Effectiveness and safety of ultra-low-dose spinal anesthesia versus perineal blocks in hemorroidectomy and anal fistula surgery: a randomized controlled trial

Abstract Background: Ultra-low-dose Spinal Anesthesia (SA) is the practice of employing minimal doses of intrathecal agents so that only the roots that supply a specific area are anesthetized. The aim of this study was to compare the effectiveness and safety of ultra-low-dose spinal anesthesia with that of Perineal Blocks (PB). Methods: A two-arm, parallel, double-blind randomized controlled trial comparing two anesthetic techniques (SA and PB) for hemorrhoidectomy and anal fistula surgery was performed. The primary outcomes were postoperative pain, complementation and/or conversion of anesthesia, and hemodynamic changes. Results: Fifty-nine patients were included in the final analysis. The mean pain values were similar in the first 48 h in both groups (p > 0.05). The individuals allocated to the SA group did not need anesthetic complementation; however, those in the PB group required it considerably (SA group, 0% vs. PB group, 25%; p = 0.005). Hemodynamic changes were more pronounced after PB: during all surgical times, the PB group showed lower MAP values and higher HR values (p < 0.05). Postoperative urinary retention rates were similar between both groups (SA group 0% vs. PB group 3.1%, p = 0.354). Conclusion: SA and PB are similarly effective in pain control during the first 48 h after hemorrhoidec-tomy and anal fistula surgery. Although surgical time was shorter among patients in the PB group, the SA technique may be preferable as it avoids the need for additional anesthesia. Furthermore, the group that received perineal blocks was under sedation with a considerable dose of propofol.

The efficacy of porcine dermal collagen to treat complex anal fistulae: results of a multicenter cohort

Introduction: The management of complex anal fistulae remains a topical surgical problem. The choice and success of surgical management are based on the balance between healing and continence. Although porcine dermal collagen (Permacol Collagen Paste [PCP]- Covidien plc, Gosport, Hampshire, UK) represents a new generation of non-solid biomaterials, its results in anal fistulae are mixed. Methods: A multicenter observational retrospective analysis of consecutive patients with cryptoglandular anal fistula treated in four colorectal surgery units was performed between 2015 and 2020. Clinical cure of the fistula was the main outcome measure. Adverse events and alterations in anal continence were secondary outcomes. Results: The study included 119 patients (87 males, 71.1%), with a mean age of 53 years (IR 44-65). Most patients had complex (80.6%) and recurrent (91.6%) fistulae. With the first PCP treatment, the overall cure rate was 41.2% (49 patients) and 45.4% with the second treatment (5 out of 17 patients). The mean follow-up period was 17 months (IR 5-25). Healing was not affected by the location and type of fistula, the existence or not of a cavity, the number of tracts, or the administration of prophylactic antibiotics. After the PCP treatment, no patient in the series had worsening of continence. Morbidity affected 22.7% of the patients (27), with postoperative abscesses being the most frequent adverse event. There were no statistical differences between the four hospitals studied. Conclusions: Permacol collagen paste is a safe and easily reproducible therapy for complicated anal fistulae that has moderate efficacy. The overall success rate is slightly over 40%, with no detriment to fecal continence. (AU)

Diagnostic value of MRI retention enema cannula enhanced scanning in high complex anal fistula / 中国医师进修杂志

Objective:To investigate the clinical diagnostic value of MRI retention enema cannula enhanced scanning in the high complex anal fistula.Methods:The clinical data of 60 anal fistula patients underwent surgery treatment from May 2020 to May 2022 in Affiliated Hospital of Shanxi University of Traditional Chinese Medicine were retrospectively analyzed. All patients underwent MRI plain scanning and enhanced scanning before operation. Compared with the surgical results, the difference between MRI plain scanning and enhanced scanning in the diagnosis of high complex anal fistula was compared.Results:All of the 60 patients successfully completed surgical treatment, and 58 cases internal orifices, 55 cases complex anal fistulas and 53 cases high anal fistulas were found intraoperatively. MRI plain scanning results showed 32 cases internal orifices, 46 cases complex anal fistulas and 42 cases high anal fistulas were found. MRI enhanced scanning results showed 54 cases internal orifices, 53 cases complex anal fistulas and 50 cases high anal fistulas were found. Based on surgical results, the coincidence rates of internal orifice, complex anal fistula and high anal fistula in MRI enhanced scanning were significantly higher than those in MRI plain scanning: 93.10% (54/58) vs. 55.17% (32/58), 96.36% (53/55) vs. 83.64% (46/55) and 94.34% (50/53) vs. 79.25% (42/53), and there were statistical differences ( χ2 = 21.76, 4.95 and 5.27; P<0.01 or <0.05). Conclusions:The MRI retention enema cannula enhanced scanning has obvious advantages in the diagnosis of high complex anal fistula, which provides scientific reference value for the diagnosis and operation of high complex anal fistula in clinic.

Effect of incision and thread-drawing selective suture in the treatment of high complex anal fistula and its influence on anal function and complications / 国际外科学杂志

Objective:To investigate the therapeutic effect of open suture and selective suture in patients with high complexity anal fistula and its effect on anal function and complications.Methods:Prospectively selected 174 patients with high complex anal fistula who were hospitalized in the Anorectal Surgery Department of the Second People′s Hospital of Yibin City from December 2018 to December 2021 as the study subjects, including 138 males and 36 females, aged from 26 to 45 years, with an average of (35.20 ± 8.86) years. According to the admission order of patients, grouped them into single and double numbers, with single numbers being the control group ( n=87) and double numbers being the observation group ( n=87). The control group was treated with traditional incision and thread hanging therapy, while the observation group was treated with selective suture through incision and thread hanging therapy. Compared the surgical time, blood loss, surgical cost, wound healing time, and anal function at 6 months after surgery between the two groups of patients. Compared the treatment effects of two groups of patients at 6 months after surgery. Compared the postoperative complications within 6 months and recurrence within 1 year between the two groups. The measurement data subject to normal distribution were expressed by mean ± standard deviation( ± s). The two groups were compared by independent sample t test, and the count data were compared by Chi-square test. Rank sum test was used for comparison of hierarchical data. Results:The surgical time in the observation group was higher than that in the control group [(44.30 ± 8.11) min vs (42.18 ± 7.25) min, ( t=-2.44, P<0.05], and the surgical cost was higher than that in the control group [(1184.81 ± 372.68) yuan vs (835.28 ± 320.03) yuan, t=-8.75, P<0.001]. There was no statistically significant difference in blood loss data between the two groups [(19.57 ± 6.07) mL vs (18.35 ± 5.25) mL, t=-1.88, P>0.05]. The length of wound healing time in the observation group was lower than that in the control group [(24.18 ± 4.35) d vs (29.35 ± 5.08) d, t=11.09, P<0.001]. The anal function score of the observation group at 6 months after surgery was lower than that of the control group [(4.80 ± 1.21) score vs (6.71 ± 1.35) score, t=14.72, P<0.001]. All patients did not experience any loss of follow-up. In the comparison of treatment effects 6 months after surgery, the observation group had a better efficacy rating than control group ( Z=3.86, P<0.001). At 6 months after surgery, the incidence of complications in the observation group was lower than that in the control group [2.30% (2/87) vs 10.34% (9/87), χ2=4.76, P<0.05]. One year after surgery, the recurrence rate in the observation group was lower than that in the control group [2.30% (2/87) vs 10.34% (9/87), χ2=4.76, P<0.05]. Conclusion:The application of incision and thread-drawing selective suture in the treatment of patients with high complex anal fistula is beneficial to the treatment effect of patients, reduces postoperative complications, and protects the anal function of patients, with good use value.

Ligation of intersphincteric fistula tract (LIFT) for the treatment of anal fistula: a prospective observational study

Background: The ligation of intersphincteric fistula fract (LIFT) technique avoids postoperative anal continence disturbances and preserves quality of life. Methods: A total of 70 patients with anal fistula (AF) were treated in the Day Surgery Unit. The LIFT technique was the primary treatment in 63 patients. The other had previously undergone placement of a loose seton (two-step approach). The mean follow-up was 66.8 months. Statistical analysis was performed using contingency tables, the chi-square test, and the Student T-test. Results: The use of LIFT was successful in 40 patients (57.1%). However, 6 patients (8.6%) presented persistence of postoperative intersphincteric fistula, being successfully treated by fistulotomy. There were no differences in this technique's success rate between high and low AF (p = 0.45). The success rate of one-step LIFT, however, was significantly higher (p = 0.03). No disturbances of continence were observed. Conclusions: The LIFT technique has a role in the treatment of AF, is suitable for ambulatory surgery, and has a low complications rate. A two-step approach is not always needed. (AU)

VAAFT PROCEDURE (Video-assisted Anal Fistula Treatment) versus open method in the treatment of high fistula in ano

Background: A common acquired anorectal condition is anal fistula. The treatment approaches that have been employed have been linked to erratic outcomes and sometimes life-threatening consequences. Video-assisted anal fistula treatment (VAAFT), a minimally invasive method, was introduced for adult patients in 2011. Objective: To know the efficacy of the VAAFT procedure in treating high anal fistulas and to compare it to open methods in the Basrah province. Methods: The present study was performed on 200 patients with high fistulas in ano in Basrah province. We divided the patients into 2 groups: Group A: treated by the VAAFT technique and Group B: treated by open fistulotomy Results: The patients treated with VAFFT revealed no occurrence of the following postoperative complication: Infection, incontinence, recurrence, anal stenosis, and bleeding. There was lower incidence of pain, short time for wound healing, rapid return to work, and more patient satisfaction compared with open fistulotomy Conclusion: An innovative method for managing ano fistula is VAAFT. Compared with traditional methods, it has a lot of benefits. It is day case surgeryno open wound.no damage to anal sphincter and no risk of incontinence, it is more affordable.it allow for clear identification of internal office, whole tract and its associated branches and cavity. The instrument can be used for multiple patients after good sterilization and disinfection. (AU)

Infliximab for anoperineal lesions in Crohn's disease: remission appears to be based on rapid combination therapy at high doses

Study Aim: The aim of the present study was to compare in real life the characteristics of treatment with infliximab according to the presence or absence of anoperineal involvement in Crohn's disease. Methods: We performed a single-center, prospective, non-interventional study, on patients with Crohn's disease in remission who had been treated with infliximab for at least 1 year. Patients with poor treatment compliance, on antibiotics, or those with a stoma were excluded. Results: We included 52 patients in this study: 34 with anoperineal lesions with or without luminal lesions, and 18 with luminal lesions only. Patients with anoperineal lesions were more likely to have undergone surgery (70.6% versus 38.9%, p = 0.027), had a shorter median time to infliximab treatment initiation (0.5 versus 5.5 years, p = 0.005), a higher mean dose of infliximab (6.6 versus 5.1 mg/kg, p = 0.015), and were more likely to receive combination treatments including infliximab (52.9% versus 11.1%, p = 0.008) than patients with luminal involvement only. Conclusions In our study, infliximab treatment was initiated more quickly, at higher doses, and more in combination therapy for anoperineal Crohn's disease than for luminal damage alone. Additional studies are required to confirm this finding and to assess the tolerance of this treatment throughout patient management. (AU)

The use of seton as a bridge to definitive ligation of the intersphincteric fistula tract procedure for fistula-in-ano: a systematic review and meta-analysis

Background: There is still controversy over the usefulness of seton placement prior to the ligation of the intersphincteric fistula tract (LIFT) surgery in the management of anal fistula. Objective: To evaluate the impact of preoperative seton placement on the outcomes of LIFT surgery for the management of fistula-in-ano. Design: systematic review and meta-analysis. Data Sources: A search was performed on the MEDLINE (PubMed), EMBASE, Scopus, Web of Science, Cochrane Library and Google Scholar databases. Study Selection: Original studies without language restriction reporting the primary healing rates with and without seton placement as a bridge to definitive LIFT surgery were included. Intervention: The intervention assessed was the LIFT with and without prior seton placement. Main Outcome Measures: The main outcome was defined as the primary healing rate with and without the use of seton as a bridge to definitive LIFT surgery. Results: Ten studiesmet the criteria for systematic review, all retrospective,with a pooled study population of 772 patients. There were no significant differences in the percentages of recurrence between patients with and without seton placement (odds ratio [OR] 1.02; 95% confidence interval [CI] 0.73-1.43: p=0.35). The I2 value was 9%, which shows the homogeneity of the results among the analyzed studies. The 10 included studies demonstrated a weighted average overall recurrence of 38% (interquartile range [IQR] 27-42.7%), recurrence with the use of setonwas 40%(IQR26.6-51.2%), and without its use, the recurrence rate was 51.3% (IQR 31.3-51.3%) Limitations: The levels of evidence found in the available literature were relatively fair, as indicated after qualitative evaluation using the Newcastle-Ottawa scale and the Attitude Heading Reference System (AHRS) evidence levels. Conclusions: Our meta-analysis suggests that the placement of seton as a bridge treatment prior to LIFT surgery does not significantly improve long-term anal fistula healing outcomes. Ligation of the intersphincteric fistula tract surgery can be performed safely and effectively with no previous seton placement. International prospective register of systematic reviews-PROSPERO registration number: CDR42020149173. (AU)

Avaliação do tratamento recorrente de fístulas anais com plasma rico em plaquetas / Assessment of recurrent anal fistulas treatment with platelet-rich plasma

ABSTRACT BACKGROUND: Surgical treatment of recurrent anal fistulas can lead to numerous complications, including fecal incontinence. Therefore, sphincter preserving techniques are gaining more popularity. OBJECTIVE: The aim of the study was to assess effectiveness of platelet-rich plasma (PRP) therapy in the patients with recurrent cryptoglandular anal fistulas. METHODS: A cohort of 18 patients with anal fistulas was enrolled into a preliminary and prospective trial. They were divided into two groups consisting of eight and ten patients respectively. PRP was injected locally in all patients, however in the group II it was applied after 7 days drainage of fistulas with polyurethane foam or negative pressure wound therapy. On average, three doses of PRP were administered, but with the opportunity to double the number of applications if it was clinically justified. The patients were evaluated in an out-patient department after fortnight and then in 1, 6, and 12 months following the last PRP application. RESULTS: Anal fistulas were closed in 4 (50%) patients from the group I and in 7 (70%) patients form the group II. Although, the difference between both groups was not statistically significant, PRP therapy should be preceded with fistulous tract drainage in all patients. Summarizing, that successful result was achieved in 11 (60%) patients from the entire group of 18 participants. CONCLUSION: The rate of recurrent cryptoglandular anal fistulas closure reaching 60%, after topical treatment with PRP, exceeds the results of other sphincter-saving methods of treatment. Therefore, it might become a novel method of anal fistulas therapy.

RESUMO CONTEXTO: O tratamento cirúrgico de fístulas anais recorrentes pode levar a inúmeras complicações, incluindo incontinência fecal. Portanto, as técnicas de preservação do esfíncter estão ganhando mais popularidade. OBJETIVO: O objetivo do estudo foi avaliar a eficácia da terapia de plasma rico em plaquetas (PRP) nos pacientes com fístulas anais criptoglandulares recorrentes. MÉTODOS: Uma coorte de 18 pacientes com fístulas anais foi inscrita em ensaio preliminar e prospectivo. Eles foram divididos em dois grupos compostos por 8 e 10 pacientes, respectivamente. PRP foi injetado localmente em todos os pacientes, porém no grupo II foi aplicado espuma de poliuretano ou terapia de feridas por pressão negativa após 7 dias de drenagem de fístulas. Em média, foram administradas três doses de PRP, mas com a oportunidade de dobrar o número de aplicações se fosse clinicamente justificado. Os pacientes foram avaliados em ambulatório após quinze dias e depois em 1, 6 e 12 meses após a última aplicação do PRP. RESULTADOS: As fístulas anais foram fechadas em 4 (50%) pacientes do grupo I e em 7 (70%) pacientes do grupo II. Embora a diferença entre ambos os grupos não tenha sido estatisticamente significante, a terapia PRP deve ser precedida de drenagem do trato fístulo em todos os pacientes. Resumindo, esse resultado bem-sucedido foi alcançado em 11 (60%) pacientes de todo o grupo de 18 participantes. CONCLUSÃO: A taxa de fechamento recorrente de fístulas anais criptoglandulares chegando a 60%, após tratamento tópico com PRP, excede os resultados de outros métodos de tratamento que preservam o esfíncter. Portanto, pode se tornar um novo método de terapia das fístulas anais.

Efficacy of low-level laser therapy on fistula-in-ano treatment / Eficácia do laser de baixa potência no tratamento das fístulas perianais

ABSTRACT Background: Treating anal fistulae is still a great challenge due to the possibility of fecal incontinence after surgery and that the use of laser has been gaining space in medicine, including as an inducing method of healing. Aim: To evaluate the efficacy of low-level laser therapy on fistula-in-ano treatment in rats. Methods: Fifteen male Wistar rats weighing approximately 250-300g were used, which were subjected to the anal fistula induction procedure and after 30 days were distributed into two groups: control group (CG, n=5) and laser group (LG, n=10) observed for another 30 days. In the CG no treatment was performed and, in the LG, low-level laser therapy was applied in fistulous tracts daily. The closure of the fistulous tract, the area of the remaining tract, the inflammatory infiltrate and vascular congestion were evaluated. Results: There was no complete closure of the tract in any of the animals. The mean area of the remaining tract was 847.2 µm2 in the CG and 248.5 µm2 in the LG (p=0.001). The mean inflammatory infiltrate score was 2.4 in the CG and 1.3 in the LG (p=0.0285), while in the evaluation of vascular congestion, 1.6 was observed in the CG and 0.6 in the LG (p=0.031). Conclusions: Low-level laser therapy was able to reduce the area of the fistulous tracts as well as decrease the inflammatory process and local vascular congestion.

RESUMO Racional: Tratamento de fístulas anais ainda é grande desafio devido à possibilidade de incontinência fecal pós-operatória; o uso do laser vem ganhando espaço na medicina, inclusive como método indutor de cicatrização. Objetivo: Avaliar a eficácia da terapia a laser de baixa potência no tratamento de fístula perianal em ratos. Métodos: Foram utilizados 15 ratos Wistar machos com peso aproximado de 250-300 g, os quais foram submetidos à indução da fístula anal e após 30 dias foram distribuídos em dois grupos: grupo controle (GC, n=5) e grupo laser (GL, n=10) observado por mais 30 dias. No GC nenhum tratamento foi realizado e no LG laserterapia de baixa intensidade foi aplicada nos trajetos fistulosos diariamente. Foram avaliados o fechamento do trajeto fistuloso, a área do trajeto remanescente, o infiltrado inflamatório e a congestão vascular. Resultados: Não houve fechamento completo do trajeto fistuloso em nenhum dos animais. A área média do trajeto remanescente foi de 847,2µm2 no GC e 248,5µm2 no GL (p=0,001). O escore médio do infiltrado inflamatório foi de 2,4 no GC e 1,3 no GL (p=0,0285), enquanto na avaliação da congestão vascular foi observado 1,6 no GC e 0,6 no GL (p=0,031). Conclusões: A terapia a laser de baixa potência foi capaz de reduzir a área dos trajetos fistulosos, bem como diminuir o processo inflamatório e a congestão vascular local.

Recidiva de fístulas perianales post quirúrgicas en la Segunda Cátedra de Clínica Quirúrgica, Hospital de Clínicas, San Lorenzo año 2008-2019 / Recurrence of post-surgical perianal fistulas in the II General Surgery Service of Clinica´s Hospital, San Lorenzo year 2008-2019

Una Fístula Anal es la comunicación anormal entre el conducto anorrectal y la piel. El objetivo central en el tratamiento de la fístula anal es eliminar la fístula y los síntomas, prevenir la recurrencia y preservar la función del esfínter anal. El único tratamiento curativo para las fístulas anales criptogénicas es la cirugía. Se realizó un estudio observacional, descriptivo con componentes analíticos, de corte transversal, con un muestreo no probabilístico de casos consecutivos en pacientes operados de fístulas anales por el Servicio de Coloproctología en la II Cátedra de Clínica Quirúrgica del Hospital de Clínicas San Lorenzo (2008-2019). De un total de 112 pacientes, no existió relación estadísticamente significativa entre el grado de obesidad, las comorbilidades, los distintos síntomas, la complejidad de la fístula ni la región comprometida y la recidiva postquirúrgica. La técnica quirúrgica más empleada fue la fistulotomía en el 75,9% de los casos. Las recidivas se vieron en 6.25% de los pacientes. En nuestra serie el riesgo de obtener una recidiva era 16 veces mayor en las fístulas complejas con relación a las simples (RR = 15,9 para p=0,001) y existió una relación estadísticamente significativa entre el tipo de cirugía realizada y el porcentaje de recidiva post quirúrgica. Las fístulas anales son una entidad nosológica de relevancia, que crea molestias hasta problemas en el desenvolvimiento tanto laboral como social por lo cual debe ser motivo de estudio exhaustivo en nuestro hospital como lo es en el mundo.

An Anal Fistula is an abnormal communication between the anorectal duct and the skin. The central goal of its treating is to eliminate the fistula and symptoms, prevent recurrence, and preserve anal sphincter function. The only curative treatment for cryptogenic anal fistulas is surgery. An observational, descriptive study was carried out with analytical components, cross-sectional, with a non-probabilistic sampling of consecutive cases in patients operated on for anal fistulas by the Coloproctology Service in the II Surgery Department of Clinica´s Hospital of San Lorenzo (2008- 2019). Out of a total of 112 patients, there was no statistically significant relationship between the degree of obesity, comorbidities, different symptoms, the complexity of the fistula or the anal region involved, and the postoperative recurrence. The most used surgical technique was fistulotomy in 75.9% of the cases. Recurrences were seen in 6.25% of the patients. In our series, the risk of obtaining a recurrence was 16 times greater in complex fistulas than in simple ones (RR = 15.9 for p = 0.001) and there was a statistically significant relationship between the type of surgery performed and the percentage of postoperative recurrence. Anal fistulas are a relevant nosological entity, which creates discomfort in both work and social development, which is why it should be the subject of exhaustive study in our hospital as it is in the world.

Effect of Zhitong-Rusheng Decoction on wound healing and serum fibronectin and epidermal growth factor levels after anal fistula operation / 国际中医中药杂志

Objective:To investigate the effect of Zhitong-Rusheng Decoction on wound healing and serum fibronectin (FN) and epidermal growth factor (EGF) levels after anal fistula operation. Methods:A total of 102 patients after anal fistula operation in our hospital from March 2018 to March 2020 were randomly divided into control group (51 cases) and observation group (51 cases) according to the random number table method. The control group was treated with conventional western treatment, while the observation group was treated with Zhitong-Rusheng Decoction on the basis of control group. The two groups were treated for 3 weeks. The clinical symptoms were scored before and after treatment, and the levels of serum FN and EGF were detected by ELISA. The wound healing time, hematochezia disappearance time, wound longitudinal diameter and wound area before and after treatment were observed. The clinical efficacy was evaluated after treatment. Results:The total effective rate was 98.0% (50/51) in the observation group and 72.6% (37/51) in the control group, with significant difference between the two groups ( χ2=13.209, P<0.01). After treatment, the pain degree score, wound exudation score and granulation morphology score of the observation group were significantly lower than those in the control group ( t=15.448, 21.424, 28.641, P<0.001). After treatment, the wound healing time [(6. 04 ± 1.20) d vs. (9.42 ± 1.58) d, t=12.166] and the disappearance time of hematochezia [(15.72 ± 2.86) d vs. (19.95 ± 4.33) d, t=6.862] of the observation group were significantly shorter than thosse of the control group( P<0.01). After treatment, the wound longitudinal diameter [(1.89 ± 0.31) cm vs. (2.82 ± 0.54) cm, t=10.666] and wound area [(3.26 ± 0.54) cm 2vs. (4.98 ± 1.10) cm 2, t=10. 024] of the observation group were significantly less than those in the control group ( P<0.01). The serum FN [(2.92 ± 0.50) mg/L vs. (2.45 ± 0.39) mg/L, t=5.293], EGF [(7.03 ± 1.44) μg/L vs. (5.47 ± 1.03) μg/L, t=6.293] of the observation group were significantly higher than those in the control group ( P<0.01). Conclusion:Zhitong-Rusheng Decoction on the basis of conventional treatment on patients after anal fistula operation has a good efficacy, which is conducive to wound healing, reducing clinical symptoms, and improving serum levels of FN and EGF.

Electroacupuncture at / 中国针灸

OBJECTIVE@#To evaluate the clinical therapeutic effect of electroacupuncture (EA) at @*METHODS@#The data of 318 patients undergoing anal fistula surgery were analyzed retrospectively. In accordance with whether accepted the combined treatment with EA at bilateral @*RESULTS@#For VAS score, there was an interaction between therapeutic method and treatment duration (@*CONCLUSION@#Electroacupuncture at

Manejo de la fístula anorrectal compleja: LIFT, colgajo de avance y otras técnicas / Management of complex anorectal fistula: LIFT, endorectal advancement flap and others techniques

Resumen Las fístulas anorrectales complejas son un desafío para el coloproctólogo. Son una patología frecuente que afecta la calidad de vida de los pacientes. La patogénesis aún no está clara, estarían involucradas citoquinas y el proceso de transición de epitelio a mesénquima. El gold standard para su estudio es la resonancia nuclear magnética, su uso por sí mismo disminuye la recurrencia. El objetivo del tratamiento es lograr la curación sin afectar la función del esfínter evitando las recidivas. Existen múltiples técnicas, siendo la de mayor aceptación la ligadura interesfinteriana del trayecto fistuloso, con tasa de curación sobre el 70%, con mínimo impacto en continencia. Esta revisión incluye otras técnicas como el colgajo endorrectal de avance, uso de sellante, permacol, células madres, Anal fistula plug, Video asisted anal fistula treatment, Over the scope clip y fistula laser closure.

Complex anal fistula are a challenge for colorectal surgeons. It is a common pathology in population. Pathogenesis is still unclear, it would be involved citokines and the process of epitelial to eesenchymal transition. The gold standard for study is MRI, its use reduces recurrences. The goal of treatment is heal the fistula without damaging the function of the sphincter and avoid recurrences. There are multiple techniques, the most accepted is ligation of intersphincteric fistula tract with cure rate over 70%, with minimal impact in continence. This review includes other techniques like rectal advancement flap, fibrin glue, permacol, stem cells, anal fistula plug, video asisted anal fistula treatment, over the scope clip and fistula laser closure.

Anal abscess microbiology as an anal fistula predictor / Microbiologia de abscesso anal como preditivo de fístula anal

ABSTRACT In order to determine the microbiology of anal abscess as a predictor of anal fistulas in patients who attended the external consultation of the Coloproctology unit of the Dr. Antonio María Pineda University Central Hospital, a prospective, descriptive, longitudinal study was conducted from September 2018 to July 2019. In this study, the population consisted of patients with a diagnosis of anal abscess, without associated comorbidities or contraindications for surgery, who agreed to be included in the study. A non-probabilistic, intentional sample consisting of 42 patients was determined. An appointment-based study protocol was applied by outpatient for patients who met the inclusion criteria applied, to perform due medical history through anamnesis, physical examination and culture taking of suppuration from the anal abscess to subsequently establish medical and surgical behavior thereof. The results were expressed in absolute numbers and percentages, a prevalence of ischiorectal abscesses was observed, followed by deep post-anal space abscesses. Anaerobic bacteria were isolated in 100% of the sample. In all fistulized patients, E. Coli was isolated as a predominant germ.

RESUMO Um estudo prospectivo, descritivo e longitudinal foi realizado de setembro de 2018 a Julho 2019 para determinar a microbiologia do abscesso anal como preditivo de fístulas anais em pacientes que compareceram à consulta externa da unidade de Coloproctologia do Hospital Central da Universidade Dr. Antonio María Pineda. Neste estudo, a população foi composta por pacientes com diagnóstico de abscesso anal, sem comorbidades ou contraindicações associadas à cirurgia, que concordaram em participar do estudo. Uma amostra intencional não probabilística, composta por 42 pacientes foi determinada. Um protocolo de estudo com base na consulta em regime ambulatorial foi aplicado aos pacientes que atenderam os critérios de inclusão estabelecidos, para realizar a anamnese, o exame físico e a devida cultura da supuração do abscesso anal para posteriormente estabelecer o comportamento médico e cirúrgico. Os resultados foram expressos em números absolutos e porcentagens, observando-se a prevalência de abscessos isquiorretais, seguidos por abscessos profundos no espaço pós-anal. Bactérias anaeróbias foram isoladas em 100% das amostras. Em todos os pacientes com fístulas, E. Coli foi isolada como um germe predominante.

Fístula perianal compleja: Tratamiento con plasma rico en plaquetas / Complex perianal fistula: Treatment with platelet-rich plasma

Paciente masculino con diagnóstico de enfermedad inflamatoria intestinal (colitis ulcerosa), corticodependiente, que consulta en nuestro servicio por fístula perianal compleja con extenso compromiso inflamatorio crónico de la región perianal, el cual fue tratado exitosamente con la aplicación local de plasma rico en plaquetas como única terapéutica. Se presentan los beneficios que se podrían obtener mediante la aplicación de plasma rico en plaquetas autólogo en el tratamiento de este tipo de fístulas. De ese modo se evitan los procedimientos quirúrgicos en un terreno inflamatorio crónico que implican altas tasas de complicaciones y recurrencia, afectando la calidad de vida.

A male patient with a diagnosis of steroid dependent inflammatory bowel disease (ulcerative colitis) sought medical care due to complex perianal fistula with extended chronic inflammation of the perianal region that was successfully treated with platelet-rich plasma as a single therapy. The benefits of autologous platelet-rich plasma for the treatment of this type of fistulas are presented. In this way, there is no need to perform surgery in a chronic inflammatory territory with high rate of complications and recurrence affecting patients' quality of life.

Consensus of Chinese experts on the diagnosis and treatment of anal fistula (2020) / 中华胃肠外科杂志

Anal fistula is one of the most common diseases in colorectal and anal surgery. Most of them are formed after the abscess of perianal space reptures. Due to the complexity and diversity of pathological changes, the clinical efficacy of some patients is not optimistic, and there may even be serious surgical complications, including delayed healing of anal fistula or varying degrees of fecal incontinence, which significantly affect the quality of life of patients and even lead to disability. The Working Committee of Clinical Guidelines of Anorectal Physicians Branch of Chinese Medical Association organized some domestic experts to discuss and prepare this expert consensus. It is suggested that comprehensive evaluation of anal fistula, including detailed medical history, physical examination and necessary auxiliary examination should be conducted before treatment. Auxiliary examinations include fistulography, ultrasound, CT or MRI. The purpose of the auxiliary examination is to accurately determine the position of the internal orifice of the anal fistula, the direction of the fistula and its relationship with the anal sphincter. Adenogenic anal fistula needs surgical treatment after diagnosis. The operation methods can be divided into two types: operations breaching sphincter and operations preserving sphincter function. The former includes anal fistulectomy, anal fistulotomy and seton placement; the latter includes ligation of intersphincteric fistula (LIFT), rectal mucosal muscle flap advancement repair, anal fistula laser closure, video-assisted anal fistula treatment, etc. It is suggested to select or combine the application according to the specific condition of patients. Bioabsorbable materials include anal fistula plug and fibrin glue. Due to the characteristics of retaining sphincter function and reusability, it is recommended to be used selectively by qualified and experienced doctors. Proper wound management after anal fistula surgery can reduce the pain of patients, promote healing and reduce the recurrence of anal fistula. Because there is a certain risk of recurrence and fecal incontinence after anal fistula surgery, for some patients with complex condition, repeated operations or impaired anal function, we must be careful when choosing reoperation, and weigh the benefits of patients and the risk of fecal incontinence.

Long-term efficacy of bioprosthetic anal fistula plug in the treatment of transsphincteric anal fistula / 中华胃肠外科杂志

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.

Papel de la medicina regenerativa y los sellantes en la enfermedad de Crohn perianal / Role of regenerative medicine and sealants in perianal Crohn's disease

La enfermedad de Crohn constituye una enfermedad inflamatoria crónica que puede cursar con fistulas complejas en hasta un 20% de los pacientes. A pesar de la intensificación del tratamiento, asociado o no a la cirugía, todavía es considerable el porcentaje de pacientes que no responden al tratamiento. En los últimos años se ha empezado a desarrollar nuevas terapias que permitan conseguir una mayor tasa de curación de estos pacientes, con las mínimas complicaciones posibles. Es cuando aparecen agentes que pretenden de forma directa el sellado o intervienen en la reducción local de la inflamación. Es objetivo de este artículo mostrar el papel de la Medicina Regenerativa en el tratamiento de estos pacientes.

Crohn's disease is a chronic inflammatory disease that can occur with complex fistulas in up to 20% of patients. Despite the intensification of treatment, associated with no surgery, the percentage of patients who do not respond to treatment is still considerable. In recent years, new therapies have been developed to achieve a higher cure rate for these patients, with the minimum possible complications. It is when agents appear to pretend as seal fistula tract as the local reduction of inflammation. The aim of this article is to show the role of Regenerative Medicine in the treatment of these patients.

Experiencia inicial en la adaptación del instrumental del tratamiento video asistido modificado de las fistulas perianales complejas (VAMAFT) / Initial experience in the adaptation of the instruments of the modified assisted video treatment of complex perianal fistulas (VAMAFT)

Introducción: Las fístulas perianales tienen dos problemas fundamentales, la tasa de recurrencia y de incontinencia fecal postoperatoria, complicaciones que varían en frecuencia dependiendo de varios factores como el tipo de fistula, la técnica quirúrgica usada y la experiencia del cirujano. Debido a esto existen técnicas quirúrgicas no conservadoras y conservadoras de esfínteres donde se incluye el tratamiento video asistido que aparece desde el año 2006 y en la cual se utiliza un sistema de video endoscopio sofisticado y de alto valor económico el cual hemos adaptado a nuestro medio. Pacientes y método: De septiembre del 2015 al 2017 en la Unidad de Coloproctología del Hospital Domingo Luciani IVSS se realizó un estudio prospectivo experimental, donde se incluyeron 18 pacientes con fístulas perianales complejas diagnosticadas previamente con Ecofistulografía 3D y los cuales se operaron con un sistema adaptado usando citoscopio pediátrico de 4 mm y energía láser. Se evaluaron parámetros referentes a la técnica así como la tasa de éxito y riesgo de incontinencia. Resultados: Tiempo quirúrgico de 40 a 80 minutos, con tasa de éxito de 89%, recidiva en 2 pacientes, con tiempo de seguimiento entre 12 a 36 meses y sin cambios en la escala de incontinencia pre y post quirúrgica. Conclusión: El tratamiento video asistido modificado para fistulas anales (VAMAFT) es una técnica innovadora y factible de realizar al adaptar algunos instrumentos, con una tasa de éxito adecuada y sin riesgo de incontinencia, pero más trabajos aleatorizados con mayor números de pacientes deben ser realizados.

Introduction: Anal fistulas have two basic problems, rate of recurrence and postoperative anal incontinence. These complications vary according to several factors such as type of anal fistula, surgical technique and the surgeon´s experience. For each cases there are different surgical techniques with and without conservation of anal sphincters like conservative video assisted anal fistula treatment, described in 2006, this technique uses a sophisticated and expensive endoscope system but that we modified to use in our hospitals. Patients and method: Between September 2015 to 2017 in the Unit of Coloproctology of Domingo Luciani Hospital, was perfomed a prospective and experimental trial in 18 patients with anal complex fistulas previously diagnosed using tridimensional anal ultrasound and operated with a modified system consisting of pediatric cystoscope of 4 mm and laser energy. Some parameters were evaluated including surgical technique, recurrence and anal incontinence rate. Results: Surgical times were between 40 to 80 minutes, success rate of 89%, recurrence in two patients with follow up of 12 to 36 months and no changes in pre and post surgical anal incontinence scale. Conclusion: Video assited modified anal fistula treatment (VAMAFT) is an innovative and feasible surgical technique to do adapting some instruments, with suitable success rate and without anal incontinence risk but many randomized research with more patients have to be perfomed.