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.     

Appraisal of the LIFT and BIOLIFT procedure: initial experience and short-term outcomes of 33 consecutive patients

Purpose

A new sphincter-saving technique known as the LIFT (ligation of intersphincteric tract) procedure has gained growing interest. Use of a bioprosthetic device has also been suggested to augment the LIFT procedure (BIOLIFT). This study evaluates outcomes of patients undergoing LIFT and BIOLIFT for repair of complex anal fistulae.

Methods

This study is a single-surgeon, single-centre retrospective review of a prospectively collected database. Study was conducted at Royal Prince Alfred Hospital Department of Colorectal Surgery, Sydney, Australia, from May 2009 to April 2012. Thirty-three patients were evaluated. Twenty-nine LIFTs and five BIOLIFT procedures were evaluated. Primary success is defined as successful healing from initial procedure while secondary success is successful healing after management of failure or recurrence.

Results

In a cohort of predominantly female (67 %) and 94 % transsphincteric fistulae, primary success was 63 %. At a median follow-up of 20 weeks (6–81 weeks), there were 11 failures and one recurrence. The median time to failure/recurrence was 3 weeks (1–25 weeks). Six patients had a subsequent fistulotomy and three patients had a BIOLIFT for non-successful outcomes. The median follow-up for those with failures/recurrences is 60 weeks (range 20–76 weeks) and secondary success was 88 %. Post-operative anal manometry studies showed a 9 % reduction of resting and 11 % reduction of squeeze pressures but this was not statistically significant. There was also no post-operative incontinence. Anterior fistulas were noted do significantly worse (47%) compared with non-anteriorly located fistulas (84 %; p?=?0.03).

Conclusions

LIFT and BIOLIFT procedures can be performed safely and effectively in a technically demanding study cohort of predominantly females with complex fistulas. Anterior fistulas have a higher risk of failure but present early and are amendable to repeat procedures. In particular, fistulotomies are useful in downstaged tracts and performing BIOLIFTs is an alternative in the management of LIFT failures and recurrences     

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.     

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.     

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.

     

Early outcomes of fluorescence angiography in the setting of endorectal mucosa advancement flaps

Background

Fistula-in-ano has a reported incidence of 31–34%. Besides fistulotomy, options for fistula repair are seton placement, endorectal advancement flap (ERAF), fibrin sealant, anal fistula plug and ligation of the intersphincteric fistula tract. Despite having a reported success rate as high as 75–98%, ERAF is not without complications, including flap breakdown, recurrence and fecal incontinence. Traditionally, maintaining a broad base to preserve blood supply has been advocated to reduce flap failure. And the aim of the present study was to evaluate outcomes of adult patients who underwent ERAF for complex fistula-in-ano with the use of intraoperative fluorescence angiography (FA) at our institution between July 2014 and July 2016.

Methods

We retrospectively reviewed consecutive cases of complex fistula-in-ano repair with ERAF and FA from a prospectively maintained dataset of adult patients with complex fistula-in-ano. Demographics, intraoperative data and 60-day outcomes were recorded and reviewed.

Results

Six patients [five males and one female with a mean age of 40 years (range 25–46 years)], with a total of seven fistulas, were identified. Six (85.7%) of these patients had undergone prior surgery for fistula-in-ano. No recurrences or complications of any type were noted at 2-week and 8-week follow-up. The majority of patients (71.4%) required flap revision based on intraoperative FA prior to flap fixation.

Conclusions

FA is safe and offers real-time assessment of flap perfusion prior to and after fixation in anal fistula repair. The rate of flap ischemia may be underestimated, and therefore, to improve outcomes in ERAF, intraoperative FA should be included in the surgical armamentarium.

     

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.

     

Easy clip to treat anal fistula tracts: a word of caution

Background and aims

Closing the internal opening by a clip ovesco has been recently proposed for healing the fistula tract, but, to date, data on benefit are poorly analyzed. The aim was to report a preliminary multicenter experience.

Materials and methods

Retrospective study was undertaken in six different French centers: surgical procedure, immediate complications, and follow-up have been collected.

Results

Nineteen clips were inserted in 17 patients (M/F, 4/13; median age, 42 years [29–54]) who had an anal fistula: 12 (71 %) high fistulas (including 4 rectovaginal fistulas), 5 (29 %) lower fistulas (with 3 rectovaginal fistulas), and 6 (35 %) Crohn’s fistulas. Out of 17 patients, 15 had a seton drainage beforehand. The procedure was easy in 8 (47 %) patients and the median operative time was 27.5 min (20–36.5). Postoperative period was painful for 11 (65 %) patients. A clip migration was noted in 11 patients (65 %) after a median follow-up of 10 days (5.5–49.8). Eleven patients (65 %) who failed had reoperation including 10 new drainages within the first month (0.5–5). After a mean follow-up of 4 months (2–7),, closing the tract was observed in 2 patients (12 %) following the first insertion of the clip and in another one after a second insertion.

Conclusion

Treatment of anal fistula by placing a clip on the internal opening is disappointing and deleterious for some patients. A better assessment before dissemination is recommended.

     

An experience with video-assisted anal fistula treatment (VAAFT) with new insights into the treatment of anal fistulae

Background

The aim of this retrospective study was to assess our experience of 41 patients with anal fistulae treated with video-assisted anal fistula treatment (VAAFT).

Methods

Forty-one consecutive patients with cryptoglandular anal fistulae were included. Patients with low intersphincteric anal fistulae or those with gross perineal abscess were excluded. Eleven (27 %) patients had undergone prior fistula surgery with 5 (12 %) having had three or more previous operations.

Results

All patients underwent the diagnostic phase as well as diathermy and curettage of the fistula tracts during VAAFT. Primary healing rate was 70.7 % at a median follow-up of 34 months. Twelve patients recurred or did not heal and underwent a repeat VAAFT procedure utilising various methods of dealing with the internal opening. There was a secondary healing rate of 83 % with two recurrences. Overall, stapling of the internal opening had a 22 % recurrence rate, while anorectal advancement flap had a 75 % failure rate. There was no recurrence seen in six cases after using the over-the-scope-clip (OTSC^®) system to secure the internal opening.

Conclusions

VAAFT is useful in the identification of fistula tracts and enables closure of the internal opening. Adequate closure is essential with the method used to close large or fibrotic internal openings being the determining factor for success or failure. The OTSC system delivered the most consistent result without leaving a substantial perianal wound. Ensuring thorough curettage and drainage of the tract during VAAFT is also important to facilitate healing. We believe that this understanding will bring about a decrease in the high recurrence rates currently seen in many series of anal fistulae.

     

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.

     

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.     

Video-assisted anal fistula treatment (VAAFT) combined with advancement flap repair in Crohn’s disease

Background

It was the aim of this prospective study to analyze both the feasibility and preliminary results of video-assisted anal fistula treatment (VAAFT) combined with advancement flap repair for complex fistulas in Crohn's disease.

Methods

All patients with perianal Crohn's disease suffering from complex fistulas who underwent definitive surgery using VAAFT combined with advancement flap repair were prospectively enrolled in the study. Only complex fistulas with concurrent stable disease and without any evidence of severe inflammatory activity or perianal sepsis were treated using the VAAFT technique. Patients with Crohn's proctitis or prior proctectomy were not candidates for the procedure. VAAFT was performed by using the VAAFT equipment (Karl Storz, Tuttlingen, Germany). Key steps included visualization of the fistula tract and/or side tracts using the fistuloscope and correct localization of the internal fistula opening under direct vision with irrigation. Diagnostic fistuloscopy was followed by advancement flap repair. In addition to feasibility, primary end points included detection of side tracts, success and continence status (assessed by the Cleveland Clinic Incontinence Score). 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 and 9 months postoperatively.

Results

Within a 3-month observation period (September to November 2011), VAAFT was attempted in 13 patients with Crohn's associated complex fistulas. The completion rate was 85 % (11/13). In these 11 patients (median age 34 years, 64 % females), complex fistulas were transsphincteric (8), suprasphincteric (2) and recto-vaginal (1). Forty-six percent (5/11) had concomitant therapy with biologic drugs. In 36 % (4/11), VAAFT was performed with fecal diversion. Median duration of surgery was 22 (range 18–42) minutes. Using VAAFT, additional side tracts not detected preoperatively could be identified in 64 % (7/11). No morbidity occurred. After a mean follow-up of 9 months, the success rate was 82 % (9/11). No deterioration of continence was documented (Cleveland Clinic Incontinence Score 2.4 vs. 1.6, p > 0.05).

Conclusion

Preliminary results of the addition of the VAAFT technique to advancement flap repair in Crohn's fistulas demonstrate that this leads to a high identification rate of occult side tracts with encouraging short-term healing rates. Moreover, a completion rate of 85 % seems promising.     

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.     

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.

     

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.     

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.     

Comparison of porcine collagen paste injection and rectal advancement flap for the treatment of complex cryptoglandular anal fistulas: a 2-year follow-up study

Background

Rectal advancement flap is the standard surgical treatment for complex cryptoglandular anal fistulas, while Permacol? collagen paste is considered an innovative treatment option for anorectal fistulas. This study aimed to compare the clinical outcomes of patients with complex cryptoglandular fistulas treated by endorectal advancement flap versus Permacol? paste.

Methods

This study was a retrospective analysis of patients with complex cryptoglandular anal fistulas. Thirty-one patients were treated with the rectal advancement flap (RAF group), while 21 were treated with Permacol? paste injection (PP group). In PP group, the approach consisted of loose seton positioning followed several weeks later by closure internal opening with a resorbable sutures associated with paste injection into the fistula track. Clinical outcomes were assessed in terms of healing rate, faecal continence and patient satisfaction.

Results

Seton drainage was done in all patients in both groups for a median duration of 8 weeks (range 4–18 weeks) before the final surgery (p?=?0.719). No patient had faecal incontinence (CGS ≥ 5) preoperatively. Five patients (16%) in the RAF group and one (5%) in the PP group experienced faecal incontinence postoperatively. The 2-year disease-free survival was 65% in the RAF group and 52% in the PP group (p?=?0.659). The median satisfaction scores were 5 (range 1–10) in the RAF group and 7 (range 2–10) in the PP group (p?=?0.299).

Conclusion

The RAF appeared superior to PP in terms of fistula healing, although this result was not statistically significant. On the contrary, PP has a potential advantage in terms of continence disorders. Permacol? paste can be considered as the initial treatment option for complex cryptoglandular anal fistulas in patients with faecal continence disorders.

     

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.     

Micro-fragmented adipose tissue injection for the treatment of complex anal fistula: a pilot study accessing safety and feasibility

Background

The aim of the present study was to evaluate the safety and efficacy of autologous, micro-fragmented and minimally manipulated adipose tissue injection associated closure of the internal opening in promoting healing of complex anal fistula.

Methods

A pilot study was conducted on patients referred to our center with anal fistula, from April 2015–December 2016. Inclusion criteria were age over 16 years old and a diagnosis of complex anal fistula according to the American Gastroenterological Association classification The patients were divided into 2 groups; the “first time group” (Group I) in which micro-fragmented adipose tissue injection with closure of the internal opening was the first sphincter-saving procedure, and the “recurrent group” (Group II) consisting of patients who had failed prior sphincter-saving procedures. The procedure was carried out 4–6 weeks after seton placement. Follow-up visits were scheduled at 7 days, and 1, 3, 6 and 12 months after surgery. Fistula healing was defined as the closure of the internal and external openings without any discharge.

Results

Out of 47 patients with complex transsphincteric anal fistula, 19 met the inclusion criteria and were selected to undergo the procedure. Twelve of these patients (Group I) had micro-fragmented adipose tissue injection as first-line treatment, and 7 (Group II) had failed previous sphincter-saving procedures. The mean operative time was 55 ± 6 min (range 50–70 min). The mean postoperative pain score measured with the visual analog pain scale was 2 ± 1.4 (range 0–4). No intraoperative difficulties related to the use of the kit were recorded. There were no cases of postoperative fever or abdominal sepsis related to the procedure and no post-treatment perianal bleeding or impaired anal continence. Only 3 cases of minor abdominal wall hematoma that did not require any treatment and 1 case of perianal abscess were observed. Patients were evaluated for a mean follow-up time of 9 ± 3.1 months (range 3–12 months). The overall healing rate was 73.7, 83.3% for Group I and 57.1% for Group II.

Conclusions

The injection of autologous, micro-fragmented and minimally manipulated adipose tissue associated with closure of the internal opening is a safe, feasible and reproducible procedure and may enhance complex anal fistula healing.

     

Die Fistulotomie

Purpose

The optimal treatment for high/complex anal fistulas remains unclear. We studied one surgeon??s results over a 10-year period, concentrating on high fistulas.

Methods

Demographic, fistula anatomy and treatment data were recorded for all patients undergoing surgery for anal fistula. Outcome data were recorded for patients who had been followed-up for a minimum of 4?weeks.

Results

In all, 180?patients were studied. Outcome data were available for 52 low and 84 high fistulas. Fistulotomy was performed for 50 low and 48 high fistulas, with closure rates of 98% and 96%, respectively. Fistula recurrence was seen in two patients with high fistulas. Symptoms of sphincter disturbance were similar after lay open of both low and high fistulas. The treatment of high fistulas by drainage seton had a lower rate of inadvertent passage of flatus but a similar rate of minor soiling compared with fistulotomy.

Conclusions

Lay open of low and high anal fistulas is effective and associated with a similar, predictable rate of minor sphincter disturbance, affecting a third to a quarter of patients with mild leakage of flatus and mucus. Patients with high fistulas can be cured; however, in case of doubt, a second opinion should be sought from an expert centre before definitive intervention.