Complex Fistula Research Articles

A scoping review of tissue interposition flaps used in vesicovaginal fistulae repair.

Research on the use of tissue interposition flaps (TIFs) in vesicovaginal fistulae (VVF) repair is a broad area where a very wide range of natural and synthetic materials have been used. The occurrence of VVF is also diverse in the social and clinical settings, resulting in a parallel heterogeneity in the published literature on its treatment. The use of synthetic and autologous TIFs in VVF repair is not yet standardized with a lack of the most efficacious type and technique of the TIF. The aim of this study was to systematically review all synthetic and autologous TIFs used in the surgical repair of VVFs. In this scoping review, the surgical outcomes of autologous and synthetic interposition flaps used in VVF treatment meeting the inclusion criteria were determined. We searched the literature using Ovid MEDLINE and PubMed databases between 1974 and 2022. Study characteristics were recorded, and data on the change in fistulae size and location, surgical approach, success rate, preoperative patient evaluation and outcome evaluation were extracted from each study independently by two authors. A total of 25 articles that met the inclusion criteria were included in the final analysis. A total of 943 and 127 patients who had received autologous and synthetic flaps, respectively, were included in this scoping review. The fistulae characteristics were highly variable with regard to their size, complexity, aetiology, location and radiation. Outcome assessments of fistulae repair in included studies were mostly based on symptom evaluation. Physical examination, cystogram and methylene blue test were the methods in order of preference. Postoperative complications, such as infection, bleeding, donor site, pain, voiding dysfunction and other complications, were reported in patients after fistulae repair in all included studies. The use of TIFs in VVF repair was common especially in complex and large fistulae. Autologous TIFs appear to be the standard of care at the moment, and synthetic TIFs were investigated in prospective clinical trials in a limited number of selected cases. Evidence levels of clinical studies evaluating the effectiveness of interposition flaps were overall low.

Closure of Fistula-in-Ano Using a Radial-Emitting Laser Probe: Initial Experience in Lagos, Nigeria.

Fistula-in-ano treatment has remained quite challenging with high failure rates and a potential for damage to the anal sphincteric complex leading to flatal or faecal incontinence. The treatment of fistula-in-ano using the fistula laser closure (FiLaC) as a minimally invasive, sphincter-saving procedure for complex disease has recently been documented. This review aimed to report the outcome of using it at the Lagos University Teaching Hospital. The procedures were performed with a radially emitting laser fibre from Biolitec AG-CeramOptec (Bonn, Germany). The duration of symptoms, type of fistula, duration of the procedures, and postoperative complications were evaluated. Eleven male patients had laser fistula-in-ano closure. The age range was 33-51 years, with a median age of 39 years and an interquartile range (IQR) of 37-47 years. Five patients were noted to have high fistula/e, whereas six had low fistula/e, seven had a single tract each, and three had three tracts each. The duration of surgery ranged, approximately from 3 to 60 min, with a median of 19 min and IQR of 9-33 min. Postoperative pain was mild in all patients and were all discharged as day case. There was no postoperative wound infection, anal incontinence, anal stenosis, and subcutaneous abscess. However, there was a recurrence in two patients. FiLaC has been demonstrated to be a reliable and safe sphincter-saving procedure for treating fistula-in-ano even for complex and high fistulae that is feasible in our subregion.

Frequency of Healing of Fistula in Patients Undergoing Video Assisted Anal Fistula Treatment in High Lying Fistula in Ano

Background: Fistula-in-ano is an abnormal tract that usually connects rectal mucosa and perianal skin thus accounting upto 90% cases with an incidence of 5.6/100.000 in women while 12.3/100.000 in men. Aim: To determine the frequency of healing in patients with high lying fistlua in ano undergoing VAAFT. Study design: Cross-sectional study. Methodology: Patients (n=153) were enrolled during study. All enrolled patients had DRE and proctoscopy before start of treatment. Fistuloscope was used to diagnose high lying fistula during examination. Metronidazole antibiotic was given to all patients both pre and post-surgery. SPSS v.26 analyzed the data. Stratification of healing data was done with respect to age and gender. Post stratification Chi-Squire test was applied with P-value ≤0.05 was taken as significant. Results: Almost 77% were males while rest (23%) patients were females. Results showed healing in 70% of patients while 30% patients failed to heal. Practical Implication: This study showed that VAAFT procedure is safe as a treatment modality in comparison to Anal Fistula Plug and conventional Seton placement for complex fistulas or high anal fistulas thus advocated sphincter saving procedure in our setups. Conclusion: It was concluded that this new surgical technique has advantages like sphincter-saving with small surgical wounds. However, fistuloscopy identifies secondary tracts or chronic abscesses. Keywords: Healing, High Lying Fistlua and VAAFT.

Chronic Cryptoglandular Anal Fistulas: Surgical Outcomes; A Retrospective Case Control Study In 148 Patients with No Risk Factors for Recurrence

Background: The success rate of surgery for anal fistulas in the literature is variable, ranging between 30-90% due to differences in etiology, risk factors for recurrences and variety of surgical and innovative techniques used in therapy of anal fistulas. Aim: We try to evaluate the surgical outcomes in patients without any known risk factor for recurrence. Materials and Methods: A retrospective study with 148 patients was performed. Fistulas were classified according to: Parks system, the modified Parks’s and the St James’s University Hospital system. MRI, TRUS and EUA were the most useful examinations. The age, duration of symptoms, location of the fistula according to the transvers anal line, the grade of complexity of AF were studied. Only patients with cryptoglandular anal infection were enrolled excluding patients with acute, subacute phase of inflammation and risk factors for recurrence. Operations performed in treatment of AF were registered. Various parameters studied underwent statistical analysis; Student t test and chi-square or Fisher exact test were used for comparisons between continuous and categorical data respectively Results: 148 patients (112 males,36 females, age range 21-74yrs, mean age 44±13, male to female ratio 3.1/1) were studied; 52(52/148, 35%) with simple and 96(96/148, 65%) with complex fistulas. MRI was necessary for classification of anal fistulas and identified the internal opening of fistula in134 patients (134/148, 93%) and in 14 inconclusive cases was identified by TRUS. LIFT was performed in complex fistulas and low intersphinceric fistulas in 102 patients (102/148, 68.6%). Fistulotomy in 41(41/148, 27.7%) with simple linear intersphincteric fistulas and laser therapy in 5(5/148, 3.4%) with simple low intersphincteric fistulas. A successful surgical outcome was achieved in 51 patients with simple (51/52, 98%) and 91(91/96, 94.8%) with complex fistulas.6 recurrences were detected (6/148, 4.05%). Conclusion: Chronic anal fistulas, in selected patients present postoperative healing rates at 98% and 94.8% for simple and complex fistulas respectively and recurrence rate at 4.05%. The most common operations were LIFT and fistulotomy.

Clinical characteristics and MRI-based phenotypes of perianal abscess formation in children with fistulizing Crohn's Disease.

The aim of this study was to explore potential correlation of the MR imaging features and clinical characteristics with formation of perianal abscess in children with Crohn's perianal fistulas (CPF). From 2010 to 2020, pediatric patients with CPF diagnosis on their first pelvic MRI were identified retrospectively. All patients were divided into two groups based on the presence or absence of perianal abscess. Baseline clinical and MRI characteristics were recorded for each patient. All the statistical calculations were performed using R (version 3.6.3). A total of 60 patients [F:M 17:43, median age 14 years (IQR 10-15), ranging 3-18 years] were included in this study. Forty-four abscesses were identified in 36/60 children (mean volume 3 ± 8.6 ml, median 0.3 ml). In 24/60 patients with perianal disease, no abscess was detected on the MRI. Ten patients (28%) showed perianal abscess on pelvic MRI at the initial diagnosis. The rate of active disease on colonoscopy (visible ulcerations/aphthous ulcers) was similar in both groups (95% vs. 94%). With regards to disease location, the majority of patients (40/60, 66.6%) in both groups had ileocolonic CD. All patients without abscess had a single perianal fistula (n = 24; 3 simple and 21 complex fistulae), however, patients with perianal abscess tended to have >1 fistulous tracts (n = 50 fistulas; all complex, 27 single, 10 double and 1 triple). Intersphincteric fistula was the most common fistula type in both groups (79% and 66%, p = 0.1). The total length of fistula (3.8 ± 1.7 vs. 2.8 ± 0.8 cm, p = 0.006) and presence of multiple external openings (n = 25 vs. 7, p = 0.019) were significantly higher in patients with abscesses, and fistula length >3.3 cm showed 80% specificity and 83% PPV for the presence of perianal abscess. Fistulas were symptomatic (pain, bleeding or drainage) at similar rates in both groups (68% and 70%, p = 0.1). Pediatric patients with CPF who develop perianal abscess have a distinct imaging phenotype defined by longer fistula length (>3.3 cm), multiple skin openings and multiple fistulous tracts (≥2) on MRI. Patients who have these features but does not have an abscess on imaging may merit more aggressive treatment (and close monitoring) to prevent the development of an abscess.

Preoperative cross-sectional imaging findings in patients with surgically complex ileocolic Crohn's disease.

The aim of this study was to evaluate the diagnostic performance of preoperative cross-sectional imaging findings using the SAR-AGA definitions in Crohn's disease (CD) patients who underwent ileocolic resection (ICR) with and without surgically complex ileocolic CD (CIC-CD). 69 CD patients [38 men; mean (± SD) age: 40.6 (16.2) years] who underwent ICR were retrospectively classified by surgical complexity by a colorectal surgeon using operative findings. CIC-CD was defined as ileal CD, not confined to the distal ileum. Two radiologists retrospectively evaluated the preoperative imaging for the presence and type of penetrating disease, stricture, or probable stricture using the SAR-AGA consensus definitions. The diagnostic performance of preoperative imaging findings was compared for patients with and without CIC-CD. Estimated blood loss (EBL), operative time (OT), conversion to open surgery, diversion, and length of hospital stay (LOS) were compared. 60.9% had CIC-CD and 79.7% underwent primary ICR. Penetrating disease was more common in patients with than without CIC-CD (76.2% vs. 40.7%, p = 0.0048) and similar among primary versus redo ICR (p = 0.12). Patients with CIC-CD had more complex fistulas (59.5% vs. 11.1%; p < 0.0001) and fewer simple fistulas (2.4% vs. 18.5%; p = 0.03) than those without. Mesenteric findings (abscess, inflammatory mass) were more frequent in patients with (35.7%) than without (0%) (p = 0.0002) CIC-CD. Stricture and probable stricture were similar (p = 0.59). CIC-CD patients had greater EBL (178cc vs. 57cc, p = 0.006), conversion rates (30% vs. 0%, p = 0.0026), and diversion (80% vs. 52%, p = 0.04). Complex fistula, mesenteric abscess, or inflammatory mass defined by the SAR-AGA guidelines suggests CIC-CD. ICR for CIC-CD had greater EBL, conversion to open surgery, and diversion.

Robotic-Assisted Laparoscopic Repair of Iatrogenic Vesico-Vaginal Fistula

<h3>Study Objective</h3> This video highlights the principles of robotic assisted laparoscopic repair of iatrogenic vesico-vaginal fistula <h3>Design</h3> Surgical video presentation. <h3>Setting</h3> Academic tertiary care center. <h3>Patients or Participants</h3> We present 2 cases of iatrogenic vesico-vaginal fistula repaired robotically. Case 1 is a 49-year-old patient with a vesico-vaginal fistula after an open supracervical hysterectomy with incidental cystotomy and repair. Case 2 is a 61-year-old patient who was referred for management of a supra-trigonal vesico-vaginal fistula as a complication of vaginal hysterectomy. <h3>Interventions</h3> Case 1 started with cystoscopy and placement of ureteral stents. The peritoneum above the vaginal cuff was incised and an anterior colpotomy was created. The bladder was dissected until the fistula was identified and the injured area was 4 cm away from the colpotomy. The fistulous margins where dissected. The bladder mucosa was repaired in 2 layers in a running fashion. The bladder was retrogradely filled, confirming the repair was watertight. The colpotomy was closed in 2 layers. The repair was reinforced with omental interposition. For case 2, a stent was placed through the vaginal fistulous opening. The stent was identified transvesically with cystoscopy. Bilateral ureteral stents were placed. Similar steps from case 1 were carried out. Cystoscopy was performed confirming an adequate repair. Bilateral ureteral stents were removed. A Foley catheter was inserted to remain in place for 3 weeks. <h3>Measurements and Main Results</h3> Both patients were discharged on post-operative day 1. The patient in case 1 had a voiding cystogram showing no evidence of residual or recurrent fistula on post-operative week 3, and urine leakage was resolved. The patient in case 2 is scheduled for follow up on post-operative week 3. <h3>Conclusion</h3> Robotic assisted repair offers optimal surgical exposure and is ideal for supra-trigonal and complex vesico-vaginal fistulas, affording good outcomes for patients.

Garg scoring system to predict long-term healing in cryptoglandular anal fistulas: a prospective validation study.

Complex anal fistulas can recur after clinical healing, even after a long interval which leads to significant anxiety. Also, ascertaining the efficacy of any new treatment procedure becomes difficult and takes several years. We prospectively analyzed the validity of Garg scoring system (GSS) to predict long-term fistula healing. In patients operated for cryptoglandular anal fistulas, preoperative magnetic resonance imaging (MRI) and postoperative MRI was done at 3 months to assess fistula healing. Scores as per the GSS were calculated for each patient at 3 months postoperatively and correlated with long-term healing to check the accuracy of the scoring system. Fifty-seven patients were enrolled, but 50 were finally included (7 were excluded). These 50 patients (age, 41.2± 12.4 years; 46 males) were followed up for 12 to 20 months (median, 17 months). Forty-seven patients (94.0%) had complex fistulas, 28 (56.0%) had recurrent fistulas, 48 (96.0%) had multiple tracts, 20 (40.0%) had horseshoe tracts, 15 (30.0%) had associated abscesses, 5 (10.0%) were suprasphincteric, and 8 (16.0%) were supralevator fistulas. The GSS could accurately predict long-term healing (specificity and high positive predictive value, 31 of 31 [100%]) but was not very accurate in predicting non-healing (negative predictive value, 15 of 19 [78.9%]). The sensitivity in predicting healing was 31 of 35 (88.6%). GSS accurately predicts long-term fistula with a high positive predictive value (100%) but is less accurate in predicting non-healing. This scoring system can help allay anxiety in patients and facilitate the early validation of innovative procedures for anal fistulas.

Regenerative and Endoscopic Treatment of Complex Recurrent Fistula in Ano: When Technology Supports Clinical Treatment

Background: Recurrent anal fistulas present a challenge to surgeons due to the high risk of post-operative incontinence caused by repeated surgery. The correct identification of the anatomy of the main and secondary fistula tracts and the individuation of abscess cavities are fundamental for correct treatment. Intraoperative endoscopic evaluation and the complete destruction of the fistula pathway can be achieved through video-assisted anal fistula treatment (VAAFT). Furthermore, the injection of human autologous Microfractured Adipose Tissue (MFAT) processed by a Lipogems® device can be used as both a bulking agent and a regenerative technique. Methods: A combined approach of VAAFT plus Microfractured Adipose Tissue Graft (MFAT) is proposed in order to treat recurrent and complex fistula in ano. Results: Three cases treated with a combination of VAAFT and MFAT grafts are described. All cases had undergone multiple interventions at the perianal level over a period ranging from 1 to 15 years. One case certainly failed due to poor patient compliance, but in the remaining two cases, the patients made a complete recovery with the disappearance of symptoms over a follow-up period of one to two years. Conclusion: The combination of video-assisted anal fistula treatment and injection of human autologous microfractured adipose tissue may be a valid, safe and feasible therapeutic option. MFAT injections are more effective in promoting tissue regeneration than simply “filling” the fistula tract and are common practice also in the treatment of Crohn’s Disease due to the immunomodulatory power of mesenchymal cells.

Clinical study and management of fistula in Ano

Background: Fistula in Ano is one disease which is easy to diagnose but difficult to cure as patients report in very late phase of the disease and it leads to problems. Aim of this study was to determine the etiology, clinical presentation, efficacy of different surgical approach, early and late post-operative complications, and recurrence rate in cases of fistula in Ano.Methods: Prospective Observational Study was conducted in Department of General Surgery, Government Medical College, Solapur from Sep 2016 to Aug 2018 with Sample size of 50 cases.Results: Most common age group affected between 18-29 years, with male preponderance. Most common etiological factor is perianal sepsis following Crypto glandular infection, with pain as most prevalent symptom. Simple fistula is more common, and in complex fistula most prevalent type is high transsphincteric fistula. Most common procedure done is fistulotomy. Most common complication is recurrence. Most number of complications was seen in fistulotomy. Maximum recurrence is seen after fistulotomy.Conclusion: Most common cause is crypto glandular infection, most common feature is pain, Fistulectomy is more efficacious, and complications are maximum with fistulotomy, highest recurrence seen after fistulotomy.

S2711 Biologic Therapies for Isolated Recurrent, Persistent Complex Perianal Fistulas Without Luminal Crohn's Disease

Introduction: Isolated complex perianal fistulas are abnormal connections between the epithelial surfaces of the anal canal and the perianal skin, meeting criteria for complex perianal fistula but without evidence of inflammatory bowel disease (IBD). While over half of patients with Crohn’s disease (CD) have perianal fistulas, isolated perianal CD is rare. Here we discuss five cases of patients presenting with isolated recurrent complex perianal fistula, and we describe their diagnostic evaluation, attempted therapies, and outcomes. Case Description/Methods: Five adults (3 women, 2 men; mean age 38 years old) with no prior GI symptoms/diseases initially presented with perianal pain (3/5), perirectal mass (2/5), diarrhea (1/5), and abdominal pain (1/5) (Table). All patents underwent exam under anesthesia (EUA) with incision and drainage (I&D) of perirectal abscesses, and setons were placed in perianal/rectal fistulas in 4/5 cases. Each patient had colonoscopy without evidence of inflammation on endoscopy or histology. Radiographic imaging (MRIs, MREs, and CT) revealed fistulas and abscesses but no evidence of luminal inflammation. All patients were treated with antibiotics and 4/5 received biologic therapy (Adalimumab, Infliximab, or Ustekinumab). Despite surgical and medical management, complex perianal fistulas were persistent in all patients at follow-up after an average of 45 months. Discussion: For patients who develop recurrent complex fistulas, a presumptive diagnosis of CD is often made. However, patients who present with complex perianal fistulas in the absence of the luminal inflammation characteristically found in CD are said to have isolated perianal disease (IPD). It is unclear whether IPD represents truly isolated severe cryptoglandular fistulas or early presentation of undiagnosed CD, which renders the best treatment approach a clinical dilemma. IPD is classically treated with antibiotics and local surgical intervention, whereas perianal CD treatment is more complex, incorporating the use of immunosuppressive therapy. The cases described in our cohort reveal the importance of a multimodal approach when treating IPD in the absence of luminal findings of CD. While classic medications for CD are unlikely to succeed when used alone for IPD, their incorporation into the treatment regimen may be critical in achieving eventual resolution of perianal disease. Given the similarity in management, it is important to consider CD in the differential for IPD patients even in the absence of luminal findings. Table 1. - Patient Summary PT # Initial Presentation Diagnostic Evaluations Subsequent Diagnosis Medical Therapies Attempted Surgical Procedures Ultimate Diagnosis and Plan (1) 39F Painful perianal mass, presumed to be an abscess or hemorrhoids Flexible sigmoidoscopyColonoscopy with bxMRIEUA Refractory perirectal and rectovaginal fistula with abscess IBD medications: AdalimumabMethotrexate Non-IBD medical therapies: CiprofloxacinMetronidazoleAmoxicillin-Clavulanic acidPrednisone I&DSeton placementFistulectomy with sphincterotomyDiverting sigmoid colostomyFistulotomy Non-healing cryptoglandular anal fistula complicated by surgery Discontinue IBD therapySurgical f/u with consideration for clinical trial of stem cell injection or transperitoneal repair (2) 34M Abdominal pain, diagnosed with sigmoid diverticulitis Colonoscopy with bxMRIMRECT scanEUA Refractory perianal fistula with abscess IBD medications: InfliximabUstekinumabTacrolimusAzathioprine Non-IBD medical therapies: MetronidazoleCiprofloxacin I&DSeton placement Isolated perianal disease in the setting of presumed CD Chronic treatment with chronic, cyclical abx (Ciprofloxacin or Amoxicillin-Clavulanic acidIBD-directed therapy (Azathioprine + Infliximab; will consider Upadacitinib once approved by the FDA)Planning for surgical f/u (3) 43M Painful perianal mass, presumed to be a rectal abscess Colonoscopy with bxMRIEUA Refractory perianal abscess Non-IBD medical therapies: Amoxicillin-Clavulanic acid I&D Isolated cryptoglandular abscess with potential hemorrhoids No need for chronic antibioticsSitz baths and PrepH as neededIf symptoms worsen will plan for EUA and surgical f/u (4) 24F Perianal pain, diagnosed as perianal abscess with fistula Colonoscopy with bxMRIEUA Refractory perianal abscess, inflammatory arthropathy IBD medications: AdalimumabInfliximabAzathioprine Non-IBD medical therapies: CiprofloxacinMetronidazole I&DSeton placement Presumed CD with perianal disease and inflammatory arthropathy IBD-directed therapy (Azathioprine + Infliximab)Planning for surgical f/u (5) 50F Diarrhea and rectal ulcers, presumed to have CD Colonoscopy with bxMRICTEUA Refractory perianal fistula with abscess IBD medications: Infliximab Non-IBD medical therapies: ColchicinePrednisone I&DSeton placementPerineal debridementLay open fistulotomy Presumed CD with perianal disease IBD-directed therapy (Infliximab) Abbreviations: Bx = biopsies. CD = Crohn’s disease. EUA = exam under anesthesia. F = female. F/U = follow up. I&D = incision and drainage. IBD = inflammatory bowel disease. M = male. MRE = magnetic resonance elastography. MRI = magnetic resonance imaging

Comparison of contrast-enhanced fat-suppressed T1-3D-VIBE and T1-TSE MRI in evaluating anal fistula.

To evaluate the accuracy of contrast-enhanced (CE) fat-suppressed three-dimensional (3D) T1-weighted imaging with volumetric interpolated breath-hold examination (FS-T1-3D-VIBE) and fat-suppressed T1-weighted turbo spin echo (FS-T1-TSE) sequence in characteristics of anal fistula. One hundred and two patients underwent perianal CE-MRI examination on a 3T scanner including FS-T1-3D-VIBE and FS-T1-TSE sequences before surgery. The performance of each sequence was evaluated in terms of fistula classification, clarity of internal opening, number and position of internal openings including the distance between internal opening and anal verge, presence of secondary tracts and blind-ending sinus tracts. MRI findings were compared with surgical findings. Signal-to-noise ratios (SNRs) and contrast-to-noise ratios (CNRs) of fistula, gluteus maximus, and subcutaneous fat were compared between CE FS-T1-TSE and CE FS-T1-3D-VIBE. Compared with CE FS-T1-TSE, CE FS-T1-3D-VIBE displayed more accurate in secondary tract, lithotomy position of the internal opening and the distance between internal opening and anal verge (P < 0.05). CE FS-T1-3D-VIBE was found superior to CE FS-T1-TSE in the clarity of the internal openings and in the diagnostic accuracy of blind-ending sinus tracts and complex fistulas in Standard Practice Task Force classification (P < 0.05). CE FS-T1-3D-VIBE achieved higher SNRs and CNRs in fistula and gluteus maximus than CE FS-T1-TSE (P ≤ 0.001). CE-MRI of FS-T1-3D-VIBE might be a more valuable noninvasive technique than FS-T1-TSE to evaluate the anal fistula on evaluating the lithotomy position of internal opening, distance between internal opening and anal verge, clarity of internal opening, secondary tract, blind-ending sinus tract and classification of the complex fistula. The trial registration number for this prospective trial was Chi-TR1800020206 and the trial registration date was December 20, 2018.

A Comparison of Different Surgical Treatments for Complex Anal Fistula: A Systematic Review.

Fistula-in-ano is a common proctological condition that primarily affects younger people and leads to chronic morbidity. An anal fistula is divided into simple and complex fistulas. A complex fistula is a challenging problem due to higher recurrence rates and incontinence associated with surgery. Many new methods have been developed for the closure of complex fistula-in-ano, but there is no single best method. The aim of this study is to identify a superior surgical technique for treating complex/high cryptoglandular perianal fistulas (HCPFs). A literature search was done using PubMed and Google Scholar for the period of 2012-2021. Articles that contain surgical treatment for complex anal fistula in the English language published in the last 10 years were included. The types of studies included were randomized controlled trials (RCTs), meta-analyses, systematic reviews, cohort studies, and traditional reviews. Articles excluded were those done more than 10 years ago, in other languages, and containing simple fistula management only. Nine studies were included in the review; a systematic review and meta-analysis concluded that no single method is effective. The ligation of the intersphincteric fistula tract (LIFT) procedure seems to be a promising and effective technique as it has a low rate of fecal incontinence as compared to other methods. Biological techniques give variable success rates so does fistula plug (FP). Mucosal advancement flap (MAF) and rerouting seton give good results according to one study. Fistula plug gives variable results and is not a preferred method.Ligation of the intersphincteric fistula tract (LIFT) seems to be a promising new technique for complex anal fistulas, but the data available is not enough to determine the best method. More randomized trials are required to compare traditional techniques and emerging new biological methods to see the best technique available.

Evaluation of Fistula Laser Closure (FiLaC) in Management of High Trans- sphincteric Fistula- in- ano

Background: In 2016, Wilhelm introduced “Fistula Laser Closure” (FiLaC) as a novel sphincter-preserving technique, using a radial emitting laser probe with an initial success rate of 81.8% in 11 patients over a median follow-up of 7.4 months. Aim of the study: To evaluate the effectiveness of the Fistula Laser Closure (FiLaC) technique in the management of high trans-sphincteric fistula-in-ano and investigate predictors of success and the impact of the procedure on anal continence. Patients and methods: This prospective cohort study, was carried out on 20 patients with high Trans- sphincteric fistula- in- ano at Department of Surgery in Al-Azhar University Hospitals, Cairo, Egypt between April 2021 and November 2021. Patients were treated by Fistula Laser Closure (FiLaC) technique and followed up for at least 6 months postoperatively. Results: There was significant difference between simple and complex fistula as regards hospital stay, Early incontinence, pain score and patient satisfaction (p&lt;0.001). Conclusion: Fistula-tract Laser Closure (FiLaC) can be considered a viable option in the treatment of high trans-sphincteric fistula especially simple type.

Correlation between imaging findings on outpatient MR enterography (MRE) in adult patients with Crohn disease and progression to surgery within 5years.

To retrospectively evaluate which key imaging features described by SAR-AGA on outpatient surveillance MRE correlate with progression to surgery in adults with CD. 52 CD patients imaged with outpatient MRE from 10/2015 to 12/2016 and with available clinical information were included. Two abdominal radiologists reviewed the MRE for the presence of active inflammation, intramural edema, restricted diffusion, stricture, probable stricture, ulceration, sacculation, simple fistula, complex fistula, sinus tract, inflammatory mass, abscess, perienteric inflammation, engorged vasa recta, fibrofatty proliferation, and perianal disease. Bowel wall thickness, length of bowel involvement, and degree of upstream dilation in strictures were quantified. Subsequent bowel resection, prior bowel surgery, and available laboratory values were recorded. The association between progression to surgery and imaging features was evaluated using a logistic regression model adjusting for demographics, prior bowel surgery, medication usage, and body mass index. 19.2% (10/52) of patients progressed to surgery. Restricted diffusion, greater degree of upstream dilation from stricture, complex fistula, perienteric inflammation, and fibrofatty proliferation were significantly more common in patients progressing to surgery (all p < 0.05). κ for these significant findings ranged 0.568-0.885. Patients progressing to surgery had longer length bowel involvement (p = 0.03). Platelet count, ESR, and fecal calprotectin were significantly higher, and serum albumin was significantly lower in patients progressing to surgery. Prior bowel surgery, sex, age, and all other parameters were similar. Radiologists should carefully describe bowel dilation upstream from strictures, penetrating and perienteric findings on outpatient MRE in CD patients, as these findings may herald progression to surgery.

Treatment of enterocutaneous fistula: a systematic review and meta-analysis.

Enterocutaneous fistula (ECF) is an abnormal communication between the gastrointestinal tract and skin, with a myriad of etiologies and therapeutic options. Management is influenced by etiology and specifics of the ECF, and patient-related factors. The aim of this study was to assess overall success, recurrence, and mortality rates of treatment for ECF. A systematic search of PubMed and Google Scholar was performed through October 2021 according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Case reports, reviews, animal studies, studies not reporting outcomes, had no available English text, included patients < 16years old or those assessing other abdominocutaneous/internal fistulas were excluded. Fifty-three studies, between 1975 and 2020, incorporating 3078 patients were included. Patient age ranged between 16 and 87years with a male:female ratio of 1.14:1. ECF developed postoperatively in 89.4%. Other common etiologies were inflammatory bowel disease, trauma, malignancy, and radiation. At least 28% of patients had complex fistulae (reported in 18 studies). Most common fistula site was small bowel. In 34 publications, 62.4% (n = 1371) patients received parenteral nutrition. In 45 publications, 72.5% underwent surgery to treat the fistula. Meta-analysis revealed an 89% healing rate; recurrence rate after initial successful treatment was 11.1%, and mortality rate was 8.5%. In a subgroup of patients who underwent combined ECF takedown and abdominal wall reconstructions (n = 315), 78% achieved fascial closure, mesh was used in 72%, hernia, and fistula recurrence rates were 19.7% and 7.6%, respectively. Treatment of ECF must be individualized according to specific etiology and location of the fistula and the patient's associated conditions.

Post-Hysterectomy Rectovaginal Fistula: A Series of Five Cases

Background: Post-hysterectomy recto-vaginal fistula (PH-RVF) is a condition where abnormal communication develops between the healing vaginal vault and the rectum secondary to an iatrogenic surgical insult. The purpose of this study was to evaluate the clinical presentation, work-up, management, and outcomes of patients with PH-RVF. Methods: Patients who underwent repair from January 2006 to December 2020 were analysed. The data was obtained retrospectively from a prospectively maintained database. Results: Five patients formed part of the study. All patients presented with faecal peritonitis required a faecal diversion. The mean distance of the fistula was 9.4 cm from the anal verge. Multi-detector CT with rectal contrast delineated the fistula in all. There were no associated fistulae. Laparoscopic repair was undertaken at a median of 12 weeks after faecal diversion. The average blood loss and mean operative time were 66 mL and 176 minutes, respectively. Tissue interposition was done in three patients. There was no major morbidity. The median hospital stay was five days. Four patients had successful repairs. A recurrence was managed with a laparotomy, fistula takedown, and rectus abdominis interposition. Bowel continuity was restored 10 weeks (mean duration) after definitive repair. At a median follow-up of 114 months, none had vaginal discharge, urinary tract infections, or complaints regarding sexual function. Conclusion: PH-RVF, a particular subset of high recto-vaginal fistula, is a complex fistula. Faecal diversion is required early in the course of management. With adequate planning, laparoscopic primary closure with or without tissue buttress is feasible, safe, and has a favourable long-term outcome.

Efficacy of Kegel exercises in preventing incontinence after partial division of internal anal sphincter during anal fistula surgery.

BACKGROUNDThe transanal opening of intersphincteric space (TROPIS) procedure, performed to treat complex anal fistulas, preserves the external anal sphincter (EAS) but involves partial incision of the internal anal sphincter (IAS). AIMTo ascertain the incidence of incontinence after the division of the IAS as is done in TROPIS and to evaluate whether regular Kegel exercises (KE) in the postoperative period can prevent incontinence due to IAS division. METHODSPatients operated on for high complex fistulas and having no preoperative continence problem (score = 0) were included in the study. All patients were operated on by the TROPIS procedure and were recommended KE (pelvic contraction exercises) 50 times/day. KE were commenced on the 10th postoperative day and continued for 1 year. Incontinence was evaluated objectively (by modified Vaizey’s scores) in the immediate postoperative period (Pre-KE group) and on long-term follow-up (Post-KE group). The incontinence scores in both groups were compared to evaluate the efficacy of KE. RESULTSOf 102 anal fistula patients operated on between July 2018 and July 2020 were included in this study. There were 90 males, the mean age was 42.3 ± 12.8, and the median follow-up was 30 mo (18-42 mo). Three patients were lost to follow-up. There were 65 recurrent fistulas, 92 had multiple tracts, 42 had associated abscess, 46 had horseshoe fistula and 34 were supralevator fistulas. All were magnetic resonance imaging-documented high fistulas (> 1/3 EAS involved). Overall incontinence occurred in 31% patients (Pre-KE group) with urge and gas incontinence accounting for the majority of cases (28.3%). The mean incontinence scores in the Pre-KE group were 1.19 ± 1.96 (in 31 patients, solid = 0, liquid = 7, gas = 8, urge = 24) and in the Post-KE group were 0.26 ± 0.77 (in 13 patients, solid = 0, liquid = 2, gas = 3, urge = 10) (P = 0.00001, t-test).CONCLUSIONDivision of the IAS led to incontinence, mainly urge incontinence, and also to a mild degree of gas and liquid incontinence. However, regular KE led to a significant reduction in incontinence (both in the number of affected patients and the severity of scores in these patients).

Factors associated with surgical repair success of female genital fistula in the Democratic Republic of Congo: Experiences of the Fistula Care Plus Project, 2017-2019.

ObjectiveWe sought to document outcomes and factors associated with surgical success in hospitals supported by the Fistula Care Plus Project in the Democratic Republic of Congo (DRC), 2017–2019.MethodsThis was a retrospective cohort study analysing routine repair data on women with Female Genital Fistula. Univariate and multivariate analyses were conducted to determine factors associated with successful fistula repair.ResultsA total of 895 women were included in this study, with a mean age of 34 years (±13 years). The majority were married or in union (57.4%) and living in rural areas (82.0%), while nearly half were farmers (45.9%). The average duration living with fistula was 8 years (±7). Vesicovaginal (70.5%) and complex (59.8%) fistulas were the most common fistula types. Caesarean section (34.7%), obstructed labour (27.0%) and prolonged labour (23.0%) were the main aetiologies, with the causal deliveries resulting in stillbirth in 88% of cases. The vaginal route (74.9%) was the primary route for surgical repair. The median duration of bladder catheterization after surgery was 14 days (interquartile range [IQR] 7–21). Multivariate analysis revealed that Waaldijk type I fistula (adjusted odds ratio [aOR]:2.71, 95% confidence interval [CI]:1.36–5.40), no previous surgery (aOR:2.63, 95% CI:1.43–3.19), repair at Panzi Hospital (aOR: 2.71, 95% CI:1.36–5.40), and bladder catheterization for less than 10 days (aOR:13.94, 95% CI: 4.91–39.55) or 11–14 days (aOR: 6.07, 95% CI: 2.21–15.31) were associated with better repair outcomes.ConclusionThe Fistula Care Plus Project in the DRC recorded good fistula repair outcomes. However, further efforts are needed to promote adequate management of fistula cases.

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

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