High Transsphincteric Fistulas Research Articles

Protocol of the LATFIA trial (Laser Assisted Treatment of Fistula in Ano): a multicentre, prospective, randomized controlled trial comparing fistula-tract laser closure (FiLaC™) with rectal advancement flap for high trans-sphincteric fistulas.

Anal fistula is one of the most common anal diseases, affecting between 1 and 3 per 10 000 people per year. Symptoms have a potentially severe effect on a patient's quality of life. Surgery is the mainstay of treatment, aiming to cure the fistula and preserve anal sphincter function. Rectal advancement flap (RAF) is currently the gold standard treatment but has recurrence rates varying between 20% and 50% and might lead to disturbance of continence. The aim of the trial described in this work is to discover if the minimally invasive fistula tract laser closure (FiLaC™) technique could achieve higher healing rates and a better functional outcome than RAF. We will perform a randomized prospective multicentre noninferiority study of the treatment of high trans-sphincteric perianal fistulas, comparing FiLaC™ with RAF in terms of fistula healing, recurrence rate, functional outcome and quality of life. Primary and secondary fistula healing will be evaluated at 26 and 52 weeks' follow-up. Quality of life will be evaluated using the SF-36 questionnaire, the Faecal Incontinence Quality of Life Scale questionnaire and the Vaizey score at 3, 6, 12 and 26 weeks postoperatively. High trans-sphincteric fistulas have a potentially severe effect on a patient's quality of life. Classical treatment with RAF is a time-consuming invasive procedure. The LATFIA trial aims to compare FiLaC™ with the gold standard treatment with RAF. In case of noninferiority, FiLaC™ treatment could be standardized as a first line treatment for high trans-sphincteric fistulas. Better conservation of the patient's anal sphincter function could possibly be obtained. Likewise, we will report on the postoperative quality of life when applying these two techniques.

OTSC Proctology clip as appropriate treatment for complicated anorectal fistula.

Evaluation of the effectiveness and tolerability of the application of an OTSC (Ovesco Endoscopy AG Tuebingen, Germany) Proctology clip as an innovative strategy of anorectal fistulae closure when established treatment strategies had already failed or were not feasible. Retrospective single-center study including consecutive patients treated between March 2014 and March 2016 with the OTSC Proctology system for anorectal fistula closure, including one rectovaginal and one rectourethral fistula. The primary outcome was the healing rate with a minimum follow up of 6 months. Healing was defined as closure of the internal fistula ostium and absence of secretion or local inflammation during follow up. A total of 66 fistula closures by the OTSC Proctology clip were investigated, including cryptoglandular fistulas (45/66 patients, 68%), fistulas associated with CED (19/66 patients, 29%), and other non-cryptoglandular fistulas (2/66 patients, 4%). 47% (31/66 patients) had a failed previous therapy. In that selected collective, a successful fistula closure was achieved in 29/66 cases (44%) after a median follow up time of 40 months (6-61 months). Suprasphincteric and high transsphincteric fistulas showed healing in 63% and 42% in CD associated fistulas. Fistula closure by the OTSC Proctology clip is an innovative, sphincter protecting treatment strategy in anorectal fistulas that can achieve long-term cure in complex anorecta.

Compartive Study between Conventional Laying-Open Technique with Sphincter Repair and Ligation of Intersphincteric Fistula Tract (LIFT) in Treatment of High Trans-Sphincteric Perianal Fistula

Abstract 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. A fistulotomy lays open the fistulous tract, thus leaving smaller unepithelized wounds, which hastens the wound healing. Until now, fistulotomy is still the most widely used. But, the high cure rate is limited by the fact that laying open a transsphincteric fistula tract and cutting both the internal and the external sphincter has the risk of fecal incontinence ranging up to 40%. Objective To retrospectively evaluate the success rate, the recurrence and incontinence when using the Conventional laying-open and sphincter Repair technique in comparison to Ligation of Intersphincteric Fistula Tract (LIFT) for treating high trans-shpincteric perianal fistula. Patients and Methods This was a cohort retrospective, comparative study that was conducted on cases of fistula in the anus, who were subjected to surgery in Ain Shams University Hospitals and Ain shams specialized hospitals in the period from October 2021 to March 2022 (at least 30 cases) to evaluate the success rate, the recurrence rate, and incontinence rate when using the conventional laying open with sphincter repair technique compared to ligation of inter-sphincteric fistula tract (LIFT) For High trans-sphincteric perianal fistula. Results Regarding Relation of recurrence with demographic data of the studied patients, de novo/recurrent, Wexner score before and after operation and complications. that there was no statistically significant relation found recurrence with demographic data of the studied patients, de novo/recurrent, Wexner score before and after operation while there was statistically significant relation found with complications. Conclusion LIFT procedure is an effective and preferred sphincter-saving technique for fistula-inano with shorter healing time and lower incidence of postoperative anal incontinence, but have higher incidence of recurrence as compared to conventional layopen with sphincter repair which have a lower incidence of recurrence but have a relatively longer Healing time and higher incidence of postoperative anal incontinence. Both techniques are effective, have post operative good results and safe in treatment of high transsphincteric perianal fistula but Further research work is still warranted to confirm the long term outcome of these 2 techniques with a larger sample size and a longer follow up period. To know which technique is superior over the other.

Statutory provisions, aims, motives, attitudes and thinking on the outpatient operation profile of general and abdominal surgery

The aim of the manuscript is to discuss and assess the implications and opportunities as well as dangers of "outpatientization" of surgical and inpatient services for general and abdominal surgery. Narrative overview with literature reference based on a PubMed search with the search terms: outpatient operations and inpatient interventions, AOP catalog, hybrid DRG, outpatient hernia surgery, outpatient proctological surgery, selective sector-equal reimbursement and day-care forms of care. RESULTS (KEY POINTS): - In the Anglo-American area, the treatment of inguinal hernias is predominantly carried out on an outpatient clinic basis. In the USA, Sweden and Denmark, for example, over 70% of all hernias are treated in an outpatient clinic setting, in Germany it is only 20%. In Germany, the catalog of operations that can be performed on an outpatient basis and other department-replacing interventions in hospitals defines outpatient interventions in accordance with §115b Social Security Code (SGB)V (Germany). - The conversion from inpatient to outpatient hernia surgery has also failed so far due to an enormous difference in revenues. According to the will of the Federal Ministry of Health, the planned forms of semistationary care are intended to relieve the nursing staff in the hospitals and thus relieve the tense situation of nursing professionals. By the end of March 2023, aspecial industry-specific reimbursement, so-called hybrid DRGs, is to be agreed, which applies regardless of whether apaid service is provided on an outpatient or inpatient basis. - According to §115b SGBV, whether ahernia can be performed under inpatient or outpatient conditions is also decided according to the location of the hernia. In the new AOP catalog, frailty is operationalized in the context factors via the degree of care and the Barthel index. If one compares the number of encryption procedures for the 5‑530 procedure (closure of an inguinal hernia) in 2005 (184,679) with the pre-corona year 2019 (179,851), it can be seen that the proportion of hernias treated in hospital remained approximately the same over aperiod of 14years. - Most elective proctological procedures can be performed on an outpatient basis. For reasons of safety (bleeding) and practicality (pain management, dressing change of large abscesses), inpatient surgery is preferred: extensive hemorrhoidectomy in the case of massive findings, large abscesses, extensive perianal fistula corrections, particularly high transsphincteric or suprasphincteric fistulas. - Guidelines based on the British Guidelines for Ambulant Surgery should be required for comprehensive outpatient treatment in surgery. The introduction of corresponding hybrid DRGs seems to be the right way to cover the costs of outpatient surgery in hospitals. The restructuring of the hospital landscape and the nationwide expansion of outpatient operations is an unavoidable requirement in view of rising costs in the healthcare system and impending financing bottlenecks, which will pose challenges for the surgical disciplines in the years to come. Outpatient surgery is already practiced in many areas but has not become established due to the different remuneration. The flat rates for the same branches can be astarting point here. Furthermore, evidence-based framework conditions must be created along the lines of the British Guidelines for Ambulant Surgery.

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.

Cohort study of fistulotomy with external tract fistulectomy and primary sphincter reconstruction in high trans-sphincteric fistula-in-ano.

Treatment of complex fistula-in-ano is challenging and there is no consensus on the optimal treatment that can provide complete healing and preserve sphincter function. The aim of this study was to evaluate fistulotomy with external tract fistulectomy and primary sphincter reconstruction (FFSR) in the treatment of high trans-sphincteric fistula. This is a prospective single-centre study including patients with a high trans-sphincteric fistula who underwent FFSR from June 2017 to June 2018. All patients were evaluated preoperatively by pelvic MRI and clinical examination. Other types of complex fistula were excluded. All patients were followed up for 1year for recurrence and incontinence. Forty patients underwent FFSR during the study period, 62.5% were men and the mean age was 37.45 (range 20-60)years. The mean time to achieve complete healing was 8.4 weeks, 35 (87.5%) patients achieved primary healing within 8 weeks and 5 (12.5%) patients required more time to achieve delayed healing. Four (10%) patients developed recurrence with a mean time for recurrence of 20 weeks. Only four (10%) patients developed incontinence; one to liquid stools and three patients only to gas. Fistulotomy with external tract fistulectomy and primary sphincter reconstruction is a safe option in the treatment of high trans-sphincteric fistula in selected patients. This showed an acceptable recurrence rate when compared with other procedures with comparable sphincter function outcomes.

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

Background: As a revolutionary sphincter-preserving approach, Wilhelm proposed "Fistula Laser Closure" (FiLaC) in 2016. It uses a radial emitting laser probe and had an initial rate of success of 81.8 percent in 11 patients with a median follow-up of 7.4 months. Aim of the study: To analyze the Fistula Laser Closure (FiLaC) technique's efficacy in treating high trans-sphincteric fistulas in ano, look at the procedure's effects on anal continence, and predictors of success. Patients and methods: This prospective cohort research was conducted between April 2021 and November 2021 on 20 patients with high transsphincteric fistula in ano at the Department of Surgery at Al-Azhar University Hospitals, Cairo, Egypt. Patients received care using the Fistula Laser Closure (FiLaC) procedure, and they were monitored for at least six months after surgery. Results: There was substantial variation between simple and complicated fistula as regards hospital stay, Early incontinence, pain score and patient satisfaction (p

Short term Outcomes of Fistula Laser Closure (FILAC) as a Sphincter Sparing Technique Versus Fistulotomy with Immediate Sphincter Reconstruction (FISR) in High Trans-Sphincteric Fistula–in-ano; a Prospective Cohort Study

Short term Outcomes of Fistula Laser Closure (FILAC) as a Sphincter Sparing Technique Versus Fistulotomy with Immediate Sphincter Reconstruction (FISR) in High Trans-Sphincteric Fistula–in-ano; a Prospective Cohort Study

Clinical study and management of fistula in Ano

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

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.

Autologous adipose-derived stromal vascular fraction and platelet concentrates for the treatment of complex perianal fistulas

BackgroundComplex perianal fistulas are a major challenge for modern surgery since 10–35% of patients have functional problems after treatment. Sphincter-saving techniques have a wide range of efficacy (10–80%). We hypothesised that autologous adipose-derived stromal vascular fraction in combination with platelet rich plasma is a new therapeutic strategy with enhanced cure and function preservation rates.MethodsAdult patients with complex cryptoglandular perianal fistulas were treated with injection of autologous adipose-derived stromal vascular fraction in combination with platelet rich plasma around and inside the fistulous tract between May 2018 and April 2019 at the General and Emergency Surgery Operative Unit of the University Hospital “P. Giaccone” of Palermo. Fistulas were confirmed by magnetic resonance imaging. Patients completed the Short Form-36 score on quality of life and the Wexner and Vaizey scores on faecal incontinence, and they were functionally studied using a three-dimensional anorectal manometry. The clinical and functional follow-up was performed at 1 year and 2 years after surgery.ResultsNine patients (4 males, 5 females; median age 42 years [19–63 years]) with high trans-sphincteric or horseshoe fistulas were treated. The average number of previous surgeries per patient was 4.8. At 1 year follow-up, 77.7% of patients were cured, while at 2 years there was 1case of relapse. The variation in Short Form-36 score in cured patients was not significant (p = 0.0936). No statistically significant differences were found in continence scores.ConclusionsThe proposed treatment is a treatment option that preserves sphincter integrity and function, potentially avoiding postoperative incontinence and the need of repeated treatments.

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

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

Outcome of Core out Fistulectomy with Anal Spincter Reconstruction and Primary Repair of Internal Opening in the Treatment of Complex Anal Fistula; A Experience of 30 Cases

Background: The principal of management of anal fistula include closure of interior opening of fistula tract, drainage of contamination or necrotic tissue, and eradication of fistulous tract with maintenance of sphincter function. The selection of surgical operation (simple fistulotomy, fistulectomy, seton placement, development flap, fibrin glue or anal plug) is decided with the aid of the route of the fistula tracts and continence status. Objectives: The aim of the study was to determine the surgical technique “core out fistulectomy with anal sphincter reconstruction and primary closure of internal opening” in the treatment of trans-sphincteric fistula (high type or long tract) or supra-sphincteric fistula in terms of fistula healing, morbidity, recurrence and anal continence. Methods: This prospective observational study was carried out in the Department of Surgery Dr Amanat khan hospital and other private hospitals, Dhaka, Bangladesh, during 5th March 2020 to 10th April 2022. A total 30 patients between the age group 20 to 70 years who were diagnosed with Fistula-in-Ano(Complex Variety) which underwent Core out Fistulectomy with Anal Spincter Reconstruction and Primary Repair of Internal Opening. This analysis was done using SPSS 24 software version. The level of significance was set to 5% (p < 0.05). Results: There were 30 (91%) men and three (9%) women with a median age of 42 years. The common anal fistula type was high transsphincteric fistula in 31 patients with deep postanal abscess in two patients and two patients were suprasphincteric fistula. Conclusions: Core out fistulectomy with anal sphincter reconstruction and major closure of inner opening is a secure and nice method for excessive trans-sphincteric fistula. It has desirable useful results and no disturbance of continence. This has to be viewed in the cure of high trans-sphincteric 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.

Long-term outcomes of an acellular dermal matrix for the treatment of complex cryptoglandular anal fistula: a pilot study.

BackgoundEffective, standardized treatments for complex anal fistula (CAF) still represent a clinical challenge. Emerging procedures attempted to achieve the healing rates of fistulotomy whilst preserving sphincter function. Acellular dermal matrix (ADM) used as a plug inserted through the fistulous tract is among newer treatment options. Varying success rates have been reported, most with short-term follow-up. The aim of this study was to report the long-term results of ADM-plug for CAF.MethodsRetrospective analysis of a prospective database of patients treated with CAF. All consecutive patients presenting at two tertiary centers (Vall d’Hebron University Hospital and Bellvitge University Hospital, Barcelona, Spain) between November 2015 and March 2019 with a single, cryptoglandular CAF were evaluated for treatment with an ADM-plug were included. The primary endpoint was absence of discharge at clinical examination at 12 month follow-up.ResultsTwenty-two patients were included [7 women and 15 men, median age 56 (33–74) years]. Most patients had high transsphincteric fistulas (63.6%). The median follow-up was 42 (21–53) months. The 12 month success rate was 68.2%, with an overall healing rate of 59.1%. 77.8% of recurrences occurred within 12 months from surgery. One plug extrusion was observed. No major complications or mortality occurred during the follow-up. Patients did not report any worsening of fecal continence.ConclusionsThis pilot study showed that more than half of patients with CAF could benefit from ADM-plug placement, preserving continence. A minimum follow-up of 12 months is recommended, because most recurrences occur during the first year.Supplementary InformationThe online version contains supplementary material available at 10.1007/s10151-022-02593-1.

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.

Molecular differences of adipose-derived mesenchymal stem cells between non-responders and responders in treatment of\xa0 transphincteric perianal fistulas

BackgroundInjection of autologous adipose tissue (AT) has recently been demonstrated to be an effective and safe treatment for anal fistulas. AT mesenchymal stem cells (AT-MSCs) mediate the healing process, but the relationship between molecular characteristics of AT-MSCs of the injected AT and fistula healing has not been adequately studied. Thus we aimed to characterize the molecular and functional properties of AT-MSCs isolated from autologous AT injected as a treatment of cryptogenic high transsphincteric perianal fistulas and correlate these findings to the healing process.Methods27 patients (age 45 ± 2 years) diagnosed with perianal fistula were enrolled in the study and treated with autologous AT injected around the anal fistula tract. AT-MSCs were isolated for cellular and molecular analyses. The fistula healing was evaluated by MRI scanning after 6 months of treatment. AT-MSC phenotype was compared between responders and non-responders with respect to fistula healing.Results52% of all patients exhibited clinical healing of the fistulas as evaluated 6 months after last injection. Cultured AT-MSCs in the responder group had a lower short-term proliferation rate and higher osteoblast differentiation potential compared to non-responder AT-MSCs. On the other hand, adipocyte differentiation potential of AT-MSCs was higher in non-responder group. Interestingly, AT-MSCs of responders exhibited lower expression of inflammatory and senescence associated genes such as IL1B, NFKB, CDKN2A, TPB3,TGFB1.ConclusionOur data suggest that cellular quality of the injected AT-MSCs including cell proliferation, differentiation capacity and secretion of proinflammatory molecules may provide a possible mechanism underlying fistula healing. Furthermore, these biomarkers may be useful to predict a positive fistula healing outcome.Trial registration: NTC04834609, Registered 6 April 2021. https://clinicaltrials.gov/ct2/show/NCT04834609

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.

Multiple scale of complexity for anorectal fistulas

Background: Anorectal fistulas are common and difficult to manage. Objective: To create a scale of complexity through the identification, description of medical history, clinical and ultrasonographic findings. To reduce the rate of recurrence and complications in fistulas is the treatment goal. Patient's inherent traits increase the complexity of anorectal fistulas with the risks of incontinence, delayed healing, infections, and requiring difficult surgeries. The aim of this study was to create a scale of complexity through identification, description of medical history, and clinical and ultrasonography (USG) findings. Patients and Methods: Retrospective study of a prospectively maintained database conducted at two Venezuelan hospitals. All patients who underwent anorectal USG examination at our institutions between 2010 and 2017 were investigated and included in the numerical scoring system, which categorizes the risk of fistula into simple, intermediate, and complex. The Chi-square test of the Statistical Program of Social Sciences (SPSS) was used to establish the significance level, P < 0.005. One thousand one hundred and seventy-three patients were evaluated, and perianal fistula was identified in 989 patients. Results: Of the 232 intersphincteric fistulas, 75.86% were simple, 22.41% were intermediate, and 1.72% were complex. Of the 295 lower transsphincteric fistulas, 51.19% were simple, 42.71% intermediate, and 6.10% were complex. Of the 327 high transsphincteric fistulas, 17.74% were simple, 59.94% were intermediate, and 22.32% were complex. Of the 48 extrasphincteric fistulas, 66.67% were intermediate, and 33.33% were complex. Finally, of the 18 suprasphincteric fistulas, 50% were intermediate and 50% were complex. Conclusions: The complexity of the fistula may not be obvious in routine thorough clinical evaluation, requiring complementary studies. Using the scale avoids excluding factors that indicate complexity, with a statistically significant difference with the classification based exclusively on tracts. Limitation: The limitation of this study is that it is a retrospective single medical group study.

Factors associated with healing, reoperation and continence disturbance in patients following surgery for fistula‐in‐ano

Fistula-in-ano (FIA) is associated with high treatment costs and has a deleterious impact on quality of life. A wide range of healing, incontinence and recurrence rates have been reported. This study aimed to identify operative, patient and disease factors that influence these outcomes after surgery for FIA. An observational cohort study of consecutive patients who were managed for FIA at a tertiary colorectal practice (1999-2019) was performed. Outcome measures included healing, impaired continence and the need to reoperate. Clinico-pathological variables, including patient comorbidities, fistula anatomy and operative approach, were assessed for their association with these outcomes. Some 411 procedures were performed on 263 patients [median age 41.8years (range 17.8-79.7years), 184 men (70.0%)]. Some 77.9% of patients achieved complete healing, 9.5% experienced some deterioration in continence postoperatively and 37.6% required reoperation at a median time of 19.0weeks. Poorer healing was associated with Crohn's disease, high trans-sphincteric fistulas, extrasphincteric fistulas and steroid usage. Poorer continence was associated with female sex, age >40years, posterior location, suprasphincteric fistulas, seton insertion and having more than three subsequent procedures. The need to reoperate was associated with female sex, high trans-sphincteric fistulas, suprasphincteric fistulas, inflammatory bowel disease and previous operations for FIA. Minimizing recurrence of FIA and preservation of continence can be competing management goals. More than one in three patients require reoperation, one in five fails to heal completely and one in ten suffers worsened continence following surgery. Awareness of the factors that contribute to these outcomes is important to the process of informed consent and managing patient expectations before surgery.