Minimal Invasive Kshara Sutra Technique (MIKST)- A New Sphincter Sparing Technique for the Management of Trans-sphincteric Fistula in Ano Wsr Ushtragriva Bhagandara

Fistulotomy has remained the gold standard in the management of fistula in ano, especially low fistula in ano. Although highly effective in the management of fistula in ano, fistulotomy is associated with considerable discomfort and incontinence. This study was designed to evaluate the role of cyanoacrylate in the management of low fistula in ano. We present our short-term results with a 6-month follow-up. Twenty patients were enrolled in the study as day cases. Patients were analyzed clinically and then subjected to trans-anal ultrasound, as diagnosis of internal opening was not palpable on per rectal examination. The fistula tracks were probed and washed with saline, and granulation tissue at external opening was debrided. The glue was then injected into the fistulous track from a syringe nozzle through an infant feeding tube. Patients were further examined in the outpatient department until 6 months. Seventeen patients got healed with primary injection with stoppage of any discharge from the fistulous track. The other two patients required one more injection and showed no signs of discharge thereafter. One patient who had two external openings continued to discharge from one opening even after two injections. Cyanoacrylate glue can be offered as an effective alternative to surgery in patients suffering from fistula in ano as it is easy, safe, non-invasive, and effective.

Anal fistula is a rather common condition in coloproctology and its management remains a challenge. Achieving healing without continence disturbance represent two relevant outcome measures in patient´s perspective. These patient´s expectations are not always easy to meet, especially in cases with complex fistulae. Multiple fistula tracts, high trans-sphincteric fistula involving more than one third of the sphincter apparatus as well as perineal fistula in Crohn´s disease are well known examples of complex fistulae. Low healing rates associated with high failure and/or recurrence rates are unfortunately common for such complex fistulae. Also, the risk of continence impairment following surgical management of such complex fistulae is high in comparison to cases with simple fistulae. Maintaining the integrity of the sphincter apparatus during surgical management of fistula in ano represents the most important aspect in preventing postoperative continence disturbance. This goal can be reached by choosing sphincter preserving surgical options.Fistula closure with a clip has been used as a sphincter preserving technique over the last decades.The use of a nitonol clip to manage anal fistula was first investigated by Prosst et al. in 2012, reporting a 90 % healing rate with the Over The Scope Clips (OTSC) in an animal study [1].Prosst and Ehni in the same year published a clinical case reporting on the successful fistula closure using an OTSC [2] . A randomized controlled pilot trial by Mascagni et al. comparing 15 patients managed with OTSC vs. 15 managed with fistulectomy and primary sphincter repair with low trans-sphincteric fistula showed a 93.3% healing rate for OTSC with reduced length of hospital stay and need for pain medication [3]. Thus, the role of OTSC in the management of anorectal fistula was established, Over the years, many series have been published with success rates varying between 20 % to 80 % [4,5]. The current literature on OTSC for the management of anorectal fistula is not only limited by the retrospective nature of the studies but very much also by the small sample sizes.More so, there is a high degree of heterogeneity in published studies with regards to follow-up and outcome measures. This probably explains why there seems to be no meta-analysis and systematic analysis on this intervention so far. Persistent postoperative pain requiring clip removal, clip migration, persistent discharge and abscess formation have been reported as complications associated with OTSC surgery [4,6]. Although some of these morbidities may partly be associated with specific patient and disease characteristics [7], the safety of clipping anal fistulae remains a topic of debate. It is therefore not surprising that no recommendation could be made for the use OTSC in the management of fistula in ano in the recently published European guidelines for the management of cryptoglandular fistula [8].In their recently published study, Deng et al. evaluated the mechanical properties and clinical application of a nickel-titanium memory alloy anal fistula clip for the closure of anal fistula in 31 patients [9]. The study population including mostly cases with complex fistula; high fistula, multiple tracts, and perianal Crohn´s. The outcomes of this experimental group were compared to those of a control group of 31 patients undergoing conventional fistula closure. No significant difference was seen between the study and the control group with regard postoperative pain on the visual pain scale (3.59 vs. 3.52), healing rate (87.1 % vs. 89.2%) and Wexner incontinence score (3.09 vs. 4.25). Preoperative work-up and follow-up included endoanal ultrasound and MRI are in accordance with international standards. These results are better that what has been reported so far for fistula clips. Analyses of cost effectiveness compared to OTSC, the short follow-up of just about six months, missing information on clip -associated morbidity and possible contraindications represent some limitations in this study.The recently published ESCP guidelines for the diagnosis and management of cryptoglandular fistula could not spell out a definite recommendation on the use of OTSC in the closure of anal fistula based on the available evidence and expert opinion. This more or less "no recommendation" may be interpreted as a sign of caution regarding this intervention, at least for practitioners in Europe.An interesting aspect of this study by Deng et al. may be the physical and chemical composition of the clip. While the OTSC used in the western world is nitonol -based, that used in this study was a nickel-titanium alloy. Therefore, may be the composition of the clip is the game changer.As Aristoteles once said: "what we have to learn to do, we learn by doing". The results reported in this study from China should not be neglected by practitioners in the western world, especially with respect to the "no recommendation" in the newly published European guidelines. The

Background Fistula in ano is a common condition treated by surgeons worldwide. Despite this, there is a paucity of high-quality data to aid decision-making. Hence, management presents a difficult and frustrating dilemma for the treating surgeon. Methods A prospective regional survey was sent to all members of General Surgeons Australia. Questions regarding surgeon demographics, patient evaluation, perianal abscess, and simple and complex fistula in ano were presented. Results Equipoise exists in the management of fistula in ano among general surgeons. This was noted in the management of simple and complex fistula in ano. Conclusion Because of the uncertainty in certain clinical scenarios and a paucity of high-quality randomized controlled trials on the management of fistula in ano, evidence-based practice is a challenge to the treating surgeon.

The American Society of Colon and Rectal Surgeons (ASCRS) is dedicated to ensuring high-quality patient care by advancing the science and prevention and management of disorders and diseases of the colon, rectum, and anus. The Clinical Practice Guidelines Committee is composed of ASCRS members who are chosen because they have demonstrated expertise in the specialty of colon and rectal surgery. This committee was created to lead international efforts in defining quality care for conditions related to the colon, rectum, and anus and develop clinical practice guidelines based on the best available evidence. Although not proscriptive, these guidelines provide information on which decisions can be made and do not dictate a specific form of treatment. These guidelines are intended for the use of all practitioners, health care workers, and patients who desire information on the management of the conditions addressed by the topics covered in these guidelines. These guidelines should not be deemed inclusive of all proper methods of care nor exclusive of methods of care reasonably directed toward obtaining the same results. The ultimate judgment regarding the propriety of any specific procedure must be made by the physician considering all the circumstances presented by the individual patient. STATEMENT OF THE PROBLEM A generally accepted explanation for the cause of anorectal abscess and fistula-in-ano is that an abscess results from obstruction of an anal gland and that a fistula is caused by chronic infection and epithelialization of the abscess drainage tract.1–4 Anorectal abscesses are described by the anatomic space in which they develop; ischiorectal (also called ischioanal) abscesses are the most common followed by intersphincteric, supralevator, and submucosal locations.5–8 Anorectal abscess occurs more often in males than females, and although an abscess may develop at any age, the peak incidence is among 20- to 40-year-olds.4,8–12 In general, an abscess is treated with prompt incision and drainage.4,6,10,13 The diagnosis and treatment of necrotizing soft tissue infections and Fournier’s gangrene are beyond the scope of this guideline. Fistula-in-ano is an epithelialized tract that connects the perianal skin with the anal canal. In patients with an anorectal abscess, 30% to 70% present with a concomitant fistula-in-ano, and, of those who do not, approximately 30% to 50% will ultimately be diagnosed with a fistula in the months to years after abscess drainage.2,5,8–10,13–16 Although an anorectal abscess is described by the anatomic space in which it forms, a fistula-in-ano is classified in terms of its relationship with the internal and external anal sphincters (eg, the Parks classification; Table 1).16 In general, intersphincteric and transsphincteric fistulas are more frequently encountered than suprasphincteric, extrasphincteric, and submucosal tract locations.9,17–19 Anal fistulas may also be classified as “simple” or “complex.”20,21 Complex anal fistulas include transsphincteric fistulas that involve greater than 30% of the external sphincter, suprasphincteric, extrasphincteric, or horseshoe fistulas and anal fistulas associated with IBD, radiation, malignancy, preexisting fecal incontinence, or chronic diarrhea.20–22 Recurrent or branching fistulas may also be described as complex. Given the attenuated nature of the anterior sphincter in women, anterior fistulas deserve special consideration and may also be considered complex. Simple anal fistulas have none of these complex features and, in general, include intersphincteric and low transsphincteric fistulas that involve less than 30% of the external sphincter. TABLE 1. - Parks classification of fistula-in-ano Fistula type Description Submucosal Superficial fistula tract. Does not involve any sphincter muscle. Intersphincteric Crosses the internal sphincter and then has a tract to the perianal skin. Does not involve any external anal sphincter muscle. Transsphincteric Tracks from the internal opening at the dentate line via the internal and external anal sphincters and then terminates in the perianal skin or perineum. Suprasphincteric Courses superiorly into the intersphincteric space over the top of the puborectalis muscle and then descends through the iliococcygeus muscle into the ischiorectal fossa and into the perianal skin. Extrasphincteric Passes from the perineal skin through the ischiorectal fossa and levator muscles and then into the rectum and lies completely outside the external sphincter complex. Adapted from Parks et al.16 Distinct from cryptoglandular processes, anorectal abscess and fistula-in-ano can be manifestations of Crohn’s disease. Among patients with Crohn’s disease, fistula-in-ano has an incidence rate of 10% to 20% in population-based studies and 50% in longitudinal studies; meanwhile, nearly 80% of patients with Crohn’s disease who were cared for at tertiary referral centers may have a history of fistula-in-ano.23,24 In Crohn’s disease, anorectal abscesses and fistulas seem to result from penetrating inflammation rather than from infection of an anorectal gland.25 Patients with fistulas related to Crohn’s disease are typically managed with a multidisciplinary approach.26 Rectovaginal fistulas (RVFs), a unique subset of fistulas in many respects, may be classified as “low,” with a tract between the distal anal canal (at or below the dentate line) and the inside of the posterior fourchette; “high,” with a tract connecting the upper vagina (at the level of the cervix) with the rectum; and “middle” with a tract that lies in between these levels.27–29 The terms “anovaginal fistula” and “low rectovaginal fistula” may be used interchangeably. RVFs may also be classified as “simple” or “complex.” Simple RVFs have a low, small-diameter (<2 cm) communication between the anal canal and vagina and typically result from obstetrical injury or infection.29 “Complex” RVFs involve a higher tract between the rectum and vagina, are of a larger diameter, or result from radiation, cancer, or complications of pelvic surgical procedures.30–33 RVFs most commonly occur as a result of obstetric injury29 but may also occur in the setting of Crohn’s disease,25 malignancy, or infection,32 or as a complication of a failed colorectal anastomosis,33 an anorectal operation,34 or radiation therapy.35 The surgical treatment of a particular fistula is influenced by the patient’s presenting symptoms, unique anatomy of the fistula tract, quality of the surrounding tissues, and previous attempts at fistula repair.36 This guideline addresses the management of cryptoglandular fistulas, RVFs, and anorectal fistulas in the setting of Crohn’s disease. MATERIALS AND METHODS These guidelines were built on the last clinical practice guidelines for the management of anorectal abscess and fistula-in-ano published in 2016.37 An organized search was performed of MEDLINE, PubMed, Embase, and the Cochrane Database of Systematic Reviews between December 1, 2015, and November 5, 2021. Key word combinations using MeSH terms included abscess, fistula, fistula-in-ano, anal, rectal, perianal, perineal, rectovaginal, anovaginal, seton, fistulotomy, stem cell, advancement flap, ligation of intersphincteric fistula tract (LIFT), fistula plug, fistula glue, video-assisted anal fistula treatment (VAAFT), fistula laser closure (FiLaC), over-the-scope clip (OTSC) device, and Crohn’s disease. The search was restricted to English-language articles and studies of adult patients. Directed searches using embedded references from primary articles were performed in selected circumstances, and other sources including practice guidelines and consensus statements from relevant societies were also reviewed. The 841 screened articles were evaluated for their level of evidence, favoring clinical trials, meta-analysis/systematic reviews, comparative studies, and large registry retrospective studies during single-institutional series, retrospective reviews, and peer-reviewed, observational studies. A final list of 269 sources was evaluated for methodologic quality, the evidence base was analyzed, and a treatment guideline was formulated by the subcommittee for this guideline (Fig. 1). The final grade of recommendation and level of evidence for each statement were determined using the Grades of Recommendation, Assessment, Development, and Evaluation system (Table 2). When the agreement was incomplete regarding the evidence base or treatment guideline, consensus from the committee chair, vice chair, and 2 assigned reviewers determined the outcome. Members of the ASCRS Clinical Practice Guidelines Committee worked in joint production of these guidelines from inception to final publication (Table 3). The entire Clinical Practice Guidelines Committee reviewed the recommendations formulated by the subcommittee. Final recommendations were approved by the ASCRS Executive Council. In general, each ASCRS Clinical Practice Guideline is updated every 5 years. No funding was received for preparing this guideline, and the authors have declared no competing interests related to this material. This guideline conforms to the Appraisal of Guidelines for Research and Evaluation checklist. TABLE 2. - The GRADE system: grading recommendations Description Benefit versus risk and burdens Methodologic quality of supporting evidence Implications 1A Strong recommendation, high-quality evidence Benefits clearly outweigh risks and burdens or vice versa RCTs without important limitations or overwhelming evidence from observational studies Strong recommendation, can apply to most patients in most circumstances without reservation 1B Strong recommendation, moderate-quality evidence Benefits clearly outweigh risks and burdens or vice versa RCTs with important limitations (inconsistent results, methodologic flaws, indirect or imprecise) or exceptionally strong evidence from observational studies Strong recommendation, can apply to most patients in most circumstances without reservation 1C Strong recommendation, low- or very-low quality evidence Benefits clearly outweigh risks and burdens or vice versa Observational studies or case series Strong recommendation but may change when higher-quality evidence becomes available 2A Weak recommendation, high-quality evidence Benefits closely balanced with risks and burdens RCTs without important limitations or overwhelming evidence from observational studies Weak recommendation, best action may differ depending on circumstances or patients’ values or societal values 2B Weak recommendation, moderate-quality evidence Benefits closely balanced with risks and burdens RCTs with important limitations (inconsistent results, methodologic flaws, indirect or imprecise) or exceptionally strong evidence from observational studies Weak recommendation, best action may differ depending on circumstances or patients’ values or societal values 2C Weak recommendation, low- or very-low quality evidence Uncertainty in the estimates of benefits, risks, and burdens; benefits, risks, and burdens may be closely balanced Observational studies or case series Very weak recommendations; other alternatives may be equally reasonable GRADE = Grades of Recommendation, Assessment, Development, and Evaluation; RCT = randomized controlled trial.Adapted from Guyatt et al.38 Used with permission. TABLE 3. - What is new in the 2022 ASCRS Clinical Practice Guidelines for the management of anorectal abscess, fistula-in-ano, and rectovaginal fistula? 2022 New recommendations 11. Minimally invasive approaches to treat fistula-in-ano that use endoscopic or laser closure techniques have reasonable short-term healing rates but unknown long-term fistula healing and recurrence rates. Grade of recommendation: weak recommendation based on low-quality evidence, 2C. 19. Anorectal fistula associated with Crohn’s disease is typically managed with a combination of surgical and medical approaches. Grade of recommendation: strong recommendation based on moderate-quality evidence, 1B. 25. Local administration of mesenchymal stem cells is a safe and effective treatment for selected patients with refractory anorectal fistulas in the setting of Crohn’s disease. Grade of recommendation: weak recommendation based on moderate-quality evidence, 2B. 2022 Updated recommendations 5. Antibiotics should typically be reserved for patients with an anorectal abscess complicated by cellulitis, systemic signs of infection, or underlying immunosuppression. Grade of recommendation: weak recommendation based on moderate-quality evidence, 2C→2B. 9. A cutting seton may be used selectively in the management of complex cryptoglandular anal fistulas. Grade of recommendation: weak recommendations based on low-quality evidence, 2B→2C. 10. The anal fistula plug and fibrin glue are relatively ineffective treatments for fistula-in-ano. Grade of recommendation: strong recommendation based on moderate-quality evidence, 2B→1B. 21. Draining setons are typically useful in the multimodality therapy of fistulizing anorectal Crohn’s disease and may be used for long-term disease control. Grade of recommendation: strong recommendation based upon moderate-quality evidence, 1C→1B. 22. Symptomatic, simple, low anal fistulas in carefully selected patients with Crohn’s disease may be treated by lay-open fistulotomy. Grade of recommendation: weak recommendation based on low-quality evidence, 1C→ 2C. 23. Endorectal advancement flaps and the LIFT procedure may be used to treat fistula-in-ano associated with Crohn’s disease. Grade of recommendation: strong recommendation based on moderate-quality evidence, 2B→1B. ASCRS = American Society of Colon and Rectal Surgeons; LIFT = ligation of intersphincteric fistula tract. FIGURE 1.: PRISMA literature search flow sheet. PRISMA = Preferred Reporting Items for Systematic Reviews and Meta-Analyses.Initial Evaluation of Anorectal Abscess and Fistula 1. A disease-specific history and physical examination should be performed evaluating symptoms, relevant history, abscess and fistula location, and presence of secondary cellulitis. Grade of recommendation: strong recommendation based on low-quality evidence, 1C. Anorectal abscess is usually diagnosed on the basis of a patient’s history and physical examination. Anorectal pain and swelling are common with superficial abscesses, whereas spontaneous drainage and fever occur less often.8–10,38 Deeper abscesses, including those in the supralevator or high ischiorectal spaces, may present with pain referred to the perineum, lower back, or buttocks.6,39,40 Evaluation of the anus and perineum may reveal erythema, calor, fluctuance, cellulitis, or tenderness on palpation or may be relatively unrevealing, particularly in patients with intersphincteric or deeper abscesses,6,10,40,41 and digital rectal examination and anoscopy/proctoscopy are occasionally needed to clarify the diagnosis. The differential diagnosis of anorectal abscess may include fissure, hemorrhoid thrombosis, pilonidal disease, hidradenitis, anorectal neoplasia, Crohn’s disease, and sexually transmitted infections.6,42,43 Patients who present with anal fistula typically report intermittent anorectal swelling and drainage. Relevant information about baseline anal sphincter function, history of anorectal operations, family history of IBD, obstetric history, and associated GI, genitourinary, or gynecologic pathology should typically be included in the patient’s history. Inspection of the perineum should involve noting the specific findings of an abscess, surgical scars, anorectal deformities, signs of possible anorectal Crohn’s disease, and the presence of an external fistula opening. Gentle probing of an external opening, when tolerated, may help confirm the presence of a fistula tract but should be done with care to avoid creating false tracts.43 Goodsall’s rule, that an anterior fistula-in-ano has a radial tract and a posterior fistula has a curvilinear tract to the anus, has generally proven to be accurate for anterior fistulas but is less accurate in cases with a posterior fistula.44–47 2. Routine use of diagnostic imaging is not typically necessary for patients with anorectal abscess or fistula. However, imaging may be considered in selected patients with an occult anorectal abscess, recurrent or complex anal fistula, immunosuppression, or anorectal Crohn’s disease. Grade of recommendation: strong recommendation based on moderate-quality evidence, 1B. In a retrospective study of 113 patients with anorectal abscess, the overall sensitivity of CT for detecting an abscess was 77% and the sensitivity of CT in immunosuppressed patients was 70%.48 An advantage of MRI over CT is its ability to identify anorectal abscesses and associated fistula tracts. In a study of 54 patients with anorectal Crohn’s disease, in which MRI and operative/clinical findings were compared, all the abscesses and 82% of the fistulas were correctly identified by MRI.49 In a 2014 prospective study of 50 patients with suspected anorectal fistula, MRI had a 95% sensitivity, 80% specificity, and 97% positive predictive value in detecting and grading the primary fistula tract.50 In a retrospective study of 136 patients specifically looking at the role of MRI in the preoperative assessment of fistula patients, Konan et al51 found that MRI identified “significant” findings defined as secondary (blind) tracts, horseshoe abscesses, or abscesses undiagnosed by physical examination or examination under anesthesia in 34% of patients. In this study, MRI provided significant findings more frequently for complex fistulas than for simple fistulas (54% vs 5%; p < 0.001). Additionally, the proportion of patients who had significant MRI contributions increased with increasing Parks grade (5% for grade 1; 48% for grade 2; 86% for grade 3; 87.5% for grade 4). A prospective trial published in 2019, including 126 patients, assessed the utility of 3-dimensional endoanal ultrasound (EAUS) and MRI in both simple (n = 68) and complex (n = 58) anal fistulas and reported comparable accuracy for the 2 modalities in cases of a simple fistula; however, MRI had significantly higher sensitivity evaluating secondary extensions in complex fistulas (97% vs 74%; p = 0.04).52 Endoanal ultrasound, in 2 or 3 dimensions and with or without peroxide enhancement, may be useful in the management of patients with abscess or fistula, and studies demonstrate concordance between EAUS and operative findings in 73% to 100% of cases.53–55 Tantiphlachiva et al56 found that preoperative EAUS may help preserve anorectal function in patients undergoing anal fistula surgery. This study retrospectively evaluated pre- and postoperative Fecal Incontinence Severity Scores in 109 patients who underwent preoperative EAUS and in 230 patients without preoperative imaging and found significantly worse Fecal Incontinence Severity Scores in the group that did not undergo preoperative EAUS at a mean follow-up of 34 weeks. The potential added value of combining diagnostic modalities to enhance the accuracy of anal fistula assessment was exemplified in a 2001 blinded study of 34 patients with anorectal Crohn’s disease in which EAUS was accurate in 91% of patients, MRI was accurate in 87% of patients, and examination under anesthesia was accurate in 91% of patients, whereas 100% accuracy was achieved when any 2 techniques were combined.57 The sensitivity, accuracy, and utility of transperineal ultrasound (TPUS), a noninvasive alternative to EAUS, have also been studied in patients with anorectal abscess, anoperineal fistulas, and RVFs.58–61 A prospective study of 23 patients with Crohn’s disease comparing the diagnostic accuracies of EAUS, TPUS, and MRI with operative findings found that the diagnostic accuracy of all 3 modalities was nearly identical.62 The authors concluded that TPUS might be considered first-line imaging because of its availability, low cost, and noninvasive nature, yet because of its operator dependency and lack of high-quality supporting data, this imaging technique has not gained widespread popularity. Anorectal Abscess 3. Patients with acute anorectal abscess should be treated promptly with incision and drainage. Grade of recommendation: strong recommendation based on low-quality evidence, 1C. The primary treatment of anorectal abscess remains surgical drainage. In general, the incision should be made large enough to provide adequate drainage while taking care not to injure the anal sphincter complex. The perianal incision should be kept as close as possible to the anal verge to minimize the length of a subsequent fistula tract should one develop. Alternatively, a surgical drain (eg, Pezzer, Malecot) can be placed into the abscess cavity63,64 if this provides adequate drainage, although this technique typically does not address loculations within an abscess cavity and generally omits primary fistulotomy. Small comparative analyses have shown comparable efficacy and higher patient satisfaction with drain placement compared to incision and drainage.65–67 Once an abscess has been drained, randomized trials report equivalent or superior abscess resolution rates with less pain and faster healing in patients whose wounds were left unpacked.68,69 After drainage, abscesses may recur in up to 44% of patients, most often within 1 year of initial treatment.2,10,70 Inadequate drainage, the presence of loculations or a horseshoe-type abscess, and not performing a primary fistulotomy are risk for recurrent abscess fistulotomy is addressed in recommendation Abscess generally a patient should have internal versus external drainage. Intersphincteric abscesses should typically be through the intersphincteric or into the anal canal via an internal it is usually to drain supralevator abscesses from the complicated of an intersphincteric abscess by the rectal to fistula supralevator abscesses because of of an ischiorectal abscess should typically be through the perianal These approaches to abscess drainage may help complex fistula that the can be to These abscesses most often involve the space and into the ischiorectal these circumstances, primary lay-open fistulotomy should typically be because these fistulas to be The a technique that the space and to address the ischiorectal spaces, is effective in the setting of a horseshoe although it may anal sphincter A technique using a posterior to the space seton placement has a high rate of abscess resolution and has been reported to preserve anorectal function compared to other operative Abscess drainage with concomitant fistulotomy may be performed in selected patients with simple anal fistulas. Grade of recommendation: weak recommendation based on moderate-quality evidence, 2B. Although 30% to 70% of patients with anorectal abscesses present with a concomitant the role of primary fistulotomy at the of abscess drainage remains Although a fistulotomy may address the and inflammation from the may the risk of a false tract when probing a fistula and can it to the the to the of sphincter randomized studies evaluating primary fistulotomy have reported results with to fistula recurrence and fecal and in a randomized controlled found that of patients treated with primary and internal had whereas reported postoperative sphincter at a follow-up of meanwhile, of 34 patients treated with incision and drainage had recurrence and reported postoperative and in a retrospective of patients treated with fistulotomy or sphincter found that after was significantly more common in patients who had a complex fistula compared to those who had a simple fistula A Cochrane that included patients from randomized controlled trials demonstrated that sphincter fistulotomy or at the of incision and drainage was associated with a significantly of abscess of fistula or abscess, or for subsequent 95% but an not incidence of at the randomized trials included in this patients with complex fistulas, recurrent abscesses, IBD, preexisting incontinence, or history of anorectal and included patients with low fistulas. Given the potential of a fistulotomy, have performing a fistulotomy with placement of a seton through the tract. A retrospective evaluated the of patients with low transsphincteric fistulas who underwent fistulotomy and then seton placement patients were patients who had anal sphincter function underwent a fistulotomy. This study reported that at 1 all patients who underwent fistulotomy reported no fistula or abscess recurrence or incontinence, supporting the of seton placement followed by fistulotomy in selected patients with a low transsphincteric When a simple fistula is encountered during incision and drainage of an anorectal abscess, fistulotomy may be performed in selected patients provided that the of healing the potential risk of fecal However, a seton to treat a fistula at the of incision and drainage patients to with a procedure to address their 5. Antibiotics should typically be reserved for patients with an anorectal abscess complicated by cellulitis, systemic signs of infection, or underlying immunosuppression. Grade of recommendation: weak recommendation based on moderate-quality evidence, 2B. In general, after performing an incision and drainage of a anorectal abscess in a patient does not healing or the recurrence rate and is typically not However, may be used selectively in patients with an anorectal abscess complicated by cellulitis, systemic or underlying Given the available evidence, the grade of this clinical practice guideline recommendation was from a 2C grade in to a 2B A retrospective study of patients with anorectal abscess who underwent incision and drainage with (n = or without (n = subsequent therapy for 5 to reported that of all patients related to anorectal infection, but was no significant between the in this Patients with surrounding cellulitis, or signs of systemic who did not had a in the rate of recurrent abscess compared with patients who received although this did not The authors also concluded that abscesses does not management or A study evaluated the of postoperative on fistula after incision and drainage of an anorectal In this randomized trial by and patients were treated with incision and drainage with or without a postoperative of and of patients in the treatment group an anal fistula versus 30% in the group < 0.001). to this study, et studied patients in a trial who no of with to anal fistula Although anorectal abscesses is not considered has been reported in up to of When is from an anorectal abscess, a combination of abscess drainage and directed the is typically for patients with systemic signs of or should also be considered in cases of recurrent infection or that an important role in treatment for or immunosuppressed patients with an anorectal Although patients with a higher and on examination typically have high resolution

Since ancient time, fistula in ano has been the most prominent condition of all anorectal disorders. Despite two millennia of efforts, fistula in ano still remains a challenging surgical condition. Over the past few decades, various techniques have been evaluated in terms of preventing its recurrence and complications. The sign and symptoms of fistula in ano resembles with Bhagandara described in Ayurveda classics. Many treatment modalities are listed in Ayurveda classics for the management of this painful disease, Ksharasutra therapy is one among them that has been proved to be highly efficacious. Though Ksharsutra therapy is a popular treatment for fistula in ano, it does have few drawbacks. Long duration of treatment, post procedural pain and long scar are some to mention. As a result, in the present era IFTAK is emerging as an innovative technique for the management of fistula in ano, without compromising the outcome compared to traditional method of Ksharasutra treatment. In this case study, the IFTAK (Interception of Fistulous Tract and Application of Ksharasutra) and partial fistulotomy was used in complex low anal fistula in ano which shows great potential in reducing both the treatment duration and post-procedural pain.

Dear Editor: Low transsphincteric fistula (LTF) is a tedious surgical disease and its treatment relies on several conventional strategies among which the most common are fistulotomy and fistulectomy. Fistulotomy consists of leaving the anal wound open but is reported to be associated with prolonged wound healing, anal deformity, and an altered continence. In light of these findings, at the end of the 1980s, authors have described a technique based on the marsupialization of wound edges to leave less raw unepithelialized tissues to heal over. Previous randomized studies have compared the outcomes of marsupialization and open wounds in the treatment of anal fistula. To date, no study has specifically compared postoperative care management and recurrence in patients who underwent fistulotomy with or without marsupialization for LTF. In this letter, we compared shortand long-term outcomes of patients with LTF undergoing fistulotomy with those of patients undergoing fistulotomy with marsupialization in the same period. From December 2007 to October 2013, consecutive patients with a diagnosis of anal fistula referred to our surgical uni t , who underwent f is tulectomy with marsupialization (M) or with open wound (OW) on a 1.5:1 ratio over a 7-year period, were prospectively enrolled. At the baseline, all patients underwent anal manometry and endoanal ultrasound. Low transsphincteric anal fistula was defined as a fistula tract traversing the lower third of the external anal sphincter at preoperative instrumental evaluation and confirmed intra-operatively. Patient follow-up was based on regular outpatient clinic visits every 3 months, and information obtained from medical records, correspondence, and telephone contact. Postoperative pain was evaluated with the visual analogue scale (VAS) 12 and 24 h after surgery. Wound healing was defined by complete re-epithelialization recorded by one independent observer who attended the outpatients’ visits and contacted the patients by phone every day afterwards to plan the final outpatient visit. Local wound care was assessed by recording the daily frequency of dressing change or even need for and frequency of who (Bmy-self^; family; district nurse) performed it . Dressing change was strictly performed only at the three daily dressing assessments (every 8 h–7 a.m., 3 p.m., and 11 p.m.), only in case the dressing appeared moist and not absolutely clean and dry. This was recorded bymeans of diaries the patients were asked to complete. In addition, wound care was monitored during outpatient follow-up visits until the wound was closed or up to 3 months after dismissal from the hospital. Wound infection was defined as the presence of local symptoms of suppuration with or without an isolated pathogenic microorganism. A recurrent fistula was assessed by clinical examination and 3D endoanal ultrasound at the outpatient clinic by a competent observer, independent from the operating team. Recurrence was defined when symptoms of the disease recurred after an interval following complete wound healing. Two hundred and sixty-eight consecutive patients with a diagnosis of anal fistula were admitted in our department. Seventythree of 268 consecutive patients with a low transsphincteric anal fistula entered the study. Forty patients were male (male/female ratio 1:2), and the median age at the time of diagnosis was 41 (31–68) years. Forty-four patients (60.2 %) had a marsupialization (M group) and 29 had an open wound (OW group). The median operating time was higher in the M group (P=0.0001). Wound bleeding was less frequent in the marsupialization group than in the OW group (16 vs. 48%, P= * Paolo Limongelli limpao@libero.it

IFTAK technique: An advanced Ksharsutra technique for management of fistula in ano

Background: Fistula in ano (FIA) is a chronic complex condition of ano-rectal sepsis characterized by cylical-pain and intermittent chronic purulent discharge. The management of fistula is challenging. In spite of all the advances in the management of FIA, no single method is univresally applicable to all types of FIA due to incontinence and recurrences associated with the individual procedures.Methods: Aims of this study were to compare the outcomes between ligation of intersphincteric fistula tract (LIFT) and conventional fistulectomy (CF) with 60 patients randomized into 2 groups, 30 in each group.Results: Mean age in LIFT was 44.17 years and in CF was 41.1 years. Successful primary healing was observed in 86.7% of LIFT and 100% of CF. Mean pain scores were lower in LIFT compared to CF when checked on Postoperative days 1, 3 and 7 significantly. Anal incontinence was seen in 10% of CF and none in LIFT and recurrence was seen at same site in LIFT in 6.66% of LIFT and none in CF both being not statistically significant.Conclusions: LIFT is a promising and sphincter saving technique which is simple and easy to learn with faster healing rates and better patient contentment but with risk of failure and recurrence. Modifications of LIFT have to be probed for minimizing the failures.

Ligation of intersphincteric fistula tract is a well-described sphincter-preserving technique for the management of fistula in ano. In 2007, we reported our early experience demonstrating a primary success rate of 94.4%. These findings have since been supported by several short-term studies, but long-term results and secondary cure rates after ligation of intersphincteric fistula tract failure remain unknown. This study aims to report a 10-year experience of ligation of intersphincteric fistula tract with extended long-term follow-up. Retrospective analysis of single-center data from May 2006 to October 2010 was performed. This study was conducted at a large tertiary hospital in Bangkok, Thailand. All patients with primary or recurrent fistula in ano who underwent a ligation of intersphincteric fistula tract procedure were included. Patients with malignancy, incontinent patients, and patients with rectovaginal fistula were excluded. Healing as defined by the absence of symptoms with no visible external opening on clinical examination. Follow-up was continued until May 2016. In total, 251 patients were identified, with a primary healing rate of 87.65% at a median follow-up of 71 months. The healing rates for low transsphincteric, intersphincteric, high transsphincteric, semihorseshoe, and horseshoe fistulas were 92.1%, 85.2%, 60.0%, 89.0%, and 40.0%. Of the 42 patients who had an unhealed fistula after previous non-ligation of intersphincteric fistula tract surgery, 38 (90.48%) healed after the first attempt at ligation of intersphincteric fistula tract. There were 31 patients with unhealed fistulas after the first ligation of intersphincteric fistula tract. Of these, 3 healed spontaneously, and the rest underwent either repeat ligation of intersphincteric fistula tract, fistulotomy (if the recurrence was intersphincteric), or simple curettage (if no internal opening was found). Ultimately, only 2 of the original 251 patients remained unhealed, and there was no change in subjective continence status after surgery. This study was limited by its retrospective design. Ligation of intersphincteric fistula tract is an effective technique for the treatment of fistula in ano, including recurrent or unhealed fistula after other procedures. See Video Abstract at http://links.lww.com/DCR/A387.

The humanity had been suffered from various diseases and among the many uncomfortable conditionsfrom the onset of civilization. Fistula in ano one of the most important one. Its anatomical situation makes it difficult to treat. It is known as Bhagandarain Ayurvedic classics. The disease was widely prevalent and numerous techniques were tried for its management. However, none of them could provide solace to the suffering mankind. Though there has been a lot of advancement in the modern surgery in recent years and many surgical diseases are treated with less invasive procedure such as laparoscopic and robotic surgeries which has revolutionized the management of surgical diseases. But fistula in ano is still the disease with high recurrence rates in present time also. Ayurveda offers an effective, safe, less invasive treatment modality called ksharsutratherapy which have been in since many centuries practice). Ksharsutratherapy has many advantages like the tract is completely excised by lekhanand improved healing simultaneously so, there are least chances of recurrence, minimal scaring and no chance of anal incontinence but Ksharsutracause certain discomfort such as long anxiety period, number of hospital visit, Discomfort and longer duration of treatment. The present study regarding interception of fistulous tract with application of ksharsutra(IFTAK) was done in the patient ofusually horse shoe type fistula, supralevator fistula, transsphinctor fistula, extra sphincter, fistula in ano which showed great potential in the management of fistula in ano by reducing the duration of treatment with minimal post operative scar.

Background: Fistula in ano is a track that connects deeply the anal canal or rectum to the skin around the anus. Fistula in ano most commonly follows an anorectal sepsis1. The main principles of management of anal fistula are closure of internal opening of fistula tract, drainage of infection or necrotic tissue, and eradication of fistulous tract with preservation of sphincter function. The objectives were to compare the various aspects like per operative complications, post-operative complications, mean hospital stay in the treatment of fistula in ano using various modalities like fistulotomy, fistulectomy, setons and lift procedure.Methods: This is a randomised, comparative, prospective study of 80 cases of fistula in ano, presenting at surgical opd of K.R. Hospital, Mysore attached to Mysore Medical College and research Institute. Out of which, 20 cases are treated by fistulectomy, 20 by seton, 20 by fistulotomy and the rest 20 cases by LIFT procedure by random selection method, during period of NOVEMBER 1, 2016 to 31st October 2017.Results: Most common age of presentation is 31-40 years and more common in males then females (M:F= 2.3:1 ). Per operative complications include bleeding seen more in patients undergoing fistulectomy. Per operative course of LIFT procedure patients was complication free. Postoperative pain seen more in patients undergoing setons procedure.Conclusions: we conclude that LIFT procedure and Fistulotomy were acceptable procedures for simple, uncomplicated low lying and high lying fistula.

Introduction: Fistula in ano is considered to be complicated and vicious due to its nature of recurrences and exacerbations. Ayurveda includes this disease under the list of Asta Mahagada (eight serious diseases that are difficult to treat by nature itself) due to this attribute. Ayurvedic literature offers various effective and safe management strategies for fistula in ano. Several works have been conducted to prove the efficacy and effectiveness of various treatment modalities mentioned in Ayurvedic texts. Kshara sutra, Kshara karma, Agnikarma, and Ksharavarti are a few to name in this list. A lacuna exists in not analyzing or compiling these works. Hence, the purpose of this systematic review is to generate evidence for efficacy, effectiveness, and safety profile of Ayurvedic interventions in the management of fistula in ano. Materials and methods: Electronic search from various online databases and clinical trial registers will be done. Manual search for gray literatures will be done from various colleges and universities. There will be no language restrictions. Three authors independently will screen all citations and abstracts to identify potentially eligible trials. Based on the inclusion criteria, full articles will be evaluated and disagreements will be discussed among the three authors. Data extraction from the included studies will be done by the three reviewers independently with extraction forms containing methods, participants, interventions, comparators/controls, and outcomes. Each of the included trials will be assessed for risk of bias. Primary data analysis will be done for both qualitative and quantitative data. Heterogeneity among trials will be assessed by inspecting forest plots. If heterogeneity is detected, and it is still considered clinically meaningful to combine studies, a random- effects model will be used. Meta-analysis will be done for pooled estimates and others would be presented as narrative synthesis and shall be represented in tabular and graphical forms. Dissemination: The systematic review will be published in a peer-reviewed journal. It will also be disseminated electronically and in print. The review may guide healthcare practices and policy framing regarding the treatment of fistula in ano with Ayurvedic interventions. Study registration: PROSPERO registration no. CRD42019131911.

Fistula is considered to be any abnormal passage which connects two epithelial surfaces. Parks fistula classification demonstrates the biggest practical significance and divides fistulae into inter-sphincteric, trans-sphincteric, supra-sphincteric, and extra-sphincteric. Diagnostic method options are retrograde (RTG) fistulography, computed tomography (CT) fistulography, and magnetic resonance imaging (MRI) of pelvic organs. The purpose of the study is to correlate clinical examination and operative findings with the findings of MRI and to draw efficacy of MRI as a preoperative diagnostic tool in the management of fistula in ano. This study was performed at the Surgery Department and MRI unit of the Radiology Department of JLNH and RC, Bhilai, from January 2014 to July 2015. Patients with perianal fistulae were included in our prospective study. All patients underwent high-spatial resolution MR imaging. MR imaging findings were correlated with the intraoperative surgical finding. MR imaging shows 7 fistulous patients with side branching and 16 with abscess cavity which was 100% intraoperatively correlated. Fifty-six patients out of 60 completely correlated with MRI for primary track which was clinically significant. MRI had 96% sensitivity and 100% specificity for primary tract and internal opening and 100% sensitivity and specificity for abscess and multiple tracks. MRI is useful in successful treatment of perianal fistulae by providing more accurate anatomical information about the amount of sphincter above the track and the position and level of the internal opening, thereby increasing the likelihood of successful surgical treatment. So, MRI is the very important preoperative investigation tool for fistula in ano.

BackgroundAn anal fistula plug is a sphincter-sparing procedure that uses biological substances to close an anorectal fistula. This study aimed to evaluate the long-term therapeutic effect of an anal fistula plug procedure in patients with trans-sphincteric fistula-in-ano and to determine the risk factors affecting fistula healing.Material/MethodsA single-center retrospective study was performed assessing long-term treatment outcomes of patients with low trans-sphincteric anal fistulas who initially underwent anal fistula plug procedures between August 2008 and September 2012. Risk factors affecting fistula healing were identified using univariate and multivariate analyses.ResultsA total of 135 patients who had low trans-sphincteric anal fistulas and underwent anal fistula plug procedures were analysed. The overall healing rate was 56% (75/135) with a median follow-up time of 8 years (range, 72–121 months). The primary reasons for treatment failure were plug extrusion (n=12, 20%) and surgical site infection (n=9, 15%), occurring within 30 days after surgery. Multiple logistic regression analysis showed that the duration of anal fistula ≥6 months was significantly associated with treatment failure using an anal fistula plug (OR=3.187, 95% CI: 1.361–7.466, P=0.008). Of the patients who failed initial treatment with an anal fistula plug, 6 (9%) had anal fistulas that healed spontaneously after 2–3 years without additional treatment.ConclusionsAs a sphincter-preserving procedure, the anal fistula plug can effectively promote healing of low trans-sphincteric anal fistulas. The long-term efficacy is good and the procedure warrants wider use in clinical practice.

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.