Transsphincteric Anal Fistula Research Articles

Comparative Study of Diluted Hydrogen Peroxide and Sulfur Hexafluoride in the Contrast-Enhanced Ultrasound Assessment of Anal Fistulas.

Endoanal ultrasound for the diagnosis of anal fistulas requires the injection of hydrogen peroxide, but it is often uncomfortable for the patient and possesses potential complications. Novel ultrasound contrast is currently available. We aimed to assess the efficacy and safety of sulfur hexafluoride as an ultrasound contrast agent for the diagnosis of perianal fistula by comparing it with those of 50% diluted hydrogen peroxide. Double-blind superiority study with 4 consecutive visits to perform an ultrasound without contrast, a hydrogen peroxide-enhanced ultrasound, a sulfur hexafluoride-enhanced ultrasound and a rectal exploration in the operating room (the gold standard). The ultrasound images were independently reviewed by three expert surgeon sonographers. This study was conducted at a single university hospital. Data from 176 patients were evaluated. Demographic and exploratory data and the ultrasound findings related to the location of the internal fistula orifice, description of the primary and secondary tracts, and presence of cavities and sphincter defects were analyzed. The complications occurring before and after the contrast agent administration and the presence of pain measured using a score were considered. Eighty-eight patients were included (men: 71.5%; mean age: 48.3 years).62.5% had a complex type and 83.7% had a transsphincteric type. Sulfur hexafluoride-enhanced ultrasounds demonstrated a higher interobserver agreement in determining the secondary tracts (κ= 0.604) and anal fistula height (κ=0.604) compared with other methods. Both hydrogen peroxide-enhanced ultrasound (90.91%) and sulfur hexafluoride-enhanced ultrasound (89.77%) detected the internal orifice more frequently than ultrasounds without contrast (62.5%) (p < 0.001),with no differences between contrast agents (p = 0.810). Sulfur hexafluoride-enhanced ultrasound were less painful than peroxide-enhanced ultrasound (p < 0.001). Most of the patients had transsphincteric anal fistulas. Sulfur hexafluoride proved comparable to hydrogen peroxide in evaluating fistulous tracts and identifying the internal orifice and additionally reduced significantly pain and discomfort. Furthermore, demonstrated a higher interobserver agreement in determining the secondary tracts and anal fistula height compared with other methods. See Video Abstract.

The management of low trans-sphincteric anal fistula during the COVID-19 pandemic: revisiting the role of the seton.

The management of trans-sphincteric anal fistula (TAF) includes several surgical options; however, during the COVID-19 pandemic, the access to the operating rooms was severely limited, leaving only the choice of minimally invasive procedures. This study aimed to evaluate the safety and effectiveness of the slow cutting seton technique for TAF performed in an outpatient setting during the COVID-19 pandemic.Patients treated for TAF between January 2020 and July 2022 and followed-up for at least 12months were retrospectively evaluated. A vascular silicone tie used as seton was positioned in the fistula tract using a Lockhart-Mummery fistula probe. The seton was maintained in moderate tension until the sphincter muscle was passed. Percentage and time for healing, recurrence, SF-36, VAS and Vaizey's Score were recorded.Fifty-eight patients [36 male/22 female, median age 56.5years (IQR 41.25-65.75) [with TAF were included. After a median time of 4months, complete healing occurred in 53 cases (91.5%), the anal pain VAS decreased from 6 to 0, the anal incontinence scores did not change significantly and the QoL improved significantly in all the SF36 domains. No complications were recorded, but the fistula recurred in five cases (8.5%). Two of them had additional seton treatment, and three underwent other surgical procedures after the COVID-19 emergency.The slow cutting seton technique is a safe and effective treatment for outpatient procedure with minimal patient discomfort. This treatment option in healthcare delivery for TAF should be reconsidered, even outside the limited in-hospital access during the COVID-19 pandemic.

Comparison of BioLIFT versus LIFT for the treatment of trans-sphincteric anal fistula: a protocol for systematic review and meta-analysis

IntroductionIdentifying the optimal treatment for anal fistula has been challenging. Since first reported in 2007, the ligation of the intersphincteric fistula tract (LIFT) procedure has reported healing rates between 40%...

Outcomes of surgery for high transsphincteric anal fistulas: prospective randomized trial

Background. Reliable data on the efficacy and safety of fistulectomy with primary sphincter repair for the treatment of high transsphincteric anal fistulas are deficient.The aim. To compare the efficacy and safety of fistulectomy with advancement muco-muscular flap (F) and fistulectomy with primary sphincter reconstruction (SR) for the treatment of high anorectal fistulas.Methods. A cohort of 92 consecutive patients with transsphincteric anal fistula involving 1/3 to 2/3 of the sphincteric complex were included in prospective randomized study. The primary endpoint was the recurrence rate. The duration of surgery, blood loss, pain intensity, postoperative complications, the duration of wound healing, incontinence, quality of life were registered.Results. Forty-six patients were randomized in each group. A statistically significant difference was obtained for operative time (Group “F” – 45 (20–160) min, Group “SR” – 33 (10–55) min). The blood loss was 3 (1–20) and 2 (1–10) ml in Groups “F” and “SR”, respectively (p = 0.482). The return to work in Groups “SR” and “F” occurred after 7 (2–14) and 8 (4–20) days, respectively (p = 0.005). The pain syndrome was significantly greater in Group “F” (p &lt; 0.05) on days 1 and 7. Recurrence rate was in 23.9 % (11 cases) in Group “F” and in 6.5 % (3 cases) in Group “SR” (p = 0.042). Incontinence was in 7 (15.2 %) people in Group “F”, in 10 patients (21.7 %) – in Group “SR” (p = 0.591). There was no statistically significant difference in postoperative complications.Conclusion. Findings can expand the indications for the treatment of high transsphincteric anorectal fistulas involving from 1/3 to 2/3 of the sphincter complex without statistically significant risk for functional results.

Ligation of the Intersphincteric Fistula Tract (LIFT) as a first approach in the surgical treatment of transsphincetric anal fistula is associated with modest initial success rates

PurposeDescribe our institutional experience with ligation of the intersphincteric fistula tract (LIFT) operation as the first procedure in the treatment of transsphincteric anal fistula and try to identify predictors of success. MethodsThis is a retrospective multi-institutional series based on two tertiary academic Hospitals in the USA. Consecutive adult patients presenting with cryptoglandular transsphincteric anal fistula that underwent a LIFT operation were included. ResultsThe study included 77 patients, of which 68% were male and 32.5% obese. Fifteen patients presented with a recurrent fistula, and preoperative seton was placed in over 80% of the cases. No intra or postoperative complications were recorded. With a median follow-up of 37 months, the success rate was 51%; LIFT failure occurred more often in younger patients. Other patient characteristics, seton placement, fistula characteristics, patient positioning, and suture used for tract ligation were not associated with treatment outcome. None of the patients referred fecal incontinence. Seventy-four percent of patients with treatment failure underwent further surgical treatment; the success rate of the second operation was 71%. ConclusionsLIFT as the first operation was associated with a modest success rate with no intra or postoperative complications. Seton placement, patient characteristics, and operative variables were not associated with failure. Most failures could be treated surgically with acceptable success rates.

Combined use of techniques of fistula ligation in the intersphincteric space and laser destruction of the fistula tract in patients with chronic paraproctitis

The OBJECTIVE was to improve the treatment outcomes of patients with chronic paraproctitis using the combination of minimally invasive techniques.METHODS AND MATERIALS. The treatment outcomes of 170 patients with transsphincteric anal fistulas of cryptoglandular origin were analyzed. The duration of the disease in both groups varied within 2–34 months. The main group included 85 patients operated with a combined minimally invasive method (laser destruction of the fistulous tract with subsequent ligation and its ligation in the intersphincter space), in the control group, 85 patients underwent LIFT procedure.RESULTS. Median follow-up for patients in the main group was 13 months, in the control group – 24 months. In the main group, relapses were registered in 10 patients (11.8 %), in the control group – in 22 patients (25.9 %). The average time for the formation of relapses in the main and control groups was 4 months. There was no clinically significant violation of the function of the rectal obturator in both groups.CONCLUSION. The ability to combine the LIFT procedure and laser destruction of the fistulous tract allows to achieve fewer relapses compared to the isolated use of the LIFT technique in patients with transsphincteric anal fistulas.

Endofistula Vacuum Therapy as an Innovative Treatment for Transsphincteric Anal Fistula: Results of a Preclinical Trial

Introduction: Transsphincteric anal fistula remains a challenging problem for both surgeons and patients. Aggressive treatments are associated with high risk of incontinence, while minimally invasive methods have a higher recurrence rate. The minimally invasive vacuum therapy has also shown superiority to other surgical methods in the treatment of upper and lower gastrointestinal tract defects. In this study, we used a porcine model to test vacuum therapy as an innovative approach in the treatment of transsphincteric anal fistula. Methods: Three Pigs (Sus Scrofa Domesticus type) underwent a surgical creation of 4 iatrogenic transsphincteric anal fistulas in localizations 2, 5, 8 and 11 o’clock in supine position. After a period of 1 month, MRI confirmed the fistula formation. The 12 established fistulas were divided into 3 Groups. Group 1 (6/12) underwent vacuum therapy treatment. Group 2 (3/12) were left with a silicone drain in situ as positive control and Group 3 (3/12) were left untreated as negative control. The treatment phase lasted 18+/-3 days. Several MRIs were done to monitor the healing process. After 4 weeks of surveillance, euthanasia and en-bloc excision of the anorectum were performed for histopathological examination. Results: All treated fistulas completely healed macroscopically. The radiological and histopathological examinations of the vacuum treated tracts confirmed the tract’s closure with evidence of less inflammatory reactions in comparison with those in the control groups. Conclusion: Endofistula vacuum therapy treatment of transsphincteric anal fistula is feasible and safe. Therefore, we are planning a prospective multicenter clinical trial.

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).&#x0D; Study Design: Comparative prospective study.&#x0D; Place and Duration of Study: Department of General Surgery, MH Rawalpindi, Pakistan from May 2018 to Dec 2021.&#x0D; 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.&#x0D; 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&lt;0.001).&#x0D; 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.

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.

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.

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.

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.

Topical Autologous Blood Clot Therapy: An Introduction and Development of Consensus Panel to Guide Use in the Treatment of Complex Wound Types

Complex or hard-to-heal wounds can be acute or chronic; the complexity is based on patient-specific local, systemic, and psychosocial factors. Use of autologous tissue can be a significant adjunct to wound closure. Grafts and flaps are the most common autologous tissue used in wound reconstruction. However, patient factors, wound size, and exposed structures may preclude using these methods as primary or even secondary closure techniques. Alternative autologous tissue therapies include those derived from adipose, epidermis or dermis, bone marrow, and blood. Limitations of these treatment modalities include access-related difficulty, cost, creation of a secondary donor site, use of singular or limited cell types, and sparse or contradictory evidence basis of their efficacy of use. A panel of providers experienced in wound care and surgical wound management was convened to create a series of publications on the use of topical autologous blood clot therapy (TABCT) in the treatment of complex wounds. This publication, the first in a series, provides an evidence basis of the gap between definition and treatment of complex wounds, an overview of the use of autologous therapies in these wounds, and the science behind TABCT. The development of a consensus panel for decision pathways and recommendations for TABCT use in specific complex wound types are also discussed. Subsequent articles will provide consensus recommendations on the use of TABCT in full-thickness wounds with exposed tendon and/or bone and undermining or tunneling wounds, in wounds in patients who are nonsurgical candidates, in those who cannot undergo sharp debridement, in patients with arterial wounds who have been maximally revascularized, and in those with transsphincteric anal fistula. This article provides a foundation of knowledge and describes the plan for consensus panel decision pathways and recommendation development of use of TABCT in the treatment of specific complex wound types.

Laser coagulation in combination with LIFT for transsphincteric anal fistulas

Aim: to improve the results of fistula treatment, to evaluate the effectiveness of the combined use of LIFT and FiLaC techniques.Patients and methods: the study included 35 patients with transsphincter fistulas of cryptopglandular etiology involved more than 1/3 of the sphincter. All patients underwent surgery with laser energy (the laser conductor speed is 1 mm per second, the wavelength is 1470 nm, the radiation output is 13 W) after the LIFT procedure.Results: the primary healing rate was 28/35 (80,0%). The patients who failed the combined procedure (cases of prolonged healing more than 3 months) underwent a second procedure ReFiLaC, which led to the closure of fistula in 2 of 3 patients. A median follow-up period was 10,2 months. No incontinence to solid and liquid stools was detected.Conclusion: preliminary results of the study permits to assess the potential of the combined low-invasive approach for anal fistulas as positive.

Surgery for anal fistulae: state of the art.

Anal fistulae (AF) are considered a challenge for colorectal surgeons, as they recur if not properly operated. Being a septic disease, they are correlated with immunodeficiency and surgery may be followed by anal incontinence (AI). The aim of this paper is to suggest a state-of-the-art treatment of AF. Pathogenesis, classification, diagnostic tools, intraoperative assessment, and surgeries proposed for AF have been reviewed, together with the results following conventional surgery and innovations aimed at sphincters' preservation. Stress causes immunodepression and favors anal sepsis, and heavy smoking facilitates AF recurrences. Evacuation fistulography, MRI, and transanal ultrasound may help the diagnosis. Fistulotomy allows high cure rate, up to 96.4%, but may cause up to 64% of AI in transsphincteric AF. Fistulectomy with rectal advancement flap is effective in 80% of these cases and avoids AI. Other options are either suturing of AF internal orifice or positioning a cutting seton. Ligation of intersphincteric fistula track (LIFT) is a costless alternative carrying a success of 57-99% with 0-23% AI. Costly innovations, i.e., autologous stem cells, porcine derma sheet (Permacol), video-assisted fistula excision (VAAFT), porcine matrix (PLUG), and laser closure (FiLaC), minimize AI, but may carry AF recurrence. Their grades of recommendation range between 2B and 2C in the Guidelines of the Italian Society of Colorectal Surgery. Postoperative incontinence in transsphincteric AF may be minimized by both costless and costly sphincter-saving procedures, the latter carrying higher recurrence rate. The success of surgery may be increased by a different lifestyle.

The results of high-position anal fistula treatment using the LIFT (ligation of intersphincteric fistula tract) procedure. A retrospective, single-center study.

Ligation of the intersphincteric fistula tract (LIFT) is an established method for the treatment of high- and lowposition anal fistulas. Numerous meta-analyses confirm the high healing success rate with simultaneous low risk of sphincter damage. The aim of the study was to evaluate the results of the treatment of patients with high-position and complex transsphincteric fistulas using the LIFT procedure. Twelve patients (M - 9, F - 3) aged between 28 and 69 years (median age 50) undergoing surgery for complex and high-position transsphincteric anal fistulas, either primary or recurrent, in the period of 2016 to 2020, were included in the study. The inclusion criterion consisted in the presence of a fistula encompassing more than 30% of the anal sphincter volume as confirmed by transrectal ultrasound. All patients were subjected to surgical treatment by means of the LIFT procedure. The follow-up period was between 6 and 51 months (average of 16 months). Follow-up visits were held at 1 and 4 weeks as well as 6 months after surgery. During the postoperative period, data were collected on the curative effect or recurrence of transsphincteric fistulas (the primary endpoint) and on the presence of postoperative complications (the secondary endpoint). A total of 10 patients (83.3%) were healed, with 2 patients (16.7%) experiencing complications as manifested by recurring intersphincteric fistula. Full recurrence of the disease was observed in 2 patients (16.7%). Slight disturbances of continence were observed in 2 out of 12 patients (16.7%).

Ligation of intersphincteric fistula tract (LIFT) with or without injection of platelet-rich plasma (PRP) in management of high trans-sphincteric fistula-in-ano: Short-term outcomes of a prospective, randomized trial

BackgroundSuccess rate after ligation of the inter-sphincteric fistula tract ranges from 40% to 75%. Platelet-rich plasma is hypothesized to improve healing by slowly releasing growth factors. The objective of the study was to compare the efficacy and outcome of ligation of the inter-sphincteric fistula tract plus platelet-rich plasma local injection versus ligation of the inter-sphincteric fistula tract alone in the management of high trans-sphincteric anal fistula in regards to postoperative pain, time for healing, morbidity, fistula closure rate, recurrence, and quality of life. MethodsThis was a prospective randomized trial. Patients with trans-sphincteric anal fistulas involving >50% of anal sphincters were included. Patients were randomly assigned to either ligation of the inter-sphincteric fistula tract plus platelet-rich plasma or ligation of the inter-sphincteric fistula tract (49 in each group). The primary endpoints were successful complete fistula closure and duration needed for healing. Secondary endpoints were morbidity, recurrence after 1 year of follow-up, postoperative pain, and quality of life. ResultsComplete primary healing was recorded in 42 patients in the ligation of the inter-sphincteric fistula tract plus platelet-rich plasma group and 32 patients in the ligation of the inter-sphincteric fistula tract group, and the difference was statistically significant (P = .03). The mean time to complete healing after ligation of the inter-sphincteric fistula tract plus platelet-rich plasma was significantly shorter than after ligation of the inter-sphincteric fistula tract alone (15.7 ± 4 days vs 21.6 ± 5.4 days; P = .03). One year after complete healing of anal fistula, recurrence was recorded in 4/42 patients in the ligation of the inter-sphincteric fistula tract plus platelet-rich plasma group and 3/32 patients in the ligation of the inter-sphincteric fistula tract group with no statistically significant difference (P = .99). Patients in the ligation of the inter-sphincteric fistula tract plus platelet-rich plasma group had significantly lower pain scores after both 1 and 7 days. Quality of life and level of happiness were significantly better 1 month after ligation of the inter-sphincteric fistula tract plus platelet-rich plasma. ConclusionLigation of the inter-sphincteric fistula tract plus platelet-rich plasma for the treatment of high trans-sphincteric fistula-in-ano is a safe modality with significantly higher successful healing rate, shorter healing time, and less postoperative pain compared with ligation of the inter-sphincteric fistula tract alone. Ligation of the inter-sphincteric fistula tract plus platelet-rich plasma does not improve the rate of recurrence; however, it results in significantly higher short-term quality of life.

A Novel Surgical Technique for Anal Fistula Surgery Designed to Preserve the Anal Sphincter Function and Anoderm.

Objectives: We reviewed surgical outcomes after introducing a novel surgical technique for anal fistula surgery designed to preserve anal sphincter function and the anoderm. Methods: We studied 200 male patients who underwent a functional preservative operative technique (FPOT group) for anal fistulas and 200 patients who underwent resection of trans-sphincteric anal fistulas (fistulectomy group) between February 2014 and September 2015. We compared complications, such as those affecting anal sphincter function, recurrence, and incontinence. Results: Fistulas recurred in three (1.5%) patients in the FPOT group and two (1%) patients in the fistulectomy group. This difference was not significant. Other complications included gas leakage and other forms of incontinence in 1 (0.5%) and 14 (7%) patients in the FPOT and fistulectomy groups, respectively. Anal function assessment demonstrated that the FPOT was significantly better at preserving function than fistulectomy in all patients. Conclusions: There were no significant differences between the FPOT and fistulectomy in terms of recurrence or complication rates. Also, because there was no decrease in postoperative anal function, we concluded that the FPOT is an effective preservative surgical technique for treating trans-sphincteric anal fistulas.

Video demonstration of the modified Parks’ technique for treatment of trans-sphincteric anal fistula

BackgroundTrans-sphincteric anal fistula (TAF) is a common type of anal fistula that can be divided into low and high subtypes. Sphincter-sparing surgery is usually used for treatment of high TAF to avoid any compromise of the anal continence. MethodsA 38-year-old male patient with recurrent Grade III TAF was treated with the modified Parks’ technique. This technique can be summarized as three main steps; each addresses a component of the anal fistula. (1) The extra-sphincteric component, which lies outside the external anal sphincter (EAS), is laid open with electrocautery. (2) The intersphincteric component is laid open, starting from the internal opening, dividing the internal anal sphincter, until the EAS fibers were reached. (3) The trans-sphincteric component that traverses the EAS was carefully curetted from the anal and the outer sides with a surgical curette. An important step of the procedure is to close the defect through which the fistula tract passed through the EAS with interrupted sutures. ResultsThe operation time was 35 min. Complete healing was achieved in 5 weeks with no persistence or recurrence of the anal fistula after a follow-up of 6 months. No affection of the continence state was recorded. ConclusionThe modified Parks’ technique is a simple and convenient operation for TAF. Further prospective studies are needed to substantiate the efficacy and safety of the procedure.