Structured magnetic resonance imaging and endoanal ultrasound anal fistulas reporting template(SMART):An interdisciplinary Delphi consensus

BACKGROUND There is still considerable heterogeneity regarding which features of cryptoglandular anal fistula on magnetic resonance imaging(MRI)and endoanal ultrasound(EAUS)are relevant to surgical decision-making.As a con-sequence,the quality and completeness of the report are highly dependent on the training and experience of the examiners.AIM To develop a structured MRI and EAUS template(SMART)reporting the minimum dataset of information for the treatment of anal fistulas.METHODS This modified Delphi survey based on the RAND-UCLA appropriateness for consensus-building was conducted between May and August 2023.One hundred and fifty-one articles selected from a systematic review of the lite-rature formed the database to generate the evidence-based statements for the Delphi study.Fourteen questions were anonymously voted by an interdisciplinary multidisciplinary group for a maximum of three iterative rounds.The degree of agreement was scored on a numeric 0–10 scale.Group consensus was defined as a score≥8 for≥80%of the panelists.RESULTS Eleven scientific societies(3 radiological and 8 surgical)endorsed the study.After three rounds of voting,the experts(69 colorectal surgeons,23 radiologists,2 anatomists,and 1 gastroenterologist)achieved consensus for 12 of 14 statements(85.7%).Based on the results of the Delphi process,the six following features of anal fistulas were included in the SMART:Primary tract,secondary extension,internal opening,presence of collection,coexisting le-sions,and sphincters morphology.CONCLUSION A structured template,SMART,was developed to standardize imaging reporting of fistula-in-ano in a simple,systematic,time-efficient way,providing the minimum dataset of information and visual diagram useful to refer-ring physicians.

Clinical Study on the Treatment of Low Anal Fistula in Infants and Young Children by Anal Gland Excision and Virtual Hanging Procedure

Objective:To compare the efficacy of anal adenectomy with virtual hanging wire and anal fistulotomy in the treatment of low anal fistula in infants and children.Methods:60 children with low anal fistula who were admitted to our hospital from October 2021 to March 2022 and met the inclusion criteria were randomly divided into two groups of 30 cases each;the treatment group was treated with anal adenectomy and virtual hanging wire surgery,and the control group was treated with anal fistula resection.The clinical efficacy after treatment was compared.Results:The total effective rate of both groups was 96.67%and the difference between the two groups was not statistically significant(P>0.05).The postoperative pain score of the treatment group was lower than that of the control group(P<0.05).The length of hospitalization and healing time of the treatment group was lower than that of the control group(P<0.05).The anal function of the patients in both groups was normal,and there was no adverse reaction.Conclusion:Anal gland excision and virtual hanging surgery for the treatment of low anal fistula in infants and children have the advantages of mild pain,reduced length of hospitalization,short healing time,and better patient experience as compared to anal fistula excision.

A case study illustrating the use of an integrated approach to treat secondary Anal Fistula Post I&D of Perianal Abscess

Background:Anal fistula is a long-term disease characterized by a tubular structure with one end opening in the anorectal canal and the other end opening on the surface of the perineum or perianal skin with chronic pus drainage.It is linked to Bhagandar in Ayurveda,and in Sushruta Samhita,Acharya has mentioned 5 forms of Bhagandar.The boil in the present case was Shukla,sthira i.e.hard and firm,with Picchila strava and Kandu resembling the features of Parisraavi bhagandar.Aim and objective:The current case was diagnosed as Parisravi bhagandar,which resembles trans-sphincteric or intersphincteric fistula in modern ano.In Ayurveda,the management of Parisraavi Bhagandar,Shastra,kshara,and Agnikarma is advised and the use of Ksharasutra,which contributes to complete cutting and healing of the track without reoccurrence,similarly Modern surgeon depends on surgery i.e radical excision of the track,ligation with Seton,and use of chemical irritants like urethane,silver nitrates,etc.A cutting seton(tight)gently slices the confined muscle to close the fistula with the least interruption to continence.This operation is especially advised when a one-stage fistulotomy poses a considerable risk of incontinence.Material and methods:The method performed here was Core Partial Fistulectomy followed by Ksharasutra application till complete healing of the wound.Discussion and conclusion:This case study provides the successful management of Parisraavi Bhagandara(high anal,trans-sphincteric fistula in ano)in 61-year-old male patient with an integrated surgical&Ayurvedic management approach.

Perianal disease in inflammatory bowel disease:Broadening treatment and surveillance strategies for anal cancer

The perianal disease affects up to one-third of individuals with Crohn's disease(CD),causing disabling symptoms and significant impairment in quality of life,particularly for those with perianal fistulising CD(PFCD).The collaborative effort between gastroenterologists and surgeons is essential for addressing PFCD to achieve fistula closure and promote luminal healing.Limited fistula healing rates with conventional therapies have prompted the emergence of new biological agents,endoscopic procedures and surgical techniques that show promising results.Among these,mesenchymal stem cells injection is a particularly hopeful therapy.In addition to the burden of fistulas,individuals with perianal CD may face an increased risk of developing anal cancer.This underscores the importance of surveillance programmes and timely interventions to prevent late diagnoses and poor outcomes.Currently,there is no established formal anal screening programme.In this review,we provide an overview of the current state of the art in managing PFCD,including novel medical,endoscopic and surgical approaches.The discussion also focuses on the relevance of establishing an anal cancer screening programme in CD,intending to propose a risk-based surveillance algorithm.The validation of this surveillance programme would be a significant step forward in improving patient care and outcomes.

Observation on Curative Effect of Self-made Wubeizi Decoction Combined with rhaFGF in Promoting Postoperative Wound Healing in Patients with Anal Fistula

[Objectives]To explore the curative effect of Self-made Wubeizi Decoction combined with recombinant human acidic fibroblast growth factor(rhaFGF)in promoting postoperative wound healing in patients with anal fistula.[Methods]A total of 82 patients with anal fistula who underwent anal fistula resection+use of setons in Luodian Hospital during January and March of 2020 were randomly divided into observation group and control group with 41 cases in each group.The control group was given rhaFGF external application regimen,and the observation group was treated with Self-made Wubeizi Decoction on the basis of the control group.After 3 weeks of treatment,the differences in curative effects of TCM syndromes were compared between the two groups.Besides,the changes in TCM symptom scores,inflammatory mediators[interleukin-12(IL-12),tumor necrosis factor-α(TNF-α),interferon-γ(IFN-γ)],anorectal functions[anal resting pressure(ARP),maximal systolic pressure(MSP)and maximum tolerated volume(MTV)of the anal canal],quality of life[GQOLI-74 scores]were compared.[Results]After 3 weeks of treatment,the total effective rate of the observation group was significantly higher than that of the control group(P<0.05);the levels of TCM symptom scores,IL-12,TNF-α,IFN-γ,ARP,MSP,and MTV in both groups were significantly lower than those before treatment,and these levels in the observation group was significantly lower than that in the control group at the same time(P<0.05).The GQOLI-74 scores of both groups were significantly higher than those before treatment,and the observation group was significantly higher than the control group(P<0.05).[Conclusions]The Self-made Wubeizi Decoction combined with rhaFGF therapy has a significant effect in promoting postoperative wound healing in patients with anal fistula.It can effectively inhibit the local inflammation of patients,facilitate the recovery of anorectal function and improve the quality of life,thus has high clinical application value.

Diagnostic performance of texture analysis in the differential diagnosis of perianal fistulising Crohn’s disease and glandular anal fistula

BACKGROUND Perianal fistulising Crohn's disease(PFCD)and glandular anal fistula have many similarities on conventional magnetic resonance imaging.However,many patients with PFCD show concomitant active proctitis,but only few patients with glandular anal fistula have active proctitis.AIM To explore the value of differential diagnosis of PFCD and glandular anal fistula by comparing the textural feature parameters of the rectum and anal canal in fat suppression T2-weighted imaging(FS-T2WI).METHODS Patients with rectal water sac implantation were screened from the first part of this study(48 patients with PFCD and 22 patients with glandular anal fistula).Open-source software ITK-SNAP(Version 3.6.0,http://www.itksnap.org/)was used to delineate the region of interest(ROI)of the entire rectum and anal canal wall on every axial section,and then the ROIs were input in the Analysis Kit software(version V3.0.0.R,GE Healthcare)to calculate the textural feature parameters.Textural feature parameter differences of the rectum and anal canal wall between the PFCD group vs the glandular anal fistula group were analyzed using Mann-Whitney U test.The redundant textural parameters were screened by bivariate Spearman correlation analysis,and binary logistic regression analysis was used to establish the model of textural feature parameters.Finally,diagnostic accuracy was assessed by receiver operating characteristic-area under the curve(AUC)analysis.RESULTS In all,385 textural parameters were obtained,including 37 parameters with statistically significant differences between the PFCD and glandular anal fistula groups.Then,16 texture feature parameters remained after bivariate Spearman correlation analysis,including one histogram parameter(Histogram energy);four grey level co-occurrence matrix(GLCM)parameters(GLCM energy_all direction_offset1_SD,GLCM entropy_all direction_offset4_SD,GLCM entropy_all direction_offset7_SD,and Haralick correlation_all direction_offset7_SD);four texture parameters(Correlation_all direction_offset1_SD,cluster prominence_angle 90_offset4,Inertia_all direction_offset7_SD,and cluster shade_angle 45_offset7);five grey level run-length matrix parameters(grey level nonuniformity_angle 90_offset1,grey level nonuniformity_all direction_offset4_SD,long run high grey level emphasis_all direction_offset1_SD,long run emphasis_all direction_offset4_SD,and long run high grey level emphasis_all direction_offset4_SD);and two form factor parameters(surface area and maximum 3D diameter).The AUC,sensitivity,and specificity of the model of textural feature parameters were 0.917,85.42%,and 86.36%,respectively.CONCLUSION The model of textural feature parameters showed good diagnostic performance for PFCD.The texture feature parameters of the rectum and anal canal in FS-T2WI are helpful to distinguish PFCD from glandular anal fistula.

Cellular angiofibroma arising from the rectocutaneous fistula in an adult: A case report

BACKGROUND Rectocutaneous fistulae are common.The infection originates within the anal glands and subsequently extends into adjacent regions,ultimately resulting in fistula development.Cellular angiofibroma(CAF),also known as an angiomy ofibroblastoma-like tumor,is a rare benign soft tissue neoplasm predominantly observed in the scrotum,perineum,and inguinal area in males and in the vulva in females.We describe the first documented case CAF that developed within a rectocutaneous fistula and manifested as a perineal mass.CASE SUMMARY In the outpatient setting,a 52-year-old male patient presented with a 2-year history of a growing perineal mass,accompanied by throbbing pain and minor scrotal abrasion.Physical examination revealed a soft,well-defined,non-tender mass at the left buttock that extended towards the perineum,without a visible opening.The initial assessment identified a soft tissue tumor,and the laboratory data were within normal ranges.Abdominal and pelvic computed tomography(CT)revealed swelling of the abscess cavity that was linked to a rectal cutaneous fistula,with a track-like lesion measuring 6 cm×0.7 cm in the left perineal region and attached to the left rectum.Rectoscope examination found no significant inner orifices.A left medial gluteal incision revealed a thick-walled mass,which was excised along with the extending tract,and curettage was performed.Histopathological examination confirmed CAF diagnosis.The patient achieved total resolution during follow-up assessments and did not require additional hospitalization.CONCLUSION CT imaging supports perineal lesion diagnosis and management.Perineal angiofibromas,even with a cutaneous fistula,can be excised transperineally.

Research Progress of Traditional Chinese and Western Medicine Dressing Change on Wound Healing After Anal Fistula Surgery

With the change of people’s lifestyle and diet,the incidence of anorectal diseases is increasing year by year.Anal fistula is a common anorectal disease.Because it cannot heal by itself,surgery has become the main treatment method.Due to the particularity of wound location and physiological structure,the wound is easily contaminated by bacteria,so dressing change after surgery plays a decisive role in wound healing.Modern western medicine and traditional Chinese medicine have different dressing changing methods respectively.In this paper,we reviewed commonly used dressing changing methods of traditional Chinese and western medicine after anal fistula surgery.

Modern management of anal fistula

Ideal surgical treatment for anal fistula should aim to eradicate sepsis and promote healing of the tract,whilst preserving the sphincters and the mechanism of continence.For the simple and most distal fistulae,conventional surgical options such as laying open of the fistula tract seem to be relatively safe and therefore,well accepted in clinical practise.However,for the more complex fistulae where a significant proportion of the anal sphincter is involved,great concern remains about damaging the sphincter and subsequent poor functional outcome,which is quite inevitable following conventional surgical treatment.For this reason,over the last twodecades,many sphincter-preserving procedures for the treatment of anal fistula have been introduced with the common goal of minimising the injury to the anal sphincters and preserving optimal function.Among them,the ligation of intersphincteric fistula tract procedure appears to be safe and effective and may be routinely considered for complex anal fistula.Another technique,the anal fistula plug,derived from porcine small intestinal submucosa,is safe but modestly effective in long-term follow-up,with success rates varying from 24%-88%.The failure rate may be due to its extrusion from the fistula tract.To obviate that,a new designed plug(GORE BioA ) was introduced,but long term data regarding its efficacy are scant.Fibrin glue showed poor and variable healing rate(14%-74%).Fi La C and video-assisted anal fistula treatment procedures,respectively using laser and electrode energy,are expensive and yet to be thoroughly assessed in clinical practise.Recently,a therapy using autologous adiposederived stem cells has been described.Their properties of regenerating tissues and suppressing inflammatory response must be better investigated on anal fistulae,and studies remain in progress.The aim of this present article is to review the pertinent literature,describing the advantages and limitations of new sphincterpreserving techniques.

Anal fistula plugvs mucosa advancement flap in complex fistula-in-ano:A meta-analysis

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.

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.

Why do we have so much trouble treating anal fistula?

Anal fistula is among the most common illnesses affecting man.Medical literature dating back to 400 BC has discussed this problem.Various causative factors have been proposed throughout the centuries,but it appears that the majority of fistulas unrelated to specific causes (e.g.Tuberculosis,Crohn’s disease) result from infection (abscess) in anal glands extending from the intersphincteric plane to various anorectal spaces.The tubular structure of an anal fistula easily yields itself to division or unroofing (fistulotomy) or excision (fistulectomy) in most cases.The problem with this single,yet effective,treatment plan is that depending on the thickness of sphincter muscle the fistula transgresses,the patient will have varying degrees of fecal incontinence from minor to total.In an attempt to preserve continence,various procedures have been proposed to deal with the fistulas.These include: (1) simple drainage (Seton);(2) closure of fistula tract using fibrin sealant or anal fistula plug;(3) closure of primary opening using endorectal or dermal flaps,and more recently;and (4) ligation of intersphincteric fistula tract (LIFT).In most complex cases (i.e.Crohn’s disease),a proximal fecal diversion offers a measure of symptom-atic relief.The fact remains that an "ideal" procedure for anal fistula remains elusive.The failure of each sphincter-preserving procedure (30%-50% recurrence) often results in multiple operations.In essence,the price of preservation of continence at all cost is multiple and often different operations,prolonged disability and disappointment for the patient and the surgeon.Nevertheless,the surgeon treating anal fistulas on an occasional basis should never hesitate in referring the patient to a specialist.Conversely,an expert colorectal surgeon must be familiar with many different operations in order to selectively tailor an operation to the individual patient.

Prevalence of anal fistula in the United Kingdom

BACKGROUND Anal fistula is a pathological connection between the anal canal and perianal skin, which most commonly develops from an infected anal crypt. While the majority of anal fistulas are idiopathic, they are also associated with Crohn’s disease (CD) and other inflammatory conditions. The prevalence of anal fistula is estimated to be 1-2 per 10000 patients, but population-based studies on anal fistula epidemiology are limited and outdated. AIM To assess the prevalence of anal fistula and relevant comorbidities, with and without CD in the United Kingdom and Europe. METHODS A retrospective population-representative observational cohort study was performed in The Health Improvement Network (THIN), a United Kingdom primary care database. Mid-year point prevalence of anal fistula was calculated on the first of July for each year between 2014 and 2017. Estimates were calculated for anal fistula overall and by CD status and standardized to the United Kingdom and European population. Prevalence of relevant comorbidities including lymphogranuloma venereum, hidradenitis suppurativa, anal presentation of sexually transmitted diseases, diabetes mellitus, and radiation in the pelvic area was reported. RESULTS The United Kingdom-standardized overall point prevalence of anal fistula was 1.80 (95%CI: 1.65-1.94) per 10000 patients in 2017, while the Europe standardized estimate was 1.83 (95%CI: 1.68-1.98) per 10000 patients. Both these standardized point prevalence estimates ranged from 1.89 to 2.36 between 2014-2016. The United Kingdom-standardized point prevalence of anal fistula without CD was 1.35 (95%CI: 1.23-1.48) per 10000 patients, while the Europe-standardized estimate was 1.39 (95%CI: 1.26-1.52) per 10000 patients. In contrast, the standardized point prevalence estimate of anal fistula with CD was lower for both United Kingdom and Europe (0.44;95%CI United Kingdom: 0.37-0.52, 95%CI Europe: 0.37-0.51) per 10000 patients in 2017. In 2017, 19% of anal fistula patients without CD and 13% of anal fistula patients with CD had at least one relevant comorbidity. These results show that anal fistulas are infrequent in the general population. 24.5% of prevalent anal fistulas are associated with CD, but other potentially etiological comorbidities are rare. CONCLUSION This real-world evidence study estimated the United Kingdom-standardized prevalence of anal fistula was 1.80 per 10000 patients in 2017. Approximately 25% of cases may be associated with CD, while other comorbidities are rare.

Treatment of peri-anal fistula in Crohn's disease

Anal fistulas are a common manifestation of Crohn's disease(CD). The first manifestation of the disease is often in the peri-anal region, which can occur years before a diagnosis, particularly in CD affecting the colon and rectum. The treatment of peri-anal fistulas is difficult and always multidisciplinary. The European guidelines recommend combined surgical and medical treatment with biologic drugs to achieve best results. Several different surgical techniques are currently em-ployed. However, at the moment, none of these tech-niques appear superior to the others in terms of healing rate. Surgery is always indicated to treat symptomatic, simple, low intersphincteric fistulas refractory to medi-cal therapy and those causing disabling symptoms. Ut-most attention should be paid to correcting the balance between eradication of the fistula and the preservationof fecal continence.

Three-dimensional endoanal ultrasonographic assessment of an anal fistula with and without H_2O_2 enhancement

AIM： To evaluate the effectiveness of three-dimensional endoanal ultrasound （3D-EAUS） in the assessment of anal fistulae with and without H202 enhancement. METHODS： Sixty-one patients （37 males, aged 17-74 years） with anal fistulae, which were not simple low types, were evaluated by physical examination and 3D-EAUS with and without enhancement. Fistula classification was determined with each modality and compared to operative findings as the reference standard. RESULTS： The accuracy of 3D-EAUS was significantly higher than that of physical examination in detecting the primary tract （84.4% vs 68.7%, P = 0.037） and secondary extension （81.8% vs 62.1%, P = 0.01） and localizing the internal opening （84.2% vs 59.7%, P = 0.004）. A contrast study with H202 detected several more fistula components including two primary suprasphincteric fistula tracks and one supralevator secondary extension, which were not detected on non-contrast study. However, there was no significant difference in accuracy between 3D-EAUS and H202- enhanced 3D-EAUS with respect to classification of the primary tract （84.4% vs 89.1%, P = 0.435） or secondary extension （81.8% vs 86.4%, P = 0.435） or localization of the internal opening （84.2% vs 89.5%, P = 0.406）. CONCLUSION： 3D-EAUS was highly reliable in the diagnosis of an anal fistula. H2O2 enhancement was helpful at times and selective use in difficult cases may be economical and reliable.

Anal fistula: Intraoperative difficulties and unexpected findings

Anal fistula surgery is a commonly performed procedure.The diverse anatomy of anal fistulae and their proximity to anal sphincters make accurate preoperative diagnosis essential to avoid recurrence and fecal incontinence.Despite the fact that proper preoperative diagnosis can be reached in the majority of patients by simple clinical examination,endoanal ultrasound or magnetic resonance imaging,on many occasions,unexpected findings can be encountered during surgery that can make the operation difficult and correct decision-making crucial.In this article we discuss the difficulties and unexpected findings that can be encountered during anal fistula surgery and how to overcome them.

Lessons learned from an audit of 1250 anal fistula patients operated at a single center:A retrospective review

BACKGROUND A complex anal fistula is a challenging disease to manage.AIM To review the experience and insights gained in treating a large cohort of patients at an exclusive fistula center.METHODS Anal fistulas operated on by a single surgeon over 14 years were analyzed.Preoperative magnetic resonance imaging was done in all patients.Four procedures were performed:fistulotomy;two novel sphincter-saving procedures,proximal superficial cauterization of the internal opening and regular emptying and curettage of fistula tracts(PERFACT)and transanal opening of intersphincteric space(TROPIS),and anal fistula plug.PERFACT was initiated before TROPIS.As per the institutional GFRI algorithm,fistulotomy was done in simple fistulas,and TROPIS was done in complex fistulas.Fistulas with associated abscesses were treated by definitive surgery.Incontinence was evaluated objectively by Vaizey incontinence scores.RESULTS A total of 1351 anal fistula operations were performed in 1250 patients.The overall fistula healing rate was 19.4%in anal fistula plug(n=56),50.3%in PERFACT(n=175),86%in TROPIS(n=408),and 98.6%in fistulotomy(n=611)patients.Continence did not change significantly after surgery in any group.As per the new algorithm,1019 patients were operated with either the fistulotomy or TROPIS procedure.The overall success rate was 93.5%in those patients.In a subgroup analysis,the overall healing rate in supralevator,horseshoe,and fistulas with an associated abscess was 82%,85.8%,and 90.6%,respectively.The 90.6%healing rate in fistulas with an associated abscess was comparable to that of fistulas with no abscess(94.5%,P=0.057,not significant).CONCLUSION Fistulotomy had a high 98.6%healing rate in simple fistulas without deterioration of continence if the patient selection was done judiciously.The sphincter-sparing procedure,TROPIS,was safe,with a satisfactory 86%healing rate for complex fistulas.This is the largest anal fistula series to date.

Prospective evaluation of a new device for the treatment of anal fistulas

AIM: To evaluate the safety of the implantation of a new device for the treatment of anal fistulas. The short-term clinical efficacy was also assessed. METHODS: This study took place at a tertiary care university hospital. Patients with a complex anal fistula of cryptoglandular origin were enrolled in the study and were treated with insertion of the new device. All patients were evaluated by clinical and physical examination, including an endoanal ultrasound at the baseline, and then at the 2 wk and 1, 2, 3 and 6-mo follow-up visits. RESULTS: Morbidity, continence status, and success rate were the main outcome measures. Ten patients underwent the placement of the new device. The fistulas were transphincteric in eight patients and extrasphincteric in the remaining two. The median duration of the surgical procedure was 34.5(range, 27-42) min. Neither intra- nor postoperative complications occurred, and all patients were discharged the day after the procedure. At the 6-mo follow-up evaluation, the final success rate was 70%. Three failures were registered: a device expulsion(on the 10 th postoperative day), the persistence of inflammatory tissue around the fistula tract(at the 2-mo follow up), and the persistence of serum discharge(at the 6-mo follow up). No patient experienced any change incontinence, as assessed by the Cleveland Clinic Fecal Incontinence score. CONCLUSION: The technical procedure is simple and has low risk of perioperative morbidity. The pre- and post-operative continence status did not change in any of the patients. The initial results at the 6-mo follow up seem to be promising. However, a longer follow-up period and a larger sample size are needed to confirm these preliminary results.

Traditional Chinese surgical treatment for anal fistulae with secondary tracks and abscess

AIM:To evaluate the efficacy and safety of traditional Chinese surgical treatment for anal fistulae with secondary tracks and abscess.METHODS:Sixty patients with intersphincteric or transsphincteric anal fistulas with secondary tracks and abscess were randomly divided into study group [suture dragging combined with pad compression(SDPC)] and control group [fistulotomy(FSLT)].In the SDPC group,the internal opening was excised and incisions at external openings were made for drainage.Silk sutures were put through every two incisions and knotted in loose state.The suture dragging process started from the first day after surgery and the pad compression process started when all sutures were removed as wound tissue became fresh and without discharge.In the FSLT group,the internal opening and all tracts were laid open and cleaned by normal saline postoperatively till all wounds healed.The time of healing,postoperative pain score(visual analogue scale),recurrence rate,patient satisfaction,incontinence evaluation and anorectal manometry before and after the treatment were examined.RESULTS:There were no significant differences between the two groups regarding age,gender and fistulae type.The time of healing was significantly shorter(24.33 d in SDPC vs 31.57 d in FSLT,P < 0.01) and the patient satisfaction score at 1 mo postoperative followup was significantly higher in the SDPC group(4.07 in SDPC vs 3.37 in FSLT,P < 0.05).The mean maximal postoperative pain scores were 5.83 ± 2.5 in SDPC vs 6.37 ± 2.33 in FSLT and the recurrence rates were 3.33 in SDPC vs 0 in FSLT.None of the patients in the two groups experienced liquid and solid fecal incontinence and lifestyle alteration postoperatively.The Wexner score after treatment of intersphincter fistulae were 0.17 ± 0.41 in SDPC vs 0.40 ± 0.89 in FSLT and transsphincter fistulae were 0.13 ± 0.45 in SDPC vs 0.56 ± 1.35 in FSLT.The maximal squeeze pressure and resting pressure declined after treatment in both groups.The maximal anal squeeze pressures after treatment were reduced(23.17 ± 3.73 Kpa in SDPC vs 22.74 ± 4.47 Kpa in FSLT) and so did the resting pressures(12.36 ± 2.15 Kpa in SDPC vs 11.71 ± 1.87 Kpa in FSLT),but there were neither significant differences between the two groups and nor significant differences before or after treatment.CONCLUSION:Traditional Chinese surgical treatment SDPC for anal fistulae with secondary tracks and abscess is safe,effective and less invasive.

Guidelines on postoperative magnetic resonance imaging in patients operated for cryptoglandular anal fistula:Experience from 2404 scans

Magnetic resonance imaging(MRI)is considered the gold standard for the evaluation of anal fistulas.There is sufficient literature available outlining the interpretation of fistula MRI before performing surgery.However,the interpretation of MRI becomes quite challenging in the postoperative period after the surgery of fistula has been undertaken.Incidentally,there are scarce data and no set guidelines regarding analysis of fistula MRI in the postoperative period.In this article,we discuss the challenges faced while interpreting the postoperative MRI,the timing of the postoperative MRI,the utility of MRI in the postoperative period for the management of anal fistulas,the importance of the active involvement and experience of the treating clinician in interpreting MRI scans,and the latest advancements in the field.