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International Journal of Surgery... Apr 2017The sepsis in intersphincteric space has important role in pathogenesis of most complex fistula-in-ano. This sepsis is like a small abscess in a closed space. This...
BACKGROUND
The sepsis in intersphincteric space has important role in pathogenesis of most complex fistula-in-ano. This sepsis is like a small abscess in a closed space. This closed space needs to be drained adequately and then kept open for the fistula-in-ano to heal properly. The aim was to lay open and drain the intersphincteric space through internal opening via transanal approach. This has been tried in submucosal and intersphincteric rectal abscesses but has never been tried in complex fistula-in-ano.
MATERIALS AND METHODS
All consecutive patients of complex high (involving >1/3 of sphincter complex) fistula-in-ano who were operated were included in the prospective cohort study. Preoperative MRI scan was done in all the patients. Transanal laying open of the intersphincteric space (TROPIS) was done through the internal opening. The external sphincter was not cut. The tracts in the ischiorectal fossa were curetted and cleaned. The incontinence scores were measured.
RESULTS
61 patients with high complex fistula-in-ano were included (follow-up:6-21 months). Male/Female:59/2, age-42.3 ± 9.5 years. 85.2% (52) were recurrent, 83.6% (51) had multiple tracts, 36.1% (22) had horseshoe tract, 34.4% (21) had supralevator extension and 26.2% (16) had associated abscess. 95.1% (58) were posterior fistula out of which 90.2% (55) were in posterior midline. Nine patients were excluded (due to tuberculosis, lost to follow-up). Fistula healed completely in 84.6% (44/52) and didn't heal in 15.4% (9/52). 4/9 of these were reoperated and fistula healed in three patients. Thus overall healing rate was 90.4% (47/52). There was no significant change in incontinence scores.
CONCLUSIONS
TROPIS is a simple effective sphincter sparing procedure to treat high complex fistula-in-ano including supralevator and horseshoe fistula.
Topics: Adult; Anal Canal; Cohort Studies; Female; Humans; Male; Middle Aged; Perineum; Prospective Studies; Rectal Fistula; Recurrence; Sepsis; Treatment Outcome; Wound Healing
PubMed: 28259693
DOI: 10.1016/j.ijsu.2017.02.095 -
La Tunisie Medicale Apr 2024Treatment of complex perianal fistulas in Crohn's disease remains a challenge especially after the failure of Infliximab. (Review)
Review
INTRODUCTION
Treatment of complex perianal fistulas in Crohn's disease remains a challenge especially after the failure of Infliximab.
AIM
Update on the different therapeutic alternatives for anal fistula in Crohn's disease after failure of Infliximab.
METHODS
A research in the medical literature on PubMed and Google Scholar was carried out. We included cohort studies, reviews and randomized double-blinded therapeutic trials. Case reports and fundamental research studies have been excluded.
RESULTS
Anti-TNF therapy, notably Infliximab remain the therapeutic option of choice. Since Infliximab efficacy has been estimated at 60%, with a significant loss-of response rate, new therapeutic strategies have been evaluated and may offer new opportunities for the management of anal fistulas: for example, Ustekinumab could be effective after failure of anti-TNF therapy, although further studies are required. Recent guidelines suggest that injection of mesenchymal stem cells is an effective and safe treatment for complex fistulas. Other surgical options have been proposed, such as endorectal advancement flap, fibrin glue injection, anal fistula plug and ligation of the intersphincteric fistula tract, but all with limited and debatable efficacy. Given the failure rate of all these options, new strategies are currently being evaluated.
CONCLUSION
Anal fistulas in Crohn's disease are a real therapeutic challenge. New medical and surgical therapies are currently being evaluated, with promising results.
Topics: Humans; Crohn Disease; Rectal Fistula; Infliximab; Treatment Failure; Gastrointestinal Agents
PubMed: 38746955
DOI: 10.62438/tunismed.v102i4.4699 -
Ugeskrift For Laeger Jan 2024Extrapulmonary tuberculosis (TB) in the gastrointestinal tract is a rare, but yet an essential differential diagnosis to patients with complex fistula disease, since the...
Extrapulmonary tuberculosis (TB) in the gastrointestinal tract is a rare, but yet an essential differential diagnosis to patients with complex fistula disease, since the initiation of immunosuppressive therapy for presumed Crohn's disease can lead to a fulminant course of TB. This case report presents a young Danish woman with a progressive complex fistula disease, where cause and treatment were uncovered by interprofessional collaboration between pulmonologists, gastroenterologists and surgeons including a screening test for TB as well as multiple biopsies from the anal fistula tissue.
Topics: Female; Humans; Crohn Disease; Rectal Fistula; Tuberculosis, Extrapulmonary; Tuberculosis, Gastrointestinal; Biopsy
PubMed: 38305264
DOI: 10.61409/V09230551 -
Ugeskrift For Laeger Dec 2020Anal abscesses are well-known conditions worldwide. The golden standard of acute treatment is incision and drainage. Knowledge of the anatomy of the anal area and the... (Review)
Review
Anal abscesses are well-known conditions worldwide. The golden standard of acute treatment is incision and drainage. Knowledge of the anatomy of the anal area and the abscess involvement of perianal spaces is crucial in order to perform safe and correct surgical treatment as summarised in this review. Pre- and perioperative imaging with magnetic resonance imaging, endoanal ultrasonography or CT facilitates correct incision and drainage, while antibiotics as conservative approach have no place in the treatment of abscesses. One third of the patients have an underlying fistula, and if suspected referral to a fistula centre is warranted.
Topics: Abscess; Anal Canal; Anus Diseases; Drainage; Humans; Rectal Fistula
PubMed: 33317691
DOI: No ID Found -
Ugeskrift For Laeger Sep 2021Cryptoglandular anal fistulas (AF) cause recurrent anal abscesses and patients risk multiple surgeries due to low healing rates of sphincter-saving procedures. Knowledge... (Review)
Review
Cryptoglandular anal fistulas (AF) cause recurrent anal abscesses and patients risk multiple surgeries due to low healing rates of sphincter-saving procedures. Knowledge of anal anatomy and imaging with MRI or endoanal sonography is crucial to classify AF as simple or complex depending on risk of anal incontinence after fistulotomy as summarised in this review. Fistulotomy has healing rates of > 90%, risks incontinence, and the procedure is reserved for simple fistulas. Complex AF are treated with a draining seton and then with sphincter-saving procedures which have long-term healing rates of about 50%.
Topics: Anal Canal; Fecal Incontinence; Humans; Magnetic Resonance Imaging; Rectal Fistula; Treatment Outcome
PubMed: 34498577
DOI: No ID Found -
Journal of Visceral Surgery Apr 2015Anal fistulas require surgical treatment to cure the fistula. Fistulotomy is the treatment of choice because of its high success rate, but it also carries a risk of... (Review)
Review
Anal fistulas require surgical treatment to cure the fistula. Fistulotomy is the treatment of choice because of its high success rate, but it also carries a risk of postoperative incontinence. Different methods have been proposed to overcome the need for dividing part or all of the sphincter, so-called "sphincter saving techniques" (SST), such as flap advancement, intrafistular injection of glue, or the insertion of a bio-prosthesis (collagen plug). However, the success rate of SSTs is lower than that of fistulotomy. Ligation of the Intersphincteric Fistula Tract (LIFT) is one of the most recent SSTs. It aims to ligate and transect the fistula by an approach through the intersphincteric space. The methodological quality of most published studies has been only average, but several studies have reported attractive success rates of 70 to 95% without postoperative incontinence. Other techniques such as endo-anal clip or injection of autologous stem cells are still anecdotal.
Topics: Anal Canal; Evidence-Based Medicine; Fecal Incontinence; Fibrin Tissue Adhesive; Humans; Ligation; Organ Sparing Treatments; Quality of Life; Rectal Fistula; Surgical Flaps; Tissue Adhesives; Treatment Outcome
PubMed: 25280598
DOI: 10.1016/j.jviscsurg.2014.08.002 -
Journal of Visceral Surgery Apr 2015The glands of Hermann and Desfosses, located in the thickness of the anal canal, drain into the canal at the dentate line. Infection of these anal glands is responsible... (Review)
Review
The glands of Hermann and Desfosses, located in the thickness of the anal canal, drain into the canal at the dentate line. Infection of these anal glands is responsible for the formation of abscesses and/or fistulas. When this presents as an abscess, emergency drainage of the infected cavity is required. At the stage of fistula, treatment has two sometimes conflicting objectives: effective drainage and preservation of continence. These two opposing constraints explain the existence of two therapeutic concepts. On one hand the laying-open of the fistulous tract (fistulotomy) in one or several operative sessions remains the treatment of choice because of its high cure rates. On the other hand surgical closure with tract ligation or obturation with biological components preserves sphincter function but suffers from a higher failure rate.
Topics: Abscess; Anus Diseases; Emergencies; Humans; Ligation; Rectal Fistula; Suction; Surgical Flaps; Treatment Outcome
PubMed: 25261376
DOI: 10.1016/j.jviscsurg.2014.07.008 -
International Braz J Urol : Official... 2017
Topics: Humans; Rectal Fistula; Urethral Diseases; Urinary Fistula
PubMed: 28124547
DOI: 10.1590/S1677-5538.IBJU.2015.0676.1 -
Journal of Gastrointestinal Surgery :... Jul 2023Autologous fat grafting (AFG) has shown promise in the treatment of complex wounds, with trials reporting good healing rates and safety profile. We aim to investigate...
BACKGROUND
Autologous fat grafting (AFG) has shown promise in the treatment of complex wounds, with trials reporting good healing rates and safety profile. We aim to investigate the role of AFG in managing complex anorectal fistulas.
METHODS
This was a retrospective review of a prospectively maintained IRB-approved database. We examined the rates of symptom improvement, clinical closure of fistula tracts, recurrence, complications, and worsening fecal incontinence. Perianal disease activity index (PDAI) was obtained for patients undergoing combination of AFG and fistula plug treatment.
RESULTS
In total, 52 unique patients underwent 81 procedures, of which Crohn's was present in 34 (65.4%) patients. The majority of patients previously underwent more common treatments such as endorectal advancement flap or ligation of intersphincteric fistula tract. Fat-harvesting sites and processing technique were selected by the plastic surgeons based on availability of trunk fat deposits. When analyzing patients by their last procedure, 41 (80.4%) experienced symptom improvement, and 29 (64.4%) experienced clinical closure of all fistula tracts. Recurrence rate was 40.4%, and complication rate was 15.4% (7 postoperative abscesses requiring I&D and 1 bleeding episode ligated at bedside). The abdomen was the most common site of lipoaspirate harvest at 63%, but extremities were occasionally used. There were no statistically significant differences in outcomes when comparing single graft treatment to multiple treatments, Crohn's and non-Crohn's, different methods of fat preparation, and diversion.
CONCLUSION
AFG is a versatile procedure that can be done in conjunction with other therapies and does not interfere with future treatments if recurrence occurs. It is a promising and affordable method to safely address complex fistulas.
Topics: Humans; Treatment Outcome; Rectal Fistula; Surgical Flaps; Fecal Incontinence; Ligation; Crohn Disease; Inflammation; Adipose Tissue; Anal Canal; Recurrence
PubMed: 37268827
DOI: 10.1007/s11605-023-05719-4 -
World Journal of Gastroenterology Oct 2014Anal 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... (Review)
Review
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 employed. However, at the moment, none of these techniques appear superior to the others in terms of healing rate. Surgery is always indicated to treat symptomatic, simple, low intersphincteric fistulas refractory to medical therapy and those causing disabling symptoms. Utmost attention should be paid to correcting the balance between eradication of the fistula and the preservation of fecal continence.
Topics: Anal Canal; Crohn Disease; Digestive System Surgical Procedures; Fecal Incontinence; Gastrointestinal Agents; Humans; Patient Care Team; Predictive Value of Tests; Rectal Fistula; Risk Factors; Treatment Outcome; Wound Healing
PubMed: 25309057
DOI: 10.3748/wjg.v20.i37.13205