Transsphincteric Fistulas Research Articles

Compartive Study between Conventional Laying-Open Technique with Sphincter Repair and Ligation of Intersphincteric Fistula Tract (LIFT) in Treatment of High Trans-Sphincteric Perianal Fistula

Abstract Background Complex anal fistula has been a hot topic in clinic. Many surgical techniques have been described for the treatment of such anal fistula, including the use of seton, fibrin glue, collagen plugs, rectal advancement flaps, fistulotomy with sphincter repair, and rerouting the fistula tract. However, the results have been variable, and no one procedure is superior to the others absolutely. It is worth our concern that the goal of any treatment procedure is to obliterate the tract and to have low recurrence rates while maintaining full continence. A fistulotomy lays open the fistulous tract, thus leaving smaller unepithelized wounds, which hastens the wound healing. Until now, fistulotomy is still the most widely used. But, the high cure rate is limited by the fact that laying open a transsphincteric fistula tract and cutting both the internal and the external sphincter has the risk of fecal incontinence ranging up to 40%. Objective To retrospectively evaluate the success rate, the recurrence and incontinence when using the Conventional laying-open and sphincter Repair technique in comparison to Ligation of Intersphincteric Fistula Tract (LIFT) for treating high trans-shpincteric perianal fistula. Patients and Methods This was a cohort retrospective, comparative study that was conducted on cases of fistula in the anus, who were subjected to surgery in Ain Shams University Hospitals and Ain shams specialized hospitals in the period from October 2021 to March 2022 (at least 30 cases) to evaluate the success rate, the recurrence rate, and incontinence rate when using the conventional laying open with sphincter repair technique compared to ligation of inter-sphincteric fistula tract (LIFT) For High trans-sphincteric perianal fistula. Results Regarding Relation of recurrence with demographic data of the studied patients, de novo/recurrent, Wexner score before and after operation and complications. that there was no statistically significant relation found recurrence with demographic data of the studied patients, de novo/recurrent, Wexner score before and after operation while there was statistically significant relation found with complications. Conclusion LIFT procedure is an effective and preferred sphincter-saving technique for fistula-inano with shorter healing time and lower incidence of postoperative anal incontinence, but have higher incidence of recurrence as compared to conventional layopen with sphincter repair which have a lower incidence of recurrence but have a relatively longer Healing time and higher incidence of postoperative anal incontinence. Both techniques are effective, have post operative good results and safe in treatment of high transsphincteric perianal fistula but Further research work is still warranted to confirm the long term outcome of these 2 techniques with a larger sample size and a longer follow up period. To know which technique is superior over the other.

Role of Laser Ablation of Fistula Tract in High Perianal Fistula

Abstract Background Complex anal fistula has been a hot topic in clinic. Many surgical techniques have been described for the treatment of such anal fistula, including the use of seton, fibrin glue, collagen plugs, rectal advancement flaps, fistulotomy with sphincter repair, and rerouting the fistula tract. However, the results have been variable, and no one procedure is superior to the others absolutely. It is worth our concern that the goal of any treatment procedure is to obliterate the tract and to have low recurrence rates while maintaining full continence. A fistulotomy lays open the fistulous tract, thus leaving smaller unepithelized wounds, which hastens the wound healing. Until now, fistulotomy is still the most widely used. But, the high cure rate is limited by the fact that laying open a transsphincteric fistula tract and cutting both the internal and the external sphincter has the risk of fecal incontinence ranging up to 40%. Aim of the Work To assess and evaluate the efficacy and safety of LASER ablation of high perianal fistula. Patients and Methods This study is a randomized prospective study which will be conducted at Ain Shams University hospitals recruiting (20) patients and will be operated upon between January 2021 and July 2021 with minimal follow up to 3 months postoperatively. Results From these studies, it emerges that this procedure has some advantages. It doesn’t affect continence, administers controlled hyperthermic effect to the tissues, has a short learning-curve and reduces postoperative hospital stay as compared to endorectal advancement flap or LIFT. However, it has also some drawbacks. It is a blind procedure, as it’s not possible a direct visualization of the fistula tract or any secondary tracts and this may lead to recurrence. It requires expensive equipment, particularly if compared to other sphincter-saving techniques. Conclusion LASER ablation is a technique that has a promising results regarding complex perianal fistula preserving anal continence and short healing period and low recurrence rate as regarding classic and other techniques.

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%...

Statutory provisions, aims, motives, attitudes and thinking on the outpatient operation profile of general and abdominal surgery

The aim of the manuscript is to discuss and assess the implications and opportunities as well as dangers of "outpatientization" of surgical and inpatient services for general and abdominal surgery. Narrative overview with literature reference based on a PubMed search with the search terms: outpatient operations and inpatient interventions, AOP catalog, hybrid DRG, outpatient hernia surgery, outpatient proctological surgery, selective sector-equal reimbursement and day-care forms of care. RESULTS (KEY POINTS): - In the Anglo-American area, the treatment of inguinal hernias is predominantly carried out on an outpatient clinic basis. In the USA, Sweden and Denmark, for example, over 70% of all hernias are treated in an outpatient clinic setting, in Germany it is only 20%. In Germany, the catalog of operations that can be performed on an outpatient basis and other department-replacing interventions in hospitals defines outpatient interventions in accordance with §115b Social Security Code (SGB)V (Germany). - The conversion from inpatient to outpatient hernia surgery has also failed so far due to an enormous difference in revenues. According to the will of the Federal Ministry of Health, the planned forms of semistationary care are intended to relieve the nursing staff in the hospitals and thus relieve the tense situation of nursing professionals. By the end of March 2023, aspecial industry-specific reimbursement, so-called hybrid DRGs, is to be agreed, which applies regardless of whether apaid service is provided on an outpatient or inpatient basis. - According to §115b SGBV, whether ahernia can be performed under inpatient or outpatient conditions is also decided according to the location of the hernia. In the new AOP catalog, frailty is operationalized in the context factors via the degree of care and the Barthel index. If one compares the number of encryption procedures for the 5‑530 procedure (closure of an inguinal hernia) in 2005 (184,679) with the pre-corona year 2019 (179,851), it can be seen that the proportion of hernias treated in hospital remained approximately the same over aperiod of 14years. - Most elective proctological procedures can be performed on an outpatient basis. For reasons of safety (bleeding) and practicality (pain management, dressing change of large abscesses), inpatient surgery is preferred: extensive hemorrhoidectomy in the case of massive findings, large abscesses, extensive perianal fistula corrections, particularly high transsphincteric or suprasphincteric fistulas. - Guidelines based on the British Guidelines for Ambulant Surgery should be required for comprehensive outpatient treatment in surgery. The introduction of corresponding hybrid DRGs seems to be the right way to cover the costs of outpatient surgery in hospitals. The restructuring of the hospital landscape and the nationwide expansion of outpatient operations is an unavoidable requirement in view of rising costs in the healthcare system and impending financing bottlenecks, which will pose challenges for the surgical disciplines in the years to come. Outpatient surgery is already practiced in many areas but has not become established due to the different remuneration. The flat rates for the same branches can be astarting point here. Furthermore, evidence-based framework conditions must be created along the lines of the British Guidelines for Ambulant Surgery.

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 < 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.

Collagen treatment of complex anorectal fistula: 3 years follow-up.

Fistula in ano is a common anorectal disease in adults. Currently, surgery remains the definitive therapeutic approach, but in some cases, it can lead to serious complications as faecal or gas incontinence. Therefore, sphincter sparing treatments should be considered for complex fistulas. One of the sphincteric preserving treatment is the filling with a dermal extract commonly called "collagen glue" as Salvecoll-E® gel. This is a multicentric, prospective, observational study on the use of Salvecoll-E® gel in treatment of complex anal fistulas. We treated 70 patients from May 2016 to May 2017. In the first phase, we debrided the fistula tract using a loose seton kept for 4-6 weeks. In the second phase, the seton was removed and the fistula tract was filled with Salvecoll-E® gel. In this article, we report results at 36 months of follow-up. Fifty patients (71.4%) had completely healed fistula within 36 months of follow-up. Twenty-eight patients (28.2%) had recurrences. Among these failures, 65% were within 6 months. All low transphincteric fistulas healed. Recurrences occurred only in median and high transphincteric fistulas. No patient had a worsening of continence status measured with Cleveland Clinic Florida Incontinence Severity score. Salvecoll-E® gel is a recent finding among sphincter-sparing treatments. In this study, we demonstrate that it is a safe option in the treatment of complex fistulas. Final results are satisfactory and in line with the best results published in literature among mini-invasive treatments.

A COMPARATIVE STUDY OFLIGATION OF INTERSPHINCTERIC FISTULA TRACT AND FISTULECTOMY IN THE MANAGEMENT OF TRANS SPHINCTERIC FISTULA IN ANO

Background: A fistulectomy involves complete excision of the fistulous tract, thereby eliminating the risk of missing secondary tracts and providing complete tissue for histopathological examination. By studying with comparing the LIFT with fistulectomy withits outcome being advantages and disadvantages in terms of hospital stay, postoperativebleeding, postoperative pain, recurrences, incontinence patient can be benefitted with early outcome with less complications associated, so this study being done to evaluate the standard procedure in terms of with less complication associated. Objectives of the study: To compare the LIFT with fistulectomy in term of operative time, postoperative, bleeding, hospital stay, wound healing, postoperative pain, recurrence, incontinence Methods: Patients satisfying inclusion criteria are enrolled within 24 hours of admission after informed consent. All the patients with Trans sphincteric fistula in ano will be evaluated with thorough clinical examination, radiological and laboratory investigations. Those who require surgery will be admitted and appropriate surgery will be performed .and analyzed for in term of operative time, postoperative bleeding, hospital stay, postoperative pain, recurrence, incontinence. Results: Majority of patients belonged to the age group of 30 -40 years. M:F is 4:1, Duration of hospital stay is significantly low in LIFT group with P<0.417, Post-operative pain is less in LIFT group with P<0.002, Post-operative woundHealing time are less with LIFT group . Incontinence is less with LIFT group when compared to Fistulectomy with P<0.0452, recurrence is noted in either group but more in LIFT group. Success rate in our study is 90% in LIFT group. Interpretation and conclusion: LIFT is associated with less postoperative pain, shorter duration of hospital stay and a quicker recovery, shorter duration of surgery, earlier return to work as compared with fistulectomy. LIFT procedure is not associated with major post-operative complications. There is no incontinence in the follow up period of six months.

A Journey through Persistence: A Case Study on Treating Chronic Perianal Fistula with Kshara Sutra Application

Objective: In this case study, an Ayurvedic medical approach called Kshara Sutra treatment is used to treat a chronic transsphincteric fistula in a 45-year-old male patient after three unsuccessful surgical operations. Methods: The patient has been experiencing peri-anal pain and discharge on and off for six years. An extensive diagnostic examination, which included an MRI fistulogram, revealed a transphincteric fistula with several external openings on the left buttock and one internal hole at 6 o’clock. Following methylene blue infiltration confirmation of the interior orifice, Kshara Sutra herapy was applied. Results: The patient responded well to Kshara Sutra therapy, showing significant improvement in pain and discharge as well as no significant side effects. At the conclusion of the therapeutic time, the fistula was seen to have fully resolved, and the patient has since been symptom-free. Conclusions: This instance highlights the Kshara Sutra therapy’s potential efficacy in treating persistent transphincteric fistulas, especially when other treatments have failed. It is necessary to conduct more study to confirm these conclusions and examine the wider Applications of this therapy for the treatment of fistulas.

Comparison of MRI and Endoanal Ultrasound in Assessing Intersphincteric, Transsphincteric, and Suprasphincteric Perianal Fistula.

Perianal fistula is a common disorder characterized by an anomalous perianal track connecting two epithelialized surfaces, most commonly the anal canal and the perianal skin. Although each has its limitations, magnetic resonance imaging (MRI) and endoanal ultrasound are currently two acceptable modalities for assessing perianal fistula. This study aimed to evaluate the accuracy of MRI and endoanal ultrasonography in diagosing perianal fistula, considering the surgical results as the references. This prospective cohort study was performed on patients with symptomatic perianal fistulas. MRI results of patients reported by the radiologist were collected along with the findings of endoanal ultrasonography performed by a gastroenterologist. These results were compared with surgical findings as the reference standard. The study enrolled 126 patients. Exactly 222 definitive fistulas were identified during surgery. Sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of ultrasound for perianal fistula were 87.38, 38.46, 92.38, 26.31, and 82.25% respectively; and for MRI were 76.12, 57.69, 93.88, 22.05, and 74.19% respectively. The accuracy of endoanal ultrasound for detecting transsphincteric and intersphincteric fistulas was higher than MRI. In contrast, the diagnostic value of MRI for detecting suprasphincteric fistulas was higher than endoanal ultrasound. Using endoanal ultrasonography to diagnose perianal fistulas is a relatively accurate method. This method may be more sensitive than MRI in detecting patients with perianal fistulas and abscesses.

A Comparison of Laser and Fistulotomy Techniques in the Treatment of Fistula-in-Ano.

Background Anal fistulas are a common complication of perianal abscesses.The treatment of anal fistulas is challenging, with persistent and high recurrence rates. The aim of this study was to evaluate the efficacy and cost-effectiveness of laser ablation compared to fistulotomy in the treatment of anal fistulas. Materials and methods The patients were examined for external and internal openings of the fistula, its number, length, type, relationship with the sphincters, and any previous history of abscess or proctological surgery. The surgical procedures, complications, incontinence, recurrence, and recovery time were evaluated and compared between the two groups. The laser ablation group received an intermittent laser application at a wavelength of 1470 nmand 10 watts for three seconds, while the fistulotomy group underwent cutting of the fistula tract with electrocautery while keeping a stylet in place. Results A total of 253 patients were included in this retrospective study, with 149 patients undergoing fistulotomy and 104 patients undergoing laser ablation. The patients were evaluated based on the type, number, and location of internal and external openings, and the length of the fistula tract according to the Parks classification. The mean follow-up period was 9.0±4.3 months. The results showed that the laser group had a shorter time to return to work and less postoperative pain compared to the fistulotomy group. However, the recurrence rate was higher in the laser group. The recurrence rate was also found to be higher in patients with low transsphincteric fistulas and in patients with diabetes mellitus. Conclusion Our study findings indicate that while laser ablation may be associated with less pain and quicker recovery time, it may also have a higher recurrence rate compared to fistulotomy.We believe that laser ablation is a valuable option for surgeons to consider early on in the treatment process, especially in cases where fistulotomy is not suitable.

Comparison of Laser Ablation and Fistulectomy with Sphincteroplasty for the Management of Transsphincteric Fistulas Following Preliminary Seton Insertion

Comparison of Laser Ablation and Fistulectomy with Sphincteroplasty for the Management of Transsphincteric Fistulas Following Preliminary Seton Insertion

Cohort study of fistulotomy with external tract fistulectomy and primary sphincter reconstruction in high trans-sphincteric fistula-in-ano.

Treatment of complex fistula-in-ano is challenging and there is no consensus on the optimal treatment that can provide complete healing and preserve sphincter function. The aim of this study was to evaluate fistulotomy with external tract fistulectomy and primary sphincter reconstruction (FFSR) in the treatment of high trans-sphincteric fistula. This is a prospective single-centre study including patients with a high trans-sphincteric fistula who underwent FFSR from June 2017 to June 2018. All patients were evaluated preoperatively by pelvic MRI and clinical examination. Other types of complex fistula were excluded. All patients were followed up for 1year for recurrence and incontinence. Forty patients underwent FFSR during the study period, 62.5% were men and the mean age was 37.45 (range 20-60)years. The mean time to achieve complete healing was 8.4 weeks, 35 (87.5%) patients achieved primary healing within 8 weeks and 5 (12.5%) patients required more time to achieve delayed healing. Four (10%) patients developed recurrence with a mean time for recurrence of 20 weeks. Only four (10%) patients developed incontinence; one to liquid stools and three patients only to gas. Fistulotomy with external tract fistulectomy and primary sphincter reconstruction is a safe option in the treatment of high trans-sphincteric fistula in selected patients. This showed an acceptable recurrence rate when compared with other procedures with comparable sphincter function outcomes.

Surgery of Simple and Complex Anal Fistulae in Adults: A Review of the Literature for Optimal Surgical Outcomes.

Anal fistulas are common anorectal conditions, and surgery is the primary treatment option. In the last 20 years of literature, there exist a large number of surgical procedures, especially for the treatment of complex anal fistulas, as they present more recurrences and continence problems than simple anal fistulas. To date, there are no guidelines for choosing the best technique. We conducted a recent literature review, mainly the last 20 years, based on the PubMed and Google Scholar medical databases, with the goal of identifying the surgical procedures with the highest success rates, lowest recurrence rates, and best safety profiles. Clinical trials, retrospective studies, review articles, comparative studies, recent systematic reviews, and meta-analyses for various surgical techniques, as well as the latest guidelines of the American Society of Colon and Rectal Surgeons, the Association of Coloproctology of Great Britain and Ireland, and the German S3 guidelines on simple and complex fistulas were reviewed. According to the literature, there is no recommendation for the optimal surgical technique. The etiology, complexity, and many other factors affect the outcome. In simple intersphincteric anal fistulas, fistulotomy is the procedure of choice. In simple low transsphincteric fistulas, the patient's selection is crucial in order to perform a safe fistulotomy or another sphincter-saving technique. The healing rate in simple anal fistulas is higher than 95% with low recurrence and without significant postoperative complications. In complex anal fistulas, only sphincter-saving techniques should be used; the optimal outcomes are obtained by the ligation of the intersphincteric fistulous tract (LIFT) and rectal advancement flaps. Those techniques assure high healing rates of 60-90%. The novel technique of the transanal opening of the intersphincteric space (TROPIS) is under evaluation. The novel sphincter-saving techniques of fistula laser closure (FiLac) and video-assisted anal fistula treatment (VAAFT) are safe, with reported healing rates ranging from 65% to 90%. Surgeons should be familiar with all sphincter-saving techniques in order to face the variability of the fistulas-in-ano. Currently, there is no universally superior technique that can treat all fistulas.

Magnetic resonance imaging in the workup of patients with perianal fistulas

BackgroundPerianal sepsis and fistulas are common lesions. Fistula-in-ano is a tedious problem because of high recurrence rates and severe unexpected complications postoperatively. Many imaging modalities are used to evaluate this area. Magnetic resonance imaging (MRI) has been considered the gold standard procedure for perianal fistula assessment, i.e., it provides the surgeon with an accurate roadmap to select the best surgical approach, determines the extent of sphincter division, and estimates the risk of postoperative incontinence. We carried out a prospective diagnostic accuracy study involving 50 patients (mean age, 42.44 years) with perianal fistulas who underwent pelvic MRI with a 1.5 Tesla scanner using multiple sequences, including diffusion and post-contrast series that were either local or systemic. This study aimed to evaluate the diagnostic validity of pelvic MRI/MR fistulogram in perianal fistula assessment, identify perianal fistula-associated findings by MRI, and optimize the MRI technique with maximum technical safety.ResultsIntersphincteric fistulas were the most common type of perianal fistula observed based on Parks’ classification. Intersphincteric, trans-sphincteric, extrasphincteric, and suprasphincteric fistulas were found in 30 (60%), 12 (24%), 4 (8%), and 4 (8%) patients, respectively. According to St. James’ classification, 21 (42%), 9 (18%), 8 (16%), 4 (8%), and 8 (16%) patients had perianal fistula grades I, II, III, IV, and V, respectively. The combination of variable MR sequences and MR fistulogram increased the diagnostic validity of MRI examinations. Our results correlated with surgical results (reference standard) with perfect interobserver reliability.ConclusionsOf all imaging modalities, MRI has become a prerequisite for a successful surgery of a perianal fistula. MRI can identify: (a) fistula morphological details, (b) the relationship between the fistulous tract and the anal sphincter, (c) fistula wound healing, (d) an active versus chronic scarred fistula, (e) postoperative stigmata, and (f) a perianal fistula from its mimics. MRI with variable sequences and MRI fistulogram are successful combinations that increase diagnostic efficiency with technical safety by avoiding both ionizing radiation and systemic gadolinium.

Evaluation of Fistula Laser Closure (FiLaC) in Management of High Trans- sphincteric Fistula- in- ano

Background: As a revolutionary sphincter-preserving approach, Wilhelm proposed "Fistula Laser Closure" (FiLaC) in 2016. It uses a radial emitting laser probe and had an initial rate of success of 81.8 percent in 11 patients with a median follow-up of 7.4 months. Aim of the study: To analyze the Fistula Laser Closure (FiLaC) technique's efficacy in treating high trans-sphincteric fistulas in ano, look at the procedure's effects on anal continence, and predictors of success. Patients and methods: This prospective cohort research was conducted between April 2021 and November 2021 on 20 patients with high transsphincteric fistula in ano at the Department of Surgery at Al-Azhar University Hospitals, Cairo, Egypt. Patients received care using the Fistula Laser Closure (FiLaC) procedure, and they were monitored for at least six months after surgery. Results: There was substantial variation between simple and complicated fistula as regards hospital stay, Early incontinence, pain score and patient satisfaction (p

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.

Short term Outcomes of Fistula Laser Closure (FILAC) as a Sphincter Sparing Technique Versus Fistulotomy with Immediate Sphincter Reconstruction (FISR) in High Trans-Sphincteric Fistula–in-ano; a Prospective Cohort Study

Short term Outcomes of Fistula Laser Closure (FILAC) as a Sphincter Sparing Technique Versus Fistulotomy with Immediate Sphincter Reconstruction (FISR) in High Trans-Sphincteric Fistula–in-ano; a Prospective Cohort Study

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.

Multiple Scale of Complexity for Anorectal Fistulas

Background: Anorectal fistulas are frequently prevalent proctological entities, in which the complexity is frequently garbled. Objective: To create a scale of complexity for fistulas based on identification, medical history, physical examination, and ultrasonography findings. Design: A retrospective and descriptive study of a prospectively maintained database. Setting: A single medical group performed three-dimensional endoanal ultrasonography at two different tertiary care hospitals in Caracas, Venezuela. Patients and Methods: All patients who underwent anorectal three-dimensional endoanal ultrasonography at the two hospitals between 2010 and 2017 were included in the study. We created an arbitrary numerical scoring system ranging from 0 to 14 points, which classifies the structure of fistulas as simple, intermediate, and complex. The chi-squared test performed with Statistical Program of Social Sciences was used to establish the significance level of P < 0.005. Sample Size: a total of 1173 patients were evaluated, and perianal fistulas were 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% were 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 fistulas may not be easy to determine, even in cases requiring further complementary studies. The application of our scale helped to prevent the factors that may be responsible for the deterioration of the complexity of fistulas, with a statistically significant difference compared to the classic Goodsall's classification, based exclusively on the anatomy of the fistula tract. Limitations: A single operative group study without surgical usefulness validation that warrants a further multicentric randomized study. Conflict of Interest: The authors have no conflict of interest to declare.