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S3-Leitlinie: Kryptoglanduläre Analfisteln: 2. revidierte Fassung, AWMF‑Registriernummer: 088/003
Abstract
Kryptoglanduläre Analfisteln sind mit 2 pro 10.000 Einwohner/Jahr eine häufige Erkrankung mit einem Häufigkeitsgipfel bei jungen männlichen Erwachsenen. Eine nicht adäquate Behandlung kann zu einer Beeinträchtigung der Lebensqualität und insbesondere zur Reduktion der Kontinenzleistung führen.
Background
The excision of an anal fistula with primary sphincter reconstruction represents a much-discussed procedure in fistula surgery. The aim of this retrospective analysis is the postoperative assessment of the recurrence rate, fecal continence and the subjective patient satisfaction.MethodA total of 153 consecutive patients were investigated, who were evaluated 1 year after an anal fistula with fistulectomy and primary sphincter reconstruction based on a questionnaire. The recurrence rate, anal incontinence and patient satisfaction were evaluated.ResultsOverall, 153 consecutive patients were analyzed. In 136 cases (89%) the fistulas were of cryptoglandular origin and in 17 cases the fistulas were associated with Crohnʼs disease. In 39% of the patients the surgeon classified the fistulas as low, in 32% as medium high and in 29% as high transsphincteric anal fistulas. Primary dehiscence of the reconstructed muscle was observed in 6% of the cases. A residual fistula within the first 8 weeks was observed in 9% of the cases. After 1 year 13% reported a recurrence of the fistula. After 5 years postsurgery, the recurrence rate was 19%. In primary fistulas of cryptoglandular origin the recurrence rate was 9%.Conclusion
Fistulectomy with primary sphincter reconstruction is a procedure with a low recurrence rate but a high risk for an impaired continence must be accepted. These observations confirm the comparatively low recurrence rate with acceptable postoperative continence and high patient satisfaction.
The surgical management of complex anal fistulas can be very challenging. Fistula closure (healing) and preservation of continence are relevant outcome measures after fistula surgery. The conflict between fistula healing and preservation of continence is met by using sphincter-sparing surgical procedures such as LIFT (“ligation of the intersphincteric fistula tract”), flap, plugs, fillers etc. At the same time, both the risk of recurrence and the probability of continence disturbance increase with the number of previous closure attempts. In such cases, reserve procedures like the gracilis flap, the cutaneous flap and the York Mason procedure (for anterior fistulas) can be used for fistula repair without the risk of sphincter damage. This article describes the repair of a chronic complex anterior fistula using a cutaneous flap.
Aim:
We describe the clinicopathological, and surgical aspects of fistula-in-ano and assess the risk associations with the recurrence of the disease in a Ghanaian teaching hospital.
Methods:
This was a retrospective observational study assessing all fistula-in-ano surgeries performed at the Korle Bu Teaching hospital from January 2014 to January 2021 and had completed at least three months follow up after wound healing. Demographic, clinical, pathological and surgical data were extracted from patient records. Logistic regression analysis was used to test for association between these variables and recurrence.
Results:
A total of 105 patients underwent 124 fistula surgeries. Their median age was 41 years, male: female ratio was 4:1 and 12 had comorbidities including human immunodeficiency virus infection and diabetes mellitus. 31% (39/124) of fistulas had previously been operated on. At surgery, 51% (64/124) of fistulas followed a single straight tract, 30% (37/124) a single curved tract and 19% (23/124) had multiple curved tracts. More than half (65/124) were trans-sphincteric, 35% (44/124) supra-sphincteric, 10% (12/124) sub-sphincteric and 2% (3/124) were intersphincteric. 60% of fistulae had a ligation of intersphincteric fistula tract (74/124), 35% (44/124) a fistulectomy and 5% a fistulotomy. Recurrence after surgery was 22.5% (28/124) which was significantly higher for fistulae with multiple curved tracts (OR 4.153, CI 1.431-12.054; p=0.012) and those with comorbidities (3.222, 1.076-9.647; p=0.037).
Conclusion:
There was high recurrence after fistula surgery with increased risk for fistulae with multiple tracts and comorbidities.
Anal fistulas are common proctological diseases. During the course the fistulas involve a variable proportion of the sphincter muscle. Depending on this, the decision has to made in individual cases whether a fistulectomy is meaningful and can be carried out without having to accept a relevant postoperative incontinence. The incontinence rates in the available but very heterogeneous and predominantly retrospective studies showed large differences ranging from 0% to 82%. A problem is the different documentation of the extent of incontinence disorders (anamnestic, clinical, scoring etc.). This also leads to vastly different results with respect to a disorder of incontinence. In contrast, there are high healing rates between 74% and 100%; however, it must be taken into consideration that the number of patients included in the studies varied between 7 and 537 and that the maximum follow-up was 120 months but was mostly much shorter. In summary, it can be ascertained that fistulectomy is still the state of the art treatment for anal fistulas, because it is still associated with the highest healing probability; however, it must be considered that the severance of sphincter muscles must be kept to a minimum, which is why a high level of experience is a prerequisite for the decision for a fistulectomy
Anorectal fistulas most commonly arise from a chronic infection of the anorectum. Although the disease is not life-threatening in most cases, recurrent inflammation may irreparably damage the anal sphincter with subsequent impairment of patient’s quality of life. Since there are no adequate conservative treatment options, surgical fistula repair is the treatment of choice. The aim of the intervention is to eliminate the fistula without impairment of the sphincter function. Complex or recurrent fistulas can be extremely challenging for the treating surgeon. One of the surgical options is fistula excision with subsequent reconstruction of the sphincter muscle. With this technique, experienced centers reported long-term healing rates of over 90% while preserving sphincter function and anal continence.
Anal fistulas are a frequently occurring clinical condition. Most of the fistulas are of cryptoglandular origin and have different tracts in relation to the sphincter muscle. Fistulas are usually classified using the modified classification according to Parks. Several surgical procedures are available. In addition to fistula excision with sphincter reconstruction and the LIFT procedure (ligation of intersphincteric fistula tract), the advancement flap is a method for the reconstruction of transsphincteric and suprasphincteric anal fistulas. The success rate ranges from 60 to 80%. The advancement flap technique is used in various modifications. This article describes the surgical procedure step-by-step and presents different approaches using a case study as an example.
Was ist neu?
Hämorrhoidalleiden Neuentwicklungen in der Therapie des Hämorrhoidalleidens wurden in den letzten Jahren vorgestellt: Segmenthämorrhoidektomie mit Versiegelungstechnik, die heute zur Standardtechnik zählt, die Doppler-gesteuerte Hämorrhoiden-Arterien-Ligatur und die submuköse Gewebedestruktion.
Analvenenthrombose Die Therapie der Analvenenthrombose ist meist konservativ. Von Stichinzisionen oder einer Thrombusexpression sollte Abstand genommen werden.
Anorektaler Abszess und anorektale Fistel Neue Verfahren zur Therapie von Analfisteln sind FiLaC (Laser-Fistel-OP) und Rafaelo (Radiofrequenzapplikation), Permacol-Kollagen-Paste, Gore-Bio-A-Plug, OTSC-Proctology, Fistulektomie mit primärer Sphinkterrekonstruktion und bei Crohn-Fisteln die Stammzelltransplantation. In der Praxis durchgesetzt hat sich bisher die Fistulektomie mit primärer Sphinkterrekonstruktion.
Analfissur Die Fissurektomie zeigt derzeit die besten Ergebnisse im Hinblick auf die Abheilungsrate. Nitropräparate und Kalziumantagonisten sind die Mittel der ersten Wahl in der konservativen Behandlung.
Analkarzinom Nach Sicherung des Tumorstadiums mittels MRT bzw. besser noch PET-CT stellt die Radiochemotherapie die Standardtherapie beim Analkarzinom dar.
Zusammenfassung
Die Analfissur ist eine der häufigsten Pathologien, welche sich dem Proktologen präsentiert. Entsprechend ist es wichtig, verlässliche Leitlinien dazu zu entwickeln. Die aktuelle Leitlinie wurde anhand eines systematischen Literaturreview von einem interdisziplinären Expertengremium diskutiert und verabschiedet.
Die akute Analfissur, soll auf Grund ihrer hohen Selbstheilungstendenz konservativ behandelt werden. Die Heilung wird am besten durch die Einnahme von Ballaststoff reicher Ernährung und einer medikamentösen Relaxation durch Kalziumkanal-Antagonisten (CCA) unterstützt. Zur Behandlung der chronischen Analfissur (CAF), soll den Patienten eine medikamentöse Behandlung zur „chemischen Sphinkterotomie“ mittels topischer CCA oder Nitraten angeboten werden. Bei Versagen dieser Therapie, kann zur Relaxation des inneren Analsphinkters Botulinumtoxin injiziert werden. Es ist belegt, dass die operativen Therapien effektiver sind. Deshalb kann eine Operation schon als primäre Therapie oder nach erfolgloser medikamentöser Therapie erfolgen. Die Fissurektomie, evtl. mit zusätzlicher Botulinumtoxin Injektion oder Lappendeckung, ist die Operation der Wahl. Obwohl die laterale Internus Sphinkterotomie die CAF effektiver heilt, bleibt diese wegen dem höheren Risiko für eine postoperative Stuhlinkontinenz eine Option für Einzelfälle.
This retrospective observational study analyses the outcomes of patients undergoing surgery for anal fistula at a single centre in order to assess recurrence and re-operation rates after different surgical techniques. During January 2005 and May 2013, all patients with anal fistula were included. Baseline characteristics, details of presentation, fistula anatomy, type of surgery, post-surgical outcomes and follow-up data were collected. The primary endpoints were long-term closure rate and recurrence rate after 2 years. Secondary endpoints were persistent pain, postoperative complications and continence status. A total of 65 patients were included. From a total amount of 93 operations, 65 were fistulotomies, 13 mucosal advancement flaps, 7 anal fistula plugs and 8 cutting-setons. The mean follow up was 80 months. Healing was achieved in 85%. The highest recurrence rate was seen in anal fistula plug with 42%. On the other hand, no recurrence was observed in the cutting-seton procedures. For all included operation no persistent postoperative pain nor incontinence was observed. In conclusion, despite all existing anal fistula operations up to date, the optimal technique with low recurrence rate and assured safety for the anal sphincter is still lacking. Nonetheless, according to our promising results for the cutting-seton technique, this technique, otherwise considered obsolete, should be further evaluated in a prospective study.
Im vorliegenden Beitrag werden anhand der vorliegenden Literatur neuere Methoden zur Therapie von kryptoglandulären Fisteln besprochen und kritisch bewertet. Diskutiert werden folgende Verfahren: Fibrinkleber, Kollagenpaste, Plugs und Mesh aus Biomaterial, Stammzellen, mit Thrombozyten angereichertes Plasma (PRP), „fistula laser closure“ (FiLaC), „video-assisted anal fistula therapy“ (VAAFT), „over the scope clip“ (OTSC). Das Vorgehen, die Studienlage sowie Vor- und Nachteile der Methoden werden ausführlich dargestellt. Bei manchen Methoden (Fibrinkleber, Plug) konnten die anfänglich guten Ergebnisse im Langzeitverlauf bzw. in randomisiert-kontrollierten Studien nicht bestätigt werden; bei anderen liegen zurzeit nur kleine Fallserien vor mit zum Teil kurzer Nachbeobachtungszeit, jedoch keine vergleichenden Studien (FiLaC, VAAFT, OTSC, Stammzellen, PRP). Die dargestellten Techniken können als mögliche Alternative eingesetzt werden, wenn die bewährten Verfahren nicht möglich sind. Ihr Vorteil liegt häufig darin, dass die Kontinenzleistung nicht tangiert wird, dafür sind jedoch die Kosten (Plug, Fibrinkleber, OTSC, FiLaC, VAAFT) oder der Aufwand (Stammzellen, PRP) nicht unerheblich. Die Ursachen für das Fistelrezidiv werden diskutiert. Dabei wird darauf eingegangen, inwieweit die beschriebenen Methoden die möglichen Ursachen eines Rezidivs therapeutisch adressieren können. In den verschiedenen Leitlinien werden diese Techniken, wenn überhaupt, zurückhaltend empfohlen, meist aufgrund der fehlenden Evidenz.
In den letzten Jahren wurde wiederholt über die sehr guten Ergebnisse der Fistulektomie mit primärer Sphinkterrekonstruktion berichtet. Die aktuell zur Verfügung stehende Literatur unterstreicht die positiven Erfahrungen. Vergleicht man die reinen Ergebniszahlen, so zeigt diese Technik die mit Abstand höchste Heilungsrate. In allen bisherigen Publikationen wurde die Gefahr einer postoperativen Kontinenzstörung nicht belegt.
Die chirurgische Therapie analer und rektaler Fistelrezidive mit starren rigiden Narbenhöhlen und Exkavationen, entsprechend der Typen 1–4 b und c nach Parks, ist schwierig. Die Idee des körpereigenen perfundierten Gewebes zur Defektfüllung ist eine häufig genutzte Therapieoption bei verschiedenen Entitäten und wurde auf die Anwendbarkeit bei der obigen Indikation überprüft. Geeignet ist der M. gracilis auf Grund seiner räumlichen Verfügbarkeit, und es wird kein funktionelles Defizit hinterlassen. Unter Stomaschutz kann mit einer hohen Erfolgswahrscheinlichkeit ein kompliziertes Analfistelrezidiv versorgt werden.
Zur differenzierten perioperativen Behandlung rekonstruktiver proktologischer Eingriffe sind seitens der Operationsebene infralevatorische (Analkanal und Übergangszone) von supralevatorischen (distales Rektum) zu unterscheiden, wobei Letztere lagebedingt keine äußere Drainagewunde beinhalten und hier somit keine spezielle Wundversorgung erforderlich ist. Dagegen wird bei Rekonstruktionen auf der Ebene des Analkanals in der Regel eine äußere Drainagewunde zur Sicherstellung der Sekretableitung angelegt, sodass die lokale Nachbehandlung wie bei sonstigen offenen proktologischen Wunden zu erfolgen hat. Hinsichtlich der Präparationstiefe ist bei allen Eingriffen mit Muskelbeteiligung eine regelhafte Single-shot-Antibiose sinnvoll. Die Stuhlentleerung vor transanalen Operationen im distalen Rektum dient der besseren intraoperativen Übersicht und vermindert die Kontamination der hier regelhaft ohne Drainage primär zu verschließenden Wunde. Eine prolongierte postoperative Nahrungskarenz ist nicht erforderlich. Eine erweiterte präoperative Vorbereitung zur Stuhlentleerung mit anschließend postoperativer Nahrungskarenz für einige Tage soll dagegen eine frühzeitige mechanische Belastung der Nähte auf der Ebene des Analkanals (Flap, Sphinkter) vermeiden. Im Weiteren ist dann, wie primär auch nach allen Eingriffen ohne Muskelbeteiligung (Anoderm, Mukosa), eine geformte Stuhlkonsistenz, möglichst unter Verzicht auf Laxanzien, anzustreben.
Thrombosis and inflammation are common causes of anorectal emergencies. Anorectal suppuration can lead to live-threatening disease (Fournier Gangrene) if is not treated immediately. Formation of subsequent fistula is rare after sufficient drainage. Abscesses caused by acne inversa are in most cases chronic suppurative lesions in the anorectal region without fistulation to the anal canal. Definitive treatment consists in radical surgical excision. Thrombosis of hemorrhoidal or anal vein is very painful, but can be managed conservatively in most cases. Local excision can be considered in patient with large segmental thrombosis and short-time duration. Acute abscess may be a first clinical manifestation of pilonidal sinus. At an acute stage, only local limited drainage of the abscess should be performed. Definitive surgery should be consist in excision with primary closure by an off-midline procedure.
Analfisteln stellen ein häufiges proktologisches Krankheitsbild dar und können mit einem Perianalabszess assoziiert auftreten. Die Ätiologie wird durch eine kryptoglanduläre Infektion im Intersphinktärraum bestimmt. Die Therapie der Analfistel ist chirurgisch. Oberstes Ziel der Fistelchirurgie bleibt die Heilung, wobei der „Erfolg“ von verschiedenen Faktoren abhängt, u. a. Erfahrung des Chirurgen, Art der Fistel, Beteiligung des Schließmuskels, Art des Operationsverfahrens sowie patientenassoziierte Faktoren. Bei der chirurgischen Therapie der komplexen Analfistel stehen verschiedene operative Verfahren zur Verfügung: die Fistelspaltung mit Schließmuskelrekonstruktion, plastische Verfahren (z. B. Mukosa-Flap, Muskel-Mukosa-Flap) sowie sog. „sphinktererhaltende“ Verfahren wie LIFT („ligation of intersphincteric fistula tract“), VAAFT („video-assisted anal fistula treatment“), die Verwendung eines Plugs, von Kollagen oder Fibrinkleber als auch Laserverfahren oder der Clip. Auf der Suche nach geeigneten Qualitätsindikatoren in der analen Fistelchirurgie besteht ein Spannungsfeld zwischen Heilung einerseits und dem Kontinenzerhalt andererseits. Identifiziert man potenzielle Qualitätsindikatoren, sind sowohl die Grundsätze der Analfistelchirurgie zu beachten als auch die entsprechende Patientenselektion bzw. Verfahrenswahl von entscheidender Bedeutung, um hohe Heilungsraten zu erreichen, ohne beträchtliche Kontinenzstörungen oder hohe Revisionsraten wegen eines Abszesses oder Rezidivs zu induzieren. Vor dem Hintergrund der vorliegenden Literatur und Leitlinien bestehen in der Bewertung von Qualitätsindikatoren erhebliche Unterschiede hinsichtlich Patientenselektion, Ätiologie der Analfistel, Dauer der Nachbeobachtung und Heterogenität der Therapieregime, die eine definitive Bewertung erschweren, welche chirurgische Therapie die beste bei der komplexen Analfistel darstellt.
In this article, guidelines and recommendations for the treatment of anal fistulas are summarized based on the current literature. Surgical procedures for treatment include the following: lay open technique, seton drainage, reconstruction techniques including suturing of the sphincter, ligation of the intersphincteric fistula tract, occlusion with biomaterials, and local injection. Innovative procedures include laser coagulation, endoscopic fistula treatment, and occlusion with over-the-scope clip. The lay open technique should only be performed in superficial fistulas, whereby in high anal fistulas, a sphincter-preserving procedure should be preferred. When using biomaterials, a significantly lower healing rate is observed. All procedures can also be performed in patients with chronic inflammatory bowel disease; however, prior effective treatment of bowel inflammation by drug therapy is required. © 2018 Springer Medizin Verlag GmbH, ein Teil von Springer Nature
Periproktitische Abszesse und anorektale Fisteln sind Folge derselben Erkrankung, einer Entzündung von rudimentär angelegten Proktodäaldrüsen, die vorwiegend im intersphinktären Spalt lokalisiert sind. Im Abszessstadium ist die ausreichend breite ovaläre Entdachung die chirurgische Therapie der Wahl. Bei entsprechender Expertise kann eine vorsichtige Fistelsuche erfolgen. Liegt ein hoher, proximaler Fistelverlauf vor, wird eine Loop-Drainage eingebracht und ein zweizeitiges operatives Vorgehen geplant. Die Spaltung einer Fistel ist das effektivste Verfahren bezüglich der Ausheilung des proktodäalen Infektionsbefundes, kann aber nur bei distaler Lokalisation erfolgen. Bei hohen transsphinktären und anderen komplexen Fistelverläufen steigt aber das Inkontinenzrisiko nach einfacher Fistulotomie, es sind daher plastische Operationsverfahren zum Fistelverschluss notwendig, die allerdings prospektiv mit höheren Rezidivraten verbunden sind. Insofern besteht bei der Fistelchirurgie ein therapeutisches Dilemma, da zum einen die Sanierung der Entzündung und zum anderen der Erhalt der analen Kontinenz erreicht werden soll. So muss jeweils individuell der richtige operative Weg zwischen Skylla und Charybdis gefunden werden. Besondere chirurgische Herausforderungen mit Erfordernis einer speziellen proktochirurgischen Erfahrung bestehen bei Rezidiv- und Crohn-Fisteln sowie bei rektovaginalen Befunden.
Analfisteln sind eine häufige Erkrankung, vor allem bei jüngeren Männern. Eine nichtadäquate Behandlung kann zur Beeinträchtigung der Lebensqualität führen, insbesondere zur Reduktion der Kontinenzleistung. Wichtige Ursachen der Analfisteln sind entzündete Proktodäaldrüsen und chronisch-entzündliche Darmerkrankungen (CED). Die Diagnostik beruht primär auf der klinischen Untersuchung. Die Klassifikation richtet sich nach der Beziehung des Fistelgangs zum Sphinkterapparat. Endoanaler Ultraschall und Magnetresonanztomographie können die Diagnostik bei komplexen Analfisteln unterstützen. Die Therapie der Analfistel ist prinzipiell operativ. Bevorzugt sollten Sphinkter-schonende Verfahren zum Einsatz kommen. Bei CED-bedingten Analfisteln steht die medikamentöse Therapie der Darmwandentzündung im Vordergrund. In diesem Beitrag werden anhand der aktuellen Literatur evidenzbasierte Richtlinien und Empfehlungen für die Diagnostik von Analfisteln zusammengestellt.
Die Stuhlinkontinenz stellt insbesondere vor dem Hintergrund der alternden Bevölkerungen eine Herausforderung für die proktologische Praxis dar. Kontinenzstörungen resultieren aus einer Vielzahl von Schädigungen des Kontinenzapparates und können nicht auf den Sphinkter reduziert werden. Eine umfangreiche Anamnese und eine einfache klinische Untersuchung ist in den meisten Fällen zur Diagnostik ausreichend. Entscheidender Faktor für die Behandlung ist die subjektive Beeinträchtigung durch Kontinenzstörungen. Die Behandlung ist in erster Linie konservativ durch Stuhlgangsregulation und Sphinktertraining. Bei der absoluten Mehrzahl der Patienten können dadurch subjektiv zufrieden stellende Ergebnisse erzielt werden. Die derzeit bekannten Operationsverfahren sind z. T. sehr invasiv und kostenträchtig. Sie können bei ausgeprägter Inkontinenz die Lebensqualität der Betroffenen deutlich verbessern, aber nur bei einem kleinen Anteil Betroffener eine komplette Kontinenzwiederherstellung garantieren.
Anorektale Fisteln sind abnorme röhrenförmige, vom After ausgehende Gänge, die im Allgemeinen nicht spontan abheilen. Obwohl die Analfistelkrankheit kein lebensbedrohliches Leiden ist, stellt ihre Behandlung vor allem bei kompliziertem Fistelgangverlauf eines der größten Probleme der Analchirurgie dar. Ihre Rezidivhäufigkeit besonders nach inadäquater Therapie verursacht nicht selten irreparable Schäden des Kontinenzorgans. Durch einen sachgerechten Eingriff kann aber eine dauerhafte Beseitigung des Analleidens erreicht werden. Die Anatomie und Morphologie des Anorektums bilden die Grundlage der Fistelentstehung und ihrer Behandlung.
Im folgenden Kapitel werden die Begleitumstände der proktologischen Behandlung dargestellt. Während die normale proktologische Diagnostik und konservative Therapie weitestgehend schmerzfrei ist, sollten bei endoskopischen und operativen Verfahren unterschiedliche Anästhesieverfahren angeboten werden. Wie in anderen Bereichen sollten auch in der Proktologie Antibiotika nur sehr gezielt und in Ausnahmefällen eingesetzt werden. Eine Darmvorbereitung ist nur bei speziellen Untersuchungen und Behandlungsverfahren erforderlich. Auch das sehr aktuelle und wichtige Kapitel der Hygiene wird hier besprochen. Obwohl es sich praktisch nie um aseptische Eingriffe handelt und fast immer in der Proktologie eine sekundäre Wundheilung eintritt, muss eine Gefährdung der Behandelten durch Infektionen insbesondere mit Problemkeimen unter allen Umständen verhindert werden.
Abszesse in der perianalen Region sind häufig. Leitsymptom ist die innerhalb kürzester Zeit auftretende, sehr schmerzhafte Schwellung, die zu einer schnellen Intervention zwingt. Häufigste Ursache ist eine Entzündung der beim Menschen rudimentär angelegten Proktodealdrüsen. Dabei stellt der Analabszess das akute und die Analfistel das chronische Stadium des gleichen Krankheitsbildes dar. In Analogie zu Untersuchungen bei Analfisteln finden sich Analabszesse überwiegend bei jüngeren Erwachsenen zwischen dem 30. und 50. Lebensjahr, wobei Männer deutlich häufiger als Frauen betroffen sind.
Background
Perianal abscesses and anal fistulas in childhood are commonly treated like abscesses and fistulas in adults. The aim of this study was clarify whether they are cryptoglandular infections as in adults and whether they are two different kinds of underlying diseases, just with the same symptoms.
Material and methods
We retrospectively analyzed all children and adolescents between 0 and 16 years of age who underwent surgical treatment for a primary perianal abscess or a primary anal fistula. The records were analyzed with respect to age at appearance of lesions, sex, diagnosis and anatomical localization of lesions.
Results
Within a time period of 20 years a total of 183 children (♀ = 22, ♂ = 161) with the clinical diagnosis of anorectal abscesses or anal fistulas were treated. Of the children 70.5% were treated during their first year of life and another 9.3% up to the age of 2 years (group 1 79.8%, n = 146). Only 20.2% were 3 years and older (group 2, n = 37). Group 1 contained significantly more male infants (m:f = 11:1); however, an almost equal sex distribution was detected for group 2 (m:f = 2.6:1), a similar result to adults. It was conspicuous that in group 1 nearly two thirds of the anal fistulas and abscesses were localized horizontally between 3:00 and 9:00 h in a lithotomy position.
Conclusion
Divergences in age and sex, as well as in anatomical localization suggest a congenital etiology for anal fistulas and perianal abscesses in infants and children.
Die konventionelle Hämorrhoidektomie (KH) gilt als der Goldstandard bei der operativen Therapie des Hämorrhoidalleidens. Die Stapler-Hämorrhoidopexie (SH) ist mit weniger Schmerzen in der unmittelbaren postoperativen Phase als die KH verbunden, jedoch sind die Raten an Residualproplaps, Hämorrhoidalprolaps und Reinterventionen wegen Prolaps im weiteren Verlauf nach SH höher als nach KH. Analfissuren sind relativ häufig und manifestieren sich durch Schmerzen bei der Defäkation. Als erste Maßnahme sollte immer ein konservativer Therapieversuch erfolgen. Dazu stehen verschiedene Substanzen (Nitroglyceryl-Trinitrat, Diltiazem u. a.) zur Verfügung. Eine operative Therapie kommt bei Versagen aller konservativen Maßnahmen zur Anwendung. Standard ist die Fissurektomie. Abszesse der Analregion sind gekennzeichnet durch starke progrediente Schmerzen, die eine zeitnahe und ausreichende operative Drainage erfordern. Eine Fistelsuche sollte nur sehr vorsichtig durchgeführt werden. Analfisteln sind in den meisten Fällen die Folge eines anorektalen Abszesses mit persistierender oder iatrogen entstandener Verbindung zum Analkanal. Eine Heilung ist nur operativ möglich. Während oberflächliche Fisteln gespalten werden können, sollten bei allen höheren Fisteln Schließmuskel-schonende Verfahren zur Anwendung kommen. Ein Verfahren mit deutlichen Vorteilen konnte bisher nicht evaluiert werden, so dass immer eine Einzelfallentscheidung des erfahrenen Operateurs erforderlich ist. Mögliche Belastungen der Betroffenen durch wiederholte Eingriffe und Kontinenzstörungen sind nicht auszuschließen. Dem Sinus pilonidalis liegt eine akute oder chronische Entzündung im Fettgewebe der Rima ani zugrunde. Eine Heilung ist nur operativ möglich. Eine offene Wundbehandlung bei größeren Befunden geht mit einer sehr langen Wundbehandlung und Arbeitsunfähigkeit einher. Diese kann durch plastische Verfahren verkürzt werden. Die Mittelliniennaht sollte wegen der erhöhten Komplikations- und Rezidivrate nicht mehr angewendet werden.
Background
The incidence of anal abscess and fistula is relatively high, and the condition is most common in young men. Methods
This is a revised version of the German S3 guidelines first published in 2011. It is based on a systematic review of pertinent literature. ResultsCryptoglandular abscesses and fistulas usually originate in the proctodeal glands of the intersphincteric space. Classification depends on their relation to the anal sphincter. Patient history and clinical examination are diagnostically sufficient in order to establish the indication for surgery. Further examinations (endosonography, MRI) should be considered in complex abscesses or fistulas. The goal of surgery for an abscess is thorough drainage of the focus of infection while preserving the sphincter muscles. The risk of abscess recurrence or secondary fistula formation is low overall. However, they may result from insufficient drainage. Primary fistulotomy should only be performed in case of superficial fistulas. Moreover, it should be done by experienced surgeons. In case of unclear findings or high fistulas, repair should take place in a second procedure. Anal fistulas can be treated only by surgical intervention with one of the following operations: laying open, seton drainage, plastic surgical reconstruction with suturing of the sphincter (flap, sphincter repair, LIFT), and occlusion with biomaterials. Only superficial fistulas should be laid open. The risk of postoperative incontinence is directly related to the thickness of the sphincter muscle that is divided. All high anal fistulas should be treated with a sphincter-saving procedure. The various plastic surgical reconstructive procedures all yield roughly the same results. Occlusion with biomaterial results in lower cure rate. Conclusion
In this revision of the German S3 guidelines, instructions for diagnosis and treatment of anal abscess and fistula are described based on a review of current literature.
Die Proktologie besitzt einen interdisziplinären Charakter mit chirurgischen, dermatologischen und venerischen Krankheitsbildern. Sie stellt im wahrsten Sinne des Wortes ein »Randgebiet« der Endoskopie dar, entzieht sich aber weitgehend der normalen, koloskopischen Diagnostik. Dennoch sind die meisten im Folgenden abgehandelten anorektalen Erkrankungen durch eine sorgfältige Inspektion, eine rektal-digitale Untersuchung und eine Proktoskopie gut erkenn- und therapierbar.
A perianal fistula is a pathological canal covered by granulation tissue connecting the anal canal and perianal area epidermis. The above-mentioned problem is the reason for the patient to visit the surgeonproctologist. Unfortunately, the disease is characterized by a high recurrence rate, even despite proper management.
The aim of the study was to determine the current condition of perianal fistula treatment methods in everyday surgical practice, considering members of the Society of Polish Surgeons. Material and methods. 1523 members of the Society of Polish Surgeons received an anonymous questionnaire comprising 15 questions regarding perianal fistula treatment in everyday practice.
Results. Results were obtained from 807 (53%) members. After receiving answers, questionnaire results were collected, analysed, and presented in a descriptive form.
Conclusions. Study results showed that most Polish surgeons choose the fistulectomy/fistulotomy method. Considering treatment of perianal fistulas the most important issue is to find the correct, primary fistula canal. Further methods should be individually selected for each patient. One should also remember that every fistula is different. Surgical departments that operate a small number of perianal fistulas should direct such patients to reference centers.
Purpose
Perianal fistulas, and specifically high perianal fistulas, remain a challenge for surgical treatment. Many techniques have been and are still being developed to improve the outcome after surgery. A systematic review and meta-analysis was performed for surgical treatment of high cryptoglandular perianal fistulas.
Methods
Medline (Pubmed, Ovid), Embase and The Cochrane Library databases were searched for relevant randomized controlled trials on surgical treatments for high cryptoglandular perianal fistulas. Two independent reviewers selected articles for inclusion based on title, abstract and outcomes described. The main outcome measurement was the recurrence/healing rate. Secondary outcomes were continence status, quality of life and complications.
Results
The number of randomized trials available was low. Fourteen studies could be included in the review. A meta-analysis could only be performed for the mucosal advancement flap versus the fistula plug, and did not show a result in favour of either technique in recurrence or complication rate. The mucosal advancement flap was the most investigated technique but did not show any advantage over any other technique. Other techniques identified in randomized studies were seton treatment, medicated seton treatment, fibrin glue, autologous stem cells, island flap anoplasty, rectal wall advancement flap, ligation of the intersphincteric fistula tract, sphincter reconstruction, sphincter-preserving seton and techniques combined with antibiotics. None of these techniques seemed superior to each other.
Conclusions
The best surgical treatment for high cryptoglandular perianal fistulas could not be identified. More randomized controlled trials are needed to find the best treatment. The mucosal advancement flap is the most investigated technique available.
Introduction
The aim of this study was to assess the impact of diabetes mellitus, Crohn’s disease, HIV/aids, and obesity on the prevalence and readmission rate of perianal abscess.
Methods
The study cohort was based on the Swedish National Patient Register and included all patients treated for perianal abscess in Sweden 1997–2009. The prevalence and risk for readmission were assessed in association with four comorbidity diagnoses: diabetes mellitus, Crohn’s disease, HIV, and/or AIDS and obesity.
Results
A total of 18,877 patients were admitted during the study period including 11,138 men and 4557 women (2.4:1). Crohn’s disease, diabetes, and obesity were associated with a significantly higher prevalence of perianal abscess than an age- and gender-matched background population (p < 0.05). In univariate analysis, neither age nor gender had any significant impact on the risk for readmission. In a multivariate Cox proportional hazard analysis, Crohns disease was the only significant risk factor for readmission of perianal abscess.
Conclusion
Crohn’s disease, diabetes, and obesity increase the risk for perianal abscess. Of these, Crohn’s and HIV has an impact on readmission. The pathogenesis and the influence of diabetes and obesity need further research if we are to understand why these diseases increase the risk for perianal abscess but not its recurrence.
Aim:
Recent advances in the treatment of fistula-in-ano have focused on surgical techniques that preserve sphincter integrity. Plugs that obliterate the lumen of the fistula track have been proposed as one such method, and may be derived from biological or delayed absorbable synthetic materials. Biological plugs have highly variable results and have not been widely adopted. The aim of this systematic review was to assess the effectiveness and safety of a delayed absorbable synthetic plug (GORE® BIO-A®) for treatment of anal fistula.
Method:
A systematic review of all literature in the English language relevant to the use of a plug to treat anal fistula and published between 1 January 2008 and 15 February 2015 was carried out by searching MEDLINE, EMBASE and the Cochrane Library of Systematic Reviews/Controlled Trials for relevant literature. Relevant articles were identified, quality assessed using the methodological index for nonrandomized studies criteria and data were extracted by two independent researchers (SKN and NNA). The identified articles were assessed with regard to fistula healing rate, duration of follow-up and complication rates related to the use of delayed absorbable synthetic fistula plugs.
Results:
Twenty six potential articles were identified from the literature search. Using the predefined inclusion and exclusion criteria, six were included in the final analysis, data extraction and data synthesis. Of these included in the review only three were prospective in design. Complete data were available for 187 of the 221 patients who underwent this treatment. The age of the participants ranged from 19 to 82 years. The fistula healing rates were reported to be between 15.8% and 72.7% at a follow-up ranging between 2 and 19 months. Early or delayed plug extrusion occurred in 16 (8.5%) of the 187 patients. Deterioration in continence was reported in 11 (5.8%) of 187 patients.
Conclusion:
There are insufficient high-quality data on the delayed absorbable synthetic (GORE® BIO-A®) fistula plug to draw meaningful conclusions regarding its effectiveness. It does, however, appear to be a simple and safe technique associated with low complication rates and a minor deterioration in continence in a few cases.
Introduction:
In a recent Cochrane review, the authors concluded that there is an urgent need for well-powered, well-conducted randomized controlled trials comparing various modes of treatment of fistula-in-ano. Ten randomized controlled trials were available for analyses: There were no significant differences in recurrence rates or incontinence rates in any of the studied comparisons. The following article reviews the studies available for treatment of fistula-in-ano with a fistula plug with special attention paid to the technique.
Material and methods:
PubMed, Medline, Embase, and the Cochrane medical database were searched up to July 2015. Sixty-four articles were relevant for this review.
Results:
Healing rates of 50-60% can be expected for treatment of complex anal fistula with a fistula plug, with a plug-extrusion rate of 10-20%. Such results can be achieved not only with plugs made of porcine intestinal submucosa but also those made of other biological or synthetic bioabsorbable mesh materials. Important technical steps are firm suturing of the head of the plug in the primary opening and wide drainage of the secondary opening.
Discussion:
Treatment of a complex fistula-in-ano with a fistula plug is an option with a success rate of 50-60% with low complication rate. Further improvements in technique and better studies are needed.
Most commonly practiced surgical "lay open" technique to treat fistula-in-ano (a common anorectal pathology) has high rate of recurrence and anal incontinence. Alternatively, a nonsurgical cost efficient treatment with Ksharasutra (cotton Seton coated with Ayurvedic medicines) has minimal complications. In our study, we have tried to compare these two techniques.
A prospective randomized control study was designed involving patients referred to the Department of General Surgery in RG Kar Medical College, Kolkata, India, from January 2010 to September 2011.
Among 50 patients, 26 were in Ksharasutra and 24 were in fistulotomy group. 86% patients were male and 54% of the patients were in the fourth decade. About 74% fistulas are inter-sphincteric and 26% were of trans-sphincteric variety. Severe postoperative pain was more (7.7% vs. 25%) in fistulotomy group, while wound discharge was more associated with Ksharasutra group (15.3% vs. 8.3%). Wound scarring, bleeding, and infection rate were similar in both groups. Ksharasutra group took more time to heal (mean: 53 vs. 35.7 days, P = 0.002) despite reduced disruption to their routine work (2.7 vs. 15.5 days work off, P <0.001). Interestingly, pain experienced was less in Ksharasutra group, there was no open wound in contrast to fistulotomy and it was significantly cost effective (Rupees 166 vs. 464).
Treatment of fistula-in-ano with Ksharasutra is a simple with low complications and minimal cost.
Psychological stress is known to affect the immunologic system and the inflammatory response. The aim of this study was to assess the presence of psychological stress, anxiety, and depression in patients with anal fistula.
Consecutive patients with anal fistula, hemorrhoids, and normal volunteers were studied prospectively. Stressful life events were recorded and subjects were asked to complete the state-trait anxiety inventory (STAI), a depression scale, and three different reactive graphic tests (RGT).
Seventy-eight fistula patients, 73 patients with grade III-IV hemorrhoids, and 37 normal volunteers were enrolled. Of the fistula patients, 65 (83 %) reported one or more stressful events in the year prior to diagnosis, compared to 16 (22 %) of the hemorrhoid patients (P = 0.001). There were no significant differences in the percentage of subjects with abnormal trait anxiety (i.e., proneness for anxiety) and depression scores between fistula patients, hemorrhoid patients, and controls. Fistula patients had significantly higher (i.e., better) scores compared to hemorrhoid patients in two of three RGT and significantly lower (i.e., worse) scores in all three RGT compared to healthy volunteers. Of 37 patients followed up for a median of 28 months (range 19-41 months) after surgery, 8 (21.6 %) had persistent or recurrent sepsis. There was no significant difference in depression, STAI, and RGT scores between patients with sepsis and patients whose fistula healed.
Our results suggest that an altered emotional state plays an important role in the pathogenesis of anal fistula and underline the importance of psychological screening in patients with anorectal disorders.
To evaluate the efficacy of the over-the-scope clip (OTSC(®)) proctology set for the closure of refractory anal fistulas.
This retrospective single-center study included all consecutive patients undergoing an OTSC(®) proctology closure of anal fistulas between October 2012 and June 2014. The OTSC(®) was only used in refractory cases after previous fistula surgery, including patients with Crohn's disease, or multiple previous surgical approaches.
There were ten patients (five males and five females) with a median age of 41 years (range 26-69 years). The etiology of the fistula was cryptoglandular in four patients, and perianal Crohn's disease in six patients (including one patient with an anovaginal fistula). The surgical procedure was technically successful in all patients. Permanent fistula closure was achieved in seven out of ten patients (70 %) within a median time of 72 days (range 31-109 days). Median total follow-up time was 230.5 days (range 156-523 days). There were three failures (30 %), including two cryptoglandular and one Crohn's disease-associated fistula. In all three cases, the OTSC(®) was lost spontaneously on days 22, 23, and 40, respectively. In three of the seven patients with successful closure, the OTSC(®) was removed after complete healing of the fistula.
The novel OTSC(®) proctology system is a safe and effective method for the closure of even complex and recurrent fistulas.
Purpose:
New technical approaches involving biologically derived products have been used to treat complex anal fistulas in order to avoid the risk of fecal incontinence. The least invasive methods involve filling out the fistula tract with fibrin glue or introduction of an anal fistula plug into the fistula canal following thorough curettage. A review shows that the new techniques involving biologically derived products do not confer any significant advantages. Therefore, the question inevitably arises as to whether the combination of a partial or limited fistulectomy, i.e., of the extrasphincteric portion of the fistula, and preservation of the sphincter muscle by repairing the section of the complex anal fistula running through the sphincter muscle and filling it with a fistula plug produces better results.
Methods:
A modified plug technique was used, in which the extrasphincteric portion of the complex anal fistula was removed by means of a limited fistulectomy and the remaining section of the fistula in the sphincter muscle was repaired using the fistula plug with fixing button.
Results:
Of the 52 patients with a complex anal fistula, who had undergone surgery using a modified plug repair with limited fistulectomy of the extrasphincteric part of the fistula and use of the fistula plug with fixing button, there are from 40 patients (follow-up rate: 77%) some kind of follow-up informations, after a mean of 19.32 ± 6.9 months. Thirty-two were men and eight were women, with a mean age of 52.97 ± 12.22 years. Surgery was conducted to treat 36 transsphincteric, 1 intersphincteric, and 3 rectovaginal fistulas. In 36 of 40 patients (90%), the complex anal fistulas or rectovaginal fistulas were completely healed without any sign of recurrence. None of these patients complained about continence problems.
Conclusion:
A modification of the plug repair of complex anal fistulas with limited fistulectomy of the extrasphincteric part of the fistula and use of the plug with fixing button seems to increase the healing rate in comparison to the standard plug technique.
Ideal surgical treatment for anal fistula should aim to eradicate sepsis and promote healing of the tract, whilst preserving the sphincters and the mechanism of continence. For the simple and most distal fistulae, conventional surgical options such as laying open of the fistula tract seem to be relatively safe and therefore, well accepted in clinical practise. However, for the more complex fistulae where a significant proportion of the anal sphincter is involved, great concern remains about damaging the sphincter and subsequent poor functional outcome, which is quite inevitable following conventional surgical treatment. For this reason, over the last two decades, many sphincter-preserving procedures for the treatment of anal fistula have been introduced with the common goal of minimising the injury to the anal sphincters and preserving optimal function. Among them, the ligation of intersphincteric fistula tract procedure appears to be safe and effective and may be routinely considered for complex anal fistula. Another technique, the anal fistula plug, derived from porcine small intestinal submucosa, is safe but modestly effective in long-term follow-up, with success rates varying from 24%-88%. The failure rate may be due to its extrusion from the fistula tract. To obviate that, a new designed plug (GORE BioA®) was introduced, but long term data regarding its efficacy are scant. Fibrin glue showed poor and variable healing rate (14%-74%). FiLaC and video-assisted anal fistula treatment procedures, respectively using laser and electrode energy, are expensive and yet to be thoroughly assessed in clinical practise. Recently, a therapy using autologous adipose-derived stem cells has been described. Their properties of regenerating tissues and suppressing inflammatory response must be better investigated on anal fistulae, and studies remain in progress. The aim of this present article is to review the pertinent literature, describing the advantages and limitations of new sphincter-preserving techniques.
Fistulotomy is considered to be the golden standard for the treatment of low perianal fistula but might have more influence on continence status than believed. This study was performed to evaluate the healing rate after a fistulotomy and to show results for continence status.
A retrospective database study was performed in one university medical center and its six affiliated hospitals. All patients treated with a fistulotomy for a low perianal fistula were identified. Healing and recurrence of the fistula were identified. Questionnaires on continence status and quality of life were mailed to all patients.
In total, 537 patients were identified. The primary etiology of the fistulas was cryptoglandular (66.5 %). Recurrence was seen in 88 patients (16.4 %) resulting in a primary healing rate of 83.6 %. After secondary treatment for the recurrence, another 40 patients healed. This resulted in a secondary healing rate of 90.3 %. The Kaplan-Meier analysis showed that at 5 years, the healing rate was 0.81 (95 % confidence interval (95 % CI) 0.71-0.85). The mean Vaizey score was 4.67 (SD 4.80). Major incontinence, defined as a Vaizey score of >6, was seen in 95 (28.0 %) patients. Only 26.3 % of the patients had a perfect continence status (Vaizey score 0). Quality of life was not different from the general population.
Fistulotomy seems to be associated with a healing rate of 0.81 (95 % CI 0.71-0.85) after 5 years. However, major incontinence is still reported by 26.8 % of patients and only 26.3 % of patients had a perfect continence status.
IntroductionThe surgical treatment of anal fistulas is a complex problem, associated with high relapse rates. Wounds frequently heal by the secondary intention. The process is time-consuming and frequently causes discomfort to the patient. Negative pressure wound therapy seems to be one of the methods which might accelerate the healing process in patients who have undergone surgery for anal fistula. Nevertheless, this approach is seldom used. The principal challenge in applying negative pressure wound therapy (NPWT) in the anal and perineal regions remains appropriate application of particular elements forming the negative pressure dressing and above all tight pasting of the foil.Description of the procedureA patient with a complex, relapsing trans-sphincteric anal fistula was admitted to hospital (Fig. 1). Before admission, temporary ileostomy was considered because of repeat fistula recurrence. However, the patient qualified for an operation with the application of a negative pressur ...
Fistula in ano is a common disease seen in the surgical outpatient department. Many procedures are advocated for the treatment of fistula in ano. However, none of the procedures is considered the gold standard. The latest addition to the list of treatment options is video-assisted anal fistula treatment (VAAFT). It is a minimally invasive, sphincter-saving procedure with low morbidity. The aim of our study was to compare the results with a premier study done previously.
The procedure involves diagnostic fistuloscopy and visualization of the internal opening, followed by fulguration of the fistulous tract and closure of the internal opening with a stapling device or suture ligation. The video equipment (Karl Storz, Tuttlingen, Germany) was connected to an illuminating source.
The study was conducted from July 2010 to March 2014. Eighty-two patients with fistula in ano were operated on with VAAFT and were followed up according to the study protocol. The recurrence rate was 15.85%, with recurrences developing in 13 cases. Postoperative pain and discomfort were minimal.
VAAFT is a minimally invasive procedure performed under direct visualization. It enables visualization of the internal opening and secondary branches or abscess cavities. It is a sphincter-saving procedure and offers many advantages to patients. Our initial results with the procedure are quite encouraging.
Background: Fistula-in-ano may be treated by closing the internal fistulous opening. An anocutaneous flap was developed to facilitate this closure. Methods: From October 1995 to April 1997, 40 patients with high trans-sphincteric or suprasphincteric anal fistulas were treated. The important components of the procedure are excision of the internal opening, excision or curettage of the tract, closure of the internal opening by an anocutaneous flap, and external drainage. Results: In two patients (5 per cent) the flap separated and the sutured internal opening was exposed. One of the two was healed 4 weeks later. In the remaining 38 patients, complete healing occurred 2-3 weeks after operation. No patient was incontinent of gas or stool. Conclusion: This procedure is technically simple, heals rapidly with minimal scarring, and cures anal fistulas while preserving the anal sphincter.
Background: In the past 2 years, we treated three women with fourth-degree lacerations or episiotomy infections presenting with persistent pain and drainage not responding to standard treatment. Cases: These women were referred for evaluation 5 weeks, 3.5 months, and 2 years postpartum. After diagnosing fistula-in-ano, we treated them with fistulotomy and curettage, which resolved the problem. Conclusion: When a patient presents with pain or drainage at her episiotomy site, fistula-in-ano should be considered.
Aim:
Treatment of perianal fistula has evolved with the introduction of new techniques and biologicals in Crohn's disease (CD). Several guidelines are available worldwide, but many recommendations are controversial or lack high-quality evidence. The aim of this work was to provide an overview of the current available national and international guidelines for perianal fistula and to analyse areas of consensus and areas of conflicting recommendations, thereby identifying topics and questions for future research.
Method:
MEDLINE, EMBASE and PubMed were systematically searched for guidelines on perianal fistula. Inclusion was limited to papers in English less than 10 years old. The included topics were classified as having consensus (unanimous recommendations in at least two-thirds of the guidelines) or controversy (fewer than three guidelines commenting on the topic or no consensus) between guidelines. The highest level of evidence was scored as sufficient (level 3a or higher of the Oxford Centre for Evidence-based Medicine Levels of Evidence 2009, http://www.cebm.net/oxford-centre-evidence-based-medicine-levels-evidence-march-2009/) or insufficient.
Results:
Twelve guidelines were included and topics with recommendations were compared. Overall, consensus was present in 15 topics, whereas six topics were rated as controversial. Evidence levels varied from strong to lack of evidence.
Conclusion:
Evidence on the diagnosis and treatment of perianal fistulae (cryptoglandular or related to CD) ranged from nonexistent to strong, regardless of consensus. The most relevant research questions were identified and proposed as topics for future research.
Proctologic fistulas are divided into pilonidal sinuses affecting the anal cleft and fistula in ano as tracts between the anus and perianal skin. An uncomplicated finding of a pilonidal sinus is treated by minimally invasive excision of the fistula tract using local anesthesia and acute abscesses must be drained prior to excision. Conservative approaches as well as radical excision are no longer recommended. In complicated situations a wide excision with plastic closure by a Limberg flap is the treatment of choice. Fistula in ano must be differentiated into subcutaneous and deep intersphincteral fistulas with no involvement of the anal sphincter and high intersphincteral transphincteral, suprasphincteral and extrasphincteral fistulas. Fistulas in the first group are candidates for fistulotomy with a low risk of incontinence and a high healing rate but the latter group has an increased risk of incontinence and fistula recurrence. Fistulas can be closed by an anal fistula plug without risk of incontinence but with a high risk of recurrence. In the case of recurrence a fistulectomy with closure of the internal opening and an anorectal advancement flap is performed.
Perianal sepsis is a common condition ranging from acute abscess to chronic fistula formation. In most cases, the source is considered to be a non-specific cryptoglandular infection starting from the intersphincteric space. The key to successful treatment is the eradication of the primary track. As surgery may lead to a disturbance of continence, several sphincter-preserving techniques have been developed. This consensus statement examines the pertinent literature and provides evidence-based recommendations to improve individualized management of patients.
AimThe treatment of transsphincteric anal fistula requires a balance between eradication of the disease and preservation of faecal control. A cutting seton is an old tool that is now out of vogue for many surgeons. We hypothesized that the concept remains reliable and safe with results that exceed those reported for many of the more recently described methods.MethodA retrospective review was conducted of real-time electronic health records (single institution, single surgeon) of patients presenting during the 14 years between 2001 and 2014 with a transsphincteric anal fistula who were treated with a cutting seton. Excluded were patients with Crohn's disease, fistulas related to malignancy or a previous anastomosis and patients whose fistula was treated by another method including a loose draining seton. Data collection included demographics, duration of the disease, duration of the treatment, outcome and continence.Results121 patients (80 male) of, mean age 40.2±12.2 years [range 18-76] with a mean follow-up of 5.1±3.3 (1-24) months were included in the analysis. The median duration of symptoms was 6 (1-84) months, 36% had failed other fistula surgery, 12% had a complex fistula with more than one track and 35% had some form of comorbidity. The median time to healing was 3 (1-18) months. 7.4% required further surgery, but eventually 98% had complete fistula healing. The incontinence rate decreased postoperatively to 11.6% from 19% before treatment with 17/121 with preexisting incontinence resolved and 8/107 new cases developing.Conclusion
Despite its retrospective non-comparative design, the study has demonstrated that a cutting seton is a safe, well tolerated, and highly successful treatment for transsphincteric anal fistula and is followed overall by improved continence. The results compare very favorably with other techniques.This article is protected by copyright. All rights reserved.
AimPermacol™ collagen paste (Permacol™ paste) is a new option for the treatment of anorectal fistula. It functions by filling the fistula tract with an acellular crosslinked porcine dermal collagen matrix suspension. The MASERATI 100 study group was set to evaluate the clinical outcome of Permacol™ paste in the treatment of anorectal fistula. This paper reports the results from the initial 30 patients enrolled in the MASERATI 100 prospective, observational clinical trial.Method
Patients (N=30) with anal fistula presenting to ten European academic surgical units were treated with a sphincter-preserving technique using Permacol™ paste. Fistula healing was assessed at 1, 3, 6, and 12 months after treatment, with the primary endpoint of fistula healing at 6-months post-surgery. Faecal continence and patient satisfaction were recorded at each follow-up visit and adverse events were monitored throughout the follow-up.ResultsOf the 28 patients with data at six months post-surgery, 15 (54%) were healed, and the healing rate was maintained at 12 months. Healing after treatment with Permacol™ paste was similar for intersphincteric to transsphincteric fistulas and primary or recurrent fistulas. Only one patient exhibited an adverse event (perianal abscess) that was possibly related to the treatment. At the last outpatient visit, over 60% of patients were satisfied or very satisfied with the operation.Conclusion
Permacol™ paste is was shown to be effective in treating primary and recurrent cryptoglandular anorectal fistula with minimal unwanted side effects.This article is protected by copyright. All rights reserved.
The aim of the study was to evaluate the impact of 3-dimensional endoanal ultrasound (3D-EAUS) on postoperative outcome in patients with anal fistula.
This prospective study compared clinical and functional outcomes of patients with and without preoperative 3D-EAUS examination one year after anal fistula surgery. Patients were prospectively followed and evaluated by a standardized protocol including physical examination, the Wexner Incontinence Score (WIS), and anorectal manometry, at baseline and one year after surgery.
A total of 196 patients were enrolled. There were no significant differences in demographic and operative parameters, except for operation time, between the two groups. At one year follow-up, the overall recurrence rates were 8.8% (9/102) in the 3D-EAUS group and 13.8% (13/94) in the examination under anesthesia (EUA) group. In the subgroup of patients with complex fistulae, the recurrence rate was numerically lower in the 3D-EAUS group (12.8% versus 22.5%; p=0.26). The WIS in the EUA group significantly worsened (0.35±0.94 versus 1.07±1.59; p=0.003) with a decreased the number of fully continent patients (82.5% versus 55%; p=0.008) while neither the WIS nor the proportion of fully continent patients in the 3D-EAUS group. Fewer patients in the 3D-EAUS group developed incontinence postoperatively (6.7% versus 33.3%; p=0.012) and they had better maximum resting pressure (MRP) and maximum squeeze pressure (MSP) than that in the EUA group.
Preoperative use of 3D-EAUS had a favorable impact on the outcome of surgical treatment for anal fistulas, especially in those with complex anal fistula. It should be routinely used in the clinical setting. This article is protected by copyright. All rights reserved.
This article is protected by copyright. All rights reserved.
The treatment of high transsphincteric fistula is a complex procedure, which may be associated with the risk of recurrence and fecal incontinence. In this study, we used an animal model to compare different types of sphincter-preserving treatments for transsphincteric fistula.
Sixteen female New Zealand rabbits, weighing 2.8-4.8 kg underwent a surgical creation of high transsphincteric fistula. After 6 weeks, magnetic resonance imaging (MRI) was performed in order to confirm fistula formation and measure the fistula diameter. The rabbits were divided into three groups. Group 1 received no plug treatment (control). Autologous dermal graft and acellular dermal matrix were used as a plug in groups 2 and 3, respectively. Five weeks after treatment, fistula tract healing was determined by measuring the largest fistula diameter with MRI. All rabbits were euthanized and the anorectum excised en bloc for histopathological examination.
According to the MRI findings, all groups showed significant healing after the treatment (p < 0.05). The healing rate of fistula diameters after treatment was 40, 66, and 29 % in the control, dermal graft, and acellular dermal matrix groups, respectively. In terms of negative healing parameters such as neutrophil, eosinophil, lymphocyte, and plasmocyte accumulation, dermal graft and acellular dermal matrix groups showed significantly lower results than those in the control group (p < 0.05).
According to MRI and histopathological results, fistula tract curettage and fistula orifice closure improved transsphincteric anal fistula healing. Additionally, in this study, plug treatment favoring autologous dermal graft resulted in better healing.
There is still no clear consensus about surgical treatment of anal fistulas. Fistulotomy or fistulectomy and primary sphincter reconstruction is still regarded with skepticism. The aim of this systematic review was to evaluate the evidence in the literature supporting the use of this technique in the treatment of complex anal fistulas. MEDLINE, EMBASE and Cochrane Library databases were searched for the period between 1985 and 2015. The studies selected were peer-reviewed articles, with no limitations concerning the study cohort size, length of the follow-up or language. Technical notes, commentaries, letters and meeting abstracts were excluded. The major endpoints were the technique adopted, clinical efficacy, changes at anorectal manometry and assessment of quality of life after the procedure. Fourteen reports (666 patients) satisfied the inclusion criteria. The quality of the studies was low. Some differences about the surgical technique emerged; however, after a weighted average duration of follow-up of 28.9 months, the overall success rate was 93.2 %, with a low morbidity rate. The overall postoperative worsening continence rate was 12.4 % (mainly post-defecation soiling). In almost all cases, the anorectal manometry parameters remained unchanged. The quality of life, when evaluated, improved significantly. Fistulotomy or fistulectomy and primary sphincteroplasty could be a therapeutic option for complex anal fistula. Success rates were very high and the risk of postoperative fecal incontinence was lower than after simple fistulotomy. Well-designed trials are needed to support the inclusion of this technique in a treatment algorithm for the management of complex anal fistulas.
Background
No single procedure for high anal fistula delivers a high cure rate while also completely protecting sphincter function. This paper reports our long-term results with the cutting seton for high fistulae and draws comparisons with advancement flap and ligation of intersphincteric fistula track (LIFT) procedures.MethodsA retrospective study of prospectively collected data in consecutive patients undergoing treatment with cutting seton for high cryptoglandular fistulae was carried out. A strict protocol dictated tightening intervals of at least 4 weeks and no muscle division. In 59 patients (male : female = 39:20) followed-up at mean 9.4 years (range 1.7–15.6 years) healing rates, continence (St Mark's score 0–24), patient-perceived overall change in bowel control (−5 to +5), faecal incontinence quality of life (FIQL) and overall patient satisfaction (visual analogue score 0–10) were assessed.ResultsPrimary and secondary healing rates were 93% and 98%. Mean continence score was 4.1, significantly worse in women than men (median 6, range 0–22 versus median 1, range 0–17; P = 0.006). Seventy-eight per cent of patients had normal continence or minor incontinence (score 0–6), 13.5% moderate incontinence (score 7–12) and 8.5% severe incontinence (score >12). Sixty-three per cent of patients had no change or improved patient-perceived overall bowel control. Mean FIQL scores were high and significantly correlated with continence. Median satisfaction score was 9.Conclusion
Cutting seton for high anal fistula achieved healing in 98% with good continence in the majority, particularly in males, and a high level of patient satisfaction. Multicentre prospective studies are needed to adequately compare cutting seton, flap and LIFT procedures.
The ligation of the intersphincteric fistula tract procedure, a sphincter-preserving technique, aims to obtain complete, durable healing, while preserving fecal continence in the treatment of transsphincteric anal fistulas.
This was a systematic review to evaluate the outcomes of the originally described (classic) ligation of the intersphincteric fistula tract procedure and the identified technical variations of the procedure.
PubMed, Web of Science, and the archive of Diseases of the Colon & Rectum were searched with the terms "ligation of intersphincteric fistula" and "ligation of intersphincteric fistula tract."
Original, English-language studies reporting the primary healing rate for each technical variation of the ligation of the intersphincteric fistula tract procedure were included. Studies were excluded when the technique used was unclear or when primary healing rate was reported in a pooled manner including outcomes from multiple technical variations of the ligation of the intersphincteric fistula tract procedure.
Outcomes associated with all of the technical variations of the ligation of the intersphincteric fistula tract procedure were investigated.
The main outcome measured was primary healing rate. Secondary outcome measures included time to healing, changes in continence, and risk factors for failure.
In all, 26 studies met criteria for review, including 1 randomized controlled trial and 25 cohort/case series. Seven technical variations of the ligation of the intersphincteric fistula tract procedure were identified and classified according to the surgical technique. Primary healing rates ranged from 47% to 95%.
The levels of evidence available in the published works are relatively low, as indicated by the Oxford Center for Evidence-Based Medicine evidence levels.
The ligation of the intersphincteric fistula tract procedure is a promising treatment option for transsphincteric fistulas, with reasonable success rates and minimal impact on continence. The true efficacy of the procedure is unknown because of the number of technical variations and the pooled results reported in the literature.
Dear Editor:We would like to comment on the paper by Gauthier and colleagues on OTSC clipping in the treatment of anal fistula. The authors present their experience collected at multiple sites with this new surgical procedure, coming to negative conclusions about its effectiveness. We appreciate the report. Having been the developers of this procedure and in the knowledge of data published by our and other groups about this technique, we however cannot agree with the way Gauthier et al. present their experience.First of all, there is some lack of definition in fundamental terminology. The title of the paper and the conclusions drawn refer to anal fistula. However, 41 % (7/17) of patients had recto-vaginal fistulae, which is a different disease entity concerning etiology, course, and treatment. Success rates of recto-vaginal fistula surgery are significantly lower when compared to anal fistulae: for local closure techniques, including advancement flaps, the literature reports success ra ...
The aim of the present study was to assess a novel autologous cartilage plug technique used to treat anal fistula in ten patients.
All ten patients had undergone at least two prior operations for recurrent fistulas. The plugs were prepared using the patients' own cartilage, which was obtained from either the nose or the ear, diced into pieces, and wrapped with oxidized regenerated cellulose. During the same session, fistula tracts were curetted using cytology brushes, and then, the cartilage plug was inserted into the tract. Routine postoperative examinations were performed at 2, 4, 8, 12, and 24 weeks after surgery. Magnetic resonance imaging was performed before surgery and at 3 and 6 months postoperatively. Relief of symptoms, radiological healing, recurrence, and continence were evaluated.
The ten patients included six males and four females, with a median age of 39 years (range 25-70 years) and a median of three previous fistula operations (range 2-7 operations). Nine patients had cryptoglandular abscess, and one patient had Crohn's disease. The majority of the patients had transsphincteric fistulas with substantial anal sphincter involvement. The cartilage donor site was the nose for one patient and the ear for nine patients. The median follow-up time was 24 months (range 10-32 months). Of the ten patients, nine had fistula treatment without any short-term complications. The fistula failed to heal in one patient. Among the nine patients whose operations were initially successful, two late recurrences were observed.
The cartilage plug seems to be a promising alternative for anal fistula treatment.
Fistula-tract Laser Closure (FiLaC™) is a sphincter-saving technique for the treatment of anal fistulas that has been shown to be successful in the short and middle term. However, the long-term success rate is unknown. This study aimed to report long-term results in performing FiLaC™.
This study was performed as a retrospective observational study. Forty-five patients who underwent FiLaC™ between July 2010 and May 2014 were evaluated. In all cases, FiLaC™ was performed with a diode laser at a wavelength of 1470 nm by means of a radial fiber. Patients and fistula characteristics, previous treatments, healing rates, failures and postoperative incontinence were reviewed.
Median follow-up time was 30 months (range 6-46 months). Thirty-five patients (78 %) had a history of previous surgery for their fistulas. Primary healing was observed in 32 patients (71.1 %), and the median healing time was 5 weeks (range 3-8 weeks). Eleven of the 13 failures (85 %) were early failures (persistent symptoms). No patient reported postoperative incontinence. The best healing rate was observed in patients who had been previously treated with loose seton (19/24, 79 %).
Long-term follow-up after FiLaC™ seems to confirm the favorable short-term success rates reported for this procedure. Although sealing of chronic anal fistulas may be obtained with FiLaC™ in a single treatment, our current strategy consists of placing a loose seton into the fistula tract a few weeks prior to laser treatment. Seton treatment facilitates the following laser procedure and seems to have favorable effects on healing.
Closing the internal opening by a clip ovesco has been recently proposed for healing the fistula tract, but, to date, data on benefit are poorly analyzed. The aim was to report a preliminary multicenter experience.
Retrospective study was undertaken in six different French centers: surgical procedure, immediate complications, and follow-up have been collected.
Nineteen clips were inserted in 17 patients (M/F, 4/13; median age, 42 years [29-54]) who had an anal fistula: 12 (71 %) high fistulas (including 4 rectovaginal fistulas), 5 (29 %) lower fistulas (with 3 rectovaginal fistulas), and 6 (35 %) Crohn's fistulas. Out of 17 patients, 15 had a seton drainage beforehand. The procedure was easy in 8 (47 %) patients and the median operative time was 27.5 min (20-36.5). Postoperative period was painful for 11 (65 %) patients. A clip migration was noted in 11 patients (65 %) after a median follow-up of 10 days (5.5-49.8). Eleven patients (65 %) who failed had reoperation including 10 new drainages within the first month (0.5-5). After a mean follow-up of 4 months (2-7),, closing the tract was observed in 2 patients (12 %) following the first insertion of the clip and in another one after a second insertion.
Treatment of anal fistula by placing a clip on the internal opening is disappointing and deleterious for some patients. A better assessment before dissemination is recommended.
Although interest in sphincter-sparing treatments for anal fistulas is increasing, few large prospective studies of these approaches have been conducted.
The study assessed outcomes after implantation of a synthetic bioabsorbable anal fistula plug.
A prospective, multicenter investigation was performed.
The study was conducted at 11 colon and rectal centers.
Ninety-three patients (71 men; mean age, 47 years) with complex cryptoglandular transsphincteric anal fistulas were enrolled. Exclusion criteria included Crohn's disease, an active infection, a multitract fistula, and an immunocompromised status.
Draining setons were used at the surgeon's discretion. Patients had follow-up evaluations at 1, 3, 6, and 12 months postoperatively.
The primary end point was healing of the fistula, defined as drainage cessation plus closure of the external opening, at 6 and 12 months. Secondary end points were fecal continence, duration of drainage from the fistula, pain, and adverse events during follow-up.
Thirteen patients were lost to follow-up and 21 were withdrawn, primarily to undergo an alternative treatment. The fistula healing rates at 6 and 12 months were 41% (95% CI, 30%-52%; total n = 74) and 49% (95% CI, 38%-61%; total n = 73). Half the patients in whom a previous treatment failed had healing. By 6 months, the mean Wexner score had improved significantly (p = 0.0003). By 12 months, 93% of patients had no or minimal pain. Adverse events included 11 infections/abscesses, 2 new fistulas, and 8 total and 5 partial plug extrusions. The fistula healed in 3 patients with a partial extrusion.
The study was nonrandomized and had relatively high rates of loss to follow-up.
Implantation of a synthetic bioabsorbable fistula plug is a reasonably efficacious treatment for complex transsphincteric anal fistulas, especially given the simplicity and low morbidity of the procedure.
The purpose of this study was to assess primary healing, recurrence and continence after endoanal advancement flap repair (EAFR).
Seventy-seven patients with fistulas-in-ano of different etiologies received endoanal advancement flap repair between 1997 and 2009. This is a prospective, non-randomized, single-centre, single-surgeon study.
Follow-up data was available for 71 patients. 47.9 % had cryptoglandular fistulas. In 40.8 %, the fistulas were due to chronic inflammatory bowel disease. In 11.3 %, the fistula was a consequence of treatment for cancer. Primary healing was observed in 41 of the cases (57.7 %). The median time to recurrence was 27 months (mean 43.43 ± 48.11) and differed significantly across the patient groups: cryptoglandular origin 51 months (mean 57.09 ± 52.57), condition after cancer treatment 43 months (mean 31 ± 23.142), inflammatory bowel disease 11 months (mean 23.65 ± 32.47) (p < 0.01). Preoperatively, 31 (44.3 %) of the patients had impaired continence vs 30 (42.9 %) postoperatively. Overall, postoperative mean Cleveland Clinic incontinence score values improved significantly (preoperative 3.74 ± 4.558 vs postoperative 2.68 ± 4.752, p = 0.03).
Full-thickness endoanal advancement flap repair is a successful treatment option for a range of fistula etiologies. Overall, fistula aetiology proved to be prognostically more relevant than fistula location. Fistulas associated with chronic inflammatory bowel disease were found to have a significantly higher rate of recurrence and shorter time to recurrence at long-term follow-up. Repeat interventions do not negatively impact postoperative continence.
Minimally invasive anal fistula treatment (MAFT) was introduced to minimize early postoperative morbidity, preserve sphincter continence, and reduce recurrence. We report our early experience with MAFT in 416 patients. Preoperative MRI was performed in 150 patients initially and subsequently thereafter. The technique involves fistuloscope-aided localization of internal fistula opening, examination and fulguration of all fistula tracks, and secure stapled closure of internal fistula opening within anal canal/rectum. MAFT was performed as day-care procedure in 391 patients (93.9 %). During surgery, internal fistula opening could not be located in 100 patients (24 %). Seven patients required readmission to hospital. Mean visual analog scale scores for pain on discharge and at 1 week were 3.1 (1–6) and 1.6 (0–3), respectively. Mean duration for return to normal activity was 3.2 days (2–11 days). Fistula recurrence was observed in 35/134 patients (26.1 %) at 1 year follow-up. MAFT may be performed as day-care procedure with benefits of less pain, absence of perianal wounds, faster recovery, and preservation of sphincter continence. However, long-term results from more centers are needed especially for recurrence.
Transanal advancement flap is a recognized technique for complex fistula. Management of the tract is open to discussion. Excision of the tract by the "core out" technique is difficult and could increase the risk of sphincter damage. Curettage is easier but it could increase the risk of recurrence. The aim of the present study was to assess the effect of both techniques on sphincter function and to study the clinical results.
This is a retrospective analysis from a prospective database. One hundred nineteen consecutive patients with high cryptoglandular anal fistula were included. "Core out" technique was performed in 78 patients (group I) and "curettage" in 41 (group II). In both, a full-thickness rectal flap was advanced over the closed internal defect. Anorectal manometry was performed to assess sphincter function. Continence was assessed using the Wexner Scale. Recurrence was defined as the presence of an abscess or fistulization.
Manometric results showed a significant decrease in the maximum resting pressure after surgery in both groups. The maximum squeeze pressure was significantly reduced only in group I (p < 0.001). No significant changes in Wexner score were observed. The overall recurrence rate was 5.88 %, five of group I (6.4 %) and two of group II (4.9 %), without statistical significance (p = 0.74).
The core-out technique causes a significant decrease in squeeze pressures, which reflects damage to the external anal sphincter. This could lead to incontinence in high-risk patients. Curettage is a simple technique that preserves the values of squeeze pressures without increasing recurrence rates.
Successful treatment for fistula in ano has eluded most surgeons. To choose the right surgery has been made more difficult, with new surgeries being added in the last decade. This article discusses the various accepted surgeries for fistula in ano - their pros & cons, & attempts to provide the status of the various procedures as it stands today.
Background:
The management of high anal fistula is often complicated and challenging. In spite of numerous new techniques, the advancement flap technique remained an integral procedure in its management. The purpose of this study was to determine the long-term outcome of advancement flap procedures for high anal fistulas.
Methods:
A retrospective review of patients who have undergone an advancement flap procedure for high anal fistula of cryptoglandular origin from June 2003 to April 2012 was performed. Patients were contacted via telephone to evaluate their continence status using the Wexner score.
Results:
Sixty-one patients with a median age of 48 (range, 19-74) years and a median follow-up of 6.5 (range, 1-59) months were evaluated. Fifty-three (86.9 %) patients had successful surgery while 8 (13.1 %) failed the procedure. Four of them underwent subsequent surgery. Of the 53 patients who had a successful procedure, 27 were successfully contacted for a telephone interview. Twenty-one (77.8 %) of them reported a Wexner score of '0'. Two (7.4 %) patients had a Wexner score of <4, another 2 had a score of '4' and '10', while the last 2 patients had a score of >10.
Conclusion:
Advancement flap procedure is effective in the management of high anal fistulas with an acceptable success rate. The majority of the patients experienced good anal continence.
Anal fistula is a common proctological problem to both patient and physician throughout surgical history. Several surgical and sphincter-sparing approaches have been described for the management of fistula-in-ano, aimed to minimize the recurrence and to preserve the continence. We aimed to systematically review the available studies relating to the surgical management of anal fistulas.
A Medline search was performed using the PubMed, Ovid, Embase, and Cochrane databases to identify articles reporting on fistula-in-ano management, aimed to find out the current techniques available, the new technologies, and their effectiveness in order to delineate a gold standard treatment algorithm.
The management of low anal fistulas is usually straightforward, given that fistulotomy is quite effective, and if the fistula has been properly evaluated, continence disturbance is minimal. On the contrary, high complex fistulas are challenging, because cure and continence are directly competing priorities.
Conventional fistula surgery techniques have their place, but new technologies such as fibrin glues, dermal collagen injection, the anal fistula plugs, and stem cell injection offer alternative approaches whose long-term efficacy needs to be further clarified in large long-term randomized trials.
AimThe study aimed to compare the rate of success and cost of anal fistula plug (AFP) insertion and endorectal advancement flap (ERAF) for anal fistula.Method
Patients receiving an AFP or ERAF for a complex single fistula tract, defined as involving more than one third of the longitudinal length of of the anal sphincter were registered in a prospective database. A regression analysis was performed of factors predicting recurrence and contributing to cost.Results71 patients (AFP 31; ERAF 40) were analyzed. Twelve (39%) recurrences occurred in the AFP and 17 (43%) in the ERAF-group (p=1.00). The median length of stay was 1.23 days and 2.0 days (p<0.001) and the mean cost of treatment was €5439 ± €2629 and €7957 ± €5905 (p=0.021). On multivariable analysis, postoperative complications, underlying inflammatory bowel disease and fistula recurring after previous treatment were independent predictors of de-novo recurrence. It also showed that length of hospital stay ≤ 1 day to be the most significant independent contributor to lower cost (p=0.023).ConclusionAFP and ERAF were equally effective in treating fistula-in-ano, but AFP has a mean cost saving of €2518 per procedure compared with ERAF. The higher cost for ERAF is due to a longer median length of stay.This article is protected by copyright. All rights reserved.
Perianal fistulas, and specifically high perianal fistulas, remain a surgical treatment challenge. Many techniques have, and still are, being developed to improve outcome after surgery. A systematic review and meta-analysis was performed for surgical treatments for high cryptoglandular perianal fistulas.
Medline (Pubmed, Ovid), Embase and The Cochrane Library databases were searched for relevant randomized controlled trials on surgical treatments for high cryptoglandular perianal fistulas. Two independent reviewers selected articles for inclusion based on title, abstract and outcomes described. The main outcome measurement was the recurrence/healing rate. Secondary outcomes were continence status, quality of life and complications.
The number of randomized trials available was low. Fourteen studies could be included in the review. A meta-analysis could only be performed for the mucosa advancement flap versus the fistula plug, and did not show a result in favour of either technique in recurrence or complication rate. The mucosa advancement flap was the most investigated technique, but did not show an advantage over any other technique. Other techniques identified in randomized studies were seton treatment, medicated seton treatment, fibrin glue, autologous stem cells, island flap anoplasty, rectal wall advancement flap, ligation of intersphincteric fistula tract, sphincter reconstruction, sphincter-preserving seton and techniques combined with antibiotics. None of these techniques seem superior to each other.
The best surgical treatment for high cryptoglandular perianal fistulas could not be identified. More randomized controlled trials are needed to find the best treatment. The mucosa advancement flap is the most investigated technique available.
Ligation of intersphincteric fistula tract (LIFT) is a relatively new technique in the treatment of complex anorectal fistulas. As it spares the anal sphincter, rates of post-operative incontinence may be lower when compared to conventional treatment. To date, there have not been enough reports of long-term fistula recurrence rates. We performed a long-term follow-up study of 75 patients who underwent LIFT following seton drainage and partial fistulotomy.
Only patients with complex cryptogenic anorectal fistulas were included. After seton insertion and partial fistulotomy, the tract was reviewed at 4 months for the absence of anorectal sepsis. Patients then underwent LIFT in a day surgery setting. Operative time, complications, recurrences and incontinence were evaluated.
Between May 2008 and June 2013, 75 patients [51 men, mean age 49.5 years, standard error of the mean (SEM) 1.4 years] were treated with a LIFT protocol. The mean operating time for LIFT was 13.2 min (SEM 1.5 min). Complications included minor bleeding, superficial wound dehiscence and perianal pain. At a mean follow-up of 14.6 months (SEM 1.7 months), there were nine (12 %) recurrences, diagnosed at a mean 9.2 months (SEM 2.7 months). They were treated with seton insertion followed by LIFT with biomesh or anorectal advancement flap, and there were no subsequent recurrences. Review of preoperative and post-operative continence scores revealed only one (1.3 %) patient with minor incontinence following LIFT. Recurrences were significantly related to fistulas with multiple tracts (p < 0.001).
Our results suggest that the protocol of seton insertion and partial fistulotomy followed by LIFT is associated with a low recurrence rate comparing well with published results from studies involving other techniques and protocols for treating anal fistula.
AimThe aetiology of Crohn's disease-related anal fistula remains obscure. Microbiological, genetic and immunological factors are thought to play a role but are not well understood. The microbiota within anal fistula tracts has never been examined using molecular techniques. The present study aimed to characterise the microbiota in the tracts of patients with Crohn's and idiopathic anal fistula. .Method
Samples from the fistula tract and rectum of patients with Crohn's and idiopathic anal fistula were analysed using fluorescent in situ hybridisation, Gram staining and scanning electron microscopy were performed to identify and quantify the bacteria present.ResultsFifty-one patients including 20 with Crohn's anal fistula, 18 with idiopathic anal fistula and 13 with luminal Crohn's disease and no anal fistula were recruited. Bacteria were not found in close association with the luminal surface of any of the anal fistula tracts.Conclusion
Anal fistula tracts generally do not harbour high levels of mucosa-associated microbiota. Crohn's anal fistulas do not seem to harbour specific bacteria. Alternative explanations for the persistence of anal fistula are needed.This article is protected by copyright. All rights reserved.