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Emile SH, Dourado J, Rogers P, Wignakumar A, Horesh N, Garoufalia Z, Wexner SD. Systematic review and meta-analysis of the efficacy and safety of stem cell treatment of anal fistulas. Tech Coloproctol 2025; 29:100. [PMID: 40205247 PMCID: PMC11982159 DOI: 10.1007/s10151-025-03138-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2024] [Accepted: 03/08/2025] [Indexed: 04/11/2025]
Abstract
BACKGROUND Since anal fistulas can be challenging to treat; numerous innovative treatments have been proposed, including stem cell therapy. This systematic review aimed to assess pooled rates of fistula healing and adverse events associated with stem cell treatment. METHODS In this PRISMA-compliant systematic review we searched PubMed and Scopus for observational and randomized studies reporting outcomes of stem cell treatment for anal fistulas. The main outcome measures were successful healing and adverse effects of stem cell therapy. RESULTS In total, 43 studies incorporating 1160 patients (53.6% male) were included. Underlying fistula etiologies were Crohn's disease (30 studies) and cryptoglandular disease (12 studies). The main origin of stem cells was from adipose tissue (34 studies) or bone marrow (6 studies). The median follow-up duration was 12 months. The combined overall pooled healing rate was 58.1% (95% confidence interval (CI) 51.5-64.7%). The pooled healing rate for Crohn's fistulas was 60.4% (95% CI 54.7-66.2%) with adipose-derived stem cells and 63.6% (95% CI 49.4-77.7%) with bone-marrow-derived cells. The pooled healing rate for cryptoglandular fistulas was 53.8% (95% CI 35.5-72.2%) with adipose-derived stem cells. The pooled complication rate was 37.3% (95% CI 27.1-47.5%). Stem cells were associated with higher odds of anal fistula healing (odds ratio (OR): 1.81, p = 0.003) and similar odds of complications (OR: 1, p = 0.986) compared with controls. CONCLUSIONS Stem cell treatment of anal fistulas was associated with promising results. The healing rate in Crohn's anal fistulas was higher than in cryptoglandular fistulas. Bone-marrow-derived stem cells were associated with marginally better outcomes than were adipose-derived cells. This finding suggests that the autoimmune inflammatory etiology of Crohn's disease may respond better to autologous myoblasts than does the infectious etiology of cryptoglandular fistulas.
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Affiliation(s)
- S H Emile
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd., Weston, FL, 33331, USA
- Colorectal Surgery Unit, General Surgery Department, Mansoura University Hospitals, Mansoura, Egypt
| | - J Dourado
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd., Weston, FL, 33331, USA
| | - P Rogers
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd., Weston, FL, 33331, USA
| | - A Wignakumar
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd., Weston, FL, 33331, USA
| | - N Horesh
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd., Weston, FL, 33331, USA
- Department of Surgery and Transplantation, Sheba Medical Center, Ramat-Gan, Israel
| | - Z Garoufalia
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd., Weston, FL, 33331, USA
| | - S D Wexner
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd., Weston, FL, 33331, USA.
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Munster LJ, Pronk AJM, Mundt MW, Hompes R, Bemelman WA, van der Bilt JDW, Buskens CJ. Prolonged Time to Diagnosis of Crohn's Disease in Patients With Perianal Fistulas Negatively Affects Long-Term Outcomes. J Crohns Colitis 2025; 19:jjae146. [PMID: 39297524 PMCID: PMC11945302 DOI: 10.1093/ecco-jcc/jjae146] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/28/2025]
Abstract
BACKGROUND AND AIM This study aims to evaluate the effect of time to Crohn's disease (CD) diagnosis on perianal fistula (PAF) outcomes in patients with a fistula as the first manifesting sign. METHODS In this multicenter, retrospective study, CD patients with a PAF preceding CD diagnosis between November 2015 and June 2022 were included. The primary outcome parameter was the time to CD diagnosis and its correlation with long-term outcomes. RESULTS In total, 126 patients with a PAF prior to CD diagnosis were identified. The median time to CD diagnosis was 15.0 months (IQR 3.8-47.3). A total of 49 patients (38.9%) had a clinically closed fistula of which 21 patients (42.9%) achieved radiological healing. Twenty-five patients (19.8%) underwent defunctioning, of which 9 patients (36.0%) needed proctectomy. Median time to CD diagnosis was shortest in patients with radiological healing (4.0 months, IQR 2.0-16.5) or clinical closure without radiological healing (11.0 months, IQR 3.0-47.8). In patients without fistula closure (n = 51), the median time to CD diagnosis was significantly longer compared to patients with fistula closure, 18.0 months vs 8.0 months (p = 0.031). In patients who needed defunctioning, the median time to diagnosis was more than twice as long compared to patients without defunctioning, 30.0 months vs 12.0 months (p = 0.054). CONCLUSION A prolonged time to CD diagnosis in patients with a PAF as a manifesting sign is associated with worse long-term outcomes. Patients in whom radiological healing could be achieved had the shortest time to CD diagnosis, emphasizing the relevance of increased clinical awareness of underlying CD in fistula patients.
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Affiliation(s)
- Liesbeth Jozefien Munster
- Department of Surgery, Flevoziekenhuis, Almere, The Netherlands
- Department of Surgery, Amsterdam UMC, Amsterdam, The Netherlands
| | | | - Marco William Mundt
- Department of Gastroenterology and Hepatology, Flevoziekenhuis, Almere, The Netherlands
| | - Roel Hompes
- Department of Surgery, Amsterdam UMC, Amsterdam, The Netherlands
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Sørensen KM, Qvist N. Fistulectomy and primary sphincter reconstruction for high cryptoglandular anal fistula: a retrospective cohort study with long-term results. Surg Endosc 2025; 39:2073-2079. [PMID: 39900860 PMCID: PMC11870885 DOI: 10.1007/s00464-025-11585-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2024] [Accepted: 01/24/2025] [Indexed: 02/05/2025]
Abstract
BACKGROUND Surgical repair for high anal fistulas is challenging and can be associated with impaired functional outcomes. This study evaluated the long-term results of transsphincteric fistulectomy with primary sphincter repair for high anal fistulas in terms of recurrence, wound healing, fecal incontinence, and quality of life. METHOD This retrospective cohort study included patients who underwent surgical repair for high anal fistulas between 2006 and 2015. Data were collected by reviewing patients' electronic hospital records, including demographic characteristics, medical conditions, surgical findings, performed procedures, and follow-up data until the last recorded visit. Functional outcomes were assessed using self-reported online questionnaires for quality of life (RAND SF-36) and fecal incontinence (Wexner score). RESULTS Fifty-five patients were included. Primary healing was achieved in 42 (76%) patients, while 13 (24%) experienced recurrence. Following reoperations for recurrence, an additional 12 patients achieved healing, resulting in an overall healing rate of 98%. The median Wexner score was significantly higher in reoperated patients, and the median scores across all eight parameters of the RAND SF-36 were lower. None of the patients required proctectomy, and two ended with permanent stomas. CONCLUSION Surgery for high anal fistulas is associated with a high success rate, but reoperations for recurrence are linked to considerable impairment in functional outcomes.
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Affiliation(s)
- Karam Matlub Sørensen
- Research Unit of Surgery, Odense University Hospital, J.B. Winsløws, Vej 4, 5000, Odense C, Denmark.
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark.
| | - Niels Qvist
- Research Unit of Surgery, Odense University Hospital, J.B. Winsløws, Vej 4, 5000, Odense C, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
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Lim G, Ng ZQ, Warrier S. Treating cryptogenic anorectal fistulas with hyperbaric oxygen therapy - an unexplored area with potential. ANZ J Surg 2025. [PMID: 39887487 DOI: 10.1111/ans.70002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2025] [Accepted: 01/21/2025] [Indexed: 02/01/2025]
Affiliation(s)
- Gillian Lim
- Colorectal Unit, Department of General Surgery, The Alfred, Melbourne, Victoria, Australia
| | - Zi Qin Ng
- Colorectal Unit, Department of General Surgery, The Alfred, Melbourne, Victoria, Australia
| | - Satish Warrier
- Colorectal Unit, Department of General Surgery, The Alfred, Melbourne, Victoria, Australia
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Yi H, Zheng Y, Yan Z. Efficacy of radial incision combined with tunnel floating line drainage in the treatment of high posterior horseshoe anal fistula and perianal flora: Randomized control trial. Medicine (Baltimore) 2024; 103:e39947. [PMID: 39465802 PMCID: PMC11479427 DOI: 10.1097/md.0000000000039947] [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: 05/19/2024] [Accepted: 09/13/2024] [Indexed: 10/29/2024] Open
Abstract
BACKGROUND Due to the high prevalence of posterior horseshoe anal fistula and causing numerous complications, this study aimed to investigate the clinical effect of radial incision combined with tunnel floating line drainage (RCTD) and arc incision internal drainage in the treatment of the disease and the influence on perianal flora. METHODS Ninety-six subjects treated with high posterior horseshoe anal fistula were stochastically assigned to a joint group (RCTD), and control group (arc incision internal drainage). The operation-related conditions, complication rate, anal function, and recurrence rate of 6 months after operation were compared, and perianal secretions were collected before operation and 1 day after operation to detect the changes of microbial flora. RESULTS After operation, it was corroborated notable difference between joint group and control group in operation time, intraoperative blood loss, wound healing time, visual analogue scale score 6 hours after operation and phase I cure rate. Chi square test analysis showed notable difference between control group (27.08%) and joint group (10.40%) in incidence of complications, in terms of number of pathogens detected around anus, significantly smaller of the incremental change for the joint subgroup versus the control subgroup 1 day after operation. CONCLUSION RCTD can be the best choice for patients with high posterior horseshoe anal fistula. This operation method has the advantages of short operation time, less trauma, fewer complications, fast recovery of anal function, and can also reduce perianal pathogenic bacteria infection.
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Affiliation(s)
- Hang Yi
- Huazhong Agricultural University Hospital, Wuhan, Hubei, P. R. China
| | - Yong Zheng
- Department of Anorectal Surgery, Wuhan Hospital of Traditional Chinese Medicine, Wuhan, Hubei, P. R. China
| | - Zhengqing Yan
- Department of Surgery, Wuhan University of Technology Hospital, Wuhan, Hubei, P. R. China
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Bopparathi S, K V NR. Extrasphincteric anal fistula with intrarectal opening extended upto thigh, successfully treated with a minimally invasive, novel surgical technique- a rare case report. Int J Surg Case Rep 2024; 123:110259. [PMID: 39255731 PMCID: PMC11413687 DOI: 10.1016/j.ijscr.2024.110259] [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: 07/13/2024] [Revised: 08/30/2024] [Accepted: 09/05/2024] [Indexed: 09/12/2024] Open
Abstract
INTRODUCTION Fistula in ano is a complex disease, and the treatment for it is still a big challenge for surgeons because of the high recurrence rate (7 %-50 %) and incontinence, and to minimize these complications numerous surgical interventions are emerging daily in the conventional system of medicine. PRESENTATION OF CASE A 48- year- old male patient came with complaints of pus discharge from an external opening in the inner aspect of his right thigh, located about 22 to 25 cm away from the anal verge for the last 15 years and was diagnosed as long extrasphincteric fistula with intrarectal opening based on clinical and MRI findings. We successfully treated this case with a minimally invasive novel surgical technique, RetroGrade Probing and Application of KharaSutra and Division of the Fistulous Tract (RGPAKS- DFT). DISCUSSION Ksharasutra is a well-known method in the treatment of anal fistula for preserving continence and a low recurrence rate. Performing retrograde probing in every single case of anal fistula can address the involved anal gland under direct vision, which is essential for preventing recurrence and pairing retrograde probing with the division of the fistulous tract significantly reduces the treatment duration with minimal tissue loss. CONCLUSION In fistula surgery, successful treatment relies on identifying the internal opening and eradicating the involved anal glands. Based on the same principle, this rare and complex anal fistula was effectively treated with this RGPAKS-DFT, resulting in no recurrence and incontinence in two years of follow-up after complete recovery.
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Affiliation(s)
- Swapna Bopparathi
- Associate Professor, Department of Shalya Tantra, National Institute of Ayurveda, Deemed to be University, Amer Road, Jaipur, Rajasthan, India.
| | - Narasimha Raju K V
- Former Head and Professor, Dept. of Kaya Chikitsa, Faculty of Ayurvedic Sciences, Jayoti Vidyapeeth Women's University, Jaipur, Rajasthan, India
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White I, Karki C, Geransar P, Leisle L, Junker S, Fleshner P. Impact of Seton Use on Clinical, Patient-Reported, and Healthcare Resource Utilization Outcomes in Complex Crohn's Perianal Fistulas: A Systematic Literature Review. Inflamm Bowel Dis 2024:izae186. [PMID: 39298676 DOI: 10.1093/ibd/izae186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2024] [Indexed: 09/22/2024]
Abstract
BACKGROUND Optimal treatment strategies for seton use in patients with Crohn's perianal fistulas (CPF) remain elusive. This systematic literature review aimed to summarize clinical, patient-reported, and healthcare resource utilization (HCRU) outcomes associated with seton use for symptomatic relief and treatment of complex CPF. METHODS Electronic databases (MEDLINE, Embase, EBM Reviews, EconLit) were searched. Titles, abstracts, and relevant full texts were screened by 2 reviewers for inclusion using prespecified PICOS-T criteria. Articles published in English between January 1, 1980 and September 6, 2021 were included; animal/in vitro studies and case reports with <5 patients were excluded. Outcomes of interest included rates of complete response/remission and fistula recurrence in patients receiving seton with/without infliximab or biologics. Data were summarized using descriptive statistics. RESULTS Overall, 56 studies were included (full texts: n = 43; congress abstracts: n = 13). CPF and clinical outcome definitions were heterogeneous. Rates (range) of complete response/remission varied widely (seton: 13%-75%; seton + infliximab: 23%-100%; seton + biologics: 23%-59%) as did rates for fistula recurrence (seton: 4%-68%; seton + infliximab: 0%-50%; seton + biologics: 0%-17%). Rates of fistula-related reintervention, new fistula or abscess formation, and abscess recurrence were also varied; more consistency was observed regarding the use of patient-reported outcomes. Few studies reported outcomes from pediatric/adolescent patients or HCRU. CONCLUSIONS Optimal use of seton in patients with CPF remains unclear. International standardization of definitions for CPF and related clinical outcomes are required to permit data comparability and identify the most effective treatment strategies involving seton use in CPF.
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Affiliation(s)
- Ian White
- Department of Surgery, Beilinson Hospital, Rabin Medical Center, Petah Tikva, Israel
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Chitra Karki
- Takeda Pharmaceuticals USA, Inc., Cambridge, MA, USA
| | - Parnia Geransar
- Takeda Pharmaceuticals International AG, Zurich, Switzerland
| | - Lilia Leisle
- Ingress-Health HWM GmbH, an affiliate of Cytel, Inc., Real World & Advanced Analytics, Berlin, Germany
| | - Sophia Junker
- Ingress-Health HWM GmbH, an affiliate of Cytel, Inc., Real World & Advanced Analytics, Berlin, Germany
| | - Phillip Fleshner
- Cedars-Sinai Medical Center, Division of Colon and Rectal Surgery, Los Angeles, CA, USA
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McCurdy JD, Crooks P, Gwaltney C, Krupnick R, Cadogan KA, Karki C. Development of a new patient-reported outcome measure for complex cryptoglandular fistulas (20-Item complex cryptoglandular fistula questionnaire ™): a qualitative study. J Patient Rep Outcomes 2024; 8:99. [PMID: 39172310 PMCID: PMC11341802 DOI: 10.1186/s41687-024-00729-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2024] [Accepted: 05/01/2024] [Indexed: 08/23/2024] Open
Abstract
BACKGROUND There are limited tools to measure the burden of disease and effectiveness of medical/surgical interventions in patients with cryptoglandular fistulas. The aim of this study was to explore concepts that are relevant and important to patients with complex cryptoglandular fistulas (CCF) and to develop a patient-centred, disease-specific, patient-reported outcome measure (PROM) to assess symptom burden and impacts of CCF. METHODS A targeted literature review was conducted, followed by one-to-one telephone interviews with five colorectal surgeons (USA, n = 3; UK, n = 1; Spain, n = 1) and 20 US adult patients with CCF to inform the development of a conceptual model and a CCF-specific PROM. The targeted literature review informed the development of the preliminary conceptual model and identified a PROM in the literature that was used as a reference to generate the draft CCF-specific PROM. The colorectal surgeon interviews provided insights on the experience of patients with CCF to refine the conceptual model, formulate probing questions for use in patient interviews, and to develop the draft CCF-specific PROM. Patients' descriptions of their experiences with symptoms and the impacts on their lives and evaluation of the draft CCF-specific PROM in concept elicitation and cognitive interviews were used to develop the final conceptual model and final CCF-specific PROM. RESULTS Ten symptoms (odour, pain during bowel movement, abscess, post-operative pain, discharge/drainage/leakage, anal/perianal pain, inflammation/swelling, skin irritation, bleeding and itchiness) and 11 impacts (discomfort, inability to exercise, embarrassment, difficulty sitting, worry about disease, adapted life to maintain hygiene, negatively impacted social life/isolation, inability to perform daily activities, reduced interest in sex, negatively impacted intimate relationships and negatively impacted mood) were reported as most salient by patients. The patient experience, clinician perspective, and literature review provided input to item generation. Evaluation of relevance and patient understanding through cognitive interviews with patients provided evidence for the content validity of the new patient-reported outcome measure: the 20-item Complex Cryptoglandular Fistula Questionnaire™ (CCFQ-20™). CONCLUSION The CCFQ-20™ is a new clinician-guided, patient-validated, disease-specific patient-reported outcome measure that measures disease impact and quality of life in patients with CCF.
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Affiliation(s)
- Jeffrey D McCurdy
- Department of Medicine, University of Ottawa and Ottawa Hospital Research Institute, General Campus, 501 Smyth Road, Box 206, Ottawa, ON, K1H 8L6, Canada.
| | - Patrick Crooks
- IQVIA Real World Solutions, Patient Centered Solutions, New York, NY, USA
| | | | - Robert Krupnick
- IQVIA Real World Solutions, Patient Centered Solutions, Cambridge, MA, USA
| | | | - Chitra Karki
- Takeda Pharmaceuticals USA Inc, Cambridge, MA, USA
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Bikkumalla S, Chandak SR, Zade AA, Reddy S, Ram Sohan P, Hatewar A. Omentoplasty in Surgical Interventions: A Comprehensive Review of Techniques and Outcomes. Cureus 2024; 16:e66227. [PMID: 39238731 PMCID: PMC11374580 DOI: 10.7759/cureus.66227] [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: 07/20/2024] [Accepted: 08/05/2024] [Indexed: 09/07/2024] Open
Abstract
Omentoplasty, a surgical technique utilizing the omentum's unique properties, has become a pivotal intervention across various surgical fields. This comprehensive review explores the historical evolution, techniques, applications, outcomes, and complications associated with omentoplasty. With its rich vascular supply, lymphatic tissue, and remarkable immunological properties, the omentum has proven invaluable in enhancing wound healing, controlling infections, and providing mechanical support in complex surgical scenarios. The review delves into the anatomy and physiology of the omentum, elucidating its role in promoting angiogenesis and combating infections. Different omentoplasty techniques, including open, laparoscopic, and robotic-assisted approaches, are compared with regard to indications, procedural steps, and outcomes. The applications of omentoplasty span general surgery, cardiothoracic surgery, neurosurgery, gynecologic surgery, and urologic surgery, highlighting its versatility and broad clinical relevance. Short-term and long-term outcomes of omentoplasty, including postoperative recovery, complication rates, recurrence rates, and quality of life, are thoroughly analyzed. The review addresses common and rare complications, emphasizing prevention and management strategies to optimize patient outcomes. Innovations in surgical techniques, the use of biomaterials, and the potential for synthetic or bioengineered omentum are discussed, underscoring the future directions and research opportunities in this field. By providing a detailed examination of omentoplasty, this review aims to enhance understanding, guide clinical practice, and inspire future research to further improve surgical outcomes and patient care.
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Affiliation(s)
- Shruthi Bikkumalla
- General Surgery, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Suresh R Chandak
- General Surgery, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Anup A Zade
- General Surgery, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Srinivasa Reddy
- General Surgery, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Poosarla Ram Sohan
- General Surgery, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Akansha Hatewar
- General Surgery, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
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Norčič G, Smrekar N, Marković S, Barišić G, Kiudelis G, Paužas H, Molnár T, Szijarto A, Šerclová Z, Roblek T, Uršič V, White I. Insights into treatment of complex Crohn's perianal fistulas. BMC Proc 2024; 18:7. [PMID: 38658942 PMCID: PMC11044286 DOI: 10.1186/s12919-024-00291-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/26/2024] Open
Abstract
Complex perianal fistula is a common complication of Crohn's disease (CD) which leads to negative impact on patient's quality of life. Successful management of the disease requires a multidisciplinary approach, including a gastroenterologist and a colorectal surgeon, applying combined surgical and medical therapy. One of frequently practiced surgical procedures is seton placement in the fistula tract, which is used to control perianal sepsis and drain the fistula, while preventing recurrent abscess formation.Darvadstrocel, a suspension of expanded, allogeneic, adipose-derived, mesenchymal stem cells, is safe and effective for treatment-refractory complex perianal fistulas in patients with Crohn's disease. Following approval of darvadstrocel, the INSPIRE registry is being conducted in order to evaluate long-term safety and effectiveness of the drug on a large, heterogenous population.An online expert meeting was held from March 20 to March 30, 2023, which provided relevant insights into the decision-making process regarding seton use and obtained feedback on the first experiences with darvadstrocel. The aim of this article is to present the perspectives from gastroenterologists and colorectal surgeons practicing in Czechia, Hungary, Israel, Lithuania, Serbia, and Slovenia in topics such as diagnosis and treatment options for patients with complex Crohn's perianal fistulas (CPF), specifically focusing on the use of setons and darvadstrocel.During this virtual session, unavailability of comprehensive data on safety and efficacy of available treatment procedures was emphasized as an important obstacle towards development of standardized recommendations and improvement of outcomes in treatment of (CPF). Furthermore, achieving consensus in seton use, duration of its placement, and frequency of change is recognized as one of CPF treatments major challenges. Despite these issues, it is important to promote better understanding and treatment of complex perianal fistulas in order to improve the quality of life of those affected by this condition.
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Affiliation(s)
- Gregor Norčič
- University Medical Centre Ljubljana, Zaloška Cesta 2, Ljubljana, Slovenia
| | - Nataša Smrekar
- University Medical Centre Ljubljana, Zaloška Cesta 2, Ljubljana, Slovenia
| | - Srđan Marković
- Clinical Hospital Centre Zvezdara, Preševska 31, Belgrade, Serbia
| | - Goran Barišić
- University Clinical Centre of Serbia, Pasterova 2, Belgrade, Serbia
| | - Gediminas Kiudelis
- Lithuanian University of Health Sciences Kaunas Clinics, Eivenių G. 2, Kaunas, Lithuania
| | - Henrikas Paužas
- Lithuanian University of Health Sciences Kaunas Clinics, Eivenių G. 2, Kaunas, Lithuania
| | - Tamás Molnár
- University of Szeged, Dugonics Tér 13, Szeged, Hungary
| | | | - Zuzana Šerclová
- Military University Hospital, U Vojenské Nemocnice 1200, Prague, Czechia
| | - Tina Roblek
- Takeda Pharmaceuticals, d.o.o., Bleiweisova Cesta 30, Ljubljana, Slovenia
| | - Viktor Uršič
- Takeda Pharmaceuticals, d.o.o., Bleiweisova Cesta 30, Ljubljana, Slovenia
| | - Ian White
- Beilinson Hospital, Rabin Medical Center, Ze'ev Jabotinsky Street 39, Petah Tikva, Israel.
- Tel Aviv University, Ramat Aviv, Tel Aviv, Israel.
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Ram E, Zager Y, Carter D, Saukhat O, Anteby R, Nachmany I, Horesh N. A Prospective, Single-Arm Study to Evaluate the Safety and Efficacy of an Autologous Blood Clot Product in the Treatment of Anal Fistula. Dis Colon Rectum 2024; 67:541-548. [PMID: 38149981 PMCID: PMC10901226 DOI: 10.1097/dcr.0000000000003190] [Citation(s) in RCA: 1] [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] [Indexed: 12/28/2023]
Abstract
BACKGROUND Surgical treatment of complex perianal fistula is technically challenging, associated with risk of failure, and may require multiple procedures. In recent years, several biologic agents have been developed for permanently eradicating anal fistulous disease with variable success. In this study, the treatment is an autologous whole-blood product created from the patients' blood. It forms a provisional matrix that was found to be safe and effective in healing acute and chronic cutaneous wounds. OBJECTIVE The study aimed to assess the efficacy and safety of an autologous blood clot product as a treatment for transsphincteric perianal fistulas. DESIGN A prospective single-arm study. SETTINGS A single tertiary medical center. PATIENTS Patients with simple or complex transsphincteric fistulas confirmed by MRI were included in the study. Cause was either cryptoglandular or Crohn's disease related (in the absence of active luminal bowel disease). INTERVENTION The outpatient procedure was performed under general anesthesia and consisted of: 1) physical debridement and cleansing of the fistula tract; 2) suture closure of the internal opening; and 3) instillation of the autologous blood clot product into the entire tract. MAIN OUTCOME MEASURES Safety and efficacy at 6- and 12-months after surgery. RESULTS Fifty-three patients (77% men) with a median age of 42 (20-72) years were included in the study. Three patients withdrew consent, and 1 patient was lost to follow-up. At the time of this interim analysis, 49 and 33 patients completed the 6- and 12-month follow-up period. Thirty-four of the 49 patients achieved complete healing (69%) at 6 months, but 20 of the 33 patients (60%) achieved healing after 1 year. All patients who achieved healing at 6 months remained healed at the 1-year mark. In a subgroup analysis of patients with Crohn's disease, 7 of 9 patients completed 1-year follow-up, with 5 patients (71%) achieving clinical remission. No major side effects or postoperative complications were noted, but 2 adverse events occurred (admission for pain control and coronavirus 2019 infection). LIMITATIONS Noncomparative single-arm pilot study. CONCLUSIONS Treatment with an autologous blood clot product in perianal fistular disease was found to be feasible and safe, with an acceptable healing rate in both cryptoglandular and Crohn's disease fistula-in-ano. Further comparative assessment is required to determine its potential role in the treatment paradigm of fistula-in-ano. See Video Abstract . BRAZO PARA EVALUAR LA SEGURIDAD Y EFICACIA DE RDVER, UN COGULO DE SANGRE AUTLOGO, EN EL TRATAMIENTO DE LA FSTULA ANAL ANTECEDENTES:El tratamiento quirúrgico de la fístula perianal compleja es técnicamente desafiante, se asocia con riesgo de fracaso y puede requerir múltiples procedimientos. En los últimos años, se han desarrollado varios agentes biológicos con el fin de erradicar permanentemente la enfermedad fistulosa anal con éxito variable. El tratamiento RD2-Ver.02 es un producto de sangre total autólogo creado a partir de la sangre de los pacientes, que forma una matriz provisional que resultó segura y eficaz para curar heridas cutáneas agudas y crónicas.OBJETIVO:Evaluar la eficacia y seguridad de RD2-Ver.02 como tratamiento para las fístulas perianales transesfinterianas.DISEÑO:Un estudio prospectivo de un solo brazo.LUGARES:Un único centro médico terciario.PACIENTES:Se incluyeron en el estudio pacientes con fístulas transesfinterianas simples o complejas confirmadas mediante resonancia magnética. La etiología fue criptoglandular o relacionada con la enfermedad de Crohn (en ausencia de enfermedad intestinal luminal activa).INTERVENCIÓN:El procedimiento ambulatorio se realizó bajo anestesia general y consistió en: 1) desbridamiento físico y limpieza del trayecto fistuloso; 2) cierre con sutura de la abertura interna; y 3) instilación de RD2-Ver.02 en todo el tracto.PRINCIPALES MEDIDAS DE VALORACIÓN:Seguridad y eficacia a los 6 y 12 meses después de la cirugía.RESULTADOS:Se incluyeron en el estudio 53 pacientes (77% varones) con una mediana de edad de 42 (20-72) años. Tres pacientes retiraron su consentimiento y un paciente se perdió durante el seguimiento. En el momento de este análisis intermedio, 49 y 33 pacientes completaron el período de seguimiento de 6 y 12 meses, respectivamente. Treinta y cuatro (34) pacientes lograron una curación completa (69%) a los 6 meses, mientras que 20 de 33 pacientes (60%) lograron una curación después de un año. Todos los pacientes que lograron la curación a los 6 meses permanecieron curados al año. En un análisis de subgrupos de pacientes con enfermedad de Crohn, 7/9 pacientes completaron un seguimiento de un año y 5 pacientes (71%) alcanzaron la remisión clínica. No se observaron efectos secundarios importantes ni complicaciones postoperatorias, mientras que ocurrieron 2 eventos adversos (ingreso para control del dolor e infección por COVID-19).LIMITACIONES:Estudio piloto no comparativo de un solo brazo.CONCLUSIONES:Se encontró que el tratamiento con RD2-Ver.02 en la enfermedad fístula perianal es factible y seguro, con una tasa de curación aceptable tanto en la fístula criptoglandular como en la de Crohn en el ano. Se requiere una evaluación comparativa adicional para determinar su papel potencial en el paradigma de tratamiento de la fístula anal. (Pre-proofed version ).
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Affiliation(s)
- Edward Ram
- Department of General Surgery B and Transplantation, Sheba Medical Hospital Center, Tel Hashomer, Ramat Gan, Israel
| | - Yaniv Zager
- Department of General Surgery B and Transplantation, Sheba Medical Hospital Center, Tel Hashomer, Ramat Gan, Israel
| | - Dan Carter
- Department of Gastroenterology, Sheba Medical Center, Tel Hashomer, Ramat Gan, Israel
| | - Olga Saukhat
- Department of Radiology, Sheba Medical Center, Tel Hashomer, Ramat Gan, Israel
| | - Roi Anteby
- Department of General Surgery B and Transplantation, Sheba Medical Hospital Center, Tel Hashomer, Ramat Gan, Israel
| | - Ido Nachmany
- Department of General Surgery B and Transplantation, Sheba Medical Hospital Center, Tel Hashomer, Ramat Gan, Israel
| | - Nir Horesh
- Department of General Surgery B and Transplantation, Sheba Medical Hospital Center, Tel Hashomer, Ramat Gan, Israel
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Aleissa M, Osumah T, Drelichman E, Mittal V, Bhullar J. Current Status and Role of Artificial Intelligence in Anorectal Diseases and Pelvic Floor Disorders. JSLS 2024; 28:e2024.00007. [PMID: 38910957 PMCID: PMC11189024 DOI: 10.4293/jsls.2024.00007] [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] [Indexed: 06/25/2024] Open
Abstract
Background Anorectal diseases and pelvic floor disorders are prevalent among the general population. Patients may present with overlapping symptoms, delaying diagnosis, and lowering quality of life. Treating physicians encounter numerous challenges attributed to the complex nature of pelvic anatomy, limitations of diagnostic techniques, and lack of available resources. This article is an overview of the current state of artificial intelligence (AI) in tackling the difficulties of managing benign anorectal disorders and pelvic floor disorders. Methods A systematic literature review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We searched the PubMed database to identify all potentially relevant studies published from January 2000 to August 2023. Search queries were built using the following terms: AI, machine learning, deep learning, benign anorectal disease, pelvic floor disorder, fecal incontinence, obstructive defecation, anal fistula, rectal prolapse, and anorectal manometry. Malignant anorectal articles and abstracts were excluded. Data from selected articles were analyzed. Results 139 articles were found, 15 of which met our inclusion and exclusion criteria. The most common AI module was convolutional neural network. researchers were able to develop AI modules to optimize imaging studies for pelvis, fistula, and abscess anatomy, facilitated anorectal manometry interpretation, and improved high-definition anoscope use. None of the modules were validated in an external cohort. Conclusion There is potential for AI to enhance the management of pelvic floor and benign anorectal diseases. Ongoing research necessitates the use of multidisciplinary approaches and collaboration between physicians and AI programmers to tackle pressing challenges.
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Affiliation(s)
- Maryam Aleissa
- Fellow of Colorectal Surgery, Ascension Providence Hospital - Michigan State University, College of Human Medicine, Southfield, Michigan, USA
- College of Medicine, Princess Nourah Bint Abdulrahman University, Riyadh, Kingdom of Saudi Arabia
| | - Tijani Osumah
- Fellow of Colorectal Surgery, Ascension Providence Hospital - Michigan State University, College of Human Medicine, Southfield, Michigan, USA
| | - Ernesto Drelichman
- Assistant Program Director of Colorectal Surgery Fellowship, Department of Surgery, College of Human Medicine, Ascension Providence Hospital-Michigan State University, Southfield, Michigan, USA
| | - Vijay Mittal
- Associate DIO Medical Education, Past Program Director, General Surgery, Department of Surgery, College of Human Medicine, Ascension Providence Hospital-Michigan State University, Southfield, Michigan, USA
| | - Jasneet Bhullar
- Program Director of Colorectal Surgery Fellowship, Clinical Assistant Professor WSUCOM/MSUCHM, Department of Surgery, College of Human Medicine, Ascension Providence Hospital-Michigan State University, Southfield, Michigan, USA
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Fousekis FS, Mpakogiannis K, Lianos GD, Koukoudis A, Christodoulou DK, Papaconstantinou I, Katsanos KH. Effectiveness and safety of darvadstrocel in patients with complex perianal fistulizing Crohn's disease: a systematic review. Ann Gastroenterol 2024; 37:46-53. [PMID: 38223244 PMCID: PMC10785025 DOI: 10.20524/aog.2023.0850] [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: 07/01/2023] [Accepted: 11/21/2023] [Indexed: 01/16/2024] Open
Abstract
Background Managing complex perianal fistulizing Crohn's disease (CD) remains challenging, despite current medical and surgical treatment approaches. Darvadstrocel, a therapy utilizing adipose-derived stem cells, shows promise in promoting tissue regeneration and healing, offering a novel and effective treatment for fistula management. Method A systematic literature search was conducted on PubMed and Scopus to identify studies involving patients with complex perianal fistulizing CD treated with darvadstrocel. Results In total, 2 randomized controlled trials (RCT), 5 observational studies with retrospective data collection and 2 observational studies with prospective design were included in the final review. Data from the European ADMIRE-CD RCT demonstrated that darvadstrocel is superior to placebo in terms of clinical and imaging improvement over both the short and long term. These findings align with the prospective studies analyzed in this systematic review. The rate of treatment-emergent adverse events in the ADMIRE-CD trial's RCTs was similar in both the darvadstrocel and control groups, with perianal abscess being the most common adverse event up to 52 weeks after drug administration. Retrospective studies indicated no side-effects beyond 52 weeks. Conclusions Darvadstrocel appears to be a new, potentially effective and safe treatment option for the management of complex perianal fistulas. However, more randomized clinical trials are needed to evaluate the efficacy and safety profile of the drug.
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Affiliation(s)
- Fotios S. Fousekis
- Division of Gastroenterology, Department of Internal Medicine, Faculty of Medicine, School of Health Sciences, University of Ioannina, Greece (Fotios S. Fousekis, Konstantinos Mpakogiannis, Anastasios Koukoudis, Dimitrios K. Christodoulou, Konstantinos H. Katsanos)
| | - Konstantinos Mpakogiannis
- Division of Gastroenterology, Department of Internal Medicine, Faculty of Medicine, School of Health Sciences, University of Ioannina, Greece (Fotios S. Fousekis, Konstantinos Mpakogiannis, Anastasios Koukoudis, Dimitrios K. Christodoulou, Konstantinos H. Katsanos)
| | - Georgios D. Lianos
- Department of Surgery, School of Health Sciences, University Hospital of Ioannina and Faculty of Medicine, University of Ioannina, Greece (Georgios D. Lianos)
| | - Anastasios Koukoudis
- Division of Gastroenterology, Department of Internal Medicine, Faculty of Medicine, School of Health Sciences, University of Ioannina, Greece (Fotios S. Fousekis, Konstantinos Mpakogiannis, Anastasios Koukoudis, Dimitrios K. Christodoulou, Konstantinos H. Katsanos)
| | - Dimitrios K. Christodoulou
- Division of Gastroenterology, Department of Internal Medicine, Faculty of Medicine, School of Health Sciences, University of Ioannina, Greece (Fotios S. Fousekis, Konstantinos Mpakogiannis, Anastasios Koukoudis, Dimitrios K. Christodoulou, Konstantinos H. Katsanos)
| | - Ioannis Papaconstantinou
- Second Department of Surgery, Aretaieion University Hospital, Medical School, National and Kapodistrian University of Athens, Greece (Ioannis Papaconstantinou)
| | - Konstantinos H. Katsanos
- Division of Gastroenterology, Department of Internal Medicine, Faculty of Medicine, School of Health Sciences, University of Ioannina, Greece (Fotios S. Fousekis, Konstantinos Mpakogiannis, Anastasios Koukoudis, Dimitrios K. Christodoulou, Konstantinos H. Katsanos)
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McCurdy JD, Weng R, Parlow S, Dawkins YM, Brar G, Oliveira L, Saloojee N, Murthy S, Kenshil S, Macdonald B, Sabri E, Moloo H, Sy R. Video Capsule Endoscopy can Identify Occult Luminal Crohn's Disease in Patients with Isolated Perianal Fistulas. J Crohns Colitis 2023; 17:1624-1630. [PMID: 37101357 DOI: 10.1093/ecco-jcc/jjad078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2022] [Indexed: 04/28/2023]
Abstract
BACKGROUND Accurate tools to distinguish Crohn's disease [CD] from cryptoglandular disease in patients with perianal fistulas without detectable luminal inflammation on ileocolonoscopy and abdominal enterography (isolated perianal fistulas [IPF]) are lacking. We assessed the ability of video capsule endoscopy [VCE] to detect luminal inflammation in patients with IPF. METHODS We studied consecutive adults [>17 years] with IPF who were evaluated by VCE after a negative ileocolonoscopy and abdominal enterography between 2013 and 2022. We defined luminal CD by VCE as diffuse erythema, three or more aphthous ulcers, or a Lewis score greater than 135. We compared rates of intestinal inflammation in this cohort with age- and sex-matched controls without perianal fistulas, who underwent VCE for other indications. We excluded persons with pre-existing inflammatory bowel disease [IBD] and exposure to non-steroidal anti-inflammatory drugs or immunosuppressive treatments. RESULTS A total of 45 patients with IPF underwent VCE without complications. Twelve patients [26%] met our definition of luminal CD. Luminal CD was more common in patients with IPF than in controls [26% vs 3%; p <0.01]. Among patients with IPF, male sex (OR [odds ratio], 9.2; 95% confidence interval [CI] [1.1-79.4]), smoking (OR, 4.5; 95% CI [0.9-21.2]), abscess (OR, 6.3; 95% CI [1.5-26.8]), rectal enhancement on magnetic resonance imaging [MRI] (OR, 9.0; 95% CI [0.8-99.3]), and positive antimicrobial serology (OR, 7.1; 95% CI, [0.7-70.0]) were more common in those with a positive VCE study. CONCLUSIONS VCE detected small intestinal inflammation suggestive of luminal CD in approximately one-quarter of patients with IPF. Larger studies are required to validate these findings.
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Affiliation(s)
- Jeffrey D McCurdy
- Department of Medicine, University of Ottawa, Ottawa, ON, Canada
- Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Robin Weng
- Department of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Simon Parlow
- Department of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Yvonne M Dawkins
- Department of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Gurmun Brar
- Department of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Liliana Oliveira
- Department of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Nav Saloojee
- Department of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Sanjay Murthy
- Department of Medicine, University of Ottawa, Ottawa, ON, Canada
- Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Sana Kenshil
- Department of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Blair Macdonald
- Ottawa Hospital Research Institute, Ottawa, ON, Canada
- Department of Medical Imaging, University of Ottawa, Ottawa, ON, Canada
| | - Elham Sabri
- Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Husein Moloo
- Ottawa Hospital Research Institute, Ottawa, ON, Canada
- Department of Surgery, University of Ottawa, Ottawa, ON, Canada
| | - Richmond Sy
- Department of Medicine, University of Ottawa, Ottawa, ON, Canada
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Mateescu T, Fulger L, Tummala D, Nelluri A, Kakarla M, Stelea L, Dumitru C, Noditi G, Dobrescu A, Paleru C, Toma AO. Exploring Health-Related Quality of Life in Patients with Anal Fistulas: A Comprehensive Study. Life (Basel) 2023; 13:2008. [PMID: 37895390 PMCID: PMC10608709 DOI: 10.3390/life13102008] [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: 07/18/2023] [Revised: 09/08/2023] [Accepted: 09/25/2023] [Indexed: 10/29/2023] Open
Abstract
Anal fistulas often cause significant impairment to patients' health-related quality of life (HRQOL). This cross-sectional study aimed to compare the HRQOL between patients with anal fistulas with inflammatory bowel disease (IBD) and those without, hypothesizing significant differences in HRQOL scores between these groups. The secondary objectives were to identify specific aspects of life quality most affected and explore potential variables influencing HRQOL. The study was conducted at the Clinical Emergency Hospital "Pius Brinzeu" in Timisoara, Romania, using a convenience sample of 175 adult patients diagnosed with anal fistulas, stratified into IBD and non-IBD groups. Quality of life was evaluated at initial hospital admission and three months post-treatment using four questionnaires: SF-36, GIQLI, HADS, and the WHOQOL-BREF. Initial SF-36 scores were marginally lower in the IBD group, with mean physical and mental scores of 52.0 and 54.5, respectively. Both groups showed an improvement after intervention, but the mean difference was higher in the IBD group, with an increase of 1.1 in physical score. Initial GIQLI scores were significantly lower in the IBD group (110) compared to the non-IBD group (116). Post-intervention, the mean scores increased to 116 and 121, respectively. HADS scores suggested higher anxiety levels in the non-IBD group (7.5 vs. 6.1), although depression scores were similar. Post-intervention, anxiety scores decreased more substantially in the non-IBD group (-0.9 vs. -0.3). The WHOQOL-BREF scores were lower across all domains for the IBD group at the initial test (physical health: 12.4, psychological health: 14.9, social relationships: 14.4, environment: 13.0). Post-intervention, scores increased marginally in the IBD group (physical health: 12.7, psychological health: 15.9, social relationships: 14.1, environment: 13.8) but varied in the non-IBD group. HRQOL, as measured by multiple questionnaires, is impacted differently in anal fistula patients with and without IBD. These findings highlight the importance of a tailored approach to managing this patient population to improve their quality of life post-treatment.
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Affiliation(s)
- Tudor Mateescu
- Department of General Surgery, “Victor Babes” University of Medicine and Pharmacy, Eftimie Murgu Square 2, 300041 Timisoara, Romania; (T.M.); (L.F.); (G.N.); (A.D.)
- Doctoral School, “Victor Babes” University of Medicine and Pharmacy, Eftimie Murgu Square 2, 300041 Timisoara, Romania
| | - Lazar Fulger
- Department of General Surgery, “Victor Babes” University of Medicine and Pharmacy, Eftimie Murgu Square 2, 300041 Timisoara, Romania; (T.M.); (L.F.); (G.N.); (A.D.)
| | - Durganjali Tummala
- Department of General Medicine, K.S. Hegde Medical Academy, Nityanandanagar, Deralakatte, Mangaluru 575018, India;
| | - Aditya Nelluri
- School of General Medicine, Sri Siddhartha Medical College, Tumakuru 572107, India
| | - Manaswini Kakarla
- Kamineni Institute of Medical Sciences, School of Medicine, Hyderabad 500001, India
| | - Lavinia Stelea
- Department of Obstetrics and Gynecology, “Victor Babes” University of Medicine and Pharmacy, Eftimie Murgu Square 2, 300041 Timisoara, Romania;
| | - Catalin Dumitru
- Department of Obstetrics and Gynecology, “Victor Babes” University of Medicine and Pharmacy, Eftimie Murgu Square 2, 300041 Timisoara, Romania;
| | - George Noditi
- Department of General Surgery, “Victor Babes” University of Medicine and Pharmacy, Eftimie Murgu Square 2, 300041 Timisoara, Romania; (T.M.); (L.F.); (G.N.); (A.D.)
| | - Amadeus Dobrescu
- Department of General Surgery, “Victor Babes” University of Medicine and Pharmacy, Eftimie Murgu Square 2, 300041 Timisoara, Romania; (T.M.); (L.F.); (G.N.); (A.D.)
| | - Cristian Paleru
- Department of Thoracic Surgery, “Carol Davila” University of Medicine and Pharmacy, Bulevardul Eroii Sanitari 8, 050474 Bucuresti, Romania;
| | - Ana-Olivia Toma
- Department of Dermatology, “Victor Babes” University of Medicine and Pharmacy, Eftimie Murgu Square 2, 300041 Timisoara, Romania
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Shivakumar V, Jayarajah U, Samarasekera DN. Characteristics and post-operative outcomes of surgery for fistula-in-ano managed at a tertiary care hospital in Sri Lanka: a retrospective study. J Int Med Res 2023; 51:3000605231194516. [PMID: 37706483 PMCID: PMC10503298 DOI: 10.1177/03000605231194516] [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: 05/13/2023] [Accepted: 07/27/2023] [Indexed: 09/15/2023] Open
Abstract
OBJECTIVES Management of fistula-in-ano is associated with recurrence and, occasionally, with anal incontinence. We investigated the clinical characteristics and outcomes of fistula-in-ano. METHODS We included patients with fistula-in-ano managed at a tertiary care center (2016-2021). We collected clinical characteristics and 1-year outcomes using questionnaires. The chi-square test was used in statistical analysis. RESULTS In total, 284 patients (231 men, 81.3%; median age 39.5 [range: 7-73] years) were included. Most patients had simple fistulae (n = 191, 67.3%). Transphincteric (n = 110, 38.7%) fistulae were the most common type, followed by intersphinteric fistulae (n = 103, 36.6%). Fistulotomy (n = 157, 55.3%) was the most common procedure. Follow-up details were traceable in 157 (55.3%) patients. At 1 year, the overall healing rate was 88.5% (n = 136). There was no association between type of surgical procedure and incontinence. The mean Vaizey score, used to assess anal incontinence, was 0.84 (range: 0-14). Incontinence was observed in 32 patients (20.9%), and flatus incontinence was the most common type (n = 17, 53.1%). Complex fistulae were associated with higher recurrence rates than simple fistulae (32.6% vs. 2.8%). CONCLUSION The healing rate in surgical treatment of fistula-in-ano was 88.5%, with acceptable complication rates. There was no association between surgical procedure type and incontinence.
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Affiliation(s)
| | - Umesh Jayarajah
- Department of Surgery, Faculty of Medicine, University of Colombo, Sri Lanka
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Cheng F, Zhong H, Huang Z, Li Z. Up-to-date meta-analysis of long-term evaluations of mesenchymal stem cell therapy for complex perianal fistula. World J Stem Cells 2023; 15:866-875. [PMID: 37700821 PMCID: PMC10494567 DOI: 10.4252/wjsc.v15.i8.866] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2023] [Revised: 06/21/2023] [Accepted: 07/19/2023] [Indexed: 08/25/2023] Open
Abstract
BACKGROUND Local mesenchymal stem cell (MSC) therapy for complex perianal fistulas (PFs) has shown considerable promise. But, the long-term safety and efficacy of MSC therapy in complex PFs remain unknown. AIM To explore the long-term effectiveness and safety of local MSC therapy for complex PFs. METHODS Sources included the PubMed, EMBASE, and Cochrane Library databases. A standard meta-analysis was performed using RevMan 5.3. RESULTS After screening, 6 studies met the inclusion criteria. MSC therapy was associated with an improved long-term healing rate (HR) compared with the control condition [odds ratio (OR) = 2.13; 95% confidence interval (95%CI): 1.34 to 3.38; P = 0.001]. Compared with fibrin glue (FG) therapy alone, MSC plus FG therapy was associated with an improved long-term HR (OR = 2.30; 95%CI: 1.21 to 4.36; P = 0.01). When magnetic resonance imaging was used to evaluate fistula healing, MSC therapy was found to achieve a higher long-term HR than the control treatment (OR = 2.79; 95%CI: 1.37 to 5.67; P = 0.005). There were no significant differences in long-term safety (OR = 0.77; 95%CI: 0.27 to 2.24; P = 0.64). CONCLUSION Our study indicated that local MSC therapy promotes long-term and sustained healing of complex PFs and that this method is safe.
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Affiliation(s)
- Fang Cheng
- Division of Gastroenterology, Zigong First People's Hospital, Zigong 643000, Sichuan Province, China
- Department of Gastroenterology, Zigong First People's Hospital, Zigong 643000, Sichuan Province, China.
| | - Huang Zhong
- Department of Gastroenterology, Zigong First People's Hospital, Zigong 643000, Sichuan Province, China
| | - Zhong Huang
- Department of Gastroenterology, Zigong First People's Hospital, Zigong 643000, Sichuan Province, China
| | - Zhi Li
- Department of Gastroenterology, Zigong First People's Hospital, Zigong 643000, Sichuan Province, China
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Phillips KE, Aljobeh A, Benammi S, Abdalla S, Calini G, Shawki SF, Larson DW, Mathis KL. Predictors of ileal pouch failure due to fistulas. Br J Surg 2023; 110:1046-1048. [PMID: 36680369 DOI: 10.1093/bjs/znac446] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Revised: 11/14/2022] [Accepted: 11/29/2022] [Indexed: 01/22/2023]
Affiliation(s)
- Kathryn E Phillips
- Mayo Clinic Alix School of Medicine, Rochester, Minnesota, USA
- Mayo Clinic Rochester, Rochester, Minnesota, USA
| | - Ahmad Aljobeh
- Mayo Clinic Alix School of Medicine, Rochester, Minnesota, USA
- Mayo Clinic Rochester, Rochester, Minnesota, USA
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Vazquez C, Kodia K, Giri B, Paluvoi N. A complex presentation and successful management of fistulizing perianal Crohn's disease extending to the mid-back. J Surg Case Rep 2023; 2023:rjad364. [PMID: 37360741 PMCID: PMC10284672 DOI: 10.1093/jscr/rjad364] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Accepted: 06/04/2023] [Indexed: 06/28/2023] Open
Abstract
Fistulizing perianal disease is a debilitating complication present in nearly half of all patients diagnosed with Crohn's disease. The majority of anal fistulas arising in these patients are complex. Treatment can be challenging with therapy often requiring both medical and surgical interventions with differing levels of symptomatic relief. Fecal diversion is an option after medical and surgical modalities have been exhausted but demonstrates limited efficacy. Complex perianal fistulizing Crohn's disease is inherently morbid and can be difficult to manage. We present a case of a young male with Crohn's, severe malnutrition and multiple perianal abscess with extensive fistula tracts up to his back; a planned fecal diversion was instituted to control sepsis and allow for wound healing and optimize medical therapy.
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Affiliation(s)
- Christopher Vazquez
- Division of Colon and Rectal Surgery, Department of Surgery, University of Miami Leonard Miller School of Medicine, Miami, FL, USA
| | - Karishma Kodia
- Division of Colon and Rectal Surgery, Department of Surgery, University of Miami Leonard Miller School of Medicine, Miami, FL, USA
| | - Bhuwan Giri
- Division of Colon and Rectal Surgery, Department of Surgery, University of Miami Leonard Miller School of Medicine, Miami, FL, USA
| | - Nivedh Paluvoi
- Correspondence address. 1295 NW 14th St, Miami, FL 33125, USA. Tel: 305-243-9110; Fax: (305) 243-7438; E-mail:
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Iglay K, Bennett D, Kappelman MD, Zhang X, Aldridge M, Karki C, Cook SF. A Systematic Review of Epidemiology and Outcomes Associated with Local Surgical and Intersphincteric Ligation Procedures for Complex Cryptoglandular Fistulas. Adv Ther 2023; 40:1926-1956. [PMID: 36905499 PMCID: PMC10129974 DOI: 10.1007/s12325-023-02452-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Accepted: 02/01/2023] [Indexed: 03/12/2023]
Abstract
INTRODUCTION This systematic literature review (SLR) assessed incidence/prevalence of cryptoglandular fistulas (CCF) and outcomes associated with local surgical and intersphincteric ligation procedures for CCFs. METHODS Two trained reviewers searched PubMed and Embase for observational studies evaluating the incidence/prevalence of cryptoglandular fistula and clinical outcomes of treatments for CCF after local surgical and intersphincteric ligation procedures for CCF. RESULTS In total 148 studies met a priori eligibility criteria for all cryptoglandular fistulas and all intervention types. Of those, two assessed incidence/prevalence of cryptoglandular fistulas. Eighteen reported clinical outcomes of surgeries of interest in CCF and were published in the past 5 years. Prevalence was reported as 1.35/10,000 non-Crohn's patients, and 52.6% of non-IBD patients were found to progress from anorectal abscess to fistula over 12 months. Primary healing rates ranged from 57.1% to 100%; recurrence occurred in a range of 4.9-60.7% and failure in 2.8-18.0% of patients. Limited published evidence suggests postoperative fecal incontinence and long-term postoperative pain were rare. Several of the studies were limited by single-center design with small sample sizes and short follow-up durations. DISCUSSION This SLR summarizes outcomes from specific surgical procedures for the treatment of CCF. Healing rates vary according to procedure and clinical factors. Differences in study design, outcome definition, and length of follow-up prevent direct comparison. Overall, published studies offer a wide range of findings with respect to recurrence. Postsurgical incontinence and long-term postoperative pain were rare in the included studies, but more research is needed to confirm rates of these conditions following CCF treatments. CONCLUSION Published studies on the epidemiology of CCF are rare and limited. Outcomes of local surgical and intersphincteric ligation procedures show differing success and failure rates, and more research is needed to compare outcomes across various procedures. (PROSPERO; registration number CRD42020177732).
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Affiliation(s)
- Kristy Iglay
- CERobs Consulting, LLC, 2612 North Lumina Ave., Wrightsville Beach, NC 28480 USA
| | - Dimitri Bennett
- Takeda Pharmaceuticals, Cambridge, MA 02139 USA
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104 USA
| | - Michael D. Kappelman
- Pediatric Gastroenterology, University of North Carolina, Chapel Hill School of Medicine, Chapel Hill, NC 27599 USA
| | - Xinruo Zhang
- CERobs Consulting, LLC, 2612 North Lumina Ave., Wrightsville Beach, NC 28480 USA
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599 USA
| | - Molly Aldridge
- CERobs Consulting, LLC, 2612 North Lumina Ave., Wrightsville Beach, NC 28480 USA
| | | | - Suzanne F. Cook
- CERobs Consulting, LLC, 2612 North Lumina Ave., Wrightsville Beach, NC 28480 USA
- Takeda Pharmaceuticals, Cambridge, MA 02139 USA
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Sautereau M, Bouchard D, Brochard C, Pigot F, Siproudhis L, Fayette JM, Train C, Laurain A, Favreau C, Abramowitz L. Prospective and multicentre study of radiofrequency treatment in anal fistula. Colorectal Dis 2023; 25:289-297. [PMID: 36128714 DOI: 10.1111/codi.16344] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Revised: 09/04/2022] [Accepted: 09/06/2022] [Indexed: 02/08/2023]
Abstract
BACKGROUND The most effective treatment for anal fistula is fistulotomy, but it involves a risk of anal incontinence. To reduce this morbidity, sphincter-sparing treatments have been developed, but their success in real life is often less than 50%. The aim is to determine the clinical healing rate 6 months after radiofrequency treatment. METHODS We planned to evaluate 50 patients from three French proctology centres. Treatment efficacy was evaluated at 6 and 12 months by means of clinical and magnetic resonance imaging examination. We evaluated morbidity and healing prognostic factors. RESULTS Fifty patients with a mean age of 51 years (22-82) were included. Eleven patients had a low trans-sphincteric fistula (LTS), 21 patients had a high trans-sphincteric fistula (HTS), eight had a complex fistula and nine had Crohn's disease fistula. After 6 months, 17 patients (34.7%) had a clinically healed fistula, including five (45.5%) with LTS fistula, seven (33.3%) with HTS fistula, one (12.5%) with complex fistula, four (44.4%) with Crohn's disease, with no significant difference between these fistula types (p: 0.142). At 12 months, the healing rate was identical. MRI in 15 out of 17 clinically healed patients showed a deep remission of 73.3% at 12 months. Energy power was associated with the success of the treatment. There was an 8.2% incidence of post-surgical complications with 4.1% being abscesses (one required surgical management). Postoperative pain was minor. No new cases or deterioration of continence have been shown. CONCLUSION Radiofrequency is effective in 34.7% of the cases as an anal fistula treatment in this first prospective study, with low morbidity and no effect on continence. Clinical healing was deep (MRI) in three-quarters at 1 year. The increase in energy power during the procedure seems to be a key point to be analysed to optimise results.
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Affiliation(s)
- Marie Sautereau
- Department of Gastroenterology and Proctology, APHP, CHU Bichat, Paris, France
| | | | - Charlène Brochard
- Digestive Physiology Unit, Rennes Pontchaillou University Hospital, University of Rennes 1, Rennes, France
| | - François Pigot
- Department of Proctology, Bagatelle Hospital, Talence, France
| | - Laurent Siproudhis
- Digestive Physiology Unit, Rennes Pontchaillou University Hospital, University of Rennes 1, Rennes, France
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Ligation of Intersphincteric Fistulous Tract vs Endorectal Advancement Flap for High-Type Fistula in Ano: A Randomized Controlled Trial. J Am Coll Surg 2023; 236:27-35. [PMID: 36519904 DOI: 10.1097/xcs.0000000000000441] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND This study aimed to compare the postoperative outcomes and success rate of the endorectal advancement flap and ligation of intersphincteric fistulous tract (LIFT) in high-type fistula in ano. STUDY DESIGN This randomized control trial included patients with high-type fistula in ano of cryptoglandular origin. The primary endpoint was complete fistula healing at the end of 6 months. However, the patients were followed up for 2 years. Other parameters studied were perioperative complications, duration of surgery, postoperative pain, hospital stay in hours, continence, and quality of life at 6 months. RESULTS A total of 84 patients were recruited (42 in each group). The healing rate in the LIFT arm was better than that in the endorectal advancement flap arm (76.2.% vs 54.7%, p = 0.039). Four patients in the endorectal advancement flap group and two in the LIFT group had flatus incontinence at the end of 6 months, but all were continent at 2 years. At the end of the first week, the Visual Analog Scale score and quality of life at 6 months were better in the LIFT arm (3.7 ± 1.16 vs 4.7 ± 0.81 and 0.7 vs 0.6, p < 0.05). The mean duration of surgery was significantly less in the LIFT group (46.43 ± 9.32 vs 89.29 ± 10.90 minutes). None had any postoperative complications, and >80% were discharged within 24 hours. CONCLUSIONS The shorter operative duration, better quality of life at 6 months, and higher healing rate make LIFT a superior treatment option for high fistula in ano. However, studies with a large sample size will be needed to verify these results.
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Kadhim AM, Altaraikhim MHO. VAAFT PROCEDURE (Video-assisted Anal Fistula Treatment) versus Open Method in the Treatment of High Fistula in Ano. JOURNAL OF COLOPROCTOLOGY 2022. [DOI: 10.1055/s-0042-1759607] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Abstract
Background A common acquired anorectal condition is anal fistula. The treatment approaches that have been employed have been linked to erratic outcomes and sometimes life-threatening consequences. Video-assisted anal fistula treatment (VAAFT), a minimally invasive method, was introduced for adult patients in 2011.
Objective To know the efficacy of the VAAFT procedure in treating high anal fistulas and to compare it to open methods in the Basrah province.
Methods The present study was performed on 200 patients with high fistulas in ano in Basrah province. We divided the patients into 2 groups: Group A: treated by the VAAFT technique and Group B: treated by open fistulotomy
Results The patients treated with VAFFT revealed no occurrence of the following postoperative complication: Infection, incontinence, recurrence, anal stenosis, and bleeding. There was lower incidence of pain, short time for wound healing, rapid return to work, and more patient satisfaction compared with open fistulotomy
Conclusion An innovative method for managing ano fistula is VAAFT. Compared with traditional methods, it has a lot of benefits. It is day case surgeryno open wound.no damage to anal sphincter and no risk of incontinence, it is more affordable.it allow for clear identification of internal office, whole tract and its associated branches and cavity. The instrument can be used for multiple patients after good sterilization and disinfection.
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Mosli MH, Almudaiheem HY, AlAmeel T, Bakkari SA, Alharbi OR, Alenzi KA, Khardaly AM, AlMolaiki MA, Al-Omari BA, Albarakati RG, Al-Jedai AH, Saadah OI, Almadi MA, Al-Bawardy B. Saudi Arabia consensus guidance for the diagnosis and management of adults with inflammatory bowel disease. Saudi J Gastroenterol 2022; 29:361671. [PMID: 36412460 PMCID: PMC10540981 DOI: 10.4103/sjg.sjg_277_22] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Revised: 08/23/2022] [Accepted: 09/05/2022] [Indexed: 02/10/2023] Open
Abstract
Optimal management of inflammatory bowel disease (IBD) relies on a clear understanding and tailoring evidence-based interventions by clinicians in partnership with patients. This article provides concise guidelines for the management of IBD in adults, based on the most up-to-date information at the time of writing and will be regularly updated. These guidelines were developed by the Saudi Ministry of Health in collaboration with the Saudi Gastroenterology Association and the Saudi Society of Clinical Pharmacy. After an extensive literature review, 78 evidence-and expert opinion-based recommendations for diagnosing and treating ulcerative colitis and Crohn's disease in adults were proposed and further refined by a voting process. The consensus guidelines include the finally agreed on statements with their level of evidence covering different aspects of IBD diagnosis and treatment.
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Affiliation(s)
- Mahmoud H. Mosli
- Department of Internal Medicine, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
- Inflammatory Bowel Disease Unit, King Abdulaziz University Hospital, Jeddah, Saudi Arabia
| | | | - Turki AlAmeel
- Department of Medicine, King Fahad Specialist Hospital, Dammam, Saudi Arabia
| | - Shakir A. Bakkari
- Division of Gastroenterology, King Saud Medical City, Riyadh, Saudi Arabia
| | - Othman R. Alharbi
- Department of Medicine, College of Medicine, King Khalid University Hospital, King Saud University, Riyadh, Saudi Arabia
| | - Khalidah A. Alenzi
- Regional Drug Information and Pharmacovigilance Center, Ministry of Health, Tabuk, Saudi Arabia
| | | | - Maha A. AlMolaiki
- Department of Pharmaceutical Care, National Guard Health Affairs, Riyadh, Saudi Arabia
| | - Bedor A. Al-Omari
- Pharmaceutical Care Services, Prince Sultan Military Medical City, Riyadh, Saudi Arabia
| | - Rayan G. Albarakati
- Department of Obstetrics and Gynecology, Majmaah University, Riyadh, Saudi Arabia
| | - Ahmed H. Al-Jedai
- Deputyship of Therapeutic Affairs, Ministry of Health, Riyadh, Saudi Arabia
| | - Omar I. Saadah
- Inflammatory Bowel Disease Unit, King Abdulaziz University Hospital, Jeddah, Saudi Arabia
- Department of Pediatrics, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Majid A. Almadi
- Department of Medicine, College of Medicine, King Khalid University Hospital, King Saud University, Riyadh, Saudi Arabia
| | - Badr Al-Bawardy
- Section of Digestive Diseases, Yale School of Medicine, New Haven, CT, USA
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25
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Bennett AL, Schwartz DA. Endoscopic Evaluation and Management of Perianal Disease. Gastrointest Endosc Clin N Am 2022; 32:747-759. [PMID: 36202514 DOI: 10.1016/j.giec.2022.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Perianal Crohn's disease is associated with decreased quality of life, high morbidity, and high health care use. Treatment goals are to provide infection control, stop fistula drainage, and heal fistula tracts while preserving the anorectal sphincter. Treatment includes a combination of medical and surgical intervention, but new techniques are using interventional endoscopy to act as either a bridge to surgery or to decrease the need for surgical intervention. The decision on which approach to pursue requires knowledge of prior surgery, altered anatomy, prior fistula treatment, and imaging and endoscopic evaluation of fistula complexity, mucosal involvement, and associated stricture or abscess.
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Affiliation(s)
- Audrey L Bennett
- Vanderbilt University Medical Center, 1301 Medical Center Drive, 1600 The Vanderbilt Clinic, Nashville, TN 37232, USA
| | - David A Schwartz
- Vanderbilt University Medical Center, Inflammatory Bowel Disease Clinic, 719 Thompson Lane, Suite 20500, Nashville, TN 37204, USA.
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Chen ZW, Zheng Y, Zhao R, Wang ZJ. Treatment of anal fistula using a decellularized porcine small intestinal submucosa plug: A non-inferiority trial. Medicine (Baltimore) 2022; 101:e29110. [PMID: 35866804 PMCID: PMC9302366 DOI: 10.1097/md.0000000000029110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2021] [Revised: 03/01/2022] [Accepted: 03/01/2022] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Using small intestinal submucosa (SIS) has increasingly become the standard method for the treatment of anal fistula. The porcine SIS manufactured by Biosis Healing is a novel biological material that has several advantages for the safe and effective repair of tissues. Our study aimed to verify the efficacy and safety of the decellularized porcine SIS (VIDASIS) anal fistula plug. METHODS We conducted a non-inferiority multicenter, randomized, controlled clinical trial involving patients with chronic anal fistula. Patients from 3 centers across China were randomized 1:1 to Biosis SIS vs commercial SIS. The primary endpoint was the healing rate and secondary endpoints included recurrence within 6 months, rate of copracrasia, healing time, pain using a visual analog scale, and patient and doctor satisfaction. RESULTS A total of 186 patients were randomized. Of these, 82 patients in the Biosis SIS and 81 in the control (commercial) SIS completed the trial (per-protocol set). The healing rate at the 6-month follow-up (full analysis set) was 92.0% for the Biosis SIS and 89.8% for the control SIS (P = .620). The rate difference of 2.2% (full analysis set; 95% confidence interval: -6.4% and 10.7%, respectively) was within the pre-specified non-inferiority margin of -10%. There were no differences between the 2 groups with regard to the secondary endpoints. No serious adverse event or death occurred. CONCLUSION Our study shows that the VIDASIS anal fistula plug manufactured by the company Biosis Healing is safe and effective and is not inferior to existing commercial SIS materials.
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Affiliation(s)
- Zhao Wen Chen
- Department of General Surgery, Peking University Third Hospital, Beijing, China
| | - Yi Zheng
- Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Rong Zhao
- Tianjin People's Hospital, Tianjin, China
| | - Zhen Jun Wang
- Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
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27
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Emile SH, Khafagy W, Elbaz SA. Impact of number of previous surgeries on the continence state and healing after repeat surgery for recurrent anal fistula. J Visc Surg 2022; 159:206-211. [PMID: 33931349 DOI: 10.1016/j.jviscsurg.2021.03.006] [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] [Indexed: 11/20/2022]
Abstract
BACKGROUND The management of recurrent anal fistulas after previous surgery is usually challenging. The present study aimed to review the characteristics and treatment outcomes of recurrent anal fistulas as compared to primary anal fistulas. METHODS The records of patients with anal fistula who underwent surgery were reviewed. Characteristics and treatment outcomes of patients with recurrent anal fistulas were compared to those of patients with primary anal fistula without a history of surgery. RESULTS The study included 138 patients with recurrent anal fistulas, 76.8% of which were complex. Failure of healing was recorded in 25 (18.1%) patients and fecal incontinence (FI) in 9 (6.5%). Patients with recurrent anal fistulas had significantly higher percentage of anterior, complex, and horseshoe fistulas than patients with primary fistulas. Surgery for recurrent anal fistulas was followed by a significantly higher rate of failure of healing than primary fistulas (18.1% vs. 9.8%, P=0.011), whereas the rates of FI were comparable amongst the two groups (6.5% vs. 2.8%, P=0.07). Patients who had more than two previous operations for anal fistula had a significantly higher rate of FI than patients who underwent one or two previous surgeries (20% vs. 3.7% vs. 14.3%, P=0.04), yet healing rates were comparable. CONCLUSION Recurrent anal fistulas were more complex than primary fistulas. Surgical treatment of recurrent anal fistula was followed by a significantly higher rate of failure of healing and similar rate of FI as compared to primary anal fistulas. The number of previous fistula surgeries had a significant effect on postoperative continence state.
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Affiliation(s)
- S H Emile
- Colorectal surgery unit, General Surgery Department, Mansoura University Hospitals, Mansoura University, Mansoura city, Egypt.
| | - W Khafagy
- Colorectal surgery unit, General Surgery Department, Mansoura University Hospitals, Mansoura University, Mansoura city, Egypt
| | - S A Elbaz
- Colorectal surgery unit, General Surgery Department, Mansoura University Hospitals, Mansoura University, Mansoura city, Egypt
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Elshamy MT, Emile SH, Abdelnaby M, Khafagy W, Elbaz SA. A pilot randomized controlled trial on ligation of intersphincteric fistula tract (LIFT) versus modified parks technique and two-stage seton in treatment of complex anal fistula. Updates Surg 2022; 74:657-666. [PMID: 35038136 DOI: 10.1007/s13304-022-01240-6] [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: 12/05/2021] [Accepted: 01/07/2022] [Indexed: 10/19/2022]
Abstract
Complex anal fistula (CAF) is a challenging condition for surgeons. This randomized trial aimed to compare ligation of the intersphincteric fistula tract (LIFT), modified Parks technique, and two-stage seton in the treatment of complex anal fistula in terms of the success of treatment and complications. This was a pilot randomized trial conducted in the period of January 2019 to December 2019 on adult patients with CAF who were allocated to one of three groups: LIFT, modified Parks technique, and two-stage seton. The main outcome measures were healing rates, time to healing, complications, operation time, and quality of life. Sixty-six patients (75.7% males) of a mean age of 45.2 years were included. Mean operation time of LIFT was significantly shorter than the other two procedures (p < 0.0001). There was a significant difference between the three groups in terms of success rate (p = 0.04) but not in regard to complications (p = 0.59). The modified Parks technique had a significantly higher success rate than LIFT (95.2% vs 68.1%, p = 0.045) whereas the success rates of two-stage seton and LIFT were not significantly different (86.9% vs 68.1%, p = 0.16). The average time to healing after LIFT was significantly shorter than the other two procedures. The quality-of-life scores were comparable among the three groups. There was a significant difference in healing rates after the three procedures as the modified Parks technique achieved the highest success rate followed by two-stage seton and then the LIFT procedure. Time to complete healing after LIFT was significantly shorter than the other two procedures. The three procedures achieved similar quality of life and complication rates.
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Affiliation(s)
- Mohamed Tarek Elshamy
- Colorectal Surgery Unit, General Surgery Department, Mansoura University Hospitals, Mansoura University, 60 El-Gomhouria Street, Mansoura, 35516, Dakahlia, Egypt
| | - Sameh Hany Emile
- Colorectal Surgery Unit, General Surgery Department, Mansoura University Hospitals, Mansoura University, 60 El-Gomhouria Street, Mansoura, 35516, Dakahlia, Egypt.
| | - Mahmoud Abdelnaby
- Colorectal Surgery Unit, General Surgery Department, Mansoura University Hospitals, Mansoura University, 60 El-Gomhouria Street, Mansoura, 35516, Dakahlia, Egypt
| | - Wael Khafagy
- Colorectal Surgery Unit, General Surgery Department, Mansoura University Hospitals, Mansoura University, 60 El-Gomhouria Street, Mansoura, 35516, Dakahlia, Egypt
| | - Samy Abbas Elbaz
- Colorectal Surgery Unit, General Surgery Department, Mansoura University Hospitals, Mansoura University, 60 El-Gomhouria Street, Mansoura, 35516, Dakahlia, Egypt
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Angriman I, Tomassi M, Ruffolo C, Bordignon G, Saadeh L, Gruppo M, Pucciarelli S, Bardini R, Scarpa M. Impact on Quality of Life of Seton Placing in Perianal Crohn's Disease. Front Surg 2022; 8:806497. [PMID: 35141271 PMCID: PMC8818691 DOI: 10.3389/fsurg.2021.806497] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2021] [Accepted: 12/20/2021] [Indexed: 11/13/2022] Open
Abstract
IntroductionOften, in perineal Crohn's disease (CD), a seton is placed to guarantee a constant drainage and prevent septic complication while biologic therapy is ongoing. This study aimed to assess the long-term quality of life after surgery for perineal CD in relation to seton placing.Patients and MethodsData of 65 consecutive patients with CD and non-CD operated on from 2014 to 2019 for perianal fistula or abscess were retrieved. Forty-three had CD and 14 of them had a seton placed during surgery and they kept it on while they had anti-TNF-alpha therapy. Patients were interviewed with the Cleveland Global Quality of Life (CGQL) and SF-12 quality of life questionnaires. Disease activity was defined as Harvey-Bradshaw Index (HBI) and Perianal Disease Activity Index (PDAI). Comparisons between groups were carried out with the nonparametric tests, and multiple regression models were used to assess predictors of quality of life.ResultsThe total CGQL score and SF-12 mental component score (MCS) were significantly higher (and thus better) in the seton group than in patients treated without seton. On the contrary, SF-12 physical component score (PCS) was not different between the two groups. HBI was significantly better in patients in the seton group. At multivariate analysis, seton placement and HBI were confirmed to be independent predictors of long-term SF-12 MCS whereas only HBI confirmed to be a predictor of total CGQL score.ConclusionsSeton placing during anti-TNF-alpha therapy is independently associated with a better MCS. Unexpectedly, this device, instead of to cause psychological distress, seems to assure patients during their biologic therapy providing psychological benefit beyond the mere medical effect.
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Affiliation(s)
- Imerio Angriman
- Chirurgia Generale III, Department of Surgical Oncological and Gastroenterological Sciences, Azienda Ospedale Università di Padova, Padua, Italy
- General Surgery Unit, Azienda Ospedale Università di Padova, Padua, Italy
- *Correspondence: Imerio Angriman
| | - Monica Tomassi
- Chirurgia Generale III, Department of Surgical Oncological and Gastroenterological Sciences, Azienda Ospedale Università di Padova, Padua, Italy
- General Surgery Unit, Azienda Ospedale Università di Padova, Padua, Italy
| | - Cesare Ruffolo
- Chirurgia Generale III, Department of Surgical Oncological and Gastroenterological Sciences, Azienda Ospedale Università di Padova, Padua, Italy
- General Surgery Unit, Azienda Ospedale Università di Padova, Padua, Italy
| | - Giovanni Bordignon
- General Surgery Unit, Azienda Ospedale Università di Padova, Padua, Italy
| | - Luca Saadeh
- General Surgery Unit, Azienda Ospedale Università di Padova, Padua, Italy
| | - Mario Gruppo
- General Surgery Unit, Azienda Ospedale Università di Padova, Padua, Italy
- Surgical Oncology Unit, Veneto Institute of Oncology IOV Istituto di Ricerca e Cura a Carattere Scientifico (IRCCS), Castelfranco Veneto, Italy
| | - Salvatore Pucciarelli
- Chirurgia Generale III, Department of Surgical Oncological and Gastroenterological Sciences, Azienda Ospedale Università di Padova, Padua, Italy
| | - Romeo Bardini
- General Surgery Unit, Azienda Ospedale Università di Padova, Padua, Italy
| | - Marco Scarpa
- Chirurgia Generale III, Department of Surgical Oncological and Gastroenterological Sciences, Azienda Ospedale Università di Padova, Padua, Italy
- General Surgery Unit, Azienda Ospedale Università di Padova, Padua, Italy
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Kumar M, Kumar M, Arora A, Ranjan A, Kant KC, PP S. The Ligation of the Intersphincteric Fistula Tract (LIFT) Technique for Simple and Complex Fistula-in-ano. JOURNAL OF COLOPROCTOLOGY 2021. [DOI: 10.1055/s-0041-1736644] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Abstract
Background Fistula-in-ano is one of the most common clinical condition encountered in a surgical outpatient department. Many treatment modalities have been described with variable outcomes but gold standard surgical treatment is yet to be agreed upon. The aim of the present study is to evaluate the treatment outcomes of ligature of intersphincteric fistula tract (LIFT) technique in the treatment of simple and complex fistula-in-ano with the primary objective of recurrence rate and broad objective of other postoperative complications during the period of study and after long-term follow-up.
Methods It is a retrospective study of prospectively collected data from the patients who have been operated for fistula-in-ano using the LIFT technique at our institute from February 2018 to March 2020 and followed-up until September 2020.
Results A total of 56 patients with fistula-in-ano were treated with the LIFT procedure during the study period, of which 20 patients had simple fistula and 36 had complex fistula. A success rate of 83% was obtained with completely healed fistulas in 46 patients. No patient developed postoperative incontinence.
Conclusion Ligature of intersphincteric fistula tract is an effective treatment modality for fistula-in-ano with less procedure-related morbidity, but it is associated with a higher recurrence rate in simple fistula than in complex fistula.
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Affiliation(s)
- Manoj Kumar
- Department of General Surgery, All India Institute of Medical Sciences, Patna, Bihar, India
| | - Manoj Kumar
- Department of General Surgery, All India Institute of Medical Sciences, Patna, Bihar, India
| | - Abhishek Arora
- Department of General Surgery, All India Institute of Medical Sciences, Patna, Bihar, India
| | - Alok Ranjan
- Department of Community and Family Medicine, All India Institute of Medical Sciences, Patna, Bihar, India
| | - Kumar Chandra Kant
- Department of General Surgery, All India Institute of Medical Sciences, Patna, Bihar, India
| | - Sreepriya PP
- Department of General Surgery, All India Institute of Medical Sciences, Patna, Bihar, India
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31
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Guo L, Luo B. A commentary on "Risk factors for postoperative recurrence of anal fistula identified by an international, evidence-based Delphi consultation survey of surgical specialists" (Int J Surg 2021; 92:106038). Int J Surg 2021; 95:106141. [PMID: 34653722 DOI: 10.1016/j.ijsu.2021.106141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Accepted: 10/05/2021] [Indexed: 11/25/2022]
Affiliation(s)
- Lijing Guo
- Department of General Surgery, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University,Beijing, 102218, China
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Zulkarnain FM, Soeselo DA, Suryanto, Singgih GG. Case report: Complex perianal fistula treated with fistula laser closure (FILAC) and suction catheter. Int J Surg Case Rep 2021; 84:106085. [PMID: 34186456 PMCID: PMC8250164 DOI: 10.1016/j.ijscr.2021.106085] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Revised: 06/04/2021] [Accepted: 06/04/2021] [Indexed: 11/26/2022] Open
Abstract
Introduction and importance A patient presented with complex perianal fistula treated with fistula laser closure (FILAC) combined with suction catheters. Case presentation Male, 29 years old, presented in our department, presented with complex perianal fistula with a history of fistulectomy and tight seton for 6 months in another health facility. Intraoperative findings were a tract of 4,5 cm long, 4 external openings, and 1 internal opening. Definitive treatment of Fistula Laser Closure (FILAC) with 13-watt power laser diode produces by BIOLITEC German. Conclusion The patient recovers within 6 months. Promising results have been shown by combining FILAC and suction catheter for complex perianal fistula.
Complex perianal fistula is a hard-to-treat diagnosis, careful approaches for its complication are needed. FILAC is a new sphincter-saving technique, Combination with a suction catheter promotes FILAC to achieved primary closure. FILAC procedure was chosen because it is a safe and effective treatment for transphinteric anal fistula Promising result have been shown by combining FILAC and suction catheter for complex perianal fistula
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Affiliation(s)
| | - Daniel Ardian Soeselo
- Department of Surgery, Pondok Indah Puri Indah Hospital, Jakarta, Indonesia; Department of General Surgery, School of Medicine and Health Sciences, Atma Jaya Catholic University of Indonesia, Jakarta, Indonesia.
| | - Suryanto
- Department of General Surgery, School of Medicine and Health Sciences, Atma Jaya Catholic University of Indonesia, Jakarta, Indonesia
| | - Gregorio Gavriel Singgih
- School of Medicine and Health Sciences, Atma Jaya Catholic University of Indonesia, Jakarta, Indonesia
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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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Utilizing Colpocleisis to Repair a Vesicovaginal Fistula in a Cervical Cancer Patient with History of Pelvic Radiation: A Case Report and Literature Review. Case Rep Urol 2021; 2021:8865146. [PMID: 34035972 PMCID: PMC8118741 DOI: 10.1155/2021/8865146] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Accepted: 04/24/2021] [Indexed: 12/14/2022] Open
Abstract
Background Vesicovaginal fistula is a rare and distressing urological condition. It is especially prevalent in developing countries with the predominant etiology secondary to obstructed labor. Radiation therapy in female patients with cervical cancer is a risk factor for vesicovaginal fistula formation in the United States. Case Presentation. A 53-year-old woman with a history of cervical cancer and radiation presented with continuous urinary incontinence. Following diagnostic vaginoscopy, a 1 cm vesicovaginal fistula was diagnosed at the vaginal apex. The patient elected for surgical repair. She subsequently underwent successful transvaginal fistula closure using colpocleisis to optimally address the systemic factors of poor wound healing associated with irradiated tissue. Because of the adjacent tissue having been compromised by pelvic radiation, we opted to use a biologic graft made of human cadaveric pericardial tissue (CPT) instead of a native tissue flap to provide additional support for the fistula repair. Conclusion A transvaginal approach for surgical repair of vesicovaginal fistula can be successful in patients with a prior history of pelvic radiation. Transvaginal colpocleisis is a viable option to augment vesicovaginal fistula repair for patients with significant comorbidities when sexual intercourse is no longer desired.
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Emile SH, Elfeki H, El-Said M, Khafagy W, Shalaby M. Modification of Parks Classification of Cryptoglandular Anal Fistula. Dis Colon Rectum 2021; 64:446-458. [PMID: 33399407 DOI: 10.1097/dcr.0000000000001797] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND The Parks classification has been used for the classification of anal fistula for several years, but it does not allow for risk factors for failure after surgery. OBJECTIVE This study aimed to describe a modification of the Parks classification of anal fistula and examine its predictive validity in the assessment of the outcome of anal fistula in terms of failure of healing and fecal incontinence. DESIGN This is a retrospective review of a prospective database. SETTING This study was conducted in the Colorectal Surgery Unit, Mansoura University Hospitals. PATIENTS Adult patients with anal fistula who underwent surgery were included. INTERVENTIONS Five risk factors for failure after fistula surgery were identified from the literature and were examined by multivariate analysis of our patients. Four risk factors proved to be significant independent predictors of failure: secondary extensions, horseshoe fistula, previous fistula surgery, and anterior anal fistula in women. We modified the Parks classification by dividing the transsphincteric type into high and low and by grouping supra- and extrasphincteric anal fistulas into 1 group. The first 3 stages were subdivided according to the absence or presence of predictors of failure. MAIN OUTCOME MEASURES The primary outcome measured was the validity of the modified Parks classification with regard to the rates of failure and fecal incontinence after surgical treatment of each stage of anal fistula. RESULTS A total of 665 patients with cryptoglandular anal fistula were included. Failure rates increased from 2.3% (95% CI, 0.9%-4.7%), to 17.4% (95% CI, 10.8%-25.9%), 19.5% (95% CI, 15%-24.6%), and 30.7% (95% CI, 9.1%-61.4%) across the 4 stages. The area under the receiver operating characteristic curve was 0.90 (95% CI, 0.85-0.94) indicating the strong discriminative ability of the final multivariable predictive model. The increase in failure and incontinence rates across the fistula stages was significant. LIMITATIONS This is a retrospective, single-center study. CONCLUSION Inclusion of predictors of poor outcome into the modified classification helped differentiate simple and complex fistulas within each stage and between the different stages, which can help in assessment and decision making for anal fistula. See Video Abstract at http://links.lww.com/DCR/B441. MODIFICACIN DE LA CLASIFICACIN DE PARKS DE LA FSTULA ANAL CRIPTOGLANDULAR ANTECEDENTES:La clasificación de Parks se ha utilizado para la clasificación de la fístula anal durante varios años, sin embargo, no tuvo en cuenta los factores de riesgo de fracaso después de la cirugía.OBJETIVO:Describir una modificación de la clasificación de Parks de fístula anal y examinar su validez predictiva en la evaluación de los resultados de la fístula anal en términos de fracaso de la cicatrización e incontinencia fecal.DISEÑO:Revisión retrospectiva de la base de datos prospectiva.AJUSTE:Unidad de Cirugía Colorrectal, Hospital Universitario de Mansoura.PACIENTES:Pacientes adultos con fístula anal intervenidos quirúgicamente.INTERVENCIONES:Se identificaron cinco factores de riesgo de fracaso después de la cirugía de fístula de la literatura y se examinaron mediante análisis multivariante de nuestros pacientes. Cuatro factores de riesgo demostraron ser importantes predictores independientes de fracaso: extensiones secundarias, fístula en herradura, cirugía de fístula previa y fístula anal anterior en mujeres. Modificamos la clasificación de Parks dividiendo el tipo transesfinteriano en alto y bajo y agrupando la fístula anal supraesfinteriana y extraesfinteriana en un grupo. Las tres primeras etapas se subdividieron según la ausencia o presencia de predictores de fracaso.PRINCIPALES MEDIDAS DE RESULTADO:Validez de la clasificación de Parks modificada con respecto a las tasas de fracaso e incontinencia fecal después del tratamiento quirúrgico de cada etapa de la fístula anal.RESULTADOS:Se incluyeron 665 pacientes con fístula anal criptoglandular. Las tasas de fracaso aumentaron del 2,3% (IC del 95%: 0,9-4,7%), al 17,4% (IC del 95%: 10,8 al 25,9%), 19,5% (IC del 95%: 15-24,6%) y 30,7% (95% IC: 9,1- 61,4%) en las cuatro etapas. El área bajo la curva característica operativa del receptor fue 0,90 (IC del 95%: 0,85-0,94), lo que indica una fuerte capacidad discriminativa del modelo predictivo multivariable final. El aumento en las tasas de fracaso e incontinencia en las etapas de la fístula fue significativo.LIMITACIONES:Estudio retrospectivo, unicéntrico.CONCLUSIÓN:La inclusión de predictores de mal resultado en la clasificación modificada ayudó a diferenciar las fístulas simples y complejas dentro de cada etapa y entre las diferentes etapas, lo que puede ayudar en la evaluación y toma de decisiones para la fístula anal. Consulte Video Resumen en http://links.lww.com/DCR/B441.
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Affiliation(s)
- Sameh Hany Emile
- Department of General Surgery, Colorectal Surgery Unit, Mansoura Faculty of Medicine, Mansoura University, Mansoura, Egypt
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Sahebally SM, O'Byrne L, Troy A, Byrnes KG, Burke J, McNamara D. A meta-analysis of marsupialisation versus none in the treatment of simple fistula-in-ano. Int J Colorectal Dis 2021; 36:429-436. [PMID: 33051699 DOI: 10.1007/s00384-020-03759-9] [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] [Accepted: 09/17/2020] [Indexed: 02/04/2023]
Abstract
INTRODUCTION Marsupialisation of post-fistulotomy wounds results in a smaller raw surface area and may improve postoperative outcomes. However, it remains a variable practice. We performed a systematic review and meta-analysis to evaluate the effectiveness of marsupialisation in the treatment of simple fistula-in-ano. MATERIALS AND METHODS PubMed, EMBASE and Cochrane databases were searched for relevant articles from inception until April 2020. All trials that reported on marsupialisation in anal fistula treatment were included. The primary outcome measure was time to complete healing, while secondary outcomes included recurrence, pain scores and incontinence. Random effects models were used to calculate pooled effect size estimates. A sensitivity analysis was performed. RESULTS Six randomised controlled trials were included capturing 461 patients. The mean (SD) age of the cohort was 39.31 (± 8.71) years. There were 395 males (85.7%). All fistulae were of the cryptoglandular aetiology. On random effects analysis, marsupialisation was associated with a significantly shorter time to healing compared with no marsupialisation (SMD - 0.97 weeks, 95% CI = - 1.36 to - 0.58, p < 0.00001). However, there was no difference in recurrence (RD = - 0.00, 95% CI = - 0.02 to 0.02, p = 0.72), pain scores at 24 h (SMD - 0.03, 95% CI = - 0.56 to 0.50, p = 0.91) or incontinence (RD = - 0.01, 95% CI = - 0.05 to 0.02, p = 0.42). On sensitivity analysis, focusing exclusively on fistulotomy for simple fistula-in-ano, the results for time to healing, recurrence and incontinence remained similar. CONCLUSIONS Marsupialisation of fistulotomy wounds for simple fistula-in-ano is associated with a significantly shorter healing time, but similar recurrence, pain scores at 24 h and incontinence rates, compared with omitting marsupialisation.
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Affiliation(s)
- Shaheel Mohammad Sahebally
- Department of Colorectal Surgery, Beaumont Hospital, Dublin 9, Ireland.
- Royal College of Surgeons, St Stephen's Green, Dublin 2, Ireland.
| | - Lisa O'Byrne
- Department of Colorectal Surgery, Beaumont Hospital, Dublin 9, Ireland
- Royal College of Surgeons, St Stephen's Green, Dublin 2, Ireland
| | - Alexandra Troy
- Department of Colorectal Surgery, Beaumont Hospital, Dublin 9, Ireland
- Royal College of Surgeons, St Stephen's Green, Dublin 2, Ireland
| | - Kevin Gerard Byrnes
- Department of Colorectal Surgery, Beaumont Hospital, Dublin 9, Ireland
- Royal College of Surgeons, St Stephen's Green, Dublin 2, Ireland
| | - John Burke
- Department of Colorectal Surgery, Beaumont Hospital, Dublin 9, Ireland
- Royal College of Surgeons, St Stephen's Green, Dublin 2, Ireland
| | - Deborah McNamara
- Department of Colorectal Surgery, Beaumont Hospital, Dublin 9, Ireland
- Royal College of Surgeons, St Stephen's Green, Dublin 2, Ireland
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de Las Casas SG, Alvarez-Gallego M, Martínez JAG, Alcolea NG, Serrano CB, Jiménez AU, Arranz MDM, Martín JLM, Migueláñez IP. Management of perianal fistula in inflammatory bowel disease: identification of prognostic factors associated with surgery. Langenbecks Arch Surg 2021; 406:1181-1188. [PMID: 33515317 DOI: 10.1007/s00423-021-02100-4] [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: 05/28/2020] [Accepted: 01/21/2021] [Indexed: 11/25/2022]
Abstract
PURPOSE As one of the clinical manifestations of inflammatory bowel disease (IBD), perianal fistula disease (PFD) can potentially impact the patient quality of life. The management of PFD employs a multidisciplinary approach which includes antibiotics, biological therapies, immunomodulators, and surgery. We analyzed the outcome and prognostic factors of anal fistula surgery in IBD patients. METHODS We conducted a retrospective study of IBD patients undergoing elective surgery for anal fistula between January 2015 and December 2018 at our University Department of Surgery. We collated demographic factors, disease activity, imaging (MRI and endoanal ultrasound), surgical interventions, and medical treatment assessing the rate of fistula closure and fecal incontinence, 2 months and 1 year after surgery. RESULTS Thirty-five IBD patients with anal fistula underwent surgery (28 Crohn's disease, four ulcerative colitis, and three indeterminate colitis). Twenty-seven patients presented with complex fistulas and eight with simple fistulas with 10 patients undergoing single-stage surgery. In 25 patients, a two-stage surgical approach was planned and performed (draining seton plus medical treatment and then second-stage surgery with curative intent). At 1 year of follow-up, the fistula healing rate was 50% for single-stage surgery and 60% for two-stage surgery (P = 0.09). Overall, 19.2% of patients developed postoperative fecal incontinence. A time interval greater than 12 months between surgeries is a favorable prognostic factor for fistula healing with the two-stage approach (P = 0.002). CONCLUSIONS In our retrospective study, two-stage surgery in IBD patients presenting with complex perianal fistulous disease results in a better medium-term outcome with a longer time interval between surgeries.
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Affiliation(s)
- Sara Gortázar de Las Casas
- General Surgery Department, La Paz University Hospital, Paseo de la Castellana, 261 28046, Madrid, Spain.
| | - Mario Alvarez-Gallego
- General Surgery Department, La Paz University Hospital, Paseo de la Castellana, 261 28046, Madrid, Spain
| | - Jose Antonio Gazo Martínez
- General Surgery Department, La Paz University Hospital, Paseo de la Castellana, 261 28046, Madrid, Spain
| | - Natalia González Alcolea
- General Surgery Department, La Paz University Hospital, Paseo de la Castellana, 261 28046, Madrid, Spain
| | - Cristina Barragán Serrano
- General Surgery Department, La Paz University Hospital, Paseo de la Castellana, 261 28046, Madrid, Spain
| | - Aitor Urbieta Jiménez
- General Surgery Department, La Paz University Hospital, Paseo de la Castellana, 261 28046, Madrid, Spain
| | | | - Jose Luis Marijuan Martín
- General Surgery Department, La Paz University Hospital, Paseo de la Castellana, 261 28046, Madrid, Spain
| | - Isabel Pascual Migueláñez
- General Surgery Department, La Paz University Hospital, Paseo de la Castellana, 261 28046, Madrid, Spain
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Wu YF, Zheng BC, Chen Q, Chen XD, Ye SS, Lin QY, Ye NH, Rong F. Video-Assisted Modified Ligation of the Intersphincteric Fistula Tract, an Integration of 2 Minimally Invasive Techniques for the Treatment of Parks Type II Anal Fistulas. Surg Innov 2020; 28:419-426. [PMID: 33275087 DOI: 10.1177/1553350620978026] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Introduction. Complex anal fistula (CAF) is a challenging anorectal condition. Although numerous treatments for its management have been proposed, none is ideal. Herein, we investigated the clinical efficacy of video-assisted modified ligation of the intersphincteric fistula tract (LIFT) in comparison with the incision-thread-drawing procedure for Parks type II anal fistulas. Methods. Male and female adult patients with Parks type II anal fistula who were randomized to receive one of two procedures in the Anorectal Surgery Unit of the Affiliated People's Hospital of Ningbo University: video-assisted modified LIFT (test group, 30 cases) or incision thread drawing (control group, 30 cases). Healing and recurrence, postoperative pain, and postoperative autonomous anal control ability were compared. Results. In the test group, the pain scores were significantly lower (P = .001) and wound healing was faster (P = .001). However, there were no marked differences between groups in operative efficacy or postoperative infection rate (all P > .05). We followed all the patients for more than 18 months, with the test group having lower Jorge-Wexner incontinence (P = .005) and fecal incontinence (FI) severity index (P = .000) scores. No significant difference in recurrence (χ2 = .351, P = .554) or healing (χ2 = 1.071, P = .301) rate was found between the 2 groups. Conclusions. We established that video-assisted modified LIFT is superior in repairing Parks type II anal fistulas, with less trauma, quicker recovery, and better anal function.
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Affiliation(s)
- Yi-Feng Wu
- Division of General Surgery, The Affiliated People' Hospital of Ningbo University, Ningbo, Zhejiang, China
| | - Bi-Chun Zheng
- Division of General Surgery, The Affiliated People' Hospital of Ningbo University, Ningbo, Zhejiang, China
| | - Quan Chen
- Division of General Surgery, The Affiliated People' Hospital of Ningbo University, Ningbo, Zhejiang, China
| | - Xu-Dong Chen
- Division of General Surgery, The Affiliated People' Hospital of Ningbo University, Ningbo, Zhejiang, China
| | - Shao-Shun Ye
- Division of General Surgery, The Affiliated People' Hospital of Ningbo University, Ningbo, Zhejiang, China
| | - Qiao-Yun Lin
- Division of General Surgery, The Affiliated People' Hospital of Ningbo University, Ningbo, Zhejiang, China
| | - Neng-Hong Ye
- Division of General Surgery, The Affiliated People' Hospital of Ningbo University, Ningbo, Zhejiang, China
| | - Fang Rong
- Division of General Surgery, The Affiliated People' Hospital of Ningbo University, Ningbo, Zhejiang, China
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Gallo G, Tiesi V, Fulginiti S, De Paola G, Vescio G, Sammarco G. Mesenchymal Stromal Cell Therapy in the Management of Perianal Fistulas in Crohn's Disease: An Up-To-Date Review. MEDICINA (KAUNAS, LITHUANIA) 2020; 56:563. [PMID: 33121049 PMCID: PMC7692376 DOI: 10.3390/medicina56110563] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Revised: 10/19/2020] [Accepted: 10/26/2020] [Indexed: 12/12/2022]
Abstract
Crohn's Disease (CD) is a chronic inflammatory disorder that potentially involves the entire gastrointestinal tract. Perianal fistulizing CD (pCD) is a serious and frequent complication associated with significant morbidities and a heavy negative impact on quality of life. The aim of CD treatment is to induce and maintain disease remission and to promote mucosal repair. Unfortunately, even the best therapeutic regimens in pCD do not have long-term efficacy and cause a significant number of side effects. Therefore, it is mandatory to study new therapeutical options such as the use of mesenchymal stromal cells (MSCs). These cells promote tissue repair via the induction of immunomodulation. The present review aims to analyze the existing updated scientific literature on MSCs adoption in the treatment of pCD to evaluate its efficacy and safety and to compare the use of bone marrow and adipose tissue derived MSCs, type of administration, and dose required for recovery.
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Affiliation(s)
- Gaetano Gallo
- Department of Medical and Surgical Sciences, University of Catanzaro, Viale Europa, 88100 Catanzaro, Italy; (V.T.); (S.F.); (G.D.P.); (G.V.)
| | - Vincenzo Tiesi
- Department of Medical and Surgical Sciences, University of Catanzaro, Viale Europa, 88100 Catanzaro, Italy; (V.T.); (S.F.); (G.D.P.); (G.V.)
| | - Serena Fulginiti
- Department of Medical and Surgical Sciences, University of Catanzaro, Viale Europa, 88100 Catanzaro, Italy; (V.T.); (S.F.); (G.D.P.); (G.V.)
| | - Gilda De Paola
- Department of Medical and Surgical Sciences, University of Catanzaro, Viale Europa, 88100 Catanzaro, Italy; (V.T.); (S.F.); (G.D.P.); (G.V.)
| | - Giuseppina Vescio
- Department of Medical and Surgical Sciences, University of Catanzaro, Viale Europa, 88100 Catanzaro, Italy; (V.T.); (S.F.); (G.D.P.); (G.V.)
| | - Giuseppe Sammarco
- Department of Health Sciences, University of Catanzaro, Viale Europa, 88100 Catanzaro, Italy;
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Treatment of fistula-in-ano: Outcome comparison between traditional surgery and novel approaches. A retrospective cohort study in a single center. JOURNAL OF SURGERY AND MEDICINE 2020. [DOI: 10.28982/josam.684298] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Long-term healing after complex anal fistula repair in patients with Crohn's disease. Tech Coloproctol 2020; 24:833-841. [PMID: 32537672 DOI: 10.1007/s10151-020-02238-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Accepted: 05/13/2020] [Indexed: 01/17/2023]
Abstract
BACKGROUND Complex anal fistula in Crohn's disease (CD) poses a challenging problem. We sought to evaluate long-term surgical healing of complex anal fistula in CD through the two robust repair options-ligation of the intersphincteric fistula tract (LIFT) and advancement flap (AF). METHODS A single-center retrospective study was conducted evaluating long-term healing rates in patients with CD with complex anal fistula undergoing LIFT or AF in 2008-2018. Fistula healing was defined as closure of external wounds, cessation of drainage and absence of pain. Short-term and long-term healing rates were compared. Cox proportional hazards model was performed to identify independent predictors of fistula healing. RESULTS The study cohort included 60 CD patients undergoing LIFT (n = 38) or AF (n = 22). The AF group included 8 dermal flaps. Patients having LIFT were younger (35 years vs 43 years; p = 0.007), more likely to have a seton at the time of repair (92% vs 68%; p = 0.03) and less likely to have had prior repair attempts (34% vs 68%; p = 0.02). Short-term fistula healing occurred in 65% (n = 39) of the overall study cohort. However, at final follow-up, median 36 months (range 6-192 months), only 46% (n = 28) of repaired fistulas were healed. Considering the overall status of the cohort's perianal health at final follow-up, including both repaired, secondary or novel anal fistulas, only 50% (n = 30) of all patients in the cohort had all fistula sites healed and maintained bowel continuity at final follow-up. On Cox proportional hazards analysis, LIFT independently predicted long-term fistula healing (hazard ratio 2.3; 95% confidence interval 1.1-4.9; p = 0.03). Only a small number of patients (n = 5; 8%) required fecal diversion (n = 3) and/or proctectomy (n = 2). CONCLUSIONS Repair of complex anal fistula in CD results in modest healing rates. LIFT independently predicts long-term healing. However, these results must be taken in context, considering differences in patient and fistula characteristics between groups. These results ought to be kept in mind when counseling CD patients with complex anal fistula.
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Emile SH. Recurrent anal fistulas: When, why, and how to manage? World J Clin Cases 2020; 8:1586-1591. [PMID: 32432136 PMCID: PMC7211523 DOI: 10.12998/wjcc.v8.i9.1586] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Revised: 04/12/2020] [Accepted: 04/22/2020] [Indexed: 02/05/2023] Open
Abstract
Anal fistula is a commonly encountered anal condition in the surgical practice. Despite being a benign condition, anal fistula remains to represent a surgical challenge, particularly the complex type of fistulas. One of the common complications of anal fistula surgery is the persistence or recurrence of the pathology, both defined as failure of surgery. Recurrent anal fistulas after previous surgery represent an even more challenging problem since they are usually associated with a higher risk of re-recurrence and continence disturbance. The present review aimed to shed light on various aspects of recurrent anal fistulas, including the different definitions of failure after surgery, risk factors of recurrence, problems associated with management of recurrent fistulas, and assessment and treatment of recurrent anal fistulas.
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Affiliation(s)
- Sameh Hany Emile
- Colorectal Surgery Unit, General Surgery Department, Mansoura University Hospitals, Mansoura University, Mansoura 35516, Egypt
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Machielsen AJHM, Iqbal N, Kimman ML, Sahnan K, Adegbola SO, Kleijnen J, Vaizey CJ, Grossi U, Tozer PJ, Breukink SO. The development of a cryptoglandular Anal Fistula Core Outcome Set (AFCOS): an international Delphi study protocol. United European Gastroenterol J 2020; 8:220-226. [PMID: 32213065 DOI: 10.1177/2050640620907570] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
PURPOSE Cryptoglandular anal fistula is a disorder with an incidence of around 1 per 5,000 people per year in European countries. Many studies have been conducted to evaluate the effectiveness of interventions for anal fistula. However, there is considerable heterogeneity in the outcomes assessed and reported in these studies. This limits research quality and complicates evidence synthesis. A solution for heterogeneity in outcome reporting is the development of a Core Outcome Set (COS). This paper describes the protocol for the development of a European COS for Anal Fistula (AFCOS). METHODS The first step will be a systematic review of the literature to identify potential outcomes that may be included in the COS. Patient interviews will be conducted in The United Kingdom and The Netherlands to ensure that both clinician-important and patient-important outcomes are captured. The outcomes will be categorized using the COMET taxonomy and taken forward to a Delphi consensus exercise. In up to three web-based Delphi surveys the outcomes will be prioritized by patients, clinicians (surgeons, gastroenterologists, and radiologists), and (clinical) researchers. The responses will be summarized and reported anonymously in subsequent round(s) facilitating convergence to a consensus opinion. The final COS will be decided during a face-to-face consensus meeting with patients, clinicians, and (clinical) researchers. DISCUSSION This study protocol describes the development of a European COS for anal fistula to improve research quality, evidence synthesis, and patient care.
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Affiliation(s)
- A J H M Machielsen
- Department of Surgery and Colorectal Surgery, Maastricht University Medical Centreþ, Maastricht, The Netherlands.,Faculty of Health, Medicine & Life Sciences, Maastricht University, Maastricht, The Netherlands
| | - N Iqbal
- Robin Phillips Fistula Research Unit, St Mark's Hospital, London, The United Kingdom.,Department of Surgery and Cancer, Imperial College London, London, The United Kingdom
| | - M L Kimman
- Department of Clinical Epidemiology and Medical Technology Assessment, Maastricht University Medical Centreþ, Maastricht, The Netherlands
| | - K Sahnan
- Robin Phillips Fistula Research Unit, St Mark's Hospital, London, The United Kingdom.,Department of Surgery and Cancer, Imperial College London, London, The United Kingdom
| | - S O Adegbola
- Robin Phillips Fistula Research Unit, St Mark's Hospital, London, The United Kingdom.,Department of Surgery and Cancer, Imperial College London, London, The United Kingdom
| | - J Kleijnen
- Department of Family Practice; Care and Public Health Research Institute, Maastricht University, Maastricht, The Netherlands
| | - C J Vaizey
- Robin Phillips Fistula Research Unit, St Mark's Hospital, London, The United Kingdom.,Department of Surgery and Cancer, Imperial College London, London, The United Kingdom
| | - U Grossi
- 4th Surgery Unit, Treviso Hospital, Treviso, Italy; University of Padua, Padua, Italy
| | - P J Tozer
- Robin Phillips Fistula Research Unit, St Mark's Hospital, London, The United Kingdom.,Department of Surgery and Cancer, Imperial College London, London, The United Kingdom
| | - S O Breukink
- Department of Surgery and Colorectal Surgery, Maastricht University Medical Centreþ, Maastricht, The Netherlands
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Alahmari A, Mansouri M, Alwaal A. Complex anal fistula involving male genital tract: a new diagnostic entity. BMJ Case Rep 2019; 12:12/10/e231702. [PMID: 31645379 DOI: 10.1136/bcr-2019-231702] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
We present three male patients who had a rare presentation of anal fistula reaching the genital tract. Patient 1: a 44-year-old diabetic man presented initially to urology clinic complaining of penile and scrotal masses increasing in size for 6 months. Patient 2: a 67-year-old diabetic man presented with chronic sinus discharge from the scrotum. Patient 3: a 37-year-old diabetic man who presented with chronic sinus draining pus-like material from the scrotum for 1 year. Patients 1 and 2: following diagnosis of perianal fistula by MRI fistulography, complete excision of the fistula was done. This required tracking the fistula surgically, a perineal midline incision to release the fistula and excision of the fistula opening in the anal canal. The patients were doing well postoperative and no recurrence of fistula at 1-year follow-up. Patient 3: he refused surgical intervention. Penile mass or scrotal discharge has not been reported to be caused by fistula-in-ano.
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Affiliation(s)
- Abdullah Alahmari
- Department of Urology, King Abdulaziz University Faculty of Medicine, Jeddah, Saudi Arabia
| | - Majed Mansouri
- Department of Surgery, King Abdulaziz University Faculty of Medicine, Jeddah, Saudi Arabia
| | - Amjad Alwaal
- Department of Urology, Marshall University, Huntington, West Virginia, USA
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Anan M, Emile SH, Elgendy H, Shalaby M, Elshobaky A, Abdel-Razik MA, Elbaz SA, Farid M. Fistulotomy with or without marsupialisation of wound edges in treatment of simple anal fistula: a randomised controlled trial. Ann R Coll Surg Engl 2019; 101:472-478. [PMID: 31155896 PMCID: PMC6667946 DOI: 10.1308/rcsann.2019.0057] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/24/2019] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Promotion of healing of the anal wound after fistulotomy may help accelerate recovery and return to work. The present study aimed to assess the effect of marsupialisation of the edges of the laid open fistula track on wound healing after anal fistulotomy for simple anal fistula. METHODS This was a prospective randomised trial on patients with simple anal fistula. Patients were randomly assigned to one of two groups; group I underwent anal fistulotomy and group II underwent anal fistulotomy and marsupialisation of the edges of the laid open track. Outcomes of the study were time to achieve complete wound healing, operation time, postoperative pain and complications. RESULTS Sixty patients of mean age of 40.8 years with simple anal fistula were randomly divided into two equal groups. No significant differences between the two groups regarding operation time (16.8 vs 18.4 minutes; P = 0.054), postoperative pain score (1.6 vs 1.2; P = 0.22), and complication rates were recorded. Group II achieved complete healing in a significantly shorter duration than group I (5.1 vs 6.7 weeks; P < 0.0001). CONCLUSION Marsupialisation of the edges of the laid open fistula track after fistulotomy resulted in quicker wound healing with similar complication and recurrence rates to lay open fistulotomy alone.
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Affiliation(s)
- M Anan
- Colorectal Surgery Unit, General Surgery Department, Mansoura University Hospitals, Mansoura University, Mansoura City, Egypt
| | - SH Emile
- Colorectal Surgery Unit, General Surgery Department, Mansoura University Hospitals, Mansoura University, Mansoura City, Egypt
| | - H Elgendy
- Colorectal Surgery Unit, General Surgery Department, Mansoura University Hospitals, Mansoura University, Mansoura City, Egypt
| | - M Shalaby
- Colorectal Surgery Unit, General Surgery Department, Mansoura University Hospitals, Mansoura University, Mansoura City, Egypt
| | - A Elshobaky
- Colorectal Surgery Unit, General Surgery Department, Mansoura University Hospitals, Mansoura University, Mansoura City, Egypt
| | - MA Abdel-Razik
- Colorectal Surgery Unit, General Surgery Department, Mansoura University Hospitals, Mansoura University, Mansoura City, Egypt
| | - SA Elbaz
- Colorectal Surgery Unit, General Surgery Department, Mansoura University Hospitals, Mansoura University, Mansoura City, Egypt
| | - M Farid
- Colorectal Surgery Unit, General Surgery Department, Mansoura University Hospitals, Mansoura University, Mansoura City, Egypt
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Use of Cadaveric Pericardial Tissue in the Surgical Treatment of Neurogenic Bladder. Case Rep Urol 2019; 2019:6182397. [PMID: 31392069 PMCID: PMC6662501 DOI: 10.1155/2019/6182397] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2019] [Accepted: 07/04/2019] [Indexed: 12/05/2022] Open
Abstract
The surgical treatments for neurogenic bladder are extremely variable. The lack of specific treatment guidelines makes this disease process even more challenging to treat. We present a case of a 55-year-old female with neurogenic bladder secondary to spinal cord injury (SCI). Her incontinence was conservatively managed with indwelling Foley drainage. Despite continued upsizing of the Foley catheters, the patient continued to have urinary leakage. The patient subsequently underwent a transvaginal bladder neck closure (BNC) with suprapubic bladder neck diversion (SPC). The urethra was successfully closed and uniquely supported with the use of cadaveric pericardial tissue (CPT). This surgical approach of neurogenic bladder provides durable continence with short operative times, minimal patient morbidity, decreased hospital length, and low risk of progressive renal dysfunction. BNC with SPC can provide an excellent management solution for neurogenic bladder from spinal cord injury refractory to conservative management.
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Omar W, Alqasaby A, Abdelnaby M, Youssef M, Shalaby M, Anwar Abdel-Razik M, Emile SH. Drainage Seton Versus External Anal Sphincter-Sparing Seton After Rerouting of the Fistula Tract in the Treatment of Complex Anal Fistula: A Randomized Controlled Trial. Dis Colon Rectum 2019; 62:980-987. [PMID: 31162376 DOI: 10.1097/dcr.0000000000001416] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Complex anal fistula is one of the challenging anorectal conditions. Several treatments have been proposed for complex anal fistula, yet none proved to be ideal. OBJECTIVE This randomized trial aimed to assess the efficacy of external anal sphincter-sparing seton in comparison with the conventional drainage seton in the treatment of complex anal fistula. DESIGN This was a prospective, randomized, single-blind controlled study. SETTINGS The study was conducted at the Colorectal Surgery Unit of Mansoura University Hospitals. PATIENTS Adult patients of both sexes with complex anal fistula were recruited and evaluated with MRI before surgery. INTERVENTIONS Patients were randomly divided into 2 groups; group 1 was treated with conventional drainage seton and group 2 was treated with external anal sphincter-sparing seton using a rerouting technique. MAIN OUTCOME MEASURES The duration of healing, incidence of recurrence or persistence, postoperative pain, and complications including fecal incontinence were measured. RESULTS Sixty patients (56 men) with a mean age of 43 years were included. Mean operation time in group 1 was significantly shorter than group 2 (29.8 ± 4.3 vs 43.8 ± 4.5 min; p < 0.0001). The mean pain score at 24 hours in group 1 was 8.1 ± 1.6 versus 5.3 ± 1.3 in group 2 (p < 0.0001). Five patients (17%) in group 1 experienced complications versus 2 (7%) in group 2. All of the patients in group 1 required a second-stage fistulotomy versus 2 patients (7%) in group 2 (p < 0.0001). Time to complete healing in group 1 was significantly (p < 0.0001) longer than group 2 (103 ± 47 vs 46 ± 18 d). Four patients (13%) in group 1 and 1 patient (3%) in group 2 experienced persistence or recurrence of anal fistula (p = 0.35). LIMITATIONS This was a single-center study with relatively small numbers in each group. CONCLUSIONS Patients treated with external anal sphincter-sparing seton after rerouting of the fistula tract achieved quicker healing and less postoperative pain than those with conventional drainage seton. Postoperative complication and recurrence rates were comparable in both groups. See Video Abstract at http://links.lww.com/DCR/A963. TRIAL REGISTRATION clinicaltrials.gov identifier: NCT03636997 (https://clinicaltrials.gov/ct2/show/NCT03636997).
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Affiliation(s)
- Waleed Omar
- Colorectal Surgery Unit, Department of General Surgery, Mansoura University Hospitals, Mansoura University, Dakahliya, Egypt
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Sanad A, Emile S, Thabet W, Ellaithy R. A randomized controlled trial on the effect of topical phenytoin 2% on wound healing after anal fistulotomy. Colorectal Dis 2019; 21:697-704. [PMID: 30740877 DOI: 10.1111/codi.14580] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2018] [Accepted: 02/02/2019] [Indexed: 12/16/2022]
Abstract
AIM Laying open fistulotomy is the standard treatment for simple anal fistula. However, healing of the resultant anal wound may be prolonged and may adversely affect a patient's lifestyle and work. This randomized trial aimed to assess the effect of topical phenytoin 2% powder spray on healing of the anal wound following fistulotomy. METHOD Adult patients with simple anal fistula who underwent anal fistulotomy were divided into two equal groups: group I applied topical phenytoin 2% powder spray on the anal wound regularly with sitz baths until complete healing was confirmed clinically and group II had regular sitz baths only. The primary outcome of the study was time to complete wound healing. Secondary outcomes were postoperative pain, complications, time to return to work and impact on lifestyle. RESULTS Sixty patients (50 of whom were men) with a mean age of 41.4 ± 12.5 years were included. Both groups had comparable pain scores at 1 week after surgery (1 ± 0.83 vs 0.86 ± 0.81; P = 0.51). The duration to complete wound healing was 41.2 ± 2.4 days in group I and 42 ± 2.5 days in group II (mean ± SD, P = 0.21). The time to return to work was 13.5 ± 2.8 days in group I and 14.1 ± 2.6 days in group II (mean ± SD, P = 0.39). No significant differences were noted between the two groups with regard to postoperative complications or impact on lifestyle. CONCLUSION The use of topical phenytoin 2% powder spray did not promote wound healing, relieve postoperative pain or accelerate patient recovery after anal fistulotomy for simple anal fistula.
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Affiliation(s)
- A Sanad
- Colorectal Surgery Unit, General Surgery Department, Mansoura University Hospitals, Mansoura University, Mansoura City, Egypt
| | - S Emile
- Colorectal Surgery Unit, General Surgery Department, Mansoura University Hospitals, Mansoura University, Mansoura City, Egypt
| | - W Thabet
- Colorectal Surgery Unit, General Surgery Department, Mansoura University Hospitals, Mansoura University, Mansoura City, Egypt
| | - R Ellaithy
- Colorectal Surgery Unit, General Surgery Department, Mansoura University Hospitals, Mansoura University, Mansoura City, Egypt
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Abstract
Anal fistula, or fistula-in-ano, is a condition involving the anal region that is common yet debilitating. Surgery is the mainstay of treatment for an anal fistula and the chances of recurrence are quite high even after corrective surgical procedures. The risk factors for recurrence can be broadly classified into four categories: 1) risk factors related to the fundamental anatomy of the fistula and presence of comorbidities, 2) lack of proper preoperative assessment of the fistula, which includes failure to recognize the internal opening and overall structure of the fistula and not supplementing the proctologic examination with sufficient imaging, 3) intraoperative loopholes that include improper procedure selection, inexperience of the surgeon, and failure to get rid of the entire tract along with its ramifications, and 4) lack of proper postoperative care in the early and late periods following the surgery. The aim of this paper, therefore, is to highlight the factors that could increase the risk of recurrence in different types of anal fistulae. Once surgeons know these risk factors, they can anticipate any complication and detect recurrence early.
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Treatment of Complicated Anal Fistula by an Endofistular Polyurethane-Sponge Vacuum Therapy: A Pilot Study. Dis Colon Rectum 2018; 61:1435-1441. [PMID: 30399049 DOI: 10.1097/dcr.0000000000001233] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Treatment of supra- and transsphincteric anal fistulas remains a clinical challenge because current treatment results are variable and potentially endanger sphincter function. OBJECTIVE Based on positive results of endoluminal polyurethane-sponge vacuum therapy in the upper and lower GI tract, a new system for endofistular vacuum therapy was developed for anal fistulas to utilize vacuum therapy to remove the endofistular pseudoepithelium and to induce granulation in the fistula tract. DESIGN This study is based on a prospective case series. PATIENTS Seven patients with complicated anal fistulas (3 associated with Crohn's disease and 4 of cryptoglandular origin) longer than 4 cm were treated. Initially, the fistula was curettaged and the first endofistular vacuum therapy sponge was positioned in the fistula tract. The inner fistula opening was closed by suture. A 125 mm Hg constant vacuum was applied to the sponge, and the endofistular vacuum therapy sponge was changed a median of 3 (3-5) times after each 48 to 72 hours of constant vacuum therapy. After final removal, the fistulas were reevaluated every other week for 3 months. MAIN OUTCOME MEASURE The main outcome measured was the closure of the fistula. RESULTS All patients tolerated the therapy well and no adverse events were observed. Fistula tract closure was demonstrated within 4 weeks after the termination of vacuum therapy. One patient with cryptoglandular fistula developed a recurrence within the follow-up of 3 months. LIMITATIONS This was an observational study that had no control arm. CONCLUSION In this pilot case series, the results are encouraging. Because endoluminal vacuum therapy would be a new and sphincter-sparing therapy, this concept warrants further investigation in controlled trials.
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