Sphincteric Fistula Research Articles

Short Term Outcomes of Fistulectomy with Primary Closure of Internal Opening for the Treatment of High Trans-sphincteric Fistula in Ano

Background: Fistulectomy with primary closure of the internal opening has been used to treat high trans-sphincteric fistula in ano. This method entails complete removal of the fistula tract from external opening to internal opening and closing the internal opening from the inside of anal canal. This study aims to assess the outcomes of fistulectomy with closure of the internal opening for high trans sphincteric fistula. Methods: Observational study was carried out in the Department of Colorectal Surgery, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh. Total 36 patients with high trans sphincteric fistula were included in this study. After preoperative MRI of anorectum, fistulectomy with closure of the internal opening was done. Results: The mean age was found 39.4 years with range from 20 to 57 years. Among 36 patients, 83.3% patients had primary wound healing within 6 weeks and rest of the patients healed within 10 weeks. Clinical squeeze pressure was reduced in 11.1% patients. Thirty two patients were available for 1 year follow up. Recurrence occurred in 21.88% (n=32) patients within the study period. 91.7% patients had Park-Brown continence grade-A and 8.3% had grade-B. Wound infection did not impair postoperative continence (p>0.05). There was statistically significant difference between wound infection and suture line dehiscence with fistula recurrence (P<0.05). Conclusion: Since the recurrence and incontinence rate were low, clinical squeeze pressure did not significantly reduced along with quick healing rate, fistulectomy with closure of the internal opening is an effective treatment option for high trans-sphincteric fistula in ano.

Effectiveness of ligation of Inter Sphincteric Fistula Tract (LIFT) in the Management of Fistulas in ano in Maharashtra Population: Retrospective Study

Background: Anal fistula is one of the most common ano- rectal problems, resulting in very negative patientexperiences. The objectives of anal fistula treatments are to achieve healing with a low recurrence rate and preserveanal function.Method: 55 adult patients were confirmed to be competent for surgery. USG examination with 7 to 10 MHZtransducer passed into the anal canal, which is carried out with the patient in the left lateral position. Serial radialimages were taken to study the location and position of the fistula. The LIFT procedure was similar to Rojanaskulproposed method. The duration of surgery and healing time were also noted.Results: 48 (87.2%) were as per Parks classification, 5 (9.09%) intersphincteric, 2 (3.63%) suprasphincteric,Classification based on course of fistula – 20 (36.3%) anterior straight, 28 (50.9%) posterior straight, 5 (9.09%) curved,and 2 (3.63%) semi-horse shoe. Classification based on the tract – 50 (90.9%) single tracts, 5 (9.09%) multiple tracts.Conclusion: LIFT technique is simple and safe, with a high rate of healing and no risk of incontinence.

A COMPARATIVE STUDY OFLIGATION OF INTERSPHINCTERIC FISTULA TRACT AND FISTULECTOMY IN THE MANAGEMENT OF TRANS SPHINCTERIC FISTULA IN ANO

Background: A fistulectomy involves complete excision of the fistulous tract, thereby eliminating the risk of missing secondary tracts and providing complete tissue for histopathological examination. By studying with comparing the LIFT with fistulectomy withits outcome being advantages and disadvantages in terms of hospital stay, postoperativebleeding, postoperative pain, recurrences, incontinence patient can be benefitted with early outcome with less complications associated, so this study being done to evaluate the standard procedure in terms of with less complication associated. Objectives of the study: To compare the LIFT with fistulectomy in term of operative time, postoperative, bleeding, hospital stay, wound healing, postoperative pain, recurrence, incontinence Methods: Patients satisfying inclusion criteria are enrolled within 24 hours of admission after informed consent. All the patients with Trans sphincteric fistula in ano will be evaluated with thorough clinical examination, radiological and laboratory investigations. Those who require surgery will be admitted and appropriate surgery will be performed .and analyzed for in term of operative time, postoperative bleeding, hospital stay, postoperative pain, recurrence, incontinence. Results: Majority of patients belonged to the age group of 30 -40 years. M:F is 4:1, Duration of hospital stay is significantly low in LIFT group with P<0.417, Post-operative pain is less in LIFT group with P<0.002, Post-operative woundHealing time are less with LIFT group . Incontinence is less with LIFT group when compared to Fistulectomy with P<0.0452, recurrence is noted in either group but more in LIFT group. Success rate in our study is 90% in LIFT group. Interpretation and conclusion: LIFT is associated with less postoperative pain, shorter duration of hospital stay and a quicker recovery, shorter duration of surgery, earlier return to work as compared with fistulectomy. LIFT procedure is not associated with major post-operative complications. There is no incontinence in the follow up period of six months.

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

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.

Modified Lift Versus Cutting Seton for Transphincteric Fistula -Experience at Tertiary Care Hospital

Background: Fistula in ano is a common disease which has high recurrence rate and high fecal incontinence rate after surgery. We compared modified LIFT (Ligation of the intersphincteric fistula tract (LIFT) through lateral approach ) with cutting seton for transphincteric fistula. Aim: This study is aimed at which procedure is better with respect to postoperative complications Study design: It was a prospective comparative study. Methods: This was a prospective comparative study from 01-01-2019 to 30-06-2021 which was conducted on 50 patients who presented with transsphincteric fistula in ano (FIA) in surgical ward of Bahawal Victoria Hospital Bahawalpur. Patients were divided into two groups .Patients of Group A underwent modified lift procedure and patients of group B underwent cutting seton procedure. Data was collected on a proforma which included patients’ name ,age ,sex, age group, comorbid disease like diabetes mellitus ,chronic liver disease, cardiovascular disease and chronic renal failure, fistula tract involving less than 50% or more than 50% external sphincter ,procedure done, healing time of wound, complications like recurrence and incontinence. Patients were followed for 6 months for healing rate ,recurrence and incontinence. Data was analysed on spss 22 version Results: In Group A, complete healing (fistula closure without recurrence) was achieved in 20 patients (80%) out of 25. There was no case of anal incontinence after the procedure. 5 (20%) patients experienced recurrence in 6 months . In Group B, complete healing (fistula closure without recurrence) was achieved in 21 patients (84%), in 6 months follow up . 4(16%) patients were diagnosed as a case of anal incontinence. There were 4 (16%) patients with recurrence. Conclusion: Modified LIFT is better in terms of incontinence where as cutting seton is better in terms of recurrence.it is suggested that for high lying fistula modified LIFT is better procedure and for low lying fistula involving less than 50% sphincter cutting seton is better procedure.. Keywords: Modified LIFT (ligation of ineter sphincteric fistula tract) ,Cutting seton , transphincteric fistula.

A prospective interventional study on ligation of intersphincteric fistula tract in patients with fistula-in-ano-as a tertiary care centre

Background: Fistula-in-ano is a very common condition encountered in proctology OPD. The treatment of fistula-in-ano is difficult due to potential risk of recurrence and fecal incontinence. Ligation of Intersphincteric Fistulous Tract is new modality of treatment for the condition. LIFT is a sphincter preserving surgery, aim of our study to evaluate the effectiveness of LIFT surgery.Methods: We did LIFT surgery in 35 cases of intersphincteric and transsphincteric types of fistula-in-ano during the period of December 2019 to July 2020. Standard investigation protocol was followed in all cases. Evaluation of effectiveness of procedure done in terms of anal incontinence, wound healing time, recurrence rate and wound infection rate.Results: 35 patients (23 men, 12 women) were included with mean age of 40 SD 10.38 years. Most of study population have Inter sphincteric fistula (62.9%), and 37.1% participants have trans sphincteric fistula. Healing time was 10-15 days (42.9%) and mean healing time is 17 SD 4.25 days. We didn’t see a single case of anal incontinence with LIFT in our study. 6 cases of recurrence were seen.Conclusions: Result from our study showed that LIFT surgery is effective modality and fulfilling the outcome of sphincter preservation.

Application of MRI Images Based on Autoregressive Model Algorithm in Diagnosis and Classification of Anal Fistula Disease

Objective: To analyze the accuracy of DWI-MRI combined with conventional MRI sequence in the diagnosis and classification of anal fistula, and to explore its application value. Methods: The clinical and imaging data of 56 patients with anal fistula confirmed by surgery were collected. All patients underwent conventional MR scans (axial T1WI, T2WI and axial, coronary, sagittal T2WI fat suppression) and axial DWI. With the surgical pathology results as the gold standard, the diagnostic compliance rate of anal fistula inside and outside mouth, main fistula, branch fistula, and abscess were observed and relied on both conventional sequence and conventional sequence combined with DWI. At the same time, the patients in this group were classified according to Parks classification of anal fistula, and the results were compared with the surgical results. Results: Fifty-six patients with anal fistula were confirmed to have 7 simple anal fistulas and 49 complicated anal fistulas. According to Parks anal fistula classification, MRI diagnosed 7 cases of intersphincteric fistula, 24 cases of trans sphincteric type fistula, 16 cases of superior sphincteric type fistula, and included 9 cases of rectal vaginal/scrotal fistula into the scope of extra-sphincteric fistula. The overall coincidence rate of scores was 87.5% (49/56). Conclusion: In preoperative MRI examination of anal fistula, compared with relying only on conventional sequences, the combined use of DWI sequences has higher accuracy in displaying the inner, outer and branch fistulas, and provides more detailed images before clinical operation. Anatomical information should be applied as a routine examination sequence for preoperative diagnosis of anal fistula.

Uses of FiLaC laser as a sphincter-preserving technique in closure of fistula tract in Upper Egypt

Aim Treatment of anal fistula as one of anorectal disease is difficult. Anal incontinence and recurrence of fistula are fearful morbidities of surgeons. Many techniques for sphincter preservation such as internal sphincter fistula tract attachment, anorectal flap application, and bioprosthetic plugs have been tried to overcome the complications. This article aimed to estimate the safety and efficacy of the FiLaC method in the management of fistulous tract. Patients and methods A total of 26 patients (22 males, four females) who underwent FiLaC diode laser treatment between October 2019 and October 2020 were admitted at the Surgical Department, Al Azhar University Hospital, Assiut, and Al-Rowad Hospital, Assiut. They were retrospectively analyzed for age and sex, BMI, American Society of Anesthesiologist score, duration of operation, fistula types, complications, and patient satisfaction. FiLaC a 15-W laser probe with a wavelength of 1470 nm and a power of 100–120 J/cm was applied to the fistulous track under the spinal anesthesia. Results The number of male patients were 22 and female patients were four, and the mean age was 35.55±10.32 years. The mean time of operation was 18.37±5.27 min. Intraoperative complications were not recorded. The period of follow-up was 12 months. A total of 23 (88.46%) patients recovered. There were three (11.53%) failures. Satisfaction score of the patients was 4.62±1.07. Conclusion FiLaC laser for the use of closure of fistulous tract is an effective, safe, minimally invasive technique for preservation of the anal sphincter, with a high success rate.

Ligation of intersphincteric fistula tract versus incision-thread-drawing procedure for complicated anal fistula: A Meta-analysis

Ligation of intersphincteric fistula tract versus incision-thread-drawing procedure for complicated anal fistula: A Meta-analysis

Improvement in quality of life in patients with Fistula-In-Ano, following surgical management, a prospective observational study

Background: Fistula-in-ano may lead to significant worsening of quality of life of affected person. But studies documenting the impact of treatment on quality of life are very limited in Indian population. Hence the current study was conducted with an objective of asseseing the improvement in quality of life in patients undergoing surgical management of fistuala-in-ano in a tertiary care teaching hospital in south India. Methodology: The current study was a prospective observational study, conducted in the department of general surgery of Dr. SMCSI Medical college hopital, between February and December 2016. A total of 45 subjects aged between 20 to 80 years, suffering from various types of fistual in ano, managed with surgical intervention were included in the study. Quality of life before and after surgery was assessed by GIQLI questionnaire. Results: Among the 45 subjects, 71.11% were males majority were aged between 41 to 60 years. The proportion of Inter sphincteric fistula was 48.88% whereas Trans-sphincteric fistula and Supra sphincteric fistula were 33.33% and 17.77% respectively. Fistulectomy was conducted in 44.44% of cases. Fistulotomy and insertion of cutting setons were done in 31.11% and 24.44% cases. Mean values of symptoms pre and post-operative were 49.50 and 66.25 and the association was statistically significant (P=<0.01). Mean associated physical disease was 14.25 before surgery and the post-operative mean was 22.76 with a statistically significant mean difference (P=<0.01). Preoperative Mean values for emotions, social integration, and effects of treatment were 7.65, 8.26 and 3.00 respectively, whereas Post-operative means were 15.27, 14.40 and 3.65. There were statistically significant mean differences for Emotions, social integration and effects of treatment. Mean Total score of pre-surgery was 89.05 and post-surgery was 120.26 with statistically significant mean difference. (P=<0.01). Conclusions: 1) There is a significant improvement in the quality of life postoperatively in patients of Fistula in ano. 2) GIQLI score is an useful tool to assess the quality of life in Fistula in ano patients.

Loose Seton: A Misnomer of Cutting Seton

Purpose: The purpose of this study was to demonstrate loose silk seton actually acts as a slow cutting seton contrary to the idea of simply drainage. Besides, to show the effect of loose seton on patient’s incontinence is mostly proportional to the degree of division of the sphincter muscle. Design: Fifty patients with high transsphincteric fistulas were treated with loose seton technique. We measured the length of high sphincteric fistula tracts, pre- and postoperative anal sphincter pressures and incontinence scores. Results: Loose seton with heavy silk resulted in 72% percent of progressive migration of the fistula tract caudally. The more the progressive migration of the loose seton loop, the less the pressure drop in both resting and squeezing in manometric studies. This study is limited by its retrospective design in prospectively collected data and covers relatively small number of patients. Conclusion: Seton is still useful technique in high perianal fistula surgery. Defining this technique as simply “loose” seton is misnomer since it acts as a slowly cutting seton and results in progressive migration of the fistula tract caudally. The more the progressive migration of the loose seton loop, the less the pressure drop would be possible after postoperatively.

Modified ligation of the intersphincteric fistula tract in the treatment of simple transsphincteric perianal fistula

To assess the efficacy and safety of modified ligation of the intersphincteric fistula tract for simple transsphincteric perianal fistula. Seventy patients with simple transsphincteric perianal fistula between October 2012 and January 2014 in our department were prospectively enrolled. According to the random number table, patients were divided into two groups: modified-LIFT group (37 cases, from the external opening close to the fistula, dissect the external sphincter fistula to the intersphincteric groove by tunneling technique, resect the lateral free fistula) and LIFT group (33 cases). Clinical parametres before and after operation were compared, and results of pelvic electromyogram (EMG) and anorectal manometry three months after operation were analyzed to evaluated anal function. The operative time, pain score, hospital stay, and healing time were not significantly different between the two groups (all P>0.05). During the median follow-up of 12 months (3-20 months), the healing rate in modified-LIFT group was 83.8% (31/37), which was significantly higher than 60% (20/33) in LIFT group (P=0.029). After operation, 4 patients had persistent unhealed wound, 2 recurred in modified-LIFT group, while 8 patients had persistent unhealed wound, and 5 recurred in LIFT group. No patients developed anal incontinence. By the pelvic EMG and anorectal manometry 3 months after operation, the duration of motor unit potential, occurrence of simple phase, mean resting pressure and maximun squeeze pressure were not significantly different. Modified-LIFT procedure for the management of simple transsphincteric perianal fistulas is a simple and effective operation with higher healing rate and similar anal function as LIFT.

Intersphincteric Approach for Deep Postanal Sepsis

See Article on Page 55-59 The article is interesting enough to draw the attention of surgeons because the intersphincteric approach for the treatment of deep postanal sepsis seems to be a novel procedure. The deep postanal space is clinically significant because it can provide routes for the extension of an infection when a cryptoglandular infection enters into this potential space, complicating treatment, potentially leaving a severe deformity and possibly compromising continence when conventional treatment is used [1, 2]. Several techniques, such as advancement flap, a fistula plug (AFP) and stem-cell injection, have been attempted to treat complex fistulas [3, 4]. However, they have the limitations of technical difficulty, unsatisfactory results and high cost. Ligation of inter sphincteric fistula tract (LIFT) has recently been introduced to overcome these limitations [5]. LIFT is technically simple and shows reproducible results with relatively satisfactory success rates. However, LIFT also has limitations in terms of indications. LIFT is not feasible if a fistula has a blind end or an accompanying abscess. Further, most studies were performed on patients with a trans-sphincteric fistula. There have been few reports on more complicated fistulas [6]. The authors' novel approach has the obvious advantages of its being a one-stage procedure and its being capable of preserving an intact sphincter, regardless of the presence of an abscess. However, this approach doesn't seem to be an entirely novel procedure, but a modification of LIFT in general. Technical differences are suturing the fistulous tract of the internal sphincter side instead of ligation and using suction drainage. There are also differences in terms of indications. The authors seem to have dealt with various conditions of infection, including abscesses, fistulas and fistulous conditions without an external opening. In my opinion, the technical similarity, the differences in indications, and the small number of patients may prevent readers of this article from taking the results as a convincing outcome. There may be few surgeons who would try an excision of an infected gland by dissecting the intersphincteric plane when there is irrefutable evidence of deep postanal space abscess. This is because LIFT is not generally indicated when there is a simultaneous abscess. Technically, LIFT can be performed even in patients with a concurrent abscess if the fistulous tract in the intersphincteric space is identified. However, technical feasibility doesn't always mean a favorable outcome. I doubt we can overcome the limitations of LIFT by simply using suction drainage. Furthermore, I am not confident that we can predict the presence of fistulous tracts in the intersphincteric space. Of special concern, a fistulous tract may not be detected in an acute stage of infection and abscess [7, 8]. Even in cases of simple perianal abscesses, a fistulotomy is not indicated when there is no identifiable internal opening [9]. When there is not an identifiable tract in the intersphincteric plane, there may be few options we can choose from. Another concern is the huge difference in success rates between the primary- and the secondary-procedure groups. The authors reported a 70% success rate, which is similar to the reported rates of LIFT. However, the success rate for the secondary-drainage group (20%) was much worse compared to that for the primary-procedure group (91%). The authors' explanation that infected glands might have been obliterated after the drainage procedure doesn't sound reasonable. The difference in the success rates more likely resulted from the small number of patients or possibility some patients being more suitable for this procedure. In short, interpreting the results and predicting the feasibility of the procedure is very difficult because of the small number of patients. There may be some patients who are good candidates for this new procedure. A large-scale study seems to be necessary to confirm the effectiveness of this procedure and to refine the indications for this procedure.

LIFT procedure: a simplified technique for fistula-in-ano

The novel modified approach through the intersphincteric plane for the treatment of fistula-in-ano, known as LIFT (ligation of inter sphincteric fistula tract) procedure, is described in detail. LIFT procedure is based on secure closure of the internal opening and removal of infected cryptoglandular tissue through the intersphincteric approach. Essential steps of the procedure include, incision at the intersphincteric groove, identification of the intersphincteric tract, ligation of intersphincteric tract close to the internal opening and removal of intersphincteric tract, scraping out all granulation tissue in the rest of the fistulous tract, and suturing of the defect at the external sphincter muscle. Attention to detail is the key for a favorable outcome.

P202 - Diverting loop ileostomy after restorative proctocolectomy for ulcerative and indeterminate colitis: predictors of outcome and quality of life

P202 - Diverting loop ileostomy after restorative proctocolectomy for ulcerative and indeterminate colitis: predictors of outcome and quality of life

Controlled, randomized trial of island flap anoplasty for treatment of trans–sphincteric fistula–in-ano: early results

Treatment of trans-sphincteric fistula is usually a compromise between recurrence and incontinence. Dermal island flap anoplasty has been found to be useful in the treatment of these fistulas. We performed a randomized trial to compare dermal island flap anoplasty with conventional treatment for trans-sphincteric fistula-in-ano. Seventy nine patients with fistula-in-ano were recruited; twenty patients with trans-sphincteric fistula confirmed by endoanal ultrasound were prospectively randomized to receive either dermal island flap anoplasty (IFA) or conventional treatment (CVN) for trans-sphincteric fistula-inano. Conventional treatment consisted of lay open fistulotomy or seton insertion if deemed unsuitable for fistulotomy. Dermal island flap anoplasty involved a cutaneous advancement flap into the rectum. Pain scores, fecal incontinence scores, operative complications, wound healing and recurrence rates were charted. Two patients in the CVN group required seton insertions, which were still intact at the 9-month follow-up. Two patients with similar high trans-sphincteric fistula in the IFA group avoided having a long-term seton. There were no differences in the postoperative pain score, incontinence score, complications, wound healing and recurrence rates between the two groups. IFA is a safe and useful method for treating transsphincteric fistula. It can be considered when a suprasphincteric extension is suspected, thus avoiding risk of incontinence or the discomfort of a long-term seton.

私の歩んできたこう門病学

Colo-Proctology Center was begun at the Department of Surgery of the Social Insurance Central Hospital in 1960. Patients with coloanal disease and number of surgeries have been gradually increased and number of patients treated at the Center were about 6, 000 and 848 instances underwent surgery in 1992.As for hemorroidal surgery, Whitehead's method had been performed in our department up to 1961, but since then Millingan-Morgan method and its modified methods have been performed.Ligation and Excision methods had been used for only 3.3 percent until 1958 in Japan but for 82.6 percent in 1977.As for fistula in ano, we presented threedimentional classification using symbols representing the extension of the fistula, sites of penetration in the sphincter and its relationship to the perirectal spaces (1972). This classification is used presently in the discussion of anal fiitula in Japan.A sphineter preserving method has been used on IIL (low inter sphincteric fistula) in which a fistulous tract is situated laterally or anteriorly to the anus. For II HC (complicated high inter sphincteric fistula) or type III (Ischiorectal fistula), conservative correction by P.H. Hanley (New Orleanse) has been used.In a treatment of anal fissure conservative methods have mostly been used ambulatory, lateral subcutaneous internal sphincterotomy has been performed in the patients with severe anal pain and only a few patients with chronic ulcer undergo surgery.As for postoperative disturbances, half of them are caused by Whitehead's method and the causes for recurrence of anorectal fistula were persistence of the primary lesion, persistence of fistula, remaining infective lesion, and inappropriate drainage.A conference on colo-proctology, in which discussion on one theme was frankly done, has been continuing, and it is useful for daily practice of colo-proctology, being well-received by doctors.Many doctors, who are interested in colo-protology, have visited the Colo-Proctology Center, after several training sessions, they have been encouraged in their work and have been trying to raise the level of knowledge and treatment in this field.