Anal fistula surgery

PURPOSE: This study was undertaken to assess results of surgery for fistula-in-ano and identify risk factors for fistula recurrence and impaired continence. METHODS: We reviewed the records of 624 patients who underwent surgery for fistula-in-ano between 1988 and 1992. Follow-up was by mailed questionnaire, with 375 patients (60 percent) responding. Mean follow-up was 29 months. Fistulas were intersphincteric in 180 patients, transsphincteric in 108, suprasphincteric in 6, extrasphincteric in 6, and unclassified in 75. Procedures included fistulotomy and marsupialization (n=300), seton placement (n=63), endorectal advancement flap (n=3), and other (n=9). Factors associated with recurrence and incontinence were analyzed by univariate and multivariate regression analysis. RESULTS: The fistula recurred in 31 patients (8 percent), and 45 percent complained of some degree of postoperative incontinence. Factors associated with recurrence included complex type of fistula, horseshoe extension, lack of identification or lateral location of the internal fistulous opening, previous fistula surgery, and the surgeon performing the procedure. Incontinence was associated with female sex, high anal fistula, type of surgery, and previous fistula surgery. CONCLUSIONS: Surgical treatment of fistula-in-ano is associated with a significant risk of recurrence and a high risk of impaired continence. Degree of risk varies with identifiable factors.Read at the meeting of The American Society of Colon and Rectal Surgeons, Orlando, Florida, May 8 to 13, 1994.     

Excision of anal fistula with closure of the internal opening: functional and manometric results

PURPOSE: The aim of this study was to evaluate the results concerning recurrence and continence after sphincter-saving surgery for fistula-in-ano. METHODS: Forty-two patients with anal fistula traversing the sphincter were operated on with fistula excision and closure of the internal opening. Patients answered a questionnaire concerning bowel habits and continence before and 3 and 12 months after surgery. A subgroup of 19 patients were also examined with anal manometry. RESULTS: Twenty-three (55 percent) patients healed primarily after surgery and a further 10 (24 percent) after one reoperation, whereas 7 (17 percent) required 2 to 4 reoperations until healed. In two patients therapy was changed to cutting seton treatment. After 1 year 21 of 36 (58 percent) patients reported improved or unaffected continence and 11 (31 percent) reported a slight and 4 (11 percent) a major decrease in continence. Detailed data on preoperative continence were missing for five patients, and one had a colostomy at late follow-up. Anal manometry showed a significant decrease in resting pressure after three months and a further decrease in both resting and squeeze pressures after one year. CONCLUSION: Surgery for anal fistula with excision and advancement flap has a fairly high initial recurrence rate but a good final success rate. A decrease in continence is seen also after this kind of surgery for anal fistula. Manometric results suggest that this is associated with an impaired internal anal sphincter function.     

Prospective clinical and manometric study of fistulotomy with primary sphincter reconstruction in the management of recurrent complex fistula-in-ano

Background and aims The aim of this study was to assess the results of fistulotomy with sphincter reconstruction in the management of recurrent complex fistula-in-ano in terms of recurrence and continence.Patients and methods Prospective study of 16 patients undergoing fistulotomy with sphincter reconstruction for recurrent complex fistula-in-ano was done. Preoperative and postoperative evaluation included physical examination, anal ultrasonography and anal manometry, with a 40-month follow-up. The Wexner Continence Grading Scale (0–20) was used to assess faecal continence.Results Fistulas were classified as high transsphincteric in 13 patients (81.3%), suprasphincteric in 2 (12.5%) and extrasphincteric in 1 patient (6.2%). Four patients (25%) had recurred twice or more. Eight patients (50%) complained of varying degrees of prior faecal incontinence. Their mean score decreased from 8.5 to 1.875 after surgery, and all the patients improved except for one whose score remained the same. On anal manometry, the differences between continent and incontinent patients before surgery [maximum resting pressure (MRP) 86.3 vs 57.6 mmHg, maximum squeeze pressure (MSP) 196.5 vs 138.6 mmHg] decreased after surgery (MRP 81.9 vs 63.7 mmHg, MSP 179.8 vs 159.3 mmHg). In fully continent patients, both the clinical score and manometric values were quite similar after surgery. Two fully continent patients (25%) developed occasional flatus incontinence and soiling, scoring two and three points, respectively. One patient recurred (6.25%) 6 months after surgery.Conclusion Fistulotomy with sphincter reconstruction seems to be an effective resource in the management of recurrent complex fistula-in-ano. It improves both anal continence and manometric values in incontinent patients without compromising them in fully continent ones.     

Initial experience of treating anal fistula with the Surgisis anal fistula plug

Background

Complex anal fistulas remain a challenge for the colorectal surgeon. The anal fistula plug has been developed as a simple treatment for fistula-in-ano. We present and evaluate our experience with the Surgisis anal fistula plug from two centres.

Methods

Data were prospectively collected and analysed from consecutive patients undergoing insertion of a fistula plug between January 2007 and October 2009. Fistula plugs were inserted according to a standard protocol. Data collected included patient demographics, fistula characteristics and postoperative outcome.

Results

Forty-four patients underwent insertion of 62 plugs (27 males, mean age 45.6?years), 25 of whom had prior fistula surgery. Mean follow-up was 10.5?months Twenty-two patients (50%) had successful healing following the insertion of plug with an overall success rate of 23 out of 62 plugs inserted (35%). Nineteen out of 29 patients healed following first-time plug placement, whereas repeated plug placement was successful in 3 out of 15 patients (20%; p?=?0.0097). There was a statistically significant difference in the healing rate between patients who had one or less operations prior to plug insertion (i.e. simple fistulas) compared with patients who needed multiple operations (18 out of 24 patients vs. 4 out of 20 patients; p?=?0.0007).

Conclusions

Success of treatment with the Surgisis anal fistula plug relies on the eradication of sepsis prior to plug placement. Plugs inserted into simple tracts have a higher success rate, and recurrent insertion of plugs following previous plug failure is less likely to be successful. We suggest the fistula plug should remain a first-line treatment for primary surgery and simple tracts.     

Patient satisfaction after surgical treatment for fistula-in-ano

PURPOSE: The surgical treatment of fistula-in-ano frequently results in recurrence of the fistula or postoperative anal incontinence. Despite these problems, most patients are satisfied with the results of their surgery. To clarify this apparent discrepancy, we attempted to identify factors that affect patient's lifestyles and may contribute to their satisfaction. METHODS: A questionnaire was mailed to 624 patients surgically treated for cryptoglandular fistula-in-ano at the University of Minnesota during a five-year period. Three hundred seventy-five patients returned their questionnaires. Patients who were followed up for a minimum of one year were included in this retrospective study. Associations between postoperative complications and patient satisfaction were identified by chi-squared tests and multiple logistic regression. Attributable fractions for patient dissatisfaction were calculated using study population dissatisfaction rates. RESULTS: Patient satisfaction was strongly associated with fistula recurrence, difficulty holding gas, soiling of undergarment, and accidental bowel movements. Effects of incontinence on patient quality of life were also significantly associated with patient satisfaction as was the number of lifestyle activities affected by incontinence. Patients with fistula recurrence reported a higher dissatisfaction rate (61 percent) than did patients with anal incontinence (24 percent), but the attributable fraction of dissatisfaction for incontinence (84 percent) was greater than that for fistula recurrence (33 percent). Patient satisfaction was not significantly associated with age, gender, history of previous fistula surgery, type of fistula, surgical procedure, time since surgery, or operating surgeon. CONCLUSION: Patient satisfaction after surgical treatment for fistula-in-ano is associated with recurrence of the fistula, the development of anal incontinence, and with the effects of anal incontinence on patient lifestyle. In our series of patients treated mainly with laying open of the fistula tract, patients with fistula recurrence had a higher dissatisfaction rate than did patients with anal incontinence. However, because anal incontinence was more prevalent than fistula recurrence, a higher fraction of dissatisfaction was attributable to anal incontinence.Presented at the meeting of the Association of Coloproctology of Great Britain and Ireland, Brighton, United Kingdom, July 10 to 12, 2000.     

Dermal island-flap anoplasty for transsphincteric fistula-in-ano

PURPOSE: The aim of this study was to assess the treatment failures of island-flap anoplasty for fistula-in-ano, a procedure designed to treat fistula without sphincter division. METHODS: Data concerning all patients having dermal island-flap anoplasty for the treatment of transsphincteric fistula were reviewed. Variables assessed were age, gender, radial fistula location, cause, Crohn's disease, previous fistula operations, other complicating illnesses, internal sphincter closure, simultaneous use of fibrin adhesive injection, and use of combined dermal and rectal flap for large fistulas. Postoperative data collected included persistence of the distal tract, recurrence of the fistula, and treatment of the recurrence. Recurrence (or persistence) of the fistula was the dependant variable and each risk factor for recurrence was assessed using chi-squared analyses. RESULTS: Seventy-three flaps were performed in 65 individuals. Recurrence developed 17 times in 13 individuals. Recurrence was more likely to occur in males, patients who have had previous treatment of fistulas, patients with large fistulas requiring combined flaps, and patients who had simultaneous fibrin glue injection. Patients with Crohn's disease and individuals having internal sphincter closure had fewer recurrences. Factors reaching statistical significance included closure of the internal sphincter, the use of fibrin glue, and cause of the fistula. CONCLUSION: No specific anatomic or demographic characteristic is sufficiently associated with failure to exclude any patient from the operation. Closure of the internal sphincter should be done as part of the procedure and fibrin glue injection should not be done simultaneously.     

V-Y Advancement Flap for Treatment of Fistula-In-Ano

PURPOSE: The management of high fistula-in-ano presents a difficult surgical challenge. Laying open of high transsphincteric, intersphincteric, and suprasphincteric fistulas is associated with incontinence. Mucosal advancement flap can be technically difficult and is associated with ectropion and incontinence. We report a new technique for the treatment of fistulas, which may eliminate these problems. PATIENTS AND METHODS: Between 1997 and 2002, 18 patients (13 males), median age 46 (range, 25–64) years with high fistula-in-ano were treated. There were ten transsphincteric, four intersphincteric, and four suprasphincteric fistulas. In all patients, perianal sepsis was allowed to resolve completely with a drainage seton before definitive surgery. The surgical technique used involved core fistulectomy, curettage of any cavity, closure of the defect in the internal anal sphincter, and a V-Y advancement buttock flap to cover the internal opening, leaving the site of the external opening for drainage while preserving both internal and external sphincters. Outcome was assessed in terms of healing and continence. RESULTS: Most patients were discharged from the hospital within 48 hours. Median follow-up was 19 (range, 3–60) months. There were three patients who failed to heal. Of these, two underwent repeat surgery and healed. Two further patients had recurrent fistulas, both of whom continued with conservative treatment. Overall, 15 of 18 (83 percent) patients experienced healing of their fistula. Continence was preserved in all patients. CONCLUSION: This procedure is easy to perform, healing is rapid, and it appears to be effective in curing fistula-in-ano while preserving both external and internal anal sphincters.     

Hydrogen peroxide-enhanced transanal ultrasound in the assessment of fistula-in-ano

Appropriate classification of the fistulous tracts in patients with fistula-in-ano may be of value for the planning of proper surgery. Conventional transanal ultrasound has limited value in the visualization of fistulous tracts and their internal openings. Hydrogen peroxide can be used as a contrast medium for ultrasound to improve visualization of fistulas. PURPOSE: This prospective study evaluates hydrogen peroxide-enhanced ultrasound in comparison with physical examination, standard ultrasound, and surgery in the assessment of fistula-in-ano. METHODS: Twenty-one consecutive patients (4 women; mean age, 42 years) with fistula-in-ano were evaluated by local physical examination (inspection, probing, and digital examination), conventional ultrasound, and hydrogen peroxide-enhanced ultrasound before surgery. Ultrasound was performed using a B&K Diagnostic Ultrasound System with a 7-MHz rotating endoprobe. Hydrogen peroxide (3%) was infusedvia a small catheter into the fistula. The results of physical examination, ultrasound, and hydrogen peroxide-enhanced ultrasound were compared with surgical data as the criterion standard. The additive value of standard ultrasound and hydrogen peroxide-enhanced ultrasound compared with physical examination was also determined. RESULTS: At surgery, 8 intersphincteric and 11 transsphincteric fistulas and 2 sinus tracts (without an internal opening) were found. During physical examination, probing was incomplete in 13 patients, the diagnosis being correct in the other 8 patients (38%) as a low (intersphincteric or transsphincteric) fistula. With conventional ultrasound, the assessment of fistula-in-ano was correct in 13 patients (62%); defects in one or both sphincters could also be found (n=8). With hydrogen peroxide-enhanced ultrasound, the fistulous tract was classified correctly in 20 patients, the overall concordance with surgery being 95%. The internal opening was found at physical examination in 15 patients (71%), with hydrogen peroxide-enhanced ultrasound in 10 patients (48%), and during surgery in 19 patients (90%). Secondary extensions, confirmed during surgery, were found in five cases. In two patients, a secondary extension with hydrogen peroxide-enhanced ultrasound was not confirmed during surgery. Both patients developed a recurrent fistula. CONCLUSION: Hydrogen peroxide-enhanced ultrasound is superior to physical examination and standard ultrasound in delineating the anatomic course of perianal fistulas. It makes accurate preoperative assessment of the fistula possible and may be of value for the surgeon in planning therapeutic strategy.Dr. Poen was supported by a grant from Janssen-Cilag B.V., The Netherlands.Presented in part at the United European Gastroenterology Week, Birmingham, United Kingdom, October 18 to 21, 1997.     

Oncological outcomes of surgery for recurrent biliary tract cancer: who are the best candidates?

BackgroundThis study aimed to investigate the impact of surgery on outcomes in patients with recurrent biliary tract cancer (BTC) and elucidate factors affecting survival after surgery for this disease.MethodsA single-center study was undertaken in 178 patients with recurrent BTC, of whom 24 underwent surgery for recurrence, 85 received chemotherapy, and 69 received best supportive care. Then, we carried out a multicenter study in 52 patients undergoing surgery for recurrent BTC (gallbladder cancer, 39%; distal cholangiocarcinoma, 27%; perihilar cholangiocarcinoma, 21%; intrahepatic cholangiocarcinoma, 13%).ResultsIn the single-center study, 3-year survival after recurrence was 53% in patients who underwent surgery, 4% in those who received chemotherapy, and 0% in those who received best supportive care (p < 0.001). Surgery was an independently prognostic factor (p < 0.001). In the multicenter series, the respective 3-year and 5-year survival after surgery for recurrence was 50% and 29% in the 52 patients. Initial site of recurrence was the only independent prognostic factor (p = 0.019). Five-year survival after surgery for recurrence in patients with single distant, multifocal distant, and locoregional recurrence was 51%, 0%, and 0%, respectively (p = 0.002). Sites of single distant recurrence included the liver (n = 13, 54%), distant lymph nodes (all from gallbladder cancer, n = 7, 29%), lung (n = 2, 9%), peritoneum (n = 1, 4%), and abdominal wall (n = 1, 4%).ConclusionSurgery may be an effective option for patients with less aggressive tumor biology characterized by single distant recurrence in recurrent BTC.     

Cutting seton without preliminary internal sphincterotomy in management of complex high fistula-in-ano

PURPOSE: The traditional treatment of a complex high fistula-in-ano by internal sphincterotomy and insertion of a cutting seton carries a risk of fecal incontinence. We have assessed the functional impact of treating patients with a complex fistula-in-ano by a cutting seton fistulotomy technique that preserves the internal sphincter. METHODS: The operative steps consisted of initial eradication of sepsis, identification of the internal and external openings of the fistula tract, excision of the fistula tract with anal canal mucosa, and insertion of a cutting silk seton around both the internal and external sphincters. In this way open drainage of the intersphincteric space was avoided, and integrity of the internal sphincter was maintained. Functional outcome following treatment with this technique, with regard to fistula eradication and effect on fecal continence was assessed in 27 patients (15 males) who were treated during a six-year period. Twenty-three patients (85 percent) had a history of previous fistula surgery. RESULTS: The fistula was cured in 26 patients (96 percent) with no reports of altered continence at the time of discharge from outpatient review. Recurrence developed in one patient (4 percent) in whom hidradenitis suppurativa was subsequently diagnosed. All four patients with Crohn's disease had their fistulas eradicated; three (75 percent) have subsequently undergone proctectomy for severe perianal and rectal Crohn's involvement. Long-term follow-up revealed three patients (19 percent, all rectovaginal fistulas) who experienced a deterioration in continence after discharge. CONCLUSIONS: Although this procedure may not be appropriate for rectovaginal fistulas, the data suggest that cutting setons are effective in treating complex fistula-in-ano, including those that have failed to respond to other forms of surgery. Avoidance of preliminary internal sphincterotomy may prevent deterioration in continence.Published in abstract form inGut 1992;33:156A and Int J Colorectal Dis 1992;7:232.     

Is anal endosonography useful in the study of recurrent complex fistula-in-ano?

INTRODUCTION: performing anal endosonography in complex fistula-in-ano allows us to design a personalized surgical strategy in each case, thereby improving results. However, there are doubts in the literature as to its utility in recurrent complex fistulas. The aim of this study was to compare the utility of anal ultrasonography in the study of primary versus recurrent complex fistula-in-ano. PATIENTS AND METHOD: prospective study of patients diagnosed and treated for complex fistula-in-ano. Physical examination and anal ultrasonography provided data on primary track, internal opening, horseshoe extension and the presence of secondary tracks or cavities in a protocol designed specifically for the study. These assessments were subsequently contrasted with operative findings. RESULTS: we included 35 patients, 19 (54.3%) with primary complex anal fistulas and 16 (45.7%) with recurrent fistulas. According to the operative findings, fistulas were classified as high transsphincteric in 28 patients (80%), suprasphincteric in 6 (17.1%) and extrasphincteric in one patient (2.9%), with no differences between groups. Physical examination correctly classified 28 of the 35 fistulous tracks, in contrast to the 32 (91.4%) correctly described on ultrasonography (80%). We did not find any statistically significant differences between the primary and the recurrent fistula groups with regard to sensibility, positive predictive value and accuracy of the anal ultrasonography for any of the parameters studied. CONCLUSION: the accuracy of anal ultrasonography does not decrease in recurrent complex fistula-in-ano.     

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.     

Die chirurgische Behandlung des anorektalen Abszesses

Treatment of anorectal suppuration includes timely and sufficient surgery. So later complications like fistula-in-ano can be ruled out. In this prospective study the data of 324 patients who had been operated because of an anorectal suppuration were examined. 38,6% of these abscesses were located in the perianal tissue, 34.6% in the intersphincter space, 19,4% in the ischiorectal fossa and 7,4% in the supralevator space. Only in 25,6% patients who were operated an anal fistula was proved. In ischiorectal abscesses we found fistula-in-ano within 47,6% of the patients, in most cases trans- and suprasphincteric fistulas. 62.1% of these patients did not need further interventions. Sixteen of 45 intraoperative diagnosed trans- and suprasphincteric fistulas did not need further operative interventions (35.6%). At 7.7% later diagnosed fistulas had to be treated operatively. 9.6% of the patients developed a new suppuration. The renunciation of an intensive primary fistula search doesnt lead to a higher persisting fistula formation. From this aspect a further exploration should be renounced in the first operation. Of course superficial fistulas can be cured in the same meeting. From this point a drainage cutting-seton should be viewed very critically. Postoperativ diagnosed high anal fistulas can be treated after fading of acute infection with continent fistulectomy.     

Results of treatment of fistula-in-ano

To evaluate the application of Parks' classification in the management of patients with fistula-in-ano, a study was undertaken to assess the outcome of surgery, especially with respect to the recurrence rate and alteration of continence. A retrospective analysis of 160 consecutive patients who were classified at the time of operation was conducted. The distribution of fistulas was as follows: intersphincteric, 41.9 percent, transsphincteric, 52.1 percent, suprasphincteric, 1.3 percent, extrasphincteric, 0. A horseshoe extension occurred in 8.8 percent of the fistulas and 3.8 percent did not exactly conform to the classification as they were either complex or combinations of more than one type of fistula. The sole immediate postoperative complication was bleeding, which occurred one week postoperatively and ceased spontaneously (0.7 percent). Alteration in continence occurred in 6 percent of patients with 2.6 percent experiencing temporary incontinence to flatus, 1.3 percent to liquid stool, and 0.7 percent to solid stool. Permanent loss of control for flatus occurred in one patient (0.7 percent) and for liquid stool in one patient (0.7 percent). No patients suffered loss of control for solid stool. Recurrence developed in 6.3 percent of patients, all between five and 25 months postoperatively. Classifcation was found to be a useful guide in the operative management of patients with fistula-in-ano. Read at the joint meeting of the American Society of Colon and Rectal Surgeons with the Section of Colo-Proctology, Royal Society of Medicine, and the Section of Colonic and Rectal Surgery, Royal Australasian College of Surgeons, New Orleans, Louisiana, May 6 to 11, 1984.     

Postresection recurrence of hepatocellular carcinoma treated by arterial embolization: analysis of prognostic factors.

Of 270 consecutive patients with hepatocellular carcinoma who underwent surgery, 50 who had recurrence and were subsequently treated with transcatheter arterial embolization were analyzed. The longest interval between surgery and recurrence in the 50 patients who underwent transcatheter arterial embolization was 7 yr. Recurrence was initially found in the remnant liver in all patients but one; extrahepatic metastases were detected in 13 patients (26%) during follow-up. A "multiple" type was the most common (64%) hepatic recurrence pattern on angiography, followed by the "solitary" (16%) and "tumor thrombus" (12%) patterns. Hepatic recurrence was most frequently found in the ipsilateral lobe (48%) relative to the site of the primary hepatocellular carcinoma. Multivariate analysis of the factors affecting survival after transcatheter arterial embolization indicated that recurrence pattern (p = 0.025) and distant metastases (p = 0.011) were significant. Of 13 patients with distant metastases, 11 had the "multiple" pattern of hepatic recurrence. Survival rates for all 50 patients after initial surgery and after transcatheter arterial embolization were 90% and 64%, respectively, at 1 yr; 52% and 24%, respectively, at 3 yr; and 27% and 5%, respectively, at 5 yr. On analysis of survival rates after transcatheter arterial embolization in 37 patients with recurrence only in the liver and of the response of recurrent hepatocellular carcinoma to transcatheter arterial embolization, a significant difference was noted between those with "partial response" and "progressive disease" (p less than 0.05) and between those with "no change" and "progressive disease" (p less than 0.05).     

Early outcomes of fluorescence angiography in the setting of endorectal mucosa advancement flaps

Background

Fistula-in-ano has a reported incidence of 31–34%. Besides fistulotomy, options for fistula repair are seton placement, endorectal advancement flap (ERAF), fibrin sealant, anal fistula plug and ligation of the intersphincteric fistula tract. Despite having a reported success rate as high as 75–98%, ERAF is not without complications, including flap breakdown, recurrence and fecal incontinence. Traditionally, maintaining a broad base to preserve blood supply has been advocated to reduce flap failure. And the aim of the present study was to evaluate outcomes of adult patients who underwent ERAF for complex fistula-in-ano with the use of intraoperative fluorescence angiography (FA) at our institution between July 2014 and July 2016.

Methods

We retrospectively reviewed consecutive cases of complex fistula-in-ano repair with ERAF and FA from a prospectively maintained dataset of adult patients with complex fistula-in-ano. Demographics, intraoperative data and 60-day outcomes were recorded and reviewed.

Results

Six patients [five males and one female with a mean age of 40 years (range 25–46 years)], with a total of seven fistulas, were identified. Six (85.7%) of these patients had undergone prior surgery for fistula-in-ano. No recurrences or complications of any type were noted at 2-week and 8-week follow-up. The majority of patients (71.4%) required flap revision based on intraoperative FA prior to flap fixation.

Conclusions

FA is safe and offers real-time assessment of flap perfusion prior to and after fixation in anal fistula repair. The rate of flap ischemia may be underestimated, and therefore, to improve outcomes in ERAF, intraoperative FA should be included in the surgical armamentarium.

     

Management of recurrent rectal cancer： A population based study in greater Amsterdam

AIM： To analyze, retrospectively in a populationbased study, the management and survival of patients with recurrent rectal cancer initially treated with a macroscopically radical resection obtained with total mesorectal excision （TME）.
METHODS： All rectal carcinomas diagnosed during 1998 to 2000 and initially treated with a macroscopically radical resection （632 patients） were selected from the Amsterdam Cancer Registry. For patients with recurrent disease, information on treatment of the recurrence was collected from the medical records.
RESULTS： Local recurrence with or without clinically apparent distant dissemination occurred in 62 patients （10%）. Thirty-two patients had an isolated local recurrence. Ten of these 32 patients （31%） underwent radical re-resection and experienced the highest survival （three quarters survived for at least 3 years）. Eight patients （25%） underwent non-radical surgery （median survival 24 rno）, seven patients （22%） were treated with radio- and/or chemotherapy without surgery （median survival 15 mo） and seven patients （22%） only received best supportive care （median survival 5 too）. Distant dissemination occurred in 124 patients （20%） of whom 30 patients also had a local recurrence. The majority （54%） of these patients were treated with radio- and/or chemotherapy without surgery （median survival 15 mo）. Twenty-seven percent of these patients only received best supportive care （median survival 6 mo）, while 16% underwent surgery for their recurrence. Survival was best in the latter group （median survival 32 mo）.
CONCLUSION： Although treatment options and survival are limited in case of recurrent rectal cancer after radical local resection obtained with TME, patients can benefit from additional treatment, especially if a radical resection is feasible.     

Experimental porcine model of complex fistula-in-ano

AIM To establish and evaluate an experimental porcine model of fistula-in-ano.METHODS Twelve healthy pigs were randomly divided into two groups. Under general anesthesia, the experimental group underwent rubber band ligation surgery, and the control group underwent an artificial damage technique. Clinical magnetic resonance imaging(MRI) and histopathological evaluation were performed on the 38 th d and 48 th d after surgery in both groups, respectively. RESULTS There were no significant differences between the experimental group and the control group in general characteristics such as body weight, gender, and the number of fistula(P 0.05). In the experimental group, 15 fistulas were confirmed clinically, 13 complex fistulas were confirmed by MRI, and 11 complex fistulas were confirmed by histopathology. The success rate in the porcine complex fistula model establishment was 83.33%. Among the 18 fistulas in the control group, 5 fistulas were confirmed clinically, 4 complex fistulas were confirmed by MRI, and 3 fistulas were confirmed by histopathology. The success rate in the porcine fistula model establishment was 27.78%. Thus, the success rate of the rubber band ligation group was significantly higher than the control group(P 0.05). CONCLUSION Rubber band ligation is a stable and reliable method to establish complex fistula-in-ano models. Large animal models of complex anal fistulas can be used for the diagnosis and treatment of anal fistulas.     

Surgical management of entero and colocutaneous fistulae in Crohn's disease: 17 year's experience

BACKGROUND AND AIMS: Fistulous disease is common in Crohn's disease, and entero- and colocutaneous fistulae are particularly debilitating and difficult to manage. We present the results of surgical management of these fistulas. PATIENTS AND METHODS: Retrospective chart review of all 51 patients with Crohn's disease (56 surgical procedures) undergoing surgery for cutaneous fistulae between 1983 and 2000. RESULTS: Previous surgery for Crohn's disease had been carried out in 43 patients (84%). The fistula site was enterocutaneous in 36 patients (64%), colocutaneous in 12 (21%), and anastomotic in 8 (14%); 9 patients (16%) also had associated enteroenteric fistulas. The onset of the fistula followed abscess drainage in 15 (27%) and occurred at the site of recurrent disease in 41 (73%). Forty patients (71%) initially underwent conservative management prior to surgery; 16 (28%) underwent surgery directly. Surgical procedures were: 25 ileocolic resections, 8 stoma revisions with resection, 8 small bowel resections 7 subtotal colectomies, 4 partial colectomies, 3 proctocolectomies, and one fistula tract excision. Mean total length of stay was 18 days (postoperative 10.7 days). Six (11%) patients had eight postoperative complications. Mean follow-up was 48.6 months (range 3-187). Recurrence as defined by either clinical examination or reoperation was documented in nine fistulas (16%), with a mean time to recurrence of 27 months. CONCLUSION: Entero-and colocutaneous fistulae usually occur from a site of active disease. Surgical management with bowel resection, including the fistula, is the preferred method of treatment. Morbidity has been low and recurrence rate lower than expected.     

Risk factors for intra-abdominal sepsis after surgery in Crohn's disease

PURPOSE: This study examined risk factors for intra-abdominal sepsis after surgery in Crohn's disease. METHODS: We reviewed 343 patients who underwent 1,008 intestinal anastomoses during 566 operations for primary or recurrent Crohn's disease between 1980 and 1997. Possible factors for intra-abdominal sepsis were analyzed by both univariate (chi-squared test) and multivariate (multiple regression) analyses. RESULTS: Intra-abdominal septic complications, defined as anastomotic leak, intra-abdominal abscess, or enterocutaneous fistula, developed after 76 operations (13 percent). Intra-abdominal septic complications were significantly associated with preoperative low albumin level (< 30 g/l; P = 0.04), preoperative steroids use (P = 0.03), abscess at the time of laparotomy (P = 0.03), and fistula at the time of laparotomy (P = 0.04). The intra-abdominal septic complication rate was 50 percent (8/16 operations) in patients with all of these four risk factors, 29 percent (10/35 operations) in patients with three risk factors, 14 percent (14/98 operations) in patients with two risk factors, 16 percent (33/209 operations) in patients with only one risk factor, and 5 percent (11/208 operations) in patients with none of these risk factors (P<0.0001). The following factors did not affect the incidence of septic complications; age, duration of symptoms, number of previous bowel resections, site of disease, type of operation (resection, strictureplasty, or bypass), covering stoma, and number, site, or method (sutured or stapled) of anastomoses. CONCLUSIONS: Preoperative low albumin level, steroid use, and the presence of abscess or fistula at the time of laparotomy significantly increased the risk of septic complications after surgery in Crohn's disease.