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Accepted: 07/06/2023] [Indexed: 09/09/2023]
Abstract
PURPOSE Currently, the anal fistula treatment which optimises healing and preserves bowel continence remains unclear. The aim of our study was to compare the relative efficacy of different surgical treatments for AF through a network meta-analysis. METHODS Systematic searches of MEDLINE, EMBASE and CENTRAL databases up to October 2022 identified randomised controlled trials (RCTs) comparing surgical treatments for anal fistulae. Fistulae were classified as simple (inter-sphincteric or low trans-sphincteric fistulae crossing less than 30% of the external anal sphincter (EAS)) and complex (high trans-sphincteric fistulae involving more than 30% of the EAS). Treatments evaluated in only one trial were excluded from the primary analyses to minimise bias. The primary outcomes were rates of success in achieving AF healing and bowel incontinence. RESULTS Fifty-two RCTs were included. Of the 14 treatments considered, there were no significant differences regarding short-term (6 months or less postoperatively) and long-term (more than 6 months postoperatively) success rates between any of the treatments in patients with both simple and complex anal fistula. Ligation of the inter-sphincteric fistula tract (LIFT) ranked best for minimising bowel incontinence in simple (99.1% of comparisons; 3 trials, n = 70 patients) and complex anal fistula (86.2% of comparisons; 3 trials, n = 102 patients). CONCLUSIONS There is insufficient evidence in existing RCTs to recommend one treatment over another regarding their short and long-term efficacy in successfully facilitating healing of both simple and complex anal fistulae. However, LIFT appears to be associated with the least impairment of bowel continence, irrespective of AF classification.
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Affiliation(s)
- S Bhat
- Surgical and Translational Research Centre, Department of Surgery, The University of Auckland, Auckland, New Zealand
- Department of Surgery, Te Whatu Ora MidCentral, Palmerston North, New Zealand
| | - W Xu
- Surgical and Translational Research Centre, Department of Surgery, The University of Auckland, Auckland, New Zealand
- Department of Surgery, Te Whatu Ora Te Toka Tumai, Whangārei, New Zealand
| | - C Varghese
- Surgical and Translational Research Centre, Department of Surgery, The University of Auckland, Auckland, New Zealand
| | - N Dubey
- Department of General Medicine, Tauranga Hospital, Te Whatu Ora, Tauranga, New Zealand
| | - C I Wells
- Surgical and Translational Research Centre, Department of Surgery, The University of Auckland, Auckland, New Zealand
- Department of Surgery, Te Whatu Ora Te Toka Tumai, Auckland, New Zealand
| | - C Harmston
- Surgical and Translational Research Centre, Department of Surgery, The University of Auckland, Auckland, New Zealand
- Department of Surgery, Te Whatu Ora Te Toka Tumai, Whangārei, New Zealand
| | - G O'Grady
- Surgical and Translational Research Centre, Department of Surgery, The University of Auckland, Auckland, New Zealand
- Auckland Bioengineering Institute, The University of Auckland, Auckland, New Zealand
| | - I P Bissett
- Surgical and Translational Research Centre, Department of Surgery, The University of Auckland, Auckland, New Zealand
| | - A Y Lin
- Department of Surgery and Anaesthesia, University of Otago, Wellington, New Zealand.
- Department of Surgery, Wellington Regional Hospital, Te Whatu Ora, Wellington, New Zealand.
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Cano-Valderrama Ó, Miguel TF, Bonito AC, Muriel JS, Fernández FJM, Ros EP, Cabrera AMG, Cerdán-Santacruz C. Surgical treatment trends and outcomes for anal fistula: fistulotomy is still accurate and safe. Results from a nationwide observational study. Tech Coloproctol 2023; 27:909-919. [PMID: 37460829 DOI: 10.1007/s10151-023-02842-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Accepted: 04/25/2023] [Indexed: 09/09/2023]
Abstract
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.
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Affiliation(s)
- Ó Cano-Valderrama
- Hospital Álvaro Cunqueiro, Complejo Hospitalario de Vigo, Pontevedra, Spain
| | | | | | - J Sancho Muriel
- Hospital Universitario Y Politécnico de La Fe, Valencia, Spain
| | | | - E Peña Ros
- Hospital Universitario Reina Sofía, Murcia, Spain
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Zhao Y, Xie W, Wu X, Li X, Guo J, Cao Q, Liang J, Chen XL, Zhao W, Sun F, Li H, Luo W, Li Y. Anal fistulotomy with one-stage shaped skin grafting for intersphincter anal fistulas: study protocol on a multicentre randomised controlled trial. Trials 2023; 24:470. [PMID: 37481545 PMCID: PMC10363312 DOI: 10.1186/s13063-023-07495-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2022] [Accepted: 07/04/2023] [Indexed: 07/24/2023] Open
Abstract
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.
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Affiliation(s)
- Yongchang Zhao
- Department of Anorectal Surgery, the First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, 510000, China
| | - Wei Xie
- Department of Gastrointestinal Surgery, Guangzhou Panyu Hexian Memorial Hospital, Guangzhou, 510000, China
| | - Xiaoshuo Wu
- Department of Anorectal Surgery, the First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, 510000, China
| | - Xiaolan Li
- Department of Anorectal Surgery, Dongguan People's Hospital, Dongguan, 523000, China
| | - Jinyan Guo
- Department of Anorectal Surgery, Jiangmen Wuyi Hospital of Chinese Medicine, Jiangmen, 529000, China
| | - Qiurui Cao
- Department of Anorectal Surgery, Jiangmen Wuyi Hospital of Chinese Medicine, Jiangmen, 529000, China
| | - Jiadi Liang
- Department of Anorectal Surgery, Dongguan People's Hospital, Dongguan, 523000, China
| | - Xin-Lin Chen
- School of Basic Medical Science, Guangzhou University of Chinese Medicine, Guangzhou, 510000, China
| | - Wentao Zhao
- Department of Anorectal Surgery, the First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, 510000, China
| | - Feng Sun
- Department of Anorectal Surgery, the First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, 510000, China
| | - Hongjie Li
- Department of Anorectal Surgery, the First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, 510000, China
| | - Weimin Luo
- Department of Anorectal Surgery, the First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, 510000, China
| | - Yuying Li
- Department of Anorectal Surgery, the First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, 510000, China.
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Bejiga G, Adilo A, Genemo E. Surgical management outcome in Fistula-in-ano: A cross-sectional study in Ethiopia. INTERNATIONAL JOURNAL OF SURGERY OPEN 2023. [DOI: 10.1016/j.ijso.2023.100605] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/29/2023]
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García-Olmo D, Gómez-Barrera M, de la Portilla F. Surgical management of complex perianal fistula revisited in a systematic review: a critical view of available scientific evidence. BMC Surg 2023; 23:29. [PMID: 36740680 PMCID: PMC9901165 DOI: 10.1186/s12893-023-01912-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Accepted: 01/10/2023] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Treating complex perianal fistulas in Crohn's disease patients remains a challenge. Classical surgical treatments for Crohn's disease fistulas have been extrapolated from cryptoglandular fistulas treatment, which have different etiology, and this might interfere with its effectiveness, in addition, they increase fecal incontinence risk. Recently, new surgical techniques with support from biological approaches, like stem cells, have been developed to preserve the function of the sphincter. We have performed a systematic literature review to compare the results of these different techniques in the treatment of Crohn's or Cryptoglandular fistula. METHODS PubMed, EMBASE, Database of Abstracts of Reviews of Effectiveness, Cochrane Central Register of Controlled Trials were searched systematically for relevant articles. We included randomized controlled trials and observational studies that referred to humans, were written in English, included adults 18+ years old, and were published during the 10-year period from 2/01/2010 to 2/29/2020. Evidence level was assigned as designated by the Scottish Intercollegiate Guidelines Network. RESULTS Of the 577 citations screened, a total of 79 were ultimately included in our review. In Crohn's disease patients, classical techniques such as primarily seton, Ligation of Intersphincteric Fistula Tracks, or lay open, healing rates were approximately 50-60%, while in cryptoglandular fistula were around, 70-80% for setons or flaps. In Crohn's disease patients, new surgical techniques using derivatives of adipose tissue reported healing rates exceeding 70%, stem cells-treated patients achieved higher combined remission versus controls (56.3% vs 38.6%, p = 0.010), mesenchymal cells reported a healing rate of 80% at week 12. In patients with cryptoglandular fistulas, a healing rate of 70% using derivatives of adipose tissue or platelets was achieved, and a healing rate of 80% was achieved using laser technology. Fecal incontinence was improved after the use of autologous platelet growth factors and Nitinol Clips. CONCLUSION New surgical techniques showed better healing rates in Crohn's disease patients than classical techniques, which have better results in cryptoglandular fistula than in Crohn's disease. Healing rates for complex cryptoglandular fistulas were similar between the classic and new techniques, being the new techniques less invasive; the incontinence rate improved with the current techniques.
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Affiliation(s)
- D. García-Olmo
- grid.419651.e0000 0000 9538 1950New Therapies Laboratory, Health Research Institute-Fundación Jiménez Díaz University Hospital (IIS-FJD/UAM), Department of Surgery, Fundación Jiménez Díaz University Hospital (UAM), Avda. Reyes Católicos, 2, 28040 Madrid, Spain
| | - M. Gómez-Barrera
- grid.512746.3Pharmacoeconomics & Outcomes Research Iberia (PORIB), Paseo Joaquín Rodrigo, 4 i, 28224 Pozuelo de Alarcón, Madrid Spain
| | - F. de la Portilla
- grid.9224.d0000 0001 2168 1229Coloproctology Unit, Clinical Management Unit of General and Gastrointestinal Surgery, Division Seville, Biomedical Research Institute (IBIS), University Hospital Virgen del Rocio/CSIC University of Seville, Seville, Spain
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Would Surgeons Like to Be Submitted to Anal Fistulotomy? An International Web-Based Survey. J Clin Med 2023; 12:jcm12030825. [PMID: 36769474 PMCID: PMC9918049 DOI: 10.3390/jcm12030825] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2022] [Revised: 01/15/2023] [Accepted: 01/18/2023] [Indexed: 01/22/2023] Open
Abstract
Traditional fistulotomy is the most performed surgical procedure in anal fistula surgery. We conducted an international online survey to explore colorectal surgeons' opinions and preferences on fistulotomy. Considering the healing and continence impairment rates reported in the literature, surgeons were invited to answer as a hypothetic patient susceptible to being submitted to fistulotomy for low and high anal fistula. A total of 767 surgeons completed the survey from 72 countries. The majority of respondents were consultants, having treated more than 20 anal fistulas in the last year. Most of them declared that anal fistula would be able to negatively affect quality of life and would be worried/anxious about it. Taking into account all aspects, 87.5% and 37.8% of respondents would agree to be treated with a fistulotomy in case of a low and high fistula, respectively, with an acceptance rate that varied worldwide. At multivariate analysis, factors correlated to the acceptance of anal fistulotomy were male gender (p = 0.003), practice of less than 20 fistula operations during last year (p = 0.020), and low fistula (p < 0.001). Surgeons recognized the extreme complexity of this approach. This study highlighted the necessity of an accurate patients' selection and the adoption of alternative strategy to reduce the risk of anal continence impairment.
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Gaertner WB, Burgess PL, Davids JS, Lightner AL, Shogan BD, Sun MY, Steele SR, Paquette IM, Feingold DL. The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Management of Anorectal Abscess, Fistula-in-Ano, and Rectovaginal Fistula. Dis Colon Rectum 2022; 65:964-985. [PMID: 35732009 DOI: 10.1097/dcr.0000000000002473] [Citation(s) in RCA: 76] [Impact Index Per Article: 25.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Affiliation(s)
- Wolfgang B Gaertner
- Division of Colon and Rectal Surgery, University of Minnesota, Minneapolis, Minnesota
| | - Pamela L Burgess
- Department of Surgery, Uniformed Services University of the Health Sciences, Eisenhower Army Medical Center, Fort Gordon, Georgia
| | - Jennifer S Davids
- Department of Surgery, University of Massachusetts, Worcester, Massachusetts
| | - Amy L Lightner
- Department of Colon and Rectal Surgery, Cleveland Clinic, Cleveland, Ohio
| | | | - Mark Y Sun
- Department of Surgery, University of Cincinnati, Cincinnati, Ohio
| | - Scott R Steele
- Department of Colon and Rectal Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Ian M Paquette
- Department of Surgery, University of Cincinnati, Cincinnati, Ohio
| | - Daniel L Feingold
- Division of Colorectal Surgery, Rutgers University, New Brunswick, New Jersey
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Fogle SE, Donahue CA, Beresneva O, Kuhnen AH, Kleiman DA, Breen EM, Schoetz DJ, Roberts PL, Marcello PW, Saraidaridis JT. Horseshoe Fistulae in the Age of LIFT. J Gastrointest Surg 2022; 26:1077-1083. [PMID: 35064458 DOI: 10.1007/s11605-021-05233-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2021] [Accepted: 12/07/2021] [Indexed: 01/31/2023]
Abstract
BACKGROUND Horseshoe fistula is a challenging benign anorectal condition to treat. The aim of this study was to assess the utilization and success of different definitive fistula repair techniques in the treatment of horseshoe fistula. METHODS This was a retrospective case series which included all patients who were treated for horseshoe fistula from 2006 to 2019 at a single, tertiary care center and whom had at least one follow-up visit. Patients were excluded if < 18 years of age or carried a diagnosis of Crohn's disease. Patients were assessed for fistula recurrence and incontinence. RESULTS Sixty-eight patients were identified. On average, they were 47 years old, 63% male, and 18% current smokers. Seventy-nine percent required seton during their treatment course. Of the 8 first attempts at fistula repair, the types of repair included flap (15%), LIFT (35%), fistulotomy (31%), plug (12%), and fistulotomy and immediate reconstruction (1%). Recurrence for these procedures was as follows: flap 30%, LIFT 21%, fistulotomy 14%, plug 88%, and fistulotomy and immediate reconstruction 0%. Twelve patients who recurred underwent 17 additional procedures to attempt to cure their fistula. Overall, of those who underwent any attempt at definitive repair, 82% of patients were cured of their fistula, 12% had a chronic seton, and 6% had a chronic fistula. Thirteen percent of those who were cured had incontinence. The mean follow-up time was 1.1 years. Patients required a median of 3 procedures (range 1-11). CONCLUSION Horseshoe fistula remains a complex anorectal condition. Successful repair can be performed in > 80% of patients. However, repair can often require multiple surgical procedures.
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Affiliation(s)
- Sydney E Fogle
- Division of Colon and Rectal Surgery, Lahey Hospital and Medical Center, 41 Mall Road, Burlington, MA, 01805, USA
| | - Colleen A Donahue
- Division of Colon and Rectal Surgery, Medical University of South Carolina, 171 Ashley Ave., Charleston, SC, 29405, USA
| | - Olga Beresneva
- Division of Colon and Rectal Surgery, Boston Medical Center, 830 Harrison Ave, 2nd Floor, Boston, MA, 02118, USA
| | - Angela H Kuhnen
- Division of Colon and Rectal Surgery, Lahey Hospital and Medical Center, 41 Mall Road, Burlington, MA, 01805, USA
| | - David A Kleiman
- Division of Colon and Rectal Surgery, Lahey Hospital and Medical Center, 41 Mall Road, Burlington, MA, 01805, USA
| | - Elizabeth M Breen
- Division of Colon and Rectal Surgery, Lahey Hospital and Medical Center, 41 Mall Road, Burlington, MA, 01805, USA
| | - David J Schoetz
- Division of Colon and Rectal Surgery, Lahey Hospital and Medical Center, 41 Mall Road, Burlington, MA, 01805, USA
| | - Patricia L Roberts
- Division of Colon and Rectal Surgery, Lahey Hospital and Medical Center, 41 Mall Road, Burlington, MA, 01805, USA
| | - Peter W Marcello
- Division of Colon and Rectal Surgery, Lahey Hospital and Medical Center, 41 Mall Road, Burlington, MA, 01805, USA
| | - Julia T Saraidaridis
- Division of Colon and Rectal Surgery, Lahey Hospital and Medical Center, 41 Mall Road, Burlington, MA, 01805, USA.
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Stijns J, Zimmerman DDE. Anal fistula, there is more than meets the eye! Tech Coloproctol 2022; 26:331-332. [DOI: 10.1007/s10151-022-02615-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Accepted: 03/14/2022] [Indexed: 12/21/2022]
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Grossi U, Romano M, Rossi S, Gallo G, Picciariello A, Felice C, Trojan D, Montagner G, Zanus G. Anal Fistula Human Amniotic Membrane Endosealing (F-HAME): A Proof of Concept Study. Front Surg 2022; 9:869923. [PMID: 35419402 PMCID: PMC8995564 DOI: 10.3389/fsurg.2022.869923] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2022] [Accepted: 03/08/2022] [Indexed: 12/14/2022] Open
Abstract
The treatment of cryptoglandular anal fistula (AF) is often a challenge for surgeons. Several sphincter-saving procedures have been described as an alternative to fistulotomy, with the common goal of promoting healing and preserve anal continence. The aim of this proof of concept study was to assess the outcomes of human amniotic membrane (HAM) implantation in cryptoglandular transphincteric AF. Two consecutive female were recruited. The primary outcome was clinical healing at 6 months. Secondary outcomes were ultrasonographic healing, complications and reinterventions, AF symptoms, fecal incontinence, psychological impact of treatment, recurrence, development of additional AF, patient satisfaction, and quality of life, as measured using validated questionnaires. Both patients (40 and 54-year-old) previously underwent incision and drainage of anal abscess with concomitant seton placement. HAM implantation was performed as a day case under local anesthesia. No intra- or post-procedural complications occurred. Clinical and radiological healing were not achieved at 6 months. However, the external outlet discharge diminished through time, with sustained improvements in quality of life. Clinical healing occurred at 7 months in both patients. Psychological impact of treatment and patient satisfaction were overall good, with improvements in the PHQ-9, GAD-7, and Short Assessment of Patients Satisfaction. HAM implantation is safe and improves patients' quality of life, progressively leading to clinical healing. Future studies are needed to assess its safety in other etiology of AF.
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Affiliation(s)
- Ugo Grossi
- II Surgery Unit, Regional Hospital Treviso, Treviso, Italy
- Department of Surgery, Oncology and Gastroenterology - DISCOG, University of Padua, Padua, Italy
| | | | - Serena Rossi
- Department of Surgery, Oncology and Gastroenterology - DISCOG, University of Padua, Padua, Italy
| | - Gaetano Gallo
- Department of Medicine, Surgery and Neurosciences, Unit of General Surgery and Surgical Oncology, University of Siena, Siena, Italy
| | - Arcangelo Picciariello
- Surgical Unit ‘M. Rubino', Department of Emergency and Organ Transplantation, University ‘Aldo Moro of Bari', Bari, Italy
| | - Carla Felice
- Department of Medicine - DIMED, University of Padua, Padua, Italy
| | | | | | - Giacomo Zanus
- II Surgery Unit, Regional Hospital Treviso, Treviso, Italy
- Department of Surgery, Oncology and Gastroenterology - DISCOG, University of Padua, Padua, Italy
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13
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A Prospective Study of Combined Sphincter Preserving Procedure (LIFT + VAAFT + FiLAC) in Complex Anal Fistula. Indian J Surg 2022. [DOI: 10.1007/s12262-021-03222-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
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14
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Schneider R, Ommer A. Spaltung von Analfisteln – noch zeitgemäß? COLOPROCTOLOGY 2022. [DOI: 10.1007/s00053-021-00583-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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15
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Lee KY, Lee J, Han EC, Kwon YH, Ryoo SB, Park KJ. Coring-out fistulectomy for perianal cryptoglandular fistula: a retrospective cohort study on 20 years of experience at a single center. Ann Surg Treat Res 2022; 102:167-175. [PMID: 35317352 PMCID: PMC8914524 DOI: 10.4174/astr.2022.102.3.167] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Revised: 01/29/2022] [Accepted: 02/10/2022] [Indexed: 11/30/2022] Open
Abstract
Purpose Cryptoglandular fistula is one of the common anal diseases requiring surgical treatment. Various surgical techniques have been introduced; however, there is no known standard technique. Coring-out fistulectomy is a surgical technique that accurately resects only the fistula tract. However, only a few cases of this procedure have been reported. We aimed to analyze the surgical outcomes of coring-out fistulectomy for cryptoglandular anal fistulas. Methods We retrospectively reviewed the medical records of patients who underwent coring-out fistulectomy for a cryptoglandular fistula between 1999 and 2019. Primary outcomes were the treatment success rate (recurrence and healing rates) and incidence of fecal incontinence. Results A total of 184 patients were included in our study. The average age of the patients was 44 years (range, 16–75 years), and 88.0% were male. Twenty-four (13.0%), 13 (7.1%), and 68 patients (37.0%) underwent operation for recurrent fistula, multiple tracts, and complex type fistula, respectively. The healing rate was 92.4%, and recurrence occurred in 15 of 170 healed patients (8.8%). Thus, the treatment success rate was 84.2%. There was no fecal incontinence except in 1 patient who had preoperative fecal incontinence because of cauda equine syndrome. In multivariable analysis of the factors affecting the treatment success rate, the complex fistula (odds ratio [OR], 14.2; 95% confidence interval [CI], 4.7–43.0; P < 0.001) and undetected internal opening during the operation (OR, 4.0; 95% CI, 1.4–11.6; P = 0.012) were significant factors. Conclusion Coring-out fistulectomy is a simple and feasible technique for sphincter-preserving anal fistula surgery.
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Affiliation(s)
- Kil-yong Lee
- Department of Surgery, The Catholic University of Korea, Uijeongbu St. Mary’s Hospital, Uijeongbu, Korea
| | - Jumyung Lee
- Department of Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Eon Chul Han
- Department of Surgery, Dongnam Institute of Radiological and Medical Sciences, Busan, Korea
| | - Yoon-Hye Kwon
- Department of Surgery, Uijeongbu Eulji Medical Center, Eulji University, Uijeongbu, Korea
| | - Seung-Bum Ryoo
- Department of Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Kyu Joo Park
- Department of Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
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16
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Treatments for the amelioration of persistent factors in complex anal fistula. Biotechnol Lett 2021; 44:23-31. [PMID: 34799826 DOI: 10.1007/s10529-021-03207-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Accepted: 11/12/2021] [Indexed: 10/19/2022]
Abstract
Anal fistulae are abnormal hollow connections between the wall of the anal canal and the perianal skin around the anus that have remained a burden on the medical sector for centuries. The complexity of this disease is attributed to a number of factors such as the degree of associated sphincter muscle, concomitant illnesses, existence of multiple fistulous tracts and the number of previous interventions. Persistence of a complex anal fistula can cause a decline in patient's physical quality of life as well as impact on the psychological status of patients who often suffer from anxiety and depression. Surgical intervention remains the gold standard for treatment, however; the risk of incontinence and high recurrence potential has led to interest into developing alternative treatment approaches such as the use of biologics, bioactives and biomaterials. One potential reason for these varied outcomes could be the multifactorial interplay between genetic, immune-related, environmental, and microbial persistence factors on tissue regeneration. Recent observations have proposed that adverse inflammatory mediators may contribute more than microbial factors. The moderate to high success rates of biotechnological advances (mesenchymal stem cells and biomaterial scaffolds) show promise as therapies for the amelioration of adverse persistent factors while facilitating a means to closing the fistula tract. The purpose of this review is to outline recent advances in biologics and combination therapies to treat persistent factors associated with complex anal fistula.
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Park MY, Yoon YS, Kim HE, Lee JL, Park IJ, Lim SB, Yu CS, Kim JC. Surgical options for perianal fistula in patients with Crohn's disease: A comparison of seton placement, fistulotomy, and stem cell therapy. Asian J Surg 2021; 44:1383-1388. [PMID: 33966965 DOI: 10.1016/j.asjsur.2021.03.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Revised: 02/16/2021] [Accepted: 03/14/2021] [Indexed: 10/21/2022] Open
Abstract
OBJECTIVE This study was designed to assess the demographic characteristics of patients with Crohn's perianal fistula (CPF) who were treated at a tertiary referral institution. Surgical outcomes were compared in groups of patients who underwent seton placement, fistulotomy, and stem cell therapy. METHODS Patients who underwent surgery for CPF between 2015 and 2017 at Asan Medical Center, Seoul, Korea, were retrospectively evaluated. Patients were divided into groups who underwent seton placement, fistulotomy, and stem cell therapy. Their clinical variables and closure rates were compared. RESULTS This study included 156 patients who underwent a total of 209 operations. More than half of the operations consisted of seton placement (67%), followed by stem cell therapy (18%) and fistulotomy (15%) patients. Of the 209 fistulas, 153 (73%) were complex, with an overall closure rate of 38% during a median follow-up of 29 months. Closure rates following fistulotomy, stem cell therapy, and seton placement were 90%, 70%, and 18%. Seton placement was more significantly frequently used than the other procedures in patients with complex fistula and those with abscesses. Of the 79 fistulas that achieved complete closure, 11 (14%) recurred. The recurrence rates did not differ among the various techniques. CONCLUSION Surgical treatment of CPF is dependent on lesion type. Seton placement was the primary draining procedure for complex fistulas and abscesses, resulting in low closure rates. Fistulotomy was the definite procedure for low type and simple fistula. Stem cell therapy showed high closure rates as definitive treatment, even for complex fistulas.
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Affiliation(s)
- Min Young Park
- Department of Colon and Rectal Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Yong Sik Yoon
- Department of Colon and Rectal Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea.
| | - Hyoung Eun Kim
- Department of Colon and Rectal Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Jong Lyul Lee
- Department of Colon and Rectal Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - In Ja Park
- Department of Colon and Rectal Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Seok-Byung Lim
- Department of Colon and Rectal Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Chang Sik Yu
- Department of Colon and Rectal Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Jin Cheon Kim
- Department of Colon and Rectal Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
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Litta F, Bracchitta S, Naldini G, Mistrangelo M, Tricomi N, La Torre M, Altomare DF, Mozzon M, Testa A, Zigiotto D, Sica G, Tutino R, Lisi G, Marino F, Luglio G, Vergari R, Terrosu G, Cantarella F, Foti N, Giuliani A, Moroni R, Ratto C. FISSIT (Fistula Surgery in Italy) study: A retrospective survey on the surgical management of anal fistulas in Italy over the last 15 years. Surgery 2021; 170:689-695. [PMID: 33846008 DOI: 10.1016/j.surg.2021.02.055] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Revised: 02/21/2021] [Accepted: 02/23/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND Surgical treatment of anal fistulas is still a challenge. The aims of this study were to evaluate the adoption and healing rates for the different surgical techniques used in Italy over the past 15 years. METHODS This was a multicenter retrospective observational study of patients affected by simple and complex anal fistulas of cryptoglandular origin who were surgically treated in the period 2003-2017. Surgical techniques were grouped as sphincter-cutting or sphincter-sparing and as technology-assisted or techno-free. All patients included in the study were followed for at least 12 months. RESULTS A total of 9,536 patients (5,520 simple; 4,016 complex fistulas) entered the study. For simple fistulas, fistulotomy was the most frequently used procedure, although its adoption significantly decreased over the years (P < .0005), with an increase in sphincter-sparing approaches; the overall healing rate in simple fistulas was 81.1%, with a significant difference between sphincter-cutting (91.9%) and sphincter-sparing (65.1%) techniques (P = .001). For complex fistulas, the adoption of sphincter-cutting approaches decreased, while sphincter-sparing techniques were mildly preferred (P < .0005). Moreover, there was a significant trend toward the use of technology-assisted procedures. The overall healing rate for complex fistulas was 69.0%, with a measurable difference between sphincter-cutting (81.1%) and sphincter-sparing (61.4%; P = .001) techniques and between techno-free and technology-assisted techniques (72.5% and 55.0%, respectively; P = .001). CONCLUSION Surgical treatment of anal fistulas has changed, with a trend toward the use of sphincter-sparing techniques. The overall cure rate has remained stable, even if the most innovative procedures have achieved a lower success rate.
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Affiliation(s)
- Francesco Litta
- Proctology Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy.
| | | | - Gabriele Naldini
- Proctology and Pelvic Floor Clinical Centre, University Hospital of Pisa, Italy
| | - Massimiliano Mistrangelo
- Surgical Science Department, University of Turin, Città della Salute e della Scienza Hospital, Turin, Italy
| | | | - Marco La Torre
- Coloproctology Unit, Salvator Mundi International Hospital, UPMC (University of Pittsburgh Medical College), Rome, Italy
| | | | - Marta Mozzon
- Chirurgia Generale, Azienda Ospedaliero Universitaria Friuli Centrale, Udine, Italy
| | | | - Daniele Zigiotto
- Proctological and Perineal Surgical Unit, Ospedale Civile Maggiore, University of Verona, Verona, Italy
| | - Giuseppe Sica
- Department of Surgical Science, University Hospital Tor Vergata, Rome, Italy
| | - Roberta Tutino
- Department of Surgical, Oncological and Stomatological Disciplines (Di. Chir. On. S.), University of Palermo, Italy
| | - Giorgio Lisi
- General Surgery, Sant'Eugenio Hospital, Rome, Italy
| | - Fabio Marino
- Unit of Surgery, National Institute of Gastroenterology "Saverio de Bellis", Research Hospital, Castellana Grotte, Bari, Italy
| | - Gaetano Luglio
- Department of Public Health, School of Medicine Federico II of Naples, Naples, Italy
| | - Roberto Vergari
- Clinica Chirurgica, Azienda Ospedaliero Universitaria Ospedali Riuniti di Ancona, Italy
| | | | | | - Nicola Foti
- UOC Chirurgia Generale e Week Surgery, Ospedale "Andosilla" di Civita Castellana (VT), Italy
| | - Antonio Giuliani
- U.O.C. Chirurgia Generale Universitaria, San Salvatore Hospital. Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, Italy
| | - Rossana Moroni
- Direzione Scientifica, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Carlo Ratto
- Proctology Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy; Catholic University of Rome, Italy
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Ambulatory seton placement followed by fistulotomy: efficacy and safety for perianal fistula treatment. Eur J Gastroenterol Hepatol 2021; 33:956-960. [PMID: 32925500 DOI: 10.1097/meg.0000000000001913] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
PURPOSE To evaluate the efficacy and safety of ambulatory seton placement followed by superficial fistulotomy as treatment of perianal fistula. METHODS Retrospective observational analysis of patients with cryptogenic perianal fistula aged 18-90 years, followed in a central hospital proctology consultation between 2006 and 2017. Data were obtained through clinical record's analysis. Fistula was characterized, using Parks Classification. A probe was passed through the fistula tract, followed by a seton, which remained in situ until superficial fistulotomy was possible. RESULTS Ninety-six patients were included (66.67% males, mean age 56 ± 15 years old). Nineteen patients (19.89%) had previous history of perianal fistula and 14 (14.58%) previous anorectal surgery. Seventy-four patients (78.72%) were submitted to fistulotomy, three (3.19%) had seton fistulotomy and one had no seton progression. Intention-to-treat and per-protocol efficacy analyses were 80.2 and 98.7%, respectively. Among the 74 patients who completed the procedure, type of fistula and time with seton were distributed as followed: 47 (63.51%) intersphincteric fistula (15 ± 31 weeks), 26 (35.14%) transsphincteric fistula (32 ± 47 weeks), one (1.35%) suprasphincteric fistula (11 weeks). Previous fistula was associated with a longer time with seton (P = 0.018). Incontinence was reported in two (2.7%) patients, who had previous perianal fistula or anorectal surgery. Two patients (2.7%) had recurrence after fistulotomy. CONCLUSION Placement of seton followed by superficial fistulotomy in an ambulatory setting is a safe and effective method for simple low perianal fistula treatment. Incontinence rate may be higher in patients with previous perianal fistula or anorectal surgery.
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20
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Chadbunchachai W, Lohsiriwat V, Paonariang K. Long-term Outcomes After Anal Fistula Surgery: Results From Two University Hospitals in Thailand. Ann Coloproctol 2021; 38:133-140. [PMID: 34098630 PMCID: PMC9021857 DOI: 10.3393/ac.2021.01.06] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Accepted: 01/06/2021] [Indexed: 11/10/2022] Open
Abstract
Purpose This study aimed to evaluate long-term outcomes after anal fistula surgery from university hospitals in Thailand. Methods A prospectively collected database of patients with cryptoglandular anal fistula undergoing surgery from 2011 to 2017 in 2 university hospitals was reviewed. Outcomes were treatment failure (persistent or recurrent fistula), fecal continence status, and chronic postsurgical pain. Results This study included 247 patients; 178 (72.1%) with new anal fistula and 69 (27.9%) with recurrent fistula. One hundred twenty-one patients (49.0%) had complex fistula; 53 semi-horseshoe (21.5%), 41 high transsphincteric (16.6%), 24 horseshoe (9.7%), and 3 suprasphincteric (1.2%). Ligation of intersphincteric fistula tract (LIFT) was the most common operation performed (n = 88, 35.6%) followed by fistulotomy (n = 79, 32.0%). With a median follow-up of 23 months (interquartile range, 12–45 months), there were 18 persistent fistulas (7.3%) and 33 recurrent fistulae (13.4%)—accounting for 20.6% overall failure. All recurrence occurred within 24 months postoperatively. Complex fistula was the only significant predictor for recurrent fistula with a hazard ratio of 4.81 (95% confidence interval, 1.82–12.71). There was no significant difference in healing rates of complex fistulas among seton staged fistulotomy (85.0%), endorectal advancement flap (72.7%), and LIFT (65.9%) (P = 0.239). Four patients (1.6%) experienced chronic postsurgical pain. Seventeen patients (6.9%) reported worse fecal continence. Conclusion Overall failure for anal fistula surgery was 20.6%. Complex fistula was the only predictor for recurrent fistula. At least 2-year period of follow-up is suggested for detecting recurrent diseases and assessing patient-reported outcomes such as chronic pain and continence status.
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Affiliation(s)
| | - Varut Lohsiriwat
- Colorectal Surgery Unit, Department of Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Krisada Paonariang
- Department of Surgery, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
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21
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Management of cryptoglandular fistula-in-ano among gastrointestinal surgeons in the Netherlands. Tech Coloproctol 2021; 25:709-719. [PMID: 33860363 PMCID: PMC8124037 DOI: 10.1007/s10151-021-02446-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Accepted: 04/01/2021] [Indexed: 02/06/2023]
Abstract
BACKGROUND Management of cryptoglandular fistula-in-ano (FIA) can be challenging. Despite Dutch and international guidelines determining optimal therapy is still quite difficult. The aim of this study was to report current practices in the management of cryptoglandular FIA among gastrointestinal surgeons in the Netherlands. METHODS Dutch surgeons and residents who are treating FIA regularly were sent a survey invitation by email. The survey was available online from September 19 to December 1 2019. The questionnaire consisted of 28 questions concerning diagnostic and surgical techniques in the treatment of intersphincteric and transsphincteric FIA. RESULTS In total, 147 (43%) surgeons responded and completed the survey. Magnetic resonance imaging was the preferred diagnostic imaging modality (97%) followed by the endo-anal ultrasound (12%). In case of a high FIA, 86% used a non-cutting seton. Most respondents removed a seton between 6 weeks and 3 months (n = 84, 58%). Fistulotomy was the procedure of preference in low transsphincteric (86%) and low intersphincteric FIA (92%). Mucosal advancement flap (MAF) and ligation of intersphincteric fistula tract (LIFT), with 78% and 46%, respectively, were the procedures that were applied most often in high transsphincteric FIA. In high intersphincteric FIA 67% performed a MAF and 33% a fistulotomy. Thirty-three percent of all respondents stated that they habitually closed the internal fistula opening, half of them used a Z-plasty. For debridement of the fistula tract the preferred method was curettage (78%). CONCLUSIONS Dutch gastrointestinal surgeons use various techniques in the management of FIA. Novel promising techniques should be investigated adequately in sufficient large trials to increase consensus. A core outcome measurement and a prospective international database would help in comparing results. Until then, treatment should be adjusted to the individual patient, governed by fistula characteristics and patient choice.
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Litta F, Parello A, Ferri L, Torrecilla NO, Marra AA, Orefice R, De Simone V, Campennì P, Goglia M, Ratto C. Simple fistula-in-ano: is it all simple? A systematic review. Tech Coloproctol 2021; 25:385-399. [PMID: 33387100 PMCID: PMC8016761 DOI: 10.1007/s10151-020-02385-5] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Accepted: 11/24/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND Simple anal fistula is one of the most common causes of proctological surgery and fistulotomy is considered the gold standard. This procedure, however, may cause complications. The aim of this systematic review was to assess the surgical treatment of simple anal fistula with traditional and sphincter-sparing techniques. METHODS A literature research was performed using PubMed, Cochrane, and Google Scholar to identify studies on the surgical treatment of simple anal fistulas. Observational studies and randomized clinical trials were included. We assessed the risk of bias of included studies using the Jadad scale for randomized controlled trials, and the MINORS Scale for the remaining studies. RESULTS The search returned 456 records, and 66 studies were found to be eligible. The quality of the studies was generally low. A total of 4883 patients with a simple anal fistula underwent a sphincter-cutting procedure, mainly fistulotomy, with a weighted average healing rate of 93.7%, while any postoperative continence impairment was reported in 12.7% of patients. Sphincter-sparing techniques were adopted to treat 602 patients affected by simple anal fistula, reaching a weighted average success rate of 77.7%, with no study reporting a significant postoperative incontinence rate. The postoperative onset of fecal incontinence and the recurrence of the disease reduced patients' quality of life and satisfaction. CONCLUSIONS Surgical treatment of simple anal fistulas with sphincter-cutting procedures provides excellent cure rates, even if postoperative fecal incontinence is not a negligible risk. A sphincter-sparing procedure could be useful in selected patients.
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Affiliation(s)
- F Litta
- Proctology Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Largo A. Gemelli, 8, 00168, Rome, Italy
| | - A Parello
- Proctology Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Largo A. Gemelli, 8, 00168, Rome, Italy
| | - L Ferri
- Proctology Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Largo A. Gemelli, 8, 00168, Rome, Italy
| | - N O Torrecilla
- Colorectal Unit, University Hospital Josep Trueta, Girona, Spain
| | - A A Marra
- Proctology Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Largo A. Gemelli, 8, 00168, Rome, Italy
| | - R Orefice
- Proctology Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Largo A. Gemelli, 8, 00168, Rome, Italy
| | - V De Simone
- Proctology Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Largo A. Gemelli, 8, 00168, Rome, Italy
| | - P Campennì
- Proctology Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Largo A. Gemelli, 8, 00168, Rome, Italy
| | - M Goglia
- Proctology Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Largo A. Gemelli, 8, 00168, Rome, Italy
| | - C Ratto
- Proctology Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Largo A. Gemelli, 8, 00168, Rome, Italy.
- Università Cattolica del Sacro Cuore, Rome, Italy.
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Leenders LAM, Stijns J, van Loon YT, Van Tilborg F, Wasowicz DK, Zimmerman DDE. The complexity of cryptoglandular fistula-in-ano can be predicted by the distance of the external opening to the anal verge; implications for preoperative imaging? Tech Coloproctol 2020; 25:109-115. [PMID: 33180233 DOI: 10.1007/s10151-020-02353-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Accepted: 09/25/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Many surgeons believe that the distance from the external opening to the anal verge (DEOAV) predicts the complexity of a cryptoglandular fistulas-in-ano and, therefore, predicts the need for additional imaging. However, there is no evidence to support this. The primary aim of this study was to determine if DEOAV can predict the complexity of a fistula. Secondary aims were clinical outcome and identification of those patients that might not benefit from preoperative imaging. METHODS All patients having surgery for cryptoglandular fistula-in-ano between January 2014 and December 2016 were evaluated. Preoperative imaging was used to classify fistulas as simple or complex. The DEAOV was measured preoperatively and was divided into categories ≤ 1 cm, 1-2 cm, or > 2 cm. The relationship between the DEOAV and complexity of the fistula was investigated. Clinical outcome was recorded and a group of patients that might not benefit from preoperative imaging was identified. RESULTS A total of 103 patients [m:f = 65:38, median age 47 (range 19-79) years] were included. Magnetic resonance imaging identified 39 simple and 64 complex fistulas. The percentage of simple fistula was 88% in fistulas with DEAOV ≤ 1 cm, 48% in DEAOV 1-2 cm and 38% in > 2 cm. There was a significant difference between the complexity of the fistula and the distance to the anal verge (p < 0.001). The overall healing rate was 88%. CONCLUSIONS The complexity of perianal fistula depends on the DEAOV. We propose that preoperative imaging should be performed in fistulas with external opening > 1 cm from the anal verge.
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Affiliation(s)
- L A M Leenders
- Department of Surgery, ETZ (Elisabeth, TweeSteden Ziekenhuis), Doctor Deelenlaan 5, 5042 AD, Tilburg, The Netherlands
| | - J Stijns
- Department of Surgery, ETZ (Elisabeth, TweeSteden Ziekenhuis), Doctor Deelenlaan 5, 5042 AD, Tilburg, The Netherlands.,Department of Surgery, UZ Brussel, Brussels, Belgium
| | - Y T van Loon
- Department of Surgery, ETZ (Elisabeth, TweeSteden Ziekenhuis), Doctor Deelenlaan 5, 5042 AD, Tilburg, The Netherlands
| | - F Van Tilborg
- Department of Radiology, ETZ Tilburg, Tilburg, The Netherlands
| | - D K Wasowicz
- Department of Surgery, ETZ (Elisabeth, TweeSteden Ziekenhuis), Doctor Deelenlaan 5, 5042 AD, Tilburg, The Netherlands
| | - D D E Zimmerman
- Department of Surgery, ETZ (Elisabeth, TweeSteden Ziekenhuis), Doctor Deelenlaan 5, 5042 AD, Tilburg, The Netherlands.
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D’Amico F, Wexner SD, Vaizey CJ, Gouynou C, Danese S, Peyrin-Biroulet L. Tools for fecal incontinence assessment: lessons for inflammatory bowel disease trials based on a systematic review. United European Gastroenterol J 2020; 8:886-922. [PMID: 32677555 PMCID: PMC7707876 DOI: 10.1177/2050640620943699] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Accepted: 06/09/2020] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Fecal incontinence is a disabling condition affecting up to 20% of women. OBJECTIVE We investigated fecal incontinence assessment in both inflammatory bowel disease and non-inflammatory bowel disease patients to propose a diagnostic approach for inflammatory bowel disease trials. METHODS We searched on Pubmed, Embase and Cochrane Library for all studies on adult inflammatory bowel disease and non-inflammatory bowel disease patients reporting data on fecal incontinence assessment from January 2009 to December 2019. RESULTS In total, 328 studies were included; 306 studies enrolled non-inflammatory bowel disease patients and 22 studies enrolled inflammatory bowel disease patients. In non-inflammatory bowel disease trials the most used tools were the Wexner score, fecal incontinence quality of life questionnaire, Vaizey score and fecal incontinence severity index (in 187, 91, 62 and 33 studies). Anal manometry was adopted in 41.2% and endoanal ultrasonography in 34.0% of the studies. In 142 studies (46.4%) fecal incontinence evaluation was performed with a single instrument, while in 64 (20.9%) and 100 (32.7%) studies two or more instruments were used. In inflammatory bowel disease studies the Wexner score, Vaizey score and inflammatory bowel disease quality of life questionnaire were the most commonly adopted tools (in five (22.7%), five (22.7%) and four (18.2%) studies). Anal manometry and endoanal ultrasonography were performed in 45.4% and 18.2% of the studies. CONCLUSION Based on prior validation and experience, we propose to use the Wexner score as the first step for fecal incontinence assessment in inflammatory bowel disease trials. Anal manometry and/or endoanal ultrasonography should be taken into account in the case of positive questionnaires.
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Affiliation(s)
- Ferdinando D’Amico
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
- Department of Gastroenterology and Inserm NGERE U1256, University Hospital of Nancy, Vandoeuvre-lès-Nancy, France
| | - Steven D Wexner
- Department of Colorectal Surgery, Cleveland Clinic Florida, Weston USA
| | | | - Célia Gouynou
- Department of Gastroenterology and Inserm NGERE U1256, University Hospital of Nancy, Vandoeuvre-lès-Nancy, France
| | - Silvio Danese
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
- IBD Center, Department of Gastroenterology, Humanitas Clinical and Research Center-IRCCS, Rozzano, Milan, Italy
| | - Laurent Peyrin-Biroulet
- Department of Gastroenterology and Inserm NGERE U1256, University Hospital of Nancy, Vandoeuvre-lès-Nancy, France
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Sahnan K, Adegbola S, Iqbal N, Twum-Barima C, Reza L, Lung P, Warusavitarne J, Hart A, Tozer P. Managing non-IBD fistulising disease. Frontline Gastroenterol 2020; 12:524-534. [PMID: 34712471 PMCID: PMC8515280 DOI: 10.1136/flgastro-2019-101234] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Revised: 06/03/2020] [Accepted: 06/07/2020] [Indexed: 02/04/2023] Open
Affiliation(s)
- Kapil Sahnan
- Department of Surgery and Cancer, Imperial College London, London, UK
- Robin Phillip’s Fistula Research Unit, St Mark's Hospital and Academic Institute, Harrow, London, UK
| | - Samuel Adegbola
- Department of Surgery and Cancer, Imperial College London, London, UK
- Robin Phillip’s Fistula Research Unit, St Mark's Hospital and Academic Institute, Harrow, London, UK
| | - Nusrat Iqbal
- Department of Surgery and Cancer, Imperial College London, London, UK
- Robin Phillip’s Fistula Research Unit, St Mark's Hospital and Academic Institute, Harrow, London, UK
| | - Charlene Twum-Barima
- Department of Surgery and Cancer, Imperial College London, London, UK
- Robin Phillip’s Fistula Research Unit, St Mark's Hospital and Academic Institute, Harrow, London, UK
| | - Lillian Reza
- Department of Surgery and Cancer, Imperial College London, London, UK
- Robin Phillip’s Fistula Research Unit, St Mark's Hospital and Academic Institute, Harrow, London, UK
| | - Phillip Lung
- Robin Phillip’s Fistula Research Unit, St Mark's Hospital and Academic Institute, Harrow, London, UK
| | - Janindra Warusavitarne
- Department of Surgery and Cancer, Imperial College London, London, UK
- Robin Phillip’s Fistula Research Unit, St Mark's Hospital and Academic Institute, Harrow, London, UK
| | - Ailsa Hart
- Robin Phillip’s Fistula Research Unit, St Mark's Hospital and Academic Institute, Harrow, London, UK
- IBD Unit, St Mark's Hospital, Harrow, UK
| | - Phil Tozer
- Department of Surgery and Cancer, Imperial College London, London, UK
- Robin Phillip’s Fistula Research Unit, St Mark's Hospital and Academic Institute, Harrow, London, UK
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Longterm outcome of anal fistula - A retrospective study. Sci Rep 2020; 10:6483. [PMID: 32300218 PMCID: PMC7162908 DOI: 10.1038/s41598-020-63541-3] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2019] [Accepted: 03/27/2020] [Indexed: 12/19/2022] Open
Abstract
This retrospective observational study analyses the outcomes of patients undergoing surgery for anal fistula at a single centre in order to assess recurrence and re-operation rates after different surgical techniques. During January 2005 and May 2013, all patients with anal fistula were included. Baseline characteristics, details of presentation, fistula anatomy, type of surgery, post-surgical outcomes and follow-up data were collected. The primary endpoints were long-term closure rate and recurrence rate after 2 years. Secondary endpoints were persistent pain, postoperative complications and continence status. A total of 65 patients were included. From a total amount of 93 operations, 65 were fistulotomies, 13 mucosal advancement flaps, 7 anal fistula plugs and 8 cutting-setons. The mean follow up was 80 months. Healing was achieved in 85%. The highest recurrence rate was seen in anal fistula plug with 42%. On the other hand, no recurrence was observed in the cutting-seton procedures. For all included operation no persistent postoperative pain nor incontinence was observed. In conclusion, despite all existing anal fistula operations up to date, the optimal technique with low recurrence rate and assured safety for the anal sphincter is still lacking. Nonetheless, according to our promising results for the cutting-seton technique, this technique, otherwise considered obsolete, should be further evaluated in a prospective study.
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Mei Z, Li Y, Zhang Z, Zhou H, Liu S, Han Y, Du P, Qin X, Shao Z, Ge M, Wang Q, Yang W. Development of screening tools to predict the risk of recurrence and related complications following anal fistula surgery: protocol for a prospective cohort study. BMJ Open 2020; 10:e035134. [PMID: 32139494 PMCID: PMC7059513 DOI: 10.1136/bmjopen-2019-035134] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2019] [Revised: 02/04/2020] [Accepted: 02/05/2020] [Indexed: 01/15/2023] Open
Abstract
INTRODUCTION Postoperative recurrence and related complications are common and related to poor outcomes in patients with anal fistula (AF). Due to being associated with short-term and long-term cure rates, perioperative complications have received widespread attention following AF surgery. This study aims to identify a set of predictive factors to develop risk prediction models for recurrence and related complications following AF surgery. We plan to develop and validate risk prediction models, using information collected through a WeChat patient-reported questionnaire system combined with clinical, laboratory and imaging findings from the perioperative period until 3-6 months following AF surgery. METHODS AND ANALYSIS This is a prospective hospital-based cohort study using a linked database of collected health data as well as the follow-up outcomes for all adult patients who suffered from AF at a tertiary referral hospital in Shanghai, China. We will perform logistic regression models to predict anal fistula recurrence (AFR) as well as related complications (eg, wound haemorrhage, faecal impaction, urinary retention, delayed wound healing and unplanned hospitalisation) during and after AF surgery, and machine learning approaches will also be applied to develop risk prediction models. This prospective study aims to develop the first risk prediction models for AFR and related complications using multidimensional variables. These tools can be used to warn, motivate and empower patients to avoid some modifiable risk factors to prevent postoperative complications early. This study will also provide alternative tools for the early screening of high-risk patients with AFR and related complications, helping surgeons better understand the aetiology and outcomes of AF in an earlier stage. ETHICS AND DISSEMINATION The study was approved by the Institutional Review Board of Shuguang Hospital affiliated with Shanghai University of Traditional Chinese Medicine (approval number: 2019-699-54-01). The results of this study will be submitted to international scientific peer-reviewed journals or conferences in surgery, anorectal surgery or anorectal diseases. TRIAL REGISTRATION NUMBER ChiCTR1900025069; Pre-results.
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Affiliation(s)
- Zubing Mei
- Department of Anorectal Surgery, Shuguang Hospital, Shanghai University of Traditional Chinese Medicine; Anorectal Disease Institute of Shuguang Hospital, Shanghai, China
| | - Yue Li
- Department of Anorectal Surgery, Shuguang Hospital, Shanghai University of Traditional Chinese Medicine; Anorectal Disease Institute of Shuguang Hospital, Shanghai, China
| | - Zhijun Zhang
- Department of Anorectal Surgery, Shuguang Hospital, Shanghai University of Traditional Chinese Medicine; Anorectal Disease Institute of Shuguang Hospital, Shanghai, China
| | - Haikun Zhou
- Department of Anorectal Surgery, Shuguang Hospital, Shanghai University of Traditional Chinese Medicine; Anorectal Disease Institute of Shuguang Hospital, Shanghai, China
| | - Suzhi Liu
- Department of Anorectal Surgery, Shuguang Hospital, Shanghai University of Traditional Chinese Medicine; Anorectal Disease Institute of Shuguang Hospital, Shanghai, China
| | - Ye Han
- Department of Anorectal Surgery, Shuguang Hospital, Shanghai University of Traditional Chinese Medicine; Anorectal Disease Institute of Shuguang Hospital, Shanghai, China
| | - Peixin Du
- Department of Anorectal Surgery, Shuguang Hospital, Shanghai University of Traditional Chinese Medicine; Anorectal Disease Institute of Shuguang Hospital, Shanghai, China
| | - Xiufang Qin
- Department of Nursing, Shuguang Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Zhuo Shao
- Department of General Surgery, Changhai Hospital, The Second Military Medical University, Shanghai, China
| | - Maojun Ge
- Department of General Surgery, Shuguang Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Qingming Wang
- Department of Anorectal Surgery, Shuguang Hospital, Shanghai University of Traditional Chinese Medicine; Anorectal Disease Institute of Shuguang Hospital, Shanghai, China
| | - Wei Yang
- Department of Anorectal Surgery, Shuguang Hospital, Shanghai University of Traditional Chinese Medicine; Anorectal Disease Institute of Shuguang Hospital, Shanghai, China
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Göttgens KWA, Wasowicz DK, Stijns J, Zimmerman D. Ligation of the Intersphincteric Fistula Tract for High Transsphincteric Fistula Yields Moderate Results at Best: Is the Tide Turning? Dis Colon Rectum 2019; 62:1231-1237. [PMID: 31490832 DOI: 10.1097/dcr.0000000000001448] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Ligation of the intersphincteric fistula tract is a well-accepted and often used surgical procedure for perianal fistulas. OBJECTIVE This study aims to confirm results of the ligation of the intersphincteric fistula tract in a specialized colorectal center. DESIGN This is a retrospective cohort study. SETTING This study took place in a large colorectal surgical department with a tertiary referral center for perianal fistulas. PATIENTS Consecutive patients were operated on with ligation of the intersphincteric fistula tract for a transsphincteric perianal fistula between 2012 and December 2018. INTERVENTIONS Patients underwent ligation of the intersphincteric fistula tract. MAIN OUTCOME MEASURES The primary outcome measured was the healing rate. The secondary outcomes measured were conversion into an intersphincteric perianal fistula, risk of recurrence, complications, and postoperative continence status. RESULTS Forty-six patients were treated with a ligation of intersphincteric fistula tract procedure. All patients (100%) had preoperative imaging in their workup. Forty patients (87%) had a high transsphincteric fistula. The primary healing rate was a disappointing 17 of 46 patients (37%). The median time until failure was 4.2 months (interquartile range, 3.5-6.5). Of the failures, 16 converted to an intersphincteric fistula (55% of failures and 35% of all patients). The mean duration of follow-up in patients without a recurrence was 9.5 months (SD 11.9). Four patients (9%) were lost to follow-up. The mean Fecal Incontinence Severity Index postoperatively was only 2.35 (SD 5.7; range, 0-30). This resulted in 9 patients (20%) having a newly impaired continence status postoperatively. Continence impairment was mild in all these patients. The risk of developing a recurrence 1 year after surgery is 64.2% (95% CI, 49%-80%). LIMITATIONS This study was limited by its retrospective design and the small numbers with possible selection bias. CONCLUSIONS Results with the ligation of intersphincteric fistula tract procedure were not as good as hoped. The effect on fecal continence, however, was minimal. The procedure might be more suitable for low transsphincteric fistulas. See Video Abstract at http://links.lww.com/DCR/A992. LA LIGADURA DEL TRACTO DE LA FÍSTULA INTERESFINTÉRICA PARA UNA FÍSTULA TRANSESFINTÉRICA ALTA, PRODUCE RESULTADOS MODERADOS EN EL MEJOR DE LOS CASOS: ¿ESTÁ CAMBIANDO LA MAREA?: La ligadura del tracto de la fístula interesfintérica es un procedimiento quirúrgico bien aceptado y de uso frecuente para las fístulas perianales. OBJETIVO Confirmar los resultados de la ligadura del tracto de la fístula interesfintérica en un centro colorrectal especializado. DISEÑO:: Estudio de cohorte retrospectivo. AJUSTE Gran departamento de cirugía colorrectal y con centro de referencia terciaria para fístulas perianales. PACIENTES Pacientes consecutivos operados con ligadura del tracto de la fístula interesfintérica para una fístula perianal transesfintérica, entre 2012 y diciembre de 2018. INTERVENCIONES Ligadura del tracto de fístula interesfintérica. PRINCIPALES MEDIDAS DE RESULTADO Tasa de cicatrización, resultados secundarios: conversión a una fístula perianal interesfintérica, riesgo de recurrencia, complicaciones y estado de continencia postoperatoria. RESULTADOS Cuarenta y seis pacientes fueron tratados con una ligadura del tracto de la fístula interesfintérica. Todos los pacientes (100 por ciento) tenían imagenología en su preparación preoperatoria. Cuarenta pacientes (87 por ciento) tenían una fístula transesfintérica alta. La tasa de cicatrización primaria fue decepcionante en 17 de 46 pacientes (37 por ciento). El tiempo medio hasta el fracaso fue de 4.2 meses (rango intercuartil 3.5-6.5). De los fracasos, 16 se convirtieron en una fístula interesfintérica (55 por ciento de los fracasos y 35 por ciento de todos los pacientes). La duración media del seguimiento en pacientes sin recurrencia fue de 9.5 meses (desviación estándar de 11.9). Se perdieron durante el seguimiento a cuatro pacientes (9 por ciento). Después de la operación, el promedio del índice de severidad de incontinencia fecal fue de solo 2.35 (desviación estándar de 5.7, rango 0-30). Esto resultó en que 9 pacientes (20 por ciento) tuvieran una continencia deteriorada postoperatoria. El deterioro de la continencia fue leve en todos estos pacientes. El riesgo de desarrollar una recurrencia a un año después de la cirugía es del 64.2 por ciento (intervalo de confianza del 95 por ciento: 49-80 por ciento). LIMITACIONES Diseño retrospectivo, números pequeños con posible sesgo de selección. CONCLUSIONES Los resultados del procedimiento con la ligadura del tracto de fístula interesfintérica no fueron tan buenos como se esperaba. El efecto sobre la continencia fecal, sin embargo, fue mínimo. El procedimiento podría ser más adecuado para las fístulas transesfintéricas bajas. Vea el Resumen del video en http://links.lww.com/DCR/A992.
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Litta F, Parello A, De Simone V, Grossi U, Orefice R, Ratto C. Fistulotomy and primary sphincteroplasty for anal fistula: long-term data on continence and patient satisfaction. Tech Coloproctol 2019; 23:993-1001. [PMID: 31538298 DOI: 10.1007/s10151-019-02093-9] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2019] [Accepted: 09/12/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND The aim of this study was to evaluate the safety and long-term efficacy of fistulotomy and primary sphincteroplasty (FIPS). Secondary endpoints were its impact on postoperative continence status and patients' satisfaction. METHODS A retrospective study was conducted on patients with cryptoglandular anal fistula (AF) who had FIPS between June 2006 and May 2017. Patients were evaluated with standardized telephone interviews and clinical/instrumental assessment. Main outcome measures included fistula healing rate, continence status, and patient satisfaction. Incontinence was defined as an inability to hold either gas, liquid, or solid stools, as well as postdefecation soiling, and was measured by the Cleveland Clinic fecal incontinence score. Patient satisfaction was evaluated by an 11-point numeric rating scale. RESULTS There were 203 patients (139 males; mean age: 48.7 years) who had FIPS. The overall healing rate was 93% (188 patients) with a mean follow-up period of 56 ± 31 months. Half of the total cohort (51%) had a complex fistula. Preoperatively, 8 (4%) patients complained of postdefecation soiling and 2 (1%) of gas incontinence. Postoperatively, 26 (13%) patients had continence impairment (de novo n = 24), mainly consisting of postdefecation soiling (10%). In univariate analysis, patients with recurrent (RR 6.153 95% CI 2.097-18.048; p = 0.002) or complex (RR 3.005 95% CI 1.203-7.506; p = 0.012) AF and those with secondary tracts (RR 8.190 95% CI 2.188-30.654; p = 0.004) or previous set on drainage (RR 5.286 95% CI 2.235-12.503; p = 0.0001) were at higher risk of incontinence. In multivariate analysis, no significant predictors were found, although fistula complexity approached statistical significance (RR 5.464 95% CI 0.944-31.623; p = 0.050). The mean patient satisfaction numeric rating scale was 9.3 ± 1.6. Lower satisfaction rates were found in patients with transphincteric (p = 0.011) or complex (p = 0.0001) AF, with secondary tracts (p = 0.041) or previous seton drainage (p = 0.008), and in those with postoperative continence impairment (p = 0.0001). Postoperative onset of incontinence was the only significant factor in multivariate analysis (p = 0.0001). CONCLUSIONS FIPS should be considered a valid therapeutic option for selected AF. However, the risk of postoperative minor fecal incontinence exists, and should be discussed during preoperative patient counselling.
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Affiliation(s)
- F Litta
- Proctology Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Largo A. Gemelli, 8, 00168, Rome, Italy.
| | - A Parello
- Proctology Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Largo A. Gemelli, 8, 00168, Rome, Italy
| | - V De Simone
- Proctology Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Largo A. Gemelli, 8, 00168, Rome, Italy
| | - U Grossi
- Proctology Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Largo A. Gemelli, 8, 00168, Rome, Italy
| | - R Orefice
- Proctology Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Largo A. Gemelli, 8, 00168, Rome, Italy
| | - C Ratto
- Proctology Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Largo A. Gemelli, 8, 00168, Rome, Italy.,Università Cattolica del Sacro Cuore, Rome, Italy
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Ratto C, Grossi U, Litta F, Di Tanna GL, Parello A, De Simone V, Tozer P, DE Zimmerman D, Maeda Y. Contemporary surgical practice in the management of anal fistula: results from an international survey. Tech Coloproctol 2019; 23:729-741. [PMID: 31368010 PMCID: PMC6736896 DOI: 10.1007/s10151-019-02051-5] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Accepted: 07/19/2019] [Indexed: 12/22/2022]
Abstract
Background Management of anal fistula (AF) remains challenging with many controversies. The purpose of this study was to explore current surgical practice in the management of AF with a focus on technical variations among surgeons. Methods An online survey was conducted by inviting all surgeons and physicians on the membership directory of European Society of Coloproctology and American Society of Colon and Rectal Surgeons. An invitation was extended to others via social media. The survey had 74 questions exploring diagnostic and surgical techniques. Results In March 2018, 3572 physicians on membership directory were invited to take part in the study 510 of whom (14%) responded to the survey. Of these respondents, 492 (96%) were surgeons. Respondents were mostly colorectal surgeons (84%) at consultant level (84%), age ≥ 40 years (64%), practicing in academic (53%) or teaching (30%) hospitals, from the USA (36%) and Europe (34%). About 80% considered fistulotomy as the gold standard treatment for simple fistulas. Endorectal advancement flap was performed using partial- (42%) or full-thickness (44%) flaps. Up to 38% of surgeons performed ligation of the intersphincteric fistula tract (LIFT) sometimes with technical variations. Geographic and demographic differences were found in both the diagnostic and therapeutic approaches to AF. Declared rates of recurrence and fecal incontinence with these techniques were variable and did not correlate with surgeons’ experience. Only 1–4% of surgeons were confident in performing the most novel sphincter-preserving techniques in patients with Crohn’s disease. Conclusions Profound technical variations exist in surgical management of AF, making it difficult to reproduce and compare treatment outcomes among different centers. Electronic supplementary material The online version of this article (10.1007/s10151-019-02051-5) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- C Ratto
- Proctology Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Largo A. Gemelli, 8, 00168, Rome, Italy.,Università Cattolica del Sacro Cuore, Rome, Italy
| | - U Grossi
- Proctology Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Largo A. Gemelli, 8, 00168, Rome, Italy. .,National Bowel Research Centre, Queen Mary University of London, London, UK.
| | - F Litta
- Proctology Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Largo A. Gemelli, 8, 00168, Rome, Italy
| | - G L Di Tanna
- Statistics Division, The George Institute for Global Health, UNSW, Sydney, Australia
| | - A Parello
- Proctology Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Largo A. Gemelli, 8, 00168, Rome, Italy
| | - V De Simone
- Proctology Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Largo A. Gemelli, 8, 00168, Rome, Italy
| | - P Tozer
- Fistula Research Unit, St Mark's Hospital and Academic Institute, London, UK.,Imperial College London, London, UK
| | - D DE Zimmerman
- Department of Surgery, ETZ (Elisabeth-TweeSteden Hospital), Tilburg, The Netherlands
| | - Y Maeda
- Department of Colorectal Surgery, Western General Hospital, Edinburgh, UK
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Garg P. Is fistulotomy still the gold standard in present era and is it highly underutilized?: An audit of 675 operated cases. Int J Surg 2018; 56:26-30. [PMID: 29886281 DOI: 10.1016/j.ijsu.2018.06.009] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2018] [Revised: 05/17/2018] [Accepted: 06/06/2018] [Indexed: 12/11/2022]
Abstract
AIM Due to fear of incontinence, fistulotomy perhaps remains highly underutilized. The aim was to analyze the efficacy of fistulotomy in a large cohort, to assess the magnitude of underutilization of fistulotomy by current classifications and to identify the subgroup in whom the fistulotomy should be done. METHODS All consecutive operated patients of fistula-in-ano were included in the study retrospectively. The fistulas were classified as per existing classifications-Parks, St James University Hospital (SJUH) and Garg classification. Smaller grades of each classification (Parks I, SJUH I-II, Garg I-II) were expected to be simple fistulas and thus amenable to fistulotomy. Objective incontinence scores were done preoperatively and postoperatively. RESULTS 675 patients were operated over a 5.5 year period (median-27 months). 25 patients were excluded. Fistulotomy was done in 353/650 (54.3%) patients and sphincter-saving procedures (SSP) performed in 297/650 (45.7%) patients. After fistulotomy, 346/353 (98%) fistulas healed after the first operation. Seven patients with recurrent fistula were cured after a repeat fistulotomy surgery. Thus the overall healing rate was 353/353 (100%). There was no significant change in continence scores. The 353 fistulotomy patients were classified as per different classifications- Parks (I-225,II-112,III-16,IV-0), SJUH(I-138,II-87,III-47,IV-65,V-16) and Garg (I-188,II-165,III-0,IV-0,V-0). 123 (36.3%) patients who could undergo fistulotomy successful were erroneously classified as complex fistula by Parks and SJUH classifications. Garg classification accurately identified all 353/353 (100%) patients were amenable to fistulotomy. CONCLUSIONS Fistulotomy is a safe procedure with remarkably high success rate (100%) and is gold-standard in majority of patients (>50%). Parks and SJUH classifications are inaccurate in selecting patients for fistulotomy. Garg classification predicts amenability to fistulotomy with very high accuracy.
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Affiliation(s)
- Pankaj Garg
- Colorectal Surgery Division, Indus Super Specialty Hospital, Mohali, Punjab, India; Garg Fistula Research Institute, Panchkula, Haryana, India.
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Barry WE, Asuelime GE, Zhou S, Hammoudeh J, Ford HR, Kim ES. Congenital Perirectal Dermoid Cyst: A Rare Cause of Complex, Recurrent Pediatric Fistula-in-ano. Front Pediatr 2018; 6:143. [PMID: 29868530 PMCID: PMC5964207 DOI: 10.3389/fped.2018.00143] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2018] [Accepted: 04/30/2018] [Indexed: 11/13/2022] Open
Abstract
Perianal abscess and fistula-in-ano are well-described in the pediatric population. They are most common in infants less than 1 year of age and often resolve with oral antibiotics; occasionally they require drainage or fistulotomy. The etiology is commonly associated with cryptoglandular obstruction and subsequent infection, however alternative diagnoses should be considered in cases of recurrent abscesses and fistulae that are refractory to standard treatments. In this report, we present the case of an 8-year-old boy with a complex, recurrent fistula-in-ano that resulted from a rare congenital perirectal dermoid cyst.
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Affiliation(s)
- Wesley E. Barry
- Division of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, CA, United States
- Department of Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, CA, United States
| | - Grace E. Asuelime
- Division of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, CA, United States
| | - Shengmei Zhou
- Department of Pathology and Laboratory Medicine, Children's Hospital Los Angeles, Los Angeles, CA, United States
| | - Jeffrey Hammoudeh
- Department of Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, CA, United States
- Division of Plastic Surgery, Children's Hospital Los Angeles, Los Angeles, CA, United States
| | - Henri R. Ford
- Division of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, CA, United States
- Department of Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, CA, United States
| | - Eugene S. Kim
- Division of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, CA, United States
- Department of Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, CA, United States
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Wang Q, He Y, Shen J. The best surgical strategy for anal fistula based on a network meta-analysis. Oncotarget 2017; 8:99075-99084. [PMID: 29228753 PMCID: PMC5716793 DOI: 10.18632/oncotarget.21836] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2017] [Accepted: 09/23/2017] [Indexed: 12/29/2022] Open
Abstract
OBJECTIVE To determine a superior surgical treatment for anal fistula through a network meta-analysis and to provide the best direction for development in this field. METHODS We conducted a systematic literature search of the PubMed, Embase and Cochrane Library databases and extracted data from randomized controlled trials, which compared healing time, incontinence and recurrence associated with surgical strategies for anal fistula. A network meta-analysis was conducted using ADDIS software by evaluating the 3 parameters. Cumulative probability values were utilized to rank the strategies under examination. Inconsistencies were also tested using node-splitting models. RESULTS Twenty articles with 1663 patients were included. Fistulotomy plus marsupialisation had the shortest healing time (P = 0.69). Seton placement was the best procedure to avoid postoperative incontinence (P = 0.66). Fistulectomy exhibited the lowest recurrence rate (Probability P = 0.40). In general, fistulotomy plus marsupialisation and surgical ligation plus biomaterial plugging revealed superior clinical efficacy. Node-splitting model testing revealed that no significant inconsistency existed in this research. CONCLUSIONS Fistulotomy plus marsupialisation exhibited preliminary superior surgical utility for anal fistula. Additionally, combination of surgical treatment with biomaterials may provide better clinical efficacy. These techniques may warrant consideration for future development in this field.
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Affiliation(s)
- Qi Wang
- The 1st Department of Gastrointestinal Surgery, Renmin Hospital of Wuhan University, Hubei Province, Wuhan 430060, P.R. China
| | - Yukun He
- Department of General Surgery, Zhongnan Hospital of Wuhan University, Hubei Province, Wuhan 430071, P.R. China
| | - Jun Shen
- Emergency Center, Zhongnan Hospital of Wuhan University, Hubei Province, Wuhan 430071, P.R. China
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Placer Galán C, Lopes C, Múgica JA, Saralegui Y, Borda N, Enriquez Navascues JM. Patrones de recurrencia/persistencia en la operación de LIFT para la fístula anal de origen criptoglandular. Estudio observacional a largo plazo. Cir Esp 2017; 95:385-390. [DOI: 10.1016/j.ciresp.2017.05.010] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2017] [Revised: 05/30/2017] [Accepted: 05/30/2017] [Indexed: 12/28/2022]
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Garg P. Comparing existing classifications of fistula-in-ano in 440 operated patients: Is it time for a new classification? A Retrospective Cohort Study. Int J Surg 2017; 42:34-40. [PMID: 28414118 DOI: 10.1016/j.ijsu.2017.04.019] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2017] [Accepted: 04/10/2017] [Indexed: 01/14/2023]
Abstract
BACKGROUND Fistula-in-ano are classified so as to grade them according to increasing complexity which can help guide their management. The classifications used are Parks, St James Hospital University (SJHU) and Standard Practice Task Force (SPTF). Laying open (fistulotomy) of the fistula tract is the most commonly done procedure for fistula-in-ano and has high success rate. The lower grade fistulas are supposed to have low risk of incontinence when laid open and vice-versa. The objective of the study was to evaluate the efficacy of the existing classifications. MATERIALS & METHODS 440 consecutive fistula-in-ano patients operated over four years were analyzed on the basis of preoperative MRI scan and operative findings. It was assessed whether the amenability to fistulotomy (measurement of fistula simplicity) correlated with the fistula-in-ano grades in different classifications. RESULTS Out of 440 patients operated, 242 underwent fistulotomy whereas 198 underwent sphincter-sparing procedures for complex fistula. As per SJHU classification, the amenability to fistulotomy was 99.1% in Grade-I, 82.1% in Grade-II, 46.2% in Grade-III, 29.0% in Grade-IV and 5.4% in Grade-V. In Park's classification, the amenability to fistulotomy was 93.5% in Grade-I, 34.8% in Grade-II, 5.4% in Grade-III and 0% in Grade-IV. As per SPTF classification, 99.3% of simple and 32.1% of complex fistulas underwent fistulotomy. Even the higher grade fistula-in-ano in all three classifications had high rate of amenability to fistulotomy. Therefore none of the above classifications were accurate. A new classification is being proposed which divides fistula-in-ano in 5 grades in order of increasing complexity. Grade I & II are simple fistulas (fistulotomy be done conveniently) and Grade III-V are high complex fistulas (fistulotomy should not be attempted). The data was analyzed as per new classification and found it to be highly accurate. CONCLUSIONS None of the existing classifications accurately correlated between the grade and the complexity of fistula. A new classification is being proposed.
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Affiliation(s)
- Pankaj Garg
- Colorectal Surgery Division, Indus Super Specialty Hospital, Mohali, Punjab, India; Garg Fistula Research Institute, Panchkula, Haryana, India.
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Garg P. Transanal opening of intersphincteric space (TROPIS) - A new procedure to treat high complex anal fistula. Int J Surg 2017; 40:130-134. [PMID: 28259693 DOI: 10.1016/j.ijsu.2017.02.095] [Citation(s) in RCA: 49] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2017] [Revised: 02/24/2017] [Accepted: 02/28/2017] [Indexed: 02/06/2023]
Abstract
BACKGROUND The sepsis in intersphincteric space has important role in pathogenesis of most complex fistula-in-ano. This sepsis is like a small abscess in a closed space. This closed space needs to be drained adequately and then kept open for the fistula-in-ano to heal properly. The aim was to lay open and drain the intersphincteric space through internal opening via transanal approach. This has been tried in submucosal and intersphincteric rectal abscesses but has never been tried in complex fistula-in-ano. MATERIALS AND METHODS All consecutive patients of complex high (involving >1/3 of sphincter complex) fistula-in-ano who were operated were included in the prospective cohort study. Preoperative MRI scan was done in all the patients. Transanal laying open of the intersphincteric space (TROPIS) was done through the internal opening. The external sphincter was not cut. The tracts in the ischiorectal fossa were curetted and cleaned. The incontinence scores were measured. RESULTS 61 patients with high complex fistula-in-ano were included (follow-up:6-21 months). Male/Female:59/2, age-42.3 ± 9.5 years. 85.2% (52) were recurrent, 83.6% (51) had multiple tracts, 36.1% (22) had horseshoe tract, 34.4% (21) had supralevator extension and 26.2% (16) had associated abscess. 95.1% (58) were posterior fistula out of which 90.2% (55) were in posterior midline. Nine patients were excluded (due to tuberculosis, lost to follow-up). Fistula healed completely in 84.6% (44/52) and didn't heal in 15.4% (9/52). 4/9 of these were reoperated and fistula healed in three patients. Thus overall healing rate was 90.4% (47/52). There was no significant change in incontinence scores. CONCLUSIONS TROPIS is a simple effective sphincter sparing procedure to treat high complex fistula-in-ano including supralevator and horseshoe fistula.
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Affiliation(s)
- Pankaj Garg
- Colorectal Surgery Division, Indus Super Specialty Hospital, Mohali, Punjab, India; Garg Fistula Research Institute, Panchkula, Haryana, India.
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Ommer A, Herold A, Berg E, Fürst A, Post S, Ruppert R, Schiedeck T, Schwandner O, Strittmatter B. German S3 guidelines: anal abscess and fistula (second revised version). Langenbecks Arch Surg 2017; 402:191-201. [PMID: 28251361 DOI: 10.1007/s00423-017-1563-z] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2016] [Accepted: 02/01/2017] [Indexed: 12/18/2022]
Abstract
BACKGROUND The incidence of anal abscess and fistula is relatively high, and the condition is most common in young men. METHODS This is a revised version of the German S3 guidelines first published in 2011. It is based on a systematic review of pertinent literature. RESULTS Cryptoglandular abscesses and fistulas usually originate in the proctodeal glands of the intersphincteric space. Classification depends on their relation to the anal sphincter. Patient history and clinical examination are diagnostically sufficient in order to establish the indication for surgery. Further examinations (endosonography, MRI) should be considered in complex abscesses or fistulas. The goal of surgery for an abscess is thorough drainage of the focus of infection while preserving the sphincter muscles. The risk of abscess recurrence or secondary fistula formation is low overall. However, they may result from insufficient drainage. Primary fistulotomy should only be performed in case of superficial fistulas. Moreover, it should be done by experienced surgeons. In case of unclear findings or high fistulas, repair should take place in a second procedure. Anal fistulas can be treated only by surgical intervention with one of the following operations: laying open, seton drainage, plastic surgical reconstruction with suturing of the sphincter (flap, sphincter repair, LIFT), and occlusion with biomaterials. Only superficial fistulas should be laid open. The risk of postoperative incontinence is directly related to the thickness of the sphincter muscle that is divided. All high anal fistulas should be treated with a sphincter-saving procedure. The various plastic surgical reconstructive procedures all yield roughly the same results. Occlusion with biomaterial results in lower cure rate. CONCLUSION In this revision of the German S3 guidelines, instructions for diagnosis and treatment of anal abscess and fistula are described based on a review of current literature.
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Affiliation(s)
- Andreas Ommer
- End- und Dickdarm-Zentrum Essen, Rüttenscheider Strasse 66, 45130, Essen, Germany.
| | | | - Eugen Berg
- Prosper-Hospital Recklinghausen, Recklinghausen, Germany
| | - Alois Fürst
- Caritas-Krankenhaus Regensburg, Regensburg, Germany
| | - Stefan Post
- Universitätsklinikum Mannheim, Mannheim, Germany
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Ommer A, Herold A, Berg E, Farke S, Fürst A, Hetzer F, Köhler A, Post S, Ruppert R, Sailer M, Schiedeck T, Schwandner O, Strittmatter B, Lenhard BH, Bader W, Krege S, Krammer H, Stange E. S3-Leitlinie: Kryptoglanduläre Analfisteln. COLOPROCTOLOGY 2016. [DOI: 10.1007/s00053-016-0110-7] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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Clinical Practice Guideline for the Management of Anorectal Abscess, Fistula-in-Ano, and Rectovaginal Fistula. Dis Colon Rectum 2016; 59:1117-1133. [PMID: 27824697 DOI: 10.1097/dcr.0000000000000733] [Citation(s) in RCA: 215] [Impact Index Per Article: 23.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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Alvandipour M, Ala S, Tavakoli H, Yazdani Charati J, Shiva A. Efficacy of 10% sucralfate ointment after anal fistulotomy: A prospective, double-blind, randomized, placebo-controlled trial. Int J Surg 2016; 36:13-17. [PMID: 27765686 DOI: 10.1016/j.ijsu.2016.10.017] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2016] [Revised: 09/25/2016] [Accepted: 10/03/2016] [Indexed: 11/19/2022]
Abstract
INTRODUCTION The most frequent problems after anal fistulotomy are pain, bleeding, and delayed or impaired wound healing. Topical Sucralfate preparation has been used to treat a wide variety of wounds. In this study, we investigate effects of 10% sucralfate ointment on wound healing and postoperative pain after fistulotomy. METHODS AND MATERIALS A total of 41 patients undergoing anorectal fistulotomy were included in this randomized, blinded, controlled trial and were randomly allocated to either sucralfate ointment (every 12 h) or placebo. The patients were visited weekly for up to 5 weeks. The intensity of pain and the wound healing were assessed. RESULTS The sucralfate group had significantly less pain at rest (1.92 ± 0.88 vs 2.96 ± 0.98; P = 0.002) and on defecation (1.68 ± 0.92 vs 3.08 ± 1.12; p < 0.001) than the placebo group from 1st to 5th post-operative visits. Complete wound healing was achieved after 8.15 ± 1 weeks in placebo group versus 5.9 ± 0.8 weeks in sucralfate group (p < 0.001). There were no significant differences in the frequencies of postoperative complications between the two groups. CONCLUSION Compared with placebo, sucralfate ointment reduced postoperative pain at rest and on defecation and improves wound healing in patients undergoing fistulotomy.
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Affiliation(s)
- Mina Alvandipour
- Department of Surgery, Imam Khomeini Hospital, Mazandaran University of Medical Sciences, Sari, Mazandaran Province, Iran
| | - Shahram Ala
- Department of Clinical Pharmacy, Pharmaceutical Sciences Research Center, Faculty of Pharmacy, Mazandaran University of Medical Sciences, Sari, Mazandaran Province, Iran.
| | - Hasan Tavakoli
- Department of Surgery, Imam Khomeini Hospital, Mazandaran University of Medical Sciences, Sari, Mazandaran Province, Iran
| | - Jamshid Yazdani Charati
- Department of Biostatics, Health Sciences Research Center, Faculty of Health, Mazandaran University of Medical Sciences, Sari, Mazandaran Province, Iran
| | - Afshin Shiva
- Department of Clinical Pharmacy, Nephrology and Kidney Transplant Research Center, Faculty of Pharmacy, Urmia University of Medical Sciences, Urmia, Iran
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Xu Y, Liang S, Tang W. Meta-analysis of randomized clinical trials comparing fistulectomy versus fistulotomy for low anal fistula. SPRINGERPLUS 2016; 5:1722. [PMID: 27777858 PMCID: PMC5052239 DOI: 10.1186/s40064-016-3406-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/13/2016] [Accepted: 09/28/2016] [Indexed: 11/10/2022]
Abstract
Objective We evaluated the efficacy of fistulectomy compared to fistulotomy, and which procedure was the best procedure for patients with low anal fistula. Methods The literature search included PubMed, EMBASE, Cochrane library, Google original studies and a manual search of reference on the topic of fistulectomy compared to fistulotomy for anal fistula that had a deadline for publication by June 2016. Randomized controlled trials studies were included in the review. The outcome variables were analyzed which including operative time, healing time, postoperative complications, recurrence and incontinence. Results Six randomized controlled trials (fistulectomy = 280, fistulotomy = 285) were considered suitable for the meta-analysis, with a total of 565 patients. The result of meta-analysis indicated no statistically significant difference in operative time [OR 4.74, 95 % CI −2.74, 12.23, p = 0.21] and healing time [OR −3.32, 95 % CI −19.86, 13.23, p = 0.69] between the fistulectomy and fistulotomy procedures. Three main postoperative complications were included, and the combined result indicated no statistically significant difference in overall complications [OR 1.39, 95 % CI 0.51, 3.78, p = 0.52] and subgroup complication. At the end of follow up, two kinds of surgical methods have the same low recurrence rate and faecal incontinence. The result revealed that there was no significant difference in rate of fistula recurrence between the fistulectomy and the fistulotomy [OR 1.39, 95 % CI 0.70, 2.73, p = 0.34]. Conclusion The meta-analysis indicates that there is no conclusive evidence if fistulectomy or fistulotomy procedure is better in the treatment of low anal fistula.
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Affiliation(s)
- Yansong Xu
- Emergency Department, The First Affiliated Hospital of Guangxi Medical University, Nanning City, People's Republic of China
| | - Siyuang Liang
- Colorectal and Anal Department, The First Affiliated Hospital of Guangxi Medical University, Nanning City, People's Republic of China
| | - Weizhong Tang
- Colorectal and Anal Department, The First Affiliated Hospital of Guangxi Medical University, Nanning City, People's Republic of China
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Ratto C, Litta F, Donisi L, Parello A. Prospective evaluation of a new device for the treatment of anal fistulas. World J Gastroenterol 2016; 22:6936-6943. [PMID: 27570429 PMCID: PMC4974591 DOI: 10.3748/wjg.v22.i30.6936] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2016] [Revised: 06/11/2016] [Accepted: 07/06/2016] [Indexed: 02/06/2023] Open
Abstract
AIM To evaluate the safety of the implantation of a new device for the treatment of anal fistulas. The short-term clinical efficacy was also assessed. METHODS This study took place at a tertiary care university hospital. Patients with a complex anal fistula of cryptoglandular origin were enrolled in the study and were treated with insertion of the new device. All patients were evaluated by clinical and physical examination, including an endoanal ultrasound at the baseline, and then at the 2 wk and 1, 2, 3 and 6-mo follow-up visits. RESULTS Morbidity, continence status, and success rate were the main outcome measures. Ten patients underwent the placement of the new device. The fistulas were transphincteric in eight patients and extrasphincteric in the remaining two. The median duration of the surgical procedure was 34.5 (range, 27-42) min. Neither intra- nor postoperative complications occurred, and all patients were discharged the day after the procedure. At the 6-mo follow-up evaluation, the final success rate was 70%. Three failures were registered: a device expulsion (on the 10(th) postoperative day), the persistence of inflammatory tissue around the fistula tract (at the 2-mo follow up), and the persistence of serum discharge (at the 6-mo follow up). No patient experienced any change incontinence, as assessed by the Cleveland Clinic Fecal Incontinence score. CONCLUSION The technical procedure is simple and has low risk of perioperative morbidity. The pre- and post-operative continence status did not change in any of the patients. The initial results at the 6-mo follow up seem to be promising. However, a longer follow-up period and a larger sample size are needed to confirm these preliminary results.
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Parthasarathi R, Gomes RM, Rajapandian S, Sathiamurthy R, Praveenraj P, Senthilnathan P, Palanivelu C. Ligation of the intersphincteric fistula tract for the treatment of fistula-in-ano: experience of a tertiary care centre in South India. Colorectal Dis 2016; 18:496-502. [PMID: 26476011 DOI: 10.1111/codi.13162] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2015] [Accepted: 08/01/2015] [Indexed: 12/24/2022]
Abstract
AIM Ligation of the intersphincteric fistula tract (LIFT) is a new sphincter-sparing surgical technique increasingly used to treat fistulae-in-ano yielding good results. The aim of this study was to evaluate its effectiveness in the treatment of complex fistulae-in-ano and to determine factors associated with recurrence and its subsequent management. METHOD A prospective observational study was performed of 167 patients with complex fistula-in-ano treated by LIFT from June 2013 to January 2014. In all patients a LIFT with partial core-out of the fistula tract was performed. RESULTS There were 167 patients of mean age 43.6 ± 12.8 years. Thirty-three fistulae were recurrent. 150 were trans-sphincteric, 16 were intersphincteric and one was a suprasphincteric fistula. The median postoperative stay was 2 (range: 1-14) days (mean = 2.4 days). At follow up there was no change in continence. The median healing time was 4 (range: 1-8) weeks. Two patients developed an intersphincteric abscess needing surgical drainage healing uneventfully. The mean follow up was 12.8 [median = 12 (range: 4-22)] months. The healing rate was 94.1%. Ten (5.9%) patients developed a recurrent fistula that was managed by a second LIFT procedure in seven, a sinus tract excision with curettage in two and seton placement in one. Recurrence was significantly associated with diabetes mellitus and perianal collections and showed an increased incidence with tract abscesses and multiple tracts. CONCLUSION LIFT has a high success rate in complex fistulae-in-ano. Recurrence is related to diabetes mellitus, perianal collections, tract abscesses and multiple tracts and a second LIFT procedure may be feasible and efficient.
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Affiliation(s)
- R Parthasarathi
- Department of Surgical Gastroenterology, GEM Hospital and Research Centre, Coimbatore, India
| | - R M Gomes
- Department of Surgical Gastroenterology, GEM Hospital and Research Centre, Coimbatore, India
| | - S Rajapandian
- Department of Surgical Gastroenterology, GEM Hospital and Research Centre, Coimbatore, India
| | - R Sathiamurthy
- Department of Surgical Gastroenterology, GEM Hospital and Research Centre, Coimbatore, India
| | - P Praveenraj
- Department of Surgical Gastroenterology, GEM Hospital and Research Centre, Coimbatore, India
| | - P Senthilnathan
- Department of Surgical Gastroenterology, GEM Hospital and Research Centre, Coimbatore, India
| | - C Palanivelu
- Department of Surgical Gastroenterology, GEM Hospital and Research Centre, Coimbatore, India
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Garg P. PERFACT procedure to treat supralevator fistula-in-ano: A novel single stage sphincter sparing procedure. World J Gastrointest Surg 2016; 8:326-334. [PMID: 27152140 PMCID: PMC4840173 DOI: 10.4240/wjgs.v8.i4.326] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2015] [Revised: 11/22/2015] [Accepted: 01/21/2016] [Indexed: 02/06/2023] Open
Abstract
AIM To prospectively perform the PERFACT procedure in supralevator anal fistula/abscess. METHODS Magnetic resonance imaging was done preoperatively in all the patients. Proximal cauterization around the internal opening, emptying regularly of fistula tracts and curettage of tracts (PERFACT) was done in all patients with supralevator fistula or abscess. All types of anal fistula and/or abscess with supralevator extension, whether intersphincteric or transsphincteric, were included in the study. The internal opening along with the adjacent mucosa was electrocauterized. The resulting wound was left open to heal by secondary intention so as to heal (close) the internal opening by granulation tissue. The supralevator tract/abscess was drained and thoroughly curetted. It was regularly cleaned and kept empty in the postoperative period. The primary outcome parameter was complete fistula healing. The secondary outcome parameters were return to work and change in incontinence scores (Vaizey objective scoring system) assessed preoperatively and at 3 mo after surgery. RESULTS Seventeen patients were prospectively enrolled and followed for a median of 13 mo (range 5-21 mo). Mean age was 41.1 ± 13.4 years, M:F - 15:2. Fourteen (82.4%) had a recurrent fistula, 8 (47.1%) had an associated abscess, 14 (82.4%) had multiple tracts and 5 (29.4%) had horseshoe fistulae. Infralevator part of fistula was intersphincteric in 4 and transsphincteric in 13 patients. Two patients were excluded. Eleven out of fifteen (73.3%) were cured and 26.7% (4/15) had a recurrence. Two patients with recurrence were reoperated on with the same procedure and one was cured. Thus, the overall healing rate was 80% (12/15). All the patients could resume normal work within 48 h of surgery. There was no deterioration in incontinence scores (Vaizey objective scoring system). This is the largest series of supralevator fistula-in-ano (SLF) published to date. CONCLUSION PERFACT procedure is an effective single step sphincter saving procedure to treat SLF with minimal risk of incontinence.
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