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World Journal of Gastroenterology Jan 2015Ideal surgical treatment for anal fistula should aim to eradicate sepsis and promote healing of the tract, whilst preserving the sphincters and the mechanism of... (Review)
Review
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 two decades, 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%). FiLaC 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 adipose-derived 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 sphincter-preserving techniques.
Topics: Anal Canal; Digestive System Surgical Procedures; Humans; Postoperative Complications; Rectal Fistula; Risk Factors; Treatment Outcome
PubMed: 25574077
DOI: 10.3748/wjg.v21.i1.12 -
Journal of Crohn's & Colitis Jan 2020
Topics: Adrenal Cortex Hormones; Anti-Bacterial Agents; Anti-Inflammatory Agents; Antibodies, Monoclonal; Crohn Disease; Drug Therapy, Combination; Humans; Immunosuppressive Agents; Induction Chemotherapy; Maintenance Chemotherapy; Rectal Fistula; Severity of Illness Index
PubMed: 31711158
DOI: 10.1093/ecco-jcc/jjz180 -
International Journal of Surgery... Sep 2019Despite a burgeoning literature during the last two decades regarding perioperative risk management of anal fistula, little is known about its risk factors that... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Despite a burgeoning literature during the last two decades regarding perioperative risk management of anal fistula, little is known about its risk factors that influence postoperative recurrence. We performed a meta-analysis to summarize and assess the credibility of evidence of potential risk factors for anal fistula recurrence (AFR) after surgery.
METHODS
Pubmed and EMBASE without language restriction were searched from inception to April 2018 that reported risk factors which predisposed recurrence after anal fistula surgery. We excluded studies that involved patients with anal fistula associated with Crohn's disease. MOOSE guidelines were followed when this meta-analysis was performed. We used random-effects models to pool relative risks (RRs) with 95% confidence intervals (CIs). Evidence from observational studies was graded into high-quality (Class I), moderate-quality (Class II/III) and low-quality (Class IV) based on Egger's P value, total sample size and between-study heterogeneity.
RESULTS
Of 3514 citations screened, 20 unique observational studies comprising 6168 patients were involved in data synthesis. High-quality evidence showed that AFR was associated with high transsphincteric fistula (RR, 4.77; 95% CI, 3.83 to 5.95), internal opening unidentified (RR, 8.54; 95% CI, 5.29 to 13.80), and horseshoe extensions (RR, 1.92; 95% CI, 1.43 to 2.59). Moderate-quality evidence suggested an association with prior anal surgery (RR, 1.52; 95% CI, 1.04 to 2.23), seton placement surgery (RR, 2.97; 95% CI, 1.10 to 8.06), and multiple fistula tract (RR, 4.77; 95% CI, 1.46 to 15.51). High-quality evidence demonstrated no significant association with gender or smoking; moderate-quality evidence also suggested no association with age, tertiary referral, alcohol use, diabetes mellitus, obesity, preoperative seton drainage, high internal opening, postoperative drainage, mucosal advancement flap surgery, supralevator extensions, location or type of anal fistula.
CONCLUSION
Several patient, surgery and fistula-related factors are significantly associated with postoperative AFR. These findings strengthen clinical awareness of early warning to identify patients with high-risk disease recurrence for AFR.
Topics: Adult; Female; Humans; Male; Postoperative Complications; Rectal Fistula; Recurrence; Risk Factors
PubMed: 31400504
DOI: 10.1016/j.ijsu.2019.08.003 -
Journal of Crohn's & Colitis Feb 2020This article is the second in a series of two publications relating to the European Crohn's and Colitis Organisation [ECCO] evidence-based consensus on the management of...
This article is the second in a series of two publications relating to the European Crohn's and Colitis Organisation [ECCO] evidence-based consensus on the management of Crohn's disease. The first article covers medical management; the present article addresses surgical management, including preoperative aspects and drug management before surgery. It also provides technical advice for a variety of common clinical situations. Both articles together represent the evidence-based recommendations of the ECCO for Crohn's disease and an update of previous guidelines.
Topics: Abdominal Abscess; Crohn Disease; Humans; Intestinal Obstruction; Intestine, Small; Rectal Fistula
PubMed: 31742338
DOI: 10.1093/ecco-jcc/jjz187 -
Gastroenterology Jun 2021The incidence and prevalence of Crohn's disease (CD) is rising globally. Patients with moderate to severe CD are at high risk for needing surgery and hospitalization and... (Review)
Review
The incidence and prevalence of Crohn's disease (CD) is rising globally. Patients with moderate to severe CD are at high risk for needing surgery and hospitalization and for developing disease-related complications, corticosteroid dependence, and serious infections. Optimal management of outpatients with moderate to severe luminal and/or fistulizing (including perianal) CD often requires the use of immunomodulator (thiopurines, methotrexate) and/or biologic therapies, including tumor necrosis factor-α antagonists, vedolizumab, or ustekinumab, either as monotherapy or in combination (with immunomodulators) to mitigate these risks. Decisions about optimal drug therapy in moderate to severe CD are complex, with limited guidance on comparative efficacy and safety of different treatments, leading to considerable practice variability. Since the last iteration of these guidelines published in 2013, significant advances have been made in the field, including the regulatory approval of 2 new biologic agents, vedolizumab and ustekinumab. Therefore, the American Gastroenterological Association prioritized updating clinical guidelines on this topic. To inform the clinical guidelines, this technical review was completed in accordance with the GRADE (Grading of Recommendations Assessment, Development and Evaluation) framework. The review addressed the following focused questions (in adult outpatients with moderate to severe luminal CD): overall and comparative efficacy of different medications for induction and maintenance of remission in patients with or without prior exposure to tumor necrosis factor-α antagonists, comparative efficacy and safety of biologic monotherapy vs combination therapy with immunomodulators, comparative efficacy of a top-down (upfront use of biologics and/or immunomodulator therapy) vs step-up treatment strategy (acceleration to biologic and/or immunomodulator therapy only after failure of mesalamine), and the role of corticosteroids and mesalamine for induction and/or maintenance of remission. Finally, in adult outpatients with moderate to severe fistulizing CD, this review addressed the efficacy of pharmacologic interventions for achieving fistula and the role of adjunctive antibiotics without clear evidence of active infection.
Topics: Adult; Crohn Disease; Decision Support Systems, Clinical; Disease Management; Female; Gastroenterology; Humans; Male; Practice Guidelines as Topic; Rectal Fistula; Severity of Illness Index; Societies, Medical
PubMed: 34051985
DOI: 10.1053/j.gastro.2021.04.023 -
World Journal of Gastroenterology Jul 2021Perianal Crohn's disease remains a challenging condition to treat and can have a substantial negative impact on quality of life. It often requires combined surgical and... (Review)
Review
Perianal Crohn's disease remains a challenging condition to treat and can have a substantial negative impact on quality of life. It often requires combined surgical and medical interventions. Anti-tumor necrosis factor (anti-TNF) therapy, including infliximab and adalimumab, remain preferred medical therapies for perianal Crohn's disease. Infliximab has been shown to be efficacious in improving fistula closure rates in randomized controlled trials. Clinicians can be faced with a number of questions relating to the optimal use of anti-TNF therapy in perianal Crohn's disease. Specific issues include evaluation for the presence of perianal sepsis, the treatment target of therapy, the ideal time to commence treatment, whether additional medical therapy should be used in conjunction with anti-TNF therapy, and the duration of treatment. This article will discuss key studies which can assist clinicians in addressing these matters when they are considering or have already commenced anti-TNF therapy for the treatment of perianal Crohn's disease. It will also discuss current evidence regarding the use of vedolizumab and ustekinumab in patients who are failing to achieve a response to anti-TNF therapy for perianal Crohn's disease. Lastly, new therapies such as local injection of mesenchymal stem cell therapy will be discussed.
Topics: Crohn Disease; Humans; Infliximab; Quality of Life; Rectal Fistula; Treatment Outcome; Tumor Necrosis Factor Inhibitors; Tumor Necrosis Factor-alpha
PubMed: 34321838
DOI: 10.3748/wjg.v27.i25.3693 -
World Journal of Gastroenterology Jul 2011Fistula-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... (Review)
Review
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.
Topics: Anal Canal; Fibrin Tissue Adhesive; Humans; Rectal Fistula; Sepsis; Surgical Flaps; Treatment Outcome
PubMed: 21876614
DOI: 10.3748/wjg.v17.i28.3277 -
Gastroenterology Jun 2021
Topics: Crohn Disease; Disease Management; Gastroenterology; Humans; Intestinal Mucosa; Minimal Clinically Important Difference; Patient Selection; Rectal Fistula; Societies, Medical
PubMed: 34051983
DOI: 10.1053/j.gastro.2021.04.022 -
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 -
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