Treatment Of Transsphincteric Anal Fistula Research Articles

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%...

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.

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.

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

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

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.

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.

Long-term efficacy of bioprosthetic anal fistula plug in the treatment of transsphincteric anal fistula

Objective: To evaluate the long-term healing rate of transsphincteric anal fistula treated with anal fistula plug procedure and the risk factors affecting the healing of anal fistula. Methods: A retrospective case-control study was conducted to analyze the clinical data of 207 patients with transsphincteric anal fistulas who received anal fistula plug procedure at the Department of General Surgery, Beijing Chaoyang Hospital of Capital Medical University from August 2008 to September 2012. Inclusion criteria: (1) consistent with the diagnosis of transsphincteric anal fistula: the anal fistula passed through the internal and external sphincter; (2) complete data; (3) initial treatment with anal fistula plug procedure. Exclusion criteria: (1) acute rectal or perianal infection or poorly controlled focal infection; (2) recent incision and drainage of perianal abscess or spontaneous rupture of abscess; (3) patients with malignant tumor; (4) patients with Crohn's disease or ulcerative colitis; (5) patients with heart, liver, brain, lung or renal insufficiency; (6) cachexia due to various chronic wasting diseases; (7) patients could not tolerate surgery. Patients were followed up for anal fistula healing. The cumulative healing rate of patients with transsphincteric anal fistula was plotted using the Kaplan-Meier method, and the factors affecting anal fistula healing were explored by univariate and multivariate logistic regression analysis. Results: There were 186 males and 21 females with age of 15 to 69 (mean 38) years. The duration of anal fistula was 3-60 (mean 15) months. Three patients had a history of previous episodes of perianal abscess and underwent incision and drainage of perianal abscess (all more than 3 months). During follow-up ending on October 31, 2018, 72 patients (34.8%) were lost to follow-up. Among 135 patients who were successfully followed up, the average follow-up period was 96 (75-124) months. Seventy-five patients had anal fistula healing, with healing rate of 55.6%. Kaplan-Meier survival curve showed that the healing time of anal fistula was prolonged and finally stabilized at 55.6%. In the patients who failed initial treatment with anal fistula plug packing, there were 6 cases whose anal fistula healed spontaneously without other treatment. Among them, 3 cases healed spontaneously 2 years and 3 cases 3 years after operation without recurrence. From 2008 to 2012, the annual healing rates of anal fistula plug treatment were 3/6, 61.5% (24/39), 42.1% (24/57), 12/15 and 12/18, respectively. Multivariate logistic regression analysis showed that the duration of anal fistula≥6 months (OR=3.187, 95% CI: 1.361-7.466, P=0.008) was an independent risk factor for anal fistula healing after treatment with anal fistula plug. Conclusion: The long-term efficacy of anal fistula plug procedure in the treatment of transsphincteric anal fistula is positive, and this procedure should be implemented as soon as possible.

High ligation of the anal fistula tract by lateral approach: A prospective cohort study on a modification of the ligation of the intersphincteric fistula tract (LIFT) technique

BackgroundLigation of the intersphincteric fistula tract (LIFT) is a sphincter-preserving operation for anal fistulas. Although it has advantages in preserving continence after surgery, it is difficult to perform owing to the narrow field of view. We performed a modified surgical procedure based on the LIFT to overcome these drawbacks. Materials and methodsTwenty-eight patients who were scheduled to undergo high ligation of the anal fistula tract by the lateral approach for the treatment of transsphincteric anal fistulas were prospectively studied. Instead of making a new stab incision on the intersphincteric groove, we dissected along the fistula tract from the external opening until the intersphincteric space appeared. The fistula tract was then ligated close to the internal anal sphincter with absorbable sutures, and the distal part of the ligation was cut off. A cored-out wound was left open for drainage. ResultsThe median follow-up was 16 months (range, 8–27 months). Of the 28 patients, 19 (68%) had simple transsphincteric fistulas and 9 (32%) had complex transsphincteric fistulas. Successful fistula closure was achieved in 21 patients (75%), with a median healing time of 4 weeks (range, 3–7 weeks). None of the patients complained of any incontinence symptoms after the procedure. Of the seven patients (25%) who failed to heal successfully, two (7%) did not heal up to 2 months after surgery and five (18%) experienced recurrence after complete healing. ConclusionHigh ligation of the anal fistula tract by lateral approach may be a useful sphincter-sparing procedure for transsphincteric anal fistulas.

Freeze-dried collagen implant for the surgical treatment of trans-sphincteric anal fistula

The aim — to improve the surgical treatment results of trans­sphincteric anal fistulas with freeze­dried collagen implant.Materials and methods. 88 patients with trans­sphincteric fistulas of rectum were operated in the of Surgery and Proctology Department from 2012 to 2017. Patients were aged 25 to 65 years old, average age constituted 54.3 ± 2.1 years. Men — 54 (61.3 %), women — 32 (38.7 %). A transanal ultrasound study with complex substance and a circular image sensor (5 — 7.5 MHz) was performed in all patients. 32 patients (36.4 %) had front, 26 (29.5 %) — lateral and 30 (34.1 %) — posterior fistulas, according to the study. Patients were divided into 2 groups depending on the method of surgical treatment. First group comprised 44 patients who were treated with the freeze­dried allogeneic collagen implant by original technic and a comparison group of 44 patients who used traditional surgical treatment methods of rectal fistulas (the fistula excision in the lumen of the gut — in 28 (63.6 %) observations, Seton Placement (ligation) — in 16 (36.4 %)). The effectiveness of operations was assessed by comparing the immediate and long­term results.Results and discussion. 2 patients (4.5 %) in the first group appeared to have wound abscess, 4 (9.1 %) — serous inflammation of operative wound. Anal incontinence was hardly in evidence. The wound healed on 10.0 ± 1.1 day. In the comparison group, local complications were observed in the early postoperative period in the form of wound suppuration in 9 (20.4 %) patients, partial incontinence of gases in 10 (22.7 %), anal incontinence of the first degree in 8 (18.9 %) %), persistent anal incontinence — in 6 (13.6 %). The wound healed on average 24.0 ± 2.1 days. Long­term results of treatment (1 to 24 months) were examined by observation and questioning of 42 patients in the main group and 41 — in comparison groups. Relapse of the disease in the main group occurred in 2 (4.7 %) patients, in the comparison group — in 7 (17.1 %). In the comparison group, stable anal incontinence was also observed in 6 (14.6 %) and partial incontinence in 8 (19.5 %).Conclusions. Surgical treatment of trans­sphincteric fistulas with freeze­dried collagen implant provides ensures reliable closure of the internal fistula opening and helps reduce the relapse rate to 4.7 compared to 17.1 % using traditional techniques.

Ligation of Intersphincteric Fistula Tract vs Ligation of the Intersphincteric Fistula Tract Plus a Bioprosthetic Anal Fistula Plug Procedure in Patients With Transsphincteric Anal Fistula

The purpose of this study was to compare the ligation of intersphincteric fistula tract (LIFT) with an additional plug (LIFT-plug) in the treatment of transsphincteric anal fistula. Both LIFT and LIFT-plug are recently reported effective alternatives of transsphincteric anal fistula. This multicenter prospective randomized study (NCT01478139) was conducted at 5 university hospitals throughout China. A total of 235 patients were randomly assigned to undergo LIFT (118 patients) or LIFT-plug (117 patients) between March 2011 and April 2013. The primary outcome measured was primary healing rate at 6 months postoperatively and healing time. Secondary outcomes included recurrence rate, postoperative pain, and incontinence rate. The LIFT procedure showed shorter operative time than the LIFT-plug procedure (26.7 min vs 28.5 min, P = 0.03). Median healing time was 22 days in LIFT-plug group vs 30 days in LIFT group (P < 0.001). The difference in visual analog scale scores across all time points was not statistically significant between the groups (P = 0.13). The primary healing rate was higher in LIFT-plug group than in LIFT group [94.0% (95% confidence interval 89.7%-98.3%) vs 83.9% (95% confidence interval 77.2%-90.6%), P < 0.001]. There were no reported incontinence and recurrence within the follow-up period of 6 months. In patients with transsphincteric anal fistulas, both LIFT-plug and LIFT are simple, safe, and effective procedures. LIFT-plug has the advantage of a higher healing rate, less healing time, and a lower early postoperative pain score.

Results of the Gore Bio-A fistula plug implantation in the treatment of anal fistula: a multicentre study.

The aim of this prospective study was to determine the efficiency of the Gore Bio-A synthetic plug in the treatment of anal fistulas. A synthetic bioabsorbable anal fistula plug was implanted in 60 patients. All fistulas were transsphincteric and cryptoglandular in origin. The healing rate after 1year of follow-up was 52% (31 out of 60 patients). No patient was lost to follow-up. The treatment had no effect on the incontinence score. The plug dislodgement rate was 10% (6 out of 60 patients). Thirty-four per cent of the patients (16 out of 47) required reoperation. The average operating time was 32±10.2min, and the average length of hospital stay was 3.3±1.8days. Synthetic plugs may be an alternative to bioprosthetic fistula plugs in the treatment of transsphincteric anal fistulas. This method might have better success rates than treatment with bioprosthetic fistula plugs.

Definitive seton management for transsphincteric fistula‐in‐ano: harm or charm?

The treatment of transsphincteric anal fistula requires a balance between eradication of the disease and preservation of faecal control. A cutting seton is an old tool that is now out of vogue for many surgeons. We hypothesized that the concept remains reliable and safe with results that exceed those reported for many of the more recently described methods. A retrospective review was conducted of real-time electronic health records (single institution, single surgeon) of patients presenting during the 14years between 2001 and 2014 with a transsphincteric anal fistula who were treated with a cutting seton. Excluded were patients with Crohn's disease, fistulae related to malignancy or a previous anastomosis and patients whose fistula was treated by another method including a loose draining seton. Data collection included demographics, duration of the disease, duration of the treatment, outcome and continence. In all, 121 patients (80 men) of mean age 40.2±12.2years (range 18-76) with a mean follow-up of 5.1±3.3 (1-24) months were included in the analysis. The median duration of symptoms was 6 (1-84) months; 36% had failed other fistula surgery, 12% had a complex fistula with more than one track and 35% had some form of comorbidity. The median time to healing was 3 (1-18) months; 7.4% required further surgery, but eventually 98% had complete fistula healing. The incontinence rate decreased postoperatively to 11.6% from 19% before treatment with 17/121 with pre-existing incontinence resolved and 8/107 new cases developing. Despite its retrospective non-comparative design, the study has demonstrated that a cutting seton is a safe, well tolerated and highly successful treatment for transsphincteric anal fistula and is followed overall by improved continence. The results compare very favourably with other techniques.

Fistulectomy with primary sphincter reconstruction in the treatment of high transsphincteric anal fistulas

The treatment of transsphincteric anal fistulas is a challenge between recurrence rate and incontinence. Many surgical and conservative procedures have been described in the treatment of anal fistulas. Fistulectomy and primary sphincter reconstruction (FPSR) has not gained great popularity in this field due to the risk of sphincter damage. The aim of this study is to evaluate FPSR in the treatment of transsphincteric fistulas. We retrospectively analyzed 50 patients with high transsphincteric fistulas of cryptoglandular origin that were treated with FPSR between 2005 and 2008. Preoperative assessment included physical and proctologic examination. Continence and pain scores were evaluated preoperatively and postoperatively. In our 50 patients, 22 patients (44%) had a previous proctologic operation and 11 patients (22%) presented with recurrent fistulas. The fistulas existed for an average of 8months. The operation time was 28 ± 16min. Mean follow-up was 22± months. The fistula healed in 44 patients (88%) who developed no recurrence. In five patients (10%), the fistula healed, but they developed a recurrence in the observation period. In one patient (2%), the fistula did not heal. Three patients developed low-grade incontinence for flatus, and one patient with 2° incontinence improved. Preoperatively and postoperatively calculated continence and pain scores showed a slight but significant elevation in the Clinical Continence Score, the German Society of Coloproctology Score showed no significant difference, and preexisting pain was reduced significantly by surgery. FPSR is a safe surgical procedure for the treatment of high transsphincteric anal fistula. The primary healing rate is high with a low risk of recurrence or incontinence.

Ligation of the intersphincteric fistula tract in the management of anal fistula. A systematic review

Over the last 5 years, the ligation of the intersphincteric fistula tract (LIFT) procedure has become increasingly popular as a sphincter-preserving technique for the treatment of anal fistula. The aim of this article was to review the published literature on the LIFT procedure. The Cochrane database and EMBASE were searched from January 1980 to November 2012, and PubMed from January 1966 to November 2012. All peer-reviewed studies that investigated the LIFT procedure for the treatment of anal fistula were eligible for inclusion. Technical notes, commentaries, letters and meeting abstracts were excluded. The primary outcome measured was the overall fistula closure rate in relation to the length of follow-up. Twenty-nine articles were originally identified using the search criteria. Thirteen were finally included for analysis. Sample sizes ranged from 18 to 93 patients, with a pooled total of 498. Most fistulae, 494 (99%), were of cryptoglandular aetiology, of which 470 (94%) were transsphincteric. Overall success rates ranged from 40 to 95%, with a pooled success of 71% (352 of 495 patients; 3 of 498 were lost to follow-up). Follow-up ranged from 1 to 55 months, with a reported mean or median of 4 to 19.5 months. One hundred and eighty-three patients were formally assessed for continence, out of whom 11 (6%) had a minor disturbance. Overall the systematic review shows that the LIFT procedure appears to be an effective sphincter-conserving approach for the treatment of transsphincteric anal fistula with a pooled healing rate of 71% over a mean or median follow-up period ranging from 4 to 19.5 months.

Simplified placement and management of cutting setons in the treatment of transsphincteric anal fistula: technical note.

We report one safe and standardized technique of seton placement and management. A simplified way to manage cutting setons helps to minimize manipulation and may reduce pain. In most patients our technique can be used with no additional anesthesia and in an outpatient setting.

Simplified placement and management of cutting setons in the treatment of transsphincteric anal fistula

Simplified placement and management of cutting setons in the treatment of transsphincteric anal fistula

Treatment of transsphincteric anal fistulas by the seton technique.

Twenty-one patients with high transsphincteric fistulas treated by the seton technique were re-examined after two to 14 years. None had recurrent fistulas, but 13 (62 percent) had some degree of continence disturbances. All patients with anal deformities had continence disorders.