Perineal Fistula Research Articles

Expert Commentary on Chronic Perineal Sinus After Proctectomy for Crohn's Disease: Risk Reduction Strategies and Management.

Expert Commentary on Chronic Perineal Sinus After Proctectomy for Crohn's Disease: Risk Reduction Strategies and Management.

Objective Perfusion Assessment in Gracilis Muscle Interposition-A Novel Software-Based Approach to Indocyanine Green Derived Near-Infrared Fluorescence in Reconstructive Surgery.

Background: Gracilis muscle interposition (GMI) is an established treatment option for complex perineal fistulas and reconstruction. The outcome is limited by complications such as necrosis, impaired wound healing and fistula persistence or recurrence. Quantifiable methods of assessing muscle flap perfusion intraoperatively are lacking. This study evaluates a novel and objective software-based assessment of indocyanine green near-infrared fluorescence (ICG-NIRF) in GMI. Methods: Intraoperative ICG-NIRF visualization data of five patients with inflammatory bowel disease (IBD) undergoing GMI for perineal fistula and reconstruction were analyzed retrospectively. A new software was utilized to generate perfusion curves for the specific regions of interest (ROIs) of each GMI by depicting the fluorescence intensity over time. Additionally, a pixel-to-pixel and perfusion zone analysis were performed. The findings were correlated with the clinical outcome. Results: Four patients underwent GMI without postoperative complications within 3 months. The novel perfusion indicators identified here (shape of the perfusion curve, maximum slope value, distribution and range) indicated adequate perfusion. In one patient, GMI failed. In this case, the perfusion indicators suggested impaired perfusion. Conclusions: We present a novel, software-based approach for ICG-NIRF perfusion assessment, identifying previously unknown objective indicators of muscle flap perfusion. Ready for intraoperative real-time use, this method has considerable potential to optimize GMI surgery in the future.

Magnetic resonance imaging as a diagnostic tool for postpartum fistula-in-ano on episiotomy scar – A case report

The objective of this case presentation is to describe a rare case of fistula-in-ano at an episiotomy site and review the importance of magnetic resonance imaging as a diagnostic tool for the detection of perineal fistulas.

Isolated anorectal atresia diagnosed in the first trimester – case report

Anorectal atresia (ARA) is a congenital anomaly with an incidence of 1:1500 to 1:5000 in newborns. This mal­for­ma­tion can be isolated, but is often associated with multiple con­ge­ni­tal anomalies. Until recently, the diagnosis was often made in the third trimester of pregnancy or even after birth but, according to a review, it was established that pre­na­tal diagnosis can be made even in the first trimester. Early diagnosis is essential for the management and planning of birth and postpartum treatment. We present the case of a fetus diagnosed with ARA at 12+0 weeks at the first-tri­mes­ter ultrasound anomalies scan. The karyotype was per­formed and the result was normal. ARA was diagnosed and considered isolated since further detailed examinations per­formed in the second and third trimesters found no other anomalies. After birth, at 36 weeks, the diagnosis was con­firmed as low anorectal atresia with perineal fistula. The new­born was scheduled for surgery at 3 months of life.

The cutback revisited — The posterior rectal advancement anoplasty for certain anorectal malformations with rectoperineal fistula

BackgroundThe repair of rectoperineal fistulae can pose a significant challenge to the pediatric surgeon given the proximity of the fistula to the urethra in males and vagina in females. In these children, a simple cutback procedure may leave the neoanus in a position anterior to the center of the sphincter, which theoretically could impair future continence. We devised an adaptation of the cutback anoplasty which we call the posterior rectal advancement anoplasty (PRAA) to treat patients with a rectoperineal fistula that is both narrow in lumen and located within, but at the anterior-most limit of the sphincter complex. Material and MethodsPatient selection, operative steps, and perioperative care of patients undergoing PRAA are detailed. Results10 children (6 males, 4 females) underwent PRAA. There were no vaginal wall or urethral injuries. At 6 months postoperatively, all patients were passing stool spontaneously. No patients required dilation of the anoplasty in the postoperative period and there were no anal strictures identified. ConclusionsA modification of the cutback anoplasty can be performed in patients with a perineal fistula and the distal fistula tract within the sphincter complex. We have demonstrated that this can be performed safely and obviates the need for an anterior rectal wall dissection, thus eliminating the risk of injury to urethra or vagina.Level of evidence: IV

H-type ano-bulbar urethral fistula with an ectopic perineal fistula in a male patient complicated with VACTER association

Congenital H-type fistula is a rare congenital rectourogenital anomaly and is less common in males than in females. A one-year-and-eight-month-old boy with an ectopic perineal fistula was incidentally diagnosed with H-type fistula when he underwent voiding cystourethrography for vesicoureteral reflux. Further examination revealed that the H-type fistula was an ano-bulbar urethral fistula. At two years of age, the patient underwent fistulectomy and also anterior sagittal anorectoplasty for the ectopic perineal fistula during the same surgery.

Evaluation and management of "low" anorectal malformation in male children: an observational study.

ARM with perineal fistula has been traditionally defined as low ARM (LARM). This study was conducted to evaluate LARM in male patients with an emphasis on the role of various factors on the outcome and follow-up of them. It was a retrospective cohort study. The clinical presentation, associated anomalies, and complications were assessed. The operative procedures included cutback anoplasty and others. The patients were followed in the outpatient department. The complications were assessed and managed accordingly. During the study period of 8years, 301 patients were admitted. The complaints included absent or abnormal anal opening, abdominal distension, constipation, and peritonitis. Most of the children (n = 214) presented in the neonatal period. The most common clinical presentation was the perineal fistula. The most common associated anomaly was urologic. Fourteen patients were referred from other centers after complications. The most common problem in follow-up was constipation. LARM in male patients may have a diverse presentation. The associated anomalies need proper assessment. Awareness may avoid delayed presentation and unwanted complications. When managed by an expert, the condition can be effectively managed. Regular follow-up is important.

Vestibular and Perineal Fistula: Outcomes of Single-stage Repair with Early Feeding and Limited Postoperative Antibiotics

Vestibular and Perineal Fistula: Outcomes of Single-stage Repair with Early Feeding and Limited Postoperative Antibiotics

867 A Novel Use for Silicone Expanders: Reducing Pelvic Dead Space and Preventing Bowel Herniation When Managing Radical Exenterative Surgery Complications

Abstract Aim To date, there is no clear consensus regarding the best way to obliterate the pelvic dead space, as seen in patients treated for recurrent perineal herniation and entero-cutaneous fistuli following total pelvic exenteration (TPE) for locally advanced rectal cancer. We present a novel technique using saline-filled breast expander to fill the dead space and create an artificial pelvic floor using the implant capsule, thus preventing intestinal herniation and fistuli formation in the multi-operated and irradiated pelvis scenario. Method We present 2 patients who initially had TPE, IGAP flap perineal reconstruction and neoadjuvant chemoradiotherapy. Patient 1 had 2 laparotomies for persistent enteroperineal fistulae in the 2-year postoperative period. Patient 2 had persistent wound discharge 2 years post TPE and underwent an enterocutaneous fistula repair and wound debridement. Both cases were complicated by perineal herniation and re-presented with persistent fistulation. A Becker 25 breast expander was placed into the pelvis and inflated with 150 ml of saline, to help contain the small bowel in the abdomen and reduce the risk of perineal re-herniation and fistulae. Results The silicone device was removed at 7-12 months, preserving its capsule, by the time the wound had healed. The wounds remained healed at post-operative follow up without any further perineal wound complications, herniation or fistuli Conclusions Addressing the dead pelvic space by using a breast expander may treat this particular TPE complication. The capsule created following placement of breast implant, facilitates artificial pelvic floor.

Early results of different types of anorectoplasty for anorectal malformations

Objective: To document our experience with the technique of surgical repair in anorectal malformations (ARM) and the short term anatomical and functional outcomes. Methods: This study included total 31 babies. Fourteen were perineal fistula cases with age range between 1 to 4 days. Ten patients had vestibular fistula and seven had rectourinary fistula. Primary diverting colostomy was done for vestibular and rectourinary fistula patients. On the other hand low imperforate anus with anoperineal fistula without associated major anomalies had undergone fistulectomy and simple anoplasty. Results: Simple anoplasty was done for fourteen perineal fistula cases. Anterior sagittal anorectoplasty (ASARP) was done for 10 vestibular fistulae and posterior sagittal anorectoplasty (PSARP) was done in 10 recto-urinary fistula cases. Simple anoplasty and vestibular anus scored good (5-6) in 70% to 71% while PSARP scored fair in 58% of the cases. Postoperative mucosal prolapse, anal stenosis and retraction occurred in two, six and one patient respectively. Redo surgery was done in mucosal prolapse and retraction cases. Four responded to anal dilation and the other needed redo surgery by a simple cutback technique for anal stricture. Continence was assessed in 23 patients whose follow-up periods were longer than 3 years. Twenty one patients had a good score and two had a fair score. No patients had a poor score. Conclusion: Our approach has the following advantages: (i) The operative technique is simple and easy to perform. (ii) Minimal complication rate with good cosmetic results. Mediscope 2021;8(2): 75-79

Sacral Curvature in Addition to Sacral Ratio to Assess Sacral Development and the Association With the Type of Anorectal Malformations.

Introduction: Sacral ratio (SR) is currently the only measurement to quantitatively evaluate sacral development in patients with anorectal malformations (ARM). This study proposes sacral curvature (SC) as a new indicator to qualitatively assess the sacrum and hypothesizes that sacral development, both quantitatively and qualitatively, can be an indicator to predict the type of ARM. The study aims to investigate the difference of SR and SC between ARM types and the association with the type of ARM.Methods and Materials: This study was retrospectively conducted between August 2008 and April 2019. Male patients with ARMs were enrolled and divided into three groups based on the types of ARM: (1) rectoperineal fistulae, (2) rectourethral-bulbar fistulae, and (3) rectourethral-prostatic or rectobladder-neck fistulae. SC was measured in the sagittal views of an MRI or a lateral radiograph of the sacrum.Results: Included in the study were 316 male patients with ARMs. SRs were 0.73 ± 0.12, 0.65 ± 0.12, and 0.57 ± 0.12 in perineal, bulbar, and prostatic/bladderneck fistula, respectively (p < 0.01). The SCs in perineal fistulae and bulbar fistulae were significantly higher than that in prostatic/bladderneck fistulae (0.25 ± 0.04, 0.22 ± 0.14, and 0.14 ± 0.18, p < 0.01). When SR ≥ 0.779, there was an 89.9% of possibility that the child has a perineal fistula. When SR ≤ 0.490 and SC ≤ 0, the possibilities of the child having prostatic/bladderneck fistulae were 91.6 and 89.5%, respectively. SC < 0 was also noted in 27 (27.8%), 19 (10.5%), and no (0%) patients of prostatic/bladderneck, bulbar, and perineal fistulae (p < 0.01), respectively. Sacral defect was noted in 63% of patients with SC ≤ 0, compared to none with SC > 0 (p < 0.01).Conclusions: The higher the rectal level is in an ARM, the lower are the objective measurements of the sacrum. SC ≤ 0 is associated with sacral defects and implies a high likelihood of prostatic/bladderneck fistulae.

CUIDADOS DE ENFERMAGEM EM PACIENTES PORTADORES DE ANOMALIA ANORRETAL

Anorectal anomalies result from embryological malformations that occur in the period of development of the anus and rectum, i.e., between the fourth and the eighth week of gestational age. Anal atresia is one of the most common types of anorectal anomaly. This condition consists of the absence of the anus or the imperforation of the anal orifice and is generally associated with urethral / perineal fistula. Anal imperforation is, per se, a cause of suffering for patients and their families, however, to this is added the stress of the need for surgical correction. In this scenario, the adequacy of nursing care in cases of anorectal anomalies should aim at offering effective technical conducts, without, above all, ignoring the need for a humanized approach given the fragility of the condition. This work conducted an integrative literature review, which sought to investigate the role of the nursing professional in the care of patients with anorectal anomalies. Nursing care could be divided into a preoperative period where the importance of patient care for maintaining nasogastric tube feeding, monitoring of the colostomy when relevant, and monitoring of meconium excretion was highlighted. In the post-operative period, the importance of watching the return of peristaltic movements, cleaning the operated area, maintaining the newborn in the supine position, and controlling the medication was emphasized. It was found the importance of all conducts to be performed respecting the integrality of the neonate patient and with the support of the family.

Histological and clinical outcome of a novel case of perineal hamartoma, atresia ani, and rectovaginal fistula in female Holestein calf

Histological and clinical outcome of a novel case of perineal hamartoma, atresia ani, and rectovaginal fistula in female Holestein calf

Lotus petal flap for unusual indication: A recto-vaginal fistula with perineal defect after vaginal delivery.

Introduction and importanceThree to five percent of vaginal deliveries are complicated by third or fourth degree perineal laceration. Misdiagnosed perineal injuries may be associated with a poor sexual and psychological prognosis. Management of old perineal tears and laceration is challenging with a high failure rate. In such condition, interposition tissue technic or local flap can be a good surgical alternative. Lotus petal Flap, usually indicated in management of large perineal defect in gynecological oncology can be used.Case presentationWe report a case of 32-year-old women presenting complex and relapsed perineal fistula after vaginal delivery associated with perineal defect treated by lotus petal flap with a good outcome.DiscussionPerineal defects are commonly encountered after oncologic, traumatic or infectious perineal excisions and described as a challenging situation. In case of perineal defects after obstetrical tears, no validated surgical filler technics are recommended. Inspired from oncologic surgical technics to fill perineal defects, Lotus Flap can be used. Its advantages are to mobilize a satisfactory tissue volume to fill important perineal defect compared to the small bulbocavernous flap with a hidden scar comparing to gracilis muscle flap. This technic is associated with a good sexual and self-imaging outcome.ConclusionLotus petal flap may be required as a solution to manage perineal defect in case of perineal fistula. This technique provides aesthetic and good results for perineal reconstruction.

Homeopathic treatment of perianal fistula in a dog - Case Report / Tratamento homeopático da fístula perianal num cão - Relato de caso

Perineal fistulas are frequently diagnosed in dogs in clinical practice. They are characterized by an inflammatory lesion in the perianal region or adjacent tissues, causing pain and discomfort to patients. In many cases, fistulas can be ulcerated. In general, corticosteroids and immunosuppressants are the treatment of choice for perianal fistulas. However, they cause various side effects. Surgical intervention is also an option, but sequelae may occur, such as fecal incontinence, the most frequent of them. From this perspective, it is evident that conventional treatments do not provide the complete restoration of the patients' health. On the other hand, homeopathic treatments are gaining space in the veterinary clinical routine with successful results for various diseases that affect animals. This study aimed to report the case of a German Spitz male dog diagnosed with perianal fistula exclusively treated by homeopathy. The prescription of medicines was based on the law of similars, and the medicines Arnica montana, Belladonna, Hamamellis virginiana, and Nitric acidum were chosen. The therapeutic protocol established restored the affected tissues' function with a complete resolution of the disease in 15 days. No complications were recorded.

Advanced Regenerative Medicine Strategies for Treatment of Perianal Fistula in Crohn's Disease.

Regenerative medicine is an emerging therapeutic method that aims to reconstruct tissues and organs. This advanced therapeutic approach has demonstrated great potential in addressing the limitations of medical and surgical procedures for treating perineal fistula in patients with Crohn's disease. Recent developments in stem cell technology have led to a massive good manufacturing practices (GMPs) production of various stem cells, including mesenchymal and embryonic cells, along with induction of pluripotent stem cells to repair damaged tissues in the fistula. The recent advances in separation and purification of exosomes, as biologic nanovesicles carrying anti-inflammatory and regenerative agents, have made them powerful tools to treat this inflammatory disease. Further, tremendous advances in nanotechnology, biomaterials, and scaffold fabrication methods enable tissue engineering methods to synthesize tissue-like structures to assist surgical techniques. This review focuses on advanced regenerative-based methods including stem cell therapy, exosome therapy, and tissue engineering used in the treatment of perianal fistula. Relevant in vitro and in vivo studies and the latest innovations in implementation of regenerative medicine for this disease are also separately reviewed. Additionally, current challenges regarding implementation of g stem cells, exosomes, and tissue engineering methods for bridging the gaps between laboratory findings and clinic application will be discussed.

A comparative multicentre study evaluating gluteal turnover flap for wound closure after abdominoperineal resection for rectal cancer

BackgroundThe aim of this study was to compare perineal wound healing between gluteal turnover flap and primary closure in patients undergoing abdominoperineal resection (APR) for rectal cancer.MethodsPatients who underwent APR for primary or recurrent rectal cancer with gluteal turnover flap in two university hospitals (2016–2021) were compared to a multicentre cohort of primary closure (2000–2017). The primary endpoint was uncomplicated perineal wound healing within 30 days. Secondary endpoints were long-term wound healing, related re-interventions, and perineal herniation. The perineal hernia rate was assessed using Kaplan Meier analysis.ResultsTwenty–five patients had a gluteal turnover flap and 194 had primary closure. The uncomplicated perineal wound-healing rate within 30 days was 68% (17/25) after gluteal turnover flap versus 64% (124/194) after primary closure, OR 2.246; 95% CI 0.734–6.876; p = 0.156 in multivariable analysis. No major wound complications requiring surgical re-intervention occurred after flap closure. Eighteen patients with gluteal turnover flap completed 12-month follow-up, and none of them had chronic perineal sinus, compared to 6% (11/173) after primary closure (p = 0.604). The symptomatic 18-month perineal hernia rate after flap closure was 0%, compared to 9% after primary closure (p = 0.184).ConclusionsThe uncomplicated perineal wound-healing rate after the gluteal turnover flap and primary closure after APR is similar, and no chronic perineal sinus or perineal hernia occurred after flap closure. Future studies have to confirm potential benefits of the gluteal turnover flap.

Accuracy of pre-operative fistula diagnostics in anorectal malformations

BackgroundSurgical safety during posterior sagittal anorectal plasty (PSARP) for anorectal malformations (ARM) depends on accurate pre-operative fistula localization. This study aimed to evaluate accuracy of pre-operative fistula diagnostics.MethodsEthical approval was obtained. Diagnostic accuracy of pre-PSARP symptoms (stool in urine, urine in passive ostomy, urinary tract infection) and examination modalities (voiding cystourethrogram (VCUG), high-pressure colostogram, cystoscopy and ostomy endoscopy) were compared to final intra-operative ARM-type classification in all male neonates born with ARM without a perineal fistula treated at a tertiary pediatric surgery center during 2001–2020.ResultsThe 38 included neonates underwent reconstruction surgery through PSARP with diverted ostomy. Thirty-one (82%) had a recto-urinary tract fistula and seven (18%) no fistula. Ostomy endoscopy yielded the highest diagnostic accuracy for fistula presence (22 correctly classified/24 examined cases; 92%), and pre-operative symptoms the lowest (21/38; 55%). For pre-operative fistula level determination, cystoscopy yielded the highest diagnostic accuracy (14/20; 70%), followed by colostogram (23/35; 66%), and VCUG (21/36; 58%). No modality proved to be statistically superior to any other.ConclusionsOstomy endoscopy has the highest diagnostic accuracy for fistula presence, and cystoscopy and high-pressure colostogram for fistula level determination. Correct pre-operative ARM-typing reached a maximum of 60–70%.

12. Does presence of a VACTERL anomaly predict an associated Gynecologic anomalies in females with Anorectal Malformation?: A Pediatric Colorectal and Pelvic Learning Consortium Study

<h3>Background</h3> VACTERL association (as defined by 3 or more anomalies in any of the following systems: vertebral, anorectal, cardiac, trachea-esophageal, renal, or limb) is present in around a third of patients with anorectal malformations (ARM). In female ARM patients' gynecologic anomalies are seen in conjunction with 1 in 5 rectovestibular and 1 in 20 rectoperineal fistulae. This study hypothesized that the presence of VACTERL association would predict an increased risk of gynecologic anomalies and this information will help to guide evaluation and management protocols. <h3>Methods</h3> This study is a cross-sectional, retrospective analysis from the prospectively-collected, multicenter registry of the Pediatric Colorectal and Pelvic Learning Consortium (PCPLC). Subjects with inflammatory bowel disease were not eligible for the PCPLC registry. The 316 female subjects with a perineal or vestibular fistula who were enrolled in the registry by January 14, 2020 were included in this study. The relationship of VACTERL association, ARM plus an anomaly in two or more VACTERL systems, with presence of a genital anomaly was evaluated with Fisher's exact test (Table 2). The relationship of each individual VACTERL system with presence of a genital anomaly was analogously assessed. P-values reported were based on a 2-sided alternative and considered significant when less than 0.05. <h3>Results</h3> 316 patients with rectoperineal (n=162, 51.3%) or rectovestibular (n=154, 48.7%) fistulae underwent VACTERL screening and gynecologic evaluation. 83 (26.3%) of patients with rectoperineal fistulae or rectovestibular fistulae had gynecologic anomalies. (Table 1). Among subjects with VACTERL association, 70.4% have a spine anomaly, 68.7% have a renal anomaly, and 70% have a cardiovascular anomaly. Genital anomalies were present in 40.9% vs. 17.9% of subjects with vs. without VACTERL association (p < 0.001). Genital anomalies were present in 31.0% vs. 16.5% of subjects with vs. without an anomaly in at least one VACTERL system (p = 0.006) Table 2. <h3>Conclusions</h3> Presence of VACTERL association in patients with rectoperineal or rectovestibular fistula correlates with an increased risk of gynecologic anomalies and should prompt early involvement of pediatric gynecology in their care.

Correlation of anorectal malformation complexity and associated urologic abnormalities

BackgroundPatients with anorectal malformations (ARM) commonly have associated urologic anomalies. Few large studies exist to accurately characterize the incidence or associations between severity of malformation and urologic diagnosis. The purpose of our study was to determine the incidence of urologic diagnoses in a large cohort of children with ARM and evaluate for any correlation between severity of ARM and the incidence and number of associated urologic diagnoses. MethodsA retrospective review was performed of patients with ARM treated at our pediatric colorectal center. All patients underwent protocolized urologic screening. ARM subtypes were ordered with increasing severity as follows in males: perineal, bulbar, prostatic and bladder neck fistulae. Females were similarly categorized as perineal, vestibular and vaginal fistulae followed by cloaca with <3 cm common channel and cloaca with >3 cm common channel. The following urologic diagnoses were assessed to determine whether a correlation existed with the severity of the ARM subtype: hydronephrosis, vesicoureteral reflux (VUR), solitary kidney, renal ascent anomalies (ectopic or pelvic), renal fusion anomalies (horseshoe or cross fused kidney), duplex kidney, hypospadias and undescended testicle. ARM subtypes were defined by distal rectal anatomy. ResultsA total of 712 patients were included in our study with a mean age of 4 years and of whom 45% were male. The overall rate of urologic anomalies was greater in males than females (65% vs 56% p < 0.026). In both sexes, the rate of urologic anomalies increased with increasing severity of ARM subtype (p<0.00010) finding that males with bladder neck fistula and females with cloacal malformations, particularly with long common channels, being the highest incidence. In males and females, the rate of hydronephrosis increased as the complexity of ARM increased and this correlated significantly (p < 0.0001 vs p < 0.0003 respectively). Similarly, the incidence of VUR also increased as complexity of ARM increased in both males and females (p = 0.01 and p<0.0001 respectively). The remaining urologic diagnoses were not significantly correlated with severity of ARM. ConclusionsUrologic anomalies occur at a high rate in children with ARM and appear to increase in frequency with increasing complexity of ARM subtype. These findings stress the importance of proper ARM screening and proactive collaboration with a clinician with expertise in pediatric urology early in the management of such children to improve early recognition of urologic diagnoses. Level of evidenceLevel III.