A meta-analysis of marsupialisation versus none in the treatment of simple fistula-in-ano.

INTRODUCTION: Marsupialisation of post-fistulotomy wounds results in a smaller raw surface area and may improve postoperative outcomes. However, it remains a variable practice. We performed a systematic review and meta-analysis to evaluate the effectiveness of marsupialisation in the treatment of simple fistula-in-ano. MATERIALS AND METHODS: PubMed, EMBASE and Cochrane databases were searched for relevant articles from inception until April 2020. All trials that reported on marsupialisation in anal fistula treatment were included. The primary outcome measure was time to complete healing, while secondary outcomes included recurrence, pain scores and incontinence. Random effects models were used to calculate pooled effect size estimates. A sensitivity analysis was performed. RESULTS: Six randomised controlled trials were included capturing 461 patients. The mean (SD) age of the cohort was 39.31 (± 8.71) years. There were 395 males (85.7%). All fistulae were of the cryptoglandular aetiology. On random effects analysis, marsupialisation was associated with a significantly shorter time to healing compared with no marsupialisation (SMD - 0.97 weeks, 95% CI = - 1.36 to - 0.58, p < 0.00001). However, there was no difference in recurrence (RD = - 0.00, 95% CI = - 0.02 to 0.02, p = 0.72), pain scores at 24 h (SMD - 0.03, 95% CI = - 0.56 to 0.50, p = 0.91) or incontinence (RD = - 0.01, 95% CI = - 0.05 to 0.02, p = 0.42). On sensitivity analysis, focusing exclusively on fistulotomy for simple fistula-in-ano, the results for time to healing, recurrence and incontinence remained similar. CONCLUSIONS: Marsupialisation of fistulotomy wounds for simple fistula-in-ano is associated with a significantly shorter healing time, but similar recurrence, pain scores at 24 h and incontinence rates, compared with omitting marsupialisation.

Sepsis in surgical inpatients: under-recognised but with significant consequences.

BACKGROUND: The true incidence of sepsis in surgical cohorts in Ireland remains unclear. According to inpatient audits, patients in surgical diagnostic groups (DRG) who developed sepsis had a longer length of stay and higher mortality rate compared with medical DRG patients who developed sepsis. AIMS: We investigated sepsis incidence on a general surgical ward to identify risk factors and strategies to improve management. METHODS: Demographics, admission and discharge details, infection risk factors, infection, and sepsis were studied prospectively on a surgical ward in July 2018. RESULTS: The mean age of 164 patients was 60.5 years (range 18-93 years), 107 (65.2%) were admitted electively, 16 (9.8%) were colonised with a multidrug-resistant organism (MDRO), and 30 (18.3%) were classified as frail on admission. Twelve (7.3%) developed sepsis (ward sepsis rate 118.2/10,000 bed days used). 'Sepsis' was documented in six cases and the national sepsis screening form used in four patients. Patients with sepsis were three times as likely to be MDRO-colonised (OR 3.56; 95% CI = 0.86-14.82; p = 0.065) or frail (OR 3.63; 95% CI = 1.07-12.35; p = 0.03), four times as likely to be an inpatient at the end of the study (OR 4.22, 96% CI 1.23-14.49; p = 0.01), and three times as likely to be readmitted (OR 3.46, 95% CI 1.02-11.76; p = 0.03). CONCLUSION: Sepsis was under-documented, and barriers exist with use of the national sepsis screening form. Frailty, which is a sepsis risk factor, should be assessed pre-operatively to maximise prevention.