Experimental porcine model of complex fistula-in-ano

AIM To establish and evaluate an experimental porcine model of fistula-in-ano.METHODS Twelve healthy pigs were randomly divided into two groups. Under general anesthesia, the experimental group underwent rubber band ligation surgery, and the control group underwent an artificial damage technique. Clinical magnetic resonance imaging(MRI) and histopathological evaluation were performed on the 38 th d and 48 th d after surgery in both groups, respectively. RESULTS There were no significant differences between the experimental group and the control group in general characteristics such as body weight, gender, and the number of fistula(P > 0.05). In the experimental group, 15 fistulas were confirmed clinically, 13 complex fistulas were confirmed by MRI, and 11 complex fistulas were confirmed by histopathology. The success rate in the porcine complex fistula model establishment was 83.33%. Among the 18 fistulas in the control group, 5 fistulas were confirmed clinically, 4 complex fistulas were confirmed by MRI, and 3 fistulas were confirmed by histopathology. The success rate in the porcine fistula model establishment was 27.78%. Thus, the success rate of the rubber band ligation group was significantly higher than the control group(P < 0.05). CONCLUSION Rubber band ligation is a stable and reliable method to establish complex fistula-in-ano models. Large animal models of complex anal fistulas can be used for the diagnosis and treatment of anal fistulas.

Ligation of intersphincteric fistula tract:What is the evidence in a review?

Broadly,complex fistulas are those that are not low transsphincteric or intersphincteric. The objectives of surgical management are to achieve fistula healing,prevent recurrences and maintain continence. The risk of incontinence associated with treatment ranges from10% to 57%. The objective of this manuscript is to review the current literature to date on the ligation of the intersphincteric fistula tract procedure(LIFT procedure) as a treatment option in these types of fistula.A search was conducted in Medline,PUBMED,EMBASE and ISI Web of Knowledge,and studies published from January 2009 to May 2013 were included. The primary outcomes were fistula healing rates,mean healing time and patient satisfaction with this surgical technique.Eighteen studies were included in this review. The total number of patients included was 592(65% male).The median age reported was 42.8 years. The most common type of fistula included was transsphincteric(73.3% of cases). The mean healing rate reported was74.6%. The risk factors for failure discovered were obesity,smoking,multiple previous surgeries and the length of the fistula tract. The mean healing time was5.5 wk,and the mean follow-up period was 42.3 wk.The patient satisfaction rates ranged from 72% to 100%. No de novo incontinence developed secondary to the LIFT procedure. There is not enough evidence that variants in the surgical technique achieve better outcomes(Bio-LIFT,LIFT-Plug,LIFT-Plus). This review indicates that the LIFT procedure is primarily effective for transsphincteric fistulas with an overall fistula closure of 74.6% and has a low impact on fecal continence. This procedure produces better outcomes at the first surgical attempt.

Ligation of intersphincteric fistula tract and its modification: Results from treatment of complex fistula

AIM: To compare healing rates between intersphincteric fistula tract (LIFT) and LIFT plus partial fistulectomy procedures. METHODS: A study of complex fistula-in-ano patients was carried out from 1 st March 2010 to 31 th January 2012. All operations were done by colorectal surgeons at a referral center in a Ministry of Public Health hospital. Data collected included patients' demographic details, fistula type determined by endorectal-ultraso-nography, preoperative and postoperative continence status, previous operations, time between diagnosis of fistula-in-ano and operation, type of surgery, healing rates, recurrence rates, and types of failure examined by endorectal-ultrasosnography, re-operation in recurrence or failure cases, and complications. RESULTS: The study involved 41 patients whose average age was 40.78 ± 11.84 years (range: 21-71 years). The major fistula type was high-transsphincteric type fistula. The median follow-up period was 24 wk. The overall success rate was 83%: in the LIFT (Ligation intersphincteric fistula tract) group the success rate was 81% and in the LIFT plus (LIFT with partial coreout fistulectomy) group it was 85% (P = 0.529). The median wound-healing time was 4 wk in both groups (P = 0.262). The median time to recurrence was 12 wk. Neither group had incontinence (Wexner incontinence score-0) and the difference in healing rates between the two groups was not statistically significant. CONCLUSION: There was no difference in results between LIFT and LIFT plus operations. The LIFT procedure is a good option for maintaining continence in management of fistula-in-ano.

PERFACT procedure:A new concept to treat highly complex anal fistula

AIM: To check the efficacy of the PERFACT procedure in highly complex fistula-in-ano.METHODS: The PERFACT procedure(proximal superficial cauterization, emptying regularly fistula tracts and curettage of tracts) entails two steps: superficial cauterization of mucosa at and around the internal opening and keeping all the tracts clean. The principle is to permanently close the internal opening by granulation tissue. This is achieved by superficial electrocauterization at and around the internal opening and subsequently allowing the wound to heal by secondary intention. Along with this, all the tracts are curetted and it is ensured that they remain empty and clean in the postoperative period until they heal completely. The latter step also facilitates the closure of the internal opening by preventing collected fluid in the tracts from entering the internal opening and thus not letting it close. Objective incontinence scoring was done preoperatively and 3 mo after the operation.RESULTS: Fifty-one patients with complex fistula-inano were prospectively enrolled. The median followup was 9 mo(5-14 mo). The mean age was 42.7 ± 11.3 years. Male:female ratio was 43:8. Fistula was recurrent in 76.5%(39/51), horseshoe in 50.1%(26/51), had multiple tracts in 52.9%(27/51), had an associated abscess in 41.2%(21/51), was anterior in 33.3%(17/51), the internal opening was not found in 15.7%(8/51) and 9.8%(5/51) of fistulas had a supralevator extension. Seven patients were excluded(5 lost to follow up, 2 with tuberculosis leading to/associated with fistula-in-ano). The success rate was 79.5%(35/44) and the recurrence rate was 20.5%(9/44). Out of these recurrences, three underwent reoperation(2 PERFACT procedure, 1 fistulotomy) and all three were successful. Thus, the overall success rate was 86.4%. The only complication was a non-healing tract in 9.1%(4/44) of patients. There was no significant change in objective incontinence scores three months after the operation. The pain was minimal, with all patients resuming their normal activities within 72 h of the operation.CONCLUSION: The PERFACT procedure is a new effective method for complex fistula-in-ano, effective even in fistula associated with abscess, supralevator fistula-in-ano and where the internal opening is nonlocalizable.

Diagnosis of anorectal tuberculosis by polymerase chain reaction,GeneXpert and histopathology in 1336 samples in 776 anal fistula patients

BACKGROUND The association of tuberculosis(TB)with anal fistulas can make its treatment quite difficult.The main challenge is timely detection of TB in anal fistulas and its proper management.There is little data available on diagnosis and management of TB in anal fistulas.AIM To detect TB in fistula-in-ano patients were analyzed in different methods utilized.METHODS A retrospective analysis of different methods,polymerase chain-reaction(PCR),GeneXpert and histopathology(HPE),utilized to detect tuberculosis in fistula-inano patients,treated between 2014-2020,was performed.The sampling was done for tissue(fistula tract lining)and pus(when available).The detection rate of various tests to detect TB and prevalence rate of TB in simple vs complex fistulae were studied.RESULTS In 1336 samples(776 patients)tested,TB was detected in 133 samples(122 patients).TB was detected in 52/703(7.4%)samples tested by PCR-tissue,in 77/331(23.2%)samples tested by PCR-pus,3/197(1.5%)samples tested with HPE-tissue and 1/105(0.9%)samples tested by GeneXpert.To detect TB,PCRtissue was significantly better than HPE-tissue(52/703 vs 3/197 respectively)(P=0.0012,significant,Fisher’s exact test)and PCR-pus was significantly better than PCR-tissue(77/331 vs 52/703 respectively)(P<0.00001,significant,Fisher’s exact test).TB fistulas were more complex than non-tuberculous fistulas[78/113(69%)vs 278/727(44.3%)respectively](P<0.00001,significant,Fisher’s exact test)but the overall healing rate was similar in tuberculous and non-tuberculous fistula groups[90/102(88.2%)vs 518/556(93.2%)respectively](P=0.10,not significant,Fisher’s exact test).CONCLUSION This is the largest study of anorectal TB to be published.The detection of TB by polymerase chain-reaction was significantly higher than by histopathology and GeneXpert.Amongst polymerase chain-reaction,pus had a higher detection rate than tissue.TB fistulas were more complex than non-tuberculous fistulas but aggressive diagnosis and meticulous treatment led to comparable overall success rates in both groups.

An NSQIP evaluation of practice patterns and outcomes following surgery for anorectal abscess and fistula in patients with and without Crohn’s disease

Background:Patients with Crohn’s disease(CD)are believed to have more aggressive anorectal abscess and fistula disease.We assessed the types of procedures performed and perioperative complications associated with the surgical management of anorectal abscess and fistula disease in patients with and without CD.Methods:The American College of Surgeons National Surgical Quality Improvement Program database(ACS-NSQIP,2005-2010)was used to calculate 30-day outcomes using regression modeling,accounting for demographics,comorbidities and surgical procedures.ICD-9 codes for anorectal abscess or fistula were used for initial selection.Patients were then stratified,based on the presence or absence of underlying CD.Local procedures included incision and drainage of abscesses,fistulotomy and seton placement.Cutaneous fistulas were considered simple,while all others were classified as complex(-vaginal,-urethral and-vesical).Results:A total of 7,218 patients(mean age 45 years;64%male)met inclusion criteria,with underlying CD in 345(4.8%).CD patients were more likely to have a seton placed(9.9 vs 8.2%,P<0.001)and be on steroids(15.4 vs 4.3%,P<0.001).Thirty-seven percent of CD patients underwent local procedures,while 46%had a proctectomy and8%underwent diversion.Fistulotomy was more common in those without underlying CD(16 vs 11%,P<0.001).The overall complication rate after local treatment was 4.9%,with no difference between patients with and without CD(7.7 vs 4.9%,P=0.144).This was not affected by fistula type-simple(7.9 vs 3.9%,P=0.194)vs complex(33 vs 7.1%,P=0.21)—or when stratified by wound(3.8 vs 2.4%;P=0.26)or systemic complications(3.8 vs 2.5%;P=0.53).Yet,complications following emergency procedures were higher in patients with CD(21.4 vs 5.9%,P=0.047).Factors significantly associated with increased complications were Crohn’s disease(OR=8.2),lack of functional independence(OR=2.0),pre-operative weight loss(OR=2.6)and pre-operative acute renal failure(OR=5.6).Steroids were also associated with a 1.7-fold increase in complications,independent from CD.Conclusions:While most patients with anorectal abscess/fistula are treated with local procedures,proctectomy and diversion use is fairly common in those with underlying CD.Although complication rates following elective local procedures for anorectal abscess/fistula are similar in patients with and without CD,they are higher in patients on steroids and in CD patients undergoing emergent procedures.