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Cryptoglandular Anal Fistulas

Authors:
  • End- und Dickdarm-Zentrum Essen

Abstract and Figures

Cryptoglandular anal fistula arises in 2 per 10 000 persons per year and is most common in young men. Improper treatment can result in fecal incontinence and thus in impaired quality of life. This S3 guideline is based on a systematic review of the pertinent literature. The level of evidence for treatment is low, because relevant randomized trials are scarce. Anal fistulae are classified according to the relation of the fistula channel to the sphincter. The indication for treatment is established by the clinical history and physical examination. During surgery, the fistula should be probed and/or dyed. Endo-anal ultrasonography and magnetic resonance imaging are of roughly the same diagnostic value and may be useful as additional studies for complex fistulae. Surgical treatment is with one of the following operations: laying open, seton drainage, plastic surgical reconstruction with suturing of the sphincter, and occlusion with biomaterials. Only superficial fistulae should be laid open. The risk of postoperative incontinence is directly related to the thickness of sphincter muscle that is divided. All high anal fistulae should be treated with a sphincter-saving procedure. The various plastic surgical reconstructive procedures all yield roughly the same results. Occlusion with biomaterials yields a lower cure rate. This is the first German S3 guideline for the treatment of cryptoglandular anal fistula. It includes recommendations for the diagnostic evaluation and treatment of this clinical entity.
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MEDICINE
CLINICAL PRACTICE GUIDELINE
Cryptoglandular Anal Fistulas
Andreas Ommer, Alexander Herold, Eugen Berg,
Alois Fürst, Marco Sailer, Thomas Schiedeck
SUMMARY
Background: Cryptoglandular anal fistula arises in 2 per
10 000 persons per year and is most common in young
men. Improper treatment can result in fecal incontinence
and thus in impaired quality of life.
Method: This S3 guideline is based on a systematic
review of the pertinent literature.
Results: The level of evidence for treatment is low, be-
cause relevant randomized trials are scarce. Anal fistulae
are classified according to the relation of the fistula
channel to the sphincter. The indication for treatment is
established by the clinical history and physical exami -
nation. During surgery, the fistula should be probed and/
or dyed. Endo-anal ultrasonography and magnetic reso -
nance imaging are of roughly the same diagnostic value
and may be useful as additional studies for complex
fistulae. Surgical treatment is with one of the following
operations: laying open, seton drainage, plastic surgical
reconstruction with suturing of the sphincter, and occlu-
sion with biomaterials. Only superficial fistulae should
be laid open. The risk of postoperative incontinence is
directly related to the thickness of sphincter muscle that
is divided. All high anal fistulae should be treated with a
sphincter-saving procedure. The various plastic surgical
reconstructive procedures all yield roughly the same
results. Occlusion with biomaterials yields a lower cure
rate.
Conclusion: This is the first German S3 guideline for the
treatment of cryptoglandular anal fistula. It includes
recommendations for the diagnostic evaluation and
treatment of this clinical entity.
Cite this as:
Ommer A, Herold A, Berg E, Fürst A, Sailer M, Schiedeck T:
Clinical practice guideline: Cryptoglandular anal fistula.
Dtsch Arztebl Int 2011; 108(42): 707–13.
DOI: 10.3238/arztebl.2011.0707
W
ith an incidence of around 2 per 10 000 head of
population per year, anal fistula is a frequent
condition with a peak incidence between 30 and 50
years of age (1). Men are affected more often than
women (2).
Method
The content of the present guideline is based on an ex-
tensive review of the literature (Figure 1). Definitions
of evidence level, recommendation grade, and consen-
sus strength were established (e1, e2) (Table 1, 2). The
text was agreed by the guideline group (Box 1) at two
consensus conferences.
Classification
Cryptoglandular anal fistulas arise from an inflam-
mation of the proctodeal glands, which in humans are
only rudimentary, and are situated in the intersphinc-
teric space (e3). A communication forms between an
opening at the level of the dentate line and one in the
perianal region.
In clinical routine, classification according to the re-
lationship to the sphincter has proved useful (3) (Figure
2). Types 4 and 5 are not cryptoglandular fistulas.
In clinical routine, intersphincteric and distal trans-
sphincteric fistulas are called low fistulas and proximal
trans-sphincteric and suprasphincteric fistulas are
called high fistulas. The most frequently encountered
are uncomplicated distal fistula tracts (e4) (evidence
level: 4; recommendation grade: 0; consensus strength:
strong consensus).
Symptoms and diagnosis
The typical symptom of anal fistula is discharge from a
perianal opening.
Digital examination and probing are sufficient for
diagnosis (4).
The tract of the fistula and its relationship to the
sphincter muscle can be investigated by probing and/or
dyeing intraoperatively with the patient under
anesthesia (5, e5).
If the history suggests it, chronic inflammatory
bowel disease should be ruled out perioperatively.
Sphincter function should be assessed before any oper-
ative intervention, on the basis of the history and, if
appropriate, an incontinence score (evidence level: 4;
recommendation grade: B; consensus strength: strong
consensus).
End- und Dickdarmpraxis Essen: Dr. med. Ommer
End- und Dickdarmzentrum Mannheim: Prof. Dr. med. Herold
Prosper Hospital Recklinghausen: Dr. med. Berg
Caritas Krankenhaus Regensburg: Prof. Dr. med. Fürst
Bethesda-Krankenhaus Hamburg: Prof. Dr. med. Sailer
Klinikum Ludwigsburg: Prof. Dr. med. Schiedeck
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In cases of complex recurring anal fistulas the use of
imaging techniques should be considered (6, e6).
Because of the radiation burden, visualization of
fistulas using contrast media (e7) and computed
tomography (CT) is regarded as obsolete.
A simple and cheap technique available is endoso-
nography, the usefulness of which can be improved by
contrast enhancement, e.g., using hydrogen peroxide.
The correlation between intra-anal ultrasonography and
intraoperative clinical examination is better than 90%
(6, e8–e10). The advantage of endosonography is that it
is easy and cheap to use, but it does depend to a high
degree on the examiner’s experience.
Magnetic resonance imaging (MRI) can be
employed either as an external investigation with or
without contrast medium, or using an intrarectal coil (7,
e11). MRI is cost-intensive, not always available, and
its diagnostic value depends on technical conditions;
however, it is to be preferred to endosonography for
lesions distant from the anus. Other advantages of MRI
are that it allows pain-free acquisition of images that
can be evaluated independently of the examiner (evi-
dence level: 1a; recommendation grade: A; consensus
strength: strong consensus).
Therapeutic procedures
A diagnosis of anal fistula is usually an indication for
surgery in order to prevent a recurring septic process.
The choice of operative technique is governed by the
fistula tract and its relation to the anal sphincter. The
literature on treating anal fistulas has been covered in
several reviews (8–10) and a Cochrane analysis (11).
Unfortunately a total of only 10 randomized studies
have been carried out, each of which compared only
partial aspects of treatment for fistula. The other studies
are observational studies from various hospitals with
inhomogeneous patient groups. Because of this, the
conclusions of the reviews are mostly of a general nature.
Published guidelines of other professional organiz-
ations (12, 13) are partly out of date, since for example
the plug technique is not included.
To produce the present guideline, the available
literature was analyzed afresh and the results set out in
evidence tables. These may be accessed via the Internet at
www.awmf.org/uploads/tx_szleitlinien/088–003l_S3_
Kryptoglanduläre_Analfisteln_2011_10.pdf (German-
language publication).
Fistulotomy
The most common operative technique in use is fistu-
lotomy, that is, division of the tissue between the fistula
tract and the anal canal. Twenty-eight studies, most of
them retrospective, that dealt with this treatment were
identified. Healing rates are between 74% and 100%.
Rates of impaired continence vary between 0 and 45%
(14–16, e12–e18). For low fistulas, a healing rate of
almost 100% can be achieved. Postoperative inconti-
nence rates are described in the literature as relatively
low, but this is still a sequela to be taken seriously. In all
cases the incontinence rate rises with the amount of
sphincter that is divided. Extensive division should al-
ways be avoided (evidence level: 2b; recommendation
grade: B; consensus strength: strong consensus).
Seton drainage
Placement of a seton drain is another frequently em-
ployed technique in anal fistula surgery. The material
used is either a strong braided non-resorbable suture or
a plastic (vessel-loop etc.) suture thread. Three differ-
ent techniques are in use:
Drainage seton (loose seton)
The aim of this technique is long-term drainage of the
abscess cavity. This helps to prevent premature closure
of the external fistula opening. The thread is removed
later to allow spontaneous healing of the fistula. Heal-
ing rates in the retrospective observational studies
identified vary between 33% and 100%. Impaired
continence is reported in 0 to 62% of cases (12, 17,
e19–e22). These data are due to the fact that interven-
tions undertaken in addition to placement of the seton
are not always clearly defined. To date, no randomized
studies exist on this subject.
Definitive healing of cryptoglandular anal fistulas,
even in the long term by leaving a loose seton in place,
PubMed literature search
“anal fistula” or “fistula in ano”
n = 5997 (date 23 February 2011)
Exclusions
Works published before 1960 (n = 248)
“Crohn” (n = 883), “cancer” (n = 556),
“irradiation” (n = 69), “pouch” (n = 177),
“infant” (n = 751), “rectourethral” (n = 100),
“rectovaginal” (n = 704), “imperforate” (n = 62)
n=2447
n=755
n=324
Exclusion of all publications whose title indicated that
they were not relevant to the content of the guideline
Exclusion of all publications whose abstract indicated
that they were not relevant to the content of the guideline
FIGURE 1
Flow chart of literature review
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can be the goal only in extremely rare cases. Usually,
further intervention is required.
Fibrosing seton
Placement of a fibrosing seton usually occurs either
primarily or secondarily in the setting of an acute or
persistent inflammation.
The aim is to fibrose the fistula tract before further
surgical interventions. Most often described in the
literature is secondary lay open of remaining fistula.
The observational studies identified in the literature
search report healing rates of nearly 100% (e12,
e23–e25). However, this is associated with a high rate
of impaired continence. Overall, the data in the litera-
ture vary between 0 and 70%.
In Germany, the fibrosing seton is used mainly in
high fistulas before definitive reconstruction surgery.
Whether the use of the seton promotes success of a
reconstructive procedure is not clear.
Cutting seton
The aim of the cutting seton is successive division of
the parts of the sphincter enclosed by the fistula tract
once the inflamed area has been cored out. The seton
may be made of various materials. Either it is stretch -
able (usually rubber) and will gradually cut through the
tissue, or repeated tightening will be required.
So-called chemical or medicated setons are a particular
case; the principle is loose placement of a thread (ksha-
rasootra), as used in ayurvedic therapy. This thread
must be changed every week. The aim of treatment is
spontaneous loss of the thread after chemical division
of the fistular tissue (17).
Thirty-five observational studies were identified,
most of them retrospective, which showed a mixed pa-
tient group including almost all types of fistula. Heal-
ing rates were reported between 80% and 100% (e13,
e15, e21, e26–e31). Reported rates of impaired conti-
nence were between 0 and 92%.
Recent reviews (18, e32) point to an unacceptably
high incontinence rate after use of the cutting seton. In
view of the current literature, the recommendation for
this method as seen in other guidelines (12, 13) should
not be continued.
In the authors’ opinion, the most important function
of seton drainage is in preparation for subsequent
definitive treatment of high anal fistulas demonstrated
during abscess drainage (evidence level: 2a; recom-
mendation grade: B; consensus strength: strong
consensus).
Closure by surgical reconstruction
The aim of the various procedures is excision of the
fistula and the cryptoglandular focus of infection with
closure of the inner fistula cavity. Five different
techniques are used:
Direct suture without advancement flap
In some studies the internal fistula cavity was not
covered up after direct suturing of the sphincter muscle;
reported healing rates were between 56% and 100%
(e33, e34).
Mucosal/submucosal advancement flap
Alternatively, the sphincter sutures can be protected by
being covered with an advancement flap. This flap can
be formed from mucosa, submucosa and superficial
parts of the internal muscle (mucosal/submucosal flap.
The 30 studies identified showed healing rates between
12% and 100% (15, e34–e45).
Rectal advancement flap
Alternatively, a rectal full thickness advancement flap
may be used to cover the sutures. The results of the 17
studies identified are largely similar to those using the
mucosal/submucosal flap, with healing rates between
33% and 100% and incontinence rates between 0 and
71% (19, e34, e39, e46–e49). Four randomized studies
have been published (19, e48–e50).
A comparison between rectal full thickness advance-
ment flap and fistula excision with primary reconstruc-
tion of the sphincter showed similar results in terms of
healing and continence. Two other studies which ran -
domized patients to receive either rectal advancement
flap or an anal fistula plug showed significantly higher
healing rates for the advancement flap but at the same
time a higher risk of impaired continence.
Anodermal advancement flap
Another option to cover the inner fistula cavity is an
anodermal or anoderm flap. This uses an advancement
flap made of anodermal tissue. The anodermal flap can
be especially advantageous in patients with a narrow
anal canal (e.g., scar tissue from previous operations)
TABLE 1
Definition of evidence levels and recommendation grades*
1
*
1
Adapted from the Centre for Evidence-Based Medicine, Oxford
Recommendation
grade
A („should“)
B („ought to“)
0 („may“)
0 („may“)
0 („may“)
Evidence
level
1a
1b
1c
2a
2b
3a
3b
4
5
Types of treatment studies
Systematic review of randomized controlled
studies (RCTs)
Individual, well-designed RCT
All-or-none principle
Systematic review of well-designed cohort
studies
Individual cohort study (including low quality
RCT; e.g., <80% follow-up)
Systematic review of well-designed case-
control studies
Individual, well-designed case-control study
Case series, or poor-quality cohort and
case-control studies
Expert opinion without explicit critical
apprais al, or based on physiology, bench
research or “first principles”
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that might prevent complete exploration and proximal
flap formation. Healing rates in the 10 observational
studies identified vary between 46% and 95%, while
impaired continence rates range from 0 to 30% (e34,
e51–e54).
Fistula excision with direct sphincter reconstruction
In fistula excision with primary reconstruction of the
sphincter muscle, after complete excision of the fistula
and its associated inflammatory tissue, primary readap-
tation of the divided sphincter apparatus is carried out.
The eight studies identified mostly treated high fistulas.
Healing rates between 54% and 97% were reported;
rates of impaired continence were noted to be 4% to
32% (e55–e58). Especially in patients with high fistu-
las, wound dehiscence after division and reconstruction
is associated with a high risk of incontinence. Overall
the data for this technique are still relatively few and
the role of reconstruction of even small sphincter
defects is at present unclear.
To sum up, surgical reconstruction is an established
technique with healing rates between 60% and 80%,
and there is no meaningful difference between the vari-
ous procedures. Reported rates of impaired continence
vary, and the risk of impaired continence must be
explained to the patient before informed consent to sur-
gery can be given (evidence level: 1b; recommendation
grade: A; consensus strength: strong consensus).
Biomaterials
Fibrin glue
After curettage of the fistula tract, the tract is filled with
fibrin glue. Results in the literature show healing rates
that vary widely between 0 and 100%. Only eight
studies give information about continence and report
having observed no impairment. The majority of these
studies are personal case series involving inhomoge -
neous patients with a wide variety of fistula types (e31,
e59–e65).
The three review articles identified in the literature
search (e66–e68) confirm the great heterogeneity of the
studies, especially since the good results reported in the
TABLE 2
Definition of consensus strengths
Consensus
Strong consensus
Consensus
Majority agreement
No consensus
Definition
More than 95% of participants
agree
75% to 95% of participants
agree
50% to 75% of participants
agree
Less than 50% of particpants
agree
BOX 1
Guideline group
For the German Society for General and Visceral
Surgery (DGAV, Deutsche Gesellschaft für Allge-
mein- und Viszeralchirurgie)
Dr. Andreas Ommer, Essen
Prof. Alexander Herold, Mannheim
Dr. Eugen Berg, Recklinghausen
Dr. Stefan Farke, Berlin
Prof. Alois Fürst, Regensburg
Dr. Franc Hetzer, Schaffhausen, Switzerland
Dr. Andreas Köhler, Duisburg
Prof. Stefan Post, Mannheim
Dr. Reinhard Ruppert, Munich
Prof. Marco Sailer, Hamburg
Prof. Thomas Schiedeck, Ludwigsburg
Dr. Bernhard Strittmatter, Freiburg
In addition to the DCAV, the following surgical professional
bodies participated in the development of this guideline:
the Surgical Working Group for Coloproctology (CACP,
Arbeitsgemeinschaft für Coloproktologie), the German
Coloproctology Society (DGK, Deutsche Gesellschaft für
Koloproktologie), and the Association of Coloproctologists
in Germany (BCD, Berufsverband der Coloproktologen
Deutschlands).
For the German Dermatological Society
Dr. Bernhard H. Lenhard, Heidelberg
For the Working Group on Urogynecology and
Surgical Reconstruction of the Pelvic Floor (AGUB,
Arbeitsgemeinschaft für Urogynäkologie und plas-
tische Beckenbodenrekonstruktion) of the German
Society of Gynecology and Obstetrics (Deutsche
Gesellschaft für Gynäkologie und Geburtshilfe)
Prof. Werner Bader, Hannover
For the German Society of Urology
Prof. Jürgen E. Gschwend, Munich
For the German Society of Digestive and Metabolic
Diseases
Prof. Heiner Krammer, Mannheim
Prof. Eduard F. Stange, Stuttgart
Complete guideline text in German
www.awmf.org/uploads/tx_szleitlinien/088–003l_S3_Kryp
toglanduläre_Analfisteln_2011_10.pdf
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earlier studies could not be reproduced in the more re-
cent ones. In the view of the guideline working group,
therefore, the use of fibrin glue should be reserved for
special cases (evidence level: 1b; recommendation
grade: B; consensus strength: strong consensus).
Anal fistula plug
The anal fistula plug is a biomedical product made of
porcine small-intestinal submucosa. Unlike the “con-
ventional” procedures, with this technique the inflam-
matory tissue is not excised, but merely occluded with
the cone-shaped plug, which acts as a matrix for the
body’s own tissue to grow into.
Some authors combine plugging with closing of the
internal fistula cavity using an advancement flap. The
published observational studies show healing rates
between 14% and 93%. Most of them did not investi-
gate continence impairment. Only three studies report
unchanged continence (19, 20, e69–e75).
The two randomized studies that compared plugging
with surgical closure found markedly lower healing
rates with plugging. One study (19) was stopped early
because of an unacceptably high rate of recurrence. It
appears to be important that the fistula tract is long
enough (20).
One review (21) found success rates to vary between
24% and 92%. The rate of recurrent abscess after fistula
plugging was 4% to 29%, and the frequency of plug
loss was 4% to 41%. A notable feature is the low mor-
bidity of the procedure. Any effect of plugging on
continence is expected to be negligible.
To sum up, plugging has added a new option for the
treatment of high anal fistula (evidence level: 1b;
recommendation grade: B; consensus strength: strong
consensus).
Other techniques
A variety of other techniques have been described in
the literature only in the form of case reports from indi-
vidual working groups: radiofrequency ablation, sta -
pling, autologous stem cells, collagen injection, Bio-
LIFT, LIFT (ligation of the intersphincteric fistula
tract) (evidence level: 5; recommendation grade: 0;
consensus strength: consensus).
Perioperative management
Postoperative care after anal surgery is unproblematic.
The external wound heals by secondary intention and
should be regularly cleaned by showering.
In anal fistulotomy or seton drainage, no special
bowel preparation or postoperative treatment is
required. Whether preoperative bowel cleansing and/or
delaying the passing of stool after the operation
influences healing rates after reconstructive surgery, or
whether antibiotic therapy does, is currently unclear
despite recent studies (22, e76). Smoking appears to
have a negative influence on results (23, e54). Stoma
placement is indicated only in exceptional cases (evi-
dence level: 5; recommendation grade: 0; consensus
strength: consensus).
Complications
Perioperative complications
Complications after anal fistula interventions are basi-
cally no different from those after other anal interven-
tions (the main ones are urinary retention and postoper-
ative bleeding). With surgical fistula reconstruction,
rates of local infection are between 5% and 20% (e77,
e78). In most cases, wound dehiscence is associated
with persistence of the fistula.
Impaired continence after anal fistula operations
Impairment of continence is a frequent complication
after anal fistula operations. The causes are usually
multifactorial, with sphincter lesions to the fore. The
risk of postoperative continence impairment rises with
the amount of sphincter that has been divided. The
degree of impairment varies greatly and depends to a
large extent on pre-existing injury. Its effect on the
patient also relates to subjective experience.
In the literature, impaired continence rates are
reported as 10% in low fistulas and 50% in high fistulas
(24, e78).
Against this background, it is important to give the
patient comprehensive information. The sphincter
apparatus must be spared as much as possible (evidence
level: 1c; recommendation grade: A; consensus
strength: strong consensus).
FIGURE 2 Classification of
anal fistulas
1. Intersphincteric
2. Trans-sphincteric
3. Suprasphincteric
4. Extrasphincteric
5. Subanodermal
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Malignant transformation
It is rare, but possible, for a malignant tumor to develop
in a chronic anal fistula. The literature provides various
case reports of advanced tumor stages (25). For this
reason, histological analysis of the resected specimen is
recommended (evidence level: 5; recommendation
grade: 0; consensus strength: strong consensus).
Conflict of interest statement
Dr. Ommer has received honoraria from the DGAV for developing four guidelines
on the subject of anal fistulas. He has also had travel and accommodation
expenses reimbursed by Gore and by Johnson & Johnson. He has received
fees from Kade and from MSD for lectures given at continuing medical
education events.
Professor Herold has received financial support for conferences from the Falk
Foundation, Johnson & Johnson, Prostrakan, MSD, and Aesculap. Other
projects received third-party support from Cook, Gore, SLA-Pharma, the Falk
Foundation, and Kreussler.
Dr. Berg has had attendance fees at conferences and travel and accommodation
expenses reimbursed by Johnson & Johnson. He has received fees from the
Falk Foundation and Johnson & Johnson for the preparation of continuing
medical education events.
Professor Fürst has received support for travel to conferences from Johnson &
Johnson and from Braun-Aesculap, and fees for carrying out commissioned
clinical studies from Bayern Innovativ GmbH.
Professor Sailer has received fees for continuing medical education events
from Covidien, Johnson & Johnson, the Falk Foundation, and Hitachi Medical.
Professor Schiedeck has had attendance fees and travel and accommodation
expenses reimbursed, and fees for preparation of scientific continuing
education events, from Aesculap Akademie GmbH, Falk Foundation e.V.,
Johnson & Johnson, and Medical GmbH. He has received fees for carrying out
commissioned clinical studies from Solesta and Medela.
Manuscript received on 12 July 2011, revised version accepted on
21 July 2011.
Translated from the original German by Kersti Wagstaff MA.
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fistula plug in fistula-in-ano: A systematic review. Colorectal Dis
2010; 12: 965–70.
KEY MESSAGES
Cryptoglandular anal fistulas are frequent (2/10 000 head of population) and
show a peak incidence in young male adults. Anal fistulas are classified by
their relationship of the fistula tract with the anal sphincter.
History, clinical examination, and intraoperative probing and/or dyeing of the
fistula tract suffice for diagnosis. Endosonography and magnetic resonance
imaging are possible additional investigations for complex fistulas or those that
are difficult to classify clinically, and for abscesses (evidence level: 1a; recom-
mendation grade: A).
Treatment for anal fistula is basically surgical. Fistulotomy should only be per-
formed on superficial fistulas. The risk of postoperative continence impairment
increases with the amount of transected sphincter (evidence level: 2b; recom-
mendation grade: B).
In all high anal fistulas, a sphincter-sparing procedure should be carried out.
The results of the various techniques for surgical reconstruction are largely
identical. In general, occlusion using biomaterials leads to lower healing rates
but also lower incontinence rates (evidence level: 1b; recommendation grade:
A).
Every treatment for anal fistula is associated with the risk of reduced conti-
nence, and this risk rises with the extent of transected sphincter. Contributing
causes, in addition to intentional transection of parts of the sphincter muscle,
include pre-existing injury, previous operations, and other factors (age, sex,
and others) (evidence level: 1c; recommendation grade: A).
712
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MEDICINE
22. Joos AK, Palma P, Jonescheit JO, Hasenberg T, Herold A: Enteral
vs parenteral nutrition in reconstructive anal surgery—a
prospective-randomized trial. Colorectal Dis 2008; 10: 605–9.
23. Zimmerman DD, Gosselink MP, Mitalas LE, et al.: Smoking
impairs rectal mucosal bloodflow—a pilot study: possible impli-
cations for transanal advancement flap repair. Dis Colon Rectum
2005; 48: 1228–32.
24. Ommer A, Wenger FA, Rolfs T, Walz MK: Continence disorders
after anal surgery – a relevant problem? Int J Colorectal Dis
2008; 23: 1023–31.
25. Gaertner WB, Hagerman GF, Finne CO, et al.: Fistula-associated
anal adenocarcinoma: good results with aggressive therapy. Dis
Colon Rectum 2008; 51: 1061–7.
Corresponding author
Dr. med. Andreas Ommer
End- und Dickdarmpraxis Essen
Rüttenscheider Str. 66
45130 Essen, Germany
aommer@online.de
@
For eReferences please refer to:
www.aerzteblatt-international.de/ref4211
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Dtsch Arztebl Int 2011; 108(42): 707–13
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MEDICINE
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Ommer et al.: eReferences
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... In addition, morbidity related to the pain caused by the progressive tightening of the system, numerous visits to the surgeon office and delayed healing are that this technique is less popular with patients. Thus, several authors did not longer recommend this technique systematically [10]. Despite these results and recommendations, cutting seton remains the only method used for the treatment of complex anal fistula in our health facilities in general and Yaoundé Central Hospital in particular. ...
Article
Full-text available
Background High anal fistulas require multiple operations and the use of sphincter sparing techniques. All these are expansive for patients living in developing countries like ours. Thus, the use of cutting seton is the main surgical method practiced here. The objective of this study was to evaluate its clinical outcomes in high anal fistula. Patients and methods We conducted a prospective study of patients undergoing cutting seton fistulotomy for high anal fistula. Preoperative and postoperative evaluation included anamnesis, clinical examination and anuscopy. Fecal continence was assessed using the Pescatori continence score (0 to 6). Results We registered 19 high transsphincteric fistulas and 1 supratrasphincteric fistula. Nine patients reported varying degrees of earlier faecal incontinence. Their mean continence score decreased from 2.8 to 2.1 (p = 0.111). It decreased from 2 to 1.5 (p = 0.495) in the diabetic patients and increased from 2.3 to 3.3 (p = 0.225) in HIV+ patients while in HIV-patients, we noted an amelioration from 1.1 to 0.6 (p = 0.049). There was no difference between pre-and postoperative values of continence in fully continent patients, although 1 patient reported minor alterations of continence (Pescatori score = 2). Healing was achieved in 17 patients with 1 case of recurrence. Conclusion The use of cutting seton in high anal fistula is an effective technique. It improves continence in incontinent patients and respects that of continent patients with a long lasting resolution of the problem of suppuration.
... On further analysis, the modified Parks technique had a higher healing rate than LIFT (95% vs 68%), yet was comparable to the two-stage seton. The healing rate after LIFT in our study (68%) falls within the range of success after LIFT reported by other investigators (65-68%) [25,26]. The healing rate after the modified Parks technique in our study was about 95%, close to that reported in the original study on the technique in which healing was successfully achieved in 93.7% of patients after a median follow-up of 12 months [9]. ...
Article
Complex anal fistula (CAF) is a challenging condition for surgeons. This randomized trial aimed to compare ligation of the intersphincteric fistula tract (LIFT), modified Parks technique, and two-stage seton in the treatment of complex anal fistula in terms of the success of treatment and complications. This was a pilot randomized trial conducted in the period of Janu-ary 2019 to December 2019 on adult patients with CAF who were allocated to one of three groups: LIFT, modified Parks technique, and two-stage seton. The main outcome measures were healing rates, time to healing, complications, operation time, and quality of life. Sixty-six patients (75.7% males) of a mean age of 45.2 years were included. Mean operation time of LIFT was significantly shorter than the other two procedures (p < 0.0001). There was a significant difference between the three groups in terms of success rate (p = 0.04) but not in regard to complications (p = 0.59). The modified Parks technique had a significantly higher success rate than LIFT (95.2% vs 68.1%, p = 0.045) whereas the success rates of two-stage seton and LIFT were not significantly different (86.9% vs 68.1%, p = 0.16). The average time to healing after LIFT was significantly shorter than the other two procedures. The quality-of-life scores were comparable among the three groups. There was a significant difference in healing rates after the three procedures as the modified Parks technique achieved the highest success rate followed by two-stage seton and then the LIFT procedure. Time to complete healing after LIFT was significantly shorter than the other two procedures. The three procedures achieved similar quality of life and complication rates.
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Perianal fistula (PF) is a common inflammatory condition affecting the perianal region including the sphincter muscles, ischioanal fossae, and the perianal skin. It is notorious to recur and, as a result, causes significant morbidity in both urban and rural population. Magnetic resonance imaging (MRI) has revolutionized imaging in PFs as it provides excellent anatomical visualization of the fistulous tracts, their origin, course, number, chronicity, opening in the external and internal anal sphincter, length of sphincter, evidence of active disease and abscess formation along the tract. It is also very useful in presurgical mapping and reduce the chances of recurrence. Most of the studies done on PFs are based on the urban population. Rural population have a completely different lifestyle which makes them susceptible to various diseases, less prevalent in the urban population. Hence, the purpose of this article is to find the prevalence of different grades in North Indian rural region close to the NCR (National Capital Region). In the study including 98 patients, the maximum number of patients were classified into grade 1 and grade 4 by MRI according to St. James' University Hospital MRI classification. This is the second reported study on prevalence of different grades of PFs in rural population in India. The higher prevalence of grade 4 PFs in our study might be secondary to illiteracy, social stigma, poor hygiene, or higher recurrence rate. Closely understanding the difference in dynamics of urban and rural population, our goal of the study is to determine the prevalence of different grades of PFs in the rural population. We also aim to familiarize physicians, radiologists, and surgeons with the MRI evaluation and grading of PF to help in presurgical mapping and thus, reducing the chances of recurrence. We also recommend further studies to evaluate psycho-social factors as a barrier in seeking early medical care in rural population.
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Background Rectovaginal fistulas represent 5% of all anorectal fistulas. For affected women, this pathology is associated with a reduction in quality of life (QoL) and self-esteem. Most commonly used methods of surgical closure have high recurrence rates or permanent perineal complaints, which in turn lead to negative effects on QoL and self-esteem. A fistula closure, using the “de-epithelialized Singapore flap” (SF), can be a good alternative therapy strategy. Method Our retrospective case series processes the long-term results of seven patients who were operated on for ano-/rectovaginal fistula using the SF. All patients underwent surgery at the University Hospital Graz, between May 2012 and July 2015. The data of the surgical follow-up examinations were collected and an additional telephone survey was carried out. The procedure is presented based on a structured description. All procedures were performed jointly by the Department of General Surgery and the Department of Plastic Surgery. Results The average age of the seven patients was 46.14 years (23–72 a). Five patients had a total of 12 previous operations with frustrating results. Of the seven patients treated, six had a permanent fistula closure (85.7%). The results of the telephone survey ( n = 6) showed a high level of patient satisfaction (100%), and an improvement in QoL (83.3%), through our surgical method. In our cohort, neither urinary nor fecal incontinence occurred. Conclusion The treatment of an ano-/rectovaginal fistula using the “de-epithelialized pudendal thigh flap” (Singapore flap) is a promising treatment alternative. In particular, patients who have had previous proctological interventions show a benefit from this procedure.
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Background: Video-assisted anal fistula treatment (VAAFT) has gained increasing acceptance as a sphincter-sparing procedure for treating complex anorectal fistulas (CAF), but no unequivocal conclusions can yet be drawn regarding its ultimate effectiveness. We reviewed the literature and performed a meta-analysis to evaluate the efficacy and safety of VAAFT in CAF patients. Methods: The study protocol was registered with the PROSPERO database (CRD42021279085). A systematic literature search was performed in the PubMed, Embase, and Cochrane Library databases up to June 2021 with no restriction on language based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We used the keywords video-assisted surgery, video-assisted anal fistula treatment, and complex anorectal fistula to identify relevant studies. Results: Fourteen trials (7 prospective and 7 retrospective) with a total of 1201 patients (mean age 43.5 years) were included. The median follow-up duration was 16.5(8-48) months. Pooled analysis showed that the rates of success, recurrence and postoperative complication across the studies were 83% (95% CI 81-85%, I2 = 37.9%), 16% (95% CI 14-18%, I2 = 4.8%), 11% (95% CI 7-15%, I2 = 72.1%), respectively. The postoperative Jorge-Wexner score used to assess the level of anal incontinence was 1.09 (95% CI, 0.9-1.27, I2 = 74.6%). The internal opening detection rate was 97.6% (95% CI 96.1-99.6%, I2 = 48.2%). Recurrence rates varied according to the closure method of internal opening from 21.4% after using staplers, 18.7% after suturing, to 23.5% after advancement flap. The hospital stay was 3.15 days (95% CI 2.96-3.35, I2 = 49.7%). Subgroup analysis indicated that the risk of heterogeneity in the urine retention group was higher compared with that of the overall group and that retrospective studies may be the source of heterogeneity for postoperative anal incontinence. r . Sensitivity analysis confirmed the stability of the pooled results. Begg's and Egger's tests showed no evidence of publication bias. Conclusions: According to the available evidence, VAAFT may be a valuable alternative to fistulotomy or seton in treating CAF and has the additional long-term benefits of reducing anal incontinence and surgical morbidity, permitting earlier healing and accelerated rehabilitation.
Article
Full-text available
Introduction. In the treatment of patients with pararectal fistula, relapses of the disease are quite common, as well as postoperative complications in the form of suppression of a postoperative wound, anal incontinence, etc. The aim of the work is to improve the results of treatment of patients with pararectal fistula by reducing the number of purulent-septic complications in the postoperative period. Materials and methods. Analysis of 105 cases of treatment of patients was carried out. All patients were divided into 2 groups by random sampling: in group I, patients, in addition to standard preoperative training, underwent fistula sanitization with 1% dioxidin solution. In the postoperative period, patients underwent dressings with 5% dioxidin ointment, and also administered per rectum ointment from 1 postoperative day for 7 days. In the second group, standard preoperative training was carried out. All patients of the comparison groups were intraoperatively seeded on the flora from the fistula. Postoperative healing of postoperative wounds, subsidence of local and systemic inflammatory response were evaluated. Results. The results show a statistically significant improvement in treatment outcomes of patients in the major group. Conclusions. Application of two-stage prevention of postoperative complications makes it possible to improve results of treatment of patients with pararectal fistulas due to reduction of amount of pathogenic microflora in area of postoperative wound, faster stopping of local and systemic inflammatory reaction, and also due to increase of number of patients with primary healing postoperative wound.
Article
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.
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Background High perianal fistula treatment remains challenging, mainly due to the variability in success and recurrence rates as well as continence impairment risks. So far, no procedure can be considered the gold standard for surgical treatment. Yet, strong efforts to identify effective and complication-free surgical options are ongoing. Fistulotomy can be considered the best perianal fistula treatment option, providing a perfect surgical field view, allowing direct access to the source of chronic inflammation. Controversy exists concerning the risk of continence impairment associated with fistulotomy. The present study aimed to assess the outcomes of fistulotomy with immediate sphincteric reconstruction regaring fistula recurrence, incontinence, and patient satisfaction. Methods This interventional study was performed at the General Surgery Department of Zagazig University Hospital during the period from July 2018 to December 2019 on 24 patients with a clinical diagnosis of high transsphincteric fistula-in-ano. The fistulous tract was laid open over the probe placed in the tract. After the fistula tract had been laid open, the tract was curetted and examined for secondary extensions. Then, suturing muscles to muscles, including the internal and external sphincters, by transverse mattress sutures. Results Our study showed that 2 patients develop incontinence to flatus ∼ 8.3%.and only one patient develop incontinence to loose stool, 4.2%. Complete healing was achieved in 83% and recurrence was 16.6%. Conclusion Fistulotomy with immediate sphincteric reconstruction is considered to be an effective option in the management of high perianal fistula, with low morbidity and high healing rate with acceptable continence state.
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Background There have been sporadic but enthusiastic reports in recent years about fistulotomy with primary sphincter repair as a radical but successful approach to dealing with complex anal fistula. Having had to overcome our own reservations we have found this method to be successful, prompting this case review. Methods Retrospective evaluation of patient records and subsequent telephone interview of all cases operated for fistulotomy with primary sphincter repair between January 2008 and May 2009. Results Of 38 patients, 34 (89%) had transsphincteric (20 “high”, 14 “low”), three (8%) suprasphincteric, one extrasphincteric fistula. Three (8%) had associated IBD. Seven (18%) had experienced recurrence following previously failed repairs. Postsurgical revision was necessary in four patients: three small wound revisions, one partial dehiscence of the sphincter reconstruction. The chart review showed“wounds completely healed” in 37 patients (97%, persistent granulation tissue at wound edges in one patient); continence was noted as “unchanged” or“continent” in 36 patients (95%; it was noted as “diminished continence for gas” in one patient, while changes were not documented for another patient). In all, 32 patients (84%) were available for telephone interview. Three (9%) reported occasional anal discomfort and slightly diminished gas continence (n, 1) and fluid stools (n, 2). One patient reported improved sphincter function. Conclusion Fistulotomy with primary sphincter reconstruction is an important adjunct to the surgical armamentarium for the treatment of anal fistula. Fistulotomy enables full exposure of the fistulous tract and excision of all inflammatory remnants and bradytrophic granulation, which can be the cause of failure of other procedures if left in situ. We are able to confirm this method to be reliable and successful even with the more complex fistula varieties and with recurrences.
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Purpose: This study assessed long-term functional outcome and explored risk factors for fistula recurrence in patients surgically treated for cryptoglandular fistulas. Methods: Three hundred ten consecutive patients were surgically treated for perianal fistulas. After exclusion of patients with inflammatory bowel disease or HIV, 179 patients remained. Patients were divided into two groups: those who received fistulotomy for low perianal fistulas and those who received rectal advancement flap for high perianal fistulas. Time to fistula recurrence was the main outcome and Cox proportional hazard models were used to assess the importance of various risk factors. Functional outcome was assessed using the Vaizey and colorectal functional outcome (COREFO) questionnaires. Results: The median follow-up duration was 76 months (range, 7-134). The 3-year recurrence rate for low perianal fistulas treated by fistulotomy (n = 109) was 7 percent (95 percent confidence interval, 1-13 percent). In high transsphincteric fistulas treated by rectal advancement flap (n = 70), the recurrence rate was 21 percent (95 percent confidence interval, 9-33 percent). In both groups, soiling was reported at 40 percent. None of the seven potential risk factors examined were statistically significant. Conclusions: Fistula recurrence rate after fistulotomy was low. No clear risk factors were found. Overall functional outcome in terms of continence was good. However, a substantial amount of patients reported soiling.
Article
Einleitung: Die Bedeutung der analen Endosonographie hinsichtlich der Beurteilung anorektaler Fisteln wird kontrovers diskutiert. Ziel der vorliegenden Untersuchung war es, die Wertigkeit der präoperativen analen Endosonographie in der Diagnostik von Analfisteln zu evaluieren.Methoden: Ausgewertet wurden die Daten von 191 Patienten (M: 121; W: 70; mittleres Alter: 44,0 ± 12,5 Jahre; Streubreite: 0,5-77 Jahre), bei denen durch eine anale Endosonographie eine Analfistel diagnostiziert wurde. Eine operative Therapie wurde bei 131 Patienten durchgeführt (69 %). Die anorektale Ultraschalluntersuchung erfolgte mit dem Sonographiegeät Combison 310A (Kretz GmbH, Zipf, Österreich) unter Verwendung der 5,0 MHz bzw. 7,5 MHz Rektalsonde. Präoperativ wurden sonographisch 44 % transsphinktere, 22 % intersphinktere, 16 % subanodermale, 8 % anovaginale, 5 % suprasphinktere, 1 % extrasphinktere und 4 % sonstige Fisteln dargestellt. 12 der darstellbaren Fisteln zeigten eine Hufeisenformation.Ergebnisse: Bei 125 von 131 Patienten (95 %) konnten die endosonographisch diagnostizierten Fistelverläufe durch den Operationssitus bestätigt werden. Nur bei 6 Patienten ergab die präoperative Endosonographie eine falsche Beurteilung. Der intraoperative Befund stimmte bei allen 12 Patienten, die ein komplexes oder hufeisenförmiges Fistelsystem aufwiesen, mit der präoperativ mittels Endosonographie erhobenen Diagnose überein.Schlussfolgerungen: Zusammenfassend korrelierte der endosonographische Befund in 95 % mit dem tatsächlichen Fistelbefund. Die vorliegenden Ergebnisse bestätigen die hohe Aussagekraft der analen Endosonographie nicht nur in der Routinediagnostik der Analfisteln sondern auch in der differenzierten Diagnostik komplexer Fistelsysteme.
Article
From January 1992 until April 1995, 31 patients with trans- and suprasphincteric anal fistulae (transsphincteric n = 21; suprasphincteric n = 4; transsphincteric in Crohn's disease n = 6) underwent a fistulectomy followed by closure of the internal opening by suture and anocutaneous flap. All patients had undergone previous operations, some several times. The recurrence rate of 13 % appeared to be low after a short follow-up. Continence was only negligibly impaired, although the anal resting pressure and contraction pressure were significantly reduced. In five patients a shortened prewarning period was noticed. Also in Crohn's fistulae the results were equivalent when the surgical treatment was performed in a non-inflammatory period.
Article
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.
Article
PURPOSE: Fibrin adhesive has been successfully used to treat fistulas-in-ano, but long-term data have been lacking. We report the results of our 18-month study examining the repair of fistulas-in-ano using autologous and commercial fibrin adhesive. METHODS: A 79-patient, prospective, nonrandomized clinical trial was performed in which fibrin adhesive was used to repair fistulas-in-ano. Twenty-six patients were treated with autologous fibrin tissue adhesive made from their own blood, and 53 patients were treated with commercial fibrin sealant. In the operating room the patient underwent an examination under anesthesia, with an attempt to identify the primary and secondary fistula tract openings. The fistula tract was then curetted. Fibrin adhesive was injected into the secondary fistula tract opening until adhesive was seen coming from the primary opening. A petroleum jelly gauze was then applied over both the primary and secondary openings, and the patient was sent home. Follow-up visits occurred one week, one month, three months, and one year later. RESULTS: Fourteen of 26 (54 percent) patients treated with autologous fibrin tissue adhesive made from their own blood had complete closure of their fistulas after a one-year follow-up, whereas 34 of 53 (64 percent) patients treated with commercial fibrin sealant had closure of their fistulas. Most treatment failures occurred within the first 3 months, but late failures were seen as far as 11 months postoperative. CONCLUSIONS: Fibrin tissue adhesive offers a unique mode of managing fistulas-in-ano, which is surgically less invasive, but recurrences up to one year later are being seen. Longer follow-up and further research is recommended for improvement.
Article
Purpose: To identify the incidence of major fecal incontinence and recurrence after staged fistulotomy using a seton. Methods: A five-year retrospective chart review of 116 patients (70 males and 46 females) ranging in age from 18 to 81 years (mean, 42 years), in whom setons were placed as part of a surgical procedure for anorectal fistulas, was carried out. Follow-up ranged from 2 to 61 months (mean, 23 months). Results: Setons were employed to identify and promote fibrosis around a complex anorectal fistula as part of a staged fistulotomy in 65 patients (56 percent). Other indications for seton placement included 24 women with anteriorly situated high transsphincteric fistulas (21 percent) and three patients with massive anorectal sepsis (floating, freestanding anus) (2.5 percent). In addition, setons were used to preclude premature skin closure and promote controlled long-term fistula drainage in 21 patients with severe anorectal Crohn's disease (18 percent) and in three patients with AIDS (2.5 percent). Major fecal incontinence (requiring the use of a perineal pad) occurred in five patients (5 percent), and recurrent fistulas were noted in three (3 percent). Conclusions: Staged fistulotomy using a seton is a safe and effective method of treating high or complicated anorectal fistulas.
Article
In assessing the results in this series, an attempt has been made to rationalize the methods of treatment and emphasize the importance of a sound anatomic basis for both classification and management. The technical methods are somewhat of a compromise. The classic methods of staged division of muscle, together with the use of the seton (for drainage only) are combined with exploration of the intersphincteric plane to eliminate the causative factor of the disease. Because these “high” fistulas are uncommon, particularly the suprasphincteric and extrasphincteric varieties, there is little information in the literature with which to compare the figures. It is hoped that the experience gained in treating these cases will act as a guide for surgeons who see complicated fistulas infrequently, and also act as a baseline for further reappraisal of treatment methods. The ultimate aim must be to obtain healing of the fistula, at the same time minimizing disturbance of function.