Fistulectomy with primary sphincter reconstruction in the treatment of high transsphincteric anal fistulas

Purpose

The treatment of transsphincteric anal fistulas is a challenge between recurrence rate and incontinence. Many surgical and conservative procedures have been described in the treatment of anal fistulas. Fistulectomy and primary sphincter reconstruction (FPSR) has not gained great popularity in this field due to the risk of sphincter damage. The aim of this study is to evaluate FPSR in the treatment of transsphincteric fistulas.

Methods

We retrospectively analyzed 50 patients with high transsphincteric fistulas of cryptoglandular origin that were treated with FPSR between 2005 and 2008. Preoperative assessment included physical and proctologic examination. Continence and pain scores were evaluated preoperatively and postoperatively.

Results

In our 50 patients, 22 patients (44 %) had a previous proctologic operation and 11 patients (22 %) presented with recurrent fistulas. The fistulas existed for an average of 8 months. The operation time was 28?±?16 min. Mean follow-up was 22± months. The fistula healed in 44 patients (88 %) who developed no recurrence. In five patients (10 %), the fistula healed, but they developed a recurrence in the observation period. In one patient (2 %), the fistula did not heal. Three patients developed low-grade incontinence for flatus, and one patient with 2° incontinence improved. Preoperatively and postoperatively calculated continence and pain scores showed a slight but significant elevation in the Clinical Continence Score, the German Society of Coloproctology Score showed no significant difference, and preexisting pain was reduced significantly by surgery.

Conclusions

FPSR is a safe surgical procedure for the treatment of high transsphincteric anal fistula. The primary healing rate is high with a low risk of recurrence or incontinence.     

S3-Leitlinie: Kryptoglanduläre Analfisteln

Background

With an incidence of 2 in 10,000/year, fistula-in-ano of cryptoglandular origin is a common disease, affecting predominantly young males. Incorrect treatment can adversely effect quality of life, particularly in terms of stool continence.

Methods

A systematic review of the literature has been undertaken.

Results

Since relevant randomized studies are scant, the level of evidence is low. The classification of anal fistulas depends on the relation between fistula channel and anal sphincter. Anamnesis and clinical examination are sufficient to establish the indication for surgery. In addition, an intraoperative probe and/or staining of the fistula channel should be performed. Endoanal ultrasound and magnetic resonance tomography are similar in predictive value. These modalities may be able to provide additional information in complex fistulas. The treatment of anal fistulas consists of one of the following surgical procedures: lay-open technique, seton drainage, plastic reconstruction with suture of the sphincter or occlusion with biomaterials. The lay-open technique should only be performed in superficial fistulas. The risk of impaired postoperative continence increases with the thickness of the divided sphincter muscle. A sphincter-saving procedure should be undertaken for all high anal fistulas. The results of the different techniques using plastic reconstruction are largely comparable. A lower healing rate is seen with occlusion using biomaterials.

Conclusion

This clinical S3 guideline provides instructions for the diagnosis and treatment of cryptoglandular fistula-in-ano for the first time in Germany.     

Combined partial fistulectomy and electro-cauterization of the intersphincteric tract as a sphincter-sparing treatment of complex anal fistula: clinical and functional outcome

Background

The aim of this study was to report a simple, effective and safe procedure, associated with minimal risk of incontinence and recurrence, for treating complex anal fistulas.

Methods

This was a prospective study of 53 consecutive patients with complex anal fistulas. The technique used included excision of the distal part of the fistula tract down to the external anal sphincter and electro-cauterization of the intersphincteric part of the tract with simple closure of the internal opening. Data collected included patient characteristics, fistula type determined by magnetic resonance imaging, pre- and postoperative continence status evaluated using the Wexner incontinence score (0–10), previous operations, hospital stay, healing time, recurrence rate and complications.

Results

The patients had a mean age of 41.37 ± 7.82 years; the most frequent fistula type was the high transsphincteric fistula; the mean follow-up period was 19 months with a success rate of 92.5 %; the mean wound healing time was 3.6 weeks; the incontinence scores were the same as before the procedure. The recurrence rate was 7.5 %.

Conclusions

Partial fistulectomy combined with electrocauterization of the intersphincteric fistula tract is a simple, and effective procedure for the treatment of complex anal fistulas.     

Treatment of Complex Anal Fistulas with the Collagen Fistula Plug

Purpose

Anal fistulas that involve a significant amount of sphincter may be difficult to treat without compromising continence function. In this study, we evaluated our experience with the Surgisis® anal fistula plug, which was recently reported to be successful in >80 percent of patients with complex fistulas.

Methods

We retrospectively collected patient and fistula characteristics, procedure details, and follow-up information for all patients treated with the anal fistula plug at our institution from January 2006 through April 2007. The outcome was considered successful if the external opening was closed and if the patient had no drainage at the last follow-up. Using multivariate statistics, we analyzed the relationship between anal fistula plug success and several key variables.

Results

From January 2006 through April 2007, 47 patients with 49 complex anal fistulas underwent 64 anal fistula plug procedures. The median follow-up time for patients who were considered healed was 6.5 (range, 3–11) months. The success rate was 31 percent per procedure and 43 percent per patient. An increased amount of external sphincter involvement was associated with a higher failure rate (P?

Conclusions

In our early experience with the anal fistula plug, 43 percent of patients with complex anal fistulas were successfully treated. Patients with less external sphincter involvement were more likely to heal.

     

Fistulectomy with primary sphincter reconstruction

Aim

Despite modern medical techniques, anatomically proximal (high) anal fistulas are still a challenge in colorectal surgery. In previous years, the standard of care was complete fistulectomy with a high rate of continence disorders. Over the past 20 to 30 years, sphincter-saving procedures have gained wide acceptance. They represent the technique used in these cases. Additionally, many patients received indefinite treatment, namely the placement of a seton to maintain surgical drainage. The main problem with all fistula surgical possibilities is the high recurrence rate of 30 to 50% in flap procedures and 100% persistence in seton treatments. In recent years, a direct repair (primary reconstruction) in distal fistulas was instigated and shows excellent results. It allowed our technique for proximal (high) anal fistulas to evolve.

Method

All patients who underwent surgery at the University Medical Center Mannheim, Department of Colo-proctology (from 06/2003 to 11/2015), were retrospectively evaluated using a prospective database. Patients who underwent fistulectomy with primary sphincter reconstruction were all included.

Results

The primary healing rate, after a mean follow-up of 11 months (7 to 200 months), was 88.2% (374 of 424). Taking into account revisionary surgeries with secondary sphincter repair, this rate reaches 95.8% (406 of 424). Factors such as gender and fistula location as related to the sphincter had significant influence on the study outcome, whereas variables such as the amount of reconstructed muscle (in mm), number of revisions, patient age, other anal operations, and concomitant medication did not. The incontinence of a subgroup of 148 patients was evaluated in detail by way of a questionnaire. Even at a preoperative baseline, 9.6% of those patients reported some minor degree of continence disorders. After the procedure, incontinence disorders were observed in 34 patients (23.0%), with 23 of these patients suffering from flatus incontinence (15.5%), 10 patients from liquid incontinence (6.8%), and 1 patient from solid fecal incontinence.

Conclusion

Fistulectomy with primary sphincter reconstruction is a feasible procedure resulting in a low recurrence rate. No other procedure has shown better results in transsphincteric fistulas. Continence disorders seem to be of minor relevance/consequence for these patients.

     

Efficacy of Anal Fistula Plug in Closure of Cryptoglandular Fistulas: Long-Term Follow-Up

Purpose

The long-term efficacy of Surgisis^® anal fistula plug in closure of cryptoglandular anorectal fistulas was studied.

Methods

Patients with high cryptoglandular anorectal fistulas were prospectively studied. Additional variables recorded were: number of fistula tracts, and presence of setons. Under general anesthesia and in prone jackknife position, patients underwent irrigation of the fistula tract by using hydrogen peroxide. Each primary opening was occluded by using a Surgisis^® anal fistula plug, which was securely sutured in place at the primary opening and tacked to the periphery of the secondary opening.

Results

Forty-six patients were prospectively enrolled during a two-year period. Follow-up was six months to two years (median, 12 months). At final follow-up, all fistula tracts had been successfully closed in 38 patients, for an overall success rate of 83 percent. Seven patients had multiple tracts, for a total of 55 fistula tracts in the series. Of the 55 individual tracts, 47 (85 percent) were closed at final follow-up. Patients with one primary opening were most likely to have successful closure by using the anal fistula plug, although this was not significant. Successful closure was not correlated with the presence of setons.

Conclusions

Long-term closure of cryptoglandular anorectal fistula tracts using Surgisis^® anal fistula plug is safe and successful in 83 percent of patients and 85 percent of tracts.     

Hybrid seton for the treatment of high anal fistulas: results of 128 consecutive patients

Background

The aim of this study was to evaluate our experience in managing high anal fistulas with a simple modification of the cutting seton.

Methods

We performed a retrospective review of standardized patient charts and of prospectively collected scores and questionnaires. Surgical outcomes of 128 consecutive, well-documented patients with high anal fistulas, including anterior transsphincteric fistulas in females, treated using a hybrid seton, were analyzed.

Results

No significant complications occurred. The mean postoperative pain scores on a visual analog scale were 3.23 and 0.61, on days 1 and 7, respectively. Complete healing was achieved in 67 cases (52.3 %) at 1 month and in all cases (100 %) at 3 months. Recurrent fistula was noted in 2 patients (1.5 %) at 6 and 12 months. The mean postoperative incontinence scores at 3 and 12 months did not differ significantly from the preoperative score (p = 0.061, Wilcoxon’s test). The depression, life style, and embarrassment item scores of the fecal incontinence quality of life index improved significantly after surgical treatment.

Conclusions

The results of this series suggest that the hybrid seton might be a valid alternative for the treatment of high anal fistulas, eliminating the need for postoperative adjustments. The slow and stable cutting of the sphincter seems to have a positive effect on the maintenance of continence. The successful outcome is associated with significant improvement in quality of life.     

S3-Leitlinie: Analabszess

Background

Anal abscesses are relatively frequent and most common in young men.

Methods

A systematic review of the literature has been undertaken.

Results

The origin of the abscess is usually the proctodeal gland in the intersphincteric space. There are different types of abscesses: intersphincteric, ischioanal and supralevatory abscesses. Anamnesis and clinical examination are sufficient to indicate surgery. Further examinations such as endosonography or magnetic resonance tomography (MRT) should be considered in recurrent or supralevatory abscesses. The timing of surgical intervention depends on clinical symptoms, whereas the acute abscess is an emergency indication. Surgery is the primary therapy approach for anal abscess. Surgical access (transrectal or perianal) depends on the localization of the abscess. The aim of surgery is to broadly drain the infection and protect anal sphincter structures. The wound should be rinsed regularly (showering with clear water). Treatment with local antiseptics carries the risk of zytotoxicity. Antibiotic treatment is necessary only in selected cases. Any attempt to locate a fistula intraoperatively should be undertaken with great care; proven evidence of a fistula is not mandatory. Although the risk of recurrent abscess or secondary fistula is low, these may be caused by insufficient drainage. The primary fistulotomy of superficial fistulas should only be performed by an experienced surgeon. In the case of ambiguous findings or high fistulas, treatment should be carried out in a second surgical procedure.

Conclusion

For the first time in Germany, this clinical S3 guideline provides instructions for the diagnosis and treatment of anal abscesses based on a systematic review of the literature.     

Initial experience of treating anal fistula with the Surgisis anal fistula plug

Background

Complex anal fistulas remain a challenge for the colorectal surgeon. The anal fistula plug has been developed as a simple treatment for fistula-in-ano. We present and evaluate our experience with the Surgisis anal fistula plug from two centres.

Methods

Data were prospectively collected and analysed from consecutive patients undergoing insertion of a fistula plug between January 2007 and October 2009. Fistula plugs were inserted according to a standard protocol. Data collected included patient demographics, fistula characteristics and postoperative outcome.

Results

Forty-four patients underwent insertion of 62 plugs (27 males, mean age 45.6?years), 25 of whom had prior fistula surgery. Mean follow-up was 10.5?months Twenty-two patients (50%) had successful healing following the insertion of plug with an overall success rate of 23 out of 62 plugs inserted (35%). Nineteen out of 29 patients healed following first-time plug placement, whereas repeated plug placement was successful in 3 out of 15 patients (20%; p?=?0.0097). There was a statistically significant difference in the healing rate between patients who had one or less operations prior to plug insertion (i.e. simple fistulas) compared with patients who needed multiple operations (18 out of 24 patients vs. 4 out of 20 patients; p?=?0.0007).

Conclusions

Success of treatment with the Surgisis anal fistula plug relies on the eradication of sepsis prior to plug placement. Plugs inserted into simple tracts have a higher success rate, and recurrent insertion of plugs following previous plug failure is less likely to be successful. We suggest the fistula plug should remain a first-line treatment for primary surgery and simple tracts.     

German S3 guideline: anal abscess

Background

The incidence of anal abscess is relatively high, and the condition is most common in young men.

Methods

A systematic review of the literature was undertaken.

Results

This abscess usually originates in the proctodeal glands of the intersphincteric space. A distinction is made between subanodermal, intersphincteric, ischioanal, and supralevator abscesses. The patient history and clinical examination are diagnostically sufficient to establish the indication for surgery. Further examinations (endosonography, MRI) should be considered in recurrent abscesses or supralevator abscesses. The timing of the surgical intervention is primarily determined by the patient's symptoms, and acute abscess is generally an indication for emergency treatment. Anal abscesses are treated surgically. The type of access (transrectal or perianal) depends on the abscess location. The goal of surgery is thorough drainage of the focus of infection while preserving the sphincter muscles. The wound should be rinsed regularly (using tap water). The use of local antiseptics is associated with a risk of cytotoxicity. Antibiotic treatment is only necessary in exceptional cases. Intraoperative fistula exploration should be conducted with extreme care if at all; no requirement to detect fistula should be imposed. The risk of abscess recurrence or secondary fistula formation is low overall, but they can result from insufficient drainage. Primary fistulotomy should only be performed in case of superficial fistulas and by experienced surgeons. In case of unclear findings or high fistulas, repair should take place in a second procedure.

Conclusion

In this clinical S3 guideline, instructions for diagnosis and treatment of anal abscess are described for the first time in Germany.     

Quantifying the extent of fistulotomy. How much sphincter can we safely divide? A three-dimensional endosonographic study

Purpose

To quantify the longitudinal division of the internal anal sphincter (IAS) and external anal sphincter (EAS) after fistulotomy using three-dimensional endoanal ultrasound (3D-EAUS) and correlate the results with postoperative faecal incontinence.

Methods

A prospective, consecutive study was performed from December 2008 to October 2010. All patients underwent 3D-EAUS before and 8?weeks after surgery. Thirty-six patients with simple perianal fistula were included. Patients with an intersphincteric or low transphincteric fistula (<66% sphincter involved) without risk factors for incontinence underwent fistulotomy. The outcome measures were the longitudinal extent of division of the IAS and EAS in relation to total sphincter length and continence (Jorge and Wexner scores).

Results

One-year follow-up revealed a 0% recurrence rate. There was a strong correlation between preoperative 3D-EAUS measurement of fistula height with intraoperative and postoperative 3D-EAUS measurement of IAS and EAS division (p?p?>?0.05).

Conclusions

In patients without risk factors, division of the EAS during fistulotomy limited to the lower two thirds of the EAS is associated with excellent continence and cure rates.     

Fistelspaltung und prim?re Sphinkterrekonstruktion zur Behandlung von Analfisteln

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.     

S3-Leitlinie: Kryptoglanduläre Analfisteln

Background

Fistula-in-ano of cryptoglandular origin is a common disease with an incidence of 2 per 10,000 inhabitants per year and the peak incidence is in young male adults. Inadequate treatment can have adverse effects on the quality of life and in particular lead to a reduction of fecal continence.

Methods

A new systematic review of the literature was performed based on the S3 guidelines published in 2011 in order to develop updated guidelines for anal fistulas.

Results

Relevant randomized studies are rare and the level of evidence is generally low. The classification and diagnostics of anal fistulas are still based on the unchanged recommendations from the previous publication. The therapy of anal fistulas can be performed by one of the following operative procedures: fistulotomy or lay-open technique, drainage seton, plastic surgery reconstruction techniques including suturing of the sphincter or occlusion with biomaterials. The new ligation of the intersphincteric fistula tract (LIFT) technique was presented in several studies. The results with respect to healing rates and continence disorders largely correspond to those of plastic reconstruction techniques. The assessment of other new techniques, such as laser, video-assisted anal fistula treatment (VAAFT) and over the scope (OTS) clips, is currently not possible due to a lack of representative literature. The lay-open technique should only be performed in cases of superficial fistulas. The risk of postoperative incontinence increases with the amount of sphincter muscle incised. In cases of high anal fistulas a sphincter preserving procedure should be preferred. The results of the various reconstruction techniques are relatively similar. Using biomaterials for occlusion the healing rate is much lower than originally reported. An assessment of the importance of new materials, such as plugs, collagen and autologous stem cells, is also not possible due to a lack of evidence.

Conclusion

These revised S3 guidelines provide evidence-based protocols and recommendations for the diagnostics and treatment options of cryptoglandular fistula-in-ano based on the currently available literature.

     

Analfistelplug

Background

The anal fistula plug has been introduced as a new procedure for the treatment of high anal fistulas. The aim of this review is to demonstrate and evaluate the current literature.

Methods

This publication is based on a systematic review of the available English and German publications.

Results

A total of 36 relevant publications were identified which present results of the two plugs used in Germany from Cook and Gore, respectively. Also two reviews in the English language were evaluated. Results concerning the fistula plug procedure are quite heterogeneous showing healing rates ranging from 14% to more than 90%. Two randomized studies reported a success rate of 20% and 29%, respectively for the Biodesign Plug formerly known as the Surgisis-Plug.Continence disorders after plug implantation were evaluated only in a few studies and newly developed disorders seem to be rare. Loss of the plug in the early postoperative period seems to be a problem. New plug models may balance this disadvantage by a better fixation of the plug to the underlying muscle. Currently there are no reproducible results for this new plug design.

Conclusion

The results presented in the current literature allow only limited conclusions to be drawn for the plug procedure. In spite of the low success rate the plug seems to be an alternative to conventional treatment for high anal fistulas due to the lower invasiveness of the procedure.     

Autologous Fibrin Glue in Treatment of Fistula in Ano

Aim: This study was done to assess the efficacy and advantage of fibrin glue therapy in anal fistulae in comparison to conventional treatment. Patients and Method: The results of treatment of anal fistula by autologous fibrin tissue adhesive in 30 patients were compared with those obtained by conventional surgery in another 30 patients. All patients in both procedures had preoperative mechanical bowel preparations and preoperative intravenous antibiotic. The two groups were matched for age, sex, fistula type and follow-up duration. Results: The non-invasive fibrin glue application was extremely satisfactory in 24 patients out of 30 patients (80%), two healed after another attempt, three showed no postoperative improvement and one patient developed intersphincteric abscess (morbidity 3.3%) Median hospital stay was 1.5 days, while patients' discomfort was minimal. There was no postoperative impairment of anal sphincter function and there was no recurrence. In the group undergoing laying open operations, recurrence occurred in five patients, median hospital stay was 3.1 days, and strong analgesia was needed. Continence disorder occurred in four patients, one patient remained incontinent only for flatus, in two patients minimal soiling persists for more than three months follow-up. Conclusion In conclusion, the above data showed that fibrin glue application in anal fistula is a simple, easy, safe, and effective procedure, although longer follow-up and bigger series are needed.     

Pro-inflammatory cytokines in cryptoglandular anal fistulas

Background

Sphincter-preserving procedures for the treatment of transsphincteric fistulas fail in at least one out of every three patients. It has been suggested that failure is due to ongoing disease in the remaining fistula tract. Cytokines play an important role in inflammation. At present, biologicals targeting cytokines are available. Therefore, detection and identification of cytokines in anal fistulas might have implications for future treatment modalities. The objective of the present study was to assess local production of a selected panel of cytokines in anal fistulas, including pro-inflammatory interleukin (IL)-1β and tumor necrosis factor α (TNF-α).

Methods

Fistula tract tissue was obtained from 27 patients with a transsphincteric fistula of cryptoglandular origin who underwent flap repair, ligation of the intersphincteric fistula tract or a combination of both procedures. Patients with a rectovaginal fistula or a fistula due to Crohn’s disease were excluded. Frozen tissue samples were sectioned and stained using advanced immuno-enzyme staining methods for detection of selected cytokines, IL-1β, IL-8, IL-10, IL-12p40, IL-17A, IL-18, IL-36 and TNF-α. The presence and frequencies of cytokine-producing cells in samples were quantitated.

Results

The key finding was abundant expression of IL-1β in 93 % of the anal fistulas. Frequencies of IL-1β-producing cells were highest (>50 positive stained cells) in 7 % of the anal fistulas. Also, cytokines IL-8, IL-12p40 and TNF-α were present in respectively 70, 33 and 30 % of the anal fistulas.

Conclusions

IL-1β is expressed in the large majority of cryptoglandular anal fistulas, as well as several other pro-inflammatory cytokines.

     

Initial experience on efficacy in closure of cryptoglandular and Crohn’s transsphincteric fistulas by the use of the anal fistula plug

Background and aims

It was the aim of this prospective study to analyze the efficacy of the Cook Surgisis® AFP? anal fistula plug (AFP) for the closure of cryptoglandular and Crohn’s disease-associated transsphincteric anorectal fistulas.

Materials and methods

All patients with transsphincteric anorectal fistulas who underwent a surgical procedure using the AFP were prospectively enrolled in this study. Inclusion criteria included transsphincteric, single-tract fistulas. Patients’ demographics, fistula etiology, surgical variables, continence (Cleveland Clinic Florida incontinence score), quality of life (fecal incontinence quality of life), and success rates were prospectively recorded. Surgery was performed in a standardized technique including irrigation of the fistula tract, placement, and internal fixation of the Cook Surgisis® AFP? anal fistula plug. No flap or excision of the fistula tract was performed. Success was defined as closure of both internal and external openings, absence of drainage without further intervention, and absence of abscess formation. Follow-up information was derived from clinical examination 3, 6, 9, and 12 months postoperatively.

Results

Within 6 months (August 2006 to January 2007), a total of 19 AFPs were inserted in 19 patients (8 females, 11 males; mean age, 38 years). Out of 19 patients, 12 had cryptoglandular and 7 had Crohn’s associated transsphincteric fistulas. Three patients were smokers, one patient had methicillin-resistant Staphylococcus aureus infection. Mean operative time was 15 min (range, 8–22); no morbidity occurred. After a mean follow-up of 279 days (SD?=?68.0) and one patient lost to follow-up, the overall success rate was 61% (12 of 18) at 9 months postoperatively. Focusing solely on cryptoglandular fistulas, the success rate was 45.5% (5 of 11), whereas it was 85.7% (6 of 7) in transsphincteric fistulas associated with Crohn’s disease. Five patients with failure of AFP (plug dislodgement, n?=?2; persistent secretion, n?=?3) had reoperation (27.8%). The reasons for failure were infection requiring drainage (n?=?2) and persistent drainage (n?=?3). No deterioration of continence was documented.

Conclusion

The success rate for the Cook Surgisis® AFP? anal fistula plug for the closure of complex anorectal fistulas both in cryptoglandular and Crohn’s associated fistulas was 45.5 and 85.7%, respectively. Further analysis is needed to explain the definite role of this innovative technique in comparison to traditional surgical techniques.     

Permacol™ collagen paste injection for the treatment of complex anal fistula: 1-year follow-up

Background

Optimal surgical treatment for anal fistula should result in healing of the fistula track and preserve anal continence. The aim of this study was to evaluate Permacol? collagen paste (Covidien plc, Gosport, Hampshire, UK) injection for the treatment of complex anal fistulas, reporting feasibility, safety, outcome and functional results.

Methods

Between May 2013 and December 2014, 21 consecutive patients underwent Permacol paste injection for complex anal fistula at our institutions. All patients underwent fistulectomy and seton placement 6–8 weeks before Permacol? paste injection. Follow-up duration was 12 months.

Results

Eighteen patients (85.7%) had a high transsphincteric anal fistula, and three female patients (14.3%) had an anterior transsphincteric fistula. Fistulas were recurrent in three patients (14.3%). Seven patients (33%) had a fistula with multiple tracts. After a follow-up of 12 months, ten patients were considered healed (overall success rate 47.6%). The mean preoperative FISI score was 0.33 ± 0.57 and 0.61 ± 1.02 after 12 months.

Conclusions

Permacol? paste injection was safe and effective in some patients with complex anal fistula without compromising continence.

     

High resolution magnetic resonance imaging of the anal sphincter using a dedicated endoanal coil

PURPOSE: To obtain high resolution images of the anal sphincter and adjacent anorectum using an endoanal coil in patients with sepsis, trauma, and low rectal tumors and to compare imaging appearances with findings at time of surgery. PATIENTS AND METHODS: A cylindrical saddle geometry coil (diameter, 9 mm; length, 75 mm) was used to examine 30 patients (mean age, 53.6 years). Pathologies included perianal sepsis (10 patients), obstetric trauma (7 patients), and low rectal tumors (13 patients). Imaging was performed on an 0.5-T Picker Asset or 1.0-T Picker HPQ Vista (Picker International, Highland Heights, OH). T ₁ and T ₂ weighted and short inversion time inversion recovery transverse images and T ₁ weighted coronal images were obtained. Intravenous gadopentetate dimeglumine (0.1 mmol/kg) was given to all patients with suspected infection and neoplasms. RESULTS: Abscesses and fistulas identified using magnetic resonance imaging (MRI) in patients with perianal sepsis were confirmed at surgery in all cases; site of fistulous internal opening into the anal canal was correctly identified in 80 percent of cases. Extent of sphincter tear was correctly assessed on endoanal MRI in all patients with obstetric trauma when compared with surgical findings. Tumor invasion of anal sphincter was seen in 38.5 percent of low rectal carcinomas. CONCLUSIONS: MRI with an endoanal coil provides detailed images of the site and extent of anal fistulas, sphincter tears, and local tumors and is of considerable value in preoperative assessment.     

Results of the Gore Bio-A fistula plug implantation in the treatment of anal fistula: a multicentre study

Background

The aim of this prospective study was to determine the efficiency of the Gore Bio-A synthetic plug in the treatment of anal fistulas.

Methods

A synthetic bioabsorbable anal fistula plug was implanted in 60 patients. All fistulas were transsphincteric and cryptoglandular in origin.

Results

The healing rate after 1 year of follow-up was 52 % (31 out of 60 patients). No patient was lost to follow-up. The treatment had no effect on the incontinence score. The plug dislodgement rate was 10 % (6 out of 60 patients). Thirty-four per cent of the patients (16 out of 47) required reoperation. The average operating time was 32 ± 10.2 min, and the average length of hospital stay was 3.3 ± 1.8 days.

Conclusions

Synthetic plugs may be an alternative to bioprosthetic fistula plugs in the treatment of transsphincteric anal fistulas. This method might have better success rates than treatment with bioprosthetic fistula plugs.