Management of low transsphincteric anal fistula with serial setons and interval muscle-cutting fistulotomy

This study evaluates low transsphincteric anal fistula managed by serial setons and interval fistulotomy, with attention to healing without recurrence and preservation of continence. Following Institutional Review Board approval, consecutive anal fistula operations performed by a single surgeon from January 1, 2009 to December 31, 2013 were retrospectively reviewed using electronic medical records and telephone interviews for patients lost to follow up. Of the 71 patients, 26（37%） had low transsphincteric fistula（23 males and 3 females; mean age： 46 years）, treated at our institution by seton placement followed by interval surgical muscle cutting and subsequent seton replacement or final fistulotomy. Of the 26 patients, 22（85%） were initially referred due to previous failed treatment, with a 30.6 month mean duration of fistula prior to referral and a mean of 2.2（range： 0–6） prior anorectal surgeries. At a mean follow-up of 11.9 months, none of the 21 patients experienced recurrence or fecal incontinence. Serial seton with interval muscle-cutting sphincterotomy followed by complete fistulotomy is an effective treatment for the management of patients who are either initially seen for low transsphincteric fistula, or referred after failed anorectal surgery for that condition.

Idiopathic fistula-in-ano

Fistula-in-ano is the most common form of perineal sepsis.Typically,a fistula includes an internal opening,a track,and an external opening.The external opening might acutely appear following infection and/or an abscess,or more insiduously in a chronic manner.Management includes control of infection,assessment of the fistulous track in relation to the anal sphincter muscle,and finally,definitive treatment of the fistula.Fistulotomy was the most commonly used mode of management,but concerns about post-fistulotomy incontinence prompted the use of sphincter preserving techniques such as advancement flaps,fibrin glue,collagen fistula plug,ligation of the intersphincteric fistula track,and stem cells.Many descriptive and comparative studies have evaluated these different techniques with variable outcomes.The lack of consistent results,level I evidence,or long-term follow-up,as well as the heterogeneity of fistula pathology has prevented a definitive treatment algorithm.This article will review the most commonly available modalities and techniques for managing idiopathic fistula-in-ano.

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.

Loose Seton: A Misnomer of Cutting Seton

Purpose: The purpose of this study was to demonstrate loose silk seton actually acts as a slow cutting seton contrary to the idea of simply drainage. Besides, to show the effect of loose seton on patient’s incontinence is mostly proportional to the degree of division of the sphincter muscle. Design: Fifty patients with high transsphincteric fistulas were treated with loose seton technique. We measured the length of high sphincteric fistula tracts, pre- and postoperative anal sphincter pressures and incontinence scores. Results: Loose seton with heavy silk resulted in 72% percent of progressive migration of the fistula tract caudally. The more the progressive migration of the loose seton loop, the less the pressure drop in both resting and squeezing in manometric studies. This study is limited by its retrospective design in prospectively collected data and covers relatively small number of patients. Conclusion: Seton is still useful technique in high perianal fistula surgery. Defining this technique as simply “loose” seton is misnomer since it acts as a slowly cutting seton and results in progressive migration of the fistula tract caudally. The more the progressive migration of the loose seton loop, the less the pressure drop would be possible after postoperatively.

Empathy in Rudyard Kipling＇s Jungle Books, Mirrored in Illustrations by John Lockwood Kipling and Aldren Watson

Rudyard Kipling＇s Jungle Boobs depict empathy in the animal and animal-human world, and the illustrations of Rudyard＇s father, John Lockwood Kipling, and the American artist and prolific illustrator, Aldren Watson, help depict that empathy. Lockwood Kipling was both influence on and interpreter of the Jungle Books, as shown above all in the development from his Beast andMan in lndia of 1891 through his illustrations for the 1894 Jungle Book, and 1895 Second Jungle Book, to his illustrations that appear in the rearranged stories of The Jungle Book, and Second Jungle Book in the 1897 Scribners Outward Bound （O/B） editions. A variation on Lockwood＇s O/B mode of Jungle Books illustrations is found in Watson＇s illustrations for the 1948 Doubleday edition, Jungle Boobs, which is the title I will use throughout.1 Part One details the influence of two animal empathy writers, Lockwood Kipling and Ernest Thompson Seton, on the Jungle Books. Part Two uses recent philosophical studies of empathy in the animal and human relationship. Part Three applies a German philosophy of art history to the new look of the O/B and Doubleday Jungle Books. Part Four interprets selected Jungle Books stories in the light of Parts one, two and three.

Can More than One Fistula Be Treated by a New Type of Seton Concomitantly?

Objective: The treatment of trans-sphincteric fistulas is a surgical challenge since eradicating the fistula tract while maintaining the anal continence is vitally important. In this study we documented the outcomes of the patients with one or more fistulas treated at the same operation with a new type of seton. Patients and Methods: The study included 78 patients with 107 high anal fistulas who were treated with seton between 2007 and 2011. Fifty seven patients had only one fistula, 13 patients had two isolated fistulas and 8 patients had three isolated fistulas. Group I was the patients with one fistula and Group II was the patients having more than one fistula. Postoperative complications, hospital stay, cutting through the sphincter and healing times and Wexner’s scores were compared between the two groups. Results: In Group I, there were 57 patients and in Group II, 21 patients were operated for 50 fistulas. No postoperative complications were observed except urinary retentions (4 patients in Group I, 3 patients in Group II). No infection on the operation site was documented in both groups, in Group I none of the patients needed extra dose of narcotic analgesic but in Group II two of the patients who had 3 fistulas were discharged on the second postoperative day because of pain on the operation site. The median for the cutting seton to cut through the sphincter was 31 days and complete healing was achieved with a median of 40 days in Group I, whereas it was 56 and 65 days respectively for Group II. There were no recurrences in our patients in both groups. Although the Wexner scores of the both groups were low, the difference between the groups was statistically significant. Conclusion: It seems to be feasible to perform seton by using a cheap, effective, easily inserted material, also in treatment of patients with more than one fistula while preserving anal continence.

Three-cavity clearance(TCC)can decrease the fistula rate after drainage of a perianal abscess:a case–control study

Objective:The aim of this study was to evaluate the safety and efficacy of three-cavity clearance(TCC)used for the treatment of perianal abscess.Methods:A case–control study of patients with perianal abscess was conducted at the Second and Third Affiliated Hospitals of Nanjing University of Chinese Medicine from June 2013 to March 2016.Clinical data from 46 patients who had TCC were analysed.At the same time,46 patients had simple incision and drainage and 46 patients had abscess drainage and cutting seton(radical abscess incision);the data from these patients were also analysed.The length of hospital stay,time of wound healing,fistula rate and anal incontinence were assessed.Results:The rate of fistula formation in the TCC group was 13.0%—significantly lower than that in the group with simple incision and drainage(39.1%,p<0.01)and similar to the group with radical abscess incision(8.7%,p>0.05).Two patients(4.3%)in the group with radical abscess incision had anal incontinence,flatus and soiling;their Wexner scores were 6 and 3,respectively.There was no anal incontinence in the TCC group or the simple incision and drainage group.There were no statistical differences in the time of wound healing and length of hospital stay among the three groups(both p>0.05).Conclusion:TCC is a safe and effective sphincter-preserving procedure for perianal abscess formation and can decrease the fistula rate after perianal abscess drainage.It appears to be a valuable method that can be used in clinical practice;however,further studies are needed to verify this finding.