BACKGROUND High complex anal fistulas are epithelialized tunnels,with the main fistula piercing above the deep external sphincter and the internal opening approaching the dentate line.Conventional surgical procedures ...BACKGROUND High complex anal fistulas are epithelialized tunnels,with the main fistula piercing above the deep external sphincter and the internal opening approaching the dentate line.Conventional surgical procedures for high complex anal fistulas remove most of the external sphincter and damage the anorectal ring.Postoperative loss of anal function can cause physical and mental damage.Transanal opening of the intersphincteric space(TROPIS)is an effective procedure that completely preserves the external anal sphincter.However,its clinical application is limited by challenges in the localization of the internal opening of a fistula and the high risk of complications.On the basis of our clinical experience,we modified the TROPIS procedure for the treatment of treating high complex anal fistulas.CASE SUMMARY A patient with a high complex anal fistula located above the anorectal ring underwent modified TROPIS,which involved sepsis drainage and identification of the internal opening in the intersphincteric space.The patient with the high complex anal fistula recovered well postoperatively,without any postoperative complications or anal dysfunction.Anal function returned to normal after 17 months of follow-up.CONCLUSION The modified TROPIS procedure is the most minimally invasive surgery for anal fistulas that minimally impairs anal function.It allows the complete removal of infected anal glands and reduces the risk of postoperative complications.Modified TROPIS via the intersphincteric approach is an alternative sphincter-preserving treatment for high complex anal fistulas.展开更多
BACKGROUND Despite tremendous progress in medical therapy and optimization of surgical strategies,considerable failure rates after surgery for complex anal fistula in Crohn’s disease have been reported.Therefore,stem...BACKGROUND Despite tremendous progress in medical therapy and optimization of surgical strategies,considerable failure rates after surgery for complex anal fistula in Crohn’s disease have been reported.Therefore,stem cell therapy for the treatment of complex perianal fistula can be an innovative option with potential long-term healing.AIM To evaluate the results of local administration of allogenic,adipose-derived mesenchymal stem cells(darvadstrocel)for complex anal Crohn’s fistula.METHODS All patients with complex anal fistulas associated with Crohn’s disease who were amenable for definite fistula closure within a defined observation period were potential candidates for stem cell injection(darvadstrocel)if at least one conventional or surgical attempt to close the fistula had failed.Darvadstrocel was only indicated in patients without active Crohn’s disease and without presence of anorectal abscess.Local injection of darvadstrocel was performed as a standardized procedure under general anesthesia including single-shot antibiotic prophylaxis,removal of seton drainage,fistula curettage,closure of the internal openings and local stem cell injection.Data collection focusing on healing rates,occurrence of abscess and follow-up was performed on a regular basis of quality control and patient care.Data were retrospectively analyzed.RESULTS Between July 2018 and January 2021,12 patients(6 females,6 males)with a mean age of 42.5(range:26-61)years underwent stem cell therapy.All patients had a minimum of one complex fistula,including patients with two complex fistulas in 58.3%(7/12).Two of the 12 patients had horse-shoe fistula and 3 had one complex fistula.According to Parks classification,the majority of fistulas were transsphincteric(76%)or suprasphincteric(14%).All patients underwent removal of seton,fistula curettage,transanal closure of internal opening by suture(11/12)or mucosal flap(1/12)and stem cell injection.At a mean follow-up of 14.3(range:3-30)mo,a healing rate was documented in 66.7%(8/12);mean duration to achieve healing was 12(range:6-30)wk.Within follow-up,4 patients required reoperation due to perianal abscess(33.3%).Focusing on patients with a minimum follow-up of 12 mo(6/12)or 24 mo(4/12),long-term healing rates were 66.7%(4/6)and 50.0%(2/4),respectively.CONCLUSION Data of this single-center experience are promising but limited due to the small number of patients and the retrospective analysis.展开更多
AIM:To investigate the efficacy of the anal fistula plug(AFP) compared to the mucosa advancement flap(MAF),considered the best procedure for patients with a complex anal fistula.METHODS:The literature search included ...AIM:To investigate the efficacy of the anal fistula plug(AFP) compared to the mucosa advancement flap(MAF),considered the best procedure for patients with a complex anal fistula.METHODS:The literature search included PubMed,EMBASE,Cochrane Library and OVID original studies on the topic of AFP compared to MAF for complex fistula-in-ano that had a deadline for publication by April 2011.Randomized controlled trials,controlled clinical trials and prospective cohort studies were included in the review.After information collection,a meta-analysis was performed using data on overall success rates as well as incidence of incontinence and morbidity.The quality of postoperative life was also included with the clinical results.RESULTS:Six studies involving 408 patients(AFP = 167,MAF = 241) were included in the meta-analysis.The differences in the overall success rates and incidence of fistula recurrence were not statistically significant between the AFP and MAF [risk difference(RD) =-0.12,95%CI:-0.39-0.14;RD = 0.13;95%CI:-0.18-0.43,respectively].However,for the AFP,the risk of postoperative impaired continence was lower(RD =-0.08,95%CI:-0.15--0.02) as was the incidence of other complications(RD =-0.06,95%CI:-0.11-0.00).The postoperative quality of life,for patients treated using the AFP was superior to that of the MAF patients.Patients treated with the AFP had less persistent pain of a shorter duration and the healing time of the fistula and hospital stay were also reduced.CONCLUSION:The AFP is an effective procedure for patients with a complex anal fistula;it has the same success rate but a lower risk of complications than the MAF and may also be associated with an improved postoperative quality of life.Additional evidence is needed to confirm these findings.展开更多
AIM: To prospectively perform the PERFACT procedure in supralevator anal fistula/abscess.METHODS: Magnetic resonance imaging was done preoperatively in all the patients. Proximal cauterization around the internal open...AIM: To prospectively perform the PERFACT procedure in supralevator anal fistula/abscess.METHODS: Magnetic resonance imaging was done preoperatively in all the patients. Proximal cauterization around the internal opening, emptying regularly of fistula tracts and curettage of tracts(PERFACT) was done in all patients with supralevator fistula or abscess. All types of anal fistula and/or abscess with supralevator extension, whether intersphincteric or transsphincteric, were included in the study. The internal opening along with the adjacent mucosa was electrocauterized. The resulting wound was left open to heal by secondary intention so as to heal(close) the internal opening by granulation tissue. The supralevator tract/abscess was drained and thoroughly curetted. It was regularly cleaned and kept empty in the postoperative period. The primary outcome parameter was complete fistula healing. The secondary outcome parameters were return to work and change in incontinence scores(Vaizey objective scoring system) assessed preoperatively and at 3 mo after surgery.RESULTS: Seventeen patients were prospectively enrolled and followed for a median of 13 mo(range 5-21 mo). Mean age was 41.1 ± 13.4 years, M:F-15:2. Fourteen(82.4%) had a recurrent fistula, 8(47.1%) had an associated abscess, 14(82.4%) had multiple tracts and 5(29.4%) had horseshoe fistulae. Infralevator part of fistula was intersphincteric in 4 and transsphincteric in 13 patients. Two patients were excluded. Eleven out of fifteen(73.3%) were cured and 26.7%(4/15) had a recurrence. Two patients with recurrence were reoperated on with the same procedure and one was cured. Thus, the overall healing rate was 80%(12/15). All the patients could resume normal work within 48 h of surgery. There was no deterioration in incontinence scores(Vaizey objective scoring system). This is the largest series of supralevator fistula-in-ano(SLF) published to date. CONCLUSION: PERFACT procedure is an effective single step sphincter saving procedure to treat SLF with minimal risk of incontinence.展开更多
目的通过对多模态MRI指标与临床指标结合分析,建立复杂性肛瘘术后肛门排粪失禁预测模型,并对模型进行验证。方法回顾性分析2020年1月至2023年5月我院肛肠科收治的71例复杂性肛瘘患者资料。统计术后三个月是否有肛门失禁症状,根据肛门失...目的通过对多模态MRI指标与临床指标结合分析,建立复杂性肛瘘术后肛门排粪失禁预测模型,并对模型进行验证。方法回顾性分析2020年1月至2023年5月我院肛肠科收治的71例复杂性肛瘘患者资料。统计术后三个月是否有肛门失禁症状,根据肛门失禁进行分组,结合患者多模态MRI数据指标及临床指标等变量进行Logistic回归分析,建立术后肛门失禁预测模型。结果71例患者中,最终共纳入71人,其中男性65人,年龄21至63岁,平均年龄39.23±10.71岁,经括约肌型46例,括约肌上型25例。Logistic回归分析结果显示,MRI肛瘘分型、MRI病变直径、肛门外括约肌(exteral anal sphincter,EAS)萎缩分级、EAS厚度、年龄是复杂性肛瘘术后并发肛门失禁的独立危险因素(P<0.05)。依此进行因素筛选从而构建预测模型,绘制受试者工作特征(receiver operating characteristic,ROC)曲线,曲线下面积(area under the curve,AUC)为0.940(P<0.001),模型预测质量评分0.87分,有较高的预测效能。结论MRI多模态成像指标结合临床风险因素建立的预测模型准确度良好,可以在治疗前方案的制订提供良好的影像学证据与参考,可以更好对肛门失禁情况进行提前预判。展开更多
文摘BACKGROUND High complex anal fistulas are epithelialized tunnels,with the main fistula piercing above the deep external sphincter and the internal opening approaching the dentate line.Conventional surgical procedures for high complex anal fistulas remove most of the external sphincter and damage the anorectal ring.Postoperative loss of anal function can cause physical and mental damage.Transanal opening of the intersphincteric space(TROPIS)is an effective procedure that completely preserves the external anal sphincter.However,its clinical application is limited by challenges in the localization of the internal opening of a fistula and the high risk of complications.On the basis of our clinical experience,we modified the TROPIS procedure for the treatment of treating high complex anal fistulas.CASE SUMMARY A patient with a high complex anal fistula located above the anorectal ring underwent modified TROPIS,which involved sepsis drainage and identification of the internal opening in the intersphincteric space.The patient with the high complex anal fistula recovered well postoperatively,without any postoperative complications or anal dysfunction.Anal function returned to normal after 17 months of follow-up.CONCLUSION The modified TROPIS procedure is the most minimally invasive surgery for anal fistulas that minimally impairs anal function.It allows the complete removal of infected anal glands and reduces the risk of postoperative complications.Modified TROPIS via the intersphincteric approach is an alternative sphincter-preserving treatment for high complex anal fistulas.
文摘BACKGROUND Despite tremendous progress in medical therapy and optimization of surgical strategies,considerable failure rates after surgery for complex anal fistula in Crohn’s disease have been reported.Therefore,stem cell therapy for the treatment of complex perianal fistula can be an innovative option with potential long-term healing.AIM To evaluate the results of local administration of allogenic,adipose-derived mesenchymal stem cells(darvadstrocel)for complex anal Crohn’s fistula.METHODS All patients with complex anal fistulas associated with Crohn’s disease who were amenable for definite fistula closure within a defined observation period were potential candidates for stem cell injection(darvadstrocel)if at least one conventional or surgical attempt to close the fistula had failed.Darvadstrocel was only indicated in patients without active Crohn’s disease and without presence of anorectal abscess.Local injection of darvadstrocel was performed as a standardized procedure under general anesthesia including single-shot antibiotic prophylaxis,removal of seton drainage,fistula curettage,closure of the internal openings and local stem cell injection.Data collection focusing on healing rates,occurrence of abscess and follow-up was performed on a regular basis of quality control and patient care.Data were retrospectively analyzed.RESULTS Between July 2018 and January 2021,12 patients(6 females,6 males)with a mean age of 42.5(range:26-61)years underwent stem cell therapy.All patients had a minimum of one complex fistula,including patients with two complex fistulas in 58.3%(7/12).Two of the 12 patients had horse-shoe fistula and 3 had one complex fistula.According to Parks classification,the majority of fistulas were transsphincteric(76%)or suprasphincteric(14%).All patients underwent removal of seton,fistula curettage,transanal closure of internal opening by suture(11/12)or mucosal flap(1/12)and stem cell injection.At a mean follow-up of 14.3(range:3-30)mo,a healing rate was documented in 66.7%(8/12);mean duration to achieve healing was 12(range:6-30)wk.Within follow-up,4 patients required reoperation due to perianal abscess(33.3%).Focusing on patients with a minimum follow-up of 12 mo(6/12)or 24 mo(4/12),long-term healing rates were 66.7%(4/6)and 50.0%(2/4),respectively.CONCLUSION Data of this single-center experience are promising but limited due to the small number of patients and the retrospective analysis.
文摘AIM:To investigate the efficacy of the anal fistula plug(AFP) compared to the mucosa advancement flap(MAF),considered the best procedure for patients with a complex anal fistula.METHODS:The literature search included PubMed,EMBASE,Cochrane Library and OVID original studies on the topic of AFP compared to MAF for complex fistula-in-ano that had a deadline for publication by April 2011.Randomized controlled trials,controlled clinical trials and prospective cohort studies were included in the review.After information collection,a meta-analysis was performed using data on overall success rates as well as incidence of incontinence and morbidity.The quality of postoperative life was also included with the clinical results.RESULTS:Six studies involving 408 patients(AFP = 167,MAF = 241) were included in the meta-analysis.The differences in the overall success rates and incidence of fistula recurrence were not statistically significant between the AFP and MAF [risk difference(RD) =-0.12,95%CI:-0.39-0.14;RD = 0.13;95%CI:-0.18-0.43,respectively].However,for the AFP,the risk of postoperative impaired continence was lower(RD =-0.08,95%CI:-0.15--0.02) as was the incidence of other complications(RD =-0.06,95%CI:-0.11-0.00).The postoperative quality of life,for patients treated using the AFP was superior to that of the MAF patients.Patients treated with the AFP had less persistent pain of a shorter duration and the healing time of the fistula and hospital stay were also reduced.CONCLUSION:The AFP is an effective procedure for patients with a complex anal fistula;it has the same success rate but a lower risk of complications than the MAF and may also be associated with an improved postoperative quality of life.Additional evidence is needed to confirm these findings.
文摘AIM: To prospectively perform the PERFACT procedure in supralevator anal fistula/abscess.METHODS: Magnetic resonance imaging was done preoperatively in all the patients. Proximal cauterization around the internal opening, emptying regularly of fistula tracts and curettage of tracts(PERFACT) was done in all patients with supralevator fistula or abscess. All types of anal fistula and/or abscess with supralevator extension, whether intersphincteric or transsphincteric, were included in the study. The internal opening along with the adjacent mucosa was electrocauterized. The resulting wound was left open to heal by secondary intention so as to heal(close) the internal opening by granulation tissue. The supralevator tract/abscess was drained and thoroughly curetted. It was regularly cleaned and kept empty in the postoperative period. The primary outcome parameter was complete fistula healing. The secondary outcome parameters were return to work and change in incontinence scores(Vaizey objective scoring system) assessed preoperatively and at 3 mo after surgery.RESULTS: Seventeen patients were prospectively enrolled and followed for a median of 13 mo(range 5-21 mo). Mean age was 41.1 ± 13.4 years, M:F-15:2. Fourteen(82.4%) had a recurrent fistula, 8(47.1%) had an associated abscess, 14(82.4%) had multiple tracts and 5(29.4%) had horseshoe fistulae. Infralevator part of fistula was intersphincteric in 4 and transsphincteric in 13 patients. Two patients were excluded. Eleven out of fifteen(73.3%) were cured and 26.7%(4/15) had a recurrence. Two patients with recurrence were reoperated on with the same procedure and one was cured. Thus, the overall healing rate was 80%(12/15). All the patients could resume normal work within 48 h of surgery. There was no deterioration in incontinence scores(Vaizey objective scoring system). This is the largest series of supralevator fistula-in-ano(SLF) published to date. CONCLUSION: PERFACT procedure is an effective single step sphincter saving procedure to treat SLF with minimal risk of incontinence.
文摘目的通过对多模态MRI指标与临床指标结合分析,建立复杂性肛瘘术后肛门排粪失禁预测模型,并对模型进行验证。方法回顾性分析2020年1月至2023年5月我院肛肠科收治的71例复杂性肛瘘患者资料。统计术后三个月是否有肛门失禁症状,根据肛门失禁进行分组,结合患者多模态MRI数据指标及临床指标等变量进行Logistic回归分析,建立术后肛门失禁预测模型。结果71例患者中,最终共纳入71人,其中男性65人,年龄21至63岁,平均年龄39.23±10.71岁,经括约肌型46例,括约肌上型25例。Logistic回归分析结果显示,MRI肛瘘分型、MRI病变直径、肛门外括约肌(exteral anal sphincter,EAS)萎缩分级、EAS厚度、年龄是复杂性肛瘘术后并发肛门失禁的独立危险因素(P<0.05)。依此进行因素筛选从而构建预测模型,绘制受试者工作特征(receiver operating characteristic,ROC)曲线,曲线下面积(area under the curve,AUC)为0.940(P<0.001),模型预测质量评分0.87分,有较高的预测效能。结论MRI多模态成像指标结合临床风险因素建立的预测模型准确度良好,可以在治疗前方案的制订提供良好的影像学证据与参考,可以更好对肛门失禁情况进行提前预判。
