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Outcomes After Operations for Anal Fistula: Results of a Prospective, Multicenter, Regional Study
Abstract
Background:
There are various surgical techniques used treat anal fistulas. The adoption and success rates of newer techniques have not been clearly established.
Objective:
The purpose of this study was to determine the healing rate after operations for anal fistulas in New England colorectal surgery practices.
Design:
We conducted a retrospective review of a prospectively collected database.
Settings:
The study was conducted at colorectal surgery practices in New England.
Patients:
A prospective, multicenter registry was created by the New England Society of Colon and Rectal Surgeons. Surgeons were invited to collect data prospectively regarding patients operated on for anal fistulas between January 1, 2011, and August 1, 2013. Fistula classification, surgical intervention, continence scores, and healing were determined by the treating surgeon.
Intervention:
Operation for anal fistula was performed.
Main outcome measures:
We measured the proportion of patients with healed fistulas at 3 months.
Results:
Sixteen surgeons submitted data regarding 240 operations for fistula with curative intent. Mean patient age was 45 ± 14 years. A total of 158 patients (66%) were men, and 110 (46%) had undergone an anorectal operation. Twenty-nine (12%) had Crohn's disease. The healing rates of fistulotomy, advancement flap, and fistula plugs at 3 months were 94% (95% CI, 89-97), 60% (95% CI, 33-77), and 20% (95% CI, 5-50). The healing rate of the ligation of intersphincteric fistula tract procedure at 3 months was 79% (95% CI, 65-88). Hospital site was the only variable associated with healing (p < 0.05). Hospitals that performed more ligation of intersphincteric fistula tract procedures had higher healing rates at 3 months (p < 0.0001).
Limitations:
This study was limited by selection bias and reporting bias.
Conclusions:
A wide variety of techniques are used to treat anal fistulas in our region. Fistulotomy continues to have excellent results. There has been enthusiastic early adoption of the ligation of intersphincteric fistula tract technique. Early healing rates after the ligation of intersphincteric fistula tract procedure appear to be excellent.
... 1). 6,10,11,[14][15][16][17][18][19][20] The median age of the included patients was 44 years, and the female/male ratio was 23%/77%. ...
... The median follow-up was greater than 1 year in all studies except in 2, both reporting a median follow-up time of more than 3 months. 16,18 The majority of the included patients were diagnosed with trans-sphincteric fistulas, although some cases of recto-vaginal and posterior horseshoe fistulas were also considered (►Tables 1 and 2). All papers contained a definition of the complete fistula healing and treatment failure criteria. ...
... 28 Moreover, only 2 studies have stratified their results according to the use of a seton, with sample sizes of 71 and 43 patients, and found a similar percentage of recurrence with and without seton use. 16,18 Most of the studies included in the present meta-analysis showed that the placement of a seton prior to the LIFT procedure had no effect on the outcome in terms of definitive healing or recurrence rates of anal fistula. For many years, the use of seton prior to LIFT surgery for fistula-in-ano has been a highly controversial subject. ...
Background There is still controversy over the usefulness of seton placement prior to the ligation of the intersphincteric fistula tract (LIFT) surgery in the management of anal fistula.
Objective To evaluate the impact of preoperative seton placement on the outcomes of LIFT surgery for the management of fistula-in-ano.
Design systematic review and meta-analysis.
Data Sources A search was performed on the MEDLINE (PubMed), EMBASE, Scopus, Web of Science, Cochrane Library and Google Scholar databases.
Study Selection Original studies without language restriction reporting the primary healing rates with and without seton placement as a bridge to definitive LIFT surgery were included.
Intervention The intervention assessed was the LIFT with and without prior seton placement.
Main Outcome Measures The main outcome was defined as the primary healing rate with and without the use of seton as a bridge to definitive LIFT surgery.
Results Ten studies met the criteria for systematic review, all retrospective, with a pooled study population of 772 patients. There were no significant differences in the percentages of recurrence between patients with and without seton placement (odds ratio [OR] 1.02; 95% confidence interval [CI] 0.73–1.43: p = 0.35). The I2 value was 9%, which shows the homogeneity of the results among the analyzed studies. The 10 included studies demonstrated a weighted average overall recurrence of 38% (interquartile range [IQR] 27–42.7%), recurrence with the use of seton was 40% (IQR 26.6–51.2%), and without its use, the recurrence rate was 51.3% (IQR 31.3–51.3%)
Limitations The levels of evidence found in the available literature were relatively fair, as indicated after qualitative evaluation using the Newcastle-Ottawa scale and the Attitude Heading Reference System (AHRS) evidence levels.
Conclusions Our meta-analysis suggests that the placement of seton as a bridge treatment prior to LIFT surgery does not significantly improve long-term anal fistula healing outcomes. Ligation of the intersphincteric fistula tract surgery can be performed safely and effectively with no previous seton placement.
International prospective register of systematic reviews—PROSPERO registration number: CDR42020149173.
... Preoperative imaging studies are pivotal in assessing the complexity of the fistula and determining its relationship to surrounding structures. MRI, endorectal ultrasound, and fistulography are commonly used to evaluate the fistula tract and abscesses [33]. In Crohn's disease, MRI is the preferred imaging modality due to its ability to provide detailed anatomical views, allowing for accurate assessment of sphincter involvement, trans-sphincteric fistulas, and multifocal disease. ...
... Subsequently, electrocautery is employed to eliminate the epithelialized tract to the greatest extent feasible, and the wound is allowed to heal in an open manner. Some studies have indicated that healing rates for fistulotomy can reach as high as 94% [33]. ...
Perianal disease with abscesses and fistulas is a commonly encountered condition, but one that is complex to manage, requiring careful diagnosis and appropriate surgical management. A thorough preoperative diagnostic evaluation is crucial to understand the specific characteristics of the condition and the patient, as well as to identify any underlying chronic inflammatory bowel diseases, such as Crohn’s disease, which may complicate the clinical picture. Surgery, primarily involving the incision and removal of the fistulous tracts, is often the only option to treat perianal fistulas. However, managing this condition may require more than one procedure, particularly to address any recurrences, which are quite common. Modern surgical techniques and the use of advanced technologies, such as ultrasound or fistulography, have improved outcomes and reduced the risks of postoperative complications. Treatment must be tailored to each patient’s specific characteristics, taking into account the complexity of the disease and the potential for recurrences. The main challenge remains achieving complete healing while reducing the risk of long-term complications and improving the patient’s quality of life. Additionally, postoperative management and long-term monitoring are essential to prevent new infections and ensure the success of the surgery.
... The current surgical approaches struggle to achieve effective fistula treatment while preserving the sphincter function because recurrence rates remain high even though more studies are needed to find predictive indicators for treatment outcomes [9]. The use of laser closure techniques and the ligation of the intersphincteric fistula tract (LIFT) procedure show promising results although studies have not provided conclusive evidence for long-term effectiveness [10]. ...
... The research data from this study implies that the surgical approach showed potential success in reducing fistula reappearances yet wider patient studies must be conducted to verify these findings. Wound infections have a strong connection to fistula recurrence as researchers observed in Hall et al., [10] who discovered surgical infections impair tissue healing and increase fistula recurrence probability. The research results demonstrate why healthcare organizations must maintain absolute infection control measures throughout both perioperative and postoperative phases. ...
Background: High trans-sphincteric fistula-in-ano presents significant management challenges owing to its complex anatomy and high risk of recurrence. Despite advancements in surgical techniques, postoperative complications and recurrences remain major concerns. Identifying the factors that influence these outcomes is crucial for optimizing the treatment strategies. This study aimed to evaluate factors affecting postoperative complications and recurrence in patients undergoing surgery for high transsphincteric fistula-in-ano. Methods: This prospective observational study was conducted at the Department of Colorectal Surgery, Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka, Bangladesh, from June 2021 to May 2022. Total 36 patients who underwent surgical management for high transsphincteric fistula-in-ano were included in this study. Patient demographics, fistula characteristics, surgical outcomes, and postoperative complications were also analyzed. Results: The recurrence rate was 19.4%, and wound infection was significantly associated with recurrence (P =0.033). No significant association was found between fistula location and recurrence (p>0.05). Postoperative continence outcomes were favorable, with 91.2% of the patients maintaining Grade A continence. Suture line dehiscence was observed in 11.1% of cases. These findings emphasize the critical role of infection control in preventing recurrence. Conclusion: Wound infection was a significant predictor of recurrence in patients with high transsphincteric fistula-in-ano, underscoring the need for stringent perioperative infection control. This study supports the effectiveness of sphincter-preserving techniques for maintaining continence. Further research with larger cohorts and longer follow-up periods is needed to optimize treatment strategies and improve patient outcomes.
... Nüks oranı çok düşüktür. Başarı oranı %90 üzeridir (24,25). ...
... Uygun seçilmiş hastalarda nüks ve fekal inkontinans oranı çok düşüktür. Başarı oranı %90 'lardadır (24,25). Bu fistül dahil önceden anal inkontinans mutlaka sorgulanmalıdır. ...
PERİANAL FİSTÜL TEDAVİSİNDE GÜNCEL YAKLAŞIMLAR
... Its pathogenesis is closely related to chronic bacterial infection of anal glands which is known as cryptoglandular infection [3]. The disease represents a wide spectrum of complexity due to various degrees of anal sphincter complex involvement and its unpredictable or multiple tracts thus leading to a high rate of recurrent fistula or persistent (unhealed) fistula after surgery [4]. Ultimately, the goals of anal fistula surgery are to achieve complete healing of the fistula tract by means of closure or removal of the tract and, more importantly, to preserve anal sphincter function. ...
... Since the results of anal fistula surgery require a long period of follow-up to determine both clinical outcomes (i.e., recurrent rate and pattern of recurrence) and patient-reported outcomes (i.e., fecal continence status and chronic postsurgical pain), there are a relatively limited number of large studies (more than 200 cases) examining these long-term outcomes [4,[6][7][8]. Moreover, to the best of our knowledge, no such large-scale studies reported these results in a comprehensive manner. ...
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.
... Anal fistulas are commonly associated with cryptoglandular infections [1], in which bacteria infiltrate the anal crypts and ducts, leading to abscess formation and fistula development. Most anal fistulas are simple intersphincteric and transsphincteric fistulas, which can be healed in over 90% of cases with surgery alone [2,3]. However, an individualized surgical approach is required for complex anal fistulas, such as fistulas with multiple routes, recurrent fistulas, or fistulas involving adjacent organs. ...
We report a rare case of an ano-Bartholin's gland fistula caused by an anal fistula in a patient without Crohn's disease (CD). A 34-year-old woman was admitted to our hospital due to purulent anal discharge and left vulvar pain. She had experienced several Bartholinitis in the past 2 years. She had no history of inflammatory bowel disease or other relevant conditions. A transanal ultrasound scan and pelvic magnetic resonance imaging showed a transsphincteric anal fistula connecting to an ano-Bartholin's gland abscess in the left vulva. Surgical findings showed that the primary opening of the anal fistula was located between the dentate line and anal verge. The fistula was treated with a sphincter-preserving subcutaneous incision of the fistula tract and internal sphincterotomy, and the Bartholin's gland abscess was effectively managed with drainage alone without excision. The postoperative recovery was successful, with no disturbance in defecation or sexual function. Although complex anal fistulas involving the female genital organs sometimes occur in patients with CD, they are exceedingly rare in patients without CD. This case shows that such fistulas can be managed with targeted anal fistula procedures with minimal invasion of the perineal area.
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... Anal fistulas are common manifestations of perianal infections that rarely heal on their own [1]. Surgical procedures are the only reliable treatment for anal fistulas [2]. High complex anal fistulas are typically complicated by their high anatomic location, the presence of branching fistulas with intricate fistula distributions and the risk of carcinogenesis [3]. ...
BACKGROUND
High complex anal fistulas are epithelialized tunnels, with the main fistula piercing above the deep external sphincter and the internal opening approaching the dentate line. Conventional surgical procedures for high complex anal fistulas remove most of the external sphincter and damage the anorectal ring. Postoperative loss of anal function can cause physical and mental damage. Transanal opening of the intersphincteric space (TROPIS) is an effective procedure that completely preserves the external anal sphincter. However, its clinical application is limited by challenges in the localization of the internal opening of a fistula and the high risk of complications. On the basis of our clinical experience, we modified the TROPIS procedure for the treatment of treating high complex anal fistulas.
CASE SUMMARY
A patient with a high complex anal fistula located above the anorectal ring underwent modified TROPIS, which involved sepsis drainage and identification of the internal opening in the intersphincteric space. The patient with the high complex anal fistula recovered well postoperatively, without any postoperative complications or anal dysfunction. Anal function returned to normal after 17 months of follow-up.
CONCLUSION
The modified TROPIS procedure is the most minimally invasive surgery for anal fistulas that minimally impairs anal function. It allows the complete removal of infected anal glands and reduces the risk of postoperative complications. Modified TROPIS via the intersphincteric approach is an alternative sphincter-preserving treatment for high complex anal fistulas.
... anorectal procedures are not as effective as compared to other general surgical procedures and often need multiple revisions with residual symptoms. 16 It is also possible that the IoL is simply more sensitive to changes in gallbladder surgery-associated symptoms than hernia or anorectal surgery. Given that gallbladders independently predict improvement, it could be considered whether such surgeries should be eligible for extra GSPT points. ...
Background
Healthcare systems globally face the issue of resource constraints and need for prioritization of elective surgery. Inclusive, explicit prioritization tools are important in improving consistency and equity of access to surgery across health systems. The General Surgical Prioritization Tool developed by New Zealand's Ministry of Health scores patients for elective non‐cancer surgery based on surgeon's clinical judgement and patient derived Impact on Life (IoL) scores. This study aims to measure the changes in patient derived IoL scores after common general surgical procedures to enable direct comparison and inform future prioritization.
Method
This longitudinal observational study enrolled 322 participants who had undergone elective general surgical procedures. Participants were contacted 3 to 9 months after their procedures and requested to complete the IoL questionnaire. The primary endpoint was the change in IoL scores after surgery among the different procedures.
Results
Overall, 229/304 (75%) participants responded to the questionnaire and there were no significant baseline differences between responders and non‐responders. Patients in the gallbladder treatment group had the greatest improvement in IoL scores. Patients across all ethnic groups had similar changes in IoL scores. Multivariate analysis showed that gallbladder surgery (relative to hernia surgery) and pre‐surgery IoL scores significantly predicted improvement.
Conclusion
The patient reported IoL score recorded at prioritization for surgery all reduced, albeit to varying amounts, after common general surgical procedures. This, combined with the fact that IoL scores predicted post‐operative improvement support their inclusion in prioritization tools in addition to surgeon derived components.
... Dong et al. showed that damage to the postoperative sphincter can lead to anal incontinence (36). Moreover, postoperative healing time for anal fistulas and anorectal abscesses is also a long process, requiring at least 3 months to recover (37). In conclusion, prevention and early intervention are particularly crucial for overweight and obese individuals who are at high risk of developing these diseases. ...
Objective
The epidemiological profile of anal fistula and anorectal abscess has not been well studied. Based on the results of a retrospective cross-sectional survey, we aimed to investigate the potential influential factors associated with anal fistula and anorectal abscess.
Methods
We conducted a retrospective analysis of outpatients who visited the proctology department at China-Japan Friendship Hospital between January 2017 and May 2022. A comprehensive questionnaire was designed to collect potential influential factors, and according to formal anorectal examination and the corresponding diagnostic criteria, all the participants were divided into patients with anal fistula or perianal abscess and healthy control group. Multiple logistic regression was used to identify factors in significant association with anal fistula and perianal abscess. Additionally, we combined restricted cubic spline regression to examine the dose-response relationship between factors and the risk of developing anal fistula or anorectal abscess.
Results
The present study included 1,223 participants, including 1,018 males and 206 females, with 275 anal fistulas, 184 anorectal abscesses, and 765 healthy controls. We found no statistically significant differences between patients and controls in basic information and preoperative assessment of life factors, except for body mass index. It was indicated that people with overweight or obesity were more prone to anal fistula (OR overweight = 1.35, 95% CI: 1.00–1.82, P = 0.047; OR obesity = 3.44, 95% CI: 2.26–5.26, P < 0.001) or anorectal abscess (OR overweight = 1.41, 95% CI: 1.00–1.99, P = 0.05; OR obesity: 2.24, 95% CI: 1.37–3.67, P = 0.001) than normal-weight individuals. The dose-response research indicated the J-shaped trend between the ascending BMI levels and the higher risk of suffering from anal fistula and anorectal abscess.
Conclusions
Our findings indicate that overweight and obesity are risk factors for anal fistula and anorectal abscess, which plays a role in the prevention of anorectal diseases. This provides some theoretical basis for clinicians to provide health education to their patients.
... Es un tratamiento eficaz para las fístulas anales simples que logra la curación en más de 90% de los pacientes. 32,33 Es fundamental evaluar la continencia del esfínter anal de todos los pacientes antes de la fistulotomía. En los pacientes con incontinencia preexistente la fistulotomía está contraindicada en todas las situaciones. ...
DEFINICIÓN El absceso anorrectal es el acúmulo de material purulento en una región o espacio cercano al ano o al recto, capaz de drenar su contenido a través de un orificio en la piel perianal o en la mucosa rectal, en tanto que una fístula anal es el proceso crónico secundario al drenaje de un absceso anal, en el que se establece un trayec-to epitelizado entre el conducto anal o el recto (orificio primario) y la piel perianal (orificio secundario). 1,2 EPIDEMIOLOGÍA En EUA se estima que hay 100 000 casos de infección anorrectal por año. En Mé-xico no existen estadísticas exactas, y los datos acerca de la incidencia y la preva-lencia son subestimados por factores como el drenaje en la consulta externa, o por el hecho de que los pacientes y los profesionales de la salud señalan que los sínto-mas son secundarios a "hemorroides", por lo que no se busca atención médica para un diagnóstico preciso. Múltiples estudios, como los de Sainio (1984), Piaz-za y col. (1990), y Nelson y col. (1995), describen la epidemiología de esta enfer-medad; entre sus hallazgos destacan la incidencia (entre 30 y 50%) de una fístula anal que se desarrolla a partir de un absceso anal. La edad media de presentación del absceso anal y de la fístula es de 40 años (rango de 20 a 60 años). Los hombres 75
... Although optimal healing rates were shown in 85% to 98% of patients undergoing fistulotomy, some degree of postoperative continence impairment was reported in 6-28% and 17.5-40% cases of low and high anal fistula, respectively [7,[10][11][12][13][14][15][16][17][18][19][20][21][22]. Therefore, several alternative sphincter-saving approaches were developed, reporting variable, disappointing success rates [23][24][25][26][27]. ...
Traditional fistulotomy is the most performed surgical procedure in anal fistula surgery. We conducted an international online survey to explore colorectal surgeons’ opinions and preferences on fistulotomy. Considering the healing and continence impairment rates reported in the literature, surgeons were invited to answer as a hypothetic patient susceptible to being submitted to fistulotomy for low and high anal fistula. A total of 767 surgeons completed the survey from 72 countries. The majority of respondents were consultants, having treated more than 20 anal fistulas in the last year. Most of them declared that anal fistula would be able to negatively affect quality of life and would be worried/anxious about it. Taking into account all aspects, 87.5% and 37.8% of respondents would agree to be treated with a fistulotomy in case of a low and high fistula, respectively, with an acceptance rate that varied worldwide. At multivariate analysis, factors correlated to the acceptance of anal fistulotomy were male gender (p = 0.003), practice of less than 20 fistula operations during last year (p = 0.020), and low fistula (p < 0.001). Surgeons recognized the extreme complexity of this approach. This study highlighted the necessity of an accurate patients’ selection and the adoption of alternative strategy to reduce the risk of anal continence impairment.
... Cerrahi drenaj ile anorektal apse tedavi edilebilir. Ancak apse drenaj yolunun epitelizasyonuyla %30-%50 hastada aylar sonra fistüller gelişebilir [3][4][5][6]. Hangi hastalarda fistül gelişeceğini kestirmek mümkün değildir. Parks günümüzde hala kabul görüldüğü gibi apseleri intersfinkterik, perianal, iskiorektal, supralevator ve submüköz apseler olarak değerlendirmiştir [1]. ...
... The Seton method is a surgical method that preserves the function of the sphincter muscle and reduces urinary incontinence compared to other methods. Fistulotomy is reported to be the most effective method in the treatment of anal fistulas and the cure rate is >90% (4)(5)(6). However, patients treated with fistulotomy are at risk of developing anal sphincter dysfunction after surgery. ...
Amaç: Lazer yöntemi (FiLaCTM), son zamanlarda anal fistül tedavisinde minimal invazif tedavi seçeneği olarak karşımıza çıkmaktadır. Anal fistül cerrahisi sonrası anal inkontinans ve fistül nüksü tedaviyi zorlaştıran postoperatif sorunlar olarak karşımıza çıkar. Çalışmamızda FiLaCTM yönteminin anal fistül tedavisinde etkinliğini ve tedavide hangi durumlarda tercih edilmesi gerektiğini araştırmayı amaçladık. Yöntem: Temmuz 2017 ile Ağustos 2018 yılları arasında Derik Devlet Hastanesi’nde FiLaCTM diyot lazer uygulanan 12 hasta çalışmaya dâhil edildi. Hastalar retrospektif olarak, yaş, cinsiyet, inkontinans gelişimi, iyileşme ve işe dönüş zamanı, fistül tipleri, MR bulguları ve komplikasyonlar açısından analiz edildi. Bulgular: Çalışmaya alınan hastaların 11’ü erkek 1 kadın olup yaş ortalaması 46 idi. İntraoperatif komplikasyon hiçbir hastada görülmedi. Ortalama takip süresi 13,5 (7-19) ay idi. Hastaların takiplerinde 4 (%33,3) hastada tam iyileşme gözlenirken, 8 (%66,7) hastada ise iyleşme sağlanamadı. Sonuç: Anal fistül tedavisi için FiLaCTM prosedürü, güvenli, minimal invaziv, sfinkter koruyucu bir tedavi seçeneği olup düşük etkinliğe sahiptir. Ancak yüksek seviyeli fistüllerde, minimal invazif girişim isteyen hastalarda başlangıç tedavisi olarak tercih edilebilir.
... Fistulotomy was thought to be the gold standard for fistulous tract treatment, however, the recurrence rate was reported to be greater than 90% [2] . However, patients who were treated with a fistulotomy had a risk of anal sphincter dysfunction postoperatively [3] . ...
... With the above in mind, it is important to note that operations which can impact the sphincter muscle such as anal fistulotomy or fistulectomy are associated with the highest success rate of any treatment for anal fistula with the least incidence of failure or recurrence (Hall et al. 2014;Abbass and Abbas 2014). Both techniques remain the most commonly performed anal fistula operations globally ). ...
... Local inflammation response, granulation tissue (GT) formation, and tissue reconstruction, the three main processes of wound healing, determine the duration and quality of healing [3]. As the main cellular constituents, GTs and fibroblasts (FBs) are essential in wound healing [4]. ...
Anal fistula is a common anorectal disease. At present, most scholars believe that its pathogenesis is related to anal gland infection. Anal fistula cannot heal on its own after the onset and must be treated surgically. The wound of anal fistula surgery is open and polluted, and it belongs to three types of three-stage healing; it is the most difficult to heal among all surgical incisions, with a long course of disease, a lot of exudation, and pain for the patient; traditional Chinese medicine has rich experience in the treatment of postoperative wound healing of anal fistula. The study aimed to evaluate the mechanism of Qingre Huayu (QRHY) Recipe on wound healing after fistulotomy on SD rats. SD rats ( n = 72 ) were randomized into three groups post-anorectal surgery. The rats in the positive control group were given potassium permanganate (PP), treatment group were given QRHY, and trauma model group were given 0.9% normal salinity. The changes in wound secretion, granulated tissue, and epithelium tissue were observed, and wound healing rates were evaluated by the discrepancies in wound area. HE and Masson’s staining as well as transmission electron microscopy were also performed. The localization as well as the measurement of Ang1, Src, and VE cadherin expression in each group adopted real-time PCR, western blot, and immunohistochemistry (IHC) assays. Statistically higher wound healing rates were observed in QRHY group on days 3, 7, and 14 compared with other groups. Histological analyses showed highly significant increase in collagen and fibroblasts, less inflammatory cells, and vascular endothelial permeability in QRHY rats. The transmission electron microscopy revealed that the intact structure of tight junctions in endothelial cells and well-organized collagen and VE-cadherin, Ang1, and Tie-2 were upregulated by QRHY, while Src was inhibited. This study showed that QRHY can promote wound healing after anal fistulas.
... The pain controlling drugs not only helps in quick recovery but also controls anxiety in patients. 6 In patients having AF diseases the internal sphincter is considered vital as it is also the main source of pain 7 . ...
Background: Anal fissure is a linear painful mucosal tearing in the distal part of anal canal. It extends from dentate to anal edge. Aim: To compare the glyceryltrinitrate ointment and internal lateral sphincterotomy for anal fissure pain relief in acute/chronic pts. Study Design: Prospective study Place and duration of study: Department of Surgery Unit-II, Fatima Memorial Hospital, Shadman Lahore from 1st October 2018 to 31stDecember 2020. Methodology: 40 pts with acute and chronic anal fissure were enrolled. Half of the patients undergo internal lateral sphincterotomy while other opted 0.2% use of glyceryl trinitrate ointment. Each patient was followed for pain, recovery, complications and recurrence until 12 months for internal lateral sphincterotomy and 18 months in glyceryl trinitrate ointment. Results: There were 24 males and 16 females with a mean age of patients as 30±3.2 years. Initial follow-up of patients showed 100% pain and fissure improvement in internal lateral sphincterotomy group as compared to 60% in glyceryl trinitrate ointment group respectively. Conclusion: Internal lateral sphincterotomy is most efficient and reliable procedure in relieving anal fissure pains. Keywords: Anal fissure, Internal lateral sphincterotomy, Glyceryl trinitrate
... Anal fistül tedavisinde cerrahi tedaviler ve teknikteki birçok gelişmeye rağmen kesin cerrahiyi takiben vakaların yaklaşık olarak % 30'unda başarısız sonuçlar ortaya çıkar, anal fistülün cerrahi tedavisi fekal kontinansı etkileyebilir ve bu da yaşam kalitesini bozabilir (1,2,5,6). Fistülotomi, anal fistüllerin tedavisinde altın standarttır, iyileşme oranı %90'ın üzerindedir (7)(8)(9). Ancak fistülotomiyle tedavi edilen hastalar postoperatif anal sfinkter fonksiyon bozukluğu gelişme riski altındadır; özellikle kadınlar, kompleks fistüller, nüksetmiş anal fistül hastaları veya önceki anorektal cerrahi geçiren hastalarda risk artmaktadır (9,10). ...
AMAÇ Anal fistül cerrahi tedavisinde bir çok yöntem uygulanmaktadır ancak yüksek nüks ve inkontinens gelişme riski nedeni ile yeni arayışlar devam etmektedir. Yeni bir teknik olan fistül traktını lazer ile kapatma(LAFT) anal fistül tedavisinde sfinkter koruyucu bir tedavi seçeneği olarak kullanılmaya başlamıştır. Biz bu çalışmamızda LAFT uyguladığımız hastaların kısa dönem sonuçlarını paylaşmayı amaçladık. GEREÇ VE YÖNTEMLER Eylül 2017–Ocak 2020 arasında 33 hastaya aynı cerrah tarafından LAFT tekniği uygulandı. LAFT bir diyot lazer kaynağına bağlı radyal fiber prob tarafından 3600 dairesel olarak yayılan lazer enerjisi kullanılarak fistül traktının kapatılması esasına dayanır. Fiber lazer fistül traktı içerisine yerleştirildi ve 1470 nm dalga boyunda ve 13 watt gücünde radyal fiber lazer, fistül traktına 3600 dairesel olarak uygulandı. Lazer prob ile fistül traktının epitel dokusuna lazer uygulanarak tüm fistül traktı boyunca geri çekilerek kapatıldı. BULGULAR Ortalama takip süresi 29.96 ay(18-45ay) idi. Hastaların 11(%33.333)’inde nüks görüldü. Ortalama nüks görülme süresi 1,75+/-0.52 ay olarak tesbit edildi. Hiç bir hastada fekal ve gaz inkontinens görülmedi. SONUÇ Anal sfinkter kaslarına minimal travma nedeni ile, fekal ve gaz inkontinens komplikasyonu olmayan kısa süreli iyi fonksiyonel sonuçları vardır. Bu avantajları nedeni ile LAFT tekniğini anal fistül cerrahi tedavisinde öneriyoruz. Uzun dönem sonuçlarının ortaya konması için daha geniş kapsamlı ve uzun süreli klinik çalışmalara ihtiyaç vardır.
... (8,9) Time of return to work was less in fibrin glue treatment that 60% of patients return to their work in less than two weeks which is approximately similar to Maralcan et al. and Cestaro et al. studies which showed that patients return to work within 7days. (8,9) Again, in our series, we found that healing rate of surgery after three months was 85.3% which is similar to Gottegens et al. study, and Hall et al. study (10,11) The healing rate of fibrin glue treatment reached 57.9% which is comparable to Malik In terms of recurrence after treatment we found in our series that recurrence rate is higher in fibrin glue treatment (47.4%) in comparison to surgery (23.5%) which is similar to a meta-analysis published by Cirocchi. (14) Also, in our series, the incidence of anal incontinence is much lower (5%) in fibrin glue treatment which is comparable to Mishra et al., Maralcan et al., and Cestaro et al. is much higher in surgery group (21%) but lower than that of Gottegens et al. and this may be due to lower number of high fistula in our study which have more risk of anal incontinence after surgery. ...
... These highly select patients result in healing rates of 80%-100%. 42,43 Rarely, this procedure is done in patients with CD due to sphincter involvement and incontinence risk, proctitis, anal canal disease, and diarrhea, in many patients. Moreover, patients with CD undergoing a fistulotomy with concurrent proctitis experience healing rates of 27%. ...
Perianal disease is a particularly morbid phenotype of Crohn's disease, affecting up to one third of patients, with a significantly diminished quality of life. Conventional medical therapy and surgical interventions have limited efficacy. Medical treatment options achieve long-term durable remission in only a third of patients. Therefore, most patients undergo an operation, leaving them with a chronic seton or at risk of incontinence with multiple interventions. Mesenchymal stem cell therapy is an emerging therapy without risk of incontinence and improved efficacy as compared with conventional therapy. Laser therapy is another new intervention. Unfortunately, up to 40% of patients still require a stoma related to perianal fistulizing disease.
... Even without damage of anal sphincter, in the early postoperative period, most cases complain of some sort of continence disorder [5]. Fistulotomy is the gold standard management of fistulous tract, but the recovery rate is more than 90% [6][7][8]. However, patients were treated with a fistulotomy had a risk of anal sphincter dysfunction postoperatively. ...
Uses of FiLaC laser as a sphincter-preserving technique in closure of fistula tract in Upper Egypt
... The reported rates of incontinence are highly variable, ranging from 0 to 82% [72,73], with an increased risk if the fistulotomy is performed at the time of the drainage of an acute abscess [74]. Nevertheless, when fistulotomy is used forsimple anal fistulas in properly selected patients, the risk of faecal incontinence is minimal or none [75,76]. ...
The gold standard in the diagnosis and treatment of proctological diseases is the exploration of the anal canal and distal rectum under anaesthesia (EUA), routinely performed as day case surgery. In selected cases it can be conducted as an outpatient exploration (OE) during a specialist surgical consultation. In the outpatient setting it is possible and safe to perform rubber band ligation, sclerotherapy and infrared coagulation for the treatment of haemorrhoidal disease, excision and incision of thrombosed external haemorrhoids, abscess drainage, setonage and fistulotomy also in case of perianal Crohn’s disease, anal warts and skin tags removal. In terms of patients’ satisfaction and success rate OE is comparable to EUA. All procedures can be performed under local anaesthesia. Pain control after the procedure is provided by oral pain killers.
The perianal region is typically the site of a fistula-in-ano tract’s opening, though this is not always the case. Complex fistulas are therefore very difficult to treat and frequently the cause of recurrence. This article describes a unique fistula-in-ano that extended posteriorly to the mid-thigh and was successfully treated with multiple modalities and secondary healing.
Background
The long-term effects of anorectal disease management on patients’ quality of life remains poorly understood.
Objectives
This study aimed to evaluate the self-reported impact of both medical and surgical interventions for benign anorectal disease, using a standardized set of validated questionnaires. These questionnaires measure various domains, including pain, constipation, fecal incontinence, bleeding, leakage, protrusion, and overall quality of life.
Design
Prospective, survey-based study.
Setting
The colorectal surgery collaborative, involving two academic and three community hospitals.
Patient and Methods
The study included all patients who presented to the clinic with benign anorectal disease between December 2017 and September 2019.
Main Outcome Measure
The primary outcomes measured were the rates of adverse events and quality of life.
Sample Size
A total of 811 individuals were invited, of whom 583 (71.9%) agreed to participate.
Results
Diagnoses among participants were as follows: hemorrhoid (369 individuals, 28.8%), fistula (283 individuals, 22.1%), fissure (116 individuals, 9.0%), and other conditions (515 individuals, 40.1%). Nonoperative treatment significantly improved only the bleeding score ( P = .046) but had no significant effect on the pain intensity score ( P = .09), pain interference score ( P = .084), itching score ( P = .463), leakage score ( P = .621), protrusion score ( P = .083), bowel incontinence score ( P = .737), constipation score ( P = .61), or quality of life score ( P = .211). Operative treatment for hemorrhoids resulted in significant improvements in the pain intensity score ( P = .012), pain interference score ( P = .015), bleeding score ( P = .007), protrusion score ( P = .006), and quality of life score ( P = .001). Operative treatment for fistulas led to significant improvements in the pain intensity score ( P = .046), pain interference score ( P = .025), leakage score ( P = .035), and quality of life score ( P = .006). Only four patients who underwent operative treatment for fissures completed the postoperative questionnaire, and thus, no data could be presented on the impact of operative treatment for fissures.
Conclusion
The routine use of patient-reported outcomes following the evaluation and treatment of classic anorectal conditions may enhance the understanding of patient’s perspective and their experiences with both medical and surgical interventions.
Limitations
This study is limited by the lack of robust long-term follow up data, use of certain nonvalidated questionnaires, and potential for selection bias, as dissatisfied patients may have sought treatment at other centers.
Conflict of Interest
The authors declare no conflict of interest.
Anorectal abscess and fistula-in-ano are common morbidities encountered in outpatient clinics. The most common etiology is cryptoglandular disease, accounting for 90% of anorectal abscesses, although multiple etiologies are known, including Crohn’s disease, obstetric injury, fissure, and infection. It is necessary for the surgeon to understand the pathophysiology and anatomy of the anal canal and pelvis and appropriate patient management based on the underlying etiology.
At least one-third of cryptoglandular abscesses will progress to fistula. Anorectal abscess should be treated with surgical drainage. Anal fistula should be evaluated with examination under anesthesia prior to determining subsequent management. With any surgical management, control of sepsis and maintenance of continence are imperative.
The attempt at local closure of a particular fistula is influenced by the patient’s symptoms, anatomy of the fistula, quality of the surrounding tissues, and previous attempts at fistula repair. Failure rates of sphincter-preserving techniques are significant, and, when one method fails, it may be important to attempt an alternative approach. Failure rates and recurrence should be discussed during the informed consent process and patient expectations set at the initiation of treatment.
Aim
Cryptoglandular anal fistulas carry a substantial burden to quality of life. Surgery is the only effective curative treatment but requires balancing fistula healing against pain, wounds and continence impairment. Sphincter-preserving procedures do exist but demonstrate variable rates of success. A lack of consistency and precision in outcome reporting and methodological quality hinders effective evidence-based decision-making. We aimed to establish a series of minimum reporting standards for interventional studies in idiopathic anal fistula, to eradicate low-quality studies, thus providing a consistent baseline of useful evidence.
Methods
An international group of 16 experts participated in a modified nominal group technique consensus. The nominal question was: ‘What should be the minimum set of reporting standards for studies of intervention in idiopathic anal fistula?’ The process was conducted between May and June 2023, culminating in a hybrid in-person/virtual meeting that took place at the Songdo International Proctology Symposium in June 2023.
Results
Initial idea generation resulted in 37 statements within the first round. Themes included variable reporting of follow-up and incontinence. Participants indicated their agreement via a 9-point Likert scale. Any statement achieving >70% consensus was retained. Subsequent group discussion condensed the list to 11 statements for further voting and a final minimum set of 12 reporting standards was created.
Conclusion
To date, this is the first study dedicated to developing minimum reporting standards for interventional studies in idiopathic anal fistula using a modified nominal group technique. These standards will instruct researchers in producing meticulous, high-quality studies that are accurate, transparent and reproducible.
Background
Empirical reviews suggested that cryptoglandular anal fistulas require surgical resolution. However, some reports have indicated the possibility of nonsurgical and conservative treatment, which is discussed in this review.
Methods
This review explores the potential of nonsurgical approaches for curing anal fistulas through bacterial inhibition and immunomodulation. The longstanding cryptoglandular theory has been a subject of controversy, prompting the reevaluation of conventional surgical interventions for anal fistulas. The review was conducted through database searches, including Medline, EMBASE, PubMed, and the Cochrane Library.
Results
Emerging evidence suggests that targeting the anaerobic environments present in anal fistulas and perianal abscesses and eradicating bacteria and their by-products may be critical for successful treatment. Immunomodulatory strategies show promise as a potential avenue for the nonsurgical management of anal fistulas.
Conclusions
Ongoing developments in pharmacological research offer opportunities for alternative treatment options, shedding light on the prospects of noninvasive anal fistula management.
Anal fistula is a challenging condition to treat. Fistulae are classified based on their relation to the anal sphincter muscle: inter-sphincteric, trans-sphincteric, supra-sphinteric, and extra-sphincteric. Goals of repair are both to eradicate the fistula while preserving continence. The approach to operative management depends on fistula type, location, and complexity as well as surgeon and patient preference. Simple, low fistulae can often be managed with fistulotomy with excellent results. For more complex fistulae, other surgical options include ligation of intersphincteric fistula tract (LIFT), anorectal advancement flap, fistula plug, fibrin glue, long term draining seton, and cutting seton.
Supra-sphincteric and high trans-sphincteric fistula are very challenging procedures for both the patient and the surgeon. We aimed to evaluate the outcomes of anal sphincter repair in the management of supra-sphincteric and high trans-sphincteric fistula-in-ano in terms of postoperative wound infection, bleeding, incontinence to flatus or stool, and recurrence within 1 year.
This single-center prospective cohort trial conducted from June 2020 to December 2023 at the Ain Shams University Hospitals included 20 patients who presented with supra-sphincteric or high trans-sphincteric fistula. There were nine (45%) male and 11 (55%) female patients, with a mean age of 41.5 years postoperatively.
The mean duration of the procedure was 90.3 min (SD ± 11.9). During the first 2 weeks, ten (50%) patients scored their postoperative pain as mild, eight (40%) as moderate, and two (10%) as severe. Wound infection occurred in two (10%) patients and postoperative bleeding in three (15%) patients in the form of spotting after defecation. There were no cases of incontinence to stool. However, there were three (15%) cases of incontinence to gases. There were two cases (10%) of recurrence at the 1‑year follow-up. Postoperative patient satisfaction was assessed on a 5‑point Likert scale after 2 weeks: One patient (5%) was very dissatisfied, three (15%) patients were dissatisfied, and two (10%) patients were unsure, while five (25%) patients were satisfied and nine (45%) were very satisfied.
Immediate sphincter repair in supra-sphincteric and high trans-sphincteric fistula through a lay-open procedure was determined to be safe, easier than classic operations, and associated with a low incidence of recurrence at the 1‑year follow-up and a high quality of life.
Purpose: To investigate the relationship between preoperative inflammatory parameters and disease severity in patients operated for perianal fistula in our clinic between 2013-2021.
Methods: Patients between the ages of 16-78 who were operated on with the diagnosis of perianal fistula in Kayseri Şehir Training and Research Hospital between 2013-2021 and who were followed up afterward were included in the study by retrospective file search method without gender discrimination. Preoperative demographic data, laboratory parameters (platelet, neutrophil, lymphocyte, monocyte, leukocyte, CRP, albumin), surgical procedures, perioperative and postoperative complications, length of stay, and recurrences were noted.
Results: 134 patients with perianal fistula were included in the study. It was determined that 71.6% (n=96) were male, and the mean age was 44.6±13.8 years. Inflammatory parameters such as crp/albumin, neutrophil/lymphocyte, lymphocyte/crp, neutrophil/crp, lymphocyte/monocyte, platelet/lymphocyte were compared with tract length, tract thickness, presence of perifistular inflammation and presence of abscess as criteria for complex fistula formation and cut of values were created. Among these scoring values, crp/albumin, lymphocyte/crp, and neutrophil/crp ratios were statistically significant in predicting the tract characteristics defined for high recurrence and complex fistula.
Conclusion: Inflammation-based scores such as crp/albumin, lymphocyte/crp, and neutrophil/crp ratios can differentiate complex fistula from simple fistula.
In this chapter, we discuss the classification and diagnosis of anal fistulas and the surgical approaches for fistula repair. According to the Parks classification, there are four main fistula types based on the location of the fistula tract in relation to the external sphincter: intersphincteric, transsphincteric, suprasphincteric, and extrasphincteric. One of the conventional repair techniques for low transsphincteric fistulas involves cutting open the tract by lay open fistulotomy. Control of a complex fistula tract with a draining seton is used as the first of a two-stage repair or as definitive therapy in patients with contraindications to repair such as concomitant fecal incontinence or active Crohn’s disease. Sphincter-preserving techniques for high transsphincteric fistulas include ligation of the intersphincteric fistula tract (LIFT) and endorectal or anodermal advancement flap with largely equivalent expected results. Biologic adjuncts such as platelet-rich plasma (PRP), acellular matrix (AM) material, and mesenchymal stem cells (MSC) represent a promising area for possibly augmenting healing of complex fistulas. Additional novel treatment techniques being developed for complex fistulas including Video-Assisted Anal Fistula Treatment (VAAFT), Fistula Tract Laser Closure (FiLaC), and Over the Scope Clip (OTSC) are also described.
A complication of incision drainage or abscess ulceration around the anus and rectum is anal fistula which manifests as the creation of irregular channels linking the rectum and anal canal with the skin circumambient to the anus. It mostly affects the male population having a yearly frequency of two cases per ten thousand individuals. Histologically in anal fistula chronic inflammatory cells and fibrous tissues are surrounded by epithelialization of variable degree, which are categorized as squamous, columnar, or transitional zone epithelium. Anal fistula influences the psychological condition of the patients, which leads to depression or anxiety symptoms, in addition to severely impacting their standards of living. In general, anal fistula cannot be treated without medical intervention and the most efficient treatment for anal fistula is surgery. The optimal treatment in the modern era includes the elimination of the infected lesion, adequate drainage, and fistula closure while minimizing injury to the anal sphincter which includes treatment with fibrin glue, fistula plug, LIFT, etc.
Introduction:
Rectovaginal fistulas (RVFs) account for approximately 40% of anorectal complications from obstetrical trauma. Treatment can be challenging requiring multiple surgical repairs. Interposition of healthy transposed tissue (lotus or Martius flap or gracilis muscle) has been used for recurrent RVF. We aimed to review our experience with gracilis muscle interposition (GMI) for post-partum RVF.
Methods:
A retrospective analysis of patients who underwent GMI for post-partum RVF from February 1995 to December 2019 was undertaken. Patient demographics, number of prior treatments, comorbidities, tobacco use, postoperative complications, additional procedures, and outcome were assessed. Success was defined as absence of leakage from the repair site after stoma reversal.
Results:
Six of 119 patients who underwent GMI did so for recurrent post-partum RVF. Median age was 34.2 (28-48) years. All patients had at least 1 previously failed procedure [median: 3 (1-7)] including endorectal advancement flap, fistulotomy, vaginoplasty, mesh interposition, and sphincteroplasty. All patients underwent fecal diversion prior to or at initial procedure. Success was achieved in 4/6 (66.7%) patients; 2 underwent further procedures (1 fistulotomy and 1 rectal flap advancement) for a final 100% success rate as all ileostomies were reversed. Morbidity was reported in 3 (50%) patients, including wound dehiscence, delayed rectoperineal fistula, and granuloma formation in one each, all managed without surgery. There was no morbidity related to stoma closure.
Conclusions:
Gracilis muscle interposition is a valuable tool for recurrent post-partum RVF. Our ultimate success rate in this very small series was 100% with a relatively low morbidity rate.
Background:
Fistula-associated anal adenocarcinoma (FAAC) is a rare consequence in patients with long-standing perianal fistulas. A paucity of data are available for this patient collective, making clinical characterization and management of this disease difficult.
Objective:
This study aimed to describe a single-center experience with FAAC patients, their clinical course, and histopathological and molecular pathological characterization.
Methods:
All patients receiving surgery for an anal fistula in 1999-2019 at a tertiary university referral hospital were included in this retrospective analysis. Patients with FAAC were eligible for histopathological analysis, including immunohistochemistry and molecular profiling.
Results:
This study included 1004 patients receiving surgical treatment for an anal fistula, of whom 242 had an underlying inflammatory bowel disease (IBD). Ten patients were diagnosed with a fistula-associated anal carcinoma (1.0%), and six of these patients had an FAAC (0.6%). The mean overall survival of FAAC patients was 24 ± 3 months. FAAC immunohistochemistry revealed positive staining for CK20, CDX2 and MUC2, while stainings for CK5/6 and CK7 were negative. All FAAC specimens revealed microsatellite stability. Molecular profiling detected mutations in 35 genes, with the most frequent mutations being TP53, NOTCH1, NOTCH3, ATM, PIK3R1 and SMAD4.
Conclusion:
FAAC is rare but associated with poor clinical outcome. Tissue acquisition is crucial for early diagnosis and therapy and should be performed in long-standing, non-healing, IBD-associated fistulas in particular. The immunophenotype of FAAC seems more similar to the rectal-type mucosa than the anal glands.
The expertise and preference of the surgeon are deciding elements in fistula management. The options available are fistulotomy, fistulectomy, or seton placement. Minimally invasive procedures have become popular recently, including fistula plugs, fibrin glue, LIFT, VAAFT, stem cells, and lasers.
Background:
Complex perineal fistulae (CPF) are among the most challenging problems in colorectal practice. Various procedures have been used to treat CPF, with none being a panacea. Our study aimed to assess the overall success and complication rates after gracilis muscle interposition in patients with CPF.
Methods:
PubMed, Scopus, and Google Scholar databases were systematically searched until January 2022 according to PRISMA 2020 guidelines. Studies including children <18 years or <10 patients were excluded, as well as reviews, duplicate or animal studies, studies with poor documentation (no report of success rate) and non-English text. An open-source, cross-platform software for advanced meta-analysis "openMeta [Analyst] ™" version 12.11.14 and Cochrane Review Manager 5.4® were used to conduct the meta-analysis of data.
Results:
25 studies, published between 2002-2021, were identified. The studies included 658 patients (409 females). Most patients had rectovaginal (50.7%) or rectourethral fistulae (33.7%). The most common causes of CPF were pelvic surgery (29.4%) and IBD (25.2%). History of radiotherapy was reported in approximately 18% of the patients. Of 658 patients with CPF, 498 (75.7%) achieved complete healing after gracilis muscle interposition. The weighted mean rate of success of the gracilis interposition procedure was 79.4% (95%CI: 73.8-85%, I2 = 75.3%), the weighted mean short-term complication rate was 25.7% (95%CI: 18.1-33.2, I2 =84.1%), and the weighted mean rate for 30-day reoperation was 3.6% (95%CI: 1.6-5.6, I2 =42%). The weighted mean rate of fistula recurrence was 16.7% (95%CI: 11-22.3%, I2=61%).
Conclusion:
Gracilis muscle interposition technique may be a viable treatment option for CPF. Further studies are needed for comparing this technique with other treatment options available for CPF.
Perianal disease is a common problem that can present with several etiologies and appearances. Acute variations of these problems include perianal abscess and fistula, which is most commonly related to cryptoglandular disease but may be the first manifestation of Crohn’s disease; hemorrhoids, which may present with bleeding, thrombosis, or prolapsing tissue; anal fissure, which can be acute or chronic and associated with pain; or a number of other infections or acute pathology. It is important to be able to do a thorough examination to properly diagnose and treat patients with these conditions. A patient may seem to have a common or straightforward history but may actually have an underlying diagnosis of Crohn’s disease, malignancy, or an undrained abscess that may be missed without appropriate and directed questioning or a thorough examination or imaging. Basic tenets of management can vary from supportive care/expectant management to a quick incision and drainage to far more complex and definitive surgical interventions, with therapy tailored uniquely to each patient.KeywordsAbscessFistulaHemorrhoidsFissureCrohn’s disease
Aim:
The aetiology of anal fistula has not been fully clarified. One of the causes of anal fistulae may be the markedly deep crypts that characterize the primary openings. We developed subcutaneous incision of the fistula tract and internal sphincterotomy (SIFT-IS) to eradicate the deep crypts. The aim of this study was to evaluate outcomes in patients with anal fistulae treated with SIFT-IS.
Method:
A retrospective study was performed over a 2-year period. Patients with transsphincteric anal fistulas who underwent SIFT-IS were enrolled. The primary endpoint was anal fistula healing rate at 16 weeks postoperatively. The secondary endpoints were healing time, postoperative complications, and clinical continence status.
Results:
One-hundred-and-fifty-one patients were enrolled. Primary healing was accomplished in 129 patients (85%). There were 17 patients (11%) with a remnant fistula and five (3%) with recurrences. The remnant fistulas healed spontaneously at more than 16 weeks postoperatively in seven patients. The median healing time was 6 (3-96) weeks. Surgical intervention was required in seven patients with a remnant fistula and four with recurrence. At the final follow-up, the wounds had healed in 148 patients (98%). No significant postoperative complications or incontinence were observed.
Conclusion:
SIFT-IS is a promising surgical option for transsphincteric anal fistulae with a satisfactory healing rate.
Perianal fistulizing Crohn's disease (PFCD) is a disabling complication of Crohn's disease (CD) that can significantly impact on patients' quality of life (QoL) and often requires multidisciplinary care. Clinical trials assessing the efficacy of medical and surgical interventions for fistulas usually evaluate outcomes such as closure of fistula tracts or radiologic healing. However, these traditional outcome assessments fail in capturing the impact of the disease from patients' perspectives. In this context, regulatory authorities have increasingly encouraged the inclusion of validated patient-reported outcomes (PRO) that assess disease activity and reveal how a patient functions and feels. This recent trend towards patient-centered care aims to ensure that improvements in efficacy outcomes are accompanied by meaningful benefits to patients. The aim of this review is to discuss currently available PRO measures (PROMS) for the assessment of PFCD to provide to physicians appropriate tools aiming to optimize patient care and disseminate the use of these instruments in clinical practice.
Background:
Magnetic resonance imaging (MRI) is used as a standard for assessment of complex perianal fistulas. Apart from textual description of the case, 3D reconstructed models from MRI further aid in understanding the entire anatomy of the fistula tract and its relation to the pelvic floor. This information is crucial as it helps surgeons to understand the extent and complexity of the disease before surgical treatment. However, 3D model generation from MRI is a time-consuming step for a radiologist as it requires tedious manual delineations to be performed on every slice of the images. The aim of this study was to develop a method that could enable radiologists to present enhanced information to surgeons for treatment of complex perianal fistulas while simultaneously reducing the manual efforts and time required to generate the information.
Methods:
A method was proposed to depict relevant anatomies of complex perianal fistula as parametric models in three-dimensional (3D) space. A plugin inside 3D Slicer software was developed for the generation of the parametric models from MRI. The levator ani muscle, internal sphincter, and external sphincter are represented as tubular structures, whereas fistula tracks and abscess are presented as splines.
Results:
Parametric models were generated to depict three cases of complex perianal fistulas and similarity measures were computed for ten cases. Visual comparison of the parametric models was made with the 3D models generated by the standard approach. The parametric models took less time to create and were able to visually present enriched information as compared to the 3D models generated by the standard approach.
Conclusions:
The proposed method, using parametric models, shows potential for faster generation and better visualization of the 3D information required for the treatment of complex perianal fistula cases.
Cryptoglandular sepsis is the leading cause of anorectal abscess, and at least one-third of abscess cases progress to anorectal fistula formation. Management of these disorders centers on the control of sepsis, amelioration of symptoms, prevention of recurrence, and preservation of continence. There are numerous techniques and methods that can be employed in disease management, some of which have stood the test of time and some have not. Creative clinicians continue to attempt to expand the treatment armamentarium such that we can arrive at a “perfect” treatment. Unfortunately, this treatment does not currently exist. In this chapter, we attempt to provide background on the majority of methods used to treat cryptoglandular abscess and fistula as well as some insight into the potential treatments of the future.
In the present study, curcumin loaded chitosan/poly ethylene glycol nanomaterial (CUR loaded CH/PEG/AgNPs) was fabricated and characterized for wound healing efficiency after fracture surgery. The interaction of functional groups and crystal nature were recorded under FTIR and XRD spectrometer and reveals that the stabilization and purity of NPs was mediated by OH/NH2 groups in chitosan. FESEM showed the presence of spherical and well dispersed particles. The average size of the particle was 13.48 nm. The CUR loaded CH/PEG/AgNPs showed higher swelling capacity (495.6 g/g) in phosphate buffer saline compared to water (140.2 g/g). The drug loading efficiency was higher in CUR loaded CH/PEG/AgNPs compared to CH/PEG films as recorded by the absorbance peak at 460 nm corresponds to curcumin in the composite. A dose dependent cytotoxicity of CUR loaded CH/PEG/AgNPs was noticed on Vero cells. The viability of Vero cells was increased to 96.5% at 100 μg/mL. A remarkable change in Vero cells such as condensed nuclei and membrane blabbing was noticed in cells treated with CUR loaded CH/PEG/AgNPs. A greater inhibition of Staphylococcus aureus and Escherichia coli was noticed at 24 h and 48 h treated with CUR loaded CH/PEG/AgNPs. A greater healing effect by increasing the wound contraction (98% on day 12) was observed with CUR loaded CH/PEG/AgNPs compared to control. Histopathological examination demonstrated that CUR loaded CH/PEG/AgNPs showed complete tissue regeneration in wound excised rats. The results of this study conclude that CUR loaded CH/PEG/AgNPs could be promising candidate to prevent microbial infections in wound, healing wound rapidly and inhibit the proliferation of apoptotic cells. Thus, CUR loaded CH/PEG/AgNPs could be a potential therapeutic agent with broad spectrum applications in the future.
• Highlights
• A new approach was used to develop curcumin-loaded chitosan/poly(ethylene glycol)/AgNPs.
• The CUR-loaded CH/PEG/AgNPs were confirmed to be crystals by XRD analysis.
• The prepared CH/PEG/AgNPs were spherical and averaged 13.48 nm in size.
• The growth of S. aureus and E. coli were inhibited mostly by CH/PEG/AgNPs treatment.
• CUR loaded CH/PEG/AgNPs showed complete tissue regeneration in wound excised mice.
INTRODUCTION: Anal fistula represents an important aspect of colorectal practice, being a distressing condition for the patient and sometimes a challenge for the surgeon. Successful surgical management of anal fistulas requires accurate preoperative assessment of the course of the primary fistulous tract and the site of any secondary extension or abscess. Fistula-in-ano has various types of clinical presentations. With time newer techniques have also evolved. Here we comparing the various treating modalities by classifying them as sphincter preserving and sphincter cutting surgeries.
AIMS AND OBJECTIVES: To compare the outcome, duration of wound healing, recurrence rate, and complications after sphincter preserving and sphincter cutting surgeries.
MATERIAL AND METHODS: A total 100 patients were taken up for the study after ethical clearance and proper informed consent. Group A (n=50) patients were selected for sphincter preserving surgeries (VAAFT+FILAC+LIFT, VAAFT+FILAC, LIFT). Group B (n=50) patients were taken up for sphincter cutting procedures (fistulectomy and fistulotomy). Simple fistulas, and those associated with tuberculosis, IBD, carcinomas, or with perianal injury were excluded from the study. Rectovaginal and anovaginal fistulas, patients with history of incontinence, or anal sphincter impairment were also excluded.
RESULTS: 66% patients were males and 34% were females. (1.94:1). Mean age of patients was 41.01+12.35 between 20-70 years. Transphincteric fistula was the most common type (61%, n=61) and perianal discharge was the most common presentation. (100%, n=100). Primary healing rate at 3 months in sphincter preserving surgeries was 84%, and 66% in cutting surgeries (p<0.05). Recurrence (p<0.05) was st more in cutting surgeries. Incontinence at 1 week (p<0.05) and hospital stay (p<0.05), were also more after cutting surgeries. However, there was no statistically significant difference in the mean healing time and pain by VAS score at 48 hours.
CONCLUSIONS: Sphincter preserving surgeries for complex fistula in ano are better in terms of less recovery time and better healing rate, less chances of incontinence, recurrence, compared to sphincter cutting surgeries. With the advent of more sphincter sparing techniques the percentage of patients undergoing sphincter cutting techniques should continue to decrease over time.
Background:
Doppler-guided hemorrhoid artery ligation and stapled hemorrhoidopexy have been used in surgical practices to avoid post-hemorrhoidectomy pain. Our study compared Doppler-guided hemorrhoid artery ligation with suture mucopexy (DGHAL-SM) and ligature-assisted pile excision (LAP) for greater than three grades of internal hemorrhoids.
Methods:
Eighty patients with greater than 3 grades of internal hemorrhoids were selected (age range: 20-28 years; average age: 23 years) between January and June 2015. The patients were randomly divided into group A (DGHAL-SM) and group B (LAP); each group had 40 patients.
Results:
With respect to the postoperative cure rate and anal skin tags, group A was inferior to group B, but the postoperative pain assessment and satisfaction were better than group B (P<0.001).
Conclusions:
The DGHAL-SM cure rate was high; the postoperative pain was mild; 97.5% of the patients did not return to hospital because of pain. LAP has a higher cure rate than DGHAL-SM, but the postoperative pain and return rate within 6 h was as high as 65%, and the postoperative satisfaction assessment was lower than DGHAL-SM. Therefore, we recommend that DGHAL-SM for outpatient surgery in patients with greater than three grades of internal hemorrhoids.
Background:
Treatment of complex anal fistula is challenging, often mandating multiple procedures. The gracilis muscle has been used to treat perineal fistulas and to repair perineal defects.
Objective:
Report the results of gracilis muscle interposition for complex anal fistula including prognostic factors for success.
Design:
Retrospective analysis of a prospective database for patients who underwent gracilis muscle interposition for complex anal fistula during 2000-2018.
Setting:
Patient demographics, operative data, and postoperative outcome were obtained from medical records; office visits were used for follow-up.
Patients:
All patients who underwent gracilis muscle interposition for complex anal fistula were included; patients who underwent gracilis muscle interposition for reasons other than complex anal fistula were excluded.
Main outcome measures:
Healing of complex anal fistula following gracilis muscle interposition and following additional procedures, when needed.
Results:
A total of 119 patients [60 males, 59 females; median age: 56 (21-85) years] were included. Initial success rate of gracilis muscle interposition was 42%; final success rate if additional procedures were undertaken was 92%. Overall success rate was 32.2% in females and 51.6% in males. Univariate analysis revealed that gender (p=0.0315) and bed rest >3 days (p=0.0078) were significantly poor prognostic factors for failure, while multivariate logistic regression model showed that length of bed rest >3 days was a significant poor prognostic factor for failure. In the female subgroup, multivariate analysis showed that bed rest ≥3 days was a significant poor prognostic factor, while in the male population there was no significant prognostic factor.
Limitation:
Retrospective nature and heterogenicity of patients.
Conclusion:
Although initial success is <50%, ultimate success following gracilis muscle interposition and other subsequent procedures is >90%. Patients must be preoperatively counselled that additional procedures will likely be required to achieve successful fistula closure. Furthermore, prolonged bedrest should be avoided following gracilis muscle interposition. See Video Abstract at http://links.lww.com/DCR/B551.
To describe a new technique for fistula-in-ano surgery aimed at total sphincter preservation, and evaluate the preliminary results concerning non-healing and intact anal function.
A prospective observational study in eighteen fistula-in-ano patients treated by ligation of intersphincteric fistula tract (LIFT) technique, from January to June 2006.
Fistula-in-ano in seventeen patients healed primarily (94.4%). There was one non-healing case (5.6%). The mean healing time was four weeks. None had disturbances in clinical anal continence.
The early outcome of the LIFT technique is quite impressive. Results warrant a larger study with long-term evaluation. This technique has the potential to become a viable option for fistula-in-ano surgery.
Transanal advancement flap repair (TAFR) has been advocated as the treatment of choice for transsphincteric fistulas passing through the upper or middle third of the external anal sphincter. It is not clear whether previous attempts at repair adversely affect the outcome of TAFR. The purpose of the present study was to evaluate the success rate of a repeat TAFR and to assess the impact of such a second procedure on the overall healing rate of high transsphincteric fistulas and on fecal continence.
Between January 2001 and January 2005, a consecutive series of 87 patients (62 males; median age, 49 (range, 27-73) years) underwent TAFR. Median follow-up was 15 (range, 2-50) months. Patients in whom the initial operation failed were offered two further treatment options: a second flap repair or a long-term indwelling seton drainage. Twenty-six patients (male:female ratio, 5:2; median age, 51 (range, 31-72) years) preferred a repeat repair. Continence status was evaluated before and after the procedures by using the Rockwood Faecal Incontinence Severity Index (RFISI).
The healing rate after the first TAFR was 67 percent. Of the 29 patients in whom the initial procedure failed, 26 underwent a repeat TAFR. The healing rate after this second procedure was 69 percent, resulting in an overall success rate of 90 percent. Both before and after the first attempt of TAFR, the median RFISI was 7 (range, 0-34). In patients who underwent a second TAFR, the median RFISI before and after this procedure was 9 (range, 0-34) and 8 (range, 0-34), respectively. None of these changes were statistically significant.
Repeat TAFR increases the overall healing rate of high transsphincteric fistulas from 67 percent after one attempt to 90 percent after two attempts without a deteriorating effect on fecal continence.
In recent decades, fibrin glue has appeared as an alternative treatment for high perianal fistulas. Early results seemed promising, with high success rates being reported. However, with increasing follow-up, the enthusiasm was tempered because of disappointing results. The aim of this retrospective study was to assess the additional value of fibrin glue in combination with transanal advancement flap, compared to advancement flap alone, for the treatment of high transsphincteric fistulas of cryptoglandular origin.
Between January 1995 and January 2006, 127 patients were operated for high perianal fistulas with an advancement flap. After exclusion of patients with inflammatory bowel disease or HIV, 80 patients remained. A consecutive series of 26 patients had an advancement flap combined with obliteration of the fistula tract with fibrin glue. Patients were matched for prior fistula surgery, and the advancement was performed identically in all patients. In the fibrin glue group, glue was installed retrogradely in the fistula tract after the advancement was completed and the fistula tract had been curetted.
Minimal follow-up after surgery was 13 months [median of 67 months (range, 13-127)]. The overall recurrence rate was 26% (n=21). Recurrence rates for advancement flap alone vs the combination with glue were 13% vs 56% (p=0.014) in the group without previous fistula surgery and 23% vs 41% (p=0.216) in the group with previous fistula surgery.
Obliterating the fistula tract with fibrin glue was associated with worse outcome after rectal advancement flap for high perianal fistulas.
PURPOSE: The management of complex perianal fistulas with endorectal advancement flap is aimed at avoiding the risk of sphincter injury associated with traditional surgical methods. Long-term follow-up is required to assess the recurrence and continence outcomes of this procedure. The aim of this study was to review our experience with endorectal advancement flap in the treatment of complex perianal fistulas and to define the predictors of successful healing. METHODS: A retrospective chart review of all patients who underwent endorectal advancement flap for complex perianal fistulas between 1988 and 2000 was performed. Follow-up was established by telephone interview. RESULTS: One hundred six consecutive endorectal advancement flap procedures were performed on 94 patients (94.4 percent). There were 56 females (59.6 percent). Mean age was 41.6 (range, 18-76) years. Crytoglandular disease was the most common cause of fistula (n = 41, 43.6 percent), followed by Crohn's disease (n = 28, 29.8 percent). At a mean follow-up of 40.3 (range, 1-149) months, the procedure was successful in 56 (59.6 percent) of 94 patients. Twelve patients underwent repeat surgery with the same technique because of initial failure, 8 of whom eventually healed. Crohn's disease was associated with a significantly higher recurrence rate (57.1 percent) when compared with fistulas in patients without Crohn's disease (33.3 percent, P < 0.04). Prior attempts at repair of the fistula were not associated with less favorable outcome of the procedure (P = 0.5). Recurrence was not associated with the type of fistula, origin, preoperative steroid use, postoperative bowel confinement, use of postoperative antibiotics, or creation of a diverting stoma. The median time to recurrence was 8 (range, 1-156) weeks; there was no postoperative mortality. Two patients had postoperative bleeding, one requiring resuture of the flap on the first postoperative day. Recurrences were observed in 15.7 percent of the patients 3 or more years after the repair. In 8 patients (9 percent), continence deteriorated after the endorectal advancement flap, a more common finding in patients who had undergone previous surgical repairs (P < 0.02). CONCLUSION: The success rate of endorectal advancement flap for complex perianal fistulas is modest. Failure is mainly correlated with the presence of Crohn's disease.
PURPOSE: This study was undertaken to assess results of surgery for fistula-in-ano and identify risk factors for fistula recurrence and impaired continence. METHODS: We reviewed the records of 624 patients who underwent surgery for fistula-in-ano between 1988 and 1992. Follow-up was by mailed questionnaire, with 375 patients (60 percent) responding. Mean follow-up was 29 months. Fistulas were intersphincteric in 180 patients, transsphincteric in 108, suprasphincteric in 6, extrasphincteric in 6, and unclassified in 75. Procedures included fistulotomy and marsupialization (n=300), seton placement (n=63), endorectal advancement flap (n=3), and other (n=9). Factors associated with recurrence and incontinence were analyzed by univariate and multivariate regression analysis. RESULTS: The fistula recurred in 31 patients (8 percent), and 45 percent complained of some degree of postoperative incontinence. Factors associated with recurrence included complex type of fistula, horseshoe extension, lack of identification or lateral location of the internal fistulous opening, previous fistula surgery, and the surgeon performing the procedure. Incontinence was associated with female sex, high anal fistula, type of surgery, and previous fistula surgery. CONCLUSIONS: Surgical treatment of fistula-in-ano is associated with a significant risk of recurrence and a high risk of impaired continence. Degree of risk varies with identifiable factors.
This study aimed to determine the outcomes and healing rate after fistula surgery across a broad spectrum of colorectal practices.
A prospective, multicenter outcomes registry was created by the New England Regional Chapter of The American Society of Colon and Rectal Surgeons. All consecutive patients undergoing surgical treatment of an anal fistula by a participating surgeon from October 1, 2007 to September 30, 2008, were entered. Demographics, fistula characteristics including Parks' classification, smoking history, previous vaginal deliveries, diagnosis of Crohn's disease, Fecal Incontinence Severity Index, and operations performed were noted. A follow-up datasheet recorded postoperative complications, healing at one and three months, and postoperative continence scores. Factors associated with healing and treatment success were compared by use of Fisher's exact test.
Twenty-five surgeons at 13 hospitals entered 245 patients (162 male, 83 female) in the registry. Seventy-five patients had recurrent fistulas, 51 had multiple tracts, 62 were smokers, and 24 had Crohn's disease. The overall healing rate was 19.5% at one month and 63.2% at three months. Female gender (P = 0.04) and recurrent fistula (P = 0.03) were associated with nonhealing, and 28.4% of patients required additional surgery. The best healing rate was associated with fistulotomy (87%), whereas a plug had the worst healing rate (32%, P = 0.001).
Surgical treatment of an anal fistula is associated with a substantial risk of nonhealing at three months. Fistulotomy had a high success rate, whereas the bioprosthetic plug had the lowest success rate. Multicenter studies comparing treatment options for similar fistulas are needed.
The novel modified approach through the intersphincteric plane for the treatment of fistula-in-ano, known as LIFT (ligation of inter sphincteric fistula tract) procedure, is described in detail. LIFT procedure is based on secure closure of the internal opening and removal of infected cryptoglandular tissue through the intersphincteric approach. Essential steps of the procedure include, incision at the intersphincteric groove, identification of the intersphincteric tract, ligation of intersphincteric tract close to the internal opening and removal of intersphincteric tract, scraping out all granulation tissue in the rest of the fistulous tract, and suturing of the defect at the external sphincter muscle. Attention to detail is the key for a favorable outcome.
This study was undertaken to assess results of surgery for fistula-in-ano and identify risk factors for fistula recurrence and impaired continence.
We reviewed the records of 624 patients who underwent surgery for fistula-in-ano between 1988 and 1992. Follow-up was by mailed questionnaire, with 375 patients (60 percent) responding. Mean follow-up was 29 months. Fistulas were intersphincteric in 180 patients, transsphincteric in 108, suprasphincteric in 6, extrasphincteric in 6, and unclassified in 75. Procedures included fistulotomy and marsupialization (n = 300), seton placement (n = 63), endorectal advancement flap (n = 3), and other (n = 9). Factors associated with recurrence and incontinence were analyzed by univariate and multivariate regression analysis.
The fistula recurred in 31 patients (8 percent), and 45 percent complained of some degree of postoperative incontinence. Factors associated with recurrence included complex type of fistula, horseshoe extension, lack of identification or lateral location of the internal fistulous opening, previous fistula surgery, and the surgeon performing the procedure. Incontinence was associated with female sex, high anal fistula, type of surgery, and previous fistula surgery.
Surgical treatment of fistula-in-ano is associated with a significant risk of recurrence and a high risk of impaired continence. Degree of risk varies with identifiable factors.
Fistula-in-ano can be associated with a number of conditions, including Crohn's disease. The majority, however, are classified as idiopathic or cryptoglandular. The aim of this study was to review the outcome of surgical management of fistula-in-ano in a specialist colorectal unit.
One hundred and four consecutive patients underwent surgery for anal fistulae between 1st January 2000 and December 2004. Data was analysed in two main groups, according to the aetiology, cryptoglandular (n = 86) and Crohn's disease (n = 18). Follow-up data was available on 91 patients.
In the cryptoglandular group, 62 patients had an inter-sphincteric tract, of which 48 underwent a single-stage fistulotomy. Of those patients with a trans-sphincteric tract, six patients underwent a single-stage fistulotomy, 13 had a seton and staged fistulotomy. Follow-up data revealed that two fistulae recurred. The median number of procedures in this group was 1 (range 1-3). There was a significant difference in the inpatient stay depending of Park's classification (p = 0.001). In the Crohn's group, three patients with an inter-sphincteric tract underwent a single-stage fistulotomy, two patients with a trans-sphincteric tract had single-stage fistulotomy, and five required a loose seton and staged fistulotomy. Eight patients had multiple fistulae which required long-term setons. Four patients from this group eventually required proctectomy. In the Crohn's group, there was a significantly increased complexity of surgery and higher recurrence. This was reflected in an increased inpatient length of stay and a greater reliance on imaging (p = 0.001). The median number of procedures in this group was 3 (range 1-5).
The majority of cryptoglandular fistula-in-ano were treated by primary fistulotomy or staged fistulotomy with a loose seton. This was associated with a low recurrence rate and low rates of faecal incontinence. There was a low reliance on imaging techniques in this group. However, we would urge caution when dealing with fistula-in-ano related to Crohn's disease. In this group of patients, the fistulae tended to be more complex and require additional imaging and multiple procedures.
We sought to determine the nature and timing of complications after common anorectal operations by using a prospective quality tracking tool.
A prospectively maintained quality database was queried to identify patients who underwent pilonidal sinus excision, hemorrhoidectomy, sphincterotomy, abscess drainage, or fistulotomy during an 11-year interval. All hospital complications were recorded by a single nurse practitioner and verified jointly by the surgical team. Any posthospital complications were registered at the first postoperative visit.
A total of 969 patients underwent one of the five index anorectal procedures during the study period. Forty-nine complications occurred in 38 patients (3.9 percent). The majority of complications were minor (40/49; 82 percent) and were primarily urinary retention, minor bleeding, and wound infection. Twenty-five of the 40 minor complications (62 percent) were identified only after hospital discharge in the outpatient setting. Eight of the nine major complications occurred in patients already hospitalized for major concomitant illnesses and were unrelated to the anorectal surgery. The remaining patient had a postoperative deep vein thrombosis.
Complications after anorectal procedures are infrequent, typically minor, and occur after hospital discharge. Major complications reflect concomitant illness, not surgical quality. Meaningful outcome measures are needed to assess the quality of anorectal surgery.