Extrasphincteric Fistulas Research Articles

Closing Perianal Fistulas Using a Laser: Long-Term Results in 103 Patients.

Primary closure of the fistula tract using energy emitted by a radial fiber connected to a diode laser is a novel procedure for treating perianal fistulas. The aim of this study was to determine the long-term effectiveness of this new technique. The surgical objective was to seal the fistula tract using laser energy. The study was conducted at a single day-case surgery center. Between April 2012 and June 2016, 103 consecutive patients with primary or recurrent perianal fistula underwent a laser closure procedure using a 12-watt laser emitting at a wavelength of 1470 nm. Patients were classified according to the Park classification, and healing was evaluated based on the perianal fistula disease severity score. Among the 103 patients treated using the laser closure procedure, 82 (80%) were men and 21 (20%) were women. The median age of the patients was 43 years (range, 18-78 y). Fifty-three patients (52%) had previous perianal fistula repair surgery. Based on the Park classification, 56 patients (54%) had intersphincteric fistula, 29 (28%) had transsphincteric fistula, 11 (11%) had suprasphincteric or extrasphincteric fistula, and 7 (7%) had superficial perianal fistula. Based on the perianal disease severity score, 41 patients (40%) obtained overall complete healing, 38 (37%) had persistent symptomatic drainage, 20 (19%) had slight drainage with minimal symptoms, and 4 (4%) had painful symptomatic drainage. This was a retrospective analysis of noncomparative data with a lack of formal prospective continence assessment. Closure of perianal fistulas using a laser should be considered as a treatment option but with modest expectations. Although our complete healing rate was not as high as in earlier studies, this technique is a reasonable option with nearly no risk of sphincter damage when treating perianal fistulas. See Video Abstract at http://links.lww.com/DCR/A545.

Understanding and Treating Supralevator Fistula-in-Ano: MRI Analysis of 51 Cases and a Review of Literature.

Supralevator fistulas are highly complex. The delineation of the supralevator fistula has become accurate because of MRI. The aim of the study was to analyze the pathophysiology and treatment of different types of supralevator fistulas. This was a prospective study. The study was conducted at a specialized fistula treatment center in North India. All of the patients with fistula-in-ano who presented in the outpatient department were assessed with a physical examination and MRI scan. The patients in whom the supralevator extension was confirmed on MRI were included in the study. The MRI scans of patients included in the study were analyzed in detail to assess the types of supralevator fistulas and other characteristics of these fistulas. The patients who were operated on were followed for cure rate and deterioration in incontinence. Of 702 patients with fistula-in-ano who were analyzed by MRI over a period of 3 years, 51 patients with supralevator fistula-in-ano were identified. The mean age was 44.3 ± 12.1 years and the male:female ratio was 16:1. The incidence of supralevator fistulas was 7.26% (51 of 702). In supralevator fistulas, the supralevator extension (upper part) was found to be in the intersphincteric plane in all of the patients. This upper part could be successfully managed by laying it open through the transanal route. The infralevator (lower) part could be of 3 types: intersphincteric (n = 13), low transsphincteric (n = 3), or high transsphincteric (n = 35). The lower part could be managed conventionally. There were no extrasphincteric fistulas. An extensive review of the literature revealed only 2 studies (total fistulas = 16) in which supralevator fistula was studied. This was a retrospective study. The upper supralevator extension in all of the supralevator fistulas is almost always in the intersphincteric plane. This upper part could be laid open through the transanal route. The lower infralevator part could be of 3 types, intersphincteric, low transsphincteric, or high transsphincteric, which could be managed conventionally. Thus, supralevator fistulas could be managed successfully and easily. See Video Abstract at http://links.lww.com/DCR/A630.

Metabolic syndrome in patients with anal fistulae

Aim of work: to study the incidence of components of metabolic syndrome in patients with anal fistulae, to analyze combinations of different components of metabolic syndrome and types of pararectal fistulae.
 Materials and Methods. A clinical examination of 508 patients (85.2% – men; 21.5% at the age of 20-39 years, 43.9% – 40-59 years, 34.6% – ≥60 years) with anal fistulae (of them 48.0% were transsphincteric and 29.3% – extrasphincteric fistulae) who underwent treatment in the department of coloproctology of municipal clinical hospital №5 of Dushanbe in the period from 2010 to 2015, was conducted with the aim of identification of components of metabolic syndrome.
 Results. In 282 patients (55.5% of the total number of patients with anal fistulae, 90.8% of them being men) components of metabolic syndrome were identified: obesity – in 229 patients (45.1% of the total patients with anal fistulae), arterial hypertension – in 115 patients (22,6%), type 2 diabetes mellitus – in 58 patients (11.4%), IHD – in 8 patients (1.6%). In the presence of components of metabolic syndrome the recurrent forms of fistulae were recorded in 16.3% of cases (in the absence – in 12.8% of cases), and complicated forms – extrasphincteric (29.3%) predominated over intrasphincteric forms (22.7%); in control group the proportion of the mentioned forms was 24.8% and 29.2%, respectively. Transsphincteric forms were most common in both groups (48.0% and 46.0%).
 Conclusions. Components of metabolic syndrome in different combinations were identified in more than half (55.5%) the patients with anal fistulae (obesity – 45.1%, arterial hypertension – 22.6%, 2 type diabetes mellitus – 11.4%, IHD – 1.6%). A tendency was recorded to a more common recurrence of anal fistulae and to a more complicated forms of anal fistulae in patients with components of metabolic syndrome.

Metabolic syndrome in patients with anal fistulae

Aim of work: to study the incidence of components of metabolic syndrome in patients with anal fistulae, to analyze combinations of different components of metabolic syndrome and types of pararectal fistulae.
 Materials and Methods. A clinical examination of 508 patients (85.2% – men; 21.5% at the age of 20-39 years, 43.9% – 40-59 years, 34.6% – ≥60 years) with anal fistulae (of them 48.0% were transsphincteric and 29.3% – extrasphincteric fistulae) who underwent treatment in the department of coloproctology of municipal clinical hospital №5 of Dushanbe in the period from 2010 to 2015, was conducted with the aim of identification of components of metabolic syndrome.
 Results. In 282 patients (55.5% of the total number of patients with anal fistulae, 90.8% of them being men) components of metabolic syndrome were identified: obesity – in 229 patients (45.1% of the total patients with anal fistulae), arterial hypertension – in 115 patients (22,6%), type 2 diabetes mellitus – in 58 patients (11.4%), IHD – in 8 patients (1.6%). In the presence of components of metabolic syndrome the recurrent forms of fistulae were recorded in 16.3% of cases (in the absence – in 12.8% of cases), and complicated forms – extrasphincteric (29.3%) predominated over intrasphincteric forms (22.7%); in control group the proportion of the mentioned forms was 24.8% and 29.2%, respectively. Transsphincteric forms were most common in both groups (48.0% and 46.0%).
 Conclusions. Components of metabolic syndrome in different combinations were identified in more than half (55.5%) the patients with anal fistulae (obesity – 45.1%, arterial hypertension – 22.6%, 2 type diabetes mellitus – 11.4%, IHD – 1.6%). A tendency was recorded to a more common recurrence of anal fistulae and to a more complicated forms of anal fistulae in patients with components of metabolic syndrome.

Three-dimensional endoanal ultrasound is accurate and reproducible in determining type and height of anal fistulas.

Surgical treatment of high anal fistulas is associated with the potential risk of faecal incontinence and recurrence. The primary aim of this study was to determine the accuracy of three-dimensional endoanal ultrasound (3D-EAUS) in the assessment of height and type of anal fistulas, compared to the intra-operative findings (gold standard). The secondary aim was to evaluate the inter-observer reproducibility of 3D-EAUS. The study design was a prospective analysis of retrospective data. 299 patients (202 men), mean age 45.3years, who underwent surgery for anal fistulas, were included. All patients were preoperatively assessed by 3D-EAUS. Two readers independently reviewed the volumes to determine the type and height of fistulas. Sensitivity, specificity, positive and negative predictive values, proportion of agreements and Cohen's kappa coefficient (κ) were calculated for both examiners. Ultrasound findings were compared with intra-operative data (reference standard), evaluated blindly by the surgeons. At surgery, 201 (67%) were transsphincteric, 49 (16%) suprasphincteric, 47 (16%) intersphincteric and two (1%) extrasphincteric fistulas. Intra-operatively, 177 (59%) were low and 122 (41%) high fistulas. The overall accuracy of 3D-EAUS was 91% for fistula type (271/299 fistulas: 97% transsphincteric, 100% intersphincteric, 57% suprasphincteric, 0% extrasphincteric) and 92% for fistula height (275/299 fistulas: 80% high and 100% low). Both readers reported very good agreement with surgery in the assessment of fistula type (proportion of agreement 0.88, κ=0.89) and height (proportion of agreement 0.90, κ=0.91). 3D-EAUS is an accurate and reproducible modality for the assessment of type and height of anal fistulas.

3D-EAUS and MRI in the Activity of Anal Fistulas in Crohn’s Disease

Aim. This study aspires to assess the role of 3D-Endoanal Ultrasound (3D-EAUS) and Magnetic Resonance Imaging (MRI) in preoperative evaluation of the primary tract and internal opening of perianal fistulas, of secondary extensions and abscess. Methods. During 2014, 51 Crohn's disease patients suspected for perianal fistula were enrolled. All patients underwent physical examination with both the methods and subsequent surgery. Results. In the evaluation of CD perianal fistulas, there are no significant differences between 3D-EAUS and MRI in the identification of abscess and secondary extension. Considering the location, 3D-EAUS was more accurate than MRI in the detection of intersphincteric fistulas (p value = 10−6); conversely, MRI was more accurate than 3D-EAUS in the detection of suprasphincteric fistulas (p value = 0.0327) and extrasphincteric fistulas (p value = 4 ⊕ 10−6); there was no significant difference between MRI and 3D-EAUS in the detection of transsphincteric fistulas. Conclusions. Both 3D-EAUS and MRI have a crucial role in the evaluation and detection of CD perianal fistulas. 3D-EAUS was preferable to MRI in the detection of intersphincteric fistulas; conversely, in the evaluation of suprasphincteric and extrasphincteric fistulas the MRI was preferable to 3D-EAUS.

EFFICACY OF ARGENTUM-QUARTZ SOLUTION IN THE TREATMENT OF PERIANAL FISTULAS: A PRELIMINARY STUDY

Objective: Nowadays, an optimal and effective medical surgery remains the gold standard for perianal fistulas. Hereby we reported preliminary results in favor of using Argentum-quartz solution for both primary and recurrent perianal fistulas. Methods: Three patients with intersphincteric and extrasphincteric fistulas were enrolled. Argentum-quartz solution was administrated twice a week for a period of 4 weeks, followed by a pause of 8 days and then another 4 weeks of treatment, totally 16 administrations. After treatment, all patients were monitored for a 4-month follow-up. Results: Complete closures of 2 extrasphincteric fistulas and a partial closure with absence of inflammation and superative phenomena in the intrasphincteric fistula were both manifested. Conclusion: Selective treatment of perianal fistulas with an argentum-quartz solution is safe and effective, and may represent a reliable alternative.

Efficiency of tacrolimus therapy for perianal Crohn's disease

To determine the efficacy of 0.1% tacrolimus ointment in patients with perianal Crohn's disease (CD). This prospective randomized trial enrolled 20 patients with perianal CD as anal fissures and rectal fistulas. The inclusion criteria were rectovaginal or extrasphincteric fistulas and purulent leakages. A study group comprised 11 patients, including 9 with anal fissures and 2 with fistulas. A control group included 9 patients, including 8 with fissures and 1 with fistulas. The study group received systemic therapy with azathioprine 2 mg/kg/day and tacrolimus ointment 2 mg/day; the control group had systemic therapy with azathioprine 2 mg/kg/day, hormone ointment 1 mg/day, and metronidazole suppositories 250 mg/day. Control examination and perianal CD activity index (PCDAI) determination were done 6 and 12 weeks after therapy initiation. At 6 weeks after beginning the study, local examination revealed the signs of anal fissure epithelialization in 5 (45.5%) of the 11 patients in the study group and in 3 (33.3%) of the 9 patients in the control one. At 12 weeks, fissure epithelialization and fistula obliteration were stated in 6 (54%) patients in the study group and in 3 (33%) of the 9 patients in the control group. At 12 weeks, PCDAI in the study and control groups was 2.00 and 4.44 scores (p = 0.01). The findings suggest that topical 0.1% tacrolimus ointment versus antibacterial suppositories and hormone ointments is effective in treating patients with perianal CD. Topical 0.1% tacrolimus ointment therapy caused a reduction in PCDAI.

Способ оперативного лечения пациентов с экстрасфинктерными параректальными свищами

Способ оперативного лечения пациентов с экстрасфинктерными параректальными свищами

Magnetic Resonance Imaging Evaluation of Perianal Fistulas

PurposeThe purpose of this study was to discuss the usefulness of magnetic resonance imaging in evaluating perianal fistulas, their ramifications, extent, associated abscesses and relations with the anal sphincter complex and its role in preoperative classification. Material & methodsA retrospective study was carried out using picture archiving and communication system. Data of 58 patients presented with a clinical suspicious of perianal fistula from April 2012 to March 2013 was collected. In all patients pre contrast T2 propeller with and without fat suppression, diffusion weighted and pre and post contrast liver acceleration volume acquisition sequences were obtained. Pulse sequences were as follows: T2 propeller (TR: 7766ms, TE: 122ms), Diffusion weighted (TR: 7000ms, TE: 67ms), LAVA (TR: 7ms, TE: 3.242ms). ResultsMRI revealed a total number of 38 fistulae in 35 (60%) patients while 13 (22%) patients had only perianal sinuses. Out of these 35 patients, 4 were females and 31 were male subjects. Out of total 38 fistulae seen in these 35 patients, 11 (29%) were transsphincteric, 24 (63%) were intersphincteric and 2 (5%) were suprasphincteric. Only 1 (3%) case was extrasphincteric fistula. Twenty-six fistulae (68%) were simple, whereas 12 (32%) showed associated abscess formation, inflammation and branching course. ConclusionOur results support that MRI is the method of choice for evaluating perianal fistulae as they display the anatomy of the sphincter muscles orthogonally with a background of good contrast resolution. Moreover, with MRI we can accurately classify perianal fistulas preoperatively along with the detection of associated infection and help in planning a successful surgery.

Der anale Crohn

In patients with Crohn's disease, perianal lesions can be found at presentation in 20 - 30 % of all cases and a majority will have fistulas or abscesses. If a fistula is suspected, careful inspection of the perianal region will often confirm the diagnosis. Further investigation should be done by magnet-resonance imaging or anal endosonography to guide preoperative planing and minimize recurrence rates. Simple, uncomplicated fistulas are primarily treated with antibiotics. For complex fistulas combined with medication and surgical treatment usually offers the best treatment. Treatment of complex fistulas by surgery alone is rarely curative and may have significant morbidity, while medical treatment has the disadvantage of high recurrence rates and significant costs for long-term therapy. In trans-, supra- and extrasphincteric fistulas, immunosuppressants or anti-TNF alpha blockers will lead to sustained clinical remission with fistula closure in 30 - 50 %. However, 25 % of all patients with perianal Croh's disease will still need surgery during the course of their disease. Fistulotomy is used for subcutaneous or short intersphincteric fistulas while it should be avoided in fistulas with significant involvmenet of the sphincter muscles to avoid fecal incontinence. Seton drainage may be used as definitve treatment or as a bridge to a secondary surgical therapy. Minimally invasive precedures, such as the anal fistula plug have also been used in Crohn's disease. Although recurrence rates are high, the procedure is easy to perform and carries a low risk of incontinence and may therefore be used as primary treatment option for complex fistulas. The fistulectomy and closure of the inner fistula opening, e. g. with a mucosal advancement flap, is still considered the standard procedure, especially for complex fistulas. Anal fissures, ulcers and strictures are non-fistulating perianal lesions of Crohn's disease.

Transperineal ultrasonography as a complementary diagnostic tool in identifying acute perianal sepsis

Successful anal fistula care in complex cases can be assisted by specialized imaging which accurately defines the site of the internal fistula opening and the fistula type. There are currently limited data concerning the clinical indications for and accuracy of transperineal ultrasound (TP-US) in acute perianal sepsis. The aims of this study were to compare the anatomical interpretation of TP-US images with magnetic resonance imaging (MRI) and surgical findings in an unselected patient cohort presenting with acute perianal sepsis. Sixty-seven consecutive patients with acute anorectal sepsis referred from the surgical department were examined using TP-US and Gadolinium-enhanced MRI with both examiners blinded to the surgical results. Fistulae were categorized by the Parks' classification of fistula type. Thirty-six abscesses were detected by MRI, 38 by TP-US and 30 by surgical examination. Operatively discordant cases showed only ischiorectal panniculitis. TP-US was more accurate in the diagnosis of superficial sepsis and MRI in the diagnosis of deep-seated perirectal infection. TP-US and MRI show concordance with operative findings in fistula diagnosis with a tendency for TP-US to overdiagnose trans-sphincteric fistulae and MRI to over diagnose extra-sphincteric fistulae. Comparison of TP-US with MRI showed good agreement for perianal abscess diagnosis (τ=0.82) and for fistula diagnosis (τ=0.68). For fistulae, TP-US showed moderate agreement with surgery (τ=0.43) with only fair agreement between MRI and surgery (τ=0.29). Transperineal ultrasound complements other imaging modalities in the anatomical diagnosis of acute perianal abscesses and fistulae. It has specific advantages over other techniques and is accurate in the detection of superficially located perirectal sepsis showing concordance with MRI and surgical findings.

Management of Fistula in Ano at King Hussein Medical Center

Results: Eighty-five patients underwent surgery for fistula-in-ano. There were 93 fistulae in our study group; with eight patients having two fistulae tracts. There were 76 (89%) males, with a mean age of 39.1 years (range 19-76). Eleven patients had superficial, 5 patients had inter-sphincteric, 68 patients had trans-sphincteric, 3 patients had supra-sphincteric and 5 patients had extra-sphincteric fistulae. Thirty-eight patients (45%) had complex fistulae. The radial site of fistulae was detected, with 44 (47%) presenting with an internal opening in the posterior anal canal, 19 (21%) opening into the anterior canal and 30 (32%) opening laterally. Fistulotomy was the commonest procedure (n=40) with marsupialization in 20 patients, followed by loose Seton (n=33), endorectal advancement flap (n=5), tight Seton (n=4) and ligation of the intersphincteric fistula tract (LIFT) procedure (n=2). Conclusions: Careful selection of the treatment method that takes into account the anatomy of the fistula, state of the anal sphincters and patient’s preference is central in the successful management of fistula-in-ano.

Frequencies of perianal fistula types using two classification systems

The aims of this study were to determine the frequencies of the perianal fistula subtypes according to the Parks and St. James's University Hospital (SJUH) classification systems and to evaluate the adequacy of these two systems for classifying and reporting perianal fistulas. Magnetic resonance imaging examinations of 52 patients (44 men, 8 women) with perianal fistula were reviewed retrospectively. The fistulas were classified according to the Parks and SJUH classification systems. According to the Parks system, 13 patients had intersphincteric (25%), 36 had transsphincteric (69.23%), and 2 had (3.84%) extrasphincteric fistulas. Only one fistula (a subsphincteric fistula) (1.92%) could not be classified. According to the SJUH system, 10 patients had grade 1 (19.23%), 2 patients had grade 2 (3.84%), 13 patients had grade 3 (25%), 21 patients had grade 4 (40.38%), and 5 patients had grade 5 (9.61%) perianal fistulas. The one (and only) subsphincteric fistula was left unclassified. The most common types are transsphincteric and intersphincteric fistulas. Although the two most commonly used classification systems are adequate for describing most perianal fistulas, there is a small percentage that is left unclassified.

Value of MR imaging in diagnosis and follow-up of perianal fistula after fibrin sealant

Fibrin glue has recently been shown to be a successful modality for treatment of complex perianal fistulas and is associated with a higher degree of patient satisfaction. Fistula healing after fibrin glue application can only be determined by adequate follow-up, with consideration of underlying tract activity not just skin healing which can be achieved by MR imaging. This study was designed to evaluate the role of MR imaging in patient selection and prediction of outcome of fibrin sealant treatment in patients with complex perianal fistulas. Twenty-four patients underwent fibrin glue after fistula tract preparation and followed up for a median of 16 months. Clinical and MRI assessment were performed to patients who had early signs of skin healing. Based on their preoperative MRI appearances, 17 patients (70.8%) had transsphincteric fistula, 5 (20.8%) had suprasphincteric fistula and 2 (8.4%) had extrasphincteric fistula. Twenty cases (83.3%) showed skin healing at a median of six (range, 2-15) weeks, 14 cases out of them remained healed till the end of follow up period (range 9-26 months) while10 cases had relapses and fistula recurrence. The success rate was 58.3% while recurrence was reported in 41.7%. In conclusion, fibrin sealant injection is a safe and useful treatment in the management of complex perianal fistula and precludes the need for more extensive surgery. MR imaging can accurately predate the clinical assessment in prediction of the outcome at an earlier stage. More than one half of the patients can actually be cured with fibrin glue when considering combined clinical and radiological evidence

Management of an extrasphincteric fistula in an HIV-positive patient by using fibrin glue: a case report with tips and tricks

BackgroundIndividuals with impaired immunity are at higher risk of perianal diseases. Concerning complex anal fistulas impaired healing and complication rates are also higher. Definitive treatment of a fistula aims controlling the purulent discharge and prevents its recurrence. It depends mainly on the trajectory of the fistula and the underlying disease.We present a case of a HIV-positive patient with a complex extrasphincteric anal fistula who was treated successfully with fibrin glue application. We further, discuss tips and tricks when applying fibrin glue as plugging material in complex anal fistulas.Case presentationA sixty-one-year-old HIV-positive male referred to us for warts and extrasphincteric fistula. Because of the patients' immunological status, we opted against surgery and recommended fibrin glue plugging. The patient was discharged the same day. A follow-up examination was performed 5 days after the initial fibrin glue application showing that the fistula canal was obstructed. Three months and a year post-intervention the fistula tract remains closed.ConclusionThe best treatment for a disease gives at least the same result with the other treatments with minimised risk for the life of the patient and minimal application effort. Conservative closure of fistula with fibrin plugging is simple, safe and with less morbidity than surgery. Our patient was successfully treated without endangering his life despite his precarious medical state. Not everybody believes in the effectiveness of fibrin glue application, however we consider this solution in cases of complex fistulas at least as primary procedure in special populations such as the immunosupressed.

An Unusual Case of Complex Transphincteric Fistula-In-Ano

Fistula in ano is a common benign perianal condition that affects predominantly male patients due to various etiological factors like repeated perianal infections, tuberculosis, Crohns disease of perineum, Hidradenitis suppurativa, HIV infection, etc. Complex variety is encountered in very few patients, which requires special treatment for its cure. Extrasphincteric fistulae occur in only 5% of total fistula in ano patients. We would like to report such an unusual case of fistula in ano where its one tract reached almost to the popliteal fossa in the posterior compartment of the thigh. CASE HISTORY A 32-year-old Hindu male patient, caterer by occupation, came with complaints of persistent foul smelling discharge from his perianal wound for one month. The patient underwent anal fistulectomy under spinal anesthesia at a charitable hospital in the city in 2006. The histopathology report showed a fistula tract with chronic inflammation. In 2007, he again took treatment from another tertiary care hospital in the city for 6 months, but the wound did not heal. Finally, he came to our institute 6 months back for further treatment. He presented with painful defecation, mucus discharge in stools and foul smelling discharge from the wound. There was no associated history of any fever, bleeding per-rectally or constipation. He did not give any history of major medical illnesses or other surgery done in the past.

Cutting seton for complex anal fistulas

A standardised protocol for performing a cutting seton has not been well described in the existing literature. The aim of this study was to examine our experience of treatment of complex anal fistulas by cutting seton over 15 years in our hospital, detailing surgical technique, results and complications. Between 1990 and 2004, 112 patients with complex anal fistulas were treated by applying cutting setons in our hospital. The elastic band from a surgical glove was used as the seton material. The seton was re-tightened for the first time in the second week after the initial operation and then at weekly intervals. There were 98 male and 14 female patients, with a median age of 43 years. Eighty-four patients had trans-sphincteric or suprasphincteric fistulas, and 28 patients had extrasphincteric fistulas. The mean operative time was 42 minutes. The mean number of seton ties was 3-3 times. The mean duration with the seton in place was 28.7 days. The mean time of the wound healing was 9.3 weeks. Median period of follow-up was 38.6 months. Recurrence was found in one patient (0.9%). Twenty-seven patients (24.1%) were noted with continence disorders, including gas incontinence in 21 patients (18.6%) and liquid stool incontinence in 6 patients (5.4%). There were no incidents of solid stool incontinence. Using the elastic band from a surgical glove as a seton with repeated tightening at weekly intervals is safe and effective, with shorter duration of wound recovery, low recurrence and less continence disorders.

Anal fistulotomy using radiowaves - long-term outcome

The aim of this paper was to analyze the results of treatment of anal fistulas using a radiowave device retrospectively. Between 2000 and 2008, 976 patients were operated on for perianal fistula. A Ellman radiowave generator was used to carry out the complete surgical procedure. In the follow-up period 155 patients were lost, remaining 821 patients were analyzed in the study. The mean follow-up time was 6.8 years. Analyzed parameters included: postoperative complications, wound healing time, off work duration, recurrence rate and incidence of anal sphincter dysfunction. Severity of gas and stool incontinence was assessed. In our study, subcutaneous fistula was diagnosed in 28.1%, inter-sphincteric in 39.1%, and trans-sphincteric in 32.8%; supra-sphincteric and extra-sphincteric fistulae were not included in the study. Single-tract fistulas were present in 85.4% and multi-tract fistulas were present in 14.6%. Postoperative complications were noticed in 1.4% of patients, which included postoperative bleeding, abscess formation, premature approximation of skin edges, prolapse of hemorrhoids and local skin allergic reactions. Postoperative gas and/or stool incontinence was noticed in 3.8%. The recurrence rate was 1.7%. Radiowave fistulotomy offers short operation time, less postoperative pain, early return to normal activity, and faster healing of the wound. The recurrence rate and continence disturbances are comparable to conventional fistulotomy procedures.

Transperineal versus hydrogen peroxide-enhanced endoanal ultrasonography in never operated and recurrent cryptogenic fistula-in-ano: a pilot study

Accurate delineation of anal fistula anatomy in recurrent cases will assist in surgical fistula eradication whilst preserving continence. Recently, transperineal ultrasonography (TPUS) has been used in perirectal inflammation where there may be advantage over endoanal ultrasonography (EAUS) in complex fistulae- in-ano which lie outside the focal range of the endoanal probe. We assessed the sensitivity of these two imaging modalities to characterize fistula-in-ano, compared to surgical findings. Hand-held 7.5 MHz TPUS was performed in the axial and sagittal planes in never-operated (Group 1, n=10) and recurrent (Group 2, n=10) cryptogenic fistulae where the ultrasonographer was blinded to the initial operative findings. This was compared with hydrogen peroxide-enhanced EAUS using a 7.5 MHz rotating probe, assessing the fistula anatomy, site of the internal opening, confirmation of Goodsall's rule and the presence of secondary tracks, abscess collections and significant horsehoeing of the track. Overall sensitivity for the detection of trans-sphincteric and extrasphincteric fistulae was 100% using both techniques with a 90% sensitivity for TPUS and an 85% sensitivity for EAUS in the prediction of the internal fistula opening site. The TPUS sensitivity for horseshoeing was poor (28.6%) as was the detection of ancillary abscesses confirmed at surgery (63.6%) but TPUS demonstrated rectovaginal fistulae. TPUS is a novel technique for use in perirectal infection which has a significant learning curve but which is highly accurate for prediction of the anatomy of complex recurrent as well as simple anal fistulae.