Fistula Surgery Research Articles

Childbearing after treatment for obstetric fistula: perspectives from survivors in Malawi

Women who suffer from an obstetric fistula endure more than just physical pain. Their ability or desire to bear children may also be affected due to physical damage to their reproductive organs. In addition, they may suffer from emotional trauma which is likely to affect their decision to have children. The aim of this study therefore was to explore in more detail the perspectives of obstetric fistula survivors about childbearing after treatment for their condition. This qualitative study was conducted at a non-governmental organisation in the Central Region of Malawi. Data was collected using in-depth interviews from 18 women who had suffered from an obstetric fistula. The study revealed that many women either had no further desire for children or were unable to bear children. Fear of dying and resulting pain from the fistula surgery deter women from wanting further pregnancies. However, there was still strong emphasis placed on childbearing, especially for the younger women who desired children as a means of maintaining their marriages. The risk of further pregnancies and mitigation strategies for reducing obstetric fistulas, should be fully communicated to women. Those who become infertile as a result of obstetric fistula may also require appropriate counselling.

Effect of incision location and type of fistula on postoperative urinary retention after radical surgery for anal fistula: a retrospective analysis

BackgroundPostoperative urinary retention (POUR) is a common complication characterized by fullness of the bladder without the ability to urinate. Its etiology in proctology surgery is multifactorial. This study aimed to identify the risk factors for POUR after radical surgery for anal fistula.MethodsWe retrospectively reviewed the clinical records of 511 patients who underwent radical surgery for anal fistula at the China-Japan Friendship Hospital from August 2022 to December 2023. Risk factors for POUR were analyzed by means of binary logistic regression analyses.ResultsPOUR occurred in 57 patients (11.2%) within 48 h post-surgery, and males were predominantly affected (84.4%). Independent risk factors included a history of urological disease (OR = 6.048; p < 0.001), incisions at position 1 (OR = 2.228; p = 0.046), high anal fistula (OR = 4.768; p < 0.001), VAS score ≥ 7 (OR = 2.805; p = 0.010), and GAD-7 score ≥ 5 (OR = 2.405; P = 0.024).ConclusionPOUR is a significant complication post-radical surgery for anal fistula, particularly among patients with urological disease, high anal fistula, and incisions at position 1. Surgeons should pay more attention to surgical methods for high anal fistulas and fistulas in the anterior rectum, and monitor postoperative bladder volume in high-risk patients. Enhanced postoperative pain and anxiety management can reduce the incidence of POUR and prevent long-term bladder damage.

Results of surgical treatment of chronic pancreatitis with a high risk of developing pancreatic cancer

Objective. To analyze the results of surgical treatment of patients with pancreatic insufficiency and a high risk of developing pancreatic cancer. Materials and methods. The study included 39 patients treated in 2019–2023. In 20 (51%) patients, it was difficult to clearly differentiate between chronic pancreatitis and pancreatic cancer. In 19 (49%) patients, the diagnosis of chronic pancreatitis was not in doubt. All patients with complicated forms of chronic pancreatitis and suspected pancreatic tumor underwent a set of laboratory tests, and routine screening methods of instrumental diagnostics were used. In addition to standard methods of examination, the levels of matrix metalloproteinases and tissue inhibitor of metalloproteinases in the blood plasma were studied. Results. The method of intraoperative multiple biopsy, improved by us, was an obligatory component of surgical care for a clear differential diagnosis of chronic pancreatitis and pancreatic cancer. In the presence of complicated chronic pancreatitis, during surgery, the biopsy was taken using a special punch instrument that resembles a pen, along the entire length of the main pancreatic duct along the upper and lower edges of the dissection in a checkerboard pattern. There were no complications of punch biopsy. Of the 20 patients in whom it was not possible to clearly differentiate between chronic pancreatitis and pancreatic cancer, 12 (60%) were diagnosed with diabetes mellitus. The characteristic changes in the pancreatic tissue gave grounds for performing extended resection interventions in these patients. In the remaining 8 (40%) patients without morphological changes inherent in malignancy, Whipple operation (2), longitudinal pancreaticoduodenectomy (2), Frey operation (2), and our proposed central pancreatic resection with preservation of the left anatomical segment (2) were performed. Drainage and resectional surgical interventions were performed in 19 (49%) patients with complicated forms of chronic pancreatitis. After radical surgical interventions for pancreatic cancer, 1 patient developed gastrostasis, and on the 11th day he underwent a relaparotomy with reconstruction of the gastroenteroanastomosis, and on the 30th day a subhepatic abscess was diagnosed in 1 patient, who underwent drainage with a subcostal mini–access with a positive effect. In 2 patients, after left–sided pancreatic resection, subdiaphragmatic abscesses were diagnosed on the left, they were treated minimally invasively with punctures and drainage under ultrasound control. Multiple organ failure occurred in 1 patient after surgery for internal pancreatic fistula, infected ascites as a complication of neglected chronic pancreatitis. The patient died. Infection of the median laparotomy wound occurred in 4 patients, and healing was achieved by controlled primary tension. Class B pancreatic fistulas occurred in 3 patients: 2 – after left–sided pancreatic resection, 1 – after longitudinal pancreaticoduodenostomy. In 1 patient, a class C permanent pancreatic fistula was formed after a combined (resection and drainage) intervention. Relaparotomy, subtotal resection with Roux–en–Y loop closure was performed. Conclusions. Morphological changes in the pancreatic tissue in chronic pancreatitis in combination with diabetes mellitus, corresponding to the development of PanIN, are direct predictors of adenocarcinoma. Multiple intraoperative pancreatic biopsies are effective in verifying pancreatic malignancy. Pre– and intraoperative diagnostics make it possible to optimize the surgical treatment of complicated forms of chronic pancreatitis and prevent the development of postoperative pancreatic fistula.

Efficacy of Using a Vessel Dilator during Surgery to Evaluate Vein Diameter and Predict Radiocephalic Arteriovenous Fistula Maturation and Patency

Background: We use vessel dilators to assess the diameter of the target vein during surgery for arteriovenous fistula (AVF) creation in hemodialysis patients. This study investigates the efficacy of using vein diameter as measured using dilators (surgical diameter; SD) versus that as measured by preoperative ultrasonography (ultrasonographic diameter; UD) to predict postoperative complications and patency. Methods: Sixty-three patients who underwent radiocephalic AVF creation and had measurements of UD and SD were retrospectively analyzed. Cutoff values for UD and SD regarding complications were used to dichotomize the patients into high and low groups for comparisons. Results: The 2-year primary and secondary patency rates overall were 66.5% and 88.9%, respectively. The optimal UD and SD cutoff values were 2.4 and 3.5 mm, respectively. The 2-year primary patency rate was higher in the high-SD group than the low-SD group (88.2% vs. 58.6%; p = 0.0426). The 2-year secondary patency rate was significantly higher in the high-UD/high-SD group than the low-UD/low-SD group (91.7% vs. 68.4%; p = 0.0067). Conclusions: Intraoperative measurement of vein diameter using dilators during AVF creation might be a useful method of predicting patency, particularly when SD is used in combination with UD.

Postoperative rectovaginal fistula: stoma may not be necessary—a French retrospective cohort

BackgroundPostoperative rectovaginal fistula leads to a loss of patients’ quality of life and presents significant challenges to the surgeon. The literature focusing specifically on postoperative rectovaginal fistulas is limited. The objective of the present study is to identify factors that can enhance the success of the management of this postoperative rectovaginal fistula.MethodsThis retrospective multicentric study included all patients undergoing surgery for rectovaginal fistulas, excluding those for whom the etiology of rectovaginal fistula was not postoperative. The major outcome measure was the success of the procedure.ResultsA total of 82 patients with postsurgical fistulas were identified, of whom 70 were successfully treated, giving a success rate of 85.4%. On average, these patients required 3.04 ± 2.72 interventions. The creation of a diversion stoma did not increase the success rate of management [odds ratio (OR) = 0.488; 95% confidence interval (CI) 0.107–2.220]. Among the 217 procedures performed, 69 were successful, accounting for a 31.8% success rate. The number of interventions and the creation of a diversion stoma did not correlate with the success of management. However, direct coloanal anastomosis was significantly associated with success (OR = 35.06; 95% CI 1.271–997.603; p = 0.036) as compared with endorectal advancement flap (ERAF). Other procedures such as Martius flap did not show a significantly higher success rate.ConclusionThe creation of a diversion stoma is not necessary in closing a fistula. ERAF should be considered as a first-line treatment prior to proposing more invasive approach such as direct coloanal anastomosis.

Study of Factors Influencing the Results of Urogenital Fistula Surgery at Brazzaville University Hospital in Congo

Study of Factors Influencing the Results of Urogenital Fistula Surgery at Brazzaville University Hospital in Congo

185 - Robotic-assisted repair surgery for recurrent complex colorectal vesical fistula: Technique of one stage surgery

185 - Robotic-assisted repair surgery for recurrent complex colorectal vesical fistula: Technique of one stage surgery

Application of prophylactic flow restriction in brachiocephalic arteriovenous fistulas

To investigate the effects of prophylactic flow restriction for brachiocephalic arteriovenous fistula on postoperative high-flow-related complications and patency rate in patients undergoing hemodialysis. Clinical data of patients with end-stage renal disease who underwent brachiocephalic arteriovenous fistula surgery for hemodialysis from February 2017 to May 2022 in Department of Nephrology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine were retrospectively analyzed. During surgery, a 4-5 mm vascular suture loop was placed around the vein near the anastomosis as a flow restriction device in 43 patients (flow restriction group), while 42 patients did not receive the prophylactic flow restriction ring (control group). All patients were followed up for 1 to 5 years. The incidence rates of complications related to the hemodialysis access pathway, including distal ischemia syndrome, the formation of arteriovenous fistula aneurysms, thrombus, high-flow congestive heart failure, anastomosis of the vein within 1 cm of the anastomosis and cephalic arch stenosis, were compared between the two groups. The natural blood flow rate of the arteriovenous fistula, anastomosis size, the internal diameter of the vein near the anastomosis, primary patency rate, assisted primary patency rate, and secondary patency rate of the arteriovenous fistula, were also evaluated and compared between the two groups. Logistic regression analysis was used to investigate the factors affecting arteriovenous fistula patency rates, as well as the impact of the flow-restricting ring on postoperative factors. Ultrasound measurements showed that the internal diameter of the vein at the site of the flow restriction ring in the flow restriction group was (3.7±0.6) mm at three months postoperatively, which was significantly smaller than the internal diameter of the narrowest part of the vein near the anastomosis in the control group [(4.1±1.0) mm, t=－2.416, P<0.01]. The postoperative anastomotic diameter and natural blood flow rate of the arteriovenous fistula in the flow restriction group were both significantly lower than those in the control group (both P<0.05). Furthermore, the incidence rates of various complications in the flow restriction group were significantly lower than those in the control group (all P<0.05). At 6, 12, and 24 months postoperatively, the primary patency rate and assisted primary patency rate in the flow restriction group were significantly higher than those in the control group (both P<0.05), while there was no significant difference in secondary patency rates between the two groups (P>0.05). Binary logistic regression analysis indicated that age, diabetes, and natural blood flow rate of the arteriovenous fistula at 3 months postoperatively were independent risk factors for primary patency rate, while the flow restriction for brachiocephalic arteriovenous fistula was an independent protective factor for primary patency rate (P<0.01 or P<0.05). The application of flow restriction was negatively correlated with anastomotic diameter at 6 and 12 months, natural arteriovenous fistula blood flow, and the incidence rates of cephalic arch stenosis and aneurysm formation (all P<0.05). The prophylactic constriction during brachiocephalic arteriovenous fistula surgery in patients undergoing hemodialysis can limit the size of the anastomosis and postoperative arteriovenous fistula blood flow, reducing complications such as cephalic arch stenosis and high-flow heart failure, and increasing primary patency rates of arteriovenous fistula and delay the reintervention of the fistula.

Clinical study on the establishment of radio-cephalic autogenous arteriovenous fistulas in small blood vessels by multi-segment balloon dilation technique.

To investigate the effect of dilating small blood vessels using a balloon dilation (BD) technique on the occurrence of radio-cephalic autogenous arteriovenous fistulas in terms of patency, blood flow, and vein diameter (VD). The subjects included in this study were all patients with chronic renal failure and required radio-cephalic arteriovenous fistula surgery for the first time and had not received dialysis before. Patients with VDs <2 mm were included as study subjects. They were either assigned treatment using a BD group or a control group that received hydrostatic dilation. The differences between the 2 groups were analyzed in terms of patency, blood flow, and VD. A total of 22 patients were enrolled in the balloon dilatation group and 20 patients in the control group. The diameters of cephalic veins (mm) of the experimental and control group were compared at various time points: immediately postoperation, 2.89 ± 0.42 versus 1.99 ± 0.28 (P < .001); 1 week later, 3.16 ± 0.59 versus 2.66 ± 0.60 (P = .022); 1 month later, 3.76 ± 0.91 versus 3.18 ± 0.83 (P = .087); and 2 months later, 4.08 ± 1.15 versus 3.38 ± 1.13 (P = .169). Brachial artery flows (mL/min) of the 2 groups at various time points were given as follows: immediately postoperation, 413.49 ± 145.09 versus 235.61 ± 87.77 (P < .001); 1 week later, 563.26 ± 206.83 versus 331.30 ± 126.78 (P < .001); 1 month later, 679.34 ± 218.56 versus 376.79 ± 156.25 (P < .001); and 2 months later, 736.31 ± 202.61 versus 394.60 ± 161.96 (P < .001). The primary patency at 1 year for the experimental group was 61.9% compared to 11.1% for the control group (P = .045). Similarly, the secondary patency rates at 1 year were 90.5% for the experimental group and 55.6% for the control group (P = .030). The results showed that the functional primary patency rate within 1 year was 57.1% versus 16.7% (P = .032), and the functional secondary patency rate within 1 year was 85.7% versus 50.0% (P = .038). BD has obvious advantages over hydrostatic dilation for chronic renal failure patients with small veins in establishing arteriovenous fistula in terms of patency and blood flow.

Supporting Women after Obstetric Fistula Surgery to Enhance Their Social Participation and Inclusion.

Obstetric fistula is a childbirth complication causing abnormal openings between the urinary, bowel, and genital tracts, leading to involuntary leakage and potential long-term disability. Even after surgical repair, women continue to face psychological and social challenges that affect their social inclusion and participation. This study explored family and service provider perspectives on current support systems and identified gaps affecting women's inclusion and participation post-fistula surgery. Building on a prior study of women who underwent obstetric fistula surgical repair, we qualitatively examined available formal and informal post-surgical supports in Ethiopia. We conducted 20 interviews with family members and service providers and analyzed them using Charmaz's grounded theory inductive analysis approach. We identified four themes that indicated the available formal support in fistula care, the impact of formal support on women's social participation and inclusion, the gaps in formal support systems, and post-surgery informal supports and their challenges. Both groups believed support needs for women after surgery remain unmet, highlighting the need to strengthen holistic support services to improve women's social inclusion and participation. This study contributes to limited research on formal and informal support for women, emphasizing the need for enhanced economic, psychological, and sexual health-related support post-obstetric fistula surgery.

Elinor Catherine Hamlin (1924-2020): 'The beloved daughter of Ethiopia'.

Elinor Catherine Hamlin (1924-2020) was a world-renowned Australian obstetrician and gynaecologist who dedicated almost her entire adult working life to eradicating obstetric fistula in Ethiopia. Leaving behind a comfortable life in Sydney and later Adelaide, she travelled with her husband Reginald Hamlin (1908-1993) to Addis Ababa in 1959, with the view to working there for three years and helping set up a midwifery school at the Princess Tsehai Memorial Hospital. But the couple ended up spending the rest of their lives in Ethiopia, where they revolutionised maternal healthcare services and standardised best practice measures for fistula patient care. In 1975 they jointly opened the Addis Ababa Fistula Hospital - at that time the only operating specialist fistula hospital in the world - which was destined to become a global centre of excellence in obstetric fistula surgery. Today the hospital carries on Catherine Hamlin's legacy as one of Sydney's most impactful medical graduates on the world stage.

Nomogram for predicting intolerable postoperative early enteral nutrition following definitive surgery for small intestinal fistula: a cohort study.

This study was designed to develop and validate a nomogram for predicting intolerable early enteral nutrition (EEN) following definitive surgery (DS) for small intestinal fistula. A total of 377 patients, recruited from January 2016 to September 2023, was randomly allocated into development ( n =251) and validation ( n =126) groups in a 2:1 ratio. Risk factors were identified using the nomogram. Its performance was assessed based on calibration, discrimination, and clinical utility, with validation confirming its effectiveness. Of the 377 patients, 87 (23.1%) were intolerant to EEN, including 59 (23.1%) in the development cohort and 28 (22.1%) in the validation cohort ( P =0.84). Four factors were identified as predictive of intolerable EEN: severe abdominal adhesion, deciliter of blood loss during DS, human serum albumin (Alb) input >40g during and within 48h post-DS, and the visceral fat area (VFA)/total abdominal muscle area index (TAMAI) ratio. The model demonstrated excellent discrimination, with a C-index of 0.79 (95% CI: 0.74-0.87, including internal validation) and robust calibration. In the validation cohort, the nomogram showed strong discrimination (C-index=0.77; 95% CI: 0.64-0.87) and solid calibration. Decision curve analysis affirmed the nomogram's clinical utility. This research introduces a nomogram that enables the individualized prediction of intolerable EEN following DS for small intestinal fistula, demonstrating a possible clinical utility.

Visceral to subcutaneous fat area ratio predicts severe abdominal adhesions in definitive surgery for anastomotic fistula after small intestine resection

Abdominal adhesions manifests following abdominal infections triggered by intestinal fistulas. The severity of such adhesions depends on the extent of fiber deposition and peritoneal fibrinolysis following peritoneal injury, which may be influenced by sustained inflammation within the abdominal cavity. In this regard, the visceral-to-subcutaneous fat area (VFA/SFA) ratio has been implicated as a potential marker of inflammation. This study aimed to explore the relationship between VFA/SFA and abdominal adhesions. This multicenter study was conducted across four tertiary institutions and involved patients who had undergone definitive surgery (DS) for intestinal fistula from January 2009 and October 2023. The presence of abdominal adhesions was determined intraoperatively. VFA/SFA was investigated as a potential risk factor for severe adhesions. The study comprised 414 patients with a median age of 50 [interquartile range (IQR) 35–66] years and a median body mass index of 20.0 (IQR 19.2–22.4) kg/m2, including 231 males with a median VFA/SFA of 1.0 (IQR 0.7–1.2) and 183 females a median VFA/SFA of 0.8 (0.6–1.1). VFA/SFA was associated with severe abdominal adhesions in males [odds ratio (OR) = 3.34, 95% CI 1.14–9.80, p = 0.03] and females (OR = 2.99, 95% CI 1.05–8.53, p = 0.04). J-shaped association between VFA/SFA ratio and severe adhesions was revealed in both sex. The increasing trend can be revealed when OR more than 0.8, and 0.6 in males and females respectively. Preoperative VFA/SFA demonstrates predictive value for statues of severe abdominal adhesions in DS for anastomotic fistula after small intestine resection.

Comprehensive Clinical Profile and Hemodialysis Outcomes in Patients Attending a Tertiary Care Hospital.

Background Chronic kidney disease (CKD) can lead to serious conditions such as anemia and cardiovascular disease, posing a growing global health challenge. End-stage renal disease (ESRD) requires treatments such as dialysis or kidney transplantation. Despite the widespread impact and rising prevalence of CKD and ESRD, comprehensive data remains limited in India. This study seeks to investigate the clinical, socio-demographic, and etiological profiles of CKD patients undergoing hemodialysis at a tertiary care hospital, with the goal of enhancing understanding and improving patient care. Methodology This retrospective cohort study, conducted at a tertiary care center, included 500 CKD patients undergoing hemodialysis, with comprehensive medical records. Data collected covered demographics (age, sex, education, and occupation), CKD etiology, disease duration, hemodialysis duration, viral marker status, blood transfusions, and vascular access details. With continuous variables reported as mean ± standard deviation (SD) and categorical variables as counts (percentages), statistical analysis was carried out using SPSS version 21 (IBM Corp., Armonk, New York, USA). The connections were examined using the Pearson Chi-square test, with P≤0.05 being deemed significant. Results The study revealed that hypertension was the primary cause of CKD in 58% of patients, followed by diabetes mellitus in 13%. A significant 93% of patients tested negative for viral markers such as human immunodeficiency virus (HIV), hepatitis C virus (HCV), and hepatitis B surface antigen (HBsAg). Hemodialysis duration varied, with 68% of patients undergoing dialysis for one to five years. Most patients had two (40%) or three (58%) dialysis sessions per week, and 84% had only one arteriovenous (AV) fistula surgery. Blood transfusions were common, with 62% of patients receiving between one and five transfusions. The gender distribution showed more males (372) than females (201), and the majority of patients were aged between 41 and 60 years. Conclusion This study highlights the importance of early detection and management of CKD, emphasizing preventive health measures, enhanced diagnostic capabilities, and sufficient resource allocation to reduce the disease burden. It also calls for further research into unknown CKD causes and strategies to improve patient care and outcomes.

Reliable Stenosis Detection Based on Thrill Waveform Analysis Using Non-Contact Arteriovenous Fistula Imaging.

Hemodialysis therapy is an extracorporeal circulation treatment that serves as a substitute for renal function. In Japan, patients receive this efficient four-hour treatment, three times per week, allowing them to maintain a social life nearly equivalent to that of healthy individuals. Before the treatment, two punctures are performed to establish extracorporeal circulation, and a high blood flow rate is essential to ensure efficient therapy. Specialized blood vessels created through arteriovenous fistula (AVF) surgery are utilized to achieve high blood flow rates. Although the AVF allows safe and efficient dialysis treatment, AVF stenosis leads to a serious problem in dialysis. To early detect this abnormal blood flow, auscultation and palpation methods are widely used in hospitals. However, these methods can only provide qualitative judgment of the AVF condition, so the results cannot be shared among other doctors and staff. Additionally, since the conventional methods require contact with the skin, some issues require consideration regarding infection and low reproducibility. In our previous study, we proposed an alternative method for auscultation using non-contact optical imaging technology. This study aims to construct a reliable AVF stenosis detection method using Thrill waveform analysis based on the developed non-contact device to solve the problem with the contact palpation method. This paper demonstrates the performance validation of the non-contact imaging in the normal AVF group (206 total data, 75 patients, mean age: 69.1 years) and in the treatable stenosis group (107 total data, 17 patients, mean age: 70.1 years). The experimental results of the Mann-Whitney U test showed a significant difference (p=0.0002) between the normal and abnormal groups, which indicated the effectiveness of the proposed method as a new possible alternative to palpation.

Study on the effect and mechanism of Yanghe decoction Huacai on tissue repair ofsyndrome after anal fistula surgery.

To observe the clinical efficacy and safety of Yanghe decoction Huacai for the repair of Yin syndrome wounds with slow-healing after anal fistula surgery. A total of 120 patients with slow-healing negative wounds with after low-grade anal fistula surgery who met the inclusion criteria were divided into a treatment group and a control group based on a random number table method, with 60 patients in the treatment group and 60 patients in the control group. The treatment group was given Yanghe decoction Huacai in combination with routine treatment; the control group was only given routine treatment, in which the wound surface was disinfected with iodine, and then covered with sterile gauze. The course of treatment in both groups was 10 d. After treatment, the wound secretion score, wound granulation tissue score, the expression levels of basic fibroblast growth factor (bFGF), transforming growth factor β1 (TGF-β1), and epidermal growth factor (EGF) in the wound, wound healing time and clinical efficacy were compared. There was no significant difference in age or gender between the two groups (P > 0.05). On the 10th and 15th days after the surgery, the wound secretion scores were higher in the treatment group than in the control group (P < 0.01). Comparing the two groups at the 10th and 15th day after surgery, the granulation tissue growth scores in the treatment group were better than the in control group (P < 0.01). On the 10th and 15th day after operation, the expression levels of bFGF, TGF-β1 and EGF factors in the treatment group were stronger than those in the control group. The healing time of the wounds in the treatment group was significantly shorter than in the control group (P < 0.01). The clinical efficacy of the two groups after treatment was compared, and the overall efficacy of the treatment group was significantly higher than that of the control group (P < 0.01). Yanghe decoction Huacai have significant efficacy in the treatment of slow-healing wounds with Yin syndrome after anal fistula surgery. It improves wound secretions, promotes the growth of wound granulation tissue, and shortens wound healing time. Its mechanism of action may be related to the control of wound inflammation. It is related to increasing the expression of bFGF, TGF-β1 and EGF in wound tissue, and promoting wound angiogenesis and fibroblast proliferation.

Postoperative pain following laser fistula closure versus ligation of the intersphincteric fistula tract: A prospective double-blinded randomized controlled trial.

Prior studies focus primarily on surgical outcomes of anal fistula treatment, such as healing rates, rather than patient-reported outcomes, such as postoperative pain, which could influence surgical choice. To compare pain scores at 6 and 24h postoperatively between laser closure and ligation of the intersphincteric tract for anal fistula. Prospective, double-blinded randomized controlled trial. A quaternary hospital in Malaysia. Patients aged 18-75years with high transsphincteric fistulas. Fistula laser closure versus ligation of the fistula tract (LIFT) treatment. Pain scores, continence, quality of life (QOL), operative time, and treatment failure were compared using chi-square, Fisher's exact test, student t-test, or Mann-Whitney with p<0.05 denoting statistical significance. Fifty-six patients were recruited (laser, n=28, LIFT, n=28). Median pain scores for laser versus LIFT at 6h postoperatively were 1.0 versus 2.0 (Rest, p=0.213) and 3.0 versus 4.0 (Movement, p=0.448), respectively. At 24h, this reduced to 2.5 in both arms at rest (p=0.842) but increased to 4.8 versus 3.5 on movement (p=0.383). Median operative time for laser was significantly shorter (32.5min) than LIFT (p<0.001). Laser treated patients trended toward quicker return to work (10.5 vs. 14.0, p=0.181) but treatment failure was similar (54% vs. 50%, p=0.71). No patients developed postoperative incontinence. Mean SF-36 scores increased from baseline (67.1±17.0; 95% CI 63.6-82.4 vs. 71.3±11.4; 95% CI 64.0-75.0) to 6months postoperatively (77.7±21.0; 95% CI 57.0-80.3 vs. 74.0±14.3; 95% CI 67.6-81.4) regardless of the type of surgery (P>0.05). Patients with prior fistula surgery (approximately 20%) led to heterogeneity. The total laser energy delivered varied depending on fistula anatomy. Laser fistula closure is an alternative to LIFT, with similar postoperative pain and shorter operative time despite more complex fistula anatomy in the laser arm, with a greater improvement in QOL. ClinicalTrials.gov: NCT06212739.

Clinical Experience of Chang'an Niushi Anorectal Academic School in Treating Wound Healing after Anal Fistula Surgery

Clinical Experience of Chang'an Niushi Anorectal Academic School in Treating Wound Healing after Anal Fistula Surgery

Tongyangxiao Lotion promotes postoperative wound healing in a rat model of anal fistula by downregulating inflammatory factors and suppressing inflammation

To explore the mechanism of Tongyangxiao Lotion (TYX) for promoting wound healing following surgery for anal fistula. The active ingredients and drug targets of TYX were explored using TCMSP and BATMAN databases, and the targets associated with wound healing were screened using GeneCards and OMIM databases; the intersecting drug and wound-related targets were analyzed with protein-protein interaction (PPI) analysis and GO and KEGG enrichment analyses. In 25 SD rat models with simulated anal fistula surgery, the effect of wound dressing with TYX at low, medium and high doses (once daily for 14 days) on wound healing were assessed in comparison with potassium permanganate (PP) solution. The granulation tissues collected from the wounds were examined for pathological changes with HE staining and for TNF-α expression using immunohistochemistry. The expressions of 1β, TNF-α, IL-6 mRNA and proteins in the granulation tissue were detected using RT-qPCR, Western blotting or ELISA. Network pharmacology analysis yielded 156 common targets between TYX and wound healing, and among them IL-1β, TNF- α, and IL-6 were identified as potential targets of TYX for promoting wound healing. Six core components of TYX were capable of binding to IL-1β, TNF-α, and IL-6 with binding energies all below -6.0 Kcal/mol. In the rat models, the wounds with TYX and PP solution dressing showed significantly reduced inflammatory cell infiltration and increased fibroblasts and collagen deposition. TYX at the 3 doses and PP solution all significantly reduced the expressions of IL-6, IL-1β, TNF-α mRNA and IL-6 protein in the granulation tissues, but TYX at the medium and high doses produced significantly stronger effects than PP solution for lowering TNF-α protein expression and mRNA expressions of TNF- α and IL-6. TYX accelerates wound healing by down-regulating the inflammatory factors and reducing inflammation in the wounds.

Implementation of a Multimodal Enhanced Recovery Protocol in Ambulatory Anorectal Surgery: A Randomized Trial.

Few studies report outcomes for enhanced recovery pathways in ambulatory anorectal surgery. We hypothesize that an ambulatory anorectal enhanced recovery pathway with multimodal analgesia can reduce postoperative opioid use. To compare postoperative opioid use in patients undergoing ambulatory anorectal surgery who receive multimodal analgesia vs. standard of care without multimodal analgesia. A prospective randomized trial of patients undergoing elective anal fistula or hemorrhoid surgery from September 2018 to May 2022. Urban teaching hospital. Adults aged 18 to 70 undergoing elective anal fistula or hemorrhoid surgery from September 2018 to May 2022. Multimodal enhanced recovery pathway including pre- and postoperative non-opioid analgesia with oral acetaminophen, gabapentin and ketolorac. Primary endpoint was oral opioid use during the first postoperative week. Secondary endpoints included maximum pain and nausea scores, adverse events and emergency room or hospital admissions during the first 30 days postoperatively. Of the 109 enrolled patients, 20 were lost to follow-up. The remaining 89 patients had a median age of 38 (range, 20-67) years and included 41 (46%) females. There were no significant differences between the enhanced recovery protocol (Arm E) and non-enhanced recovery protocol (Arm NE) groups in terms of preoperative and surgical characteristics. The study primary endpoint, oral MME use during the first week, was significantly higher among patients in the NE arm (79 mg; range, 0-600) than patients in the E arm (8 mg; range, 0-390) (p = 0.002). On subgroup analysis, both fistula and hemorrhoid surgery patients assigned to the NE arm took significantly higher oral MME in the first week than patients in the E arm. There was no significant difference in secondary endpoints. Patients and providers were not blinded. Our findings are limited to hemorrhoid and fistula surgery and may not be applicable to other anorectal procedures. Enhanced recovery protocols including multimodal analgesia should be used in elective anal fistula and hemorrhoid surgery to decrease postoperative opioid use. See Video Abstract . ClinicalTrials.gov ID NCT03738904.