|
1
|
Van De Putte D, Depuydt M, Colpaert J, Van Ramshorst GH. Ligation of the intersphincteric fistula fract (LIFT) in complex anorectal fistulas: retrospective analysis of the outcomes in a tertiary hospital. Updates Surg 2025:10.1007/s13304-025-02174-5. [PMID: 40335785 DOI: 10.1007/s13304-025-02174-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2024] [Accepted: 03/09/2025] [Indexed: 05/09/2025]
Abstract
Anal fistula treatment remains a surgical challenge. This study focuses on the efficiency and safety of the Ligation of Intersphincteric Fistula Tract (LIFT) procedure for high intersphincteric anorectal fistulas, aiming to identify prognostic factors for success and complications. A retrospective chart review was conducted on all patients who underwent LIFT procedure at a tertiary referral hospital between January 2013 and January 2021. The primary endpoint was the success rate of fistula closure, confirmed with clinical investigation. Secondary endpoints included postoperative complications, reintervention and self-reported incontinence. Logistic regression analyses were performed for assessing prognostic factors for fistula closure and postoperative complications. Ninety-two patients were included in the study; after a median follow-up of 19.3 months, fistula closure was achieved in 71% (n = 65) and in 89% (n = 82) after reinterventions. 46% (n = 42) reported persistent symptoms, although 83% of which (n = 32/42) had succesful fistula tract closure by clinical evaluation. One patient developed incontinency for gas. Smoking emerged as a significant risk factor for fistula closure failure, OR = 6.75, 95% CI = [1.65, 27.69], p = 0.030. Wound dehiscence was the most common complication, occuring in 25% (n = 23). Prolonged oral antibiotics demonstrated a significant protective effect against wound dehiscence, OR = 0.31, 95% CI = [0.10, 0.96], p = 0.036. The LIFT procedure is an efficient and safe treatment for complex perianal fistula. Patient satisfaction emerged as a crucial treatment goal, as patients can remain symptomatic after fistula closure. Emphasizing smoking cessation is integral to the treatment approach. The findings suggest prolonged antibiotic treatment as a potential preventive measure for wound dehiscence.
Collapse
Affiliation(s)
- Dirk Van De Putte
- Gastrointestinal Surgery, Ghent University Hospital, Corneel Heymanslaan 10, 9000, Ghent, Belgium
| | - Martijn Depuydt
- Gastrointestinal Surgery, Ghent University Hospital, Corneel Heymanslaan 10, 9000, Ghent, Belgium.
- Department of Surgery, Ghent University, Corneel Heymanslaan 10, Ghent, Belgium.
| | - Jan Colpaert
- Department of Surgery, A.S.Z. Aalst, Merestraat 80, Aalst, Belgium
| | | |
Collapse
|
|
2
|
Gaillard M, Van den Broeck S, Op de Beeck B, Wouters K, Stijns J, Van de Putte D, Gys B, Houben B, Van Dessel E, Bislenghi G, Komen N. Protocol of the LATFIA trial (Laser Assisted Treatment of Fistula in Ano): a multicentre, prospective, randomized controlled trial comparing fistula-tract laser closure (FiLaC™) with rectal advancement flap for high trans-sphincteric fistulas. Colorectal Dis 2024; 26:1038-1046. [PMID: 38499516 DOI: 10.1111/codi.16951] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2023] [Revised: 02/11/2024] [Accepted: 02/23/2024] [Indexed: 03/20/2024]
Abstract
AIM Anal fistula is one of the most common anal diseases, affecting between 1 and 3 per 10 000 people per year. Symptoms have a potentially severe effect on a patient's quality of life. Surgery is the mainstay of treatment, aiming to cure the fistula and preserve anal sphincter function. Rectal advancement flap (RAF) is currently the gold standard treatment but has recurrence rates varying between 20% and 50% and might lead to disturbance of continence. The aim of the trial described in this work is to discover if the minimally invasive fistula tract laser closure (FiLaC™) technique could achieve higher healing rates and a better functional outcome than RAF. METHOD We will perform a randomized prospective multicentre noninferiority study of the treatment of high trans-sphincteric perianal fistulas, comparing FiLaC™ with RAF in terms of fistula healing, recurrence rate, functional outcome and quality of life. Primary and secondary fistula healing will be evaluated at 26 and 52 weeks' follow-up. Quality of life will be evaluated using the SF-36 questionnaire, the Faecal Incontinence Quality of Life Scale questionnaire and the Vaizey score at 3, 6, 12 and 26 weeks postoperatively. CONCLUSION High trans-sphincteric fistulas have a potentially severe effect on a patient's quality of life. Classical treatment with RAF is a time-consuming invasive procedure. The LATFIA trial aims to compare FiLaC™ with the gold standard treatment with RAF. In case of noninferiority, FiLaC™ treatment could be standardized as a first line treatment for high trans-sphincteric fistulas. Better conservation of the patient's anal sphincter function could possibly be obtained. Likewise, we will report on the postoperative quality of life when applying these two techniques.
Collapse
Affiliation(s)
- Marie Gaillard
- Department of Abdominal Surgery, Antwerp University Hospital, Edegem, Belgium
- Antwerp ReSURG, Antwerp Surgical Training, Anatomy and Research Centre (ASTARC), Faculty of Medicine and Health Sciences, University of Antwerp, Wilrijk, Belgium
| | - Sylvie Van den Broeck
- Department of Abdominal Surgery, Antwerp University Hospital, Edegem, Belgium
- Antwerp ReSURG, Antwerp Surgical Training, Anatomy and Research Centre (ASTARC), Faculty of Medicine and Health Sciences, University of Antwerp, Wilrijk, Belgium
| | - Bart Op de Beeck
- Department of Radiology, Antwerp University Hospital, Edegem, Belgium
| | - Kristien Wouters
- Clinical Trial Center, Antwerp University Hospital, Edegem, Belgium
| | - Jasper Stijns
- Department of Abdominal Surgery, University Hospital Brussels, Jette, Belgium
| | - Dirk Van de Putte
- Department of Abdominal Surgery, University Hospital Ghent, Ghent, Belgium
| | - Ben Gys
- Department of Abdominal Surgery, Hospital St. Dimpna, Geel, Belgium
| | - Bert Houben
- Department of Abdominal Surgery, Jessa Hospital, Hasselt, Belgium
| | - Els Van Dessel
- Department of Abdominal Surgery, GasthuisZusters Hospital, Antwerp, Belgium
| | - Gabriele Bislenghi
- Department of Abdominal Surgery, University Hospital Leuven, Leuven, Belgium
| | - Niels Komen
- Department of Abdominal Surgery, Antwerp University Hospital, Edegem, Belgium
- Antwerp ReSURG, Antwerp Surgical Training, Anatomy and Research Centre (ASTARC), Faculty of Medicine and Health Sciences, University of Antwerp, Wilrijk, Belgium
| |
Collapse
|
|
3
|
Reza L, Gottgens K, Kleijnen J, Breukink S, Ambe PC, Aigner F, Aytac E, Bislenghi G, Nordholm-Carstensen A, Elfeki H, Gallo G, Grossi U, Gulcu B, Iqbal N, Jimenez-Rodriguez R, Leventoglu S, Lisi G, Litta F, Lung P, Millan M, Ozturk E, Sackitey C, Shalaby M, Stijns J, Tozer P, Zimmerman D. European Society of Coloproctology: Guidelines for diagnosis and treatment of cryptoglandular anal fistula. Colorectal Dis 2024; 26:145-196. [PMID: 38050857 DOI: 10.1111/codi.16741] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Revised: 07/11/2023] [Accepted: 08/03/2023] [Indexed: 12/07/2023]
Abstract
AIM The primary aim of the European Society of Coloproctology (ESCP) Guideline Development Group (GDG) was to produce high-quality, evidence-based guidelines for the management of cryptoglandular anal fistula with input from a multidisciplinary group and using transparent, reproducible methodology. METHODS Previously published methodology in guideline development by the ESCP has been replicated in this project. The guideline development process followed the requirements of the AGREE-S tool kit. Six phases can be identified in the methodology. Phase one sets the scope of the guideline, which addresses the diagnostic and therapeutic management of perianal abscess and cryptoglandular anal fistula in adult patients presenting to secondary care. The target population for this guideline are healthcare practitioners in secondary care and patients interested in understanding the clinical evidence available for various surgical interventions for anal fistula. Phase two involved formulation of the GDG. The GDG consisted of 21 coloproctologists, three research fellows, a radiologist and a methodologist. Stakeholders were chosen for their clinical and academic involvement in the management of anal fistula as well as being representative of the geographical variation among the ESCP membership. Five patients were recruited from patient groups to review the draft guideline. These patients attended two virtual meetings to discuss the evidence and suggest amendments. In phase three, patient/population, intervention, comparison and outcomes questions were formulated by the GDG. The GDG ratified 250 questions and chose 45 for inclusion in the guideline. In phase four, critical and important outcomes were confirmed for inclusion. Important outcomes were pain and wound healing. Critical outcomes were fistula healing, fistula recurrence and incontinence. These outcomes formed part of the inclusion criteria for the literature search. In phase five, a literature search was performed of MEDLINE (Ovid), PubMed, Embase (Ovid) and the Cochrane Database of Systematic Reviews by eight teams of the GDG. Data were extracted and submitted for review by the GDG in a draft guideline. The most recent systematic reviews were prioritized for inclusion. Studies published since the most recent systematic review were included in our analysis by conducting a new meta-analysis using Review manager. In phase six, recommendations were formulated, using grading of recommendations, assessment, development, and evaluations, in three virtual meetings of the GDG. RESULTS In seven sections covering the diagnostic and therapeutic management of perianal abscess and cryptoglandular anal fistula, there are 42 recommendations. CONCLUSION This is an up-to-date international guideline on the management of cryptoglandular anal fistula using methodology prescribed by the AGREE enterprise.
Collapse
Affiliation(s)
| | | | - Jos Kleijnen
- KSR Ltd & Maastricht University Medical Center (MUMC+) -CAPHRI, Maastricht, Netherlands
| | | | | | | | | | | | | | | | | | - Ugo Grossi
- Treviso Regional Hospital, Treviso, Italy
| | | | | | | | | | | | | | | | - Monica Millan
- La Fe University and Polytechnic Hospital, Valencia, Spain
| | | | | | | | | | | | | |
Collapse
|
|
4
|
Khamar J, Sachdeva A, McKechnie T, Lee Y, Tessier L, Hong D, Eskicioglu C. Cutting seton for the treatment of cryptoglandular fistula-in-ano: a systematic review and meta-analysis. Tech Coloproctol 2023; 28:12. [PMID: 38091125 DOI: 10.1007/s10151-023-02886-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2023] [Accepted: 10/21/2023] [Indexed: 12/18/2023]
Abstract
BACKGROUND The use of cutting seton (CS) for the management of cryptoglandular fistula-in-ano has remained controversial because of reports of fecal incontinence, postoperative pain, and extended healing time. The aim of this review was to provide the first synthesis of studies investigating the use of CS for the treatment of cryptoglandular fistula-in-ano. METHODS MEDLINE, Embase, and CENTRAL were searched up to October 2022. Randomized controlled trials and observational studies comparing CS with alternative interventions were included, along with single-arm studies evaluating CS alone. The primary outcome was fistula-in-ano recurrence, and secondary outcomes included incontinence, healing time, proportion with complete healing, and postoperative pain. Inverse variance random-effects meta-analyses were used to pool effect estimates. RESULTS After screening 661 citations, 29 studies were included. Overall, 1513 patients undergoing CS (18.8% female, mean age: 43.1 years) were included. Patients with CS had a 6% (95% CI: 3-12%) risk of recurrence and a 16% (95% CI: 5-38%) risk of incontinence at 6 months. CS patients had an average healing time of 14.6 weeks (95% CI: 10-19 weeks) with 73% (95% CI: 48-89%) of patients achieving complete healing at 6 months postoperatively. There was no difference in recurrence between CS and fistulotomy, advancement flap, two-stage seton fistulotomy, or draining seton. CONCLUSIONS Overall, this analysis shows that CS has comparable recurrence and incontinence rates to other modalities. However, this may be at the expense of more postoperative pain and extended healing time. Further comparative studies between CS and other modalities are warranted.
Collapse
Affiliation(s)
- J Khamar
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada
| | - A Sachdeva
- Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - T McKechnie
- Division of General Surgery, Department of Surgery, McMaster University, St. Joseph's Healthcare, 50 Charlton Avenue East, Hamilton, ON, L8N 4A6, Canada
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - Y Lee
- Division of General Surgery, Department of Surgery, McMaster University, St. Joseph's Healthcare, 50 Charlton Avenue East, Hamilton, ON, L8N 4A6, Canada
- Harvard T.H. Chan School of Public Health, Harvard University, Boston, MA, USA
| | - L Tessier
- Division of General Surgery, Department of Surgery, McMaster University, St. Joseph's Healthcare, 50 Charlton Avenue East, Hamilton, ON, L8N 4A6, Canada
| | - D Hong
- Division of General Surgery, Department of Surgery, McMaster University, St. Joseph's Healthcare, 50 Charlton Avenue East, Hamilton, ON, L8N 4A6, Canada
- Division of General Surgery, Department of Surgery, St. Joseph's Healthcare, Hamilton, ON, Canada
| | - C Eskicioglu
- Division of General Surgery, Department of Surgery, McMaster University, St. Joseph's Healthcare, 50 Charlton Avenue East, Hamilton, ON, L8N 4A6, Canada.
- Division of General Surgery, Department of Surgery, St. Joseph's Healthcare, Hamilton, ON, Canada.
| |
Collapse
|
|
5
|
Chaveli Diaz C, Esquiroz Lizaur I, Marzo Virto J, Oteiza Martínez F, Gonzalez Álvarez G, de Miguel Velasco M, Ciga Lozano MÁ. Fistulectomy and endorectal advancement flap repair for cryptoglandular anal fistula: recurrence and functional outcome over 10 years of follow-up. Int J Colorectal Dis 2021; 36:841-846. [PMID: 33580275 DOI: 10.1007/s00384-021-03867-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/27/2021] [Indexed: 02/04/2023]
Abstract
PURPOSE To examine long-term recurrence and anal continence of patients with anal fistula treated by fistulectomy and endorectal advancement flap repair. METHOD Retrospective analysis of a prospective cohort of 115 patients (77.4% males, mean age 48.9 years) requiring 130 procedures, with a minimum follow-up of 10 years. Recurrence included reappearance of fistula after wound healing or presence of an abscess or chronic suppuration in the operated area at follow-up. Fecal incontinence was evaluated by the Cleveland Clinic Florida (CCF-FI) fecal incontinence scoring system. RESULTS The mean and SD duration of the follow-up period was 155.5 (21.7) months. Recurrence developed in 31 (23.8%) cases, 28 (90.3%) of which within the first year, with a mean time to recurrence of 4.9 (2.9) months. The success rate was 76.2%. Anal continence was normal in 80% of patients before surgery, 63.8% at 1-year follow-up, and 71.5% at the end of follow-up (p < 0.001). Overall, continence worsened in 16.9% of cases. The mean (95% CI) CCF-FI score was 0.78 (0.35-1.21) preoperatively, 1.04 (0.64-1.43) at 1 year after surgery, 0.90 (0.52-1.29) at 5 years, and 1.16 (0.66-1.67) at the end of the study (p < 0.05). Neither recurrence nor continence was significantly associated with previous anal or fistula surgical procedures or complexity of the fistula. CONCLUSION In this study, fistulectomy and endorectal advancement flap repair was associated with a long-term high rate of success. Most recurrences occurred within the first year and continence showed a mild deterioration over time. CLINICAL TRIAL REGISTRATION Not applicable.
Collapse
Affiliation(s)
- Carlos Chaveli Diaz
- Unit of Colorectal Surgery, Department of Surgery, Complejo Hospitalario de Navarra, C/ Irunlarrea 3, Secretaría de Cirugía, Pabellón H3, E-31008, Pamplona, Spain.
| | - Irene Esquiroz Lizaur
- Unit of Colorectal Surgery, Department of Surgery, Complejo Hospitalario de Navarra, C/ Irunlarrea 3, Secretaría de Cirugía, Pabellón H3, E-31008, Pamplona, Spain
| | - José Marzo Virto
- Unit of Colorectal Surgery, Department of Surgery, Complejo Hospitalario de Navarra, C/ Irunlarrea 3, Secretaría de Cirugía, Pabellón H3, E-31008, Pamplona, Spain
| | - Fabiola Oteiza Martínez
- Unit of Colorectal Surgery, Department of Surgery, Complejo Hospitalario de Navarra, C/ Irunlarrea 3, Secretaría de Cirugía, Pabellón H3, E-31008, Pamplona, Spain
| | - Gregorio Gonzalez Álvarez
- Unit of Colorectal Surgery, Department of Surgery, Complejo Hospitalario de Navarra, C/ Irunlarrea 3, Secretaría de Cirugía, Pabellón H3, E-31008, Pamplona, Spain
| | - Mario de Miguel Velasco
- Unit of Colorectal Surgery, Department of Surgery, Complejo Hospitalario de Navarra, C/ Irunlarrea 3, Secretaría de Cirugía, Pabellón H3, E-31008, Pamplona, Spain
| | - Miguel Ángel Ciga Lozano
- Unit of Colorectal Surgery, Department of Surgery, Complejo Hospitalario de Navarra, C/ Irunlarrea 3, Secretaría de Cirugía, Pabellón H3, E-31008, Pamplona, Spain
| |
Collapse
|
|
6
|
Villiger R, Cabalzar-Wondberg D, Zeller D, Frei P, Biedermann L, Schneider C, Scharl M, Rogler G, Turina M, Rickenbacher A, Misselwitz B. Perianal fistulodesis – A pilot study of a novel minimally invasive surgical and medical approach for closure of perianal fistulae. World J Gastrointest Surg 2021; 13:187-197. [PMID: 33643538 PMCID: PMC7898183 DOI: 10.4240/wjgs.v13.i2.187] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Revised: 11/20/2020] [Accepted: 12/23/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Perianal fistulae strongly impact on quality of life of affected patients.
AIM To challenge and novel minimally invasive treatment options are needed.
METHODS Patients with Crohn’s disease (CD) in remission and patients without inflammatory bowel disease (non-IBD patients) were treated with fistulodesis, a method including curettage of fistula tract, flushing with acetylcysteine and doxycycline, Z-suture of the inner fistula opening, fibrin glue instillation, and Z-suture of the outer fistula opening followed by post-operative antibiotic prophylaxis with ciprofloxacin and metronidazole for two weeks. Patients with a maximum of 2 fistula openings and no clinical or endosonographic signs of a complicated fistula were included. The primary end point was fistula healing, defined as macroscopic and clinical fistula closure and lack of patient reported fistula symptoms at 24 wk.
RESULTS Fistulodesis was performed in 17 non-IBD and 3 CD patients, with a total of 22 fistulae. After 24 wk, all fistulae were healed in 4 non-IBD and 2 CD patients (overall 30%) and fistula remained closed until the end of follow-up at 10-25 mo. In a secondary per-fistula analysis, 7 out of 22 fistulae (32%) were closed. Perianal disease activity index (PDAI) improved in patients with fistula healing. Low PDAI was associated with favorable outcome (P = 0.0013). No serious adverse events were observed.
CONCLUSION Fistulodesis is feasible and safe for perianal fistula closure. Overall success rates is at 30% comparable to other similar techniques. A trend for better outcomes in patients with low PDAI needs to be confirmed.
Collapse
Affiliation(s)
- Roxanne Villiger
- Department of Gastroenterology and Hepatology, University Hospital of Zurich, Zurich 8091, Switzerland
| | | | - Daniela Zeller
- Department of Surgery, Zeller Surgery, Zurich 8008, Switzerland
| | - Pascal Frei
- Department of Gastroenterology and Hepatology, University Hospital of Zurich, Zurich 8091, Switzerland
| | - Luc Biedermann
- Department of Gastroenterology and Hepatology, University Hospital of Zurich, Zurich 8091, Switzerland
| | - Christian Schneider
- Department of Gastroenterology and Hepatology, University Hospital of Zurich, Zurich 8091, Switzerland
| | - Michael Scharl
- Department of Gastroenterology, University Hospital of Zurich, Zurich 8091, Switzerland
| | - Gerhard Rogler
- Department of Gastroenterology and Hepatology, University Hospital of Zurich, Zurich 8091, Switzerland
| | - Matthias Turina
- Visceral- and Transplant Surgery, University Hospital of Zurich, Zurich 8091, Switzerland
| | - Andreas Rickenbacher
- Visceral- and Transplant Surgery, University Hospital of Zurich, Zurich 8091, Switzerland
| | - Benjamin Misselwitz
- Department of Gastroenterology and Hepatology, University Hospital of Zurich, Zurich 8091, Switzerland
- Visceral Surgery and Medicine, University Hospital of Bern, Bern 3010, Switzerland
| |
Collapse
|
|
7
|
Leila G, Saeideh P, Hajar K, Ali BP, Vahid HS, Ali N, Reza SA, Laleh M. A randomized trial study on the effect of amniotic membrane graft on wound healing process after anal fistulotomy. JOURNAL OF COLOPROCTOLOGY 2021. [DOI: 10.1016/j.jcol.2017.03.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Abstract
Objective Human amniotic membrane (HAM) used as a wound coverage for more than a century. The aim of this study is to evaluate the efficacy of amniotic membrane on wound healing and reduce post-operative complication.
Study design Randomized clinical trial study.
Place and duration of study Surgery Department, Shahid Faghihi Hospital, Shiraz, in the period of between Sep. 2014 and Nov. 2015.
Methodology 73 patients with anal fistula were divided into two groups. The patients suffered from simple perianal fistula (low type) without any past medical history. Fistulotomy were performed for all of them and in interventional group HAM were applied as biologic dressing. Their wound healing improvement was evaluated post-operative in two groups.
Results From 73 patients participated in the study, 36 patients were in control group and 37 patients were in intervention group. According to the analysis of images taken from the wound, the rate of wound healing was 67.39% in intervention group and 54.51% in control group (p < 0.001). Discharge, pain, itching and stool incontinency was lower in intervention group. Analysis of pathology samples taken from the wound showed no differences between two groups.
Conclusion HAM application could lead to improvement of wound healing and reduced post-operative complications. In conclusion, HAM may act as a biologic dressing in the patients with anal fistula.
Collapse
Affiliation(s)
- Ghahramani Leila
- Shiraz University of Medical Sciences, Colorectal Research Center, Shiraz, Iran
| | - Pirayeh Saeideh
- Shiraz University of Medical Sciences, Colorectal Research Center, Shiraz, Iran
| | - Khazraei Hajar
- Shiraz University of Medical Sciences, Colorectal Research Center, Shiraz, Iran
| | - Bagher pour Ali
- Shiraz University of Medical Sciences, Colorectal Research Center, Shiraz, Iran
| | | | - Noorafshan Ali
- Shiraz University of Medical Sciences, Anatomy Department, Stereology Research Center, Shiraz, Iran
| | - Safarpour Ali Reza
- Shiraz University of Medical Sciences, Gasteroentrohepatology Research Center, Shiraz, Iran
| | - Mousavi Laleh
- Shiraz University of Medical Sciences, Colorectal Research Center, Shiraz, Iran
| |
Collapse
|
|
8
|
Cheung XC, Fahey T, Rogers AC, Pemberton JH, Kavanagh DO. Surgical Management of Idiopathic Perianal Fistulas: A Systematic Review and Meta-Analysis. Dig Surg 2021; 38:104-119. [PMID: 33503621 DOI: 10.1159/000512652] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Accepted: 10/25/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND Perianal fistula is a common colorectal condition with an incidence of 9 per 100,000. Many surgical treatments exist, all aiming to eliminate symptoms with minimal risk of recurrence and impact upon continence. Despite extensive evaluation of the therapeutic modalities, no clear consensus exists as to what is the gold standard approach. This systematic review aimed to examine all available evidence pertaining to the surgical management of perianal fistulas. Primary outcomes examined were recurrence and incontinence. SUMMARY This study was conducted according to PRISMA guidelines. Primary outcomes were analyzed for each group and expressed as pooled odds ratio with confidence intervals of 95%. 687 studies were identified from which 28 relevant studies were included. There was no significant difference in rates of incontinence identified between various surgical approaches. Glues and plugs show higher recurrence rates. Newer treatments continue to emerge with promise but lack supporting evidence of benefit over conventional therapies. Key Messages: While we await more robust randomized data, we will continue to proceed cautiously trying to offset the benefits of fistula healing against the inherent risk of altered continence.
Collapse
Affiliation(s)
| | - Tom Fahey
- Department of Postgraduate Studies, RCSI, Dublin, Ireland
| | - Ailin C Rogers
- Department of Postgraduate Studies, RCSI, Dublin, Ireland
| | | | - Dara Oliver Kavanagh
- Department of Surgery, Tallaght University Hospital, Dublin, Ireland, .,Department of Surgical Affairs, RCSI, Dublin, Ireland,
| |
Collapse
|
|
9
|
Zahid A, Byrne C, Solomon MJ, Young CJ. Assessing Surgeons' Preferences in the Management of Fistula In Ano. Int Surg 2021; 105:483-488. [DOI: 10.9738/intsurg-d-16-00185.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/20/2025] Open
Abstract
Background
Fistula in ano is a common condition treated by surgeons worldwide. Despite this, there is a paucity of high-quality data to aid decision-making. Hence, management presents a difficult and frustrating dilemma for the treating surgeon.
Methods
A prospective regional survey was sent to all members of General Surgeons Australia. Questions regarding surgeon demographics, patient evaluation, perianal abscess, and simple and complex fistula in ano were presented.
Results
Equipoise exists in the management of fistula in ano among general surgeons. This was noted in the management of simple and complex fistula in ano.
Conclusion
Because of the uncertainty in certain clinical scenarios and a paucity of high-quality randomized controlled trials on the management of fistula in ano, evidence-based practice is a challenge to the treating surgeon.
Collapse
Affiliation(s)
- Assad Zahid
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Royal Prince Alfred Hospital, University of Sydney, Sydney, Australia
- Discipline of Surgery, Royal Prince Alfred Hospital, University of Sydney, Sydney, Australia
| | - Chris Byrne
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Royal Prince Alfred Hospital, University of Sydney, Sydney, Australia
- Surgical Outcome Research Centre (SOuRCe), Royal Prince Alfred Hospital, University of Sydney, Sydney, Australia
| | - Michael J Solomon
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Royal Prince Alfred Hospital, University of Sydney, Sydney, Australia
- Discipline of Surgery, Royal Prince Alfred Hospital, University of Sydney, Sydney, Australia
- Surgical Outcome Research Centre (SOuRCe), Royal Prince Alfred Hospital, University of Sydney, Sydney, Australia
| | - Christopher J. Young
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Royal Prince Alfred Hospital, University of Sydney, Sydney, Australia
- Discipline of Surgery, Royal Prince Alfred Hospital, University of Sydney, Sydney, Australia
| |
Collapse
|
|
10
|
Amato A, Bottini C, De Nardi P, Giamundo P, Lauretta A, Realis Luc A, Piloni V. Evaluation and management of perianal abscess and anal fistula: SICCR position statement. Tech Coloproctol 2020; 24:127-143. [PMID: 31974827 DOI: 10.1007/s10151-019-02144-1] [Citation(s) in RCA: 54] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2019] [Accepted: 12/23/2019] [Indexed: 02/07/2023]
Abstract
Perianal sepsis is a common condition ranging from acute abscess to chronic anal fistula. In most cases, the source is considered to be a non-specific cryptoglandular infection starting from the intersphincteric space. Surgery is the main treatment and several procedures have been developed, but the risks of recurrence and of impairment of continence still seem to be an unresolved issue. This statement reviews the pertinent literature and provides evidence-based recommendations to improve individualized management of patients.
Collapse
Affiliation(s)
- A Amato
- Coloproctology Unit, Department of Surgery, Borea Hospital, Sanremo, Italy.
| | - C Bottini
- Unit of Surgery, Hospital S. Antonio Abate, Gallarate, VA, Italy
| | - P De Nardi
- Gastrointestinal Surgery, San Raffaele Scientific Institute, Milan, Italy
| | - P Giamundo
- Department of Colorectal Surgery, Policlinico di Monza, Monza, Italy
| | - A Lauretta
- Unit of General Oncologic Surgery, Centro di Riferimento Oncologico di Aviano (CRO), IRCCS Aviano, Aviano, Italy
| | - A Realis Luc
- Coloproctology Unit, Hospital S. Rita, Vercelli, Italy
| | - V Piloni
- Diagnostic Imaging Centre "Diagnostica Marche", Osimo Stazione, Ancona, Italy
| |
Collapse
|
|
11
|
Amato A, Bottini C, De Nardi P, Giamundo P, Lauretta A, Realis Luc A, Piloni V. Evaluation and management of perianal abscess and anal fistula: SICCR position statement. Tech Coloproctol 2020; 24:127-143. [DOI: 14) evaluation and management of perianal abscess and anal fistula: siccr position statement.a.amato, c.bottini, p.de nardi, p.giamundo, a.lauretta, a.realis luc & v.piloni.tech coloproctol 2020 24:127-143 doi 10.1007/s10151-019-02144-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2019] [Accepted: 12/23/2019] [Indexed: 09/10/2023]
|
|
12
|
Baker L, Williams L, Winter R, Cahill C, Davis A, Fergusson D. Influence of adjuvant antibiotics on fistula formation following incision and drainage of anorectal abscesses: a systematic review protocol. Syst Rev 2019; 8:95. [PMID: 30987666 PMCID: PMC6463650 DOI: 10.1186/s13643-019-1002-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2018] [Accepted: 03/25/2019] [Indexed: 01/30/2023] Open
Abstract
BACKGROUND Development of fistula-in-ano following incision and drainage (I&D) of anorectal abscesses occurs in over 30% of patients. It is associated with significant patient morbidity and societal cost. The use of antibiotics following drainage is controversial, with randomized controlled trials reporting opposing conclusions regarding their influence on the rate of fistula formation. Given the significant burden associated with their development, it is imperative to determine strategies to minimize their occurrence. The objective of this review is to summarize the available evidence on the role of antibiotics following I&D of anorectal abscesses on fistula formation. Secondary objectives include determining if antibiotics are associated with morbidity, repeat presentation to the emergency department, and requirement for reoperation. METHODS/DESIGN MEDLINE, EMBASE, CINAHL, Cochrane Central Registry of Controlled Trials, http://apps.who.int/trialsearch , and clinicaltrials.gov will be searched to identify published and ongoing unpublished interventional and observational studies evaluating the role of antibiotics post I&D on the incidence of fistula formation. There will be no restriction on language, date, or journal. Title and abstracts as well as full texts will be screened in duplicate based on inclusion and exclusion criteria. The Cochrane Risk of Bias tool and ROBINS-I will be used to assess risk of bias in randomized and non-randomized studies, respectively. Our primary outcome is the incidence of fistula formation; secondary outcomes include morbidity, representation to ED, and reoperation. Study heterogeneity will be calculated with Cochran's Q test, P value, and I 2 index. SASS (version 9.4) will be used for meta-analysis. DISCUSSION This is the first study to review the available evidence on adjuvant antibiotics and incidence of fistula formation following I&D of anorectal abscesses. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42018092044.
Collapse
Affiliation(s)
- Laura Baker
- Department of Colorectal Surgery, Division of Surgery, The Ottawa Hospital, Ottawa, Canada
- Clinical Epidemiology Program, The University of Ottawa, Ottawa, Canada
- Department of Surgery, University of Ottawa, Ottawa, Canada
| | - Lara Williams
- Department of Colorectal Surgery, Division of Surgery, The Ottawa Hospital, Ottawa, Canada
- Faculty of Medicine, The University of Ottawa, Ottawa, Canada
| | - Remington Winter
- Department of Colorectal Surgery, Division of Surgery, The Ottawa Hospital, Ottawa, Canada
- Faculty of Medicine, The University of Ottawa, Ottawa, Canada
| | - Caitlin Cahill
- Department of Colorectal Surgery, Division of Surgery, The Ottawa Hospital, Ottawa, Canada
- Faculty of Medicine, The University of Ottawa, Ottawa, Canada
| | - Alexandra Davis
- Department of Surgery, University of Ottawa, Ottawa, Canada
- Library Services, The Ottawa Hospital, Ottawa, Canada
| | - Dean Fergusson
- Clinical Epidemiology Program, The University of Ottawa, Ottawa, Canada
- Ottawa Hospital Research Institute, Ottawa, Canada
| |
Collapse
|
|
13
|
Wang Q, He Y, Shen J. The best surgical strategy for anal fistula based on a network meta-analysis. Oncotarget 2017; 8:99075-99084. [PMID: 29228753 PMCID: PMC5716793 DOI: 10.18632/oncotarget.21836] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2017] [Accepted: 09/23/2017] [Indexed: 12/29/2022] Open
Abstract
OBJECTIVE To determine a superior surgical treatment for anal fistula through a network meta-analysis and to provide the best direction for development in this field. METHODS We conducted a systematic literature search of the PubMed, Embase and Cochrane Library databases and extracted data from randomized controlled trials, which compared healing time, incontinence and recurrence associated with surgical strategies for anal fistula. A network meta-analysis was conducted using ADDIS software by evaluating the 3 parameters. Cumulative probability values were utilized to rank the strategies under examination. Inconsistencies were also tested using node-splitting models. RESULTS Twenty articles with 1663 patients were included. Fistulotomy plus marsupialisation had the shortest healing time (P = 0.69). Seton placement was the best procedure to avoid postoperative incontinence (P = 0.66). Fistulectomy exhibited the lowest recurrence rate (Probability P = 0.40). In general, fistulotomy plus marsupialisation and surgical ligation plus biomaterial plugging revealed superior clinical efficacy. Node-splitting model testing revealed that no significant inconsistency existed in this research. CONCLUSIONS Fistulotomy plus marsupialisation exhibited preliminary superior surgical utility for anal fistula. Additionally, combination of surgical treatment with biomaterials may provide better clinical efficacy. These techniques may warrant consideration for future development in this field.
Collapse
Affiliation(s)
- Qi Wang
- The 1st Department of Gastrointestinal Surgery, Renmin Hospital of Wuhan University, Hubei Province, Wuhan 430060, P.R. China
| | - Yukun He
- Department of General Surgery, Zhongnan Hospital of Wuhan University, Hubei Province, Wuhan 430071, P.R. China
| | - Jun Shen
- Emergency Center, Zhongnan Hospital of Wuhan University, Hubei Province, Wuhan 430071, P.R. China
| |
Collapse
|
|
14
|
Mascagni D, Pironi D, Pontone S, Tonda M, Eberspacher C, Panarese A, Miscusi G, Grimaldi G, Catania A, Santoro A, Filippini A, Sorrenti S. Total fistulectomy, sphincteroplasty and closure of the residual cavity for trans-sphincteric perianal fistula in the elderly patient. Aging Clin Exp Res 2017; 29:101-108. [PMID: 27830517 DOI: 10.1007/s40520-016-0652-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2016] [Accepted: 10/12/2016] [Indexed: 12/19/2022]
Abstract
BACKGROUND Perianal fistula is a complex and frequent disease. At present, no treatment nor technique has shown an absolute superiority in terms of efficacy and recurrence rate. The technique has to be chosen considering the balance between faecal continence preservation and disease eradication. Rarely concomitant perianal abscess and fistula are treated at the same time, and often time to complete recovery is long. AIMS The aim of this study was to evaluate the possibility of treating the abscess and the fistula tract in one procedure with total fistulectomy, sphincteroplasty and an almost complete closure of the residual cavity, thus reducing the healing time in older patients. METHODS A non-randomized single-centre series of 86 patients from 2007 to 2012 with low-medium trans-sphincteric perianal fistula (< 30% of external sphincter involvement) with or without synchronous perianal abscess were treated with total fistulectomy, sphincteroplasty and closure of the residual cavity technique. RESULTS Success rate was 97.7% with a healing time of 4 weeks; overall morbidity was 16.2%; recurrence rate was 2.3%; no major alterations of continence were observed. DISCUSSION Fistulectomy, sphincteroplasty and closure of the residual cavity are associated with a low rate of recurrence and good faecal continence preservation in older patients. This technique can be safely used even with a concomitant perianal abscess, with reduction in healing time and in the number of surgical procedures needed. CONCLUSIONS Total fistulectomy with sphincteroplasty and partial closure of the residual cavity, as described, is a safe procedure but has to be performed by dedicated colorectal surgeons.
Collapse
Affiliation(s)
| | - Daniele Pironi
- Department of Surgical Sciences, Sapienza University, Rome, Italy.
| | - Stefano Pontone
- Department of Surgical Sciences, Sapienza University, Rome, Italy
| | - Maya Tonda
- Department of Surgical Sciences, Sapienza University, Rome, Italy
| | | | | | | | | | - Antonio Catania
- Department of Surgical Sciences, Sapienza University, Rome, Italy
| | - Alberto Santoro
- Department of Surgical Sciences, Sapienza University, Rome, Italy
| | - Angelo Filippini
- Department of Surgical Sciences, Sapienza University, Rome, Italy
| | | |
Collapse
|
|
15
|
Patel A, Gillespie C, Kiosoglous AJ. Unexpected complication after radical (inguinal) orchidectomy: trans-sphincteric anoscrotal fistula. BMJ Case Rep 2017; 2017:bcr-2016-218078. [PMID: 28073875 DOI: 10.1136/bcr-2016-218078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Anoscrotal fistula is an extremely rare condition involving an epithelialised tract between the anal canal and scrotal wall. It is more commonly seen as a congenital phenomenon in the paediatric population, and has not previously been described in the literature in adults. We present the case of a man aged 52 years who developed a complex anoscrotal fistula after a radical inguinal orchidectomy for an intratesticular seminoma. A postsurgical wound-site infection developed into a chronically discharging wound refractory to antibiotic treatment prompting further investigation. By way of MRI, a 10 cm long trans-sphincteric anoscrotal fistula was found. The patient was successfully treated by fistuloscopic curettage, internal closure using an Ovesco clip, and negative pressure dressing. We present for the first time a rare anoscrotal fistula in an adult.
Collapse
Affiliation(s)
- Amit Patel
- Department of Urology, Queen Elizabeth II Jubilee Hospital, Acacia Ridge, Queensland, Australia
| | - Chris Gillespie
- Department of General Surgery, Queen Elizabeth II Jubilee Hospital, Acacia Ridge, Queensland, Australia
| | - Anthony J Kiosoglous
- Department of Urology, Queen Elizabeth II Jubilee Hospital, Acacia Ridge, Queensland, Australia.,University of Queensland, School of Medicine and Surgery, Brisbane, Australia
| |
Collapse
|
|
16
|
Zawadzki A, Johnson LB, Bohe M, Johansson C, Ekelund M, Nielsen OH. An open prospective study evaluating efficacy and safety of a new medical device for rectal application of activated carbon in the treatment of chronic, uncomplicated perianal fistulas. Int J Colorectal Dis 2017; 32:509-512. [PMID: 27878619 PMCID: PMC5355500 DOI: 10.1007/s00384-016-2726-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/18/2016] [Indexed: 02/04/2023]
Abstract
PURPOSE It has been proposed that biological/chemical substances in the intestine might play a role in the occurrence and deterioration of perianal fistulas. Elimination of such unidentified factors from the lower gastrointestinal tract might offer a new strategy for the management of anal fistulas. The aim of this study was to evaluate the clinical effects on non-Crohn's disease perianal fistula healing, and the safety and tolerability of a new medical device that applies high-purity, high-activity granular activated carbon locally into the rectum twice daily of patients with perianal fistulas without any concomitant medication. METHODS An open, single-arm, prospective study with active treatment for 8 weeks and an optional follow-up until week 24 ( ClinicalTrial.gov identifier NCT01462747) among patients with chronic, uncomplicated perianal fistulas scheduled for surgery was conducted. RESULTS Of 28 patients included, 10 patients (35.7%) showed complete fistula healing (closed, no discharge on palpation) after 8 weeks; seven of these patients, corresponding to 25% of the enrolled patients, remained in remission for up to 31 weeks. At week 8, there was a statistically significant reduction in the discharge visual analog scale (p = 0.04), a significant improvement in the patient-perceived quality of life for the category of embarrassment (p = 0.002), and a trend toward improvement in the other assessment categories. CONCLUSIONS The treatment was well tolerated, and patient acceptance was high. The results support the efficacy and safety of locally administered activated carbon for the treatment of patients with chronic uncomplicated perianal fistulas not receiving any other medication for fistula problems.
Collapse
Affiliation(s)
- Antoni Zawadzki
- Department of Clinical Sciences, Division of Surgery, Skåne University Hospital, Lund University, Malmö, Sweden
| | - Louis Banka Johnson
- Department of Clinical Sciences, Division of Surgery, Skåne University Hospital, Lund University, Malmö, Sweden
| | - Måns Bohe
- Department of Clinical Sciences, Division of Surgery, Skåne University Hospital, Lund University, Malmö, Sweden
| | - Claes Johansson
- Department of Surgery, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Mats Ekelund
- Department of Clinical Sciences, Division of Surgery, Skåne University Hospital, Lund University, Malmö, Sweden
| | - Ole Haagen Nielsen
- Department of Gastroenterology D112, Medical Section, Herlev Hospital, University of Copenhagen, Herlev Ringvej 75, DK-2730 Herlev, Denmark
| |
Collapse
|
|
17
|
Rafferty JF, Snyder JR. Reoperative surgery for persistent anal fistulae. SEMINARS IN COLON AND RECTAL SURGERY 2015. [DOI: 10.1053/j.scrs.2015.09.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
|
|
18
|
Köckerling F, Alam NN, Narang SK, Daniels IR, Smart NJ. Treatment of Fistula-In-Ano with Fistula Plug - a Review Under Special Consideration of the Technique. Front Surg 2015; 2:55. [PMID: 26528482 PMCID: PMC4607815 DOI: 10.3389/fsurg.2015.00055] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2015] [Accepted: 09/30/2015] [Indexed: 12/13/2022] Open
Abstract
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.
Collapse
Affiliation(s)
- Ferdinand Köckerling
- Department of Surgery and Center for Minimally Invasive Surgery, Academic Teaching Hospital of Charité Medical School, Vivantes Hospital , Berlin , Germany
| | - Nasra N Alam
- Exeter Surgical Health Services Research Unit (HeSRU), Royal and Exeter Hospital , Exeter , UK
| | - Sunil K Narang
- Exeter Surgical Health Services Research Unit (HeSRU), Royal and Exeter Hospital , Exeter , UK
| | - Ian R Daniels
- Exeter Surgical Health Services Research Unit (HeSRU), Royal and Exeter Hospital , Exeter , UK
| | - Neil J Smart
- Exeter Surgical Health Services Research Unit (HeSRU), Royal and Exeter Hospital , Exeter , UK
| |
Collapse
|
|
19
|
Amato A, Bottini C, De Nardi P, Giamundo P, Lauretta A, Realis Luc A, Tegon G, Nicholls RJ. Evaluation and management of perianal abscess and anal fistula: a consensus statement developed by the Italian Society of Colorectal Surgery (SICCR). Tech Coloproctol 2015; 19:595-606. [PMID: 26377581 DOI: 10.1007/s10151-015-1365-7] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2015] [Accepted: 08/11/2015] [Indexed: 12/14/2022]
Abstract
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.
Collapse
Affiliation(s)
- A Amato
- Department of Surgery, Coloproctology Unit, Hospital of Sanremo, Via Borea, 56, Sanremo, IM, Italy.
| | - C Bottini
- Deparment of Surgery, Hospital S. Antonio Abate, Gallarate, VA, Italy
| | - P De Nardi
- Division of Gastrointestinal Surgery, San Raffaele Scientific Institute, Milan, Italy
| | - P Giamundo
- Deparment of General Surgery, Hospital Santo Spirito, Bra, CN, Italy
| | - A Lauretta
- Department General Surgery, Hospital Santa Maria dei Battuti, San Vito al Tagliamento, PD, Italy
| | - A Realis Luc
- Coloproctology Unit, Hospital S. Rita, Vercelli, Italy
| | - G Tegon
- Proctology Unit, Hospital S. Camillo, Treviso, Italy
| | - R J Nicholls
- Emeritus Consultant Surgeon, St Mark's Hospital, London, England, UK
| |
Collapse
|
|
20
|
Göttgens KWA, Smeets RR, Stassen LPS, Beets G, Breukink SO. Systematic review and meta-analysis of surgical interventions for high cryptoglandular perianal fistula. Int J Colorectal Dis 2015; 30:583-93. [PMID: 25487858 DOI: 10.1007/s00384-014-2091-8] [Citation(s) in RCA: 65] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/01/2014] [Indexed: 02/04/2023]
Abstract
PURPOSE 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. 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 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. 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 mucosa advancement flap is the most investigated technique available.
Collapse
Affiliation(s)
- K W A Göttgens
- Department of Surgery, Maastricht University Medical Centre, Post box 5800, 6202 AZ, Maastricht, The Netherlands,
| | | | | | | | | |
Collapse
|
|
21
|
Murphy PD, Papettas T. Surgical Management of Crohn’s Disease. CROHN'S DISEASE 2015:143-161. [DOI: 10.1007/978-3-319-01913-0_11] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/05/2025]
|
|
22
|
Mendes CRS, Ferreira LSDM, Sapucaia RA, Lima MA, Araujo SEA. Video-assisted anal fistula treatment: technical considerations and preliminary results of the first Brazilian experience. ACTA ACUST UNITED AC 2014; 27:77-81. [PMID: 24676305 PMCID: PMC4675488 DOI: 10.1590/s0102-67202014000100018] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2013] [Accepted: 12/19/2013] [Indexed: 01/28/2023]
Abstract
BACKGROUND Anorectal fistula represents an epithelized communication path of infectious origin between the rectum or anal canal and the perianal region. The association of endoscopic surgery with the minimally invasive approach led to the development of the video-assisted anal fistula treatment. AIM To describe the technique and initial experience with the technique video-assisted for anal fistula treatment. TECHNIQUE A Karl Storz video equipment was used. Main steps included the visualization of the fistula tract using the fistuloscope, the correct localization of the internal fistula opening under direct vision, endoscopic treatment of the fistula and closure of the internal opening which can be accomplished through firing a stapler, cutaneous-mucosal flap, or direct closure using suture. RESULTS The mean distance between the anal verge and the external anal orifice was 5.5 cm. Mean operative time was 31.75 min. In all cases, the internal fistula opening could be identified after complete fistuloscopy. In all cases, internal fistula opening was closed using full-thickness suture. There were no intraoperative or postoperative complications. After a 5-month follow-up, recurrence was observed in one (12.5%) patient. CONCLUSION Video-assisted anal fistula treatment is feasible, reproducible, and safe. It enables direct visualization of the fistula tract, internal opening and secondary paths.
Collapse
Affiliation(s)
| | | | | | - Meyline Andrade Lima
- Hospital Santa Izabel, Santa Casa de Misericordia da Bahia, Salvador, BA, Brazil
| | | |
Collapse
|
|
23
|
Sheikh P, Baakza A. Management of Fistula-in-Ano-The Current Evidence. Indian J Surg 2014; 76:482-6. [PMID: 25614724 PMCID: PMC4297991 DOI: 10.1007/s12262-014-1150-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2014] [Accepted: 07/16/2014] [Indexed: 01/06/2023] Open
Abstract
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.
Collapse
Affiliation(s)
- Parvez Sheikh
- />Department of Colorectal Surgery, Saifee Hospital, Laud Mansion, 3rd floor, 21 M. Karve Road, Mumbai, 400004 India
| | - Atef Baakza
- />K.J. Somaiya Medical College, Sion, Mumbai, India
| |
Collapse
|
|
24
|
Vergara-Fernandez O, Espino-Urbina LA. Ligation of intersphincteric fistula tract: What is the evidence in a review? World J Gastroenterol 2013; 19:6805-6813. [PMID: 24187455 PMCID: PMC3812479 DOI: 10.3748/wjg.v19.i40.6805] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2013] [Revised: 08/13/2013] [Accepted: 08/20/2013] [Indexed: 02/06/2023] Open
Abstract
Broadly, complex fistulas are those that are not low transsphincteric or intersphincteric. The objectives of surgical management are to achieve fistula healing, prevent recurrences and maintain continence. The risk of incontinence associated with treatment ranges from 10% to 57%. The objective of this manuscript is to review the current literature to date on the ligation of the intersphincteric fistula tract procedure (LIFT procedure) as a treatment option in these types of fistula. A search was conducted in Medline, PUBMED, EMBASE and ISI Web of Knowledge, and studies published from January 2009 to May 2013 were included. The primary outcomes were fistula healing rates, mean healing time and patient satisfaction with this surgical technique. Eighteen studies were included in this review. The total number of patients included was 592 (65% male). The median age reported was 42.8 years. The most common type of fistula included was transsphincteric (73.3% of cases). The mean healing rate reported was 74.6%. The risk factors for failure discovered were obesity, smoking, multiple previous surgeries and the length of the fistula tract. The mean healing time was 5.5 wk, and the mean follow-up period was 42.3 wk. The patient satisfaction rates ranged from 72% to 100%. No de novo incontinence developed secondary to the LIFT procedure. There is not enough evidence that variants in the surgical technique achieve better outcomes (Bio-LIFT, LIFT-Plug, LIFT-Plus). This review indicates that the LIFT procedure is primarily effective for transsphincteric fistulas with an overall fistula closure of 74.6% and has a low impact on fecal continence. This procedure produces better outcomes at the first surgical attempt.
Collapse
|
|
25
|
Abstract
CRYPTOGLANDULAR ANAL FISTULA: Perianal abscesses are caused by cryptoglandular infections. Not every abscess will end in a fistula. The formation of a fistula is determined by the anatomy of the anal sphincter and perianal fistulas will not heal on their own. The therapy of a fistula is oriented between a more aggressive approach (operation) and a conservative treatment with fibrin glue or a plug. Definitive healing and the development of incontinence are the most important key points. ANAL FISSURES: Acute anal fissures should be treated conservatively by topical ointments, consisting of nitrates, calcium channel blockers and if all else fails by botulinum toxin. Treatment of chronic fissures will start conservatively but operative options are necessary in many cases. Operation of first choice is fissurectomy, including excision of fibrotic margins, curettage of the base and excision of the sentinel pile and anal polyps. Lateral internal sphincterotomy is associated with a certain degree of incontinence and needs critical long-term observation.
Collapse
Affiliation(s)
- W Heitland
- Klinik für Viszeral-, Thorax- und Gefässchirurgie, Klinikum München Bogenhausen, Städtisches Klinikum München GmbH, Englschalkinger Str. 77, 81925, München, Deutschland.
| |
Collapse
|
|
26
|
Cirocchi R, Trastulli S, Morelli U, Desiderio J, Boselli C, Parisi A, Noya G. The treatment of anal fistulas with biologically derived products: is innovation better than conventional surgical treatment? An update. Tech Coloproctol 2012. [PMID: 23207714 DOI: 10.1007/s10151-012-0948-9] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
New technical approaches involving biologically derived products have been applied in the treatment for anal fistulas in order to avoid the risk of fecal incontinence. The aim of this review was to evaluate the scientific evidence present in the literature regarding these techniques. Trials comparing surgery (fistulotomy, advancement mucosal flap closure and placement of seton) versus fibrin glue, fistula plug or acellular dermal matrix were considered. In fibrin glue versus traditional surgical treatment the healing rate was higher in the surgery group, and the recurrence rate was lower in the traditional surgery group, but these results were not statistically relevant. In acellular dermal matrix (ADM) versus traditional surgical treatment the recurrence rate of fistulas was significantly lower in the ADM group, but non-significant differences were recorded in incontinence and anal deformity. Our review shows that there are no significant advantages of the new techniques involving biologically derived products. Further randomized controlled trials are needed.
Collapse
Affiliation(s)
- Roberto Cirocchi
- Department of General Surgery, St. Maria Hospital, University of Perugia, Via Tristano di Joannuccio, 05100, Terni, Italy
| | | | | | | | | | | | | |
Collapse
|
|
27
|
Sheikh P. Controversies in fistula in ano. Indian J Surg 2012; 74:217-20. [PMID: 23730047 DOI: 10.1007/s12262-012-0594-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2012] [Accepted: 05/15/2012] [Indexed: 12/16/2022] Open
Abstract
Managing a complex fistula in ano can be a daunting task for most surgeons; largely due to the two major dreaded complications-recurrence & fecal incontinence. It is important to understand the anatomy of the anal sphincters & the aetiopathological process of the disease to provide better patient care. There are quite a few controversies associated with fistula in ano & its management, which compound the difficulty in treating fistula in ano. This article attempts to clear some of those major controversies.
Collapse
Affiliation(s)
- Parvez Sheikh
- Saifee Hospital, Mumbai, India ; Nova Specialty Center, Mumbai, India
| |
Collapse
|
|
28
|
Ommer A, Herold A, Berg E, Fürst A, Sailer M, Schiedeck T. Cryptoglandular anal fistulas. DEUTSCHES ARZTEBLATT INTERNATIONAL 2011; 108:707-13. [PMID: 22114639 PMCID: PMC3221436 DOI: 10.3238/arztebl.2011.0707] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/12/2011] [Accepted: 07/21/2011] [Indexed: 02/06/2023]
Abstract
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, 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. 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.
Collapse
|
|
29
|
Bleier JIS, Moloo H. Current management of cryptoglandular fistula-in-ano. World J Gastroenterol 2011; 17:3286-91. [PMID: 21876615 PMCID: PMC3160531 DOI: 10.3748/wjg.v17.i28.3286] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2010] [Revised: 09/02/2010] [Accepted: 09/09/2010] [Indexed: 02/06/2023] Open
Abstract
Fistula-in-ano is a difficult problem that physicians have struggled with for centuries. Appropriate treatment is based on 3 central tenets: (1) control of sepsis; (2) closure of the fistula; and (3) maintenance of continence. Treatment options continue to evolve - as a result, it is important to review old and new options on a regular basis to ensure that our patients are provided with up to date information and options. This paper will briefly cover some of the traditional approaches that have been used as well as some newer promising procedures.
Collapse
|
|
30
|
Fucini C, Giani I. Why do we have to review our experience in managing cases with idiopathic fistula-in-ano regularly? World J Gastroenterol 2011; 17:3297-9. [PMID: 21876617 PMCID: PMC3160533 DOI: 10.3748/wjg.v17.i28.3297] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2010] [Revised: 11/12/2010] [Accepted: 11/19/2010] [Indexed: 02/06/2023] Open
Abstract
“Why do we have to review our experience in managing idiopathic fistula-in-ano regularly?” In order to answer this apparently simple question, we reviewed our clinical and surgical cases and most important relevant literature to find a rational and scientific answer. It would appear that whatever method you adopt in fistula management, there is a price to pay regarding either rate of recurrence (higher with conservative methods) or impairment of continence (higher with traditional surgery). Since, at the moment, reliable data to identify a treatment as a gold standard in the management of anal fistulas are lacking, the correct approach to this condition must consider all the anatomic and clinicopathological aspects of the disease; this knowledge joined to an eclectic attitude of the surgeon, who should be familiar with different types of treatment, is the only guarantee for a satisfactory treatment. As a conclusion, it is worthwhile to remember that adequate initial treatment significantly reduces recurrence, which, when it occurs, is usually due to failure to recognise the tract and primary opening at the initial operation.
Collapse
|
|
31
|
Bleier JI, Moloo H. Management of Cryptoglandular Fistula-in-Ano. SEMINARS IN COLON AND RECTAL SURGERY 2011. [DOI: 10.1053/j.scrs.2010.09.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
|