Fistulotomy Group Research Articles

Use of Anal Fistula Plug for Treatment of Fistula-in-ano: A Novel Technique?

Abstract Background: Fistula-in-ano is a chronic phase of anorectal suppuration characterized by purulent discharge. The conventional gold standard fistulotomy opens the entire track to heal with secondary intention. Anal fistula plug (AFP) is one of the newer modalities where the track is debrided from within and plugged with a biodegradable material made of porcine small intestinal submucosa. Materials and Methods: A total of 100 patients were enrolled in a randomized prospective study into two groups: conventional fistulotomy (CF) group and AFP group with 50 patients in each arm. The demography and surgical outcomes were assessed for postoperative pain, discharge and recovery, and failure. Results: All 100 patients included in the study had a history of anorectal suppuration which led to the residual anal fistula. Postoperative pain and analgesic requirements were equal in the two groups. The recovery period and return to work were shorter in the AFP group, and this difference was statistically significant. The success rate was 100% in the CF group as compared to 76% in the AFP group. There was no significant complication, failure, or recurrence in the CF group as against allergy (1), extrusion of plug (2), and failure/recurrence (9) in the AFP group. Conclusion: Our study shows that the application of bioprosthetic plugs may be an alternative option in a select group of patients. AFP has also shown to have a faster recovery with less morbidity and comparable success rates.

Comparison of the Outcome of Fistulectomy Versus Fistulotomy in Treatment of Fistula in Ano

Aim: To compare the outcome of fistulectomy versus fistulotomy in treatment of fistula in ano. Study design: Randomized Controlled Trial Setting and duration: Department of General Surgery, CMH, Lahore from March 2019 to september2019. Methodology: Through the outpatient department of the general surgery unit at the Combined Military Hospital in Lahore, a total of 112 patients who met the selection criteria were invited to participate in the study. After that, each of the patients was assigned a number and placed into one of two groups. In the group A patients, a fistulectomy was performed. Fistulotomy was performed on members of group B. Each and every operation was performed under spinal anaesthetic. The number of minutes required for the operation was tallied beginning with the incision and continuing through the wound dressing. After surgery, patients were moved to the surgical ward to recover and get follow-up care for a period of twenty-four hours. After that, patients were monitored for a total of four weeks after their operations. It was determined how many days the wound would take to heal in total. SPSS was utilized in order to perform the data analysis. Results: In the fistulectomy group, the mean surgical time was 33.00 minutes with a standard deviation of 4.31 minutes, whereas in the fistulotomy group, the mean operative time was 19.55 minutes with a standard deviation of 2.87 minutes. In the fistulectomy group, the average length of time needed for healing was 31.84 4.67 days, whereas in the fistulotomy group, the average length of time needed for healing was 20.63 4.95 days. Conclusion: Fistulotomy is a therapeutic option that is both straightforward and successful for treating simple perianal fistulas. Keywords: Fistulectomy, fistulotomy, fistula in ano, operative time, duration of healing

A Comparison of Laser and Fistulotomy Techniques in the Treatment of Fistula-in-Ano.

Background Anal fistulas are a common complication of perianal abscesses.The treatment of anal fistulas is challenging, with persistent and high recurrence rates. The aim of this study was to evaluate the efficacy and cost-effectiveness of laser ablation compared to fistulotomy in the treatment of anal fistulas. Materials and methods The patients were examined for external and internal openings of the fistula, its number, length, type, relationship with the sphincters, and any previous history of abscess or proctological surgery. The surgical procedures, complications, incontinence, recurrence, and recovery time were evaluated and compared between the two groups. The laser ablation group received an intermittent laser application at a wavelength of 1470 nmand 10 watts for three seconds, while the fistulotomy group underwent cutting of the fistula tract with electrocautery while keeping a stylet in place. Results A total of 253 patients were included in this retrospective study, with 149 patients undergoing fistulotomy and 104 patients undergoing laser ablation. The patients were evaluated based on the type, number, and location of internal and external openings, and the length of the fistula tract according to the Parks classification. The mean follow-up period was 9.0±4.3 months. The results showed that the laser group had a shorter time to return to work and less postoperative pain compared to the fistulotomy group. However, the recurrence rate was higher in the laser group. The recurrence rate was also found to be higher in patients with low transsphincteric fistulas and in patients with diabetes mellitus. Conclusion Our study findings indicate that while laser ablation may be associated with less pain and quicker recovery time, it may also have a higher recurrence rate compared to fistulotomy.We believe that laser ablation is a valuable option for surgeons to consider early on in the treatment process, especially in cases where fistulotomy is not suitable.

Fistulotomy versus Fistulectomy for Fistula-in-Ano: A Randomized Prospective Study.

Background Fistula-in-ano is common surgical ailment yet challenging to treat. Current management remains majorly dependent on two conventional surgical options (fistulotomy and fistulectomy), surgeon's preference, and their experience. Methods This prospective, randomized study was conducted to compare fistulotomy with fistulectomy in the management of patients with simple fistula-in-ano. Fifty patients were recruited and randomized into two groups each containing 25 patients: group I was managed by fistulotomy and group II was managed by fistulectomy. The outcomes of the study include operating time, postsurgery hospital stay, wound healing time, postoperative pain, and postoperative complications. Results Of the 50 patients, 11 (22%) were female and 39 (78%) were male with a mean age of 40.62 ± 12.86 years. The operating time in patients in the fistulotomy group was 21.96 ± 1.90 minutes and in the fistulectomy group was 31.32 ± 2.99 minutes ( p ≤ 0.001). The mean postsurgical hospital stay in the fistulotomy group was 1.32 ± 0.47 days and in the fistulectomy group was 2.32 ± 0.69 days ( p ≤ 0.001), respectively. Mean Visual Analog Scale score was higher in fistulectomy when compared with the fistulotomy at 6 hours and at discharge ( p ≤ 0.05). Postoperative complications were also found to be less in fistulotomy patients compared with patients who underwent fistulectomy. Conclusion In comparison to a fistulectomy, fistulotomy has a slight edge in terms of operating time, postsurgery hospital stay, wound healing time, postoperative pain, and postoperative complications. Fistulotomy yielded better results than fistulectomy and we recommend fistulotomy procedure as a treatment of choice in patients with simple low lying fistula-in-ano.

A Study of Management of Fistula in Ano at a Tertiary Health Care Centre

A Fistula is an abnormal communication between any two epithelial-lined surfaces. Fistula in Ano is an abnormal communicationbetween the anal canal and the perineal skin. Fistula in ano denotes the chronic phase of anorectal sepsis and is characterized by chronic purulent drainage or cyclical pain associated with abscess reaccumulation followed by intermittent spontaneous decompression. Present study was a prospective study in Department of Surgery, Fathermuller medical college and hospital. The source of data for our study was 60 patients who presented with their complaints to the surgery OPD. 60 cases of Fistula in Ano were selected and randomly divided in for the three surgical modalities equally (20 patients in each group). Group A was Fistulectomy Group. Group B was Fistulotomy Group and Group C was Seton Application group.

Low lying fistula-in-ano - fistulotomy or fistulectomy

Background: Fistula-in-ano is very common benign anal condition in day to day surgical practice which is treatable. The treatment is challenging even for an experienced surgeons due to its chronic and recurring nature. There are various treatment modalities available for management of anal fistula. Our aim is to study the outcome of fistulotomy and fistulectomy in patients with simple low-lying fistula. Methods: A prospective Randomised clinical study was done on 55 patients, they were randomized into two groups of fistulotomy (n=25) and fistulectomy (n=30) in GSVM medical college over a period of two years. Aim of the study was to compare the operative time, healing time, treatment outcome, complications and recurrence rate. The results were analyzed using SPSS version 22 using tests like student’s t test and chi square test. Results: The mean operative time of fistulotomy was 18.3 minutes and that of fistulectomy was 34.2 minutes, which is statistically significant ( p-value =0.008).Duration of healing in fistulotomy group (11 days) compared to fistulectomy group (22 days), which is statistically significant (p<0.001).Incidence of incontinence in fistulotomy group observed in 2 cases and in fistulectomy group was observed in 3 cases , which is insignificant (p-value=.797)There was recurrence in one case in both the groups in six months of follow-up period. Conclusion: Fistulotomy is better for treating low fistula-in-ano in terms of high healing rate, shorter operating time, shorter healing time which ultimately reduces the hospital stay and incidence of complications is comparable in both the groups.

916 Endoscopic Fistulotomy vs. Redo Surgery for the Treatment of Pouch-to-Pouch Fistula in Patients With Inflammatory Bowel Disease

INTRODUCTION: Pouch-to-pouch fistula is a rare yet challenging complication in patients who underwent ileal pouch-anal anastomosis. The aim of this study was to compare endoscopic fistulotomy and redo pouch surgery in the management of pouch-to-pouch fistula. METHODS: All consecutive patients with pouch-to-pouch sinuses treated with endoscopic fistulotomy vs. redo surgery from 2000 to 2018 were identified. The primary outcomes were surgery-free survivals and post-procedural complications. RESULTS: This historical cohort study included a total of 59 patients (endoscopic fistulotomy, N = 40 and redo surgery, N = 19). Complete resolution of the fistula was achieved in 29/37 (78.4%) patients, partial healing was seen in 8/37 (21.6%) patients with endoscopic fistulotomy while an initial complete healing was obtained in all patients receiving redo surgery. During a foolow-up of 1.4 years, subsequent surgery was needed in 4 (10.0%) patients with endoscopic fistulotomy and 4 (21.1%) patients with initial redo surgery (P = 0.45). Kaplan-Meier surgery-free survivals after initial procedure showed no statistical difference between the two groups (P = 0.42). The rate of adverse events in the endoscopic fistulotomy group was significantly lower than that in the surgery group (5.6% vs. 68.4%, P &lt; 0.001). Patients receiving redo surgery had complications of a higher Clavien-Dindo class as well. CONCLUSION: Surgery-free survival were comparable between patients treated with endoscopic fistulotomy and redo surgery, while pouch redo surgery was found to be associated with a higher immediate complete healing rate yet a higher morbidity.

A comparative study of fistulotomy and fistulectomy in management of simple fistula in ano

Background: Fistula in ano is one of the commonest benign anorectal condition encountered during the day today practice. There are different treatment modalities available for the management of anal fistula. These include fistulotomy, fistulectomy, LIFT, seton placement, advancement flaps and use of biological agents like fibrin glue. In this prospective randomized clinical study, we have studied the outcomes after fistulotomy and fistulectomy in patients with simple low-lying fistula.Methods: Total 84 patients with simple low-lying fistula were randomized into two groups of fistulotomy and fistulectomy (42 patients each). The intraoperative and postoperative findings noted, and the results are compared. The results are analyzed using statistical tests like student’s t test and chi square test.Results: The mean duration of surgery in fistulotomy group was 28.6min and that of fistulectomy group was 31.7 min. The difference in duration of surgery is statistically not significant (p&gt;0.05). The median duration of wound healing was shorter in the fistulotomy group (12 days) compared to the fistulectomy group (21 days) and the difference is statistically highly significant (p&lt;0.001). The incidence of incontinence in fistulotomy group observed in 5 cases compared to single case in fistulectomy group. This difference is again statistically significant. Recurrence observed in one case from both the groups each within 6 months post-op period.Conclusions: The results of fistulotomy and fistulectomy are comparable with respect to duration of surgery, postoperative pain and recurrence rate. The postoperative wound healing is faster in fistulotomy; while incontinence is also higher in fistulotomy group.

A comparative study between fistulotomy and fistulectomy in management of low anal fistulae

Background: Fistula in ano is a silent menace in human beings, the treatment is a challenging one even for experienced surgeons, fistula in ano forms a good majority of treatable benign lesions of rectum and anal canal. Aim was to study the efficacy of fistulotomy and fistulectomy in the treatment of low anal fistulae.Methods: A randomized control study was conducted to compare fistulotomy with fistulectomy in patients with low anal fistulae.Results: The operating time in fistulotomy group was 12.13minutes±2.11minutes and in fistulectomy group was 22.23±3.36minutes. The post-surgery hospital stays in Group I was 1.80±0.66days and in Group II was 2.60±0.563 days. The wound healing time in Group I was 24.20±2.95 days which was considerably less when compared to patients in Group II where it was 31.50±4.34 days.Conclusions: Fistulotomy has a slight edge over fistulectomy in the treatment of low anal fistulas since it has shorter operating time, less post-operative pain, less complications, quicker wound healing time, less incontinence and a comparable recurrence rate.

Comparative study on efficacy of fistulotomy and Ligation of intersphincteric fistula tract (LIFT) procedure in management of fistula-in-ano

Background: Fistula-in-ano is one of the most common benign anal conditions in daily surgical practice. Present study aims at comparing the efficacy of open fistulotomy and ligation of intersphincteric fistula tract (LIFT) procedure based on its post-operative outcomes.Methods: A comparative study was carried out among 50 subjects attending Department of Surgery, K. R. Hospital, Mysuru over a period of 10 months. Subjects of either sex diagnosed with anal fistula were included in the study. Patients with recurrent fistulas, Crohn’s disease, anal or distal rectal cancers were excluded from the study. Descriptive statistics, unpaired t-test, Fischer exact chi-square test were used to analyse the results.Results: The mean age group of the study subjects was 44.6±8.34 and 41.3±9.71 years among fistulotomy and LIFT procedure group respectively. The gender distribution showed a higher number of males (38) as compared to females (12). There was 23 inter-sphincteric, 2 trans-sphincteric fistula in fistulotomy group and 22 inter-sphincteric, 3 trans-sphincteric fistula in LIFT group. The average operative time for fistulotomy was significantly shorter at 19.6 minutes, compared with 28.4 minutes for LIFT procedure. Wound infection detected in 1 (4%) and 2 (8%) subjects in fistulotomy and LIFT groups, respectively. 1 (4%) subject among fistulotomy group developed anal incontinence. The average healing time for fistulotomy was 8 weeks compared to 3 weeks for LIFT procedure. Total 3 (12%) subjects developed recurrence in LIFT procedure, but no recurrence was observed in fistulotomy group.Conclusions: LIFT procedure is effective and sphincter saving technique for fistula in ano with shorter healing time and lower incidence of postoperative anal incontinence, as compared to open fistulotomy.

Endoscopy Upper

Endoscopy Upper

Incidence of Anal Fistula and Recurrent Abscesses following Management of Perianal Abscess

Introduction: Most perianal abscesses originate from an infected anal gland. Obstruction of these glands leads to stasis, bacterial overgrowth and ultimately abscess. Approximately 10% of perirectal abscesses are thought not to be due to infected anal glands. It is unclear why some patients completely heal and others have recurrent disease.&#x0D; Objective: To assess the incidence of anal fistula and recurrent abscess after incision and drainage of perianal abscess.&#x0D; Materials and Methods: A prospective observational study was done on 140 patients operated upon for perianal abscess in Combined Military Hospital, Dhaka. They underwent for one group only drainage, for other group drainage with primary fistulotomy under general or spinal anesthesia over two years from January 2015 to December 2016. The patients were followed up for an average 13 months (range, 4-18 months) after abscess drainage or until a fistula appears and abscess recurs. Their duration of hospital stay was 1–3 days. After discharge from hospital, they were examined in follow-up within 7 to 14 days. Subsequently, they were examined on a monthly basis until drainage ceased or until it became obvious that a fistula-in-ano had developed.&#x0D; Results: Total 140 patients were treated for perianal abscess. Those patients were divided into two groups. The first group of 84 patients (60%) who underwent incision and drainage only. The second group consisted of 56(40%) patients who had low fistulas identified at the time of abscess drainage and underwent primary fistulotomy. The incidence of fistula formation after the operative procedures were 37(44.05%) in incision and drainage group and 5(8.93%) were in primary fistulotomy group. The most common site of abscess formation was posterior to anus. The incidence of recurrent abscess were 7(8.33%) in incision and drainage group; 2(3.57%) in primary fistulotomy group. The overall fistula formation (44.05% and 8.93%) and recurrence of abscess (8.33% and 3.57%) is low in primary fistulotomy group.&#x0D; Conclusion: In this study the overall incidence of anal fistula is much higher than recurrence of perianal abscess following management of perianal abscess. Primary fistulolotomy at the time of drainage for perianal abscess reslult in a fewer persistent fistulas and recurrence of abscess.&#x0D; Journal of Armed Forces Medical College Bangladesh Vol.12(2) 2016: 26-29

Patients Satisfaction and Outcome of Fistulotomy Versus Fistulectomy for Low Anal Fistula

<i>Introduction:</i> Anal fistulae are still negatively influencing the patient's quality of life by causing minor pain, social hygienic embarrassment, and in severe cases, frank sepsis. Although a number of surgical techniques have been proposed to treat this condition, there is still no single ideal technique for the treatment of this disease. Generally, fistulectomy is an adequate surgical procedure for the treatment of a simple or low transsphincteric fistula while others reported that fistulotomy continues to have excellent results. <i>Patients and Methods:</i> This study represented parallel prospective randomized clinical trial where 200 patients were divided randomly into two main groups; A and B. Group A patients were subjected to fistulotomy and those of group B were subjected to fistulectomy for low anal fistulae. The study included all patients having low anal fistulae complicating perianal abscesses. Patients with high fistulae and patients with multiple external openings were excluded. The primary end point was anal incontinence and the secondary end points were time off from work, postoperative pain, wound discharge, wound healing and patients’ satisfaction. <i>Results:</i> The mean operative time, time taken for wound discharge to cease and time taken for complete healing was significantly less in patients of group A. Regarding the occurrence of fecal incontinence, no permanent cases were reported in our series but temporary incontinence was observed in 2 patients in fistulotomy group while in fistulectomy group there were 4 patients. Therefore, the overall patient satisfaction mean values were 90.6 ± 8.87and 85.6 ± 13.2 for patients in group A and B respectively with statistically insignificant distribution. <i>Conclusion:</i> Fistulotomy could be used as a primary treatment of low anal fistula as being safe and simple to perform with good patient’s satisfaction as regard postoperative pain and outcome.

Comparing Ksharasutra (Ayurvedic Seton) and open fistulotomy in the management of fistula-in-ano.

Background:Most commonly practiced surgical “lay open” technique to treat fistula-in-ano (a common anorectal pathology) has high rate of recurrence and anal incontinence. Alternatively, a nonsurgical cost efficient treatment with Ksharasutra (cotton Seton coated with Ayurvedic medicines) has minimal complications. In our study, we have tried to compare these two techniques.Materials and Methods:A prospective randomized control study was designed involving patients referred to the Department of General Surgery in RG Kar Medical College, Kolkata, India, from January 2010 to September 2011.Results:Among 50 patients, 26 were in Ksharasutra and 24 were in fistulotomy group. 86% patients were male and 54% of the patients were in the fourth decade. About 74% fistulas are inter-sphincteric and 26% were of trans-sphincteric variety. Severe postoperative pain was more (7.7% vs. 25%) in fistulotomy group, while wound discharge was more associated with Ksharasutra group (15.3% vs. 8.3%). Wound scarring, bleeding, and infection rate were similar in both groups. Ksharasutra group took more time to heal (mean: 53 vs. 35.7 days, P = 0.002) despite reduced disruption to their routine work (2.7 vs. 15.5 days work off, P <0.001). Interestingly, pain experienced was less in Ksharasutra group, there was no open wound in contrast to fistulotomy and it was significantly cost effective (Rupees 166 vs. 464).Conclusion:Treatment of fistula-in-ano with Ksharasutra is a simple with low complications and minimal cost.

Fistulotomy in the Tertiary Setting can Achieve High Rates of Fistula Cure with an Acceptable Risk of Deterioration in Continence

IntroductionSurgery is the mainstay of treatment of anal fistulas. Low fistulas are often laid open, but higher fistulas present a more difficult problem. Patient choice centres on a compromise between risk of recurrence and risk of impairment of continence. We aimed to determine the efficacy and safety of fistulotomy at a tertiary referral centre, in particular the additional risk of impairment of continence following fistulotomy of the often recurrent, multiply-operated patients seen. MethodsPatients undergoing surgery under the senior author (RKSP) for an anal fistula during the study period (2005–2006) were identified, and a thorough review of the patients' clinical records was undertaken. Demographic, fistula anatomy, treatment and follow-up data were obtained. ResultsEighty-four patients underwent either fistulotomy (50), insertion of permanent loose (drainage) seton (28) or EUA with or without drainage of abscess. Mean length of follow up was 11 months (SD 14.22). In the fistulotomy group, we found an overall success rate of 93 %. Secondary extensions were associated with failure to achieve cure (P = 0.008). Nine patients (20 %) suffered deterioration in continence after surgery. A longer time to referral was associated with impaired final continence. In the group referred from a surgeon in secondary care, 91 % of patients were cured, and continence impairment (mostly minor) rose from 32 % at referral to 40 % after surgery. ConclusionsWe have shown that it is safe and reasonable to offer fistulotomy to appropriate patients despite previous surgery and within the tertiary setting. By so doing, a very high rate of healing can be achieved in patients who have previously failed. The additional risk of impairment of continence is around one in five, and in the majority will represent only minor incontinence.

Acute abscess with fistula: long-term results justify drainage and fistulotomy

Conventional treatment of anal abscess by a simple drainage continues to be routine in many centers despite retrospective and randomized data showing that primary fistulotomy at the time of abscess drainage is safe and efficient. The purpose of this study is to report the long-term results of fistulotomy in the treatment of anal abscesses. This is a prospective nonrandomized study of 165 consecutive patients treated for anal abscess in University Hospital Hassan II, Fez, Morocco, between January 2005 and December 2010. Altogether 102 patients were eligible to be included in the study. Among them, 52 were treated by a simple drainage and 50 by drainage with fistulotomy. The results were analyzed in terms of recurrence and incontinence after a median follow-up of 3.2 years (range 2-6 years). The groups were comparable in terms of age, gender distribution, type and size of abscess. The recurrence rate after surgery was significantly higher in the group treated by drainage alone (88 %) compared to other group treated by drainage and fistulotomy (4, 8 %) (p < 0.0001). However, there was a tendency to a higher risk of fecal incontinence in the fistulotomy group (5 % vs 1 %), although this difference was not significant (p = 0.27). In the group treated by drainage and fistulotomy, high fistula tract patients are more prone to develop incontinence and recurrence, mainly within the first year. A long-term follow-up seems not to influence the results of fistulotomy group. These findings confirm that fistulotomy is an efficient and safe treatment of anal abscess with good long-term results. An exception is a high fistula, where fistulotomy may be associated with a risk of recurrence and incontinence.

Traditional Chinese surgical treatment for anal fistulae with secondary tracks and abscess

To evaluate the efficacy and safety of traditional Chinese surgical treatment for anal fistulae with secondary tracks and abscess. Sixty patients with intersphincteric or transsphincteric anal fistulas with secondary tracks and abscess were randomly divided into study group [suture dragging combined with pad compression (SDPC)] and control group [fistulotomy (FSLT)]. In the SDPC group, the internal opening was excised and incisions at external openings were made for drainage. Silk sutures were put through every two incisions and knotted in loose state. The suture dragging process started from the first day after surgery and the pad compression process started when all sutures were removed as wound tissue became fresh and without discharge. In the FSLT group, the internal opening and all tracts were laid open and cleaned by normal saline postoperatively till all wounds healed. The time of healing, postoperative pain score (visual analogue scale), recurrence rate, patient satisfaction, incontinence evaluation and anorectal manometry before and after the treatment were examined. There were no significant differences between the two groups regarding age, gender and fistulae type. The time of healing was significantly shorter (24.33 d in SDPC vs 31.57 d in FSLT, P < 0.01) and the patient satisfaction score at 1 mo postoperative follow-up was significantly higher in the SDPC group (4.07 in SDPC vs 3.37 in FSLT, P < 0.05). The mean maximal postoperative pain scores were 5.83 ± 2.5 in SDPC vs 6.37 ± 2.33 in FSLT and the recurrence rates were 3.33 in SDPC vs 0 in FSLT. None of the patients in the two groups experienced liquid and solid fecal incontinence and lifestyle alteration postoperatively. The Wexner score after treatment of intersphincter fistulae were 0.17 ± 0.41 in SDPC vs 0.40 ± 0.89 in FSLT and trans-sphincter fistulae were 0.13 ± 0.45 in SDPC vs 0.56 ± 1.35 in FSLT. The maximal squeeze pressure and resting pressure declined after treatment in both groups. The maximal anal squeeze pressures after treatment were reduced (23.17 ± 3.73 Kpa in SDPC vs 22.74 ± 4.47 Kpa in FSLT) and so did the resting pressures (12.36 ± 2.15 Kpa in SDPC vs 11.71 ± 1.87 Kpa in FSLT), but there were neither significant differences between the two groups and nor significant differences before or after treatment. Traditional Chinese surgical treatment SDPC for anal fistulae with secondary tracks and abscess is safe, effective and less invasive.

Suprapapillary needleknife fistulotomy: a safe and effective method for accessing the biliary system

Suprapapillary needleknife fistulotomy is performed when standard biliary cannulation methods have failed. However, its role is controversial, with conflicting reports on its use. This study aimed to determine the efficacy and safety of needleknife fistulotomy after failure of conventional cannulation techniques. All patients who underwent needleknife fistulotomy were identified from a single tertiary referral center database prospectively maintained from 1997 to 2007. A total of 2,603 patients underwent endoscopic retrograde cholangiopancreatography (ERCP) over the 10-year period. Fistulotomy was performed for 352 patients (13.5%), with 317 of these patients (90.1%) experiencing successful biliary cannulation. With the use of fistulotomy, the total cannulation success rate increased from 79.0 to 91.2% (P < 0.0001). Endoscopic management of choledocholithiasis and hepatobiliary malignancy increased from 48.9 to 55.1% (P < 0.001), and from 12.0 to 16.0% (P < 0.001) for all cases. The complication rate was significantly higher for the patients who underwent fistulotomy than for those who did not (4.8% vs. 2.1%; P < 0.001), which can be explained by a higher rate of mild bleeding in the fistulotomy group. However, no significant difference in pancreatitis or perforation between the two groups was observed. In addition, no fatalities occurred after fistulotomy. Suprapapillary needleknife fistulotomy is an effective method for accessing the biliary system after failed standard cannulation. Despite a higher rate of mild bleeding, fistulotomy was not associated with an increased risk of serious complications.

Long-term outcome following mucosal advancement flap for high perianal fistulas and fistulotomy for low perianal fistulas

In this study, we determined the long-term outcome of perianal fistulas treated with mucosal advancement flap (MF) or fistulotomy (FT). One hundred three patients with perianal fistulas were treated by MF for high fistulas or FT for low fistulas and were retrospectively assessed by case-note review and examined at the out-patient clinic. The localization and time of recurrence of the fistula were recorded. Forty-one patients [median follow-up of 72 months (range 48-99)] were treated by an MF, and 62 patients [median follow up of 75 months (range 48-99)] were treated by FT. After 12, 48, and 72 months, the fistula had recurred in 9 (22%), 26 (63%), and 26 (63%) patients of the MF group and in 4 (7%), 16 (26%), and 24 (39%) patients of the FT group, respectively. Eighteen (69%) of the recurrences in the MF group and ten (33%) of the FT group occurred within 24 months after surgery (p=0.01). Four (15%) of the recurrences in the MF group and 13 (54%) of the recurrences in the FT group were present in a different localization (p=0.007). The success rate of both FT and MF techniques decreases with time. Recurrence appears to be caused by failure of treatment and by recurrent patient disease.

3395 Clinical usefulness of primary endoscopic choledochoduodenal fistulotomy in patients with ampullary cancer.

Background: In patients with ampullary cancer, the use of endoscopic choledochoduodenal fistulotomy (endoscopic fistulotomy) between the bulged suprapapillary intraduodenal part of the bile duct and the duodenum by needle-knife sphincterotome (NKS) has been reported sporadically as an alternative to failed bile duct cannulation and subsequent endocopic biliary drainage such as biliary stenting or endoscopic sphincterotomy (EST). However, endoscopic fistulotomy can be performed primarily, for both successful biliary drainage and avoidance of recurrent symptoms by possible stent dysfunction or fatal bleeding by EST, in patients especially with suprapapillary bulged, distorted, or friable to bleeding papilla causing failed endoscopic biliary drainage procedures. Aim: To evaluate safety and clinical usefulness of primary endoscopic fistulotomy in patients with ampullary cancer. Methods: Of the 29 patients with ampullary cancer requiring biliary drainage, 13 patients(44.8%) with suprapapillary bulged papilla underwent fistulotomy using NKS (HPC-2, Wilson-Cook Medical Co, NC) alone or followed by upward extension of the fistulous orifice using standard sphincterotome (fistulotomy group). The remaining 16 patients underwent transpapillary stenting with standard techniques (transpapillary stenting group). In both groups, the success rate of bile duct cannulation and effective biliary drainage was assessed and compared. Results: Bile duct cannulation was successful in 12 patients (92.3%) of the fistulotomy group and 13 patients (81.3%) of the transpapillary stenting group (p>0.05), and complication was mild bleeding in 1 patient (7.7%) and cholangitis by stent occlusion in 1 patient (6.3%), respectively (p>0.05). The success rate of initial biliary drainage by endoscopic fistulotomy and transpapillary stenting was 100% and 84.6% (p>0.05), respectively. In 13 patients, biliary drainage was used as a definite treatment and the symptom-free duration was 3.2 months in 7 patients (52.8%)of the fistulotomy group and 3.9 months in 6 patients (37.5%) of the transpapillary stenting group (p>0.05). Conclusions: Endoscopic fistulotomy is as effective as transpapillary stenting in preoperative or palliative decompression of the obstructed bile duct due to the ampullary cancer. Without the need of biliary stenting, this can be employed primarily with safety in selective patitients when bulged suprapapillary intraduodenal part of the bile duct is observed definitely.