Sphincter-sparing Techniques Research Articles

Quality of Life After Abdomioperineal Resection for Rectal Carcinoma

Background: Abdominoperineal resection (APR) has long been a standard treatment for rectal cancer, particularly for tumors located very distally or in patients with poor sphincter function. Despite the rise of sphincter-sparing techniques, APR remains essential in certain cases. This study aims to evaluate the impact of APR on the quality of life (QoL) in rectal cancer patients. Objective: To assess the quality of life in rectal cancer patients following APR, focusing on physical, psychological, sexual, and social functioning. Method: This prospective observational study was conducted at Sher-e-Bangla Medical College & Hospital, Barisal, over six months (July-December 2015). Patients who underwent APR for rectal cancer and were at least three months post-surgery were included. QoL was evaluated based on patients' self-assessments across four dimensions: physical, psychological, sexual, and social functioning. Result: The study included patients with a mean age of 48 years (range: 23-75 years), with 40% being early middle-aged (31-40 years). Stoma-related issues were reported by 56% of patients, while 64% experienced odor problems. Psychological distress was prevalent, with 52% feeling discomfort, 44% experiencing depression or anxiety, and 12% reporting suicidal tendencies. Sexual dysfunction was significant, affecting 55% of men, with 83.8% completely impotent. Social functioning was compromised, with 42% reducing social activities. Overall, 24% of patients rated their QoL as poor, 14% as extremely poor, 26% as average, and 36% as good. Conclusion: Rectal cancer patients post-APR experience considerable limitations across all QoL dimensions, underscoring the need for targeted interventions to improve their overall well-being.

Injection of Freshly Collected Adipose Tissue for the Treatment Complex Cryptoglandular Anal Fistula: Case Report

AbstractIntroduction Perianal fistula is a common colorectal disease which is caused mainly by cryptoglandular disease. Although most cases are treated successfully by surgery, management of complex perianal fistulas (CPAF) remains a challenge with limited results in recurrence and sometimes associated with fecal incontinence. The CPAF treatment with autologous adipose-derived mesenchymal stem cells (ASCs) had become a research hotspot. The technique started to be used in the treatment of Crohn's disease (CD) fistulas, where the studies showed safe and goods result from the procedure. Cultured ASCs have been used but this approach requires the preceding collection of adipose tissue, time for isolation of ASCs and subsequent in vitro expansion, need for laboratory facilities, and expertise in cell culturing. These factors have been getting over by using the commercially available alternative, allogenic ASCs. Treatment with allogeneic ASCs has shown good results in patients with CD fistulas, however with the disadvantage of being expensive. Objective To show that the injection with freshly collected adipose tissue is an alternative to treatment with autologous or allogenic ASCs with several advantages. Methods: In this case report, we show our first experience in the treatment of CPAF with the application of collected adipose tissue in a tertiary referral hospital from Belo Horizonte, Brazil. Results The patient had a good postoperative recuperation with a complete fistula healing after 8 months without adverse effects. Conclusion Injection with freshly collected adipose tissue is a promising and apparently safe sphincter-sparing technique in the treatment of CPAF.

Long term results of video-assisted anal fistula treatment for complex anal fistula: another shattered dream?

Complex anal fistula represents a burden for patients, and its management is a challenge for surgeons. Video-assisted anal fistula treatment (VAAFT) is one sphincter-sparing technique. However, data on its long-term effectiveness are scant. We aimed to explore the outcomes of VAAFT in a retrospective cohort of patients referred to a tertiary centre. Consecutive adult patients with a minimum of 2 years' follow-up after VAAFT were reviewed. Patients were followed up to 5 years postoperatively. Failure was defined as incomplete healing of the external orifice(s) during the first 6 months. Recurrence was defined as new radiologically and/or clinically confirmed onset of the fistula after primary healing. A generalized linear model was fitted to evaluate the association between failure and sociodemographic characteristics. Predictors of recurrence were determined in a subgroup analysis of patients found to be free from disease at 6 months postoperatively. Overall, 106 patients (70% male; mean age 41 years) were reviewed. Of these 86% had a previous seton placement. Fistulas were either high trans-sphincteric (74%), suprasphincteric (12%) or extrasphincteric (13%). Eight (7%) patients experienced postoperative complications, none of which required reintervention. Mean follow-up was 53 ± 13.2 months. VAAFT failed in 14 (13%) patients. The overall recurrence rate ranged from 29% at 1 year to 63% at 5 years. Multiple external orifices, suprasphincteric fistula, younger age, previous surgery and higher complexity of the fistulous tract were independent risk factors for recurrence. VAAFT is a safe sphincter-sparing technique. The initially high success rate decreases over time and relates to a higher degree of complexity.

Surgical treatment trends and outcomes for anal fistula: fistulotomy is still accurate and safe. Results from a nationwide observational study.

The aim of the present study was to analyse current surgical treatment preferences for anal fistula (AF) and its subtypes and nationwide results in terms of success and complications. A retrospective multicentre observational cohort study was conducted. The study period was 1year (2019), with a follow-up period of at least 1year. A descriptive analysis of patient characteristics and trends regarding technical options was performed. Univariate and multivariate Cox regression models were used to analyse factors associated with healing and faecal incontinence (FI). Fifty-one hospitals were involved, providing data on 1628 patients with AF. At a median follow-up of 18.3 (9.9-28.3) months, 1231 (75.9%) patients achieved healing, while 390 (24.1%) did not; failure was catalogued as persistence in 279 (17.2.0%) patients and as recurrence in 111 (6.8%). On multivariate analysis, factors associated with healing were fistulotomy (OR 5.5; 95%CI 3.8-7.9; p < 0.001), simple fistula (OR2.1; 95%CI 1.5-2.8; p < 0.001), single tract (HR1.9; 95%CI 1.3-2.8; p < 0.001) and number of preparatory surgeries (none vs. 3; HR1.8; 95%CI 1.2-2.8; p = 0.006). Regarding de novo FI, in the multivariate analysis previous anal surgery (OR1.5, 95%CI 1.0-2.4, p = 0.037), age (OR1.02, 95%CI 1.00-1.04, p = 0.002) and being female (OR1.7, 95%CI 1.1-2.5, p = 0.008) were statistically related. Anal fistulotomy is the most used procedure for AF, especially for simple AF, with a favourable overall balance between healing and continence impairment. Sphincter-sparing or minimally invasive sphincter-sparing techniques resulted in lower rates of healing. In spite of their intended sphincter-sparing design, a certain degree of FI was observed for several of these techniques.

Emerging Data on Fistula Laser Closure (FiLaC) for the Treatment of Perianal Fistulas; Patient Selection and Outcomes.

Fistula laser closure (FiLaC) is a relatively new sphincter-sparing technique in fistula surgery that was initially reported in 2011. It involves the radial dissipation of laser energy in the fistula tract and, through a combination of coagulation and shrinkage of the tract, is proposed to result in progressive sealing of fistulas. Early studies have suggested minimal impact on continence and touted the advantage of minimal morbidity with potential of repeat procedures if the technique fails initially. Despite early promising results, ten years on, questions remain on the technique, patient selection and long-term outcomes. This narrative review assesses the evidence reported to-date of radially emitting laser fistula surgery in the treatment of perianal fistulas.

Fistula Laser Closure (FiLaC™) for fistula-in-ano-yet another technique with 50% healing rates?

Treatment of ano-cutaneous fistulas remains a therapeutic challenge. Fistula Laser Closure (FiLaC™) is a relatively new technique for the treatment of ano-cutaneous fistulas. This study aimed to determine the success rate of fistula closure using FiLaC™. Secondary endpoints included adverse events and patient characteristics associated with treatment success. This was a retrospective cohort study of consecutive patients subjected to FiLaC™ at Digestive Disease Center, Bispebjerg University Hospital, Copenhagen, between March 2017 and July 2019. All patients had a one-track fistula not suitable for fistulotomy. All were treated with a draining seton for at least 8 weeks prior to laser closure. Fistulas were ablated with a 360-degree emitting 12-watt 1470 nm laser probe. The inner fistula opening was closed with absorbable suture. All patients were followed with clinical examination including MRI or EAUS 1 year after the procedure. In total, 66 patients with 68 fistulas were included. Two patients had a high intersphincteric, 20 had low transsphincteric, 41 high transsphincteric and 5 had suprasphincteric fistulas. Fistula aetiology was cryptoglandular in 83.8%, whereas the rest were due to Crohn's disease. Thirty-one (45.6%) were subjected to a second FiLaC™ procedure. Follow-up was median 19 months (12-26 months). Ultimately, 30 of 68 (44.1%) of the fistulas healed. No cases of incontinence following FiLaC™ were observed, but a single patient developed an abscess. Fistula closure with FiLaC™ had success rates comparable to that of other sphincter-sparing techniques. The technique seems safe with respect to adverse events and risk of incontinence.

Robot-assisted anorectal pull-through for anorectal malformations with rectourethral and rectovesical fistula: feasibility and short-term outcome.

Multiple structures in the anorectal area are closely related to defecation, voiding and sexual function. Although laparoscopic-assisted anorectal pull-through is widely accepted as a minimally invasive surgical technique, controversy still exists for ARMs with rectourethral fistulas. Intraoperative injuries more or less involve the perirectal sphincters and neurovascular tissue. Seventeen selected infants with ARMs underwent robot-assisted anorectal pull-through (RAARP) between October 2016 and January 2018. The application of nerve- and sphincter-sparing technique in RAARP was detailed. The feasibility and early outcomes were evaluated. All procedures were completed without conversion. The robotic system facilitated clear dissections between different anatomical layers. Under direct vision, the fistula was easier to repair, and the rectal pouch was precisely placed in the center of the striated muscle complex. During the follow-up of 11.6months, 13 patients resumed normal defecation. The other four children experienced mild constipation or fecal incontinence. Their continence and defecation functions showed favorable evolution. RAARP is a safe and effective alternative for the treatment of ARMs, which provides an advantage in further minimizing the injury to perirectal nerves and sphincters.

FISSIT (Fistula Surgery in Italy) study: A retrospective survey on the surgical management of anal fistulas in Italy over the last 15 years

BackgroundSurgical treatment of anal fistulas is still a challenge. The aims of this study were to evaluate the adoption and healing rates for the different surgical techniques used in Italy over the past 15 years. MethodsThis was a multicenter retrospective observational study of patients affected by simple and complex anal fistulas of cryptoglandular origin who were surgically treated in the period 2003–2017. Surgical techniques were grouped as sphincter-cutting or sphincter-sparing and as technology-assisted or techno-free. All patients included in the study were followed for at least 12 months. ResultsA total of 9,536 patients (5,520 simple; 4,016 complex fistulas) entered the study. For simple fistulas, fistulotomy was the most frequently used procedure, although its adoption significantly decreased over the years (P < .0005), with an increase in sphincter-sparing approaches; the overall healing rate in simple fistulas was 81.1%, with a significant difference between sphincter-cutting (91.9%) and sphincter-sparing (65.1%) techniques (P = .001). For complex fistulas, the adoption of sphincter-cutting approaches decreased, while sphincter-sparing techniques were mildly preferred (P < .0005). Moreover, there was a significant trend toward the use of technology-assisted procedures. The overall healing rate for complex fistulas was 69.0%, with a measurable difference between sphincter-cutting (81.1%) and sphincter-sparing (61.4%; P = .001) techniques and between techno-free and technology-assisted techniques (72.5% and 55.0%, respectively; P = .001). ConclusionSurgical treatment of anal fistulas has changed, with a trend toward the use of sphincter-sparing techniques. The overall cure rate has remained stable, even if the most innovative procedures have achieved a lower success rate.

LIFT: a feasible option for primary and recurrent fistulas

Background The development of a surgical solution for anal fistulas with minimal recurrence and morbidity remains a challenge. Ligation of the intersphincteric fistula tract (LIFT), however, is a sphincter sparing technique that provides complete resolution of the transsphincteric fistula as well as minimizing recurrence and fecal incontinence. Our goal is to evaluate the efficacy of fistula tract ligation for primary and recurrent fistulas. Methods A retrospective single-center case study was conducted from data between 2015 and 2019 in a large district hospital in Antwerp, Belgium. Patients who underwent LIFT were included. Demographic patient data as well as primary outcome during the follow-up period were collected. A systematic literature review and analysis was conducted with terms [ANAL FISTULA] [TREATMENT] [LIFT] [LIGATION OF INTERSPHINCTERIC FISTULA]. Primary healing and recurrence associated with surgical modifications were investigated. Results 4 out of 25 patients presented with early failure (84% primary success rate) after a median follow-up period of 7 months. The median time until recurrence was 105 days. The success rate after a redo ligation was 100%. Twenty-eight studies were included for review and divided into three groups depending on the technical variation of the used technique. The success rate was 74.2% for the LIFT group, 72.9% in the LIFT + group, and 77.5% in the mLIFT group p = .92. Conclusion LIFT is a feasible treatment option for primary and recurrent fistulas, with excellent success rates where fistula characteristics rather than chosen technique dictate the surgical outcome.

Ligation of intersphincteric fistula tract (LIFT) in treatment of anal fistula: An updated systematic review, meta-analysis, and meta-regression of the predictors of failure

BackgroundLigation of intersphincteric fistula tract has gained increasing popularity as a sphincter-sparing technique for complex anal fistula. The present review aimed to investigate the pooled success and complication rates of ligation of intersphincteric fistula tract in the published literature and to explore the risk factors for failure after ligation of intersphincteric fistula tract. MethodsA Preferred Reporting Items for Systematic Reviews and Meta-Analyses-compliant literature search was conducted. Electronic databases were searched in the period of January 2007 through April 2019 for studies that assessed the outcome of the ligation of intersphincteric fistula tract procedure. The main outcomes of the review were the pooled success and complication rates of ligation of intersphincteric fistula tract, predictors of failure after ligation of intersphincteric fistula tract, operation time, hospital stay, and how failures were managed. ResultsTwenty-six studies comprising 1,378 patients (996 male) were included in this review. The mean age of patients was 42.3 ± 4.2 years. The weighted mean rate of success was 76.5%. The median follow-up duration was 16.5 months. The weighted mean complication rate was 13.9%. The most common complication was wound dehiscence. Fecal incontinence was recorded in 1.4% of patients. Factors that were statistically significantly associated with failure after the ligation of intersphincteric fistula tract procedure were horseshoe fistulas, fistulas associated with Crohn’s disease, and those with a history of previous fistula surgery. ConclusionThe pooled success and complication rates of the ligation of intersphincteric fistula tract procedure were about 76% and 14%, respectively. Horseshoe fistulas, Crohn’s disease, and previous fistula surgery were identified as predictors for failure after ligation of intersphincteric fistula tract procedure.

Short-term efficacy and safety of three novel sphincter-sparing techniques for anal fistulae: a systematic review.

The surgical treatment of complex anal fistulae, particularly those involving a significant portion of the anal sphincter in which fistulotomy would compromise continence, is challenging. Video-assisted anal fistula treatment (VAAFT), fistula tract laser closure (FiLaC™) and over-the-scope clip (OTSC®) proctology system are all novel sphincter-sparing techniques targeted at healing anal fistulae. In this study, all published articles on these techniques were reviewed to determine efficacy, feasibility and safety. A systematic search of major databases was performed using defined terms. All studies reporting on experience of these techniques were included and outcomes (fistula healing and safety) evaluated. Eighteen studies (VAAFT-12, FiLaC™-3, OTSC®-3) including 1245 patients were analysed. All were case series, and outcomes were heterogeneous with follow-up ranging from 6 to 69months and short-term (<1year) healing rates of 64-100%. Morbidity was low with only minor complications reported. There was one report of minor incontinence following the first reported study of FiLaC™, and this was treated successfully at 6months with rubber band ligation of hypertrophied prolapsed mucosa. There are inconsistencies in the technique in studies of VAAFT and FiLaC™. All three techniques appear to be safe and feasible options in the management of anal fistulae, and short-term healing rates are acceptable with no sustained effect on continence. There is, however, a paucity of robust data with long-term outcomes. These techniques are thus welcome additions; however, their long-term place in the colorectal surgeon's armamentarium, whether diagnostic or therapeutic, remains uncertain.

Treatment of Complex Fistula-in-Ano With a Nitinol Proctology Clip.

The treatment of complex anocutaneous fistulas remains a major therapeutic challenge balancing the risk of incontinence against the chance of permanent closure. The purpose of this study was to investigate the efficacy of a nitinol proctology clip for closure of complex anocutaneous fistulas. This is a single-center cohort study with retrospective analysis of all of the treated patients. Data were obtained from patient records and MRI reports, as well as follow-up telephone calls and clinical follow-up with endoanal ultrasonography. All of the patients were treated for high transsphincteric and suprasphincteric anocutaneous fistulas at the Digestive Disease Center, Bispebjerg Hospital, between May 2013 and February 2015. All of the patients were treated with the nitinol proctology clip. Primary outcome was fistula healing after proctology clip placement, as evaluated through clinical examination, endoanal ultrasonography, and MRI. The fistula healing rate 1 year after the clip procedure was 54.3% (19 of 35 included patients). At the end of follow-up, 17 (49%) of 35 patients had persistent closure of the fistula tracks. No impairment of continence function was observed. Treatment outcome was not found to be statistically associated with any clinicopathological characteristics. The study is limited by its retrospective and nonrandomized design. Selection bias may have occurred, because treatment options other than the clip were available during the study period. The small number of patients means that there is a nonnegligible risk of type II error in the conclusion, and the follow-up may be too short to have detected all of the failures. Healing rates were comparable with those of other noninvasive, sphincter-sparing techniques for high-complex anocutaneous fistulas, with no risk of incontinence. Predictive parameters for fistula healing using this technique remain uncertain. See Video Abstract at http://links.lww.com/DCR/A347.

Ligation of the intersphincteric fistula tract technique in the treatment of anal fistula

Background: Management of anal fistula is a challenging issue in surgical practice. No single technique is appropriate for treatment of all types of fistulas. The aim of this study was to evaluate the efficacy and safety of a new sphincter-sparing technique: ligation of the intersphincteric fistula tract (LIFT) for management of anal fistula.Methods: Over a period of 18 months from January 2015 to June 2016 twenty-one patients (12 males and 9 females) with transsphincteric anal fistula were treated with the LIFT procedure. Patients were followed up for at least six months postoperatively for fistula recurrence, rate of wound healing and effect on fecal continence.Results: Fistula healing rate was (90.5%); recurrence rate was 9.5% in the form of down staging to intersphincteric fistulas. Mean time of healing of intersphincteric wound was 32±7.4 days (ranged from 17 to 58 days). Mean time of healing of the external opening wound was 27±5.8 days (ranged from 19 to 56 days). No postoperative changes in fecal continence.Conclusions: LIFT operation is a safe and effective management of transsphincteric anal fistula, this technique has high healing rate with no effect on fecal continence.

OC-094 Interim results of a european, multi-centre, prospective, observational study of permacol™ collagen paste injection for the treatment of anal fistulas

<h3>Introduction</h3> Historically, the treatment of anal fistulas has required a compromise between successful fistula healing and preservation of continence. The aim of this study (NCT01624350) is to evaluate clinical outcomes of anal fistulas treated with Permacol™ collagen paste. <h3>Method</h3> Patients (N = 98) with magnetic resonance imaging-confirmed intersphincteric or transsphincteric anal fistulas, cryptoglandular primary or recurrent, from ten European sites were treated with Permacol™ collagen paste. Fistula healing, adverse events, and patient satisfaction were assessed up to 12 months post-surgery, with fistula healing at 6 months confirmed by clinical assessment as the primary endpoint. Cox regression analyses were performed to determine if patient or fistula characteristics correlate with better healing. <h3>Results</h3> The median follow-up was 26.8 weeks (range 0.1–62.4 weeks), with 87 and 46 patients having healing data at 6 months and 12 months, respectively. At 6 months follow-up, 51 (58.6%) patients exhibited a clinically-healed anal fistula, including 20/35 (57.1%) that were recurrent at the time of treatment. At 12 months, 19 (41.3%) patients were healed. Younger patients and those with evidence of expulsion or leakage of Permacol™ collagen paste were the only variables associated with a significantly increased risk of failure (p = 0.0017 and p = 0.0068, respectively). A total of six serious adverse events were reported, four of which (perianal abscess, n = 2; non-healing fistula tract, n = 1; complex regional pain syndrome, n = 1) were possibly related to the device and/or the procedure. Continence was preserved throughout the follow-up. At their last visit, over 70% of patients reported being satisfied or very satisfied with their operation, indicating that some patients were satisfied even though their fistula did not heal. <h3>Conclusion</h3> These preliminary results demonstrate that Permacol™ collagen paste is a well-tolerated, sphincter-sparing technique for the treatment of anal fistulas with low morbidity. <h3>Disclosure of interest</h3> P. Giordano Grant/Research Support from: Covidien, Consultant for: Covidien, Speaker Bureau of: Covidien, P. Sileri Grant/Research Support from: Covidien, S. Buntzen Grant/Research Support from: Covidien, Speaker Bureau of: Medtronic, A. Stuto Grant/Research Support from: Covidien, J. Nunoo-Mensah Grant/Research Support from: Covidien, L. Lenisa Grant/Research Support from: Covidien, B. Singh Grant/Research Support from: Covidien, Speaker Bureau of: Covidien, O. Thorlacius-Ussing Grant/Research Support from: Covidien, B. Griffiths Grant/Research Support from: Covidien, D. Ziyaie Grant/Research Support from: Covidien, Speaker Bureau of: Covidien.

Improved quality of care for patients undergoing an abdominoperineal excision for rectal cancer

IntroductionNew diagnostics, the emergence of total mesorectal excision and neoadjuvant treatments have improved outcome for patients with rectal cancer. Patients with distal rectal cancer undergoing an abdominoperineal excision seem to do worse compared to those treated with sphinctersparing techniques. The aim of this study was to evaluate the quality of care for patients undergoing an abdominoperineal excision for distal rectal cancer during the last 15 years. Materials and methodsAll patients with rectal cancer, who underwent an abdominoperineal excision between December 1996 and December 2010 in 5 Dutch hospitals were analysed. Patients were divided into three cohorts; 1996–2001, 2001–2005 and 2006–2010. All data was extracted from medical records. Results477 patients were identified. There was no significant difference in sex, age, BMI, prior pelvic surgery and ASA stages between the cohorts. MRI became a standard tool in the work-up, the use increased from 4.5% in the first, to 95.1% in the last cohort (p < 0.0001). Neoadjuvant treatment shifted from predominantly none (64.9% in cohort 1) to short course radiotherapy (66.7% in cohort 2) and chemoradiation therapy (55.7% in cohort 3). There was a trend towards a decreased circumferential resection margin involvement in the cohorts (18.8%, 16.7% and 11.4%; p = 0.142). Accidental bowel perforations have significantly decreased from 28.6%, and 21.7% to 9.2% in cohort 3 (p < 0.0001). ConclusionSignificant improvements in work-up, neoadjuvant and surgical treatment have been made for patients with low rectal cancer, undergoing an abdominoperineal excision. These improvements result in improved short term outcome.

Fistules anales avec prolongement en fer à cheval

Horseshoe extensions in anal fistulas are uncommon but represent a challenging condition for their management. They are associated with substantial morbidity and carry a significant risk of anal incontinence. First operative time needs to address the drainage of the horseshoe extension and following operations are for main fistula track. Sphincter sparing techniques are conceivable but their efficacy has not been specifically assessed in this situation.

Ligation of Intersphincteric Fistula Tract

Transsphincteric fistulotomy is associated with a variable degree of fecal incontinence that is directly related to the thickness of the sphincter mechanism overlying the fistula. Staged fistulotomy with seton or the use of cutting seton designed to reduce the proportionate incontinence rates have failed to do so. This has resulted in attempts to find novel sphincter-sparing techniques in the past 2 decades including draining seton, fibrin sealant, anal fistula plug, dermal advancement, and endorectal advancement flaps. These operations have a variable success rates of 30% to 80% reported in the literature. In 2007, Rojanasakul from Thailand demonstrated a novel technique, ligation of intersphincteric fistula tract, and reported a 94% success rate in a small series. Since then, a few other small cohorts of patients have been reported in the literature with success rates varying from 57% to 82%. An institutional review board-approved study was proposed to measure our results and compare them with the published data. This study was undertaken to evaluate the success of ligation of intersphincteric fistula tract procedures in a group of unselected transsphincteric fistulas deemed unsuitable for lay-open fistulotomy. The procedure was performed in 3 different settings: a public institution, a major university hospital, and a large private hospital. A total of 40 patients underwent 41 ligation of intersphincteric fistula tract procedures performed by 6 Board-certified colon and rectal surgeons. In a mean follow-up of 18 weeks, 74% of the patients achieved healing. In patients who underwent ligation of intersphincteric fistula tract as their primary procedure, the healing rate was 90%. The limitation of this study is its "case series" nature and the short mean follow-up period of 18 weeks. Ligation of intersphincteric fistula tract has had excellent success in transsphincteric fistulas in multiple small series. A larger number of patients and longer follow-up period are needed to validate the early favorable results.

Evolution of Treatment of Fistula in Ano

Fistula-in-ano is a common medical problem affecting thousands of patients annually. In the past, the options for treatment of fistula-in-ano were limited to fistulotomy and/or seton placement. Current treatment options also include muscle-sparing techniques such as a dermal island flap, endorectal advancement flap, fibrin sealent injection, anal fistula plug, and most recently ligation of the intersphincteric fistula tract (procedure). This study seeks to evaluate types and time trends for treatment of fistula-in-ano. A retrospective review from 1975 to 2009 was performed. Data were collected and sorted into 5-year increments for type and time trends of treatment. Fistulotomy and partial fistulotomy were grouped as cutting procedures. Seton placement, fibrin sealant, dermal flap, endorectal flap, and fistula plug were grouped as noncutting procedures. Statistical analysis was performed for each time period to determine trends. With institutional review board approval, the records of 2,267 fistula operations available for analysis were included. Most of the patients were men (74 vs. 26%). Cutting procedures comprised 66.6% (n = 1510) of all procedures. Noncutting procedures were utilized in 33.4% (n = 757), including Seton placement alone 370 (16.3%), fibrin sealant 168 (7.4%), dermal or endorectal flap 147 (6.5%), and fistula plug 72 (3.2%). The distribution of operations grouped in 5-year intervals is as follows: 1975-1979, 78 cutting and one noncutting; 1980-1984, 170 cutting and 10 noncutting; 1985-1989, 54 cutting and five noncutting; 1990-1994, 37 cutting and six noncutting; 1995-1999, 367 cutting and 167 noncutting; 2000-2004, 514 cutting and 283 noncutting; 2005-2009, 290 cutting and 285 noncutting. The percentage of cutting and noncutting procedures significantly differed over time, with cutting procedures decreasing and noncutting procedures increasing proportionally (χ(2) linear-by-linear association, p < 0.05). Fistula-in-ano remains a common complex disease process. Its treatment has evolved to include a variety of noncutting techniques in addition to traditional fistulotomy. With the advent of more sphincter-sparing techniques, the number of patients undergoing fistulotomy should continue to decrease over time. Surgeons should become familiar with various surgical techniques so the treatment can be tailored to the patient.

Cryptoglandular anal fistula

Fistula arising from the glands of the anal crypts is the most common form of anoperineal sepsis. It is characterized by a primary internal orifice in the anal canal, a fistulous tract, and an abscess and/or secondary perineal orifice with purulent discharge. Antibiotics are not curative. The treatment of an abscess is urgent and consists, whenever possible, of incision and drainage under local anesthesia. Definitive treatment of the fistulous tract can await a second stage. The primary aim is to control infection without sacrificing anal continence. Fistulotomy is the basis for all treatments but the specific technique depends on the height of the fistula in relation to the sphincteric mechanism. Overall results of fistulotomy are excellent but there is some risk of anal incontinence. This explains the growing interest in sphincter sparing techniques such as the mucosal advancement flap, the injection of fibrin glue, and the plug procedure. However, results of these procedures are not yet good enough and leave much room for improvement.

Ligation of the Intersphincteric Fistula Tract: An Effective New Technique for Complex Fistulas

The management of complex fistulas is difficult. Maintaining continence while achieving durable fistula closure is the goal of surgical management. This study describes our experience with a novel sphincter-sparing technique called the ligation of the intersphincteric fistula tract, which involves ligation and division of the fistula tract in the intersphincteric space. All patients from July 2007 to December 2008 with trans- or suprasphincteric fistula treated with the procedure were prospectively followed. Procedures were performed by surgeons with fellowship training in a referral center. Demographic data, comorbidities, previous repair attempts, and postoperative data were collected. A total of 39 patients underwent a ligation of the intersphincteric fistula tract during a 17-month period. Median age was 49 years. A total of 29 patients (74%) had previous attempts at repair, with a median of 2 failed repairs. Follow-up data were available in 90% (35 of 39). Median follow-up was 20 weeks. Successful fistula closure was achieved in 57% of the patients (20 of 35). Median time to failure was 10 weeks (range, 2-38 weeks). No patient reported any subjective decrease in continence after the procedure. Ligation of the intersphincteric fistula tract is a new sphincter-sparing procedure for complex transsphincteric fistula. The success rate is comparable with other sphincter-preserving techniques. Importantly, it appeared to effectively preserve continence. Adding safe, muscle-sparing surgical options to our armamentarium for dealing with transsphincteric fistula is essential. Additionally, the procedure is easy to learn and has very low cost. Long-term follow-up and randomized, controlled trials are necessary to assess efficacy and durability.