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Asian Journal of Surgery Aug 2019Perianal sepsis and fistula is a troublesome disease in the field of colorectal surgery in term of recurrence and fecal incontinence. The aim of our study is to evaluate... (Review)
Review
Perianal sepsis and fistula is a troublesome disease in the field of colorectal surgery in term of recurrence and fecal incontinence. The aim of our study is to evaluate the role of 'one stage complex anal fistula excision with reconstruction of anal sphincter without stool diversion' regarding fecal incontinence and recurrence. This was prospective cohort study on 175 patients of complex high peri-anal fistulae, the patients were subjected to fistulectomy and reconstruction (primary suture repair) of anal sphincter without stool diversion, the patients were followed up 1 year postoperatively after complete healing of the wound regarding their continence to stool and gases using Wexner score and recurrence of the fistula which is examined clinically and radio-logically using MRI. Among the 175 patients only four had developed fecal incontinence with varying degrees in which 2 patients developed gas incontinence and 2 patients developed soiling, after 3 months 8 patients had recurrence and after 6-9 months 6 patients developed recurrence . Also at the end of follow up period upon performing the confirmatory MRI, 2 patients showed hidden fistulous tracts ending into a high abscess cavity. This ends up into total of 16 recurrent cases. Five patients experienced delayed wound healing. In conclusion, Compared to other treatment modalities for complex anal fistula found in literature, it had been found that one stage surgery (fistulectomy with primary sphincter repair) has good results regarding healing of the fistula with low risk of incontinence, low recurrence rate and good wound healing.
Topics: Adolescent; Anal Canal; Cohort Studies; Digestive System Surgical Procedures; Feasibility Studies; Fecal Incontinence; Female; Follow-Up Studies; Humans; Male; Middle Aged; Prospective Studies; Plastic Surgery Procedures; Rectal Fistula; Recurrence; Time Factors; Treatment Outcome; Wound Healing; Young Adult
PubMed: 30738718
DOI: 10.1016/j.asjsur.2018.12.005 -
Techniques in Coloproctology Oct 2023Currently, the anal fistula treatment which optimises healing and preserves bowel continence remains unclear. The aim of our study was to compare the relative efficacy... (Meta-Analysis)
Meta-Analysis Review
PURPOSE
Currently, the anal fistula treatment which optimises healing and preserves bowel continence remains unclear. The aim of our study was to compare the relative efficacy of different surgical treatments for AF through a network meta-analysis.
METHODS
Systematic searches of MEDLINE, EMBASE and CENTRAL databases up to October 2022 identified randomised controlled trials (RCTs) comparing surgical treatments for anal fistulae. Fistulae were classified as simple (inter-sphincteric or low trans-sphincteric fistulae crossing less than 30% of the external anal sphincter (EAS)) and complex (high trans-sphincteric fistulae involving more than 30% of the EAS). Treatments evaluated in only one trial were excluded from the primary analyses to minimise bias. The primary outcomes were rates of success in achieving AF healing and bowel incontinence.
RESULTS
Fifty-two RCTs were included. Of the 14 treatments considered, there were no significant differences regarding short-term (6 months or less postoperatively) and long-term (more than 6 months postoperatively) success rates between any of the treatments in patients with both simple and complex anal fistula. Ligation of the inter-sphincteric fistula tract (LIFT) ranked best for minimising bowel incontinence in simple (99.1% of comparisons; 3 trials, n = 70 patients) and complex anal fistula (86.2% of comparisons; 3 trials, n = 102 patients).
CONCLUSIONS
There is insufficient evidence in existing RCTs to recommend one treatment over another regarding their short and long-term efficacy in successfully facilitating healing of both simple and complex anal fistulae. However, LIFT appears to be associated with the least impairment of bowel continence, irrespective of AF classification.
Topics: Humans; Fecal Incontinence; Network Meta-Analysis; Wound Healing; Anal Canal; Ligation; Rectal Fistula; Treatment Outcome
PubMed: 37460830
DOI: 10.1007/s10151-023-02845-8 -
Tidsskrift For Den Norske Laegeforening... Jan 2019
Review
Topics: Anti-Bacterial Agents; Crohn Disease; Drug Therapy, Combination; Gastrointestinal Agents; Humans; Immunosuppressive Agents; Rectal Fistula; Tumor Necrosis Factor-alpha
PubMed: 30644688
DOI: 10.4045/tidsskr.17.1055 -
Techniques in Coloproctology Apr 2021Crohn's anal fistula is a challenging condition, and may require multiple surgical procedures. To replicate successful procedures, these must be adequately reported in... (Review)
Review
A systematic review of the quality of reporting of interventions in the surgical treatment of Crohn's anal fistula: an assessment using the TIDiER and Blencowe frameworks.
BACKGROUND
Crohn's anal fistula is a challenging condition, and may require multiple surgical procedures. To replicate successful procedures, these must be adequately reported in the literature. The aim of this study was to review the quality of reporting of components of surgical interventions for Crohn's anal fistula.
METHODS
A systematic review was conducted. It was registered with PROSPERO (CRD:42019135157). The Medline and EMBASE databases were searched for studies reporting interventions intended to close fistula in patients with Crohn's disease, published between 1999 and August 2019. Abstracts and full texts were screened for inclusion by two reviewers. Dual extraction of data was performed to compare reporting to the TIDiER and Blencowe frameworks for reporting of interventions.
RESULTS
Initial searches identified 207 unique studies; 38 full texts were screened for inclusion and 33 were included. The most common study design was retrospective cohort (17/33), and the most frequently reported interventions were anal fistula plug (n = 8) and fibrin glue (n = 6). No studies showed coverage of all domains of TIDieR. Reporting was poor among domains related to who provided an intervention, where it was provided, and how it was tailored. Reporting of domains in the Blencowe framework was poor; the majority of studies did not report the component steps of procedures or efforts to standardise them.
CONCLUSIONS
This study demonstrates that reporting on technical aspects of interventions for Crohn's anal fistula is poor. Surgeons should aim to improve reporting to allow accurate reproduction of techniques both in clinical practice and in clinical trials.
Topics: Crohn Disease; Digestive System Surgical Procedures; Humans; Rectal Fistula; Retrospective Studies; Treatment Outcome
PubMed: 33599902
DOI: 10.1007/s10151-020-02359-7 -
Techniques in Coloproctology Jun 2021Management of cryptoglandular fistula-in-ano (FIA) can be challenging. Despite Dutch and international guidelines determining optimal therapy is still quite difficult....
BACKGROUND
Management of cryptoglandular fistula-in-ano (FIA) can be challenging. Despite Dutch and international guidelines determining optimal therapy is still quite difficult. The aim of this study was to report current practices in the management of cryptoglandular FIA among gastrointestinal surgeons in the Netherlands.
METHODS
Dutch surgeons and residents who are treating FIA regularly were sent a survey invitation by email. The survey was available online from September 19 to December 1 2019. The questionnaire consisted of 28 questions concerning diagnostic and surgical techniques in the treatment of intersphincteric and transsphincteric FIA.
RESULTS
In total, 147 (43%) surgeons responded and completed the survey. Magnetic resonance imaging was the preferred diagnostic imaging modality (97%) followed by the endo-anal ultrasound (12%). In case of a high FIA, 86% used a non-cutting seton. Most respondents removed a seton between 6 weeks and 3 months (n = 84, 58%). Fistulotomy was the procedure of preference in low transsphincteric (86%) and low intersphincteric FIA (92%). Mucosal advancement flap (MAF) and ligation of intersphincteric fistula tract (LIFT), with 78% and 46%, respectively, were the procedures that were applied most often in high transsphincteric FIA. In high intersphincteric FIA 67% performed a MAF and 33% a fistulotomy. Thirty-three percent of all respondents stated that they habitually closed the internal fistula opening, half of them used a Z-plasty. For debridement of the fistula tract the preferred method was curettage (78%).
CONCLUSIONS
Dutch gastrointestinal surgeons use various techniques in the management of FIA. Novel promising techniques should be investigated adequately in sufficient large trials to increase consensus. A core outcome measurement and a prospective international database would help in comparing results. Until then, treatment should be adjusted to the individual patient, governed by fistula characteristics and patient choice.
Topics: Anal Canal; Humans; Ligation; Netherlands; Prospective Studies; Rectal Fistula; Recurrence; Surgeons; Treatment Outcome
PubMed: 33860363
DOI: 10.1007/s10151-021-02446-3 -
Surgical Infections Jun 2022Non-surgical intervention has been proposed for the management of perianal abscess (PA) and fistula-in-ano (FIA), with potential benefits in terms of quality of life,...
Non-surgical intervention has been proposed for the management of perianal abscess (PA) and fistula-in-ano (FIA), with potential benefits in terms of quality of life, wound healing, and functional outcome, although this strategy remains rare and controversial. Here, we aimed to compare the intermediate-term outcomes of non-surgical management with those of surgical incision and/or drainage. A study of pediatric patients with first-time PA and/or FIA was conducted retrospectively from January 2010 to December 2020. The patient population was stratified by surgical and non-surgical management. The clinical outcomes, including PA recurrence, FIA formation, and wound healing time, were compared between the surgical and non-surgical management groups. A total of 457 patients managed for first-time PA and/or FIA were eligible for the current study. Of these patients, 169 (50.9%) patients received non-surgical intervention. There were no differences in terms of age, gender distribution, wound healing course, or abscess size between the two groups. Furthermore, no difference was noted between the two groups in terms of PA recurrence and/or FIA development rates and revisits for additional treatment. Although PA/FIA management is still controversial, non-surgical intervention exhibited promising outcomes for most cases of first-time PA/FIA, with fewer hospital admissions and surgical procedures and similar recurrence and fistula formation incidences. Immediate surgical intervention might be avoided because PA/FIA has a chance for spontaneous resolution in children.
Topics: Abscess; Anus Diseases; Child; Humans; Quality of Life; Rectal Fistula; Retrospective Studies; Treatment Outcome
PubMed: 35647894
DOI: 10.1089/sur.2021.351 -
Techniques in Coloproctology Jul 2017One in three patients with Crohn's disease will develop a perianal fistulae, and one third of these will achieve long-term healing or closure. A barrier to conducting... (Review)
Review
BACKGROUND
One in three patients with Crohn's disease will develop a perianal fistulae, and one third of these will achieve long-term healing or closure. A barrier to conducting well-designed clinical trials for these patients is a lack of understanding of prognostic factors. This systematic review sets out to identify factors associated with prognosis of perianal Crohn's fistulae.
METHODS
This review was registered on the PROSPERO database (CRD42016050316) and conducted in line with PRISMA guidelines along a predefined protocol. English-language studies assessing baseline factors related to outcomes of fistulae treatment in adult patients were included. Searches were performed on MEDLINE and Embase databases. Screening of abstracts and full texts for eligibility was performed prior to extraction of data into predesigned forms. Bias was assessed using the QUIPS tool.
RESULTS
Searches identified 997 papers. Following removal of duplicates and secondary searches, 923 were screened for inclusion. Forty-seven papers were reviewed at full-text level and 13, 2 of which were randomised trials, were included in the final qualitative review. Two studies reported distribution of Crohn's disease as a prognostic factor for healing. Two studies found that CARD15 mutations decreased response of fistulae to antibiotics. Complexity of fistulae anatomy was implicated in prognosis by 4 studies.
CONCLUSIONS
This systematic review has identified potential prognostic markers, including genetic factors and disease behaviour. We cannot, however, draw robust conclusions from this heterogeneous group of studies; therefore, we recommend that a prospective cohort study of well-characterised patients with Crohn's perianal fistulae is undertaken.
Topics: Adult; Aged; Aged, 80 and over; Anti-Bacterial Agents; Crohn Disease; Female; Humans; Male; Middle Aged; Mutation; Nod2 Signaling Adaptor Protein; Prognosis; Rectal Fistula; Treatment Outcome; Wound Healing; Young Adult
PubMed: 28639073
DOI: 10.1007/s10151-017-1647-3 -
The Journal of International Medical... Feb 2021Cryptoglandular perianal fistula is a common benign anorectal disorder that is managed mainly with surgery. A fistula is typically defined as a pathological... (Review)
Review
Cryptoglandular perianal fistula is a common benign anorectal disorder that is managed mainly with surgery. A fistula is typically defined as a pathological communication between two epithelialized surfaces. More specifically, perianal fistula manifests as an abnormal tract between the anorectal canal and the perianal skin. Perianal fistulas are often characterized by significantly decreased patient quality of life. The cryptoglandular theory of perianal fistulas suggests their development from the proctodeal glands, which originate from the intersphincteric plane and perforate the internal sphincter with their ducts. Involvement of proctodeal glands in the inflammatory process could play a primary role in the formation of cryptoglandular perianal fistula. The objective of this narrative review was to investigate the current knowledge of the pathogenesis of cryptoglandular perianal fistula with the specific aims of characterizing the potential role of proinflammatory factors responsible for the development of chronic inflammation. Further studies are crucial to improve the therapeutic management of cryptoglandular perianal fistulas.
Topics: Anal Canal; Humans; Quality of Life; Rectal Fistula; Treatment Outcome
PubMed: 33595349
DOI: 10.1177/0300060520986669 -
Inflammatory Bowel Diseases Jun 2022Perianal fistula (PAF), a complication of Crohn's disease (CD), is associated with substantial economic costs and poor prognosis. We determined prevalence of PAF CD in...
BACKGROUND
Perianal fistula (PAF), a complication of Crohn's disease (CD), is associated with substantial economic costs and poor prognosis. We determined prevalence of PAF CD in the United States and compared costs and health care resource utilization (HRU) of PAF CD patients with matched non-PAF CD patients.
METHODS
This was a retrospective cohort study of claims data from the IBM MarketScan Commercial Database from October 1, 2015, to September 30, 2018. Eligible patients were aged 18 to 89 years with ≥2 CD diagnoses. Patients with PAF CD had ≥1 PAF diagnosis or procedure code and were matched with non-PAF CD patients. Cumulative prevalence of PAF CD in the US population was calculated across total patients in MarketScan. All-cause and gastrointestinal (GI)-related costs and HRU were compared between groups using a generalized linear model (GLM).
RESULTS
Cumulative 3-year prevalence of PAF was 7.70% of patients with CD (N = 81,862) and 0.01% of the US population. Among PAF CD (n = 1218) and matched non-PAF CD (n = 4095) patients, most all-cause costs and HRU were GI-related. Mean total all-cause and GI-related health care costs per patient and per year for PAF CD were $85,233 and $71,612, respectively, vs $40,526 and $29,458 for non-PAF CD (P < .0001). Among PAF CD vs non-PAF CD patients, GLM-adjusted proportions of patients with GI-related inpatient, outpatient, or pharmacy visits, mean GI-related inpatient length of stay, and mean GI-related surgeries were higher (P < .0001 for all comparisons).
CONCLUSIONS
Costs and HRU are significantly higher for patients with PAF CD vs non-PAF CD patients, highlighting the economic burden of the disease.
Topics: Crohn Disease; Delivery of Health Care; Health Care Costs; Humans; Patient Acceptance of Health Care; Rectal Fistula; Retrospective Studies; United States
PubMed: 34525184
DOI: 10.1093/ibd/izab198 -
European Journal of Medical Research Jan 2015Endorectal ultrasonography (ERUS) and magnetic resonance imaging (MRI) allow exploring the morphology of the rectum in detail. Use of such data, especially assessment of... (Review)
Review
Endorectal ultrasonography (ERUS) and magnetic resonance imaging (MRI) allow exploring the morphology of the rectum in detail. Use of such data, especially assessment of the rectal wall, is an important tool for ascertaining the perianal fistula localization as well as stage of the cancer and planning it appropriate treatment, as stage T3 tumors are usually treated with neoadjuvant therapy, whereas T2 tumors are initially managed surgically. The only advantage of ERUS over MRI is the possibility of assessing T1 tumors that could be treated by transanal endoscopic microsurgery. However, MRI is better for visualizing most radiological prognostic features in rectal or anal cancer such as a circumferential resection margin less than 1 mm, T stage at T1-T2 or T3 tumors with extramural extension less than 5 mm, absence of extramural vascular invasion, N stage at N0/N1, and tumors located in the middle or upper third of the rectum. It can also evaluate the intersphincteric space or levator ani muscle involvement. Increased signal on diffusion weighted imaging (DWI) and low apparent diffusion coefficient (ADC) values as well as an irregular contour and heterogeneous internal signal intensity seem to predict the involvement of pelvic lymphatic nodes better than their size alone. Computed tomography as well as other examination techniques, including digital rectal examination, contrast edema, recto- and colonoscopy, are less useful in staging of rectal cancer but still are very important screening tools.
Topics: Endosonography; Humans; Magnetic Resonance Imaging; Rectal Fistula; Rectal Neoplasms
PubMed: 25586770
DOI: 10.1186/s40001-014-0078-0