Cryptoglandular Infection Research Articles

Role of magnetic resonance imaging in evaluation of perianal fistulas

ABSTRACT The term “fistula in ano” refers to an aberrant track connecting the anal canal with the perineum and is one of the common anorectal disorders.[1] It is a common disorder that affects both men and women with male predominance and can cause substantial discomfort and pain. Therefore the effective management of a perianal fistula is crucial to avoid complications, including abscess development, incontinence, and recurrence. Identification of the fistula’s internal opening, the primary source of cryptoglandular infection, the path of the primary track, and the location of any secondary tracks or abscesses are all crucial for effective fistula care.MRI(Magnetic resonance imaging) of the pelvis is the preferred imaging modality to detect and evaluate perianal fistulas due to its high spatial resolution and multiplanar capabilities, which provide exquisite details of the pelvis.

Predictive Factors and Timing of Developing Anal Fistula after Drainage of Cryptoglandular Anorectal Abscess: A Retrospective Cohort Study

Background: Cryptoglandular infection is one of the main causes of common anorectal infections that presents in conjunction with abscess following anal fistula after drainage. Objective: To evaluate the rate and predictive factors of fistula formation following anorectal abscess drainage, and the timing of fistula diagnosis. Materials and Methods: The present study was a retrospective study of 232 patients with cryptoglandular anorectal abscess that underwent drainage in the operating room under anesthesia between 2010 and 2019. The predictive factors of fistula development were analyzed using Cox’s proportional hazard. Results: Seventy out of 232 patients (30%) developed anorectal fistula after drainage of anorectal abscess. Median follow-up time was 35.5 months, and 25.02% (95% CI 19.89 to 31.19) of patients developed fistula within 12 months after the surgery. Independent factors in developing anal fistula after drainage were female gender (HR 2.17, 95% CI 1.15 to 4.14, p=0.017), alcohol consumption (HR 2.24 95% CI 1.20 to 4.22, p=0.012), and driver (HR 2.80, 95% CI 1.08 to 7.25, p=0.034). The protective factors are gauze packing (HR 0.43, 95% CI 0.23 to 0.82, p=0.009) and identifiable organism from pus culture (HR 0.59, 95% CI 0.36 to 0.99, p=0.046). Conclusion: After drainage of a cryptoglandular anorectal abscess, there is a need to raise the awareness concerning anorectal fistula in female patient, alcohol drinkers, and those who work as drivers. Bacterial cultures should be taken, and gauze drain should be positioned. The potential fistula formation should be monitored in the first year after the operation with an option of extending to a second year.

Effect of Agnikarma in Perianal Subcutaneous Fistula- A Case Report

Fistula-in-ano is a debilitating disease affecting anorectal region. It is an abnormal tract lined with fibrous tissue and unhealthy granulation tissue. It usually begins from a perianal abscess caused by cryptoglandular infection. The abscess burst spontaneously and forms fistula-in-ano. It may also seen in association with other diseases like Crohn’s disease, lymphogranuloma venereum, actinomycosis, malignancy and TB. It is distressing to the patient and the surgeon due to its recurrent nature and the complications like postoperative incontinence. The disease can be classified as low anal and high anal fistulae on the basis of its internal opening. Perianal subcutaneous fistula is included under low anal fistula. Generally, the modern treatment measures for fistula-in-ano include fistulectomy, fistulotomy, advancement flaps, fistula clip closure, LIFT technique, VAAFT procedure, anal fistula plug repair, fibrin glue and seton technique. The prime aim of the treatment is to eradicate the tract and drain the site of infection while preserving anal continence. In Ayurveda, Fistula-in-ano can be correlated with Bhagandara on the basis of signs and symptoms. Since it is difficult to treat, Acharya Susruta considered it as one among Ashtamahagada. He described the treatment as Shastra Karma, Kshara Karma, Agni Karma. In the present case study, a 35-year old male patient visited the OPD with perianal subcutaneous fistula was selected for Agnikarma after fistulotomy to reduce the treatment period and to improve the quality of living. Daily dressing was done with Jathyadi ghrta and the patient was cured within 21 days of intervention. The follow up was done for next 3 months and no complications were noted.

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.

A randomized, controlled clinical study to evaluate the role of Sarjarasa Apamarga Ksharasutra in the management of Bhagandara w.s.r to fistula-in-ano

Fistula-in-ano is one of the most common ailments pertaining to ano-rectal region, is prevalent all over the world and its occurance is 8.6 cases per 100,000 population.[1] The main cause known for fistula-in-ano is crypto glandular infection of anal crypts. In Ayurveda, according to similar clinical features the disease Bhagandara can be correlated with fistula in ano. Presently Ksharasutra therapy is found most approaching and attractive treatment modality among para-surgical procedures for fistula in ano. Guggulu Apamarga Ksharasutra which is widely used, having good binding nature and anti-inflammatory effect, But the main complaints reported by the patients are pain and discomfort during and after Ksharasutra procedure. So, instead of Guggulu, Sarjarasa was taken which is having binding property, Vedanasthapaka, Vrana Ropana and Vrana Shodhana Guna, for the Ksharasutra preparation.[2] A total of 30 subjects were taken, Trial group treated with Sarjarasa Apamarga Ksharasutra and control group treated with Guggulu Apamarga Ksharasutra. The study shows Sarjarasa Apamarga Ksharasutra had high efficacy in subjective parameters like pain and burning sensation compared to Guggulu Apamarga Ksharasutra. There were no complications like necrosis, stenosis, anal incontinence after application of Sarjarasa Apamarga Ksharasutra.

Surgical treatment of rectovaginal fistula—predictors of outcome and effects on quality of life

PurposeTo determine the results after rectovaginal fistula (RVF) repair and find predictors of outcome. Primary objective was fistula healing. Secondary outcomes were morbidity and patient health-related quality of life (HRQoL).MethodAn observational study of 55 women who underwent RVF repair including both local procedures and tissue transposition 2003–2018 was performed. Baseline patient and fistula characteristics were registered, combined with a prospective HRQoL follow-up and a general questionnaire describing fistula symptoms.ResultsHealing rate after index surgery was 25.5% (n = 14) but the final healing rate was 67.3% (n = 37). Comparing the etiologies, traumatic fistulas (iatrogenic and obstetric) had the highest healing rates after index surgery (n = 11, 45.9%) and after repeated operations at final follow-up (n = 22, 91.7%) compared with fistulas of inflammatory fistulas (Crohn’s disease, cryptoglandular infection, and anastomotic leakage) that had inferior healing rates after both index surgery (n = 7, 7.1%) and at final follow-up (n = 13, 46.4%). Fistulas of the category others (radiation damage and unknown etiology) included a small amount of patients with intermediate results at both index surgery (n = 1, 33.3%) and healing rate at last follow-up (n = 2, 66.7%). The differences were statistically significant for both index surgery (p = 0.004) and at final follow-up (p = 0.001). Unhealed patients scored lower than both healed patients and the normal population in 6/8 Rand-36 domains, but the differences were not statistically significant.ConclusionsMost traumatic rectovaginal fistulas closed after repeated surgery whereas inflammatory fistulas had a poor prognosis. Low healing rates after local repairs suggest that tissue transfer might be indicated more early in the treatment process. Unhealed fistulas were associated with reduced quality of life.Trial registration Clinicaltrials.gov No. NCT05006586.

A Retrospective Critique of the Various Sphincter-preserving Surgical Procedures for Ischiorectal Fistula.

In the 1950s, the cause of anal fistulas was identified as an infection of the anal gland (cryptoglandular infection theory). Thereafter, treatment for this disorder began in the 1960s with the lay-open procedure, which involved incising the sphincter and the fistula tract. However, it was found that too much invasion into the sphincter could result in postoperative fecal incontinence. Thus, to reduce such risk, sphincter-preserving surgery was applied for superficial anal fistula in 1961 and for deep anal fistula (ischiorectal fistula) in 1965. Over the years, more effective sphincter-preserving procedures for ischiorectal fistula have been developed to improve the quality of life of the patient. In this review article, we aim to first introduce the basic surgical techniques for ischiorectal fistula. We will discuss the anatomy of the anus and the pathogenesis of ischiorectal fistula and will provide some diagnostic methods. Representative sphincter-preserving procedures that have been performed for ischiorectal fistula since 1965 will also be categorized and outlined chronologically. The discussion will look at the following techniques for ischiorectal fistula and outline the advantages and disadvantages of each procedure so that they can be used as a reference for ischiorectal fistula surgery in the future: the lay-open procedure (fistulotomy and fistulectomy), the Hanley procedure (first partial sphincter-preserving procedure), the muscle-filling procedure, the Moriya method and Ui method (modified partial sphincter-preserving procedure), the Takano method and the sphincter-preserving lateral procedure (complete sphincter-preserving procedure), the seton method (a cross between the lay-open procedure and sphincter-preserving procedure), and the overseas sphincter-preserving procedure.

Long-term outcome of ligation of inter-sphincteric fistula tract (LIFT) for management of trans-sphincteric anal fistula

BackgroundAfter abscess formation, an anal fistula is a common consequence, with crypto-glandular infection being the most commonly accepted causative cause. The goal of this study was to see how well closure of the inter-sphincteric fistula tract affects the outcome of trans-sphincteric fistula surgery. MethodsPatients with perianal trans-sphincteric fistulas who underwent ligation of inter-sphincteric fistula tract (LIFT) were studied prospectively in this cohort study. All patients had the identical anesthetic approach, followed by LIFT with two years’ follow-up. Resultslength of the fistulous tract had a substantial effect on the result. The presence of piles with fistula among the studied patients has no effect on the outcome. Mean operative time was 36.2 min and post operative pain was mild in most patients and concomitant anal fissure or piles has no effect on final result of LIFT procedure The mean time for wound healing was four weeks. Three patients had hidradenitis suppurativa and no any unusual histopathology results shown in the excised parts. ConclusionLIFT was an effective and straightforward sphincter-preserving technique in treating simple trans-sphincteric anal fistulas with excellent long-term control of trans-sphincteric fistula. More similar studies with a large number of patients are still needed to assess this surgical technique for trans-sphincteric fistula.

Treatment of Trans-Sphincteric Fistula-In-Ano with Combined Therapy of Laser and Kshara Sutra

Fistula-in-ano is most infectious disease among all the ano-rectal disorders since ancient times. Over the past few decades, various techniques are being evaluated in terms to prevent its recurrence and complications; it is still a challenging surgical disease. The sign and symptoms of fistula in ano resembles with Bhagandar described in Ayurvedic classics. Kshara sutra therapy (medicated thread) practiced in Ayurveda Since ancient time for the management of Naadi Vrana and Bhagandar. Kshara sutra therapy has revolutionized the treatment of fistula-in-ano, as it treat the main culprit of fistula that is cryptoglandular origin but the drawback of Kshara sutra therapy are as it takes more number of hospital visit, long anxiety period and discomfort. In present time LASER therapy is used in various medical surgery and also in proctology like in fistula as FILAC, DLPL etc. Diode LASER 980nm (Radial Fibre) burns unhealthy granulation tissues in 360° manner with less or minimal pain, LASER act as photo evaporation effect and leads to the shrinkage of the fistula tract. But if we do LASER in internal opening of fistula it provides a bare area for microbes and creates a chance to re-infects the crypts and anal glands, which further leads recurrent fistula formation. Therefore a novel technique for sphincter preserving surgery proposed as combined therapy of Kshara sutra ligation for main culprit that is cryptoglandular infection as SMAK (Sub Mucosal Application of Kshara Sutra) and LASER, shrink the remaining fistula tract instantly

To study the management of Fistula-In-Ano: An experience at tertiary care centre in rural area, can achieve acceptable fistula care

Background: Fistula In-Ano is one of the major ano-rectal issues. Crypto glandular infection is the main cause, can be multiple that extends from same primary opening. Fistulectomy, sphincter saving operations usually recommended for fistula. Objectives: 1. to assess the modes of presentation. 2. To assess treatment modality 3. To assess post-operative outcome. Material and method: Prospective cohort study 49 patients included, carried out at dept. of surgery tertiary care centre, MUHS Nasik, Maharashtra India, between Jan 2014 to Jan 2019. Result: Maximum patients observed in 46-55 years age group (42.87%). M:F ratio was 3.9:1 Most of them low socioeconomic class. (85.72%) showed low fistula, posteriorly situated with single external opening. Surgeries were fistulectomy, fistulotomy, fistulectomy with closure and curettage. Minimum complication observed infection, incontinence, recurrence. Duration of healing (46.94%) observed in 7-12 weeks, primary healing was (95.91%). Conclusion: A Good outcome was achieved in the majority of patients with few complications; however there is a need for large-scale trials to evaluate the different surgical treatment modalities.

Evaluation and management of perianal abscess and anal fistula: SICCR position statement.

Perianal sepsis is a common condition ranging from acute abscess to chronic anal fistula. In most cases, the source is considered to be a non-specific cryptoglandular infection starting from the intersphincteric space. Surgery is the main treatment and several procedures have been developed, but the risks of recurrence and of impairment of continence still seem to be an unresolved issue. This statement reviews the pertinent literature and provides evidence-based recommendations to improve individualized management of patients.

Prevalence of Anal Fistulas in Europe: Systematic Literature Reviews and Population-Based Database Analysis.

IntroductionDespite the fact that perianal fistulas are associated with significant morbidity and impaired quality of life, their prevalence in Europe is unknown. The aim of this study was to estimate the prevalence of perianal fistulas in Europe, overall and according to etiology.MethodsTwo independent literature reviews were performed using different search strategies to maximize the identification of potentially relevant studies. Data from relevant articles were used to estimate the prevalence of perianal fistulas in Europe. The robustness of the estimate was evaluated using data from a large population-based database from the UK.ResultsA total of 26 studies provided epidemiological data on perianal fistulas, of which 16 provided suitable data to estimate the prevalence. Estimations using these data yielded a total prevalence of 1.69 per 10,000 population. Cryptoglandular infection and Crohn’s disease (CD) were the predominant etiologies, with prevalence rates at 0.86 and 0.76 per 10,000 population, respectively. Comparison of prevalence data from the UK population-based database with the European population resulted in a standardized prevalence estimate of all perianal fistulas of 1.83 per 10,000 population, confirming the robustness of the literature-based estimate.ConclusionAlthough in terms of incidence cryptoglandular fistulas were clearly predominant, the prevalence of fistulas in CD and cryptoglandular infection appeared more balanced. This is due to the longer duration and higher frequency of relapses of fistulas in CD. The estimated prevalence implies that perianal fistulas meet the criteria to be considered as a rare condition in Europe (prevalence less than 5 per 10,000 population).FundingThis study was funded by Takeda Pharmaceutical U.S.A., Inc. and TiGenix SAU.Electronic Supplementary MaterialThe online version of this article (10.1007/s12325-019-01117-y) contains supplementary material, which is available to authorized users.

MANAGEMENT OF BHAGANDARA W.S.R TO COMPLICATED FISTULA-IN-ANO: A CASE REPORT

Bhagandara (Fistula-in-ano) is a disease which occurs in the region of anal canal described in Ayurveda literature. It is an infective condition of the anal canal usually caused by crypto glandular infection of anal crypts. There is an abnormal communication between two epithelial surfaces and track is lined by unhealthy granulation tissue. The present case study was conducted on a male patient aged 85-years-old suffering from the disease for last one and half year. Patient came to us recurrence after incision and drainage of perianal abscess. K?arasutra therapy using IFTAK (Interception of fistulous tract with the application of Kh?arasutra) technique of treatment was adopted. The daily dressing was done with jatyaditaila. The patient was cured completely within 8 weeks of treatment. There was no side effect or any complication after regular follow up of 2 months. The treatment technique was proved to be a very effective and convective treatment option.

A Video Assisted Anal Fistula Treatment “VAAFT Technique” for Anal Fistulas

Fistula in ano -: It is a complete tract with two openings in anorectal region, one in the external surface, second in the anal canal or in higher anatomical structures1. Fistula in ano commonly develops as a symptomatic or asymptomatic abscess due to cryptoglandular infection; treatment depends upon the location of the anatomy or tract of the fistula. General principle for management of Fistula in ano-Irrigation of the whole fistulous tract, part of the fistulous track which is opened outside should be excised, obliteration of the internal opening is the key of success, excised tract should be send for histopathological investigation to rule out other pathology e.g Tuberculosis.

Effectiveness of ligation of intersphincteric fistula tract (LIFT) in the management of fistulas in ano

Background: Fistula in ano is an abnormal connection between the epithelized surface of anal canal and usually the perianal skin. It is a benign treatable lesion of rectum and anal canal. Crypto glandular infection accounts for about ninety percent of the cases. The estimated prevalence of an anal fistula is 12 to 28/1000000 of the population per year with male to female ratio 1.8:1. Ligation of intersphincteric fistula tract is a new sphincter saving method with good result in the management of anal fistula. The aim of study was to evaluate the effectiveness and functional outcomes of the ligation of intersphinteric fistula tract (LIFT).Methods: This prospective study includes sixteen patients who were operated for fistulas in ano at Bundelkhand Medical College and Associated Hospital, Sagar from January 2015 to June 2017. Patients above the age of 20 years, proved cases of fistulas in ano without co-morbid conditions and no previous surgical intervention were included in the study. Patients presenting with fistulas from another source such as crohn’s disease, tuberculosis, anal cancer and recurrent fistulas were excluded. A detailed history, clinical presentation, digital rectal examination, anal ultrasound and routine investigations were done in all cases.Results: In the present study most of the patients were male and presents with perianal discharge. The diagnosis is made by clinical history, per rectal examination and anal ultrasonography. All the sixteen patients with fistula in ano underwent ligation of intersphincteric fistula tract (LIFT). The patients were followed for a period of three months. Most of the cases (87.5%) healed within 4-6 weeks. The recurrence of fistula occurs in four cases (25%). Recurrence is due to infection and technical error in the procedures. There were no deaths in the study.Conclusions: The LIFT technique proved to be safe and effective in the treatment of fistula in ano.

Endoscopic ultrasound-guided cyanoacrylate glue injection for treatment of ano-urethral fistula

Background:Perianal fistulas are a frequent cause of morbidity and occur due to cryptoglandular infection, Crohn’s disease, radiotherapy, and malignancy. Perianal fistula occurring as a complication of anal canal surgery is an infrequent cause. We report endoscopic ultrasound (EUS)-guided management of a case of postsurgical perianal fistula with cyanoacrylate glue injection.Case Report:A 35-year-old man presented with recurrent urinary tract infection requiring multiple courses of antibiotics for the past 15 years. He was operated for imperforate anus at birth and developed anal stricture requiring repeated bougienage dilation till 4 years of age. After anal dilatation, he had intermittent passing of urine through anal opening and was diagnosed to have ano-urethral fistula. He underwent multiple surgeries (three times) for the repair of fistula till the age of 16 and remained well till the age of 33. He presented with recurrent urinary tract infection. Radial EUS showed a tortuous fistula in anal canal communicating with prostatic urethra which was visualized due to air bubbles. A linear EUS-guided glue injection was planned. The patient was catheterized. Glue was injected into the middle part of fistula with successful closure. While injecting glue, the Foley’s catheter was rotated to avoid sticking of glue to the catheter. The patient is symptom-free on follow-up for 1 year. To conclude, we can say that EUS-guided cyanoacrylate glue can be safely attempted to treat postsurgical ano-urethal fistula.

A descriptive analysis of management of fistula-in-ano

Background: A fistula-in-ano is an abnormal hollow tract that is lined with granulation tissue and which have a primary opening inside the anal canal and a secondary opening in the perianal skin. 90% of the cases, the origin is from crypto glandular infection. Leads to ano rectal abscess and chronic infection causes fistulae in ano. Various techniques have been described for management of fistula in ano but there are risk of recurrence and incontinence. The objective of this study was to know the usefulness of investigative procedures in early and accurate diagnosis of fistula in ano. And to study the efficacy of different modalities of surgical approach with reference to post-operative hospital stay and complications like pain, bleeding and sphincter in continence and outcome in respect to persistence/recurrence of fistulae. Methods: A total of 50 patients with clinically diagnosed fistula in ano were included in the study. All patients were subjected to surgical intervention. The study was conducted at V.S. hospital between June 2007 to November 2009. Follow up of the patients obtained up to 1 year. Results: Commonest age of presentation in our series was 20-30 years. Males were more affected as compared to females. Low level fistula is more common and was seen in 66% cases where as 34%patients had high level fistula. Patients with Seton placement procedure require longer post-operative hospital stay (14.2 days) as compared to other two surgical procedures. Incidences of pain, bleeding and incontinence were more in Fistulectomy as compared to Fistulotomy. But recurrences were found in 4 (8%) in Fistulotomy while not a single case of recurrence was reported in other two surgical modalities. Conclusions: Fistulotomy has a higher recurrence rate than fistulectomy. But fistulotomy may be preferred for low anal fistulas as it is associated with less chances of incontinence and has significantly less incidence of post-operative complications and is associated with less hospital stay duration.

Evaluation and management of perianal abscess and anal fistula: a consensus statement developed by the Italian Society of Colorectal Surgery (SICCR).

Perianal sepsis is a common condition ranging from acute abscess to chronic fistula formation. In most cases, the source is considered to be a non-specific cryptoglandular infection starting from the intersphincteric space. The key to successful treatment is the eradication of the primary track. As surgery may lead to a disturbance of continence, several sphincter-preserving techniques have been developed. This consensus statement examines the pertinent literature and provides evidence-based recommendations to improve individualized management of patients.

Perianal Sepsis in Hematologic Malignancy: MR Imaging Appearances and Distinction from Cryptoglandular Infection in Immunocompetent Patients.

To use magnetic resonance (MR) imaging to document the appearance of perianal infection in patients with a hematologic malignancy (HM) compared with that in immunocompetent control patients. After an ethical waiver was obtained, 38 patients with an HM were matched by age and sex to 38 control patients with no history of immunocompromise or Crohn disease. Both groups had undergone MR imaging for perianal symptoms and/or systemic sepsis. Two radiologists who were blinded to the diagnosis independently reviewed the MR images and recorded the size and distribution of abscesses and/or fistula tracts, the extent of perianal edema, and the likely diagnosis. Groups were compared by using the Mann-Whitney-Wilcoxon, χ(2), or Fisher exact test. Receiver operating characteristic (ROC) curves were constructed to estimate the ability of MR imaging to help distinguish patients with an HM from control patients. Patients with an HM had significantly greater perianal edema than did control patients (mean arc angle of anal canal involved, 220° vs 60°; P < .001). However, they had significantly lower rates of fistula (15 [39.5%] vs 35 [92.1%] of 38; P < .001). Abscesses were similar in frequency (10 [26.3%] vs 17 [44.7%] of 38; P = .15) and were unrelated to the degree of neutropenia (P = .71) or the use of chemotherapy (P = .10). Surgical treatment was rarely required in patients with an HM, either during the acute illness (four [10.5%] of 38) or thereafter (three [7.9%] of 38). MR imaging had an excellent ability to help discriminate patients with HM from immunocompetent patients (areas under the ROC curve, 0.91 and 0.97). Perianal infection in patients with an HM is more likely to cause diffuse perianal edema and is less likely to cause fistulas than in immunocompetent patients. MR imaging can help distinguish patients with an HM from those without immunocompromise.

Simple anal fistulae

The perianal abscess is a disease process that affects the general population, predominantly middle-aged men. Perianal abscesses are believed to result from infection of the anal crypt glands, which seed infection of the perianal tissues.1 The principle of management for cryptoglandular infection is incision and drainage, facilitating clearance of the perianal sepsis. The pathogenesis of anal fistulae is intimately related to that of the perianal abscess; these fistulae contribute to the abscess and are a sequela of the treatment.2 Parks3 described their interrelation aptly, stating that the abscess is the acute process and the fistula the chronic process in perianal sepsis.