Outcome of treatment of high fistula in ANO, with fistulectomy plus seton placement.

Objective: To determine post procedure recurrence and incontinence rate for high fistula-in-ano cases, who underwent procedure of fistulectomy and Seton placement. Study Design: Descriptive study. Setting: Department of General Surgery, Khyber Teaching Hospital Peshawar. Period: January to December, 2018. Material & Methods: This study was conducted over 50 patients with diagnosis of high fistula-in-ano, treated with combined procedure of fistulectomy and Seton placement. Patients follow up was done for one year for recurrence and incontinence. Results: Out of 50 patients, 28(56%) were male and 22(44%) were female. Overall male to female ratio was 1.27:1. Average age of patient was 36.88 years+6.63 SD. Flatus Incontinence was observed in single case (2%), no patient reported stool Incontinence. Recurrence of disease was found in 2 patients (4%). All patients were followed for one year. Conclusion: This technique for treating high Fistula-in-ano showed overall low recurrence and incontinence rates during follow up, thus reducing morbidity and costs associated with recurrent surgery for Fistula-in-ano.

Loose Thick Seton Suture Stimulates Rapid Healing and Lower Recurrence Rate in the Treatment of High Type Fistula in Ano

BACKGROUND: Fistula in ano is a chronic problem for the patients. It causes distressing because of foul odor and soiling with recurrent infection and discharge. Recurrence and anal sphincter injury were the most critical complications following surgery. Loose, thick seton placement was the most promising surgical operation. AIM: To reduce the time of seton placement, therefore, decreasing the suffering of patients from soiling and multiple dressing. PATIENTS AND METHODS: A retrospective study, one hundred patients with high type fistula in ano treated surgically in Al-Sader Medical city and Al-Najaf daily private clinic, Najaf city, Iraq, from February 2018 to March 2019. Fistulography and magnetic resonance imaging have taken from all patients. After that, fistulectomy with loose, thick seton suture placed for 3 months. Patients with the persistence of high fistula tract underwent a second surgery and third operation until complete healing. RESULTS: One hundred patients with high type fistula in ano with male 96 (96%) and female patients were 4 (4%). The rate of complete healing among male patients after the first operation was 90 (93%), while female patients showed a 4 (100%) rate of complete healing after the first operation. Three of the remaining male patients with persistently high fistula tract showed complete healing after the second operation, whereas 3 (3%) the rate of complete healing was 100% after the third operation. CONCLUSION: A loose, thick seton placed in high type fistula tract for 3 months provides excellent protection to the external anal sphincter with less recurrence rate and rapid healing.

The Use of Seton as a Bridge to Definitive Ligation of the Intersphincteric Fistula Tract Procedure for Fistula-in-ano: A Systematic Review and Meta-analysis

Background There is still controversy over the usefulness of seton placement prior to the ligation of the intersphincteric fistula tract (LIFT) surgery in the management of anal fistula. Objective To evaluate the impact of preoperative seton placement on the outcomes of LIFT surgery for the management of fistula-in-ano. Design systematic review and meta-analysis. Data Sources A search was performed on the MEDLINE (PubMed), EMBASE, Scopus, Web of Science, Cochrane Library and Google Scholar databases. Study Selection Original studies without language restriction reporting the primary healing rates with and without seton placement as a bridge to definitive LIFT surgery were included. Intervention The intervention assessed was the LIFT with and without prior seton placement. Main Outcome Measures The main outcome was defined as the primary healing rate with and without the use of seton as a bridge to definitive LIFT surgery. Results Ten studies met the criteria for systematic review, all retrospective, with a pooled study population of 772 patients. There were no significant differences in the percentages of recurrence between patients with and without seton placement (odds ratio [OR] 1.02; 95% confidence interval [CI] 0.73–1.43: p = 0.35). The I2 value was 9%, which shows the homogeneity of the results among the analyzed studies. The 10 included studies demonstrated a weighted average overall recurrence of 38% (interquartile range [IQR] 27–42.7%), recurrence with the use of seton was 40% (IQR 26.6–51.2%), and without its use, the recurrence rate was 51.3% (IQR 31.3–51.3%) Limitations The levels of evidence found in the available literature were relatively fair, as indicated after qualitative evaluation using the Newcastle-Ottawa scale and the Attitude Heading Reference System (AHRS) evidence levels. Conclusions Our meta-analysis suggests that the placement of seton as a bridge treatment prior to LIFT surgery does not significantly improve long-term anal fistula healing outcomes. Ligation of the intersphincteric fistula tract surgery can be performed safely and effectively with no previous seton placement.International prospective register of systematic reviews—PROSPERO registration number: CDR42020149173.

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

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.

Comparative perianal fistula closure rates following autologous adipose tissue-derived stem cell transplantation or treatment with anti-tumor necrosis factor agents after seton placement in patients with Crohn’s disease: a retrospective observational study

Background Perianal fistula is one of the most common complications in Crohn’s disease, and various medical and surgical treatments are being tried. The aim of this study was to compare the perianal fistula closure rates following treatment with anti-tumor necrosis factor (TNF) agents or autologous adipose tissue-derived stem cell (auto-ASC) transplantation with Crohn’s disease (CD). Methods CD patients who underwent seton placement for perianal fistula from January 2015 to December 2019 at a tertiary referral center were retrospectively reviewed. Patients were divided into two groups, one that received sequential treatments with anti-TNF agents (anti-TNF group) and the other that underwent auto-ASC transplantation (stem cell group). Clinical variables and fistula closure rates were compared in the two groups. Results Of the 69 patients analyzed, 39 were treated with anti-TNF agents and 30 underwent auto-ASC transplantation. Compared with the stem cell group, patients in the anti-TNF group were older (p=0.028), were more frequently male (p=0.019), had fistulas with more penetrating behavior (p=0.002), had undergone surgery more frequently (p=0.010), and had a shorter interval from seton placement to intended treatment (p<0.001). During a median follow-up of 46 months (range, 30–52.5 months), fistula closure rates were significantly faster (83.3% vs. 23.1%, p<0.001), and the mean interval from seton placement to fistula closure significantly shorter (14 vs. 37 months, p<0.001) in the stem cell than in the anti-TNF group. Three patients experienced fistula recurrence, all in the stem cell group. Conclusions Medical treatment using anti-TNF agents and auto-ASC transplantation are feasible treatment options after seton placement for Crohn’s perianal fistula. However, the closure rate was significantly faster and the time to closure significantly shorter in patients who underwent auto-ASC transplantation than medical treatment. Trial registration This study was retrospectively registered and approved by the Institutional Review Board of Asan Medical Center, number 2020-1059.

DOP38 An observational study to evaluate the burden of illness in patients with Crohn’s Disease with and without perianal fistulas in the USA

Background Crohn’s disease (CD) is a chronic inflammatory condition of the gastrointestinal tract that can lead to complications such as perianal fistulas (PAFs). This study compared disease burden, experiences and health-related quality of life between patients who have CD with PAFs (CPF) and those who have CD without PAFs (non-PAF CD). Methods This cross-sectional, observational study was conducted in three cohorts of US patients aged 18–89 years with self-reported physician-diagnosed CD: (1) non-PAF CD; (2) CPF without PAF-related surgery; and (3) CPF with PAF-related surgery. Data on medical and surgical interventions, CD-specific symptoms and Fecal Incontinence Quality of Life (FIQL) were collected via a web-enabled questionnaire. Statistical comparisons were assessed at the 0.05 level. Results The mean (standard deviation) age of patients in cohorts 1 (n = 300), 2 (n = 51) and 3 (n = 52) was 47 (16.4), 40 (12.2) and 39 (13.1) years, respectively. In patients with CPF (cohort 2 + 3), 59 (57%) reported multiple fistulas and 48 (47%) reported fistula recurrence/persistence. Compared with cohort 1 (non-PAF CD), more patients with CPF reported currently receiving biologic treatment or immunomodulators for CD (58% vs 43% and 23% vs 15%, respectively; both p = 0.01). More patients with CPF also reported undergoing ≥ 1 CD-related surgery and experiencing ≥ 1 failures of CD-related surgery (79% and 20%, respectively) versus cohort 1 (53% and 9%, respectively; both p &lt; 0.001). In cohort 3, 63% of patients had ≥ 3 PAF-related surgeries, and in those receiving seton placement (n = 37), 8% reported placement failure. Post-surgical/seton placement complications were common; the most frequently reported were worsening of pain and swelling around the anus (33%) and fever/infection (29%). CD-specific symptom frequency and severity results indicated a high symptom burden across cohorts; fatigue was reported with the highest frequency and severity. Faecal incontinence (FI) and leakage-related symptoms affected greater proportions of patients in cohorts 2 and 3, often with greater severity and frequency, compared with cohort 1 (Fig.1). Across all cohorts, 58% of patients (cohort 1/2/3, n = 158/35/40) reported experiencing FI and completed the FIQL questionnaire: cohorts 2 and 3 reported lower (worse) FIQL scores across domains than cohort 1 (Fig.2). Conclusion The burden of illness in patients with CPF is substantial, with medical and surgical intervention rates, and symptom severity and frequency greater than for those with non-PAF CD. Higher disease burden, including FI, was noted in patients with CPF compared with the non-PAF CD cohort. An unmet need remains for improved management and outcomes of CPF. Sponsor: Takeda Pharmaceuticals USA, Inc.

The effect of suture selection in complex anal fistulas on the success of cutting seton placement and patient comfort

Objective: The aim of our study was to compare the success rates of suture selection, recovery times and pain associated with local wound infection and seton placement in patients undergoing cutting seton placement for complex anal fistula. Methods: The study included a total of 90 patients who were admitted with the diagnosis of complex anal fistula between January 2015 and July 2018. Results: The first session and other revision appointments demonstrated that the number of patients who required fistulotomy was significantly higher in group-1 as the seton failed to complete the transection (p = 0.001). When the patients were asked to rate pain for 3 different conditions according to numeric rating scale (NRS), the patients in group-2 had significantly higher pain in all 3 cases compared to the patients in group-1 (p = 0.001). The impact of the suture material on local infection was examined and it was determined that the results of cultures for seton material were significantly more positive in group-1 (p = 0.001). Conclusions: We conclude that a multi-stage tight seton placement with silk material can lead to satisfactory results by aiming to shorten the cutting time of silk seton. doi: https://doi.org/10.12669/pjms.36.4.1920 How to cite this:Akici M, Ersen O. The effect of suture selection in complex anal fistulas on the success of cutting seton placement and patient comfort. Pak J Med Sci. 2020;36(4):---------. doi: https://doi.org/10.12669/pjms.36.4.1920 This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.