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1.
A. Herold A. Ommer A. Fürst F. Pakravan D. Hahnloser B. Strittmatter T. Schiedeck F. Hetzer F. Aigner E. Berg M. Roblick D. Bussen A. Joos S. Vershenya 《Techniques in coloproctology》2016,20(8):585-590
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.2.
B. Fabiani C. Menconi J. Martellucci I. Giani G. Toniolo G. Naldini 《Techniques in coloproctology》2017,21(3):211-215
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.3.
R. S. van Onkelen M. P. Gosselink M. van Meurs M. J. Melief W. R. Schouten J. D. Laman 《Techniques in coloproctology》2016,20(9):619-625
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.4.
Purpose
Initial success rates for fibrin glue ablation of cryptoglandular transsphincteric fistulas have been disappointing. We examined long-term outcomes after initially successful fibrin glue ablation of cryptoglandular transsphincteric fistulas.Methods
Retrospective review identified 36 adult patients with cryptoglandular transsphincteric fistula Tisseel VH® fibrin glue ablation that was performed from May 2000 to March 2005. Fibrin glue ablations were performed under supervision of fellowship-trained colorectal surgeons. Follow-up interval was based on time until recurrence of fistula or time of last fistula-free evaluation.Results
Twenty-four men and 12 women patients had a mean age of 50 (range, 27–85) years. Twenty patients responded to initial fibrin glue ablation treatment. Two additional patients healed with secondary fibrin glue ablation. Sixty-six percent (22/33 patients) of cryptoglandular transsphincteric fistulas were closed at three months. Eleven patients failed fibrin glue ablation at a mean of 33 (range, 6–41) days. Seventeen of 22 short-term success patients (3 months) were available for long-term follow-up. Ninety-four percent (16/17 patients) remained healed at final long-term follow-up. The remaining patient recurred just before the six-month follow-up.Conclusions
Despite the suboptimal early success rate of fibrin glue ablation for cryptoglandular transsphincteric fistulas, when a fistula does close for at least six months this appears to be a durable closure. A single patient recurred after appearing healed at the three-month check.5.
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.6.
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.7.
Purpose
This study aims to evaluate pubovisceral muscle and anal sphincter defects in women with previous vaginal delivery and fecal incontinence and to correlate the findings with the severity of symptoms using the combined anorectal and endovaginal 3D ultrasonography with a new ultrasound scoring system.Methods
Consecutive female patients with previous vaginal delivery and fecal incontinence symptoms were screened. Fecal incontinence was assessed with the Cleveland Clinic Florida fecal incontinence scale, and the extent of defects was assessed by an ultrasound score based on results of anorectal and endovaginal 3D ultrasound. Fecal incontinence was assessed with the Cleveland Clinic Florida fecal incontinence scale.Results
Of 84 women with previous vaginal delivery and fecal incontinence, 21 (25%) had intact pubovisceral muscles and anal sphincters; 63 (75%) had a pubovisceral muscle or anal sphincter defect, or both. Twenty-eight (33%) had a pubovisceral muscle defect [23% with an external anal sphincter (EAS) defect or combined EAS/internal anal sphincter defects; 11% with intact anal sphincters]. Thirty-five (42%) had intact pubovisceral muscles and an anal sphincter defect. Compared with women with intact pubovisceral muscles/anal sphincter defects, patients with pubovisceral muscle defects had significantly higher incontinence scores and significantly higher ultrasound scores indicating more extensive defects. Incontinence symptoms correlated positively with the ultrasound score, measurements of sphincter defects, and area of the levator hiatus.Conclusions
Evaluation of both pubovisceral muscles and anal sphincters is important to identify defects and determine treatment for women with fecal incontinence after vaginal delivery. The severity of fecal incontinence symptoms is significantly related to the extent of defects of the pubovisceral muscles and anal sphincters.8.
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.9.
Operative Verfahren bei hohen kryptoglandulären Analfisteln: Systematische Übersicht und Metaanalyse
K. W. A. Göttgens R. R. Smeets L. P. S. Stassen G. Beets S. O. Breukink 《coloproctology》2016,38(2):93-105
Purpose
Perianal fistulas, and specifically high perianal fistulas, remain a challenge for surgical treatment. Many techniques have been and are still being developed to improve the outcome after surgery. A systematic review and meta-analysis was performed for surgical treatment of 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 mucosal advancement flap versus the fistula plug, and did not show a result in favour of either technique in recurrence or complication rate. The mucosal advancement flap was the most investigated technique but did not show any 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 the intersphincteric fistula tract, sphincter reconstruction, sphincter-preserving seton and techniques combined with antibiotics. None of these techniques seemed 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 mucosal advancement flap is the most investigated technique available.10.
Aim
Obstetric anal sphincter injuries are a significant risk factor for faecal incontinence. Correct identification and successful primary repair are important. The aim of this study was to review the outcome of all patients, with an obstetric anal sphincter injury, referred to our unit.Method
This is a retrospective review of 1495 patients over a 12-year period. All had a third or fourth degree tear and were referred at 4-months postpartum.Results
Endoanal ultrasonography demonstrated residual sphincter defect in 792 (53%) and normal sphincters, with no evidence of repair, in 661 (44%). The majority of injuries involved both the external and internal sphincters (n = 501). Significant reductions in resting pressure and voluntary squeeze pressures were seen when those with a sphincter defect were compared to those with intact sphincters. However, there was no significant difference in the mean (SD) Cleveland Clinic faecal incontinence scores (5.8 (5.8) and 4.3 (5.5), p = 0.8).Conclusion
Third and fourth degree tears appear to be over diagnosed. Primary repair appears to be unsuccessful in the majority of cases. There appears to be poor correlation between objective and subjective assessment of sphincter function.11.
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.12.
A. Arroyo P. Moya M. A. Rodríguez-Prieto M. J. Alcaide M. M. Aguilar M. Bellón M. T. Pérez-Vázquez F. Candela R. Calpena 《Techniques in coloproctology》2017,21(2):149-153
Background
Photodynamic therapy (PDT) is a new procedure for the treatment of anal fistula. This preliminary study was designed to investigate the safety and effectiveness of this new technique in the treatment of anal fistula.Methods
Ten patients were treated with PDT. Intralesional 5-aminolevulinic acid (ALA) 2% was directly injected into the fistula. The internal and external orifices were closed. After an incubation period of 2 h, the fistula was irradiated using an optical fibre connected to a red laser (MULTIDIODE 630 PDT, INTERmedic, Spain) operating at 1 W/cm for 3 min (180 Joules). Patient demographics, operation notes and complications were recorded.Results
There were no complications. The average length of patient follow-up was 14.9 months (range 12–20 months). We could observe primary healing in eight patients (80%). Two patients (20%) showed persistence of suppuration after the operation. No patient reported incontinence postoperatively.Conclusions
PDT is a potential sphincter-saving procedure that is safe, simple and minimally invasive and has a high success rate.13.
Purpose
Sparing the extrinsic autonomic innervation of the internal anal sphincter during total mesorectal excision is important for the preservation of anal sphincter function. This study electrophysiologically confirmed the topography of the internal anal sphincter nerve supply during laparoscopic-assisted transanal minimally invasive surgery for total mesorectal excision.Methods
This prospective study was conducted at two large multispecialty referral centers. Six patients (five males and one female) aged between 45 and 65 years with low rectal cancer (≤5 cm from the anal verge) were enrolled. Surgery was performed under electric stimulation of the pelvic autonomic nerves with observation of the electromyographic signals of the internal anal sphincter.Results
The minimally invasive transanal surgical approach enabled advantageous visualization of the pelvic autonomic nerves in all patients. In particular, extrinsic innervation to the internal anal sphincter near the levator muscle was consciously spared under electrophysiological confirmation. The evoked absolute electromyographic amplitudes of the internal anal sphincter during transanal minimally invasive surgery were significantly lower than the initial results of the laparoscopic approach [3.7 μV (interquartile range 2.4; 5.7) vs. 4.3 μV (interquartile range 3.1; 8.6); p?=?0.002]. Five key zones of risk for pelvic autonomic nerve damage were identified. No complications occurred.Conclusions
The electromyographic results of this preliminary study indicate advantages for sparing the internal anal sphincter innervation during transanal minimally invasive mesorectal dissection considering the specific in situ neuroanatomical topography.14.
Purpose
Sparing the extrinsic autonomic innervation of the internal anal sphincter during total mesorectal excision is important for the preservation of anal sphincter function. This study electrophysiologically confirmed the topography of the internal anal sphincter nerve supply during laparoscopicassisted transanal minimally invasive surgery for total mesorectal excision.Methods
This prospective study was conducted at two large multispecialty referral centers. Six patients (five males and one female) aged between 45 and 65 years with low rectal cancer (≤5 cm from the anal verge) were enrolled. Surgery was performed under electric stimulation of the pelvic autonomic nerves with observation of the electromyographic signals of the internal anal sphincter.Results
The minimally invasive transanal surgical approach enabled advantageous visualization of the pelvic autonomic nerves in all patients. In particular, extrinsic innervation to the internal anal sphincter near the levator muscle was consciously spared under electrophysiological confirmation. The evoked absolute electromyographic amplitudes of the internal anal sphincter during transanal minimally invasive surgery were significantly lower than the initial results of the laparoscopic approach (3.7 μV (interquartile range 2.4; 5.7) vs. 4.3 μV (interquartile range 3.1; 8.6); p = 0.002). Five key zones of risk for pelvic autonomic nerve damage were identified. No complications occurred.Conclusions
The electromyographic results of this preliminary study indicate advantages for sparing the internal anal sphincter innervation during transanal minimally invasive mesorectal dissection considering the specific in situ neuroanatomical topography.15.
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.16.
Cigdem Benlice Merve Yildiz Semih Baghaki Ilknur Erguner Deniz Cebi Olgun Sebnem Batur Sibel Erdamar Pinar Ambarcioglu Ismail Hamzaoglu Tayfun Karahasanoglu Bilgi Baca 《International journal of colorectal disease》2016,31(2):291-299
Purpose
The treatment of high transsphincteric fistula is a complex procedure, which may be associated with the risk of recurrence and fecal incontinence. In this study, we used an animal model to compare different types of sphincter-preserving treatments for transsphincteric fistula.Methods
Sixteen female New Zealand rabbits, weighing 2.8–4.8 kg underwent a surgical creation of high transsphincteric fistula. After 6 weeks, magnetic resonance imaging (MRI) was performed in order to confirm fistula formation and measure the fistula diameter. The rabbits were divided into three groups. Group 1 received no plug treatment (control). Autologous dermal graft and acellular dermal matrix were used as a plug in groups 2 and 3, respectively. Five weeks after treatment, fistula tract healing was determined by measuring the largest fistula diameter with MRI. All rabbits were euthanized and the anorectum excised en bloc for histopathological examination.Results
According to the MRI findings, all groups showed significant healing after the treatment (p?<?0.05). The healing rate of fistula diameters after treatment was 40, 66, and 29 % in the control, dermal graft, and acellular dermal matrix groups, respectively. In terms of negative healing parameters such as neutrophil, eosinophil, lymphocyte, and plasmocyte accumulation, dermal graft and acellular dermal matrix groups showed significantly lower results than those in the control group (p?<?0.05).Conclusion
According to MRI and histopathological results, fistula tract curettage and fistula orifice closure improved transsphincteric anal fistula healing. Additionally, in this study, plug treatment favoring autologous dermal graft resulted in better healing.17.
Background
One hundred consecutive applications of a new clipping device, the OTSC® Proctology (Ovesco Endoscopy AG), were analyzed to assess its efficacy for the treatment of complex anorectal fistulas.Methods
In patients with anorectal fistulas, minimally invasive surgery with the OTSC® Proctology system was performed according to a standardized technique: the fistula tract was debrided using a special fistula brush, and the clip was applied on the internal fistula opening. In some of the patients, postoperative pain was evaluated using a visual analog scale. After 6 months, the postoperative clinical course and the fistula healing were assessed.Results
A total of 100 OTSC® Proctology procedures were performed in 96 patients with 55 transsphincteric, 38 suprasphincteric, 2 extrasphincteric, and 5 rectovaginal fistulas. In all but 11 fistulas (8 Crohn’s disease, 3 ulcerative colitis), the fistulas were of cryptoglandular origin. The median operation time was 32 min (range 17–66 min). There were no major intraoperative technical problems. All patients found the postoperative pain to be tolerable with standard pain medication. The short-term results of 99 clip applications were analyzed: the healing rate for first-line fistula therapy was 79 %, whereas in recurrent fistulas, the success rate was 26 %. OTSC® Proctology was successful in 45 % of fistulas associated with inflammatory bowel disease and in 20 % of rectovaginal fistulas.Conclusions
OTSC® Proctology provides convincing results as first-line treatment for complex cryptoglandular fistulas. It is a safe, effective, minimally invasive, and sphincter-sparing procedure with postoperative pain comparable to other types of fistula surgery.18.
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.19.
S. O. Adegbola K. Sahnan G. Pellino P. J. Tozer A. Hart R. K. S. Phillips J. Warusavitarne O. D. Faiz 《Techniques in coloproctology》2017,21(10):775-782
Background
The surgical treatment of complex anal fistulae, particularly those involving a significant portion of the anal sphincter in which fistulotomy would compromise continence, is challenging. Video-assisted anal fistula treatment (VAAFT), fistula tract laser closure (FiLaC?) and over-the-scope clip (OTSC®) proctology system are all novel sphincter-sparing techniques targeted at healing anal fistulae. In this study, all published articles on these techniques were reviewed to determine efficacy, feasibility and safety.Methods
A systematic search of major databases was performed using defined terms. All studies reporting on experience of these techniques were included and outcomes (fistula healing and safety) evaluated.Results
Eighteen studies (VAAFT—12, FiLaC?—3, OTSC®—3) including 1245 patients were analysed. All were case series, and outcomes were heterogeneous with follow-up ranging from 6 to 69 months and short-term (< 1 year) healing rates of 64–100%. Morbidity was low with only minor complications reported. There was one report of minor incontinence following the first reported study of FiLaC?, and this was treated successfully at 6 months with rubber band ligation of hypertrophied prolapsed mucosa. There are inconsistencies in the technique in studies of VAAFT and FiLaC?.Conclusions
All three techniques appear to be safe and feasible options in the management of anal fistulae, and short-term healing rates are acceptable with no sustained effect on continence. There is, however, a paucity of robust data with long-term outcomes. These techniques are thus welcome additions; however, their long-term place in the colorectal surgeon’s armamentarium, whether diagnostic or therapeutic, remains uncertain.20.