Transsphincteric Fistulas Research Articles

Transanal Opening of Intersphincteric Space for Fistula-in-Ano.

The role of the intersphincteric space in the pathogenesis of fistula-in-ano is being increasingly recognized. Submucosal and intersphincteric rectal abscesses have been surgically managed by laying open and draining the intersphincteric space as well as by the modified ligation of intersphincteric fistula tract (LIFT) procedure. In 2017, the transanal opening of intersphincteric space (TROPIS) technique was reported for the treatment of high, complex anal fistulae. We aim to investigate the advantages of performing the TROPIS procedure in patients with fistula-in-ano. This was a prospective cohort study investigating the outcomes in patients who had undergone a procedure using the TROPIS technique for the treatment of fistula-in-ano. Preoperative magnetic resonance imaging scans and electronic colonoscopies were performed on all patients. A clinical database evaluating the following variables was constructed: age, gender, body mass index (BMI), previous fistula surgery, type of fistula, postoperative complications, duration of follow-up, success rate, and incontinence scores pre- and postoperatively. The TROPIS procedure was performed on 41 patients with fistula-in-ano with a follow-up time of 6-23months. The characteristics of the patients were as follows: 36 males, 6 females, mean age 38.6±13.2years, and mean BMI 23.5±3.9kg·m-2. All patients (41) had transsphincteric fistulae, and 90.2% (37) had high fistula. Of the 41 patients, 22% (9) had recurrent fistulae, 29.27% (12) had horseshoe fistulae, 7.3% (3) had supralevator fistulae, and 14.6% (6) had an associated abscess. The fistula healed completely in 85.3% (35) of patients and failed to heal in 14.7% (6) of patients, and the healing of high fistula was 86.5% (32). Of those patients who had not healed completely, 2 were found to have contracted iatrogenic infections due to foreign residues and underwent surgery with the passing of a loose seton. The additional 4 patients who had not healed underwent a fistulotomy and healed completely thereafter. There were no significant changes in incontinence scores. The incontinence scores were .15 ± .36 preoperatively and .22 ± .47 3months postoperatively (t = -1.438, P = .16). The TROPIS technique is a novel sphincter-preserving procedure, which can be effectively used in treating fistula-in-ano.

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.

The use of rerouting operation in the treatment of high arching transsphincteric and suprasphincteric anal fistula: an observational study

Background Perianal fistula is a common disease that has no medical treatment, and cure is only achieved by surgery. Fistulotomy is associated with minimal recurrence; however, incontinence is not uncommonly reported. Many sphincter-saving procedures can avoid fecal incontinence; however, they are associated with significantly higher recurrence. Anal fistula rerouting, described in 1985, entailed staged transposition of the fistulous track to the intersphincteric or submucous space, after which fistulotomy was done. Apparently, minimal recurrence and minimal incontinence could be achieved; however, the operation did not gain much popularity. Patients and methods This prospective study reports the results of rerouting operation in 54 (45 males; age 22–69 years) with high arching transsphincteric and suprasphincteric fistulae. All patients underwent two-stage rerouting operation: in stage I, the track was transposed to the intersphincteric space, and in stage II, the intersphincteric fistula was laid open. Main outcome measures were as follows: continence was assessed using Wexner score after complete healing of the first-stage and second-stage wounds, and every 3 months thereafter for 1 year. Recurrence was defined as persistent purulent discharge from an external opening or from the anal canal. The least follow-up was 9 months. Results Three (5.5%) patients had recurrence; two were treated by fistulotomy and the other refused further intervention. Four (7.4%) patients had minor incontinence. One patient developed track gangrene that was treated by track excision and completed staged rerouting successfully. Conclusions Rerouting operation for high arching transsphincteric and suprasphincteric fistulae is associated with low recurrence and minimal incontinence.

Multiple Scale of Complexity for Anorectal Fistulas

Background: Anorectal fistulas are common and difficult to manage. Objective: To create a scale of complexity through the identification, description of medical history, clinical and ultrasonographic findings. To reduce the rate of recurrence and complications in fistulas is the treatment goal. Patient's inherent traits increase the complexity of anorectal fistulas with the risks of incontinence, delayed healing, infections, and requiring difficult surgeries. The aim of this study was to create a scale of complexity through identification, description of medical history, and clinical and ultrasonography (USG) findings. Patients and Methods: Retrospective study of a prospectively maintained database conducted at two Venezuelan hospitals. All patients who underwent anorectal USG examination at our institutions between 2010 and 2017 were investigated and included in the numerical scoring system, which categorizes the risk of fistula into simple, intermediate, and complex. The Chi-square test of the Statistical Program of Social Sciences (SPSS) was used to establish the significance level, P < 0.005. One thousand one hundred and seventy-three patients were evaluated, and perianal fistula was identified in 989 patients. Results: Of the 232 intersphincteric fistulas, 75.86% were simple, 22.41% were intermediate, and 1.72% were complex. Of the 295 lower transsphincteric fistulas, 51.19% were simple, 42.71% intermediate, and 6.10% were complex. Of the 327 high transsphincteric fistulas, 17.74% were simple, 59.94% were intermediate, and 22.32% were complex. Of the 48 extrasphincteric fistulas, 66.67% were intermediate, and 33.33% were complex. Finally, of the 18 suprasphincteric fistulas, 50% were intermediate and 50% were complex. Conclusions: The complexity of the fistula may not be obvious in routine thorough clinical evaluation, requiring complementary studies. Using the scale avoids excluding factors that indicate complexity, with a statistically significant difference with the classification based exclusively on tracts. Limitation: The limitation of this study is that it is a retrospective single medical group study.

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

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

The effectiveness of the ligation of intersphincteric fistula tract technique in the treatment of simple trans-sphincteric anal fistula

Background The best cure for anal fistula, while maintaining the anal sphincter complex and complete continence, should remove inflammation and facilitate healing of the tract. The primary cure for anal fistula is surgery. There have been several surgical techniques mentioned. Intersphincteric fistula tract [ligation of the intersphincteric fistula tract (LIFT)] ligation, with the benefit of reducing anal incontinence, is a novel surgical technique. The low probability of an impaired sphincter function is one of the key benefits of the procedure. Aim To analyze the success rate of LIFT for patients with anal fistulas. Patients and methods From December 2017 to June 2019, 20 patients were added to this longitudinal study. Patients were treated with intersphincteric fistula (LIFT) technique, and effects were observed and reported, including recurrence rate, incontinence rate, and other postoperative complications. A follow-up cycle of up to 12 months has been completed. Results A total of 20 patients have been examined. The mean operation time was 39 min (range, 25–55 min), and there were no intraoperative complications. The average full healing rate was 90% and the recurrence rate was 10%. No patients have experienced incontinence. Conclusions LIFT technique is an effective method in the treatment of anal fistula with reduced risk of recurrence and anal incontinence.

A comparative study of ligation of intersphincteric fistula tract (LIFT) and conventional fistulotomy in treatment of fistula-in-ano

Background: A hospital randomized control study was conducted at a tertiary care Hospital, to compare outcomes between the Ligation of Intersphincteric Fistula Tract (LIFT) technique and conventional fistulotomy for the treatment of low trans-sphincteric fistula in ano, including 50 patients of low trans-sphincteric fistula in ano randomly divided into two groups. LIFT technique was used in first group while Conventional Fistulotomy was performed in another. Mean duration of operation was significantly less and mean hospital stay, post-operative pain and analgesics need was significantly less in cases operated with LIFT. Mean time for complete healing was significantly less in cases operated with LIFT technique and the difference in complication rate was statistically nonsignificant. Recurrence was reported in 3 (12%) and 1 (4%) cases operated by LIFT and fistulotomy respectively. Ligation of Intersphincteric Fistula Tract (LIFT) procedure is effective and preferred sphincter saving technique for fistula-in-ano. Despite slightly more recurrence, LIFT procedure has certain advantages over standard fistulotomy like shorter operative time, less postoperative pain, shorter hospital stay and faster wound healing and early resumption of normal duties.

A case report on the management of Riju bhagandara (low anal trans-sphincteric fistula) by modified conventional Ksharasutra therapy

Bhagandara (~anal fistula) is a challenging surgical condition due to its high recurrence rate and anal incontinence. Acharya sushruta has explained surgical and para-surgical techniques for its management. Ksharasutra therapy is a time-tested para-surgical modality for Bhagandara with least recurrence (3.33%). Modified conventional technique of application of Ksharasutra is aimed to eliminate infected source and facilitate healing in short duration. A 30-year-old male patient presented with recurrent painful swelling with intermittent pus discharge from the base of the scrotum for one and half years. He underwent incision and drainage twice in the last six months. Magnetic resonance imaging revealed an anterior fistulous tract representing as St. James Type 1 Fistula, which varied from clinical features. He was treated with Modified Conventional Kshara Sutra Therapy (MC-KST) and whole length of fistulous tract was healed completely within five weeks. Anal fistula with scrotal extension is considered a complex manifestation to manage. In MC-KST method, tract was intercepted nearer to sphincter and infected crypto-glandular lesion was eradicated by Ksharasutra. The study concluded that MC-KST is one option to manage anal fistula with scrotal extension to preserve normal perineal structures.

Is a Lateral Internal Sphincterotomy Necessary after Fistulotomy in a Fissure–Fistula Complex?

Background: Fissure–fistula complex is a poorly described condition involving patients with chronic anal fissure and associated fistula-in-ano. Currently, there are no published guidelines on the surgical management of this problem. Objective: The aim of this study was to help establish guidelines for the surgical management of patients with fissure–fistula complex. Design: The study was designed as a retrospective cohort study. Setting: Data were obtained from the operative reports and medical records of patients from two colorectal surgery practices in southeast Michigan from 2000 to 2019. Patients and Methods: Forty-nine patients (47% female, 53% male) with fissure–fistula complexes were included for data analysis. The average age was 45 years. A total of 45 patients (92%) had no previous anorectal surgery, 45 (92%) had a posterior fissure complex, 26 (53%) had an intersphincteric fistula, and 23 (47%) had a low transsphincteric fistula. Although this was a retrospective study, data were described for outcomes of patients who received only a simple fistulotomy as a treatment for fissure–fistula complex. Main Outcome Measures: The primary outcome was the necessity of a lateral internal sphincterotomy after fistulotomy for resolution of the fissure. Sample Size: Forty-nine patients. Results: Three patients (6%) required repeat fistulotomy or abscess drainage during the follow-up period, and only one patient (2%) required a lateral sphincterotomy to resolve the chronic fissure. Forty-five patients (98%) healed their fissures after fistulotomy without sphincterotomy (95% confidence interval [89.1, 99.9]). Conclusions: Our study demonstrated that there is no likely need for a lateral internal sphincterotomy in addition to a fistulotomy in patients with a fissure–fistula complex for resolution of the chronic fissure. Clinical guidelines for the management of this condition should highlight primary fistulotomy as the standard treatment of fissure–fistula complex. Limitations: This study was limited by its retrospective nature and small sample size. Conflict of Interest: None.

Video Assisted Anal Fistula Treatment (VAAFT) for Treating a Complex Posttraumatic Anal Fistula: Case Report

Introduction: Anal fistula is an abnormal pathway that connects the anorectal tract to the perianal skin. The Park’s classification describes four different types of anal fistulas depending on their links with the sphincter apparatus. In this paper, we report an interesting case of post-traumatic complex trans-sphincteric fistula treated with VAAFT procedure. Case Presentation: A 60-year-old-male patient, from an accidental fall, developed a gluteal abscess with a high trans-sphincteric anal fistula and a secondary tract leading to a large second abscess located in the right ischiorectal fossa. An abscess incision was done, and a draining seton was placed in another Institution. The patient came to our Hospital and underwent surgery using Video Assisted Anal Fistula Treatment (VAAFT) procedure. Conclusions: VAAFT is an effective and safe procedure for complex anal fistula, even when they have a post-traumatic origin.

Comparative study between intersphinecteric ligation of perianal fistula versus conventional fistulotomy with or without seton in the treatment of perianal fistula: A prospective randomized controlled trial

BackgroundFistula-in-ano is one of the most common benign anal conditions in daily surgical practice.The goals in the treatment of an anal fistula are to eradicate sepsis and to eliminate the primary fistula opening, any associated tracts, and any secondary openings without a change in continence. Conventional fistulotomy (lay open of the fistula tract) is a commonly used procedure and is still relied on by the majority of surgeons as the gold standard for the treatment of perianal fistula. Ligation of the Intersphincteric Fistula Tract (LIFT) is a new sphincter-preserving technique for the treatment of anal fistula. ObjectiveTo compare the efficacy of open fistulotomy and ligation of intersphincteric fistula tract (LIFT) procedure based on its post-operative outcomes. Patients and methodsThe Present study is A prospective randomized controlled trial which included 30 patients presented with low transsphincteric perianal fistula 27 (90%) males and 3 (10%) females divided into two groups each group consisted of 15 patients. Group, I subjected to inter sphincteric ligation of perianal fistula (LIFT) procedure. Group II patients subjected to conventional fistulotomy. The study lasts 2 years from May 2017 to May 2019 with Follow up for 6 months duration. Operative time in our study was significantly higher in group (I) Managed by LIFT with a mean of 32.53 min than group (II) managed by fistulotomy with a mean of 20.87mins. Wound healing was faster in a group (I) managed by LIFT than group (II) managed by fistulotomy, as the mean time for complete wound healing was (4.53) weeks after LIFT and (5.67) weeks after fistulotomy. ResultsThere was no case of incontinence after performing the LIFT technique in all our patients in group I. there were 2 cases of incontinence to gases only after fistulotomy in group II. The healing rate after LIFT was 80% (12/15 patients). The healing rate after fistulotomy was 93.3% (14/15 patients). ConclusionLIFT procedure is an effective and preferred sphincter-saving technique for fistula-in-ano with shorter healing time and lower incidence of postoperative anal incontinence, as compared to open fistulotomy.

Long-Term Clinical Results of Use of an Anal Fistula Plug for Treatment of Low Trans-Sphincteric Anal Fistulas.

BackgroundAn anal fistula plug is a sphincter-sparing procedure that uses biological substances to close an anorectal fistula. This study aimed to evaluate the long-term therapeutic effect of an anal fistula plug procedure in patients with trans-sphincteric fistula-in-ano and to determine the risk factors affecting fistula healing.Material/MethodsA single-center retrospective study was performed assessing long-term treatment outcomes of patients with low trans-sphincteric anal fistulas who initially underwent anal fistula plug procedures between August 2008 and September 2012. Risk factors affecting fistula healing were identified using univariate and multivariate analyses.ResultsA total of 135 patients who had low trans-sphincteric anal fistulas and underwent anal fistula plug procedures were analysed. The overall healing rate was 56% (75/135) with a median follow-up time of 8 years (range, 72–121 months). The primary reasons for treatment failure were plug extrusion (n=12, 20%) and surgical site infection (n=9, 15%), occurring within 30 days after surgery. Multiple logistic regression analysis showed that the duration of anal fistula ≥6 months was significantly associated with treatment failure using an anal fistula plug (OR=3.187, 95% CI: 1.361–7.466, P=0.008). Of the patients who failed initial treatment with an anal fistula plug, 6 (9%) had anal fistulas that healed spontaneously after 2–3 years without additional treatment.ConclusionsAs a sphincter-preserving procedure, the anal fistula plug can effectively promote healing of low trans-sphincteric anal fistulas. The long-term efficacy is good and the procedure warrants wider use in clinical practice.

High failure rates following ligation of the intersphincteric fistula tract for transsphincteric anal fistulas: are preoperative MRI measurements of the fistula tract predictive of outcome?

Treatment of transsphincteric fistulas (TSFs) with fistulotomy after an indwelling seton is tempered by risks of incontinence and litigation. Thus, ligation of the TSF tract has been popularized as an alternative option. We previously reported on 107 patients who underwent ligation of the intersphincteric fistula tract (LIFT), with a 46% failure rate. Posterior fistula was the only predictor of recurrence. The aim of the present work was to investigate whether the length, width or depth of the fistula measured on preoperative MRI was correlated with recurrence. Following institutional review board approval, a retrospective analysis of our prospective Complex Anal Fistula Database from 1 January 2011 to 31 August 2019 was performed. Patients with TSF who underwent preoperative MRI and LIFT were included. Fistula location was classified as anterior, posterior or lateral. MRI measurements of fistula length, width and depth (in the intersphincteric groove) were performed. The type and rate of postoperative recurrence were analysed. 173 patients underwent MRI for an anal fistula; of these 40 underwent LIFT and 22/40 (55%) had preoperative MRI. There was no difference in the length, width or depth of anterior (n=9), posterior (n=7) or lateral (n=6) fistula tracts. The overall recurrence rate was 9/22 (41%). Posterior TSFs had the highest recurrence rate (5/7, 71%). The mean length, width, and depth of the fistula tract, measured at the preoperative site of LIFT in the intersphincteric groove, did not correlate with recurrence regardless of fistula location.

Power of 3D Transrectal Ultrasonography and Magnetic Resonance Imaging in Diagnosis of Cryptogenic Rectal Fistulae

Background. The only radical curative treatment for rectal fistulae is surgery. The choice of surgery requires precise characterisation of the fistulous tract. The most common instrumental methods for rectal fistula diagnosis are transrectal ultrasonography (TRUS) and magnetic resonance imaging (MRI).Objectives. Comparative assessment of the diagnostic power of 3D TRUS and MRI techniques in revealing cryptogenic anal fistulae with respect to intraoperative examination.Methods. The study enrolled 92 patients with rectal fistulae aged 27 to 66 years. Fistulous opening was external in 47 (51.1%) and obliterated in 45 (48.9%) patients. The average patient age was 42.7 ± 15.9 years. Surgery for acute paraproctitis 14 to 32 days prior to examination was in history of 58 (63.1%) patients. All patients had preoperative subsequent 3D TRUS and MRI compared with intraoperative examination results.Results. The rate of correct fistulous tract type diagnosis verified with intraoperative revision was 96.7% (89/92) with 3D TRUS and 82.6% (76/92) with MRI (p = 0.0027). The error rate of 3D TRUS estimation of external sphincter involvement was 1.1% (1/92), sensitivity 96.6%, specificity 93.5%, overall accuracy 94.5%. The MRI error rate was 21.7% (20/92), with a statistically significant difference for sensitivity and overall accuracy (p < 0.0001). The rate of correct estimation of internal fistulous localisation in “anorectal clock” was 97.8% (90/92) with 3D TRUS and 90% (81/90) with MRI (p = 0.0342). Internal fistula was not detected with MRI in 2/92 (2.2%) cases, which explains the deviation. Intraoperative revision identified total 113 abscesses. The rate or correct abscess estimation was 97.3% (110/113) with 3D TRUS and 74.7% (71/95) with MRI. MRI failed to detect abscess in 18/113 (15.9%) cases (p < 0.0001).Conclusion. 3D transrectal ultrasonography is statistically superior over magnetic resonance imaging in estimating internal fistula localisation in “anorectal clock”, fistulous type, as well as the fistulous tract location relative to external sphincteric tissue in patients with transsphincteric anal fistulae. Estimation of pararectal and intramural abscesses was also significantly different.

Effects of an anal fistula plug on anal function after surgery for treatment of a trans-sphincteric anal fistula.

The aim of this study was to evaluate the anal function in patients with trans-sphincteric anal fistulas who underwent an anal fistula plug procedure, and analyze risk factors that might affect post-operative anal function. This was an observational, retrospective study of patients diagnosed with trans-sphincteric anal fistulas and initially underwent anal fistula plug procedures between August 2008 and September 2012 at our institute. The analysis includes clinical characteristics, anal fistula healing, and the Wexner score for pre- and post-operative anal function (0 = no incontinence to 20 = complete incontinence). A total of 123 patients who had an adequate follow-up in the end were included. The median duration of follow-up was 8years (range 72-121months). The overall healing rate was 56% (69/123), and 33 (26.8%) patients had decreased anal function after surgery. The post-operative Wexner score on anal function was significantly higher than that before the operation (p < 0.001), as well as scores of gas, liquid stool, solid stool incontinence, and alteration in lifestyle (p < 0.05). Based on multiple logistic regression analysis, a high body mass index (p < 0.001) and long distance between the external opening and anal verge (p = 0.003) were significantly associated with a decline in post-operative anal function. As a sphincter-preserving technique for the treatment of anal fistulas, the anal fistula plug procedure might impair the anal function. Especially for patients with obesity or long distance between the external opening of anal fistula and anal verge, the reduced anal function is more likely to occur after treatment with anal fistula plug therapy.

Comparative analysis of the results of treatment of trans- and suprasphincteric anal fistulae by thermo-obliteration of fistula track with diode laser or monopolar electrocoagulation

The objective of the study was to compare the results of two methods of thermo-obliteration of the fistula track by diode laser or monopolar electrocoagulation in patients with trans- and suprasphincteric anal fistulas. Methods and materials . 52 patients (men - 40, women - 12) were included in the study. 29 patients underwent laser coagulation (Laser group) and 23 patients underwent monopolar electrocoagulation (ME group) of fistula track combined with closure of internal fistula opening. Mean age of patients in Laser group was (46±13) years, in ME group - (41±12) years. In the Laser group, 11 (38 %) patients had suprasphincteric fistulae, and 18 (62 %) had transsphincteric fistulae passing through a superficial or deep portion of the external anal sphincter. In the ME group, 9 (39.1 %) patients had an suprasphincteric fistula and 14 (60.9 %) had a transsphincteric fistulae. The minimal period for assessing the healing rate was 2 months after surgery. Results. The average follow-up period after Laser was (9.5±3.0) (5-18) months, after ME - (12.2±7.3) (2-22) months. Primary healing of fistula in 2 months after surgery was 19/29 (65.5 %; 10 transsphincteric and 9 suprasphincteric fistulas) in the Laser group versus 7/23 (30.4 %; 5 transsphincteric and 1 suprasphincteric fistulas) in the ME group (p&lt;0.05). There were no cases of fecal incontinence development after laser or monopolar coagulation of fistula track. Conclusion. A comparative analysis of the first results showed that although in both groups, after thermo-obliteration of the fistula track, the frequency of non-healing of fistula exceeds 30 %, in the group where a diode laser was used, the results were statistically significantly better compared to the group of monopolar electrocoagulation (65.5 against 30.4 %).

LIFT: a feasible option for primary and recurrent fistulas

Background The development of a surgical solution for anal fistulas with minimal recurrence and morbidity remains a challenge. Ligation of the intersphincteric fistula tract (LIFT), however, is a sphincter sparing technique that provides complete resolution of the transsphincteric fistula as well as minimizing recurrence and fecal incontinence. Our goal is to evaluate the efficacy of fistula tract ligation for primary and recurrent fistulas. Methods A retrospective single-center case study was conducted from data between 2015 and 2019 in a large district hospital in Antwerp, Belgium. Patients who underwent LIFT were included. Demographic patient data as well as primary outcome during the follow-up period were collected. A systematic literature review and analysis was conducted with terms [ANAL FISTULA] [TREATMENT] [LIFT] [LIGATION OF INTERSPHINCTERIC FISTULA]. Primary healing and recurrence associated with surgical modifications were investigated. Results 4 out of 25 patients presented with early failure (84% primary success rate) after a median follow-up period of 7 months. The median time until recurrence was 105 days. The success rate after a redo ligation was 100%. Twenty-eight studies were included for review and divided into three groups depending on the technical variation of the used technique. The success rate was 74.2% for the LIFT group, 72.9% in the LIFT + group, and 77.5% in the mLIFT group p = .92. Conclusion LIFT is a feasible treatment option for primary and recurrent fistulas, with excellent success rates where fistula characteristics rather than chosen technique dictate the surgical outcome.

Factors associated with healing, reoperation and continence disturbance in patients following surgery for fistula‐in‐ano

Fistula-in-ano (FIA) is associated with high treatment costs and has a deleterious impact on quality of life. A wide range of healing, incontinence and recurrence rates have been reported. This study aimed to identify operative, patient and disease factors that influence these outcomes after surgery for FIA. An observational cohort study of consecutive patients who were managed for FIA at a tertiary colorectal practice (1999-2019) was performed. Outcome measures included healing, impaired continence and the need to reoperate. Clinico-pathological variables, including patient comorbidities, fistula anatomy and operative approach, were assessed for their association with these outcomes. Some 411 procedures were performed on 263 patients [median age 41.8years (range 17.8-79.7years), 184 men (70.0%)]. Some 77.9% of patients achieved complete healing, 9.5% experienced some deterioration in continence postoperatively and 37.6% required reoperation at a median time of 19.0weeks. Poorer healing was associated with Crohn's disease, high trans-sphincteric fistulas, extrasphincteric fistulas and steroid usage. Poorer continence was associated with female sex, age >40years, posterior location, suprasphincteric fistulas, seton insertion and having more than three subsequent procedures. The need to reoperate was associated with female sex, high trans-sphincteric fistulas, suprasphincteric fistulas, inflammatory bowel disease and previous operations for FIA. Minimizing recurrence of FIA and preservation of continence can be competing management goals. More than one in three patients require reoperation, one in five fails to heal completely and one in ten suffers worsened continence following surgery. Awareness of the factors that contribute to these outcomes is important to the process of informed consent and managing patient expectations before surgery.

EVALUATION OF LIGATION OF INTERSPHINCTERIC FISTULAS TRACT (LIFT) FOR THE TREATMENT OF TRANSSPHINCTERIC ANAL FISTULA

Background: Fistula-in-ano consists of a primary track which passes from the internal opening in the anal canal to the external opening in the perineum. Most of the anal fistulas are originated from the infection of anal glands which are connected to the anal crypts (cryptoglandular origin). Age distribution is spread throughout adult life with maximal incidence between the third and fifth decades. Men are 2 to 5 times more likely to develop anal fistula than women. Objective: The aim of this study was to evaluate the LIFT technique for the treatment of trans-sphincteric anal fistula. Patients and Methods: This study included 20 patients with trans-sphincteric fistula from August 2018 till April 2020, while anal fistula due to specific disease and other types of law anal fistula have been excluded from the study. Regarding demographic data, 90% of the included patients were males and the mean age was 38 years. The median duration of symptoms was 8 months, and the median length of the fistula tracts was 7cm. The mean BMI of patients was 38, seven patients (35%) were diabetic. All patients were investigated with pre-operative MRI and 3D CT fistulography. Results: The main finding of this study was overall healing of 80% of patients, with a 6 months follow-up. There were 1 failure, and 3 recurrences between 3 and 6 months after surgery. No patients reported de novo incontinence, and all patients reported normal control. The median time for wound healing was 4 weeks. Conclusion: LIFT Technique is quite, simple and excellent in long term control of trans-sphincteric fistula, but actually the corner stone in management of perianal fistula is the accurate diagnosis of the type of fistula, which need good preoperative imaging by both surgeon and radiologist, followed by good intraoperative assessment of the type of fistula for selection of the appropriate Technique of each type.