Management  of Complex Fistula in Ana with Fistulotomy and Stage Procedure

Background: Complex fistula in ano is a troublesome disease and is difficult to treat. Complex fistula in ano occurs in various forms like multiple external and/or internal openings, internal opening above the dentate line, external opening far away from anal verge, anterior tract etc. They are almost invariably recurrent and frequently associated with other systemic diseases like tuberculosis, inflammatory bowel disease, malignancy etc.A complex fistula in ano has various modalities of treatments like application of setons, fistulotomy or fistulectomy, endorectal advancement flap, anocutaneous advancement flap, fistula plug, fibrin glue, electrocauterization of tract/laser and ligation of intersphincteric fistula tract (LIFT). Objective: The purpose of the study is to evaluate the outcome of complex fistula in ano by fistulotomy and staged procedure. Methods: The study was held in Dhaka medical college Hospital and various private hospitals located in Dhaka and Brahmonbaria within duration of 8 years (from January, 2011 to January, 2018). Among 256 patients (221 male, 35 female) with median age 48 years (30 to 72 years) with the diagnosis of complex fistula in ano, 135 underwent fistulotomy with application of Seton with stage procedure. 121 patients underwent single stage fistulotomy. 158 patients had history of previous operations. After stage procedure, regular follow up was done every week until wound healing occurred. Result: Among 256 patients 121 patients (47%) underwent single stage, 133 (52%) patients underwent two stage and 2 patients underwent three stage procedure during the trial period. Majority of the patients had minor incontinence; that is flatus and/or loose stool incontinence. But they only persisted for an average of 10 to 16 days and subsided spontaneously. None of the patient had any major (solid stool) incontinence. 4 patients (2%) had recurrence of fistula on an average of 3-6 months after complete healing. Recurrence occurred in the form of abscess, automatically burst internally, recurrent fistula.2 patients developed bleeding after single stage procedure and was managed by cauterization. Conclusion: With adequate postoperative care and regular follow up, application of Seton with ‘staged procedure’ in cases of complex fistula in ano is very effective and has very minimal complications. Chance of major incontinence and recurrence is also less. J Dhaka Medical College, Vol. 27, No.1, April, 2018, Page 83-87

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A novel modification of the Endorectal Advancement Flap for complex anal fistulas: surgical technique and outcomes

10.21203/rs.3.rs-43719/v1 ◽

2020 ◽

Author(s):

Hassan Al-Turaihi ◽

Blears Elizabeth ◽

Sugumar Kavin ◽

Deshmukh Maya ◽

Deshmukh Ganesh

Keyword(s):

Fecal Incontinence ◽

Advancement Flap ◽

Absorbable Suture ◽

Internal Opening ◽

Anal Fistulas ◽

Fistula In Ano ◽

Endorectal Advancement Flap ◽

Flap Failure ◽

Complex Fistula

Abstract Background Fistula-in-ano is a common problem encountered by surgeons which can be classified as either simple or complex. Complex fistulas (CF) cause higher morbidity and are much more challenging to treat. Although numerous treatment options are available for CF, none are proven to be 100% effective. The endorectal advancement flap (EAF) procedure was developed as an alternative to conventional surgical treatments for CF. Herein, we describe a novel modification of the EAF procedure along with surgical outcomes in terms of recurrence, fecal incontinence and factors associated with flap failure. Methods A retrospective review of patients with complex fistula-in-ano who underwent EAF between 2004-2019 was done. The conventional EAF procedure was modified by performing transverse imbrication of the internal sphincter over the internal fistula opening. The incidence of post-operative recurrence and fecal incontinence were calculated from chart documentation at the last available date of follow-up. Also, the association between various clinical and demographic factors and post-operative flap failure were calculated using Chi-squared test and student’s t-test or Mann-Whitney U test with statistical significance at alpha <0.05. Results With a median follow-up of 6.6 months (range: 1.6-84.5 months), 99 patients with CFs underwent a modified EAF. Of these, 93% (92/99) had a successful procedure, 7% (7/99) experienced recurrence and 3% (3/99) experienced postoperative fecal incontinence. Systemic steroid or immunomodulatory therapy use (p=0.001) and patients with diagnosed inflammatory bowel disease (p<0.0001) were associated with increased rate of flap failure.Conclusion EAF with transverse imbrication of the internal opening using interrupted, absorbable suture is an effective technique to treat complex or recurrent anal fistulas. It is associated with a low risk of recurrence (7%) and fecal incontinence (3%) and a valid treatment option for complex fistula-in-ano.

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LONG-TERM OUTCOMES OF LIGATION OF INTERSPHINCTERIC FISTULA TRACT FOR COMPLEX FISTULA-IN-ANO: MODIFIED OPERATIVE PROCEDURE EXPERIENCE

ABCD Arquivos Brasileiros de Cirurgia Digestiva (São Paulo) ◽

10.1590/0102-672020180001e1404 ◽

2018 ◽

Vol 31 (4) ◽

Cited By ~ 4

Author(s):

Ke WEN ◽

Yun-Fei GU ◽

Xue-Liang SUN ◽

Xiao-Peng WANG ◽

Shuai YAN ◽

...

Keyword(s):

Success Rate ◽

Operative Procedure ◽

Cleveland Clinic ◽

Fistula Tract ◽

Long Term Outcomes ◽

Fistula In Ano ◽

Complex Fistula ◽

Intersphincteric Fistula

ABSTRACT Background: It is important but difficult to treat complex fistula-in-ano due to the high recurrent rate and following incontinence. Ligation of the intersphincteric fistula tract (LIFT), a novel surgical procedure with the advantage of avoiding anal incontinence, has a variable success rate of 57-94.4 %. Aim: To evaluate the long-term outcomes of modified LIFT operative procedure - ligation of intersphincteric fistula tract - to treat complex fistula-in-ano. Methods: Retrospective analysis of 62 cases of complex fistula-in-ano. The group was treated with the modified approach of LIFT (curved incision was made in the anal canal skin; purse-string suture was performed around the fistula; the residual fistulas were removed in a tunnel-based way) and had a follow-up time of more than one year. Patient´s preoperative general condition, postoperative efficacy and their anal function were compared. Results: The median age of the participants was 34, and 43 (69.4%) cases were male. Forty-one (66.1%) cases were of high transsphincteric fistula, four (6.5%) cases of high intrasphincter fistula, and 17 (27.4%) cases of anterior anal fistula in female. The median follow-up duration was 24.5 (range, 12-51) months. The success rate in the end of follow-up was 83.9% (52/62). The anorectal pressure and Cleveland Clinic Florida Fecal Incontinence (CCF-FI) evaluated three months before and after the operation did not find apparent changes. Conclusions: Compared with LIFT, the modified LIFT remarkably reduces postoperative failure and the recurrence rate of complex fistula with acceptable long-term outcomes.

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A comparative study in the management of fistula in ANO using various modalities

International Surgery Journal ◽

10.18203/2349-2902.isj20182226 ◽

2018 ◽

Vol 5 (6) ◽

pp. 2223 ◽

Cited By ~ 2

Author(s):

Ramachandra M. L. ◽

Mayank Garg

Keyword(s):

Fistulous Tract ◽

Selection Method ◽

Fistula Tract ◽

Internal Opening ◽

Necrotic Tissue ◽

Fistula In Ano ◽

Sphincter Function ◽

Medical College ◽

Operative Complications ◽

Comparative Prospective Study

Background: Fistula in ano is a track that connects deeply the anal canal or rectum to the skin around the anus. Fistula in ano most commonly follows an anorectal sepsis1. The main principles of management of anal fistula are closure of internal opening of fistula tract, drainage of infection or necrotic tissue, and eradication of fistulous tract with preservation of sphincter function. The objectives were to compare the various aspects like per operative complications, post-operative complications, mean hospital stay in the treatment of fistula in ano using various modalities like fistulotomy, fistulectomy, setons and lift procedure.Methods: This is a randomised, comparative, prospective study of 80 cases of fistula in ano, presenting at surgical opd of K.R. Hospital, Mysore attached to Mysore Medical College and research Institute. Out of which, 20 cases are treated by fistulectomy, 20 by seton, 20 by fistulotomy and the rest 20 cases by LIFT procedure by random selection method, during period of NOVEMBER 1, 2016 to 31st October 2017.Results: Most common age of presentation is 31-40 years and more common in males then females (M:F= 2.3:1 ). Per operative complications include bleeding seen more in patients undergoing fistulectomy. Per operative course of LIFT procedure patients was complication free. Postoperative pain seen more in patients undergoing setons procedure.Conclusions: we conclude that LIFT procedure and Fistulotomy were acceptable procedures for simple, uncomplicated low lying and high lying fistula.

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COMPARATIVE STUDY BETWEEN LIFT PROCEDURE VERSUS SETON PLACEMENT IN THE MANAGEMENT OF FISTULA IN ANO

10.36106/gjra/8001906 ◽

2021 ◽

pp. 61-64

Author(s):

S. Yashwanth ◽

T. Praneeth

Keyword(s):

Postoperative Pain ◽

Fistula Tract ◽

Internal Opening ◽

Fistula In Ano ◽

Medical College ◽

Group 12 ◽

Group A ◽

Intersphincteric Fistula ◽

Group B ◽

Seton Placement

INTRODUCTION: A stula-in-ano, is a chronic abnormal communication, usually lined by granulation tissue, which runs outwards from the anorectal lumen. The standards of anal stula surgery are to obliterate the stula, prevent recurrence and maintain sphincter work. Ligation of Intersphincteric Fistula Tract (LIFT) is the most promising surgical technique based on secure closure of the internal opening and removal of the infected crypto glandular tissue through intersphincteric approach. AIMS: To compare the effectiveness of LIFT over SETON procedure based on Postoperative pain on day 1 and2, Short term recurrence, Healing, Procedural visits PATIENTS AND METHODS: A prospective, single centered, interventional study in 60 patients with stula-in-ano admitted to general surgical wards in Narayana Medical College and Hospital, Nellore. From November 2018 to November 2020. Patients were divided into two groups, group A including patients undergoing LIFT procedure and group B, including patients undergoing SETON placement of Fistula-in- ano. RESULTS: Maximum patients were in 41-60 years in the LIFT Group 18(60%), 51-60 years in the SETON group 12(40%). Maximum patients were male 21 in each group (70%), and female were 9 in each group (30%). In the present study, Visual Analog Scale (0,1,2,3) in LIFT group on POD 1, were 2, 20, 6, 2 and in SETON group on POD 1 were 0, 9, 16, 5 respectively. Similarly, visual analogue scale (0,1,2,3) in LIFT group on POD 2, were 19.8.3.0 and in SETON group on POD 2 were 5, 20, 5, 0respectively. Patients who underwent LIFT procedure had a satisfactory postoperative period and the wound healed in all the cases. CONCLUSION: we conclude that LIFT gives good outcomes in terms of Postoperative pain on day 1 and 2, wound healing rate, single time procedure and recurrence during our short follow-up period of 6 months.

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P614 Micro-fragmented autologous adipose tissue injection for fistula-in-ano (MAATIFA) in patients with Crohn’s disease: A prospective observational study

Journal of Crohn s and Colitis ◽

10.1093/ecco-jcc/jjz203.742 ◽

2020 ◽

Vol 14 (Supplement_1) ◽

pp. S511-S511

Author(s):

A Sturiale ◽

B Fabiani ◽

D Cafaro ◽

C Menconi ◽

F Celedon Porzio ◽

...

Keyword(s):

Adipose Tissue ◽

Anal Fistula ◽

Perianal Fistula ◽

Advancement Flap ◽

Fistula Tract ◽

Time Interval ◽

Internal Opening ◽

Complex Anal Fistula ◽

Related Complex

Abstract Background The use of adipose-derived mesenchymal stem cells showed great regenerative properties. They were used in several surgical fields such as plastic, orthopaedic and colorectal surgery with good results. It was recently published their efficacy to treat Crohn-related anal fistula but they were obtained through a laboratory process with significant costs. The aim of the study is to evaluate the effect of the micro-fragmented autologous adipose tissue injection associated with the advancement flap for the treatment of Crohn-related complex perianal fistula in one surgical step. Methods From January 2017 to February 2018 all the patients that fulfil the following criteria were enrolled in the study. Inclusion criteria were Crohn-related complex anal fistula confirmed by pelvic magnetic resonance or 3D-360° transanal ultrasound, fistula drained with a seton from 4 to 6w, first sphincter-saving procedure. The harvested fat from the abdominal wall was processed using the Lipogems® kit (Figure 1). The internal opening was closed through 2/0 PDS stiches with mucosal flap above it. The final product was then injected around the internal opening and fistula tract previously debrided (Figure 2 and 3). Outcomes were determined at 1-3-6-12 months follow-up assessing success rate, defined as clinical remission without any discharge. Results Ten patients underwent the procedure in the time interval between two biologic drug administration (6 infliximab –4 adalimumab). The homogenous follow-up was 12 months with an overall healing rate of 60%. No perioperative or postoperative complications were recorded. Conclusion Micro-fragmented autologous adipose tissue injection showed promising results to promote Crohn-related complex anal fistula healing. These good results are probably related to the reduction of inflammation and the activation of a reparative mechanisms.

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Outcome of Seton in the Management of Complex Fistula in Ano in a Tertiary Care Center in Bangladesh

Journal of Shaheed Suhrawardy Medical College ◽

10.3329/jssmc.v12i1.51613 ◽

2021 ◽

Vol 12 (1) ◽

pp. 15-19

Author(s):

Md Armanul Islam ◽

Md Mahfuzur Rahman Khan ◽

Md Mustafizur Rahman ◽

SM Quamrul Akther ◽

Md Mozammel Hoque ◽

...

Keyword(s):

Anal Fistula ◽

Care Center ◽

Fistulous Tract ◽

Tertiary Care ◽

Fistula Tract ◽

Internal Opening ◽

Narcotic Analgesics ◽

Cross Sectional ◽

Fistula In Ano ◽

Complex Fistula

Background: The management of high and complex anal fistulas remain a therapeutic challenge as it is often associated with recurrence and anal incontinence. The oldest and theoretically the simplest technique is to use a seton. The aim of this study is to find out the outcome of seton in the treatment of complex fistula in ano. Materials and methods: This cross-sectional study was done in surgical units of ShSMCH and colorectal surgery units of BSMMU from September 2014 to August 2015. Fifty patients with high anal fistula having internal opening above dentate line and with multiple fistulas tract were included by purposive sampling. Patients with low anal fistula, fistula in ano associated with Crohn’s disease, active abdominal tuberculosis, carcinoma of rectum, previous radiation therapy, with recurrent fistula in ano and in whom the internal opening could not be located were excluded. After initial evaluation, the fistula tract and opening were located. The skin and anoderm overlying the fistulous tract were incised. This double-strand seton was then tied over itself on the sphincter without excessive tension. The long end of each suture was tapped to the patient’s medial thigh. Postoperatively warm sitz bath after each bowel movement was advised. The patients were informed in detail about the presence of seton prosthesis and they were warned about the possible serous discharge that would continue until the seton dropped, and the wound healed. Data were recorded on the predesigned questionnaire and analyzed using SPSS version 16. Results: Among 50 cases mean age was 41 years, M: F was 4.5:1. Discharge from perianal sinus, pain, swelling and itching were common clinical presentation. All of the patients were discharged on the third postoperative day. None required readmission or needed narcotic analgesics after discharge. The average time for the seton to cut through the sphincter was 1 to 3 months. 28% had complete healing at 1 month and 66% at 3 months postoperatively. Flatus Incontinence was noted 16% cases followed by recurrence (6%), liquid stool incontinence (4%) and postoperative anal stricture was (2%) of cases. Conclusion: This study found that the seton is a safe and low morbidity option for the treatment of high and complex fistula-in-ano, having higher healing rates, with good quality of life. It can therefore be recommended as the standard treatment for complex fistula-in-ano. J Shaheed Suhrawardy Med Coll, December 2020, Vol.12(1); 15-19

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Outcome of fecal incontinence in the two-staged seton fistulotomy for complex fistula in ANO.

The Professional Medical Journal ◽

10.29309/tpmj/2021.28.08.3187 ◽

2021 ◽

Vol 28 (08) ◽

pp. 1061-1066

Author(s):

Rabia Ikram ◽

◽

Shafique ur Rehman ◽

Haroon Javaid Majid ◽

Arif Javed ◽

...

Keyword(s):

Fecal Incontinence ◽

Feeding Tube ◽

Fistula Tract ◽

Ethical Review ◽

Lithotomy Position ◽

Internal Opening ◽

Suitable Alternative ◽

Fistula In Ano ◽

Complex Fistula ◽

Second Procedure

Objective: To determine the frequency of fecal incontinence in the two-staged Seton fistulotomy in complex fistula in ano. Study Design: Prospective Cohort study. Setting: Surgical Out-patient Department at Shaikh Zayed Hospital Lahore. Period: September 2015 till March 2016. Material & Methods: After ethical review board approval, data was collected from 100 patients who fulfilled the inclusion criteria. All the procedures were conducted in the lithotomy position, under spinal or general anesthesia. A rigid sigmoidoscopy and proctoscopy was done prior to intervention. Fistula tract was marked using hydrogen peroxide (H202) for the identification of the internal opening. The external opening was gently probed using a standard 3 mm blunt-tipped probe till the internal opening was reached. The portion of the track outside the sphincter mechanism and any lateral tracts were laid open. A feeding tube of size 5 French was loosely tied around the remaining muscular portion of the sphincter complex. The seton was left in place for six weeks followed by secondary fistulotomy. Patients were evaluated for incontinence one month after the second procedure. Results: In our study, mean age was calculated as 47.38+10.96 years, 73%(n=73) were male and 27%(n=27) were females, frequency of fecal incontinence in the two-staged Seton fistulotomy in complex fistula in ano was recorded in 17%(n=17). Conclusion: The frequency of fecal incontinence in the two-staged seton fistulotomy for complex fistula in ano was acceptable in our study population and in tandem with literature. The procedure may be a suitable alternative to loose-seton placement alone.

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Use of Seton in Management of High Variety of Anal Fistula

Anwer Khan Modern Medical College Journal ◽

10.3329/akmmcj.v8i2.33662 ◽

2017 ◽

Vol 8 (2) ◽

pp. 100-104

Author(s):

Mohammad Noor A Alam ◽

Sharmin Abbasi

Keyword(s):

Anal Fistula ◽

Low Cost ◽

Dentate Line ◽

Internal Opening ◽

Efficacy And Safety ◽

Medical College ◽

Small Channel ◽

A Prospective Study ◽

Low Rate

Background: Anal fistula is an abnormal communicative small channel that has an internal opening and an external opening and connected by the primary track. Our study evaluate the effectiveness of seton in high variety anal fistula.Objectives: Evaluation the efficacy and safety of seton as surgical management of high anal fistula. Methods: This is a prospective study done on 57 patients in BIRDEM hospital and some other clinic of Dhaka city in 3 years period with high variety of anal fistula which is above the dentate line and were treated with seton .Outcome measured during follow up period were- successfully healed, recurrence, incontinence, percentage of complications and patients satisfaction.Result: Among 57 patients mean age was 38.2+_6.8 years. Overall outcome of the patients showed-fistula completely healed in 51 patients, incontinence occurred in 2 patients and recurrence occurred in 4 patients.Conclusion: Seton is relatively safe, effective and low cost for the management of high anal fistula with low rate of incontinence. It can therefore, be recommended as the standard of treatment for high variety fistula in ano.Anwer Khan Modern Medical College Journal Vol. 8, No. 2: Jul 2017, P 100-104

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