Transsphincteric Fistulas Research Articles

Author response: Ligation of intersphincteric fistula tract (LIFT) for trans-sphincteric cryptoglandular anal fistula: long-term impact on faecal continence

Author response: Ligation of intersphincteric fistula tract (LIFT) for trans-sphincteric cryptoglandular anal fistula: long-term impact on faecal continence

Efficacy and Efficiency of Cyanoacrylate Glue in Fistula-in-Ano.

Most research on fistula-in-ano (FIA) is being done to improve surgical outcomes and reduce complications. Cyanoacrylate glue (CAG) is one of the promising options. We evaluated the efficacy and efficiency of CAG in the treatment of FIA. A cohort of 30 patients were included who underwent treatment using CAG. Each patient followed up at one, three, and six months to evaluate improvement in pain, discomfort, and recurrence. Patients with recurrence were treated with fistulectomy. Themean age of the cohort was 48.2±14.5 years, with a male-to-female ratio of 6:1, having four diabetic patients. Inter-sphincteric (16.54%) and trans-sphincteric (13.43%) fistulae were more common than extra-sphincteric (1.4%) fistula. The efficacy of CAG was 73%, and the procedure was found efficient with significant improvement in discomfort (p-value: 0.017). The recurrence rate was 27%, which occurred more in diabetic patients (p-value: 0.001) and trans-sphincteric fistula (p-value: 0.035). Conclusion: The CAG application is a simple and safe daycare procedure. However, the incidence of discharge and relief in pain was significantly less, but it cannot be advised to every patient of FIA. A young patient without comorbidities andwith inter-sphincteric low fistula can best be treated by this method.

A Successful Case of Using a New Method of Surgical Treatment of Patients with Transsphincteric Pararectal Fistulas

INTRODUCTION: Surgical treatment of high transsphincteric and extrasphincteric pararectal fistulas (PFs) is one of the unsolved problems of modern coloproctological practice. Currently, there is no uniform approach in treatment of these kinds of PFs. AIM: To present a clinical case of successful application of the developed method of treatment of high transsphincteric PFs using resorbable АПТОС® threads with notches and antibacterial coating. The paper presents a case of application of the developed method for the treatment of high transsphincteric PFs using resorbable АПТОС® threads with notches and antibacterial coating in a patient admitted to a surgical department on a planned basis with complaints of the presence of a skin defect in the perianal area with permanent purulent discharge, periodic elevation of body temperature to 37.5°С–38.0°С accompanied by pain in the anus area. Detailed description of surgical intervention method is given. Within the first 3 days after the surgical intervention, low-grade body temperature persisted (37.3°С–37.5°С). The pain syndrome was most pronounced throughout the first postoperative day, in the following days analgesics were not required. On the 7th day, the patient was discharged in satisfactory condition under supervision of a surgeon at the local clinic. On the control examinations at 1 and 6 months, no data on recurrence, anal incontinence were obtained. CONCLUSION: The presented clinical case demonstrates reasonability and effectiveness of the method developed by authors for surgical treatment of high transsphincteric PFs with use of resorbable АПТОС® threads with notches and antibacterial coating.

Optimizing Surgical Technique for Improved Fistula Treatment

Especially transphincteric anorectal fistulas have shown to be complex with involvement of many anatomical structures and rather high recurrence rates. The need for modularity in the annular dissecting fistula as well as in the sphincteric functioning became pronounced in treatment for the disorder. This is done so that conditions such as fecal incontinence are not realized in the process of undergoing surgery. The patient was a 52-year-old man with many symptoms of the disease including transphincteric fistula with many openings internally or externally. An example of a patient suitable for using the new surgical method for assessment of the outcome would be a patient with no clinical conditions such as diabetes or hypertension. This approach uses modern approaches in drainage together with the ancient Ayurveda technique of Kshara sutra technique in the treatment of the tissue in order to ensure that there is a constant drainage of the contents of the fistulous tract. Among all these techniques, methylene blue infiltration has been found quite helpful in identifying the fistula tract. These procedures are aimed at achieving maximum surgical effect which will minimize the possibility of the recurrence of the illness and enhance the muscular tone of the anal sphincter. The characteristics of the patient’s healing state also evolved in treatment: several changes were observed already on the 10th day after the operation. After the second month, the patient had no signs of the fistula tract any more: there were no recurrences or complications. Since there are neither other known influences that could significantly influence the general status of the patient, the presence of markers that could suggest how well the surgical intervention addressed the fistulas stresses the potential of the approach as a set of basic strategies for managing difficult fistulas. From the article, one may infer the important of precision and innovation in performing surgeries. Also, it has the potential to enhance patients’ outcome and exclude the factors of long-term adverse effects commonly seen in anorectal fistulas.

Evaluation of the outcomes of fistulotomy with primary sphincter reconstruction in the management of high trans-sphincteric fistula and supra-sphincteric fistula-in-ano : Asingle-center prospective cohort study.

Supra-sphincteric and high trans-sphincteric fistula are very challenging procedures for both the patient and the surgeon. We aimed to evaluate the outcomes of anal sphincter repair in the management of supra-sphincteric and high trans-sphincteric fistula-in-ano in terms of postoperative wound infection, bleeding, incontinence to flatus or stool, and recurrence within 1year. This single-center prospective cohort trial conducted from June 2020 to December 2023 at the Ain Shams University Hospitals included 20patients who presented with supra-sphincteric or high trans-sphincteric fistula. There were nine (45%) male and11 (55%) female patients, with a mean age of 41.5years postoperatively. The mean duration of the procedure was 90.3 min (SD ± 11.9). During the first 2weeks,ten (50%) patients scored their postoperative pain as mild, eight (40%) as moderate, and two (10%) as severe. Wound infection occurred in two (10%) patients and postoperative bleeding in three (15%) patients in the form of spotting after defecation. There were no cases of incontinence to stool. However, there were three (15%) cases of incontinence to gases. There were two cases (10%) of recurrence at the 1‑year follow-up. Postoperative patient satisfaction was assessed on a 5‑point Likert scale after 2weeks: One patient (5%) was very dissatisfied, three (15%) patients were dissatisfied, andtwo (10%) patients were unsure, while five (25%) patients were satisfied and nine (45%) were very satisfied. Immediate sphincter repair in supra-sphincteric and high trans-sphincteric fistula through a lay-open procedure was determined to be safe, easier than classic operations, and associated with alow incidence of recurrence at the 1‑year follow-up and ahigh quality of life.

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.

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.

Use of 3D Anorectal Ultrasonography in the Preoperative Assessment of Complex Anal Fistulas and Patterns of Healing, Failure, and Recurrence After Ligation of the Intersphincteric Fistula Tract (LIFT).

To use three-dimensional anorectal ultrasonography (3D-US) to evaluate the outcome of ligation of the intersphincteric fistula tract (LIFT) in patients with crypto-glandular transsphincteric fistula and describing the patterns of healing, failure, and recurrence rate. After classifying the fistula and determining the length of the sphincter muscle to be transected, the patients were submitted to LIFT. The accuracy of pre- and postoperative 3D-US with 360° endoprobe (16 MHz) with automatic scanning and clinical findings was evaluated against surgical findings. Three outcomes were considered: healing, failure (persistent anal fistula through the original external opening or intersphincteric), and recurrence (reappearance of the anal fistula). Sixty-three patients of both sexes were evaluated. The 3D-US assessment revealed primary healing in 50 (79.3%) patients, although in 6 (9.5%) cases healing was delayed and the cavity was without communication with the anal canal. The procedure failed in 9 (15.9%) and fistula recurred in 4 (6.3%), all of whom underwent a second surgery based on a new 3D-US, resulting in a 92.3% (12/13) healing rate on 3D-US. A 3D-US was found to be useful in the preoperative assessment of fistulas by quantifying the percentage of muscle to be transected, and in the postoperative assessment by identifying healing, types of failure, and recurrence. The 3D-US was accurate and consistent with surgical findings.

Comparative Study between Ligation of Trans-sphincteric Fistula Tract and Fistulectomy in Treatment of Fistula in Ano

Comparative Study between Ligation of Trans-sphincteric Fistula Tract and Fistulectomy in Treatment of Fistula in Ano

Efficacy of Ksharasutra Therapy in the Management of Bhagandara (Fistula-in-ano): A Case Study

Bhagandara, or Fistula-in-Ano as it is termed in modern medical parlance, is a persistent and distressing condition that gives rise to an abnormal connection between the anorectal canal and the perianal skin. While conventional surgical approaches to the condition prove adequately effective, they tend to produce high rates of complications and recurrences. Hence, this study. which sets out to explore the effectiveness of Ksharasutra, an Ayurvedic para-surgical intervention, regarding the management and treatment of Bhagandara. Ksharasutra treatment is performed by inserting a medicated thread, prepared specifically for the purpose, along the fistulous tract, where the thread slowly cuts through the tract and healing it over a period. The patient chosen for inclusion in the case study is a 35-year-old male who displayed the classic characteristic signs of suffering from a low trans-sphincteric fistula on initial presentation, i.e. recurring secretion of blood, pus, and other discharge from a swelling in the perianal region as well as severe pain. The treatment was performed over 8 weeks, with regular weekly changes of the thread and visits to the clinic. Significant improvement was observed, including the complete healing of the fistulous tract, with no complications or relapses noted post-treatment. The study concludes the potential of Ksharasutra treatment as a viable alternative to conventional approaches to the treatment of Bhagandara, as it is not only safer a significantly lower rate of complications and recurrence but also promotes quicker healing and a higher quality of life for patients. The study underscores the need to develop the standardized protocol for treatment and test the long-term effects of Ksharasutra therapy for Fistula-in-Ano on broader sample sizes.

Validation of a 3D-printed model of cryptoglandular perianal fistulas.

Visualising the course of a complex perianal fistula on imaging can be difficult. It has been postulated that three-dimensional (3D) models of perianal fistulas improve understanding of the perianal pathology, contribute to surgical decision-making and might even improve future outcomes of surgical treatment. The aim of the current study is to investigate the accuracy of 3D-printed models of perianal fistulas compared with magnetic resonance imaging (MRI). MRI scans of 15 patients with transsphincteric and intersphincteric fistulas were selected and then assessed by an experienced abdominal and colorectal radiologist. A standardised method of creating a 3D-printed anatomical model of cryptoglandular perianal fistula was developed by a technical medical physicist and a surgeon in training with special interest in 3D printing. Manual segmentation of the fistula and external sphincter was performed by a trained technical medical physicist. The anatomical models were 3D printed in a 1:1 ratio and assessed by two colorectal surgeons. The 3D-printed models were then scanned with a 3D scanner. Volume of the 3D-printed model was compared with manual segmentation. Inter-rater reliability statistics were calculated for consistency between the radiologist who assessed the MRI scans and the surgeons who assessed the 3D-printed models. The assessment of the MRI was considered the 'gold standard'. Agreement between the two surgeons who assessed the 3D printed models was also determined. Consistency between the radiologist and the surgeons was almost perfect for classification (κ = 0.87, κ = 0.87), substantial for complexity (κ = 0.73, κ = 0.74) and location of the internal orifice (κ = 0.73, κ = 0.73) and moderate for the percentage of involved external anal sphincter in transsphincteric fistulas (ICC 0.63, ICC 0.52). Agreement between the two surgeons was substantial for classification (κ = 0.73), complexity (κ = 0.74), location of the internal orifice (κ = 0.75) and percentage of involved external anal sphincter in transsphincteric fistulas (ICC 0.77). Our 3D-printed anatomical models of perianal fistulas are an accurate reflection of the MRI. Further research is needed to determine the added value of 3D-printed anatomical models in preoperative planning and education.

Subtotal fistulectomy and sliding anoderm flap: A new sphincter-sparing technique for anal fistula.

The underlying causes of failure or recurrence after ligation of the intersphincteric fistula tract are postulated to be refistulization, breakdown of the closure wound in the intersphincteric plane and faecal contents entering the internal opening, thereby causing recurrent infection. The aim of this study is to demonstrate the outcomes of subtotal fistulectomy with sliding anoderm flaps to prevent refistulization. This retrospective study used prospectively collected data. Patients with transsphincteric or intersphincteric fistulas were enrolled between August 2021 and July 2023. An anal manometric study was performed before and after surgery. Faecal incontinence was evaluated using the faecal incontinence severity index (FISI). Failure was defined as nonhealing of the surgical wound or fistula. Fifty-one patients who underwent subtotal fistulectomy with a sliding anoderm flap were included. After a median follow-up of 12 months (range 4-27 months), primary healing was achieved in 49 patients (96%). Two patients experienced treatment failure, while none developed postoperative recurrence. The median healing time was 10 weeks (range 6-24 weeks). The FISI scores did not change significantly after the surgery. The median resting pressure significantly reduced after surgery [125 cmH2O (range 59-204 cmH2O) vs. 99 cmH2O (range 36-176 cmH2O); p = 0.0001]. The median squeeze pressure significantly decreased after surgery [356 cmH2O (range 137-579 cmH2O) vs. 329 cmH2O (range 72-594 cmH2O; p = 0.005)]. Subtotal fistulectomy with a sliding anoderm flap showed excellent healing rates with no postoperative deterioration of anal function.

Complex Transphincteric Fistula Treatment: A Case Study Demonstrating Swift Recovery and Innovative Techniques in Surgical Intervention

The target of this case report is to see the way of effective treatment for a transphincteric fistula in a 56 years old male patient who has not had any earlier surgeries despite this problem already exists for one year. What was remarkable about that was that the fistulogram with MRI demonstrated the interesting structure of the fistula: both openings – the send and the outflow – were at the 12 o’clock brightest place, hence a more precise treatment having to be employed. Utilizing methylene blue infiltration and metal probing for prompt and exact diagnosis, the next step was the formulation of a detailed treatment approach that would best suit the needs of our patient. As a part of treatment regimen , it was decided to use an Ayurvedic approach called kshara sutra therapy. the treatment had a planned part where we removed sections of the distal tract, and finally packing left intermittent openings. After a two-month-long remarkably successful treatment. Such impressive results reflect the effectiveness of the multifaceted approach. , this case marks a major step forward through introducing the specification of the new strategies that capable of controlling difficult fistulas. These observations in this study suggest tailored treatment and may lead subsequent planning of therapeutic interventions that should be similar for near future clinical conditionings. Futhermore, they are the main advocates of considering patients' needs and applying a holistic vision in medicine.

Addition of Platelet-Rich Plasma to Endorectal Advancement Flap Repair Does Not Enhance the Healing of Cryptoglandular Transsphincteric Fistulas.

The endorectal advancement flap repair is often performed for the treatment of cryptoglandular transsphincteric fistulas. However, this procedure fails in approximately one out of four patients. Based on its supposed healing properties platelet-rich plasma might enhance the outcome of this procedure. To evaluate and to compare the short- and long-term outcomes after endorectal advancement flap repair with and without platelet-rich plasma injection in patients with a cryptoglandular transsphincteric fistula. Retrospective cohort study. Tertiary referral hospital for proctology in the Netherlands. Consecutive patients with a cryptoglandular transsphincteric fistula. Inverse propensity score-weighted comparison was used to adjust for confounding and selection bias. Endorectal advancement flap repair with and without platelet-rich plasma injection. Clinical fistula closure within one year without need for a re-intervention (primary healing), clinical fistula closure within one year corrected for re-interventions (secondary healing), overall fistula healing within one year and long-term outcomes assessed by a questionnaire. In total, 219 patients underwent an endorectal advancement flap repair. In 88 patients (40.2%) platelet-rich plasma was injected. No significant difference was observed in primary healing (67.0% vs. 69.5%, p = 0.71), secondary healing (37.5% vs. 43.5%, p = 0.60), and overall healing (73.9% vs. 77.1%, p = 0.58) between patients with and without platelet-rich plasma injection, respectively. Long-term follow-up was available in 67.1% of the patients with a mean follow-up of 6.8 years (standard deviation: 3.7 years). Within all patients who reached fistula healing, both primary and secondary, within one year and had available long-term follow-up data, recurrence rates also were not significantly different (6.3% vs. 2.9%, p = 0.37). Propensity-scored weighted analysis showed that patients treated with an platelet-rich plasma injection were not more likely to achieve primary healing (odds ratio [OR] 1.0; 95% confidence interval [CI] 0.5 - 1.9), secondary healing (OR 1.1; 95% CI 0.2 - 3.2), overall healing (OR 0.9; 95% CI 0.5 - 1.7) or recurrence at long-term follow-up (OR 1.1; 95% CI 0.4 - 18.8) as compared to patients without platelet-rich plasma injection. Retrospective design, lack of postoperative imaging and assessment of long-term follow-up using a questionnaire. Addition of platelet-rich plasma injection does not improve the short- and long-term outcome of endorectal advancement flap repair in patients with a cryptoglandular transsphincteric fistula treated in a tertiary referral center. See Video Abstract.

Integrative management of high transsphincteric fistula-in-ano with a rectal opening: A case report

Abstract Transsphincteric fistula is a type of complex anal fistula, often considered a refractory surgical condition, which has the potential to produce complications, such as recurrent infections, abscess formation, and incontinence. A 48-year-old male farmer was diagnosed with a high transsphincteric fistula abscess with a secondary rectal opening based on clinical examination and magnetic resonance imaging findings. Under saddle block, incision and drainage of fistula abscess was performed, followed by threading of Apamarga Kshara Sutra (medicated seton) between the abscess cavity and the primary internal opening at 6 o’clock on the dentate line. Another internal opening was also identified in the lower rectum, left as it is. Panchavalkala Kwatha for sitz bath once a day, Varunadi Kwatha 20 mL twice a day orally, Kachanar Guggulu (500 mg) two tablets three times a day, and Apamarga Kshara Tail (AKT) dressing was prescribed for 124 days to facilitate optimal healing and management. Prophylactic as well as therapeutic antibiotics and analgesics were administered for 7 days. The fistula took 103 days for complete healing with a unit healing time of 0.251 day/cm3. Medicated seton on the dentate line facilitated drainage of the infected gland and healed the secondary rectal opening. Ischiorectal abscess cavity healed by secondary intention. This case report demonstrates that a high transsphincteric fistula-in-ano with a rectal opening can be successfully managed without fistulotomy to treat the secondary rectal opening. Chemical debridement of the infected anal gland was achieved by a medicated seton, and a new seton was replaced every 7 days until the cutting and healing of the fistula track. It also facilitated the drainage of the exudate. Wound management by AKT and adjuvant medicament supported faster recovery.

Evaluation of unenhanced three-dimensional endoanal ultrasound scan in preoperative assessment of perianal sepsis

Background: Perianal sepsis which includes perianal fistula and abscess is a common clinical condition that requires thorough preoperative evaluation to decrease the recurrence rate and to plan relevant surgery according to the anatomy of the fistula. MRI and 3D EAUS are two important preoperative investigations that delineate the anatomy of simple and complex fistula tracts. Due to lower cost and easier use 3D EAUS is a safe and reliable first-line investigation in evaluating perianal abscess. Methods: This is a retrospective and prospective analysis of patients with perianal sepsis who underwent pre-operative unenhanced 3D-EAUS in the departments of Colorectal surgery, Gastrointestinal surgery, and General surgery in our hospital. A B-K medical 2052 transducer was used for the study and the surgical assessment was done by multiple surgeons from multiple departments. Results: A total of 255 patients were assessed. The accuracy for primary fistula tracts and internal opening was 83.53% and 88.62% respectively. The kappa coefficient of correlation was k=0.70 (substantial agreement) for the fistula tract and k=0.81 (near perfect agreement) for the internal opening. The sensitivity, and specificity of primary tracts and internal openings were calculated. Transphincteric fistulas were 57% in our study. Conclusions: Unenhanced 3D EAUS is a reliable first-line investigation in preoperative evaluation of perianal fistula and abscess. Transphincteric fistula is the most common type of fistula. There is a high chance of correlation for the primary tract if a non-colorectal specialist performs the fistula surgery after 3D-EAUS without blinding.

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.

Distalization of perianal fistulas after loose silicone seton drainage is a myth

BackgroundIt is often stated that loose seton drainage results in distal migration of a fistula tract in perianal fistula. The aim of the present study was to assess this distalization of trans- and suprasphincteric perianal fistulas after a silicone seton has been inserted.MethodsConsecutive patients who underwent loose seton placement for the management of a transsphincteric or suprasphincteric fistula between January 2016 and December 2021 with a pre- and postoperative magnetic resonance imaging (MRI) were included in the present retrospective study. The height of the external anal sphincter (EAS) and the level of penetration of perianal fistula through the EAS or puborectal muscle (PRM) were determined on MRI. Primary outcome was migration of the fistula tract through the EAS and PRM.ResultsThirty-eight patients with perianal fistulas were included. Median height of the EAS was 28 (IQR 25–34) mm before seton placement and 27 (IQR 24–33) mm afterward. Median level of perforation was 32 (IQR 17–40) mm before seton placement and 28 (IQR 17–40) mm afterward (p = 0.37). One fistula (3%) was downgraded from mid to low transsphincteric and was laid open after 14.9 months of loose seton drainage.ConclusionsNo statistically significant distalization of complex fistula tracts after loose silicone seton drainage was found. Some complex fistulas may downgrade to a less complex fistula after long-term seton drainage. However, loose silicone seton drainage should not be offered to patients as a treatment option to downgrade a complex fistula to a simple one or even have the hope to heal it.

OTSC Proctology clip as appropriate treatment for complicated anorectal fistula.

Evaluation of the effectiveness and tolerability of the application of an OTSC (Ovesco Endoscopy AG Tuebingen, Germany) Proctology clip as an innovative strategy of anorectal fistulae closure when established treatment strategies had already failed or were not feasible. Retrospective single-center study including consecutive patients treated between March 2014 and March 2016 with the OTSC Proctology system for anorectal fistula closure, including one rectovaginal and one rectourethral fistula. The primary outcome was the healing rate with a minimum follow up of 6 months. Healing was defined as closure of the internal fistula ostium and absence of secretion or local inflammation during follow up. A total of 66 fistula closures by the OTSC Proctology clip were investigated, including cryptoglandular fistulas (45/66 patients, 68%), fistulas associated with CED (19/66 patients, 29%), and other non-cryptoglandular fistulas (2/66 patients, 4%). 47% (31/66 patients) had a failed previous therapy. In that selected collective, a successful fistula closure was achieved in 29/66 cases (44%) after a median follow up time of 40 months (6-61 months). Suprasphincteric and high transsphincteric fistulas showed healing in 63% and 42% in CD associated fistulas. Fistula closure by the OTSC Proctology clip is an innovative, sphincter protecting treatment strategy in anorectal fistulas that can achieve long-term cure in complex anorecta.

A Comprehensive Case Study on the Successful Treatment of Perianal Fistula in a Four-Year-Old Male

This case study gives a thorough account of how a four-year-old boy who had been experiencing recurrent discomfort and perianal discharge for six months was diagnosed, treated, and then recovered. An MRI fistulogram revealed a transphincteric fistula with both the internal and exterior apertures placed at the 9 o'clock position, despite the absence of concomitant diseases and prior procedures. The treatment method used methylene blue infiltration to verify the internal aperture and then metal probe probing of the track. From the exterior to the internal opening, a partial fistulotomy was carried out, and the raw proximal track was treated with Kshara sutra. Surprisingly, the fistula was fully cured in just three months. This case study gives priceless information that could direct future treatments and serves as a testimonial to the efficiency of such a therapy method in controlling juvenile fistulas.