High Transsphincteric Anal Fistula Research Articles

Outcomes of surgery for high transsphincteric anal fistulas: prospective randomized trial

Background. Reliable data on the efficacy and safety of fistulectomy with primary sphincter repair for the treatment of high transsphincteric anal fistulas are deficient.The aim. To compare the efficacy and safety of fistulectomy with advancement muco-muscular flap (F) and fistulectomy with primary sphincter reconstruction (SR) for the treatment of high anorectal fistulas.Methods. A cohort of 92 consecutive patients with transsphincteric anal fistula involving 1/3 to 2/3 of the sphincteric complex were included in prospective randomized study. The primary endpoint was the recurrence rate. The duration of surgery, blood loss, pain intensity, postoperative complications, the duration of wound healing, incontinence, quality of life were registered.Results. Forty-six patients were randomized in each group. A statistically significant difference was obtained for operative time (Group “F” – 45 (20–160) min, Group “SR” – 33 (10–55) min). The blood loss was 3 (1–20) and 2 (1–10) ml in Groups “F” and “SR”, respectively (p = 0.482). The return to work in Groups “SR” and “F” occurred after 7 (2–14) and 8 (4–20) days, respectively (p = 0.005). The pain syndrome was significantly greater in Group “F” (p < 0.05) on days 1 and 7. Recurrence rate was in 23.9 % (11 cases) in Group “F” and in 6.5 % (3 cases) in Group “SR” (p = 0.042). Incontinence was in 7 (15.2 %) people in Group “F”, in 10 patients (21.7 %) – in Group “SR” (p = 0.591). There was no statistically significant difference in postoperative complications.Conclusion. Findings can expand the indications for the treatment of high transsphincteric anorectal fistulas involving from 1/3 to 2/3 of the sphincter complex without statistically significant risk for functional results.

Comparison of Recurrence of High Trans-Sphinteric Anal Fistula After Vaaft and Tight Setons in Military Hospital Rawalpindi

Objective: To compare the recurrence rate in patients undergoing fistulectomy using tight setons with those using videoassisted anal fistula treatment (VAAFT).
 Study Design: Comparative prospective study.
 Place and Duration of Study: Department of General Surgery, MH Rawalpindi, Pakistan from May 2018 to Dec 2021.
 Methodology: We included 200 patients with high trans-sphincteric anal fistula (simple or complex) of age 18 to 60 years, having ASA I or II. Group- A comprised patients undergoing treatment with VAAFT, while Group- B included patients undergoing treatment with Tight Seton in conventional surgery. Patients were followed for three months after the procedure. Patients having a history of discharge around or in the vicinity of the previous external opening of the anal fistula were labelled as having a recurrence. Recurrence was confirmed on MRI Fistulogram.
 Results: The mean age of patients in Group-A was 42.10±8.26 years, and in Group-B was 42.17±7.91 years (p=0.95). There were 58 male patients in Group-A and 55 male patients in Group-B (p=0.67). The mean duration of the fistula was 5.30±1.64 months in Group-A and 5.22±1.61 months in Group-B (p=0.72). Recurrence was diagnosed in 24 patients in Group-B and only 06 patients in Group-A (p<0.001).
 Conclusion: Video-assisted anal fistula treatment (VAAFT) has a lower recurrence rate than Tight Setons in conventional surgery in treating high trans-sphinteric anal fistula.

Comparison between application of platelet rich plasma and mucosal advancement flap in patients with high transsphincteric anal fistulas: a randomized control trial.

There is still a search for a standard method of therapy for high anal fistulas. The aim of this trial was a comparison between a modified two stage minimally invasive procedure, consisting of loose-seton placement with the subsequent application of platelet rich plasma with mucosal advancement flap for the treatment of high transsphincteric anal fistulas of crypto-glandular origin. The study was designed as a prospective, randomized trial including 96 patients. Curettage of fistulous tracts, and loose-seton placement was performed in those patients with active inflammation, and if the diameter of a fistulous tract exceeded 3 mm. Afterwards, the patients were randomly assigned to either the PRP group or MAF group, consisting of 49 patients, and 47 patients, respectively. There was no significant statistical difference (p=0.152) between both investigated groups of patients regarding closure of fistulas since it was achieved in 35 (71.43%) patients from group I, compared to 27 (57.45%) patients from group II. The diameter of fistulous tracts below 4 mm exerted a significant impact (p < 0.001) on the healing process after PRP application because fistulas with the narrow tracts were closed in 34 (87.18%) patients, whereas a wider fistula was healed in 1 (10%) patient. The local application of PRP in high, unbranched, and with narrow tracts trans-sphincteric anal fistulas of crypto-glandular origin, following loose-seton drainage is an effective, simple, and a safe method of therapy with a low rate of morbidity.

The Value of Cutting Seton for High Transsphincteric Anal Fistula in the Era of Its Misery.

ObjectivesWe studied the outcome of cutting seton in the treatment of a high transsphincteric anal fistula in Sudan.MethodsThis was a prospective study of high transsphincteric anal fistulas at Kassala Police Hospital, Sudan, over the course of 24 months (2016–2017). The main outcomes measured were recurrence, incontinence and primary healing rates.ResultsThe cases of 72 patients treated with cutting seton for high transsphincteric fistula were analysed, with 50 (70%) of the patients being male and 22 (30%) being female. Forty-eight (66.7%) patients required two sessions of seton tightening with a duration of seton treatment of 30 days and 24 (33.3%) patients required three sessions with a duration of seton treatment of 45 days. Only one patient (1.4%) had flatus incontinence. Three (4.2%) patients had minimal bleeding from the seton site and two (2.8%) patients experienced fistula recurrence. Twenty-six (36%) patients achieved complete healing within 30 days, while 36 (54.3%) patients healed within 60 days. The remaining seven (9.7%) patients healed after 60 days. Chronic pain was reported by two (2.8%) patients after complete healing.ConclusionIn Sudan, cutting seton remains relevant, as it produces minimal incontinence with a low recurrence rate in high transsphincteric fistula treatment.

Ligation of intersphincteric fistula tract (LIFT) with or without injection of platelet-rich plasma (PRP) in management of high trans-sphincteric fistula-in-ano: Short-term outcomes of a prospective, randomized trial

BackgroundSuccess rate after ligation of the inter-sphincteric fistula tract ranges from 40% to 75%. Platelet-rich plasma is hypothesized to improve healing by slowly releasing growth factors. The objective of the study was to compare the efficacy and outcome of ligation of the inter-sphincteric fistula tract plus platelet-rich plasma local injection versus ligation of the inter-sphincteric fistula tract alone in the management of high trans-sphincteric anal fistula in regards to postoperative pain, time for healing, morbidity, fistula closure rate, recurrence, and quality of life. MethodsThis was a prospective randomized trial. Patients with trans-sphincteric anal fistulas involving >50% of anal sphincters were included. Patients were randomly assigned to either ligation of the inter-sphincteric fistula tract plus platelet-rich plasma or ligation of the inter-sphincteric fistula tract (49 in each group). The primary endpoints were successful complete fistula closure and duration needed for healing. Secondary endpoints were morbidity, recurrence after 1 year of follow-up, postoperative pain, and quality of life. ResultsComplete primary healing was recorded in 42 patients in the ligation of the inter-sphincteric fistula tract plus platelet-rich plasma group and 32 patients in the ligation of the inter-sphincteric fistula tract group, and the difference was statistically significant (P = .03). The mean time to complete healing after ligation of the inter-sphincteric fistula tract plus platelet-rich plasma was significantly shorter than after ligation of the inter-sphincteric fistula tract alone (15.7 ± 4 days vs 21.6 ± 5.4 days; P = .03). One year after complete healing of anal fistula, recurrence was recorded in 4/42 patients in the ligation of the inter-sphincteric fistula tract plus platelet-rich plasma group and 3/32 patients in the ligation of the inter-sphincteric fistula tract group with no statistically significant difference (P = .99). Patients in the ligation of the inter-sphincteric fistula tract plus platelet-rich plasma group had significantly lower pain scores after both 1 and 7 days. Quality of life and level of happiness were significantly better 1 month after ligation of the inter-sphincteric fistula tract plus platelet-rich plasma. ConclusionLigation of the inter-sphincteric fistula tract plus platelet-rich plasma for the treatment of high trans-sphincteric fistula-in-ano is a safe modality with significantly higher successful healing rate, shorter healing time, and less postoperative pain compared with ligation of the inter-sphincteric fistula tract alone. Ligation of the inter-sphincteric fistula tract plus platelet-rich plasma does not improve the rate of recurrence; however, it results in significantly higher short-term quality of life.

COMPARATIVE STUDY BETWEEN STAGED RE-ROUTING AND RECTAL ADVANCEMENT FLAP WITH CURETTAGE OF FISTULA TRACT IN TREATMENT OF HORSE SHOE PERIANAL FISTULA

Background: Complex anal fistula has been a hot topic in clinic. Many surgical techniques have been described for the treatment of such anal fistula, including the use of seton, fibrin glue, collagen plugs, rectal advancement flaps, fistulotomy with sphincter repair, and rerouting the fistula tract. However, the results have been variable, and no one procedure is superior to the others absolutely. It is worth our concern that the goal of any treatment procedure is to obliterate the tract and to have low recurrence rates while maintaining full continence. Comparison was made between the two procedures (re-routing and rectal advancement flap) to stand on the superiority of each one over the other. We compared data including: Healing time, post operative bleeding and infection, recurrence rates and continence. Patients and Methods: The study was conducted over 40 patients with high trans-sphincteric fistulas, randomly divided into 2 equal groups, who underwent Rerouting of the tract in one group and rectal advancement flap in the other group.Results: Rerouting technique and rectal advancement flap have nearly similar incidence of post operative complications and continence but rectal advancement flap is associated with short healing period and a high recurrence rate as compared to re-routing technique.Conclusion: In patients with high trans-sphincteric anal fistulas, rectal advancement falp has a short healing period but a high recurrence rate which was statistically insignificant.

Clinical Effect of Tunnel-Like Fistulectomy Plus Draining Seton Combined with Incision of Internal Opening of Anal Fistula (TFSIA) in the Treatment of High Trans-Sphincteric Anal Fistula.

BackgroundThe aim of this study was to investigate the clinical effect of tunnel-like fistulectomy plus draining seton combined with incision of internal opening of anal fistula (TFSIA) in the treatment of high transsphincteric anal fistula.Material/MethodsThere were 80 patients with high transsphincteric anal fistula randomly divided into TFSIA group and control group, 40 cases in each group. The control group was treated with cutting seton, and the seton was tightened weekly after discharge from the hospital until the seton dropped off. In the TFSIA group, the anal fistula was dissected and resected in tunnel-like form through the external opening to the intersphinceteric space, drained with seton through the tunnel, and cut open the internal opening of the anal fistula and the intersphincteric space and expanded the drainage. The operative time, blood loss, postoperative uroschesis, anal wound pain score, healing time, Wexner anal incontinence score, keyhole-like deformity, and recurrence rate were compared between the 2 groups.ResultsThe differences of the blood loss, operative time, anal wound pain score at 6 hours after operation, postoperative uroschesis and the recurrence rate after operation were not statistically significant (P>0.05), but the TFSIA were better than the control group in the anal wound pain score at 1 week after operation, healing time, Wexner anal incontinence score, and anal keyhole-like deformity rate (P<0.05).ConclusionsTFSIA is effective in treating high transsphincteric anal fistula, and it can reduce adverse complications after operation.

Predictive factors for recurrence of high transsphincteric anal fistula after placement of seton

BackgroundThe optimal surgical treatment for high transsphincteric fistula-in-ano (FIA) should attain complete eradication of the fistulous track and, in the same time, not compromising the anal sphincters. The present study aimed to investigate the predictive factors for recurrence of high transsphincteric FIA after placement of draining seton and to evaluate the efficacy and complications of seton treatment for high cryptoglandular anal fistula. Materials and methodsThis is a retrospective case–control study of patients with high transsphincteric FIA who were treated with seton placement. Variables analyzed were the characteristics of FIA, incidence of recurrence, postoperative complications including fecal incontinence (FI), and the predictive factors for recurrence. ResultsA total of 251 patients (232 males) with high transsphincteric FIA were treated with loose seton placement. Patients were followed for a median period of 16 mo. Recurrence of FIA was recorded in 26 of patients (10.3%) after a mean duration of 12.2 ± 3.9 mo of seton removal. Previously recurrent fistula (odds ratio [OR] = 2.81, P = 0.02), supralevator extension (OR = 3.19, P = 0.01) and anterior fistula (OR = 3.36, P = 0.004), and horseshoe fistula (OR = 5.66, P = 0.009) were the most significant predictors of recurrence. FI was detected in eight patients (3.2%). Female gender (OR = 15.2, P = 0.0003) and horseshoe fistula (OR = 8.66, P = 0.01) were the significant risk factors for FI after the procedure. ConclusionsSignificant risk factors for recurrence of FIA were previous fistula surgery, anterior anal fistula, and presence of secondary tracks or branches as supralevator extension, and horseshoe fistula.

Early experience with the modificated approach of ligation of the intersphincteric fistula tract for high transsphincteric fistula.

Transsphincteric fistulotomy is associated with a variable degree of fecal incontinence. Ligation of the intersphincteric fistula tract (LIFT), a novel surgical procedure with the advantage of avoiding anal incontinence, has a variable success rate of 57-94%. We evaluated a modified approach from it. Our aim was to review the preliminary results using this technique for high transsphincteric fistula. A retrospective analysis of a consecutive series of high transsphincteric fistula patients who underwent the modified LIFT (mLIFT) procedure was performed. The surgical technique involved making a lateral incision from external opening to intersphincteric groove; ligation of the fistula tract within the intersphincteric space; and complete excision of the distal part of fistula from external opening to external sphincter. The patients were followed for healing time, recurrence, fecal continence disturbance, and any other associated morbidity. Over a 2-year period, 43 patients with high transsphincteric anal fistula were treated by mLIFT technique. Four patients were lost at follow-up. In a mean follow-up of 15 months, 34/39 (87.2%) of the patients achieved primary or secondary healing. Five patients had persistent symptoms and required further surgical treatment. The second procedures were successful, and finally resulting in an overall healing rate of 100%. The Wexner incontinence scale was 0 (0-20) both before and at 6 months after the procedure. The mLIFT procedure for high transsphincteric fistula appeared to effectively preserve continence and achieved a comparable success rate to other sphincter-preserving techniques.

Fistulectomy with primary sphincter reconstruction in the treatment of high transsphincteric anal fistulas

The treatment of transsphincteric anal fistulas is a challenge between recurrence rate and incontinence. Many surgical and conservative procedures have been described in the treatment of anal fistulas. Fistulectomy and primary sphincter reconstruction (FPSR) has not gained great popularity in this field due to the risk of sphincter damage. The aim of this study is to evaluate FPSR in the treatment of transsphincteric fistulas. We retrospectively analyzed 50 patients with high transsphincteric fistulas of cryptoglandular origin that were treated with FPSR between 2005 and 2008. Preoperative assessment included physical and proctologic examination. Continence and pain scores were evaluated preoperatively and postoperatively. In our 50 patients, 22 patients (44%) had a previous proctologic operation and 11 patients (22%) presented with recurrent fistulas. The fistulas existed for an average of 8months. The operation time was 28 ± 16min. Mean follow-up was 22± months. The fistula healed in 44 patients (88%) who developed no recurrence. In five patients (10%), the fistula healed, but they developed a recurrence in the observation period. In one patient (2%), the fistula did not heal. Three patients developed low-grade incontinence for flatus, and one patient with 2° incontinence improved. Preoperatively and postoperatively calculated continence and pain scores showed a slight but significant elevation in the Clinical Continence Score, the German Society of Coloproctology Score showed no significant difference, and preexisting pain was reduced significantly by surgery. FPSR is a safe surgical procedure for the treatment of high transsphincteric anal fistula. The primary healing rate is high with a low risk of recurrence or incontinence.

Long-term Outcomes of Human Acellular Dermal Matrix Plug in Closure of Complex Anal Fistulas With a Single Tract

Bioprosthetic plugs represent a promising technique for the treatment of anal fistula simple because they allow simple and repeatable application, preservation of sphincter integrity, minimal patient discomfort, and subsequent surgical options if needed. However, success rates vary widely. The aim of this study was to assess long-term outcome in patients treated with an acellular dermal matrix plug for closure of complex single-tract anal fistulas. This was a retrospective analysis of a prospective database. The study was conducted at a university hospital in Beijing, People's Republic of China. The study population comprised 114 patients treated between January 2007 and May 2010 for complex high transsphincteric anal fistula with a single tract. Fistulas were treated with an acellular dermal matrix plug derived from donated human skin. The main outcome measures were fistula closure rate and postoperative incontinence (Wexner scores). No mortality or major complications were observed. The overall success rate was 54.4% (62/114), with a median follow-up of 19.5 (range, 11-46) months. Of the 52 patients with plug failure, 11 (21%) had plug extrusion and 9 (17%) had sepsis. Most plug failures occurred within 30 days, with only 1 plug failure occurring 6 months after surgery. On multiple logistic regression analysis, smoking (P < .001), long distance between external opening (P < .001), and performance of the operation by a nonexpert surgeon (P = .018) were significantly associated with plug failure. Of 40 patients who underwent cutting seton placement after plug failure, 33 (82.5%) reported a successful outcome. However, the rate of incontinence 6 months after seton placement was 75% (30/40), whereas the rate in the overall study population 6 months after insertion of the ADM plug was 1.75% (2/114; P < .001). This study was limited by its retrospective nature. Given the low morbidity and relative simplicity of the procedure, we suggest that an acellular dermal matrix plug is a reasonable option for closure of complex anal fistulas with a single tract.

Non-cutting setons for progressive migration of complex fistula tracts: a new spin on an old technique

We introduced a modification of the loose seton for high transsphincteric fistula which involved daily self-rotation of the seton by 360°, which we call the progressive migration technique. The outcomes were evaluated. A retrospective review was undertaken of all operations for anal fistula performed by a single colorectal surgeon from Jan. 2002-Dec. 2007. Twenty-four patients with high transsphincteric fistulas were treated with loose, 0-silk setons. Patients were asked to rotate the seton daily, one revolution in each direction, pulling the knot through the fistula tract. Follow-up was done by phone with questionnaires to address incontinence pain scores, satisfaction, and recurrence. The patients' mean age was 48 years (range, 22-77 years), with M/F ratio of 3:1. The mean duration for seton in place was 14 months (range, 2-40 months). Follow-up ranged from 12-81 months (mean, 45 months). The progressive migration technique resulted in the gradual healing of the fistula tract in 75% of patients (n = 18), with no recurrence (setons completely worked their way to the surface [n = 9], or tract migration was extensive to allow a safe completion fistulotomy [n = 9]). All were fistula free. Twenty-five percent (n = 6) had Crohn's disease. Reported incontinence rates were 0% for solid and liquid stool and 8% (n = 2) for flatus. Twenty-five percent (n = 6) tolerated the setons poorly, and an alternative procedure was performed. Simple daily self-rotation of a heavy silk seton, resulting in progressive migration of the fistula tract, is an alternative technique for treating complex, high transsphincteric anal fistulas.

Long-Term Results Change Conclusions on BioGlue in the Treatment of High Transsphincteric Anal Fistulas

de la Portilla, Fernando M.D., Ph.D., M.A.E.C.P; Rada, Ricardo M.D., M.A.E.C.P; Vega, Juan M.D., M.A.E.C.P; Cisneros, Nieves Ph.D., M.A.E.C.P; Maldonado, Victor Hugo M.D., M.A.E.C.P; Sánchez-Gil, José M. M.D., Ph.D., M.A.E.C.P Author Information

Outcomes of anal fistula surgery in patients with inflammatory bowel disease

Background Anal fistulas in patients with Crohn's disease are especially difficult to manage because of nonhealing and incontinence. We reviewed our outcomes for the newer sphincter-preserving techniques of anal fistula plug and fibrin glue compared with standard treatments of advancement flap closure and seton drain insertion. Methods This was a retrospective study of patients with inflammatory bowel disease treated for high transsphincteric anal fistulas. The primary outcome was healing and continence at 12 weeks postoperatively. Results Between 1997 and 2009, 51 patients with anal fistulas and inflammatory bowel disease were identified in the St Paul's Hospital Anal Fistula Database. Postoperative healing rates at 12 weeks for the fistula plug, fibrin glue, flap advancement, and seton drain groups were 75%, 0%, 20%, and 28%, respectively. Continence scores were not altered by these procedures. Conclusions Closure of the primary fistula opening in patients with inflammatory bowel disease using a biologic anal fistula plug had improved healing compared with fibrin glue, seton drain, and flap advancement. Given its low morbidity and relative simplicity, the anal fistula plug should be considered for treating high transsphincteric anal fistulas in patients with inflammatory bowel disease.

Anal fistula plug and fibrin glue versus conventional treatment in repair of complex anal fistulas

Introduction High transsphincteric fistulas are difficult to treat because fistulotomy of involved sphincter muscle results in incontinence. We compare our outcomes for anal fistula plug, fibrin glue, advancement flap closure, and seton drain insertion. Methods This is a retrospective study of patients treated for high transsphincteric anal fistulas. The primary outcome was full healing at 12 weeks postoperatively. Results Between 1997 and 2008, 232 patients with anal fistula were identified in the St. Paul's Hospital Anal Fistula Database. Postoperative healing rates at the 12-week follow-up for the fistula plug, fibrin glue, flap advancement, and seton drain groups were 59.3%, 39.1%, 60.4%, and 32.6%, respectively ( P < .0001). Conclusions Closure of the primary fistula opening using a biological anal fistula plug and anal flap advancement result in similar fistula healing rates in patients with high transsphincteric fistulae. These 2 strategies are superior to seton placement and fibrin glue. Given the low morbidity and relative simplicity of the procedure, the anal fistula plug is a viable alternative treatment for patients with high transsphincteric anal fistulas.

The Use of the Loose Seton Technique as a Definitive Treatment for Recurrent and Persistent High Trans-Sphincteric Anal Fistulas: A Long-Term Outcome

BackgroundThe loose seton technique (suggested to avoid any external anal division following seton placement, to ensure anal continence) was assessed as the ultimate approach for primary as well as recurrent and persistent anal fistula. Study DesignBetween 2000 and 2006, 97 patients were operated for trans-sphincteric anal fistula, 41 patients of whom (42.3%) underwent the loose seton technique. The outcome was assessed periodically at the outpatient colorectal clinic and finally by detailed telephonic questionnaire. Mean age was 45.3 years. Thirty one operations were elective (75.6%). Fifteen (36.5%) patients had concomitant diseases, of whom three suffered from Crohn’s disease. Twenty nine patients had previous anal operations. ResultsThe time from seton placement to its removal ranged from 3 to 7 months. At short-term follow-up, early complications were noted in five patients (bleeding in one and abscess formation in four). Late complications included liquid stool soiling in one patient (2.4%), solid soiling in two, and mucous discharge in three. Post-operative clinical assessment of incontinence according to Cleveland Clinic Incontinence Score revealed scoring ranging from 2 to 6 in those six patients. Neither gross stool nor flatus incontinence was noted. Fistula recurrence (persistence) was noted in eight (19.5%) patients and successfully treated by the same loose seton technique. ConclusionsThe loose seton technique for trans-sphincteric anal fistula carries favorable results and can be safely applied while preserving the external sphincter function. We also recommend repeating the technique in case of post-operative fistula recurrence or persistence.