• Humans
• Crohn Disease/complications
• Crohn Disease/nursing
• Rectal Fistula/etiology
• Rectal Fistula/therapy
• Nurse's Role
• Quality of Life
• Female
• Male

• Crohn’s disease
• perianal fistula
• seton

• Takeda Pharmaceuticals

• Anal continence
• Health-related quality of life
• Loose seton
• Modified loose seton
• Perianal fistula

• Female
• Humans
• Male
• Observational Studies as Topic
• Patient Satisfaction
• Postoperative Period
• Quality of Life
• Rectal Fistula/surgery
• Wound Healing

• Zealand Region

• Complex perianal fistula
• Crohn’s disease
• Cryptoglandular fistula
• Surgery

• Abscess/surgery
• Anus Diseases
• Colon
• Female
• Humans
• Rectal Fistula/surgery
• Rectovaginal Fistula/surgery
• Surgeons

There are many surgical methods of sphincter preservation in treating complex anal fistula, but the therapeutic effects of each operation are different. Therefore, this study aimed to compare the impact of other treatment methods through a network meta-analysis to evaluate the best sphincter preservation method for treating complex anal fistula.

We searched PubMed, Embase, Cochrane Library, China National Knowledge Infrastructure, Chinese Biomedical Literature Database, VIP Journal Database, and the Wanfang Database to collate randomized controlled trials on sphincter-preserving surgery for complex anal fistula.

A total of 29 articles were included in this meta-analysis. The cure rates showed no statistically significant differences between any two interventions (P > 0.05). The recurrence rate results showed that the rate of patients after Fistulectomy was higher than others (P < 0.05). The incidence rate of complications showed that the incidence rate after fistulectomy treatment was higher than that of others (P < 0.05). The surface under the cumulative ranking (SUCRA) was used to arrange their advantages and disadvantages, and a larger SUCRA value indicates that the intervention may be more effective. The results showed that TROPIS may have the highest cure rate (SUCRA = 78.6%), stem cell transplantation (SCT) may have the lowest recurrence rate (SUCRA = 85.5%), and imLIFT may have the least complications (SUCRA = 88.2%).

According to the existing literature data, for patients with complex anal fistula, TROPIS may be the surgical method with the highest cure rate, SCT may be the treatment method with the lowest recurrence rate, and imLIFT may be the surgical method with the lowest incidence of postoperative complications.

PROSPERO, identifier: CRD42020221907.

• Crohn’s disease
• Female sexual function
• Fistulotomy
• Perianal fistula
• Quality of life
• Seton

• Surgery
• digestive
• equipment
• other
• physiology
• treatment

Crohn's disease (CD) is a transmural inflammatory bowel disease (IBD) that can affect any part of the gastrointestinal (GI) tract. With the disease's progression, adhesions and transmural fissuring, intra-abdominal abscesses, and fistula tracts may develop. An anal fistula (or fistula-in-ano) is a chronic abnormal epithelial lined tract communicating the anorectal lumen (internal opening) to the perineal or buttock skin (external opening). The risk of fistula development varies from 14%-38%. It can cause significant morbidity, which adversely impacts the quality of life. It is mostly believed that an anal crypt gland infection causes anal abscesses, leading to fistula development. Crohn's disease's pathogenesis involves Th1 and Th17 hypersensitivity due to an unknown antigen within the intestinal mucosa.

Evidence to support this review was gathered via the Pubmed database. Search terms used were combinations of "Perianal fistula," "seton," "immunotherapy." Studies were reviewed and cross‐referenced for additional reports.

Setons are surgical thread loops passed from the external to the internal opening of the fistula tract and exteriorized through the anorectal canal, facilitating abscess drainage and inciting a local inflammatory reaction, thus promoting the resolution of the fistula. Biologicals such as anti-tumor necrosis factor (TNF) antibody (infliximab, adalimumab, certolizumab), anti-IL-12/23 (ustekinumab), and anti-α₄β₇ integrin antibody (vedolizumab) have been approved for Crohn's disease targeting the Th1/Th17-mediated inflammation. Other therapeutic modalities are fistulotomy, cyanoacrylate glue, bioprosthetic plugs, mucosal advancement flap, ligation of inter-sphincteric fistula tract (LIFT), diverting stoma, proctectomy, video-assisted anal fistula treatment (VAAFT), and fistula laser closure (FiLaC).

Our review found that chronic seton therapy should be the primary approach, especially if the patient has a perianal abscess. It has a low incidence of re-intervention, recurrent abscess formation, and side-branching of the fistulous tract, with preservation of the fistulous tract's patency and cost-effectiveness. The major disadvantage of seton therapy is the discomfort and time to achieve stability. Among the biologicals, infliximab is the only therapy which has a statistically significant effect on the healing rate of perianal Crohn's fistula compared to placebo, but the major disadvantage associated with anti-TNF as sole therapy is high re-intervention rate, prolong maintenance therapy, high recurrence rate, and severe side effects. We hypothesize that the two aspects should be addressed concurrently to increase the fistula healing or closure rate. First, the seton should be used as initial therapy to maintain tract patency to allow abscess drainage and minimize the intestinal flora colonization within the tract mucosa, thereby leukocytic infiltration and propagation of inflammation within the tract. The second aspect that has to be considered is that we should target the initial stimulation of the Th1/Th17 mediated hypersensitivity instead of a factor/cytokine involved in the inflammation mediation. Although the unknown antigen triggering such hypersensitivity is not clear, we could target the RAR-related orphan receptor γ (RORγ)-T (transcription factor involved in activation of Th17 cells) and the T-bet (transcription factor involved in activation of Th17 cells) within the GI mucosa by a novel target immune therapy.

• biologicals
• crohn's disease
• fistulotomy
• infliximab
• perianal fistula
• seton
• ustekinumab
• vedolizumab

One of the most challenging phenotypes of Crohn’s disease is perianal fistulizing disease (PFCD). It occurs in up to 50% of the patients who also have symptoms in other parts of the gastrointestinal tract, and in 5% of the cases it occurs as the first manifestation. It is associated with severe symptoms, such as pain, fecal incontinence, and a significant reduction in quality of life. The presence of perianal disease in conjunction with Crohn’s disease portends a significantly worse disease course. These patients require close monitoring to identify those at risk of worsening disease, suboptimal biological drug levels, and signs of developing neoplasm. The last 2 decades have seen significant advancements in the management of PFCD. More recently, newer biologics, cell-based therapies, and novel surgical techniques have been introduced in the hope of improved outcomes. However, in refractory cases, many patients face the decision of having a stoma made and/or a proctectomy performed. In this review, we describe modern surgical management and the most recent advances in the management of complex PFCD, which will likely impact clinical practice.

• Crohn’s disease
• Inflammatory bowel disease
• Surgical treatment
• Perianal fistulas
• Anorectal fistula

• Crohn Disease/diagnosis
• Crohn Disease/surgery
• Fecal Incontinence
• Humans
• Quality of Life
• Rectal Fistula/etiology
• Rectal Fistula/surgery
• Surgical Stomas

• anal diseases
• inflammatory bowel disease
• crohn's disease

• Adult
• Crohn Disease/complications
• Crohn Disease/surgery
• Drainage/methods
• Feasibility Studies
• Female
• Humans
• Male
• Middle Aged
• Prospective Studies
• Rectal Fistula/etiology
• Rectal Fistula/surgery
• Treatment Outcome

• Complex perianal fistulas
• Knot-free seton
• Loose seton
• Rectal fistula

The aim of our study was to compare the success rates of suture selection, recovery times and pain associated with local wound infection and seton placement in patients undergoing cutting seton placement for complex anal fistula.

The study included a total of 90 patients who were admitted with the diagnosis of complex anal fistula between January 2015 and July 2018.

The first session and other revision appointments demonstrated that the number of patients who required fistulotomy was significantly higher in group-1 as the seton failed to complete the transection (p = 0.001). When the patients were asked to rate pain for 3 different conditions according to numeric rating scale (NRS), the patients in group-2 had significantly higher pain in all 3 cases compared to the patients in group-1 (p 0.001). The impact of the suture material on local infection was examined and it was determined that the results of cultures for seton material were significantly more positive in group-1 (p = 0.001).

We conclude that a multi-stage tight seton placement with silk material can lead to satisfactory results by aiming to shorten the cutting time of silk seton.

• Anal fistula
• Local infection
• Seton

• Burden
• Complex perianal fistulas
• Crohn’s disease
• Epidemiology
• Outcomes
• Systematic literature review
• Treatment

• Adipose Tissue/cytology
• Combined Modality Therapy/methods
• Cost of Illness
• Crohn Disease/complications
• Cutaneous Fistula/epidemiology
• Cutaneous Fistula/etiology
• Cutaneous Fistula/therapy
• Drainage/methods
• Humans
• Immunosuppressive Agents/therapeutic use
• Quality of Life
• Rectal Fistula/epidemiology
• Rectal Fistula/etiology
• Rectal Fistula/therapy
• Recurrence
• Stem Cell Transplantation
• Stem Cells
• Treatment Failure
• Tumor Necrosis Factor-alpha/antagonists & inhibitors

• Anal sepsis
• aetiology
• anal fistula
• investigation
• surgical treatment

• Crohn's perianal fistula
• anti-TNF
• seton

• Comfort Drain
• Fistula-in-ano
• anal fistula
• complex fistula
• loose seton

A number of techniques have been described for the treatment of a transsphincteric anal fistula. In this report, we aimed to introduce a relatively new two-stage technique, application of advancement flap after loose seton placement, to present its technical aspects and to document our results.

Included in this retrospective study were 13 patients (10 males, 3 females) with a mean age of 42 years who underwent a two-stage seton and advancement flap surgery for transsphincteric anal fistula between June 2008 and June 2013. In the first stage, a loose seton was placed in the fistula tract, and in the second stage, which was performed three months later, the internal and external orifices were closed with advancement flaps.

All the patients were discharged on the first postoperative day. The mean follow-up period was 34 months. Only one patient reported anal rigidity and intermittent pain, which was eventually resolved with conservative measures. The mean postoperative Wexner incontinence score was 1. No recurrence or complications were observed, and no further surgical intervention was required during follow-up.

The two-stage seton and advancement flap technique is very efficient and seems to be a good alternative for the treatment of a transsphincteric anal fistula.

• Anal fistula
• Flap
• Seton
• Surgery

Background: Patients with Crohn’s disease (CD) are believed to have more aggressive anorectal abscess and fistula disease. We assessed the types of procedures performed and perioperative complications associated with the surgical management of anorectal abscess and fistula disease in patients with and without CD.

Methods: The American College of Surgeons National Surgical Quality Improvement Program database (ACS-NSQIP, 2005-2010) was used to calculate 30-day outcomes using regression modeling, accounting for demographics, comorbidities and surgical procedures. ICD-9 codes for anorectal abscess or fistula were used for initial selection. Patients were then stratified, based on the presence or absence of underlying CD. Local procedures included incision and drainage of abscesses, fistulotomy and seton placement. Cutaneous fistulas were considered simple, while all others were classified as complex (-vaginal, -urethral and -vesical).

Results: A total of 7,218 patients (mean age 45 years; 64% male) met inclusion criteria, with underlying CD in 345 (4.8%). CD patients were more likely to have a seton placed (9.9 vs 8.2%, P < 0.001) and be on steroids (15.4 vs 4.3%, P < 0.001). Thirty-seven percent of CD patients underwent local procedures, while 46% had a proctectomy and 8% underwent diversion. Fistulotomy was more common in those without underlying CD (16 vs 11%, P < 0.001). The overall complication rate after local treatment was 4.9%, with no difference between patients with and without CD (7.7 vs 4.9%, P = 0.144). This was not affected by fistula type—simple (7.9 vs 3.9%, P = 0.194) vs complex (33 vs 7.1%, P = 0.21)—or when stratified by wound (3.8 vs 2.4%; P = 0.26) or systemic complications (3.8 vs 2.5%; P = 0.53). Yet, complications following emergency procedures were higher in patients with CD (21.4 vs 5.9%, P = 0.047). Factors significantly associated with increased complications were Crohn’s disease (OR = 8.2), lack of functional independence (OR = 2.0), pre-operative weight loss (OR = 2.6) and pre-operative acute renal failure (OR = 5.6). Steroids were also associated with a 1.7-fold increase in complications, independent from CD.

Conclusions: While most patients with anorectal abscess/fistula are treated with local procedures, proctectomy and diversion use is fairly common in those with underlying CD. Although complication rates following elective local procedures for anorectal abscess/fistula are similar in patients with and without CD, they are higher in patients on steroids and in CD patients undergoing emergent procedures.

• Crohn’s disease
• National Surgical Quality Improvement Program (NSQIP)
• anorectal abscess
• anorectal diseases
• fistula-in-ano

• Anal fistula
• Fistula in ano

• Anus Diseases/diagnosis
• Anus Diseases/therapy
• Crohn Disease/diagnosis
• Crohn Disease/therapy
• Humans

• Digestive System Surgical Procedures/methods
• Gastroenterology/standards
• Humans
• Organ Sparing Treatments/methods
• Rectal Fistula/diagnosis
• Rectal Fistula/surgery
• Surgery, Computer-Assisted/methods

• Adult
• Aged
• Demography
• Female
• Humans
• Male
• Middle Aged
• Rectal Fistula/surgery
• Suture Techniques
• Sutures
• Treatment Outcome
• Young Adult