Management Of Complex Anal Fistulas Research Articles

Recent advances in the diagnosis and treatment of complex anal fistula.

Anal fistula can be a challenging condition to manage, with complex fistulas presenting even greater difficulties. The primary concerns in treating this condition are a risk of damage to the anal sphincters, which can compromise fecal continence, and refractoriness to treatment, as evidenced by a high recurrence rate. Furthermore, the treatment of complex anal fistula involves several additional challenges. Satisfactory solutions to many of these obstacles remain elusive, and no consensus has been established regarding the available treatment options. In summary, complex anal fistula has no established gold-standard treatment, and the quest for effective therapies continues. This review discusses and highlights groundbreaking advances in the management of complex anal fistula over the past decade.

An integrative approach with TROPIS, Tube in Tract and IFTAK therapy in the management of Complex Anal Fistula: An experience

The management of complex anal fistulae is a challenging job because of the possible risk of damage to the anal sphincter leading to fecal continence, high reoccurrence rate, and delayed wound healing. Other challenges include proper drainage of the tract without disturbing anatomical alignment and painless defecation. This case presented to the outpatient department with a history of recurrent boil in the perianal region and painful pus discharge from the site for 15 days. The case was diagnosed as a case of complex fistula-in-ano and was managed by an integrative approach operative procedure under spinal saddle block anesthesia. Principles of application of Interception of Fistulous Tract and Application of Ksharasutra (IFTAK), transanal opening of intersphincteric space, and tube in tract technique were applied in the management. With necessary analgesia and antibiotics for five days, the patient was given Triphala guggulu internally, and sitz bath with Haritaki (Terminalia chebula Retz.) and Neem (Azadirachta indica A. Juss.) decoction, postoperatively. Wound dressing was done by application of a gauze piece soaked in Apamarga kshara taila. The management resulted in a painless recovery and the patient started attending his daily routine activities from the 7th post-operative day onwards. Pus discharge ceased soon after the operative procedure. Complete healing of postoperative wounds was achieved in ten weeks with prescribed postoperative care and regimen. For the last year, the patient is free from anal discomfort and no reoccurrence has been reported till now.

The Efficacy of Porcine Dermal Collagen to Treat Complex Anal Fistulae. Results of a Multicenter Cohort

Abstract Introduction The management of complex anal fistulae remains a topical surgical problem. The choice and success of surgical management are based on the balance between healing and continence. Although porcine dermal collagen (Permacol Collagen Paste [PCP]- Covidien plc, Gosport, Hampshire, UK) represents a new generation of non-solid biomaterials, its results in anal fistulae are mixed. Methods A multicenter observational retrospective analysis of consecutive patients with cryptoglandular anal fistula treated in four colorectal surgery units was performed between 2015 and 2020. Clinical cure of the fistula was the main outcome measure. Adverse events and alterations in anal continence were secondary outcomes. Results The study included 119 patients (87 males, 71.1%), with a mean age of 53 years (IR 44–65). Most patients had complex (80.6%) and recurrent (91.6%) fistulae. With the first PCP treatment, the overall cure rate was 41.2% (49 patients) and 45.4% with the second treatment (5 out of 17 patients). The mean follow-up period was 17 months (IR 5–25). Healing was not affected by the location and type of fistula, the existence or not of a cavity, the number of tracts, or the administration of prophylactic antibiotics. After the PCP treatment, no patient in the series had worsening of continence. Morbidity affected 22.7% of the patients (27), with postoperative abscesses being the most frequent adverse event. There were no statistical differences between the four hospitals studied. Conclusions Permacol collagen paste is a safe and easily reproducible therapy for complicated anal fistulae that has moderate efficacy. The overall success rate is slightly over 40%, with no detriment to fecal continence.

Trends in Treatment for Hemorrhoids, Fistula, and Anal Fissure: Go Along the Current Trends.

Recent trends in benign anal disease treatment are minimizing surgery to preserve normal anorectal anatomical unit and its functions. However, some surgeons still prefer and are confident with the use of conventional solid surgical methods. In this report, we will investigate the recent trends in the treatment for hemorrhoids, fistula, and anal fissure. The practice guidelines of advanced countries, including UK, Italy, France, USA, Japan, and ESCP, are referred to in this review. Opinions suggested in international meetings were also added. In the management of hemorrhoids, surgical treatments and office procedures were recommended according to a patient's status and preference. For the management of complex anal fistula, novel sphincter-preserving surgical techniques are more widely accepted than a sphincter-dividing procedure of immediate repair following fistulectomy. The treatment of anal fissures is well covered in the guidelines of the ASCRS.

Comparison between recent sphincter-sparing procedures for complex anal fistulas-ligation of intersphincteric tract vs transanal opening of intersphincteric space.

Complex anal fistulas are difficult to treat. The main reasons for this are a higher recurrence rate and the risk of disrupting the continence mechanism because of sphincter involvement. Due to this, several sphincter-sparing procedures have been developed in the last two decades. Though moderately successful in simple fistulas (50%-75% healing rate), the healing rates in complex fistulas for most of these procedures has been dismal. Only two procedures, ligation of intersphincteric fistula tract and transanal opening of intersphincteric space have been shown to have good success rates in complex fistulas (60%-95%). Both of these procedures preserve continence while achieving high success rates. In this opinion review, I shall outline the history, compare the pros and cons, indications and contraindications and future application of both these procedures for the management of complex anal fistulas.

Sphincter-Preserving Fistulectomy Is an Effective Minimally Invasive Technique for Complex Anal Fistulas.

BackgroundThe optimal treatment of complex anal fistulas remains unclear, though many different sphincter-preserving procedures have been described. A minimally invasive technique with a better outcome is desired. The purpose of this study was to present a new technique—sphincter-preserving fistulectomy (SPF) and its clinical outcomes.Materials and MethodsA retrospective study was performed to compare the efficacy and outcomes of SPF with ligation of the intersphincteric fistula tract (LIFT) in the management of complex anal fistulas in regards to postoperative pain, complications, wound healing time, recurrence, overall success rate, fecal continence function, and quality of life. Continence function was evaluated using the Wexner incontinence scale and anal manometry. The fecal incontinence quality of life (FIQL) scale was used to assess patients' quality of life.ResultsFrom June 2020 to July 2021, 41 patients with 43 SPF procedures and 35 patients with 35 LIFT procedures were included. Postoperative pain was comparable between two groups. The morbidity rate and the mean wound healing time in the SPF group were lower than those in the LIFT group (2.3% vs. 48.6%, p < 0.001; 1.4 ± 0.3 vs. 1.7 ± 0.4 months, p = 0.001). At a mean follow-up duration of 11.4 ± 3.5 months in the SPF group and 10.7 ± 4.3 months in the LIFT group, SPF achieved a better overall success rate than LIFT (97.7% vs. 77.1%, p = 0.014). Three patients in the SPF group and 4 patients in the LIFT group who all underwent a simultaneous fistulotomy procedure complained new incontinence of flatus. There was no statistical difference between the two groups in regards to the Wexner scores (p = 0.790), the maximum resting anal canal pressure (p = 0.641), the maximum squeeze pressure (p = 0.289), and the FIQL scores including lifestyle (p = 0.188), coping (p = 0.188), depression (p = 0.850), and embarrassment (p = 0.910).ConclusionsSPF is a novel, safe, and effective minimally invasive technique for the management of complex anal fistulas, with a promising success rate and negligible impairment on continence. Future prospective studies are needed to evaluate the long-term outcomes of SPF.

Video-assisted anal fistula treatment versus fistulectomy and sphincter repair in the treatment of high cryptoglandular anal fistula: a randomized clinical study.

BackgroundVideo-assisted anal fistula treatment (VAAFT) may have a recurrence rate comparable to that of fistulectomy and sphincter repair (FSR) in the treatment of high anal fistula and with potential advantages in wound healing, functional outcome and quality of life. The aim and objectives of the study are to compare the outcome of VAAFT with that of FSR for high cryptoglandular anal fistula.MethodsThis was a single-centre randomized controlled trial of adults with high anal fistula comparing FSR with VAAFT. Primary outcome was fistula recurrence. Secondary outcomes were results of anal manometry, quality of life and faecal continence. A power calculation of 33 patients in each arm (1 : 1) was based on recurrence in the FSR and VAAFT groups of 5 per cent and 30 per cent respectively. Follow-up at 6 months after surgery included physical examination, MRI, anal manometry, quality-of-life assessment (RAND SF 36 questionnaire) and faecal-continence assessment (Wexner score).ResultsThe study was terminated early due to high recurrence rates in both groups. A total of 45 patients were included. Recurrence rates were 65 per cent for VAAFT and 27 per cent for FSR, with hazard ratio 4.18 (P = 0.016). Length of the fistula was a risk factor with an association with recurrence (hazard ratio 1.8, P = 0.020). There were significant differences in quality of life in favour of FSR and in anal manometry in favour of VAAFT with a significant improvement in Wexner score in both groups.ConclusionFSR was associated with a lower recurrence rate than VAAFT in the management of complex anal fistulae in this single-centre study but the study was terminated early due to higher than predicted recurrence rate in both groups.Registration numberNCT02585167 (http://www.clinicaltrials.org).

Management of Complex Cryptoglandular Anal Fistula: Challenges and Solutions.

Anal fistulae can be a very difficult disease to manage. The management of complex fistulae is even more challenging. The risk to the fecal continence mechanism due to damage to the anal sphincters and refractoriness to the treatment (high recurrence rate) pose the two biggest challenges in the management of this disease. Apart from these, there are several other challenges in the treatment of complex fistulae. The intriguing and uphill task is that satisfactory solutions to most of these challenges are still not known, and there is hardly any consensus on whatever treatment solutions are available. To summarize, there is no gold-standard treatment available for treating complex anal fistulae, and the search for a satisfactory treatment option is still on. In this review, the endeavor has been to discuss and highlight recent path-breaking updates in the management of complex anal fistulae.

How to deal with complex anal fistula in an immunosuppressed patient.

We describe a practical approach to the management of complex anal fistula in an immunocompromised patient. We define our treatment motifs: to close the internal opening, maintain external drainage until internal opening and tract healed; minimize sphincter damage. We hope other authors can build on this case technique to improve fistula surgery outcomes.

A new understanding of the principles in the management of complex anal fistula

The management of complex anal fistula is confusing and far from satisfactory. Due to this reason, most colorectal surgeons are not comfortable dealing with this disease and tend to avoid it. Despite the innovation of several new procedures in the last few years, the cure rate of complex anal fistula has not improved much. This points out that there is some flaw with our current understanding of the disease pathogenesis as well as its management.All the surgical procedures described to treat anal fistulas in complex anal fistulas were analyzed. The reasons were sought as why most of the procedures don’t work well in complex fistulas. Based on that, the pathophysiology of complex anal fistula was understood from a totally new perspective.The new hypothesis has been categorized in three cardinal principles-Intersphincteric tract is like an abscess in a closed space (ISTAC), draining all pus and ensuring continuous drainage (DRAPED) and healing occurs progressively till it is interrupted irreversibly by a collection (HOPTIC). The surgical procedures which take care of all these three principles have a high success rate in complex fistulas. The success rate falls in the procedures which ignore one or more of these principles.These principles are logical and are basics of wound healing process anywhere in the body but were somehow ignored in the management of complex anal fistulas. These principles fill the void in the understanding of complex anal fistula and when integrated in the management, the cure rate improves drastically.

Complex anal fistulae management by combined technique approach: an experience

Background: The aim of this study is to evaluate our experience in the management of complex anal fistulae by combined technique approach. Ideal surgical treatment for complex anal fistula should aim to eradicate the source of infection and promote healing of the tract, while preserving the sphincters and the mechanism of anal continence. Even with the evolving newer techniques complex anal fistulae have higher rates of recurrence and functional disability as anal incontinence. The requirement of multiple surgeries for recurrence and the newer techniques like anal fistula plug are expensive and will become a burden for patients living in developing countries like ours. Thus, apart from Ligation of Intersphincteric fistula tract, the use of cutting seton is the main surgical method practiced here. This article focuses on the approach to the complex anal fistula management through evidence-based treatment strategies.Methods: Author conducted a prospective study of 35 complex anal fistulae patients undergoing combined technique approach with cutting Seton, Ligation of Intersphincteric Fistula tract and fistulotomy. Results: All patients recovered well with no complications in postoperative period. After 2 years of follow up patients are recurrence free and only 2 patients had partial incontinence with improving trend.Conclusions: The use of cutting Seton in high anal fistula is an effective technique. LIFT technique is good for Transphincteric tracts without previous scarring; it can be easily learned and applied. We can conclude that combined technique was an effective procedure and valid alternative for complex anal fistula management.

Management of anal fistula

Anal fistula is a chronic condition that may present de novo or after an acute anorectal abscess. Manage­ment goal is to eradicate the fistula and prevent recurrence while maintaining continence. Simple or low anal fistulas are best treated with a primary fistulotomy with excellent healing rates and func­tional outcomes. The management of complex anal fistulas is more difficult and controversial. No proved surgical procedure has gained acceptable as the gold standard yet. Over the last two decades, many sphinc­ter-preserving procedures were introduced with the common goal of minimizing the injury to the anal sphincter and preserving the optimal function. Recently, a number of new techniques were developed and proposed such as ligation of intersphincteric fistula tract (LIFT); endorectal advancement flap (EAF); vid­eo-assisted anal fistula treatment (VAAFT); fistula tract laser closure (FiLAC); fibrin sealants and anal fis­tula plug (AFP), and adipose-derived stem cells (ASC). There are multiple techniques available for complex anal fistula repair. The best technique is not known yet, and the evidence available suffers from a lack of high-quality data and presents with very few large randomized studies. This review summarizes the man­agement of anal fistulas and the current techniques available. It describes some new technologies, too. Scr Sci Med 2017;49(3):15-18

Long-term results of ligation of intersphincteric fistula tract (LIFT) for management of anal fistula

BackgroundLigation of intersphincteric fistula tract technique is a new sphincter saving method with good results in management of anal fistula, but few studies report long-term follow-up data. Material and methodsThis study investigated the use of ligation of intersphincteric fistula tract as a sphincter saving method based on long term results. This was a retrospective review of prospectively collected data. The study was conducted at two tertiary care university medical centers. 36 patients with complex fistula from January 2010 to January 2014 treated with classic ligation of intersphincteric fistula tract were retrospectively followed. Demographic data, previous repair attempts, the type of the fistula and score of fecal continence were collected. The procedure was performed by colorectal surgeons. Primary healing rate, failures and fecal incontinence score of patients were followed for 6–48 months. ResultsA total of 36 patients underwent ligation of intersphincteric fistula tract during 24 months. The mean age of the patients was 35 years and 50% had two previous attempts at surgery. A total of 25 patients (69/5%) had high transsphincteric fistula. The mean follow up was 27 months. Successful fistula closure was achieved in 63/8% of the patients (23 of 36). The mean time of recurrence was 4.5 weeks. Only one (2/77%) patient reported gas incontinence (score: 3) after the procedure. ConclusionThe recurrence rate and fecal incontinence were measured. The ligation of intersphincteric fistula is a promising sphincter-preserving procedure that is simple and safe. Our study demonstrates favorable long-term results of ligation of intersphincteric fistula tract for management of complex anal fistulas.

Therapeutic management of complex anal fistulas by installing a nitinol closure clip: study protocol of a multicentric randomised controlled trial—FISCLOSE

IntroductionComplex anal fistulas are responsible for pain, faecal incontinence and impaired quality of life. The rectal mucosa advancement flap (RMAF) procedure to cover the internal opening of the fistula remains...

Fistulotomy or fistulectomy and primary sphincteroplasty for anal fistula (FIPS): a systematic review.

There is still no clear consensus about surgical treatment of anal fistulas. Fistulotomy or fistulectomy and primary sphincter reconstruction is still regarded with skepticism. The aim of this systematic review was to evaluate the evidence in the literature supporting the use of this technique in the treatment of complex anal fistulas. MEDLINE, EMBASE and Cochrane Library databases were searched for the period between 1985 and 2015. The studies selected were peer-reviewed articles, with no limitations concerning the study cohort size, length of the follow-up or language. Technical notes, commentaries, letters and meeting abstracts were excluded. The major endpoints were the technique adopted, clinical efficacy, changes at anorectal manometry and assessment of quality of life after the procedure. Fourteen reports (666 patients) satisfied the inclusion criteria. The quality of the studies was low. Some differences about the surgical technique emerged; however, after a weighted average duration of follow-up of 28.9months, the overall success rate was 93.2%, with a low morbidity rate. The overall postoperative worsening continence rate was 12.4% (mainly post-defecation soiling). In almost all cases, the anorectal manometry parameters remained unchanged. The quality of life, when evaluated, improved significantly. Fistulotomy or fistulectomy and primary sphincteroplasty could be a therapeutic option for complex anal fistula. Success rates were very high and the risk of postoperative fecal incontinence was lower than after simple fistulotomy. Well-designed trials are needed to support the inclusion of this technique in a treatment algorithm for the management of complex anal fistulas.

Clinical application of MRI in the management of complex anal fistulas

To explore the accuracy and clinical value of preoperative MRI for complex anal fistulas. The MRI status of internal/external opening, fistula track and perianal abscess was analyzed for 24 complex anal fistulas patients. Their outcomes were compared with the final surgical diagnoses. The accuracy rates of internal opening, external opening, fistula tracks and perianal abscess were 87%, 97%, 92% and 16/17 respectively. MRI is helpful for evaluating accurately the extent and complexity of anal fistulas and guiding surgical therapy. Key words: Rectal fistula; Magnetic resonance imaging

Total Fistulectomy With Simple Closure of the Internal Opening in the Management of Complex Cryptoglandular Fistulas

Total fistulectomy with simple closure of the internal opening has been used for the management of complex anal fistulas. This approach involves complete removal of the fistula tract and closure of the internal opening with sutures. This study aimed to report long-term outcomes in patients with complex cryptoglandular fistulas who undergo this procedure. This is a retrospective review of a prospectively collected consecutive series. This study was conducted at a community-based hospital with a specialized colorectal unit. : Patients included in this study had cryptoglandular fistulas and underwent total fistulectomy with simple closure of the internal opening between 1997 and 2007. The main outcome measures were success rate and postoperative continence (Cleveland Clinic Florida Fecal Incontinence Scale). Treatment was considered successful if the external opening was closed and no drainage was present at the last follow-up. Success was achieved in 187 (74%) patients with a median follow-up time of 70 (range, 14-141) months. Patients with posterior transsphincteric or suprasphincteric fistulas had a higher success rate than those with other types of fistulas (82% vs 67%;p = 0.014), and patients for whom the procedure failed were significantly younger than those for whom the procedure was a success (mean, 45 vs 50 years; p = 0.010). Of 160 patients with success who had no previous surgery, 89 (56%) had normal continence postoperatively (CCF-FI score = 0). The limitations of this study include its retrospective nature, the potential for selection bias, and the lack of preoperative continence scores. Total fistulectomy with simple closure of the internal opening is effective for the long-term closure of complex cryptoglandular fistulas.However, this procedure may affect continence despite its sphincter-sparing quality. Nonetheless, the high success rate in patients with posterior transsphincteric or suprasphincteric fistulas renders this procedure a reasonable option in this subgroup of patients with complex fistulas.

Clinical role of a modified seton technique for the treatment of trans-sphincteric and supra-sphincteric anal fistulas

We have devised a modified seton technique that resects the external fistula tract while preserving the anal sphincter muscle. This study assessed the technique when used for the management of complex anal fistulas. Between January 2006 and December 2007, 239 patients (208 males and 31 females, median age: 41years) underwent surgery for complex anal fistulas using the technique. Of the 239 patients, 198 patients had trans-sphincteric fistula and 41 patients had supra-sphincteric fistula. The durations of the surgeries were 17min (47, 13) [median (range, interquartile range)] for trans-sphincteric fistulas and 38 (44, 16) for supra-sphincteric fistulas. The durations of the surgeries were significantly (P<0.05) longer for supra-sphincteric fistula than trans-sphincteric fistula. The hospital stays were 4 (13, 2) days and 5 (14, 3) days, respectively, for trans- and supra-sphincteric fistulas. The durations of seton placement until the spontaneous dropping of the seton were 42 (121, 48) and 141 (171, 55) days respectively. The recurrence rate was 0% in patients with trans-sphincteric fistulas and 4.9% (2 of 41) in patients with supra-sphincteric fistulas (P<0.01). Serious incontinence was not observed. The technique provided favorable results for the treatment of complex anal fistulas and could be safely applied while preserving the sphincter function and conserving fecal continence.

Outcomes With the Use of Bioprosthetic Grafts to Reinforce the Ligation of the Intersphincteric Fistula Tract (BioLIFT Procedure) for the Management of Complex Anal Fistulas

This study was undertaken to determine the outcomes of patients whose complex anal fistulas were managed by ligation of the intersphincteric fistula tract reinforced with a bioprosthetic graft (BioLIFT procedure). A retrospective analysis was performed of all patients whose anal fistula was managed by use of the BioLIFT technique between May 2005 and May 2008, who had a minimum of 1 year of follow-up after their last treatment. The BioLIFT technique using a bioprosthetic graft was used to treat a complex anal fistula in 31 patients (22 men, 9 women; mean age, 48 y (range, 30-68 y). Clinical healing of the fistula, defined as the absence of drainage with no evidence of residual fistula tract, occurred in 29 (94%) patients. No complications occurred that required intervention. The BioLIFT procedure is effective for the management of complex fistulas-in-ano. Randomized clinical trials comparing this technique with other sphincter-preserving methods for fistula management need to be performed to further determine the role of this technique in the management of anal fistulas.

A Tale of Two (Anal Fistula) Plugs: Is there a Difference in Short-Term Outcomes?

Treatment of complex anal fistulas presents an ongoing challenge to colorectal surgeons. The anal fistula plug is an attractive definitive option due to its minimal risk of incontinence, simple design, and easy application. Our objective was to compare the Cook Surgisis AFP plug and the newer Gore Bio-A plug in the management of complex anal fistulas. A retrospective chart review of patients treated with Cook and Gore fistula plugs between August 2007 and December 2009 was performed. Success was defined as closure of all external openings and absence of drainage and abscess formation. Twelve Cook patients underwent 16 plug insertions and 10 Gore patients underwent 11 plug insertions. The overall procedural success rate in the Gore group was 54.5 per cent (6 of 11) versus 12.5 per cent (2 of 16) in the Cook group. The reasons for failure were unknown in the majority of patients and plug dislodgement in two patients. Our short-term results with the Gore fistula plug suggest a higher procedural success rate in comparison to the Cook plug. Patients should be cautioned regarding potentially high failure rates; however, longer follow-up and a larger patient population are needed to confirm significant differences in fistula plug efficacy.