Transanal Opening of the Intersphincteric Space to Treat Anal Fistula: A Systematic Review and Meta-Analysis.

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.

Anal fistula is a common surgical problem with high incidence and causes suffering to patients. The management of high and complex anal fistula is challenging. The purpose of this work is to develop drug-laden elastomer not only to act as seton in the surgical management of anal fistula but also provide painkilling effect during the treatment. Elastic silicone bands were fabricated with different concentrations of lidocaine, with different in vitro drug release profiles. Muscle cutting experiment showed that the drug-laden elastic silicone bands were as effective as the surgical rubber bands in cutting function. Preliminary clinical trial indicated that the drug-laden silicone bands can be used as setons with analgesic effect in the treatment of anal fistula. The findings showed that the drug-laden elastic silicone bands are potentially useful as seton for surgical treatment of anal fistula.

In an attempt to improve the quality of life of patients with high anal fistula, we developed a new mechanical device, a "fistulectome," which excises the fistula tract in a totally controlled manner, particularly useful in the treatment of high anal fistulas. The "fistulectomy set" consists of a flexible shaft, cannulation and fixation guides, an incisor mouth, and a handle, which is simultaneously used for motor housing. The principle of the treatment is to excise approximately 2-mm thickness of the fistula tract circumferentially, which in fact is a "coring-out" procedure. The fistula tract is likewise transformed into a cylindrical cavity encircled by healthy tissue. This is achieved by the fistulectomy set, consisting of a flexible shaft, cannulation and fixation guides, an incisor mouth, and a handle simultaneously used for motor housing. Between March 2001 and April 2002, a total of 13 consecutive patients with anal fistula underwent excision of fistula tracts. All patients except one had previously been operated on for anal fistula. The distribution of fistulas was as follows: transsphincteric, six patients; suprasphincteric, three patients; extrasphincteric, three patients; multiple, one patient. Mean follow-up was 13.4 (range 7.5-18) months. Gas incontinence in one patient, soiling in one patient, and recurrence in one patient was observed. No recurrences, stool, or gas incontinence were observed in ten patients. Excision of fistula tract performed by the recently developed fistulectome is a minimally invasive, safe, and effective method to be considered in the treatment of anal fistula. The results obtained up to date were encouraging, although the patient number was limited.

Treatment of anal fistulas by use of adhesives is an attractive method because of its simplicity and it can be performed on an ambulatory basis. Furthermore, if the treatment is unsuccessful, adhesive use does not subsequently prevent the surgeon from utilizing alternative surgical techniques and/or products. BioGlue Surgical Adhesive is a two-component surgical adhesive composed of bovine serum albumin and glutaraldehyde. We evaluated the usefulness of BioGlue for the treatment of high transsphincter anal fistulas. Patients diagnosed with high transsphincter anal fistulas of cryptoglandular origin, whether relapsed or not, were included in this study. A seton was placed before the injection of BioGlue into the fistula track of high transsphincter anal fistulas in patients with secondary tracts and/or purulent collections. Clinical charts, operative reports, and endoanal echography results obtained for each patient were reviewed. Fourteen patients (13 males; mean age, 39.9 (range, 24-66) years) with high transsphincter anal fistulas of cryptoglandular origin were recruited into the study. The average time of symptom evolution was 35.6 (range, 2-96) months. Ten of 14 cases were for relapsed fistulas. Six patients required the placement of a seton 37 (range, 32-42) days before the BioGlue injection. Patients were followed for a mean length of 13.92 (range, 3-21) months, and the fistula healed completely in only seven patients (50 percent). These preliminary results demonstrate that BioGlue may be useful for treating patients with high transsphincter anal fistulas. Further prospective long-term studies are needed.

To investigate the more reliable and effective operations for high anal fistula. From Jan. 2002 to Oct. 2004, 117 cases suffering from high anal fistula were divided into two groups, and received tying therapy on main fistula with external anal fistulae excision (62 cases) or tying therapy on main fistula with external anal fistulae laid aside (55 cases). The curing time and recurrence were compared between the two groups. There were no significant differences in basic clinical data between the two groups. There were 37 cases of high simple fistula, and 25 cases of complicated fistulae in resection group, while 39 cases of simple fistula and 16 cases of complicated fistulae in laying aside group. The curing time was 15-20 (17+/-2) days and no recurrence occurred after follow-up for half a year in resection group. The curing time was 25-55 (35+/-8) days and recurrence occurred in 6 cases (10.9%) in laying aside group including one case of high simple anal fistula and five cases of high complicated anal fistulae. There was statistical significance in treatment efficacy for high complicated anal fistulae (chi2=6.23, P=0.013), and the overall efficacy (chi2=5.06, P=0.024) between the two groups. Tying therapy on main fistula with external anal fistulae excision is a more effective treatment for high complicated anal fistulae.

Objective: To analyze the clinical characteristics of adverse reactions to subcutaneous specific immunotherapy (SCIT) with house dust mites in children with allergic rhinitis (AR) and comorbidities, and to explore targeted prevention and management strategies. Methods: A single-center retrospective cohort study was conducted. A total of 133 children with AR who received house dust mite SCIT at the Children's Desensitization Center of the Third Affiliated Hospital of Sun Yat-sen University from March 2020 to August 2023 were selected as the study subjects for the analysis of the overall incidence of adverse reactions. The cohort included 94 males and 39 females, with an age range of 5 to 15 years, a median age of 9 years, and a mean age of 8.5 years. A total of 119 children with three main disease types were included for further analysis, including pure AR (70 cases), AR combined with bronchial asthma (AR+AS) (40 cases), and AR combined with atopic dermatitis (AR+AD) (9 cases). Patients were grouped based on the occurrence of adverse reactions during the entire treatment course: the local adverse reaction group (70 cases) vs. the no local adverse reaction group (49 cases), and the systemic adverse reaction group (39 cases) vs. the no systemic adverse reaction group (80 cases).Differences in baseline characteristics between the occurrence and non-occurrence groups were compared to identify high-risk factors for SCIT adverse reactions. Based on primary disease type, the incidence of SCIT adverse reactions per injection was compared among these different disease type groups. Compare the incidence rates of SCIT adverse reactions during the initiation and maintenance phases among the three groups of children. Comparison of categorical data between groups was performed using the χ² test, with pairwise comparisons adjusted by the Bonferroni correction. For continuous data, inter-group comparisons were conducted using the t-test (for normally distributed data) or the Mann-Whitney U test (for non-normally distributed data). Results: A total of 4 186 injections were administered in 133 children (1 995 during the initiation phase and 2 191 during the maintenance phase). The overall incidence of local adverse reactions was 4.83% (202/4 186 injections), and the overall incidence of systemic adverse reactions was 2.17% (91/4 186 injections). The serum total IgE levels for house dust mites in the local adverse reaction group were significantly higher than those in the no local adverse reaction group [620 (238, 1 000) kUA/L vs. 371 (196.5, 758) kUA/L, Z=-2.084, P=0.037]. Similarly, both mite sIgE [ 77.6 (40.5, 145) kUA/L vs. 44.4 (17.7, 85.1) kUA/L, Z=-2.621, P=0.009] and serum total IgE [620 (332, 1 916) kU/L vs. 407 (199, 796)kU/L, Z=-2.463, P=0.014] were significantly higher in the systemic adverse reaction group compared to the no systemic adverse reaction group. The incidence rates per injection for both Grade I systemic adverse reactions (AR+AS group: 2.59% vs. pure AR group: 0.78%, χ²=1 461.468, P<0.001; AR+AS group: 2.59% vs. AR+AD group: 1.77%, χ²=21.759, P<0.001) and Grade Ⅱ systemic adverse reactions (AR+AS group: 1.52% vs. pure AR group: 0.18%, χ²=10.726, P=0.001; AR+AS group: 1.52% vs. AR+AD group: 1.06%, χ²=12.632, P<0.001) in the AR with asthma (AR+AS) group were significantly higher than those in both the pure AR group and the AR with atopic dermatitis (AR+AD) group. Furthermore, the incidence rates of both local adverse reactions (7.95% vs. 2.13%, χ²=64.66, P<0.001) and systemic adverse reactions (3.82% vs. 0.84%, χ²=35.54, P<0.001) were significantly higher during the maintenance phase compared to the initial phase. Conclusion: Children with allergic rhinitis and comorbid asthma have an increased risk of systemic adverse reactions to SCIT, and the risk is higher during the maintenance phase than during the initiation phase. An individualized management strategy grounded in risk assessment should be implemented in clinical practice to improve treatment safety.

The incidence of anal abscess and fistula is relatively high, and the condition is most common in young men. This is a revised version of the German S3 guidelines first published in 2011. It is based on a systematic review of pertinent literature. Cryptoglandular abscesses and fistulas usually originate in the proctodeal glands of the intersphincteric space. Classification depends on their relation to the anal sphincter. Patient history and clinical examination are diagnostically sufficient in order to establish the indication for surgery. Further examinations (endosonography, MRI) should be considered in complex abscesses or fistulas. The goal of surgery for an abscess is thorough drainage of the focus of infection while preserving the sphincter muscles. The risk of abscess recurrence or secondary fistula formation is low overall. However, they may result from insufficient drainage. Primary fistulotomy should only be performed in case of superficial fistulas. Moreover, it should be done by experienced surgeons. In case of unclear findings or high fistulas, repair should take place in a second procedure. Anal fistulas can be treated only by surgical intervention with one of the following operations: laying open, seton drainage, plastic surgical reconstruction with suturing of the sphincter (flap, sphincter repair, LIFT), and occlusion with biomaterials. Only superficial fistulas should be laid open. The risk of postoperative incontinence is directly related to the thickness of the sphincter muscle that is divided. All high anal fistulas should be treated with a sphincter-saving procedure. The various plastic surgical reconstructive procedures all yield roughly the same results. Occlusion with biomaterial results in lower cure rate. In this revision of the German S3 guidelines, instructions for diagnosis and treatment of anal abscess and fistula are described based on a review of current literature.

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.

Long-term outcomes of (Gore) fistula plug versus ligation of intersphincteric fistula tract for anal fistula

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. 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 6-8weeks before Permacol™ paste injection. Follow-up duration was 12months. 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 12months, 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 12months. Permacol™ paste injection was safe and effective in some patients with complex anal fistula without compromising continence.

Ablation of anal fistula tract using a radial laser-emitting probe is a sphincter-preserving technique. The objective of investigating the safety and efficacy of laser treatment for complex anal fistula. This was a prospective and observational analysis of the long-term outcomes of 172 patients who underwent laser ablation of the fistula tract. This was a multicentre, single-arm study, involving 20 Spanish centres. Patients with cryptoglandular anal fistulas with an external orifice, high intersphincteric fistula or low intersphincteric fistula with faecal incontinence, transsphincteric fistula and suprasphincteric fistula. A probe housing a 12-watt laser emitting at a wavelength of 1470 nm and an energy level of 100 joule/cm was used. Complete treatment success was defined as the closure of the external opening and the absence of fistula drainage, with closure of the fistula tract confirmed by clinical evaluation. Partial success was defined as the external opening remaining open but without drainage. Surgical complications, including continence disorders, were also assessed. Patients were evaluated at 1, 3, 6, and 12 months after surgery. A total of 172 patients underwent laser ablation of the fistula tract with a median age of 51 (43-61) years. The majority of them were men (62,8%). A total of 133 patients (77.32%) were followed up for a minimum of 12 months. The number of patients with complete healing was 59 (44.3%) and partial healing was observed in seven (5.26%). Healing (clinical and radiological) was not achieved in 67 patients (50.37%). Nine reported adverse events. None of the patients experienced permanent anal incontinence. It is the loss to follow-up of up to 20% of patients, as many patients do not tolerate waiting within a strict visit schedule. Laser ablation of the fistula tract is a sphincter-preserving procedure with an acceptable long-term success rate.

Background: Anal fistula is a chronic condition characterized by an abnormal communication between the anal canal and perianal skin, often resulting in persistent discharge, pain, and frequent recurrences. Conventional treatment approaches, including fistulotomy and seton placement, are associated with prolonged healing time and risks of postoperative complications such as incontinence. In recent years, platelet-rich plasma (PRP) has gained attention as a biological therapy due to its ability to enhance tissue regeneration and wound healing. PRP contains concentrated growth factors that stimulate fibroblast proliferation, angiogenesis, and extracellular matrix remodeling, potentially facilitating fistula closure with improved postoperative outcomes. Objective: This study aims to evaluate the efficacy of platelet-rich plasma (PRP) in the treatment of anal fistula, assessing its impact on healing rates, time to complete epithelialization, postoperative pain reduction, and recurrence rates in comparison to conventional surgical methods. Methods: A prospective study was conducted on 100 patients diagnosed with low and high transsphincteric anal fistula at a tertiary care hospital. Participants were randomly allocated into two groups: the PRP-treated group (n=50), where PRP was injected into the fistula tract following debridement, and the control group (n=50), which underwent standard surgical management without PRP. Patients with secondary anal fistula due to Crohn’s disease, tuberculosis, or malignancy were excluded. The primary outcome measures included fistula healing rates, time to complete epithelialization, postoperative pain scores, and recurrence rates, evaluated over a follow-up period of six months. Statistical analysis was performed using SPSS software, with a p-value &lt; 0.05 considered statistically significant. Results: The mean age of participants was 41.6 ± 12.4 years, with a male predominance of 68 percent. The healing rate in the PRP group was significantly higher at 84.0 percent compared to 60.0 percent in the control group (p = 0.010). Patients treated with PRP experienced faster wound closure, with a mean healing time of 5.9 ± 1.7 weeks versus 8.5 ± 2.4 weeks in the control group (p &lt; 0.001). Postoperative pain scores, assessed using the Visual Analogue Scale (VAS), were lower in the PRP group at one week postoperatively (3.2 ± 1.1) compared to the control group (5.6 ± 1.4, p = 0.015). Recurrence was observed in 16.0 percent of PRP-treated patients versus 34.0 percent in the control group (p = 0.038). No significant complications, including fecal incontinence or severe infections, were reported in either group. Conclusion: The findings suggest that platelet-rich plasma (PRP) is an effective adjunct therapy in the treatment of anal fistula, significantly enhancing healing rates, reducing postoperative pain, and lowering recurrence compared to conventional surgical methods. Given its autologous nature, minimal invasiveness, and regenerative properties, PRP may serve as a promising alternative in the management of anal fistula. Further large-scale randomized controlled trials are recommended to establish PRP as a standard treatment option.

Despite a thousand-year history of anal fistula treatment, long-term outcomes have not been optimal, which encourages us to explore new surgical approaches. One of the methods of surgical treatment of anal fistulas is the use of ligature (Seton) in its different modifications. This review analyzes the literature data on the use of different modifications of seton treatment of anal fistulas. The analysis of publications showed the great interest in the use of the method, yet there is neither clear scheme nor systematic approach to applying it in clinical practice. Further study, as well as randomized researches, are required to find the optimal treatment and improve surgery results of using seton when dealing with anal fistula.

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.

To analyse the safety and effectiveness of platelet-rich plasma (PRP) in anal fistula patients. Online databases including PubMed, Embase, Cochrane Library, and Web of Science were searched from inception to December 5, 2022, for eligible studies about evaluating the efficacy of platelet-rich plasma (PRP) in treating anal fistula. Literature search, screening, data extraction, and quality assessment were carried out by two independent investigators. The overall cure rate, the complete cure rate, the recurrence rate, and the adverse event rate with their 95% confidence intervals (95% CI) were the primary calculation indexes. Subgroup analyses were conducted primarily according to whether PRP was combined with other treatments. Softwares of MedCalc 18.2 and Review Manager 5.3 were used for meta-analysis. A total of 14 studies with 514 patients were included in the meta-analysis. The overall cure rate of 14 studies was 72.11% (95% CI 0.64-0.79). The cure rate of PRP alone was 62.39% (95% CI 0.55-0.69). The combined cure rate of PRP with other treatments was 83.12% (95% CI 0.77-0.88). The cure rate of interventions involving PRP were superior to the cure rate of surgery methods without using PRP significantly in the 4 randomized controlled studies (RR = 1.30, 95% CI 1.10-1.54, p = 0.002). The complete cure rate of the 8 studies was 66.37% (95% CI 0.52-0.79). The recurrence rate of the 12 studies was 14.84% (95% CI 0.08-0.24). The adverse event rate of the 12 studies was 6.31% (95% CI 0.02-0.12). PRP showed favorable safety and effectiveness in the treatment of anal fistula, especially combined with other treatment procedures.