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,conven...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 twodecades,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%).Fi La C 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 adiposederived 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 sphincterpreserving techniques.展开更多
AIM:To evaluate the effectiveness of three-dimensional endoanal ultrasound (3D-EAUS) in the assessment of anal fistulae with and without H2O2 enhancement.METHODS: Sixty-one patients (37 males, aged 17-74 years) with a...AIM:To evaluate the effectiveness of three-dimensional endoanal ultrasound (3D-EAUS) in the assessment of anal fistulae with and without H2O2 enhancement.METHODS: Sixty-one patients (37 males, aged 17-74 years) with anal fi stulae, which were not simple low types, were evaluated by physical examination and 3D-EAUS with and without enhancement. Fistula classification was determined with each modality and compared to operative findings as the reference standard.RESULTS: The accuracy of 3D-EAUS was significantly higher than that of physical examination in detecting the primary tract (84.4% vs 68.7%, P=0.037) and secondary extension (81.8% vs 62.1%, P=0.01) and localizing the internal opening (84.2% vs 59.7%, P=0.004). A contrast study with H2O2 detected several more fistula components including two primary suprasphincteric fistula tracks and one supralevator secondary extension, which were not detected on non-contrast study. However, there was no significant difference in accuracy between 3D-EAUS and H2O2-enhanced 3D-EAUS with respect to classification of the primary tract (84.4% vs 89.1%, P=0.435) or secondary extension (81.8% vs 86.4%, P=0.435) or localization of the internal opening (84.2% vs 89.5%, P=0.406).CONCLUSION: 3D-EAUS was highly reliable in the diagnosis of an anal fistula. H2O2 enhancement was helpful at times and selective use in diffi cult cases may be economical and reliable.展开更多
Anal fistula is among the most common illnesses affecting man.Medical literature dating back to 400 BC has discussed this problem.Various causative factors have been proposed throughout the centuries,but it appears th...Anal fistula is among the most common illnesses affecting man.Medical literature dating back to 400 BC has discussed this problem.Various causative factors have been proposed throughout the centuries,but it appears that the majority of fistulas unrelated to specific causes (e.g.Tuberculosis,Crohn’s disease) result from infection (abscess) in anal glands extending from the intersphincteric plane to various anorectal spaces.The tubular structure of an anal fistula easily yields itself to division or unroofing (fistulotomy) or excision (fistulectomy) in most cases.The problem with this single,yet effective,treatment plan is that depending on the thickness of sphincter muscle the fistula transgresses,the patient will have varying degrees of fecal incontinence from minor to total.In an attempt to preserve continence,various procedures have been proposed to deal with the fistulas.These include: (1) simple drainage (Seton);(2) closure of fistula tract using fibrin sealant or anal fistula plug;(3) closure of primary opening using endorectal or dermal flaps,and more recently;and (4) ligation of intersphincteric fistula tract (LIFT).In most complex cases (i.e.Crohn’s disease),a proximal fecal diversion offers a measure of symptom-atic relief.The fact remains that an "ideal" procedure for anal fistula remains elusive.The failure of each sphincter-preserving procedure (30%-50% recurrence) often results in multiple operations.In essence,the price of preservation of continence at all cost is multiple and often different operations,prolonged disability and disappointment for the patient and the surgeon.Nevertheless,the surgeon treating anal fistulas on an occasional basis should never hesitate in referring the patient to a specialist.Conversely,an expert colorectal surgeon must be familiar with many different operations in order to selectively tailor an operation to the individual patient.展开更多
Anal fistula surgery is a commonly performed procedure.The diverse anatomy of anal fistulae and their proximity to anal sphincters make accurate preoperative diagnosis essential to avoid recurrence and fecal incontine...Anal fistula surgery is a commonly performed procedure.The diverse anatomy of anal fistulae and their proximity to anal sphincters make accurate preoperative diagnosis essential to avoid recurrence and fecal incontinence.Despite the fact that proper preoperative diagnosis can be reached in the majority of patients by simple clinical examination,endoanal ultrasound or magnetic resonance imaging,on many occasions,unexpected findings can be encountered during surgery that can make the operation difficult and correct decision-making crucial.In this article we discuss the difficulties and unexpected findings that can be encountered during anal fistula surgery and how to overcome them.展开更多
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) entail...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.展开更多
BACKGROUND Anal fistula is a pathological connection between the anal canal and perianal skin, which most commonly develops from an infected anal crypt. While the majority of anal fistulas are idiopathic, they are als...BACKGROUND Anal fistula is a pathological connection between the anal canal and perianal skin, which most commonly develops from an infected anal crypt. While the majority of anal fistulas are idiopathic, they are also associated with Crohn’s disease (CD) and other inflammatory conditions. The prevalence of anal fistula is estimated to be 1-2 per 10000 patients, but population-based studies on anal fistula epidemiology are limited and outdated. AIM To assess the prevalence of anal fistula and relevant comorbidities, with and without CD in the United Kingdom and Europe. METHODS A retrospective population-representative observational cohort study was performed in The Health Improvement Network (THIN), a United Kingdom primary care database. Mid-year point prevalence of anal fistula was calculated on the first of July for each year between 2014 and 2017. Estimates were calculated for anal fistula overall and by CD status and standardized to the United Kingdom and European population. Prevalence of relevant comorbidities including lymphogranuloma venereum, hidradenitis suppurativa, anal presentation of sexually transmitted diseases, diabetes mellitus, and radiation in the pelvic area was reported. RESULTS The United Kingdom-standardized overall point prevalence of anal fistula was 1.80 (95%CI: 1.65-1.94) per 10000 patients in 2017, while the Europe standardized estimate was 1.83 (95%CI: 1.68-1.98) per 10000 patients. Both these standardized point prevalence estimates ranged from 1.89 to 2.36 between 2014-2016. The United Kingdom-standardized point prevalence of anal fistula without CD was 1.35 (95%CI: 1.23-1.48) per 10000 patients, while the Europe-standardized estimate was 1.39 (95%CI: 1.26-1.52) per 10000 patients. In contrast, the standardized point prevalence estimate of anal fistula with CD was lower for both United Kingdom and Europe (0.44;95%CI United Kingdom: 0.37-0.52, 95%CI Europe: 0.37-0.51) per 10000 patients in 2017. In 2017, 19% of anal fistula patients without CD and 13% of anal fistula patients with CD had at least one relevant comorbidity. These results show that anal fistulas are infrequent in the general population. 24.5% of prevalent anal fistulas are associated with CD, but other potentially etiological comorbidities are rare. CONCLUSION This real-world evidence study estimated the United Kingdom-standardized prevalence of anal fistula was 1.80 per 10000 patients in 2017. Approximately 25% of cases may be associated with CD, while other comorbidities are rare.展开更多
AIM:To evaluate the efficacy and safety of traditional Chinese surgical treatment for anal fistulae with secondary tracks and abscess.METHODS:Sixty patients with intersphincteric or transsphincteric anal fistulas with...AIM:To evaluate the efficacy and safety of traditional Chinese surgical treatment for anal fistulae with secondary tracks and abscess.METHODS:Sixty patients with intersphincteric or transsphincteric anal fistulas with secondary tracks and abscess were randomly divided into study group [suture dragging combined with pad compression(SDPC)] and control group [fistulotomy(FSLT)].In the SDPC group,the internal opening was excised and incisions at external openings were made for drainage.Silk sutures were put through every two incisions and knotted in loose state.The suture dragging process started from the first day after surgery and the pad compression process started when all sutures were removed as wound tissue became fresh and without discharge.In the FSLT group,the internal opening and all tracts were laid open and cleaned by normal saline postoperatively till all wounds healed.The time of healing,postoperative pain score(visual analogue scale),recurrence rate,patient satisfaction,incontinence evaluation and anorectal manometry before and after the treatment were examined.RESULTS:There were no significant differences between the two groups regarding age,gender and fistulae type.The time of healing was significantly shorter(24.33 d in SDPC vs 31.57 d in FSLT,P < 0.01) and the patient satisfaction score at 1 mo postoperative followup was significantly higher in the SDPC group(4.07 in SDPC vs 3.37 in FSLT,P < 0.05).The mean maximal postoperative pain scores were 5.83 ± 2.5 in SDPC vs 6.37 ± 2.33 in FSLT and the recurrence rates were 3.33 in SDPC vs 0 in FSLT.None of the patients in the two groups experienced liquid and solid fecal incontinence and lifestyle alteration postoperatively.The Wexner score after treatment of intersphincter fistulae were 0.17 ± 0.41 in SDPC vs 0.40 ± 0.89 in FSLT and transsphincter fistulae were 0.13 ± 0.45 in SDPC vs 0.56 ± 1.35 in FSLT.The maximal squeeze pressure and resting pressure declined after treatment in both groups.The maximal anal squeeze pressures after treatment were reduced(23.17 ± 3.73 Kpa in SDPC vs 22.74 ± 4.47 Kpa in FSLT) and so did the resting pressures(12.36 ± 2.15 Kpa in SDPC vs 11.71 ± 1.87 Kpa in FSLT),but there were neither significant differences between the two groups and nor significant differences before or after treatment.CONCLUSION:Traditional Chinese surgical treatment SDPC for anal fistulae with secondary tracks and abscess is safe,effective and less invasive.展开更多
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 ...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.展开更多
AIM: To evaluate the safety of the implantation of a new device for the treatment of anal fistulas. The short-term clinical efficacy was also assessed. METHODS: This study took place at a tertiary care university hosp...AIM: To evaluate the safety of the implantation of a new device for the treatment of anal fistulas. The short-term clinical efficacy was also assessed. METHODS: This study took place at a tertiary care university hospital. Patients with a complex anal fistula of cryptoglandular origin were enrolled in the study and were treated with insertion of the new device. All patients were evaluated by clinical and physical examination, including an endoanal ultrasound at the baseline, and then at the 2 wk and 1, 2, 3 and 6-mo follow-up visits. RESULTS: Morbidity, continence status, and success rate were the main outcome measures. Ten patients underwent the placement of the new device. The fistulas were transphincteric in eight patients and extrasphincteric in the remaining two. The median duration of the surgical procedure was 34.5(range, 27-42) min. Neither intra- nor postoperative complications occurred, and all patients were discharged the day after the procedure. At the 6-mo follow-up evaluation, the final success rate was 70%. Three failures were registered: a device expulsion(on the 10 th postoperative day), the persistence of inflammatory tissue around the fistula tract(at the 2-mo follow up), and the persistence of serum discharge(at the 6-mo follow up). No patient experienced any change incontinence, as assessed by the Cleveland Clinic Fecal Incontinence score. CONCLUSION: The technical procedure is simple and has low risk of perioperative morbidity. The pre- and post-operative continence status did not change in any of the patients. The initial results at the 6-mo follow up seem to be promising. However, a longer follow-up period and a larger sample size are needed to confirm these preliminary results.展开更多
BACKGROUND Perianal fistulae are either primary(idiopathic)or secondary[commonly associated with Crohn’s disease,(CD)].It is assumed,although not proven,that the pathophysiology differs.AIM To systematically compare ...BACKGROUND Perianal fistulae are either primary(idiopathic)or secondary[commonly associated with Crohn’s disease,(CD)].It is assumed,although not proven,that the pathophysiology differs.AIM To systematically compare the clinical phenotypes,cytokine and phosphoprotein profiles of idiopathic and CD-related perianal fistulae.METHODS Sixty-one patients undergoing surgery for perianal fistula were prospectively recruited(48 idiopathic,13 CD)into a cohort study.Clinical data,including the Perineal Disease Activity Index(PDAI)and EQ-5D-5L were collected.Biopsies of the fistula tract,granulation tissue,internal opening mucosa and rectal mucosa were obtained at surgery.Concentrations of 30 cytokines and 39 phosphoproteins were measured in each biopsy using a magnetic bead multiplexing instrument and a chemiluminescent antibody array respectively.Over 12000 clinical and 23500 laboratory measurements were made.RESULTS The PDAI was significantly higher(indicating more active disease)in the CD group with a mean difference of 2.40(95%CI:0.52-4.28,P=0.01).Complex pathoanatomy was more prevalent in the CD group,namely more multiple fistulae,supralevator extensions,collections and rectal thickening.The IL-12p70 concentration at the internal opening specimen site was significantly higher(median difference 19.7 pg/mL,99%CI:0.2-40.4,P=0.008)and the IL-1RA/IL-1βratio was significantly lower in the CD group at the internal opening specimen site(median difference 15.0,99%CI=0.4-50.5,P=0.008).However in the remaining 27 cytokines and all 39 of the phosphoproteins across the four biopsy sites,no significant differences were found between the groups.CONCLUSION CD-related perianal fistulae are more clinically severe and anatomically complex than idiopathic perianal fistulae.However,overall there are no major differences in cytokine and phosphoprotein profiles.展开更多
Objective: To explore the clinical diagnostic value of transperineal volume ultrasound combined with two-dimensional high-frequency ultrasound for anal fistula. Methods: A total of 52 patients with anal fistula admitt...Objective: To explore the clinical diagnostic value of transperineal volume ultrasound combined with two-dimensional high-frequency ultrasound for anal fistula. Methods: A total of 52 patients with anal fistula admitted to the Affiliated Hospital of Shaanxi University of Traditional Chinese Medicine from December 2017 to July 2018 were selected. They were all undergoing transperineal 3D volume ultrasound combined with 2D high-frequency ultrasound examination, and the diagnosis results were analyzed. The results of ultrasonography and surgical pathology were compared. Results: Among 52 patients, 3D volume ultrasound combined with 2D high-frequency ultrasound were used to diagnose 32 cases of anal fistula intersphincteric type, 14 cases of transsphincter type, 5 cases of supra-sphincter type, and 1 case of extra-sphincter type. T supervisor classification accuracy rate is 90%. The detection rate of branch pipes was 92%, and the compliance rate of internal fistula was 95%. Two-dimensional high-frequency ultrasound was used to diagnose 34 cases of anal fistula intersphincteric type, 14 cases of transsphincter type, 4 cases of supra-sphincter type, and 0 cases of extra-sphincter type. The detection rate of branch canals was 42%, and the accuracy of type classification was 90%. The coincidence rate was 95%. There was a statistically significant difference in the detection rate of the anal fistula branch and the coincidence rate of the internal fistula between the two methods (both P Conclusion: 1) The overall coincidence rate of three-dimensional volumetric ultrasound combined with two-dimensional high-frequency ultrasound in the diagnosis of anal fistula is high;2) Three-dimensional volumetric ultrasound technology has great application prospects in infants and anal fistulas.展开更多
Anal fistula is a common disease in anorectal department that typically describes a miscommunication between the anorectum and the perianal skin. At present, surgical treatment is effective for anal fistulae, but the ...Anal fistula is a common disease in anorectal department that typically describes a miscommunication between the anorectum and the perianal skin. At present, surgical treatment is effective for anal fistulae, but the formation of fistula is different due to individual difference, consequently leading to a limited efficacy of surgical treatment. TCM has recently shown its unique advantages in accelerating the wound healing after anal fistula surgery, but the standards for syndrome differentiation of anal fistulae are still in deficiency. Thereby, this article mainly explored the key points of common syndromes, TCM nursing methods and health guidance of anal fistulae, in order to further develop the advantages of TCM and standardize related nursing management .展开更多
Purpose: This study aimed to report clinical data and recurrence rates in patients with anterolateral low fistulas who underwent open fistulectomy with sphincter fixation. Methods: The study group consisted of 133 con...Purpose: This study aimed to report clinical data and recurrence rates in patients with anterolateral low fistulas who underwent open fistulectomy with sphincter fixation. Methods: The study group consisted of 133 consecutive patients with anterolateral, low intersphincteric, or low trans-sphincteric fistulas who had undergone open fistulectomy with sphincter fixation between January 2006 and December 2010. This procedure involves complete removal of the fistula tract by incision of anal sphincters, followed by fixation of the sphincter muscles. Results: Success was achieved in 127 (95.5%) patients with a median follow-up time of 12 months. Anal fistula recurred in 4 cases (3%). Non-healing fistula with persistent anal discharge developed in 2 patients. Maximal resting pressure, but not maximal squeeze pressure, was significantly decreased after surgery. Five patients (4%) developed temporary anal incontinence after surgery. Conclusions: Open fistulectomy with sphincter fixation was effective for the management of patients with anterolateral low fistula in this study. The high success rate suggests that this procedure is a reasonable option in this group of patients.展开更多
Anal fistula is one of the three greatest anorectal diseases with a high prevalence.The traditional treatments(e.g.,surgery) for fistula have limitations due to damage to the internal anal sphincter of patients.With r...Anal fistula is one of the three greatest anorectal diseases with a high prevalence.The traditional treatments(e.g.,surgery) for fistula have limitations due to damage to the internal anal sphincter of patients.With recent advances in biomaterials,treatments based on biomaterial filling (e.g.,scleraprotein injection,fistula plug) have emerged as novel therapies for fistula.The anal fistula plug(e.g.,based on small intestinal submucosa(SIS)) has attracted increasing attention because of short term healing rate and biocompatibility.However,challenges remain for this method such as plug falling as observed in clinics.To address this,this paper analyzes the case of SIS falling under physiological condition from mechanical point of view using ANSYS simulation.It then proposes three new geometrical structures for fistula plug and compares their mechanical behavior(e.g.,axial stress,reaction of constraint) with that of clinically used structure(cone shape).Based on the simulation,it optimizes the geometric parameters of fistula plug.The approach developed here can help to improve the design of fistula plug for better clinical treatments.展开更多
文摘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 twodecades,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%).Fi La C 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 adiposederived 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 sphincterpreserving techniques.
文摘AIM:To evaluate the effectiveness of three-dimensional endoanal ultrasound (3D-EAUS) in the assessment of anal fistulae with and without H2O2 enhancement.METHODS: Sixty-one patients (37 males, aged 17-74 years) with anal fi stulae, which were not simple low types, were evaluated by physical examination and 3D-EAUS with and without enhancement. Fistula classification was determined with each modality and compared to operative findings as the reference standard.RESULTS: The accuracy of 3D-EAUS was significantly higher than that of physical examination in detecting the primary tract (84.4% vs 68.7%, P=0.037) and secondary extension (81.8% vs 62.1%, P=0.01) and localizing the internal opening (84.2% vs 59.7%, P=0.004). A contrast study with H2O2 detected several more fistula components including two primary suprasphincteric fistula tracks and one supralevator secondary extension, which were not detected on non-contrast study. However, there was no significant difference in accuracy between 3D-EAUS and H2O2-enhanced 3D-EAUS with respect to classification of the primary tract (84.4% vs 89.1%, P=0.435) or secondary extension (81.8% vs 86.4%, P=0.435) or localization of the internal opening (84.2% vs 89.5%, P=0.406).CONCLUSION: 3D-EAUS was highly reliable in the diagnosis of an anal fistula. H2O2 enhancement was helpful at times and selective use in diffi cult cases may be economical and reliable.
文摘Anal fistula is among the most common illnesses affecting man.Medical literature dating back to 400 BC has discussed this problem.Various causative factors have been proposed throughout the centuries,but it appears that the majority of fistulas unrelated to specific causes (e.g.Tuberculosis,Crohn’s disease) result from infection (abscess) in anal glands extending from the intersphincteric plane to various anorectal spaces.The tubular structure of an anal fistula easily yields itself to division or unroofing (fistulotomy) or excision (fistulectomy) in most cases.The problem with this single,yet effective,treatment plan is that depending on the thickness of sphincter muscle the fistula transgresses,the patient will have varying degrees of fecal incontinence from minor to total.In an attempt to preserve continence,various procedures have been proposed to deal with the fistulas.These include: (1) simple drainage (Seton);(2) closure of fistula tract using fibrin sealant or anal fistula plug;(3) closure of primary opening using endorectal or dermal flaps,and more recently;and (4) ligation of intersphincteric fistula tract (LIFT).In most complex cases (i.e.Crohn’s disease),a proximal fecal diversion offers a measure of symptom-atic relief.The fact remains that an "ideal" procedure for anal fistula remains elusive.The failure of each sphincter-preserving procedure (30%-50% recurrence) often results in multiple operations.In essence,the price of preservation of continence at all cost is multiple and often different operations,prolonged disability and disappointment for the patient and the surgeon.Nevertheless,the surgeon treating anal fistulas on an occasional basis should never hesitate in referring the patient to a specialist.Conversely,an expert colorectal surgeon must be familiar with many different operations in order to selectively tailor an operation to the individual patient.
文摘Anal fistula surgery is a commonly performed procedure.The diverse anatomy of anal fistulae and their proximity to anal sphincters make accurate preoperative diagnosis essential to avoid recurrence and fecal incontinence.Despite the fact that proper preoperative diagnosis can be reached in the majority of patients by simple clinical examination,endoanal ultrasound or magnetic resonance imaging,on many occasions,unexpected findings can be encountered during surgery that can make the operation difficult and correct decision-making crucial.In this article we discuss the difficulties and unexpected findings that can be encountered during anal fistula surgery and how to overcome them.
文摘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.
基金funded by Takeda Pharmaceuticals International Inc.
文摘BACKGROUND Anal fistula is a pathological connection between the anal canal and perianal skin, which most commonly develops from an infected anal crypt. While the majority of anal fistulas are idiopathic, they are also associated with Crohn’s disease (CD) and other inflammatory conditions. The prevalence of anal fistula is estimated to be 1-2 per 10000 patients, but population-based studies on anal fistula epidemiology are limited and outdated. AIM To assess the prevalence of anal fistula and relevant comorbidities, with and without CD in the United Kingdom and Europe. METHODS A retrospective population-representative observational cohort study was performed in The Health Improvement Network (THIN), a United Kingdom primary care database. Mid-year point prevalence of anal fistula was calculated on the first of July for each year between 2014 and 2017. Estimates were calculated for anal fistula overall and by CD status and standardized to the United Kingdom and European population. Prevalence of relevant comorbidities including lymphogranuloma venereum, hidradenitis suppurativa, anal presentation of sexually transmitted diseases, diabetes mellitus, and radiation in the pelvic area was reported. RESULTS The United Kingdom-standardized overall point prevalence of anal fistula was 1.80 (95%CI: 1.65-1.94) per 10000 patients in 2017, while the Europe standardized estimate was 1.83 (95%CI: 1.68-1.98) per 10000 patients. Both these standardized point prevalence estimates ranged from 1.89 to 2.36 between 2014-2016. The United Kingdom-standardized point prevalence of anal fistula without CD was 1.35 (95%CI: 1.23-1.48) per 10000 patients, while the Europe-standardized estimate was 1.39 (95%CI: 1.26-1.52) per 10000 patients. In contrast, the standardized point prevalence estimate of anal fistula with CD was lower for both United Kingdom and Europe (0.44;95%CI United Kingdom: 0.37-0.52, 95%CI Europe: 0.37-0.51) per 10000 patients in 2017. In 2017, 19% of anal fistula patients without CD and 13% of anal fistula patients with CD had at least one relevant comorbidity. These results show that anal fistulas are infrequent in the general population. 24.5% of prevalent anal fistulas are associated with CD, but other potentially etiological comorbidities are rare. CONCLUSION This real-world evidence study estimated the United Kingdom-standardized prevalence of anal fistula was 1.80 per 10000 patients in 2017. Approximately 25% of cases may be associated with CD, while other comorbidities are rare.
基金Supported by Grants from Chinese Ministry of Education,No. 210077 and No.20093107110005Shanghai Municipal Education Commission,No.10ZZ77Shanghai Science and Technology Commission,No.10QA1406600
文摘AIM:To evaluate the efficacy and safety of traditional Chinese surgical treatment for anal fistulae with secondary tracks and abscess.METHODS:Sixty patients with intersphincteric or transsphincteric anal fistulas with secondary tracks and abscess were randomly divided into study group [suture dragging combined with pad compression(SDPC)] and control group [fistulotomy(FSLT)].In the SDPC group,the internal opening was excised and incisions at external openings were made for drainage.Silk sutures were put through every two incisions and knotted in loose state.The suture dragging process started from the first day after surgery and the pad compression process started when all sutures were removed as wound tissue became fresh and without discharge.In the FSLT group,the internal opening and all tracts were laid open and cleaned by normal saline postoperatively till all wounds healed.The time of healing,postoperative pain score(visual analogue scale),recurrence rate,patient satisfaction,incontinence evaluation and anorectal manometry before and after the treatment were examined.RESULTS:There were no significant differences between the two groups regarding age,gender and fistulae type.The time of healing was significantly shorter(24.33 d in SDPC vs 31.57 d in FSLT,P < 0.01) and the patient satisfaction score at 1 mo postoperative followup was significantly higher in the SDPC group(4.07 in SDPC vs 3.37 in FSLT,P < 0.05).The mean maximal postoperative pain scores were 5.83 ± 2.5 in SDPC vs 6.37 ± 2.33 in FSLT and the recurrence rates were 3.33 in SDPC vs 0 in FSLT.None of the patients in the two groups experienced liquid and solid fecal incontinence and lifestyle alteration postoperatively.The Wexner score after treatment of intersphincter fistulae were 0.17 ± 0.41 in SDPC vs 0.40 ± 0.89 in FSLT and transsphincter fistulae were 0.13 ± 0.45 in SDPC vs 0.56 ± 1.35 in FSLT.The maximal squeeze pressure and resting pressure declined after treatment in both groups.The maximal anal squeeze pressures after treatment were reduced(23.17 ± 3.73 Kpa in SDPC vs 22.74 ± 4.47 Kpa in FSLT) and so did the resting pressures(12.36 ± 2.15 Kpa in SDPC vs 11.71 ± 1.87 Kpa in FSLT),but there were neither significant differences between the two groups and nor significant differences before or after treatment.CONCLUSION:Traditional Chinese surgical treatment SDPC for anal fistulae with secondary tracks and abscess is safe,effective and less invasive.
文摘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.
文摘AIM: To evaluate the safety of the implantation of a new device for the treatment of anal fistulas. The short-term clinical efficacy was also assessed. METHODS: This study took place at a tertiary care university hospital. Patients with a complex anal fistula of cryptoglandular origin were enrolled in the study and were treated with insertion of the new device. All patients were evaluated by clinical and physical examination, including an endoanal ultrasound at the baseline, and then at the 2 wk and 1, 2, 3 and 6-mo follow-up visits. RESULTS: Morbidity, continence status, and success rate were the main outcome measures. Ten patients underwent the placement of the new device. The fistulas were transphincteric in eight patients and extrasphincteric in the remaining two. The median duration of the surgical procedure was 34.5(range, 27-42) min. Neither intra- nor postoperative complications occurred, and all patients were discharged the day after the procedure. At the 6-mo follow-up evaluation, the final success rate was 70%. Three failures were registered: a device expulsion(on the 10 th postoperative day), the persistence of inflammatory tissue around the fistula tract(at the 2-mo follow up), and the persistence of serum discharge(at the 6-mo follow up). No patient experienced any change incontinence, as assessed by the Cleveland Clinic Fecal Incontinence score. CONCLUSION: The technical procedure is simple and has low risk of perioperative morbidity. The pre- and post-operative continence status did not change in any of the patients. The initial results at the 6-mo follow up seem to be promising. However, a longer follow-up period and a larger sample size are needed to confirm these preliminary results.
基金Supported by Bowel and Cancer Research charity,No.MMBG1J3R
文摘BACKGROUND Perianal fistulae are either primary(idiopathic)or secondary[commonly associated with Crohn’s disease,(CD)].It is assumed,although not proven,that the pathophysiology differs.AIM To systematically compare the clinical phenotypes,cytokine and phosphoprotein profiles of idiopathic and CD-related perianal fistulae.METHODS Sixty-one patients undergoing surgery for perianal fistula were prospectively recruited(48 idiopathic,13 CD)into a cohort study.Clinical data,including the Perineal Disease Activity Index(PDAI)and EQ-5D-5L were collected.Biopsies of the fistula tract,granulation tissue,internal opening mucosa and rectal mucosa were obtained at surgery.Concentrations of 30 cytokines and 39 phosphoproteins were measured in each biopsy using a magnetic bead multiplexing instrument and a chemiluminescent antibody array respectively.Over 12000 clinical and 23500 laboratory measurements were made.RESULTS The PDAI was significantly higher(indicating more active disease)in the CD group with a mean difference of 2.40(95%CI:0.52-4.28,P=0.01).Complex pathoanatomy was more prevalent in the CD group,namely more multiple fistulae,supralevator extensions,collections and rectal thickening.The IL-12p70 concentration at the internal opening specimen site was significantly higher(median difference 19.7 pg/mL,99%CI:0.2-40.4,P=0.008)and the IL-1RA/IL-1βratio was significantly lower in the CD group at the internal opening specimen site(median difference 15.0,99%CI=0.4-50.5,P=0.008).However in the remaining 27 cytokines and all 39 of the phosphoproteins across the four biopsy sites,no significant differences were found between the groups.CONCLUSION CD-related perianal fistulae are more clinically severe and anatomically complex than idiopathic perianal fistulae.However,overall there are no major differences in cytokine and phosphoprotein profiles.
文摘Objective: To explore the clinical diagnostic value of transperineal volume ultrasound combined with two-dimensional high-frequency ultrasound for anal fistula. Methods: A total of 52 patients with anal fistula admitted to the Affiliated Hospital of Shaanxi University of Traditional Chinese Medicine from December 2017 to July 2018 were selected. They were all undergoing transperineal 3D volume ultrasound combined with 2D high-frequency ultrasound examination, and the diagnosis results were analyzed. The results of ultrasonography and surgical pathology were compared. Results: Among 52 patients, 3D volume ultrasound combined with 2D high-frequency ultrasound were used to diagnose 32 cases of anal fistula intersphincteric type, 14 cases of transsphincter type, 5 cases of supra-sphincter type, and 1 case of extra-sphincter type. T supervisor classification accuracy rate is 90%. The detection rate of branch pipes was 92%, and the compliance rate of internal fistula was 95%. Two-dimensional high-frequency ultrasound was used to diagnose 34 cases of anal fistula intersphincteric type, 14 cases of transsphincter type, 4 cases of supra-sphincter type, and 0 cases of extra-sphincter type. The detection rate of branch canals was 42%, and the accuracy of type classification was 90%. The coincidence rate was 95%. There was a statistically significant difference in the detection rate of the anal fistula branch and the coincidence rate of the internal fistula between the two methods (both P Conclusion: 1) The overall coincidence rate of three-dimensional volumetric ultrasound combined with two-dimensional high-frequency ultrasound in the diagnosis of anal fistula is high;2) Three-dimensional volumetric ultrasound technology has great application prospects in infants and anal fistulas.
文摘Anal fistula is a common disease in anorectal department that typically describes a miscommunication between the anorectum and the perianal skin. At present, surgical treatment is effective for anal fistulae, but the formation of fistula is different due to individual difference, consequently leading to a limited efficacy of surgical treatment. TCM has recently shown its unique advantages in accelerating the wound healing after anal fistula surgery, but the standards for syndrome differentiation of anal fistulae are still in deficiency. Thereby, this article mainly explored the key points of common syndromes, TCM nursing methods and health guidance of anal fistulae, in order to further develop the advantages of TCM and standardize related nursing management .
文摘Purpose: This study aimed to report clinical data and recurrence rates in patients with anterolateral low fistulas who underwent open fistulectomy with sphincter fixation. Methods: The study group consisted of 133 consecutive patients with anterolateral, low intersphincteric, or low trans-sphincteric fistulas who had undergone open fistulectomy with sphincter fixation between January 2006 and December 2010. This procedure involves complete removal of the fistula tract by incision of anal sphincters, followed by fixation of the sphincter muscles. Results: Success was achieved in 127 (95.5%) patients with a median follow-up time of 12 months. Anal fistula recurred in 4 cases (3%). Non-healing fistula with persistent anal discharge developed in 2 patients. Maximal resting pressure, but not maximal squeeze pressure, was significantly decreased after surgery. Five patients (4%) developed temporary anal incontinence after surgery. Conclusions: Open fistulectomy with sphincter fixation was effective for the management of patients with anterolateral low fistula in this study. The high success rate suggests that this procedure is a reasonable option in this group of patients.
基金supported by the Major International (Regional) Joint Research Program of China (11120101002)the National Natural Science Foundation of China(10825210 and 31050110125)the National 111 Project of China(B06024)
文摘Anal fistula is one of the three greatest anorectal diseases with a high prevalence.The traditional treatments(e.g.,surgery) for fistula have limitations due to damage to the internal anal sphincter of patients.With recent advances in biomaterials,treatments based on biomaterial filling (e.g.,scleraprotein injection,fistula plug) have emerged as novel therapies for fistula.The anal fistula plug(e.g.,based on small intestinal submucosa(SIS)) has attracted increasing attention because of short term healing rate and biocompatibility.However,challenges remain for this method such as plug falling as observed in clinics.To address this,this paper analyzes the case of SIS falling under physiological condition from mechanical point of view using ANSYS simulation.It then proposes three new geometrical structures for fistula plug and compares their mechanical behavior(e.g.,axial stress,reaction of constraint) with that of clinically used structure(cone shape).Based on the simulation,it optimizes the geometric parameters of fistula plug.The approach developed here can help to improve the design of fistula plug for better clinical treatments.
