Transsphincteric Fistulas Research Articles

Clinical study and management of fistula in Ano

Background: Fistula in Ano is one disease which is easy to diagnose but difficult to cure as patients report in very late phase of the disease and it leads to problems. Aim of this study was to determine the etiology, clinical presentation, efficacy of different surgical approach, early and late post-operative complications, and recurrence rate in cases of fistula in Ano.Methods: Prospective Observational Study was conducted in Department of General Surgery, Government Medical College, Solapur from Sep 2016 to Aug 2018 with Sample size of 50 cases.Results: Most common age group affected between 18-29 years, with male preponderance. Most common etiological factor is perianal sepsis following Crypto glandular infection, with pain as most prevalent symptom. Simple fistula is more common, and in complex fistula most prevalent type is high transsphincteric fistula. Most common procedure done is fistulotomy. Most common complication is recurrence. Most number of complications was seen in fistulotomy. Maximum recurrence is seen after fistulotomy.Conclusion: Most common cause is crypto glandular infection, most common feature is pain, Fistulectomy is more efficacious, and complications are maximum with fistulotomy, highest recurrence seen after fistulotomy.

Comparison of Recurrence of High Trans-Sphinteric Anal Fistula After Vaaft and Tight Setons in Military Hospital Rawalpindi

Objective: To compare the recurrence rate in patients undergoing fistulectomy using tight setons with those using videoassisted anal fistula treatment (VAAFT).
 Study Design: Comparative prospective study.
 Place and Duration of Study: Department of General Surgery, MH Rawalpindi, Pakistan from May 2018 to Dec 2021.
 Methodology: We included 200 patients with high trans-sphincteric anal fistula (simple or complex) of age 18 to 60 years, having ASA I or II. Group- A comprised patients undergoing treatment with VAAFT, while Group- B included patients undergoing treatment with Tight Seton in conventional surgery. Patients were followed for three months after the procedure. Patients having a history of discharge around or in the vicinity of the previous external opening of the anal fistula were labelled as having a recurrence. Recurrence was confirmed on MRI Fistulogram.
 Results: The mean age of patients in Group-A was 42.10±8.26 years, and in Group-B was 42.17±7.91 years (p=0.95). There were 58 male patients in Group-A and 55 male patients in Group-B (p=0.67). The mean duration of the fistula was 5.30±1.64 months in Group-A and 5.22±1.61 months in Group-B (p=0.72). Recurrence was diagnosed in 24 patients in Group-B and only 06 patients in Group-A (p<0.001).
 Conclusion: Video-assisted anal fistula treatment (VAAFT) has a lower recurrence rate than Tight Setons in conventional surgery in treating high trans-sphinteric anal fistula.

Autologous adipose-derived stromal vascular fraction and platelet concentrates for the treatment of complex perianal fistulas

BackgroundComplex perianal fistulas are a major challenge for modern surgery since 10–35% of patients have functional problems after treatment. Sphincter-saving techniques have a wide range of efficacy (10–80%). We hypothesised that autologous adipose-derived stromal vascular fraction in combination with platelet rich plasma is a new therapeutic strategy with enhanced cure and function preservation rates.MethodsAdult patients with complex cryptoglandular perianal fistulas were treated with injection of autologous adipose-derived stromal vascular fraction in combination with platelet rich plasma around and inside the fistulous tract between May 2018 and April 2019 at the General and Emergency Surgery Operative Unit of the University Hospital “P. Giaccone” of Palermo. Fistulas were confirmed by magnetic resonance imaging. Patients completed the Short Form-36 score on quality of life and the Wexner and Vaizey scores on faecal incontinence, and they were functionally studied using a three-dimensional anorectal manometry. The clinical and functional follow-up was performed at 1 year and 2 years after surgery.ResultsNine patients (4 males, 5 females; median age 42 years [19–63 years]) with high trans-sphincteric or horseshoe fistulas were treated. The average number of previous surgeries per patient was 4.8. At 1 year follow-up, 77.7% of patients were cured, while at 2 years there was 1case of relapse. The variation in Short Form-36 score in cured patients was not significant (p = 0.0936). No statistically significant differences were found in continence scores.ConclusionsThe proposed treatment is a treatment option that preserves sphincter integrity and function, potentially avoiding postoperative incontinence and the need of repeated treatments.

Subcutaneous incision of the fistula tract and internal sphincterotomy (SIFT-IS): a novel surgical procedure for transsphincteric anal fistula.

The aetiology of anal fistula has not been fully clarified. One of the causes of anal fistulas may be the markedly deep crypts that characterize the primary openings. We developed subcutaneous incision of the fistula tract and internal sphincterotomy (SIFT-IS) to eradicate these deep crypts. The aim of this study was to evaluate outcomes in patients with anal fistula treated with SIFT-IS. A retrospective study was performed over a 2-year period. Patients with transsphincteric anal fistula who underwent SIFT-IS were enrolled. The primary endpoint was the anal fistula healing rate at 16 weeks postoperatively. The secondary endpoints were healing time, postoperative complications and clinical continence status. One hundred and fifty one patients were enrolled. Primary healing was accomplished in 129 patients (85%). There were 17 patients (11%) with a remnant fistula and five (3%) with a recurrence. The remnant fistulas healed spontaneously at more than 16 weeks postoperatively in seven patients. The median healing time was 6 (3-96)weeks. Surgical intervention was required in seven patients with a remnant fistula and four with recurrence. At the final follow-up, the wounds had healed in 148 patients (98%). No significant postoperative complications or incontinence were observed. Subcutaneous incision of the fistula tract and internal sphincterotomy is a promising surgical option for transsphincteric anal fistulas, with a satisfactory healing rate.

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.

Outcome of Core out Fistulectomy with Anal Spincter Reconstruction and Primary Repair of Internal Opening in the Treatment of Complex Anal Fistula; A Experience of 30 Cases

Background: The principal of management of anal fistula include closure of interior opening of fistula tract, drainage of contamination or necrotic tissue, and eradication of fistulous tract with maintenance of sphincter function. The selection of surgical operation (simple fistulotomy, fistulectomy, seton placement, development flap, fibrin glue or anal plug) is decided with the aid of the route of the fistula tracts and continence status. Objectives: The aim of the study was to determine the surgical technique “core out fistulectomy with anal sphincter reconstruction and primary closure of internal opening” in the treatment of trans-sphincteric fistula (high type or long tract) or supra-sphincteric fistula in terms of fistula healing, morbidity, recurrence and anal continence. Methods: This prospective observational study was carried out in the Department of Surgery Dr Amanat khan hospital and other private hospitals, Dhaka, Bangladesh, during 5th March 2020 to 10th April 2022. A total 30 patients between the age group 20 to 70 years who were diagnosed with Fistula-in-Ano(Complex Variety) which underwent Core out Fistulectomy with Anal Spincter Reconstruction and Primary Repair of Internal Opening. This analysis was done using SPSS 24 software version. The level of significance was set to 5% (p < 0.05). Results: There were 30 (91%) men and three (9%) women with a median age of 42 years. The common anal fistula type was high transsphincteric fistula in 31 patients with deep postanal abscess in two patients and two patients were suprasphincteric fistula. Conclusions: Core out fistulectomy with anal sphincter reconstruction and major closure of inner opening is a secure and nice method for excessive trans-sphincteric fistula. It has desirable useful results and no disturbance of continence. This has to be viewed in the cure of high trans-sphincteric fistula.

The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Management of Anorectal Abscess, Fistula-in-Ano, and Rectovaginal Fistula.

The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Management of Anorectal Abscess, Fistula-in-Ano, and Rectovaginal Fistula.

Long-term results of minimally invasive surgical treatment of extra- and transsphincteric perianal fistulas using postoperative rehabilitation programs

Introduction. A modern promising trend in coloproctology is the use of minimally invasive surgical technologies in the surgical treatment of extra- and transsphincteric perianal fistulas, in particular laser technology FiLaC (Fistula Laser Closure). Surgical treatment of patients with extra- and transsphincteric perianal fistulas requires proper routing, stratification of the used methods of surgical treatment, postoperative rehabilitation and dynamic evaluation of the obtained results, including in the long-term period. Purpose of the study. In a comparative aspect, to evaluate the long-term results of surgical treatment of trans- and extrasphincteric perianal fistulas using the standard FiLaC technology and the developed modified FiLaC technology and the use of 2 or 4-component complex programs of physiotherapeutic postoperative rehabilitation. Material and methods. The study included 180 operated patients with trans- and extrasphincteric perianal fistulas, who were divided into two groups depending on the method of surgical intervention. In the 1st group (90 patients), the standard FiLaC technology was used for minimally invasive surgical treatment of fistulas; in the 2nd group (90 patients), a modified FiLaC technology, which provides for the opening of purulent streaks and laser coagulation of the intrasphincteric part of the fistula with a Biolitec laser (power 12 W, 100 J/cm), was applied. Each group was divided into 3 subgroups depending on the postoperative rehabilitation program used: in the 1st (main group), a 4-component program of postoperative rehabilitation was used, in the 2nd (comparison group) — a 2-component program, and in the 3rd (control group), the program of postoperative rehabilitation was not used. To evaluate the results obtained, the authors used a basic set (clinical examination with an assessment of the general condition, laboratory tests, high-resolution anoscopy, examination of the fistula tract with a button probe), additional instrumental methods (transrectal ultrasound (TRUS) with sonoelastometry, examination of the functional state of the rectal obturator), as well as a subjective assessment of the degree of improvement after treatment on the Clinical Global Impression Scale (Srikrishna S., Robinson D., Cardozo L. (2010)) and an assessment of the quality of life according to the SF-36 questionnaire (Ware JE et al. SF-36 Health Survey. Manual and interpretation guide. The Health Institute, New England Medical Center. Boston, Mass. 1993), which allow assessing the dynamics of the patient’s clinical and functional status in the process of rehabilitation, which is an urgent topic of scientific research. Long-term results were tracked over a period of 19 months up to 3 years (median 31 months). Results and discussion. The comparative analysis of the long-term results (up to 3 years), depending on the type of minimally invasive surgical treatment and the postoperative rehabilitation program used, showed that in the group of patients operated on using the FiLaC technology, the majority had good results — 96.7% of patients in the main group, 90,1% in the comparison group and 84% in the control group. In the comparative analysis of the long-term results of treatment (up to 3 years) in the patients with chronic paraproctitis after performing surgery using a modified FiLaC technology under the influence of the developed postoperative rehabilitation programs, it was found that: 59 people (65,5%) had good characteristics, 19 people (21.1%) had satisfactory characteristics, and 12 people (13,4%) had unsatisfactory characteristics. The differences were statistically significant p=0,002, which indicates that the long-term results were statistically significantly better in the main group than in patients of the control group who did not have rehabilitation measures. Conclusions. The obtained results demonstrated the benefits of using the modified FiLaC technology in the surgical treatment of transsphincteric and extrasphincteric fistulas of the rectum, which was confirmed by a 1,3-fold decrease in the incidence of relapses compared with the data obtained using the traditional FiLaC technology. The proportion of relapses in the main group of patients (when using a 4-component program of postoperative rehabilitation) decreased by 5,8 (comparison group) and 16,1 (control group) times, respectively (median observations 31 months), which allows us to recommend the developed modified FiLaC technology and comprehensive postoperative rehabilitation programs for wide introduction into the clinical practice of coloproctologists in the surgical treatment of transsphincteric and extrasphincteric perianal fistulas.

Ligation of Intersphincteric Fistula Tract (LIFT) with or Without Injection of Bone Marrow Mononuclear Cells in the Treatment of Trans-sphincteric Anal Fistula: a Randomized Controlled Trial

BackgroundLigation of intersphincteric fistula tract (LIFT) is a sphincter-saving procedure used for treatment of complex anal fistula. The current study aimed to assess the outcome of local injection of bone marrow mononuclear cells (BM-MNCs) in conjunction with LIFT as compared to LIFT alone in regards to healing rate, time to healing, and ultimate success rate. MethodsThis was a prospective randomized trial on patients with trans-sphincteric anal fistula. Patients were randomly allocated to one of two equal groups: LIFT and LIFT with BM-MNC injection. The main outcome measures were healing at 10 weeks of follow-up, recurrence after healing, and complications. ResultsSeventy patients (48 male and 22 female) of a mean age of 37.9±10.4 years were included. The mean time to complete healing after LIFT + BM-MNCs was significantly shorter than after LIFT alone (20.5±5.2 vs 28.04±5.8 days; P < 0.0001). The ultimate success rates of both groups were similar (LIFT = 60% vs LIFT with BM-MNCs = 68.6%, P = 0.62). There was no significant difference in the mean operation time or complication rate between the two groups. Secondary extension and previous anal surgery were significant independent predictors of failure of healing. ConclusionLIFT combined with BM-MNC injection was associated with a shorter time to complete healing than LIFT alone. However, BM-MNC injection did not have a significant impact on the overall healing and ultimate success rate.

Fistula in Ano: A Modified Approach - A Case Report

Management of fistula is one the most notorious job for the surgeon because of its ill site, chronicity, and recurrences. Treatment modalities like anal fistula plug, mucosal flap advancement, fibrin glue, and VAAFT (Video Assisted Anal Fistula Treatment) are there but ksharsutra has edge on them for its success rate and non-recurrence. Even after its better results, weekly sitting and pain during changing of ksharsutra and discomfort of ksharsutra being in situ makes it difficult for patient to pursue the treatment. Hence, a new approach was mandatory. Considering fistula to be a dushtavrana, shashti upakrama like lekhan, shodhan and ropan were applied in a patient of high-anal transphincteric fistula. Partial fistulectomy, excessive curettage (lekhan) from its internal opening was done. Internal opening was closed and wound was allowed to heal by second intension with the help of shodhan and ropan tail. Post-operative antibiotics and anti-inflammatory were given. It was observed that wound healed at good rate without discomfort of patient in 25 days. It underlines importance of shashtiupkrama in modern age of surgery also.

Establishing a rabbit model of perianal fistulizing Crohn’s disease

BACKGROUNDCrohn's disease (CD) is a chronic nonspecific intestinal inflammatory disease. The aetiology and pathogenesis of CD are still unclear. Anal fistula is the main complication of CD and is a difficult problem to solve at present. The main limitation of developing new therapies is bound up with the short of preclinical security and effectiveness data. Therefore, an ideal animal model is needed to establish persistent anal fistula and an inflamed rectal mucosa.AIMTo improve the induction method of colitis and establish a reliable and reproducible perianal fistulizing Crohn’s disease animal model to evaluate new treatment strategies.METHODSTwenty male New Zealand rabbits underwent rectal enema with different doses of 2,4,6-trinitrobenzene sulfonic acid to induce proctitis. Group A was treated with an improved equal interval small dose increasing method. The dosage of group B was constant. Seven days later, the rabbits underwent surgical creation of a transsphincteric fistula. Then, three rabbits were randomly selected from each group every 7 d to remove the seton from the fistula. The rabbits were examined by endoscopy every 7 days, and biopsy forceps were used to obtain tissue samples from the obvious colon lesions for histological analysis. The disease activity index (DAI), colonoscopy and histological scores were recorded. Perianal endoscopic ultrasonography (EUS) was used to evaluate the healing of fistulas.RESULTSExcept for the DAI score, the colonoscopy and histological scores in group A were significantly higher than those in group B (P < 0.05). In the ideal model rabbit group, on the 7th day after the removal of the seton, all animals had persistent lumens on EUS imaging, showing continuous full-thickness high signals. Histological inspection of the fistula showed acute and chronic inflammation, fibrosis, epithelialization and peripheral proctitis of the adjoining rectum.CONCLUSIONThe improved method of CD colitis induction successfully established a rabbit perianal fistula CD preclinical model, which was confirmed by endoscopy and pathology.

Long-term outcome of ligation of inter-sphincteric fistula tract (LIFT) for management of trans-sphincteric anal fistula

BackgroundAfter abscess formation, an anal fistula is a common consequence, with crypto-glandular infection being the most commonly accepted causative cause. The goal of this study was to see how well closure of the inter-sphincteric fistula tract affects the outcome of trans-sphincteric fistula surgery. MethodsPatients with perianal trans-sphincteric fistulas who underwent ligation of inter-sphincteric fistula tract (LIFT) were studied prospectively in this cohort study. All patients had the identical anesthetic approach, followed by LIFT with two years’ follow-up. Resultslength of the fistulous tract had a substantial effect on the result. The presence of piles with fistula among the studied patients has no effect on the outcome. Mean operative time was 36.2 min and post operative pain was mild in most patients and concomitant anal fissure or piles has no effect on final result of LIFT procedure The mean time for wound healing was four weeks. Three patients had hidradenitis suppurativa and no any unusual histopathology results shown in the excised parts. ConclusionLIFT was an effective and straightforward sphincter-preserving technique in treating simple trans-sphincteric anal fistulas with excellent long-term control of trans-sphincteric fistula. More similar studies with a large number of patients are still needed to assess this surgical technique for trans-sphincteric fistula.

Comparison between application of platelet rich plasma and mucosal advancement flap in patients with high transsphincteric anal fistulas: a randomized control trial.

There is still a search for a standard method of therapy for high anal fistulas. The aim of this trial was a comparison between a modified two stage minimally invasive procedure, consisting of loose-seton placement with the subsequent application of platelet rich plasma with mucosal advancement flap for the treatment of high transsphincteric anal fistulas of crypto-glandular origin. The study was designed as a prospective, randomized trial including 96 patients. Curettage of fistulous tracts, and loose-seton placement was performed in those patients with active inflammation, and if the diameter of a fistulous tract exceeded 3 mm. Afterwards, the patients were randomly assigned to either the PRP group or MAF group, consisting of 49 patients, and 47 patients, respectively. There was no significant statistical difference (p=0.152) between both investigated groups of patients regarding closure of fistulas since it was achieved in 35 (71.43%) patients from group I, compared to 27 (57.45%) patients from group II. The diameter of fistulous tracts below 4 mm exerted a significant impact (p < 0.001) on the healing process after PRP application because fistulas with the narrow tracts were closed in 34 (87.18%) patients, whereas a wider fistula was healed in 1 (10%) patient. The local application of PRP in high, unbranched, and with narrow tracts trans-sphincteric anal fistulas of crypto-glandular origin, following loose-seton drainage is an effective, simple, and a safe method of therapy with a low rate of morbidity.

Outcome of different surgical procedures for fistula-in-ano: a single centre-based study

Background: Fistula-in-ano is an abnormal communication between anal canal/rectum and perianal skin. It is considered to be chronic sequelae of cryptoglandular perianal abscess. Surgical treatment is the standard of care. However, the surgical techniques have evolved over time in order to give a satisfactory non-recurring result without jeopardising continence mechanism. Our aim was to study the feasibility and outcome of various surgical procedures done for fistula-in-ano.Methods: This study was conducted in colorectal division of department of general surgery SKIMS Srinagar, from 2017-2019. All patients underwent a surgical procedure which was deemed feasible for a particular case. Pre-operative data and post-operative outcome/complications were studied over a mean follow up of 12 months. Final inferences were drawn after analysing the data using various statistical tools.Results: Fistula-in-ano has male predominance (8:1), with intersphincteric fistula being the commonest type (48%) in our study. Majority of our patients underwent fistulectomy (72.5%) with or without Seton placement. Over a mean follow up of 12 months, only 19 patients (15.32%) developed recurrence. Incontinence was observed in 15 patients (12.09%). The risk of recurrence was observed to be directly related to the complexity of fistula.Conclusions: Fistulectomy is safe and effective for low intersphincteric and trans-sphincteric fistulas with acceptable rates of recurrence. Benefit of radical excision in high fistulas with multiple secondary tracts should be carefully weighed against risk of post-operative incontinence.

Human Amniotic Membrane for the Treatment of Cryptoglandular Anal Fistulas.

Background: Implantation of the amniotic membrane and their derivatives can have a beneficial effect on tissue repair and regeneration. We report for the first time the implant of an amniotic membrane in a patient affected by cryptoglandular anal fistula. Methods: A patch of human amniotic membrane was implanted in a female patient affected by an anterior transphincteric fistula. Following an accurate curettage of the anal fistula, the cryopreserved amniotic membrane was thawed and then washed in the operating room; one side of the membrane was transfixed with a resorbable suture thus creating an implantable fusiform patch. The membrane was subsequently implanted into the fistula tract from the external to the internal opening. The inner and outer parts of the membrane were then sutured to the internal and external fistula openings. Results: No intraoperative or postoperative complications occurred. The patient was discharged one day after the procedure after an uneventful hospitalization. At the 1-week, 1- and 3-month follow-up visits no pain (VAS 0) was referred by the patient and no inflammation was evident at the level of the previous external fistula opening. Conclusions: The implant of human amniotic membrane in a patient affected by cryptoglandular anal fistula was safely and easily performed. Moreover, future studies to assess the efficacy in the long-term follow-up are needed.

Long-term outcomes of an acellular dermal matrix for the treatment of complex cryptoglandular anal fistula: a pilot study.

BackgoundEffective, standardized treatments for complex anal fistula (CAF) still represent a clinical challenge. Emerging procedures attempted to achieve the healing rates of fistulotomy whilst preserving sphincter function. Acellular dermal matrix (ADM) used as a plug inserted through the fistulous tract is among newer treatment options. Varying success rates have been reported, most with short-term follow-up. The aim of this study was to report the long-term results of ADM-plug for CAF.MethodsRetrospective analysis of a prospective database of patients treated with CAF. All consecutive patients presenting at two tertiary centers (Vall d’Hebron University Hospital and Bellvitge University Hospital, Barcelona, Spain) between November 2015 and March 2019 with a single, cryptoglandular CAF were evaluated for treatment with an ADM-plug were included. The primary endpoint was absence of discharge at clinical examination at 12 month follow-up.ResultsTwenty-two patients were included [7 women and 15 men, median age 56 (33–74) years]. Most patients had high transsphincteric fistulas (63.6%). The median follow-up was 42 (21–53) months. The 12 month success rate was 68.2%, with an overall healing rate of 59.1%. 77.8% of recurrences occurred within 12 months from surgery. One plug extrusion was observed. No major complications or mortality occurred during the follow-up. Patients did not report any worsening of fecal continence.ConclusionsThis pilot study showed that more than half of patients with CAF could benefit from ADM-plug placement, preserving continence. A minimum follow-up of 12 months is recommended, because most recurrences occur during the first year.Supplementary InformationThe online version contains supplementary material available at 10.1007/s10151-022-02593-1.

Outcomes in High Perianal Fistula Repair Using Video-Assisted Anal Fistula Treatment Compared With Seton Use: A Randomized Controlled Trial.

BackgroundAnal fistula, or fistula-in-ano, is a chronic abnormal communication between the epithelialized surface of the anal canal and the perianal skin. Video-assisted anal fistula treatment (VAAFT) is a novel, minimally invasive, and sphincter-saving alternative to traditional seton use. This study aimed to determine the short-term and long-term outcomes of VAAFT compared with seton treatment.Material and methodsThis randomized control trial was conducted at the Department of Surgery, Services Hospital, Lahore, from August 2014 to July 2020. Patients were randomly assigned to either the VAAFT group or the seton group, and postoperative outcomes were assessed for up to three years.ResultsThe study included 80 patients (64 men and 16 women) with a mean age of 39.1 ± 11.2 years. The most common type of fistula was a transsphincteric fistula (n=36, 45%). The mean duration of surgery was significantly longer in the VAAFT group (78.6 minutes) compared with the seton group (36.97 minutes; p=0.000). The mean pain score was significantly higher in the VAAFT group (4.22) compared to the seton group (2.82, p=0.000). The mean time to return to work was shorter in the VAAFT group (7.4 days) than in the seton group (9.2 days, p=0.000). The mean healing time was significantly shorter for patients treated with VAAFT (5.75 weeks) than for those treated with a seton (9.7 weeks; p=0.000). Fistula recurrence after one, two, or three years was not significantly different between groups, and neither group had incidences of anal incontinence.ConclusionsVAAFT is associated with earlier healing time and earlier return to work than the traditional seton technique, with no significant difference in fistula recurrence. VAAFT is minimally invasive and, when used in patients where indicated, allows for a prompter return to routine life for the patients, which is an optimal outcome for both patients and physicians.

The Value of Cutting Seton for High Transsphincteric Anal Fistula in the Era of Its Misery.

ObjectivesWe studied the outcome of cutting seton in the treatment of a high transsphincteric anal fistula in Sudan.MethodsThis was a prospective study of high transsphincteric anal fistulas at Kassala Police Hospital, Sudan, over the course of 24 months (2016–2017). The main outcomes measured were recurrence, incontinence and primary healing rates.ResultsThe cases of 72 patients treated with cutting seton for high transsphincteric fistula were analysed, with 50 (70%) of the patients being male and 22 (30%) being female. Forty-eight (66.7%) patients required two sessions of seton tightening with a duration of seton treatment of 30 days and 24 (33.3%) patients required three sessions with a duration of seton treatment of 45 days. Only one patient (1.4%) had flatus incontinence. Three (4.2%) patients had minimal bleeding from the seton site and two (2.8%) patients experienced fistula recurrence. Twenty-six (36%) patients achieved complete healing within 30 days, while 36 (54.3%) patients healed within 60 days. The remaining seven (9.7%) patients healed after 60 days. Chronic pain was reported by two (2.8%) patients after complete healing.ConclusionIn Sudan, cutting seton remains relevant, as it produces minimal incontinence with a low recurrence rate in high transsphincteric fistula treatment.

Fistulectomy and incontinence: do we really need to worry?

Anal fistula is often considered to be a dilemma because of the need to maintain a fine balance between postoperative incontinence and recurrence. We tried to find whether apprehension of causing incontinence should stop us from performing fistulectomy. The aim of this study was to determine whether fistulectomy was associated with increased rate of fecal incontinence and recurrence, compared to other procedures used for the treatment of anal fistula. It was a prospective, single center, observational study. All patients with anal fistula operated at a tertiary care teaching institute over a period of two years were included in the study. Recurrence rates and fecal incontinence were compared between patients subjected to fistulectomy and other procedures for treatment of fistula in ano. A total of 124 patients with anal fistula were included. 92.8% patients were ≤ 60 years of age with high male preponderance (89.5%). Perineal discharge was the commonest complaint (95.96%). Intersphincteric (47.58%) followed by transphincteric fistulas (45.16%) accounted for the majority of fistulas. Fistulectomy was the most common procedure, performed in 90 (72.58%) patients. Incontinence occurred in 8/90 (8.88%) from the fistulectomy group and 2/34 (5.9%) patients in other surgery group, p=0.726. Recurrence occurred in 8/90 (8.88%) from the fistulectomy group and 8/34 (23.5%) patients from other surgery group, p=0.038. Overall rates of incontinence and recurrence were 8.1% and 12.9% respectively. Fistulectomy, as compared to other procedures, results in less chances of recurrence without compromising continence.

Clinical experience of applying a modified FILaC procedure for treatment of complex anal fistulas

Surgical treatment of complicated anal fistulas remains one of the most difficult issues of coloproctology. In this study we used a modification of Fistula Laser Closure procedure in complex treatment of patients with anal fistulas. The purpose of our study was to assess the short-term and remote results of applying the modified FiLaC procedure in patients with complex anal fistulas and compare these results with conventional fistulectomy. The patients with complex transsphincteric and extrasphincteric anal fistulas were prospectively divided into FiLaC and conventional fistulectomy groups. The operative duration was longer, by 31% (p&lt;0.05), in the FiLaC group compared to the control group. The healing of fistulas was faster by 42% (p&lt;0.05)in the FiLaC group (7.3 ± 0.5 weeks versus 12.6 ± 0.7 weeks). The Wexner Incontinence scale scores were significantly lower (p&lt;0.05) in the FiLaC group. The recurrence of rectal fistula after the surgery was observed in 37.2% in the control group versus 17.5% in the FiLaC group (p&lt;0.05) (median follow up period — 13 months). The pressure parameters of the anal sphincter were significantly higher (p&lt;0.05) in the longterm follow-up period in patients of the FiLaC group and continence was maintained in 92.5% of the FiLaC group. Thus, the study has shown that the modified FiLaC procedure accelerates the healing time of the fistula by 42% (p&lt;0.05), reduces the number of fistula recurrences from 37.2% to 17.5% (p&lt;0.05), and has minimal negative effects on anal continence.