Hybrid Video-Assisted Fistula Treatment With Seton Tie for Management of Fistula In Ano: Results of a Novel Technique.

BackgroundThis is the first in human assessment of the BioHealx® assisted fistula treatment (BAFT) procedure for the primary healing rate of non-branching transsphincteric fistula in ano. The BAFT procedure consists of compression apposition closure of the lumen of the fistula tract from the internal opening across the transsphincteric length of the fistula tract with a bioabsorbable implant (BioHealx device) and distal fistulectomy. This medium-term follow-up study assesses the healing and functional outcome at the last follow-up (12–40 months; average 23.4 months) following this procedure.MethodsThe study was a multi-center, prospective, single-arm (non-randomized), non-blinded, clinical study for elective compression closure of non-branching transsphincteric anal fistula of cryptoglandular origin. Participants were recruited from three sites (two hospitals in Budapest, Hungary and one hospital in Szeged, Hungary). The primary outcome was combined fistula and fistulectomy wound healing, and fecal incontinence quality of life scores (FIQL) were a secondary outcome. Fistula healing was assessed independently in cases where the fistulectomy wound had not fully healed.ResultsThirty-two adults, (18–75 years; M- 27 vs F- 5) were included in the study. The 30-day complication rate was 4/32 (12.5%) and was restricted to the fistulectomy wound with no device-related complications. All patients were assessed in person at 12 months, and patients with unhealed fistulectomy wounds were reassessed after 12 months to confirm fistula healing status. The data demonstrated that 27/32 (84.4%) of transsphincteric fistulas were healed with no recurrences. There were 3(9.4%) persistent transsphincteric fistulas and 2 (6.3%) with undocumented fistula healing with healing fistulectomy wound at last follow-up. Assessment of available baseline and last follow-up FIQL scores demonstrated stable or improved scores for 30/31 (96.8%). Surgeon assessment reflected ease of adoption.ConclusionsThis first in human assessment of the BAFT procedure for transsphincteric cryptoglandular fistula in ano demonstrated an 84.4% rate of primary healing without recurrence of transsphincteric fistulas with preservation of fecal continence quality of life in 96.8% of patients. Successful compression apposition closure of the fistula tract lumen within the anal sphincter complex delivered the healing rate by primary intention of the fistula tract without any device-related complications or migration. Surgeon mastery of the procedure is straightforward. These outcome data support both a high rate of initial healing and durability of the BAFT procedure for transsphincteric cryptoglandular fistula in ano that are favorable when compared to LIFT, endoanal flap, cutting seton, or fistulotomy/sphincteroplasty surgical options.

Twenty-six (26) transsphincteric anal fistulate with secondary high extension and sixteen (16) suprasphincteric anal fistulate with secondary high extensions have been treated successfully over a period of 3 years. The operative technique depends on exploration of the intersphincteric plane with removal of the primary source of the infection, together with excision of the primary tract, and drainage of he secondary high extensions. The patients have been followed for 2 years without recurrence. Continence for flatus and liquid feces was 92.1% and 96.15%, respectively, in the transsphincteric and 75% and 93.75%, respectively, in the suprasphincteric group but the continence for solid feces was 100% in both. Thus, the so-called excision technique for treatment of high fistula is safe and results are excellent.

The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Management of Anorectal Abscess, Fistula-in-Ano, and Rectovaginal Fistula.

High ligation of the anal fistula tract by lateral approach: A prospective cohort study on a modification of the ligation of the intersphincteric fistula tract (LIFT) technique

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. 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. 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 8months. The operation time was 28 ± 16min. 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. 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.

Fistula in ano is a common proctological disease. Several authors stated that internal and external anal sphincters preservation is in the interest of continence maintenance. The aim of the present study is to report our experience using a decisional algorithm on sphincter saving procedures that achieved us to obtain good results with low rate of complications. From 2008 to 2011, 206 patients underwent surgical treatment for anal fistula; 28 patients underwent perianal abscess drainage plus seton placement of trans-sphincteric or supra-sphincteric fistula (13.6 %), 41 patients underwent fistulotomy for submucosal or low inter-sphincteric or low trans-sphincteric anal fistula (19.9 %) and 137 patients underwent partial fistulectomy or partial fistulotomy (from cutaneous plan to external sphincter muscle plan) and cutting seton placement without internal sphincterotomy for trans-sphincteric anal fistula (66.50 %). Healing rates have been of 100 % and healing times ranged from 1 to 6 months in 97 % of patients treated by setons. Transient fecal soiling was reported by 19 patients affected by trans-sphincteric fistula (11.5 %) for 4-6 months and then disappeared or evolved in a milder form of flatus occasional incontinence. No major incontinence has been reported also after fistulotomy. Fistula recurred in five cases of trans-sphincteric fistula treated by seton placement (one with abscess) (1/28) (3.5 %) and four with trans-sphincteric fistula (4/137) (3 %). Our algorithm permitted us to reduce to 20 % sphincter cutting procedures without reporting postoperative major anal incontinence; it seems to open an interesting way in the treatment of anal fistula.

Transsphincteric anal fistula is a common and challenging diagnosis for patients and surgeons alike. Ligation of the intersphincteric fistula tract (LIFT) following non-cutting seton placement represents an established definitive treatment with many technical variations. Unfortunately, up to 53% of attempted LIFTs fail. We aim to describe a modified LIFT approach and evaluate outcomes at our institution. Thirty-two patients from 2021 to 2024 underwent the modified LIFT approach which included the offsetting of the transected fistula ends with interposing muscle plication, along with closure of the internal opening, and wide excision of the external opening. Retrospective chart review was performed to assess rates of primary wound healing, complications, recurrence, and incontinence. Recurrences were grouped into three types: typeI, sinus tract or recurrent abscess without an internal opening; typeII, conversion to an intersphincteric fistula; and typeIII, transsphincteric recurrence. The majority of patients were male (69%) with a mean age of 44years and mean BMI 31.6kg/m2. Median operative time was 88min. Primary healing rate was 94%. Median healing period was 7 (range 4-16) weeks. Of the 10 recurrences, (5 typeI, 5 typeII, and 0 typeIII), median time to recurrence was 6months after the primary wound healed. No patients experienced any postoperative incontinence or urinary retention. In this cohort of patients with transsphincteric fistulas undergoing the LIFT procedure, the addition of offsetting muscle plication effectively limited transsphincteric recurrence. Further investigation is warranted to directly compare this LIFT adaptation to previously published literature.

AimThe aetiology of anal fistula has not been fully clarified. One of the causes of anal fistulas may be the markedly deep crypts that characterize the primary openings. We developed subcutaneous incision of the fistula tract and internal sphincterotomy (SIFT‐IS) to eradicate these deep crypts. The aim of this study was to evaluate outcomes in patients with anal fistula treated with SIFT‐IS.MethodA retrospective study was performed over a 2‐year period. Patients with transsphincteric anal fistula who underwent SIFT‐IS were enrolled. The primary endpoint was the anal fistula healing rate at 16 weeks postoperatively. The secondary endpoints were healing time, postoperative complications and clinical continence status.ResultsOne hundred and fifty one patients were enrolled. Primary healing was accomplished in 129 patients (85%). There were 17 patients (11%) with a remnant fistula and five (3%) with a recurrence. The remnant fistulas healed spontaneously at more than 16 weeks postoperatively in seven patients. The median healing time was 6 (3–96) weeks. Surgical intervention was required in seven patients with a remnant fistula and four with recurrence. At the final follow‐up, the wounds had healed in 148 patients (98%). No significant postoperative complications or incontinence were observed.ConclusionSubcutaneous incision of the fistula tract and internal sphincterotomy is a promising surgical option for transsphincteric anal fistulas, with a satisfactory healing rate.

Objective: To evaluate the long-term healing rate of transsphincteric anal fistula treated with anal fistula plug procedure and the risk factors affecting the healing of anal fistula. Methods: A retrospective case-control study was conducted to analyze the clinical data of 207 patients with transsphincteric anal fistulas who received anal fistula plug procedure at the Department of General Surgery, Beijing Chaoyang Hospital of Capital Medical University from August 2008 to September 2012. Inclusion criteria: (1) consistent with the diagnosis of transsphincteric anal fistula: the anal fistula passed through the internal and external sphincter; (2) complete data; (3) initial treatment with anal fistula plug procedure. Exclusion criteria: (1) acute rectal or perianal infection or poorly controlled focal infection; (2) recent incision and drainage of perianal abscess or spontaneous rupture of abscess; (3) patients with malignant tumor; (4) patients with Crohn's disease or ulcerative colitis; (5) patients with heart, liver, brain, lung or renal insufficiency; (6) cachexia due to various chronic wasting diseases; (7) patients could not tolerate surgery. Patients were followed up for anal fistula healing. The cumulative healing rate of patients with transsphincteric anal fistula was plotted using the Kaplan-Meier method, and the factors affecting anal fistula healing were explored by univariate and multivariate logistic regression analysis. Results: There were 186 males and 21 females with age of 15 to 69 (mean 38) years. The duration of anal fistula was 3-60 (mean 15) months. Three patients had a history of previous episodes of perianal abscess and underwent incision and drainage of perianal abscess (all more than 3 months). During follow-up ending on October 31, 2018, 72 patients (34.8%) were lost to follow-up. Among 135 patients who were successfully followed up, the average follow-up period was 96 (75-124) months. Seventy-five patients had anal fistula healing, with healing rate of 55.6%. Kaplan-Meier survival curve showed that the healing time of anal fistula was prolonged and finally stabilized at 55.6%. In the patients who failed initial treatment with anal fistula plug packing, there were 6 cases whose anal fistula healed spontaneously without other treatment. Among them, 3 cases healed spontaneously 2 years and 3 cases 3 years after operation without recurrence. From 2008 to 2012, the annual healing rates of anal fistula plug treatment were 3/6, 61.5% (24/39), 42.1% (24/57), 12/15 and 12/18, respectively. Multivariate logistic regression analysis showed that the duration of anal fistula≥6 months (OR=3.187, 95% CI: 1.361-7.466, P=0.008) was an independent risk factor for anal fistula healing after treatment with anal fistula plug. Conclusion: The long-term efficacy of anal fistula plug procedure in the treatment of transsphincteric anal fistula is positive, and this procedure should be implemented as soon as possible.

The purpose of this study was to assess the influence of identification of the location of the internal opening of anal fistula on the recurrence rate after surgical treatment in patients with primary transsphincteric anal fistulas. The influence of preoperative rectal ultrasound on the treatment results was studied. One hundred thirty-one patients operated in the period February 1992 to July 2005 were analyzed. Endorectal ultrasound (ERUS) was not performed (till February 2004) on 103 out of the 131 patients, while the other 28 received ERUS (from March 2004). We performed either cutting seton technique or fistulectomy according to the course of fistulous tract (high or low transsphincteric fistulas). The recurrence rate of anal fistula was assessed after the complete healing of the anal fistula after 6 months. In patients in whom ERUS was not performed, the internal opening was identified by endoscopy in 41.7% and in 47.6% intraoperatively. In patients in whom ERUS was preoperatively performed, the internal opening was identified in 85.8%. In all the studied groups, the internal opening of anal fistula was not localized in 13 patients (9.9%). Recurrence of the fistulas occurred in ten patients (7.6%); in seven out of 13 patients, the internal opening was not found (53.85%), and in three out of 118, the internal opening was identified (2.54%). Relative risk of anal fistula recurrence was 20-fold higher in patients in whom the internal opening was not identified than in those with the internal opening identified. Preoperative ERUS doubled the identification rate and thus decreased the risk of recurrence.

Treatment of transsphincteric fistulas (TSFs) with fistulotomy after an indwelling seton is tempered by risks of incontinence and litigation. Thus, ligation of the TSF tract has been popularized as an alternative option. We previously reported on 107 patients who underwent ligation of the intersphincteric fistula tract (LIFT), with a 46% failure rate. Posterior fistula was the only predictor of recurrence. The aim of the present work was to investigate whether the length, width or depth of the fistula measured on preoperative MRI was correlated with recurrence. Following institutional review board approval, a retrospective analysis of our prospective Complex Anal Fistula Database from 1 January 2011 to 31 August 2019 was performed. Patients with TSF who underwent preoperative MRI and LIFT were included. Fistula location was classified as anterior, posterior or lateral. MRI measurements of fistula length, width and depth (in the intersphincteric groove) were performed. The type and rate of postoperative recurrence were analysed. 173 patients underwent MRI for an anal fistula; of these 40 underwent LIFT and 22/40 (55%) had preoperative MRI. There was no difference in the length, width or depth of anterior (n=9), posterior (n=7) or lateral (n=6) fistula tracts. The overall recurrence rate was 9/22 (41%). Posterior TSFs had the highest recurrence rate (5/7, 71%). The mean length, width, and depth of the fistula tract, measured at the preoperative site of LIFT in the intersphincteric groove, did not correlate with recurrence regardless of fistula location.

Background: anal fistula is a common proctologic problem. It is a common cause of chronic irritation to both patients and surgeons. It is a disease of antiquity. Even with all that work and research, started 2500 years ago, or may be more, man didn’t find the ideal treatment for perianal fistulas. Objective: The purpose of this study is to evaluate sphincter saving techniques used in management of transsphincteric anal fistula as regard rapid recovery, incidence of postoperative stool incontinence and recurrence rate. Patients and Methods: our study was a prospective study of 60 patients who had transsphincteric anal fistula and were admitted to Al-Azhar University Hospitals from July 2017 till January 2019. The patients were divided into 3 groups according to the management procedure, group A was managed by seton technique, group B was managed by ligation of transsphincteric fistula tract (LIFT) and group C was managed by endorectal advancement flap (ERAF). Results: there were no differences of demographic data and characters of fistula among the three groups, however some differences were noticed regarding postoperative morbidity due to early complication including urine retention, bleeding, hematoma, infection and wound disruption but it was not statistically significant, there were statistically significant difference regarding postoperative pain, recurrence and incidence of stool incontinence. Conclusion: high transsphincteric fistula warrants more sphincter sparing techniques to avoid the most likely sphincter dysfunction which could be happened after traditional surgery like fistulectomy and cutting seton for this type of complex anal fistula.

To explore the diagnostic value of magnetic resonance imaging(MRI) in anal fistula. A total of 2160 patients were clinically diagnosed with anal fistula at the Sixth Affiliated Hospital of Sun Yat-sen University from March 2010 to September 2015. Among them, 232 cases with operative history at other hospital, 218 with Crohn's disease, 6 with rectum cancer and 8 with other disease were excluded, and 1696 patients were finally enrolled and retrospectively analyzed. The saggital FSE T2WI imaging was confirmed based on the midline of body, and then the coronal and axial scanning line were confirmed. The key point was that the coronal scanning line must parallel and the axial scanning line must be perpendicular to the major axis of anal canal. The characteristics of anal fistula were recorded, and anal fistula were classified as five types, including intersphincteric, transphincteric, suprasphincteric, extrasphincteric and superficial fistula according to the Parks classification and our experience. The distribution of internal opening was described by using lithotomy position clock method. Of 1696 patients, 1456 were males and 240 females with median age of 26.5 (0.2 to 87.0) years. Age of 8.4% (143/1696) cases was under 20 years old, of 57.4%(973/1696) cases was between 20 to 40, of 28.4%(482/1696) cases was between 40 to 60, of 5.8%(98/1696) cases was over 60. The 1696 MR examinations included 1128 on 1.5T MR and 568 on 0.5T MR. Of all the anal fistulas was 29.0%(492) high position and 71.0%(1204) was low position. Among the 1696 patients, 1057 were intersphincteric fistulas(62.3%), 407 were transphincteric fistulas(24.0%), 68 were suprasphincteric fistulas(4.0%), 54 were extrasphincteric fistulas (3.2%), 67 were superficial fistulas(4.0%), and 43(2.5%) were difficult to classify. A total of 1996 internal openings were found and most of them were located around the dentate line of 5-7 o'clock in lithotomy position(47.7%, 952/1996). Anal fistula mainly occur in young men, and the most common type is intersphincteric fistula. MRI can accurately classify anal fistulas and clearly demonstrate internal openings, and provide reliable evidence for clinical treatment and surgery.

Background: Fistula-in-ano consists of a primary track which passes from the internal opening in the anal canal to the external opening in the perineum. Most of the anal fistulas are originated from the infection of anal glands which are connected to the anal crypts (cryptoglandular origin). Age distribution is spread throughout adult life with maximal incidence between the third and fifth decades. Men are 2 to 5 times more likely to develop anal fistula than women. Objective: The aim of this study was to evaluate the LIFT technique for the treatment of trans-sphincteric anal fistula. Patients and Methods: This study included 20 patients with trans-sphincteric fistula from August 2018 till April 2020, while anal fistula due to specific disease and other types of law anal fistula have been excluded from the study. Regarding demographic data, 90% of the included patients were males and the mean age was 38 years. The median duration of symptoms was 8 months, and the median length of the fistula tracts was 7cm. The mean BMI of patients was 38, seven patients (35%) were diabetic. All patients were investigated with pre-operative MRI and 3D CT fistulography. Results: The main finding of this study was overall healing of 80% of patients, with a 6 months follow-up. There were 1 failure, and 3 recurrences between 3 and 6 months after surgery. No patients reported de novo incontinence, and all patients reported normal control. The median time for wound healing was 4 weeks. Conclusion: LIFT Technique is quite, simple and excellent in long term control of trans-sphincteric fistula, but actually the corner stone in management of perianal fistula is the accurate diagnosis of the type of fistula, which need good preoperative imaging by both surgeon and radiologist, followed by good intraoperative assessment of the type of fistula for selection of the appropriate Technique of each type.

The purpose of this study was to compare the ligation of intersphincteric fistula tract (LIFT) with an additional plug (LIFT-plug) in the treatment of transsphincteric anal fistula. Both LIFT and LIFT-plug are recently reported effective alternatives of transsphincteric anal fistula. This multicenter prospective randomized study (NCT01478139) was conducted at 5 university hospitals throughout China. A total of 235 patients were randomly assigned to undergo LIFT (118 patients) or LIFT-plug (117 patients) between March 2011 and April 2013. The primary outcome measured was primary healing rate at 6 months postoperatively and healing time. Secondary outcomes included recurrence rate, postoperative pain, and incontinence rate. The LIFT procedure showed shorter operative time than the LIFT-plug procedure (26.7 min vs 28.5 min, P = 0.03). Median healing time was 22 days in LIFT-plug group vs 30 days in LIFT group (P < 0.001). The difference in visual analog scale scores across all time points was not statistically significant between the groups (P = 0.13). The primary healing rate was higher in LIFT-plug group than in LIFT group [94.0% (95% confidence interval 89.7%-98.3%) vs 83.9% (95% confidence interval 77.2%-90.6%), P < 0.001]. There were no reported incontinence and recurrence within the follow-up period of 6 months. In patients with transsphincteric anal fistulas, both LIFT-plug and LIFT are simple, safe, and effective procedures. LIFT-plug has the advantage of a higher healing rate, less healing time, and a lower early postoperative pain score.