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.

Laser coagulation in combination with LIFT for transsphincteric anal fistulas

Aim: to improve the results of fistula treatment, to evaluate the effectiveness of the combined use of LIFT and FiLaC techniques.Patients and methods: the study included 35 patients with transsphincter fistulas of cryptopglandular etiology involved more than 1/3 of the sphincter. All patients underwent surgery with laser energy (the laser conductor speed is 1 mm per second, the wavelength is 1470 nm, the radiation output is 13 W) after the LIFT procedure.Results: the primary healing rate was 28/35 (80,0%). The patients who failed the combined procedure (cases of prolonged healing more than 3 months) underwent a second procedure ReFiLaC, which led to the closure of fistula in 2 of 3 patients. A median follow-up period was 10,2 months. No incontinence to solid and liquid stools was detected.Conclusion: preliminary results of the study permits to assess the potential of the combined low-invasive approach for anal fistulas as positive.

THE OUTCOME OF LIMBERG FLAP RECONSTRUCTION PROCEDURE FOR PRIMARY NATAL CLEFT PILONIDAL SINUS DISEASE: FOUR YEARS’ EXPERIENCE AT A TEACHING HOSPITAL IN PAKISTAN

Background: Natal cleft pilonidal sinus disease is known for its high recurrence rate after surgery. Different surgical procedures are being used for its treatment and these vary from wide excision followed by healing with secondary intention to excision followed by reconstruction with a flap. Limberg flap reconstruction procedure has been used by many surgeons as their primary choice owing to its low recurrence rate and less postoperative complications. Objective: The objective of this study was to assess the outcome of Limberg flap reconstruction procedure in patients with primary natal cleft pilonidal sinus disease. Methods: This descriptive case series was conducted at Ghurki trust teaching hospital, Lahore, Pakistan, between January 2015 to December 2018. 110 consecutive patients with primary natal cleft pilonidal sinus disease were included in this study. Informed consent was taken from these patients and all patients underwent Limberg flap reconstruction procedure. The evaluated outcomes of this procedure included duration of hospital stay, postoperative pain, primary healing, surgical site Infection, seroma formation, flap necrosis and, recurrence. Results: The patients age ranged between 18 years to 60 years. The mean age was 26.6 ±8.6 years. 73 patients (66.36 %) were males and 23 patients (33.63%) were females. The duration of disease ranged between 1 month to 6 months with a mean of 3.7±1.7 months. The mean operating time was 47.50±5.14 minutes. The mean duration of hospital stay was 1.87±0.80 days. The mean postoperative pain score calculated by the visual analogue scale (VAS) twenty-four hours after the surgery was 3.45. 95 patients (86.36%) had complete primary healing without any complication. 9 patients (8.18%) had a surgical site infection and 6 patients (5.45 %) had seroma formation. No patient suffered from flap necrosis. 2 patients (1.81%) who had complete primary healing presented with recurrence of the disease within six months of the procedure with a period of one year of follow-up designated for every patient. Conclusion: Limberg flap reconstruction procedure is a safe and efficacious treatment option for primary natal cleft pilonidal sinus disease because it provides early complete primary healing in most patients, and shortens the duration of hospital stay thus reducing the cost of treatment. The pain scores fall in the moderate post-operative pain score category and the complication rates and the recurrence rates are very low.

A comparative study of Ligation of Intesphincteric Fistula Tract versus conventional fistulectomy in management of low fistula in ano: a randomized control trial

Background: Fistula in ano (FIA) is a chronic complex condition of ano-rectal sepsis characterized by cylical-pain and intermittent chronic purulent discharge. The management of fistula is challenging. In spite of all the advances in the management of FIA, no single method is univresally applicable to all types of FIA due to incontinence and recurrences associated with the individual procedures.Methods: Aims of this study were to compare the outcomes between ligation of intersphincteric fistula tract (LIFT) and conventional fistulectomy (CF) with 60 patients randomized into 2 groups, 30 in each group.Results: Mean age in LIFT was 44.17 years and in CF was 41.1 years. Successful primary healing was observed in 86.7% of LIFT and 100% of CF. Mean pain scores were lower in LIFT compared to CF when checked on Postoperative days 1, 3 and 7 significantly. Anal incontinence was seen in 10% of CF and none in LIFT and recurrence was seen at same site in LIFT in 6.66% of LIFT and none in CF both being not statistically significant.Conclusions: LIFT is a promising and sphincter saving technique which is simple and easy to learn with faster healing rates and better patient contentment but with risk of failure and recurrence. Modifications of LIFT have to be probed for minimizing the failures.

Outcome of Core Out Fistulectomy and the Ligation of Anal Fistula Tract: A Single Center Experience in Malaysia

Introduction: Fistula-in-ano is a benign anorectal disease which always poses a big dilemma to the surgeons because of their significant recurrent rate following surgery. Materials and Methods: A cross-sectional study involving 42 patients undergoing core out fistulectomy in the Hospital Tengku Ampuan Afzan, Kuantan, Pahang, Malaysia were included in this study. Demographic data of patients were assessed. Endoanal ultrasound (EAUS) was done prior to the surgery to determine types of fistula and classified using Park’s classification. Follow up was made post-operatively at 4th week, 2nd month, 3rd month, 4th month, 5th month and 6th month to look for the duration of healing or recurrence. Results: 5 out of 42 patients were lost to follow up leaving 37 patients available for the analysis. Mean age of the patient was 38.4 (13.8) years old. Transphincteric and intersphincteric type of fistula accounted for 54.5% and 40.1%, respectively. 62.2% (n=23) of patients achieved primary healing after the procedure. The mean for healing duration was 3.7 (3.1) months. Recurrence of the disease was seen only in 37.8% (n=14) of the patients. Conclusions: Even though we managed to achieve significant success rate cumulatively, recurrence of fistula still impose a significant challenge toward patient’s management. Therefore, further prospective study with a bigger sample size is recommended to look into this method to reduce recurrence of fistula.

A modified longitudinal incision via transoral sublabial approach for removal of the nasal vestibular cyst: a clinical observation

ObjectiveThe aim of this study was to investigate the clinical effect of the removal of nasal vestibular cysts through a modified longitudinal incision via a transoral sublabial approach.MethodIn 28 cases, a nasal vestibular cyst was removed through a modified longitudinal incision via a transoral sublabial approach. A visual analogue scale score was used to evaluate the numbness of the nasal alar and upper lip. Post-operative complications were recorded. Medical photographs were used for assessment.ResultsFor all patients, incisions reached clinical primary healing one week after surgery. All patients were free of post-operative haematoma, infection, oronasal fistula and malformation. In the first week and the first month after surgery, numbness of the nasal alar and upper lip was recorded in few cases. The patients were followed up for 2–57 months without recurrence.ConclusionRemoval of nasal vestibular cysts via a transoral sublabial approach with a modified longitudinal incision is a minimally invasive and simple surgical method with few complications and a quick recovery.

Treatment of complex trans- and extrasphincteric fistulas by laser thermo-obliteration of fistula tract: preliminary results

The aim of this study was to assess the preliminary results of treatment of patients with complex transand extrasphincteric fistulas by laser thermo-obliteration of fistula tract. Materials and methods. The analysis was conducted on 28 patients with complex trans- and extrasphincteric fistulas (24 males and 4 females). The age of patients ranged from 29 to 68 years (on the average 43±12.4). In 8 (28.6 %) patients there were extrasphincteric fistulas, in 20 (71.4 %) — transsphincteric fistulas. The minimum assess period at which healing or preservation of the fistula was diagnosed was 2 months after the surgery. Results. The average period of follow-up was 3.5±4.9 (0.5–14) months. Control examination in terms of 2 months or more after the procedure was carried out in 20/28 (71.4 %). The primary healing rate was 9/20 (45 %). Of these, 7 (77.8 %) patients had transsphincteric fistulas and 2 (22.2 %) patients had extrasphincteric. The disease reccurred in 11 (55 %) of the 20 supervised patients. There was no cases of the development of anal incontinence after the operation. Conclusion. Laser thermo-obliteration of the fistula tract is a mini-invasive, sphincter-preserving method, which is indicated in patients with complex fisulas, in cases where traditional operation is associated with a high risk of postoperative anal incontinence. However, to obtain more reliable results, further patient recruitment and assessment of long-term treatment results are required.

Effects of Collagen Membrane on Bone Level and Periodontal Status of Adjacent Tooth After Third Molar Surgery

Background: After the surgical extraction of an impacted lower third molar, periodontal status and distal bone level of the adjacent second molar could be affected negatively. Healing type has been effected periodontal status and distal bone level of the adjacent second molar after third molar surgery. Absorbable materials have some benefits including promoting wound healing through isolation, clot and wound stabilisation, and haemostasis; enhancing primary wound coverage. The aim of this study was to compare primary and secondary healing and collagen-membrane-based primary healing after surgical removal of partially erupted impacted third molars (3Ms), evaluating the distal alveolar bone level (ABL) and periodontal status of the adjacent second molars (2Ms). Materials and Methods: Patients who met the inclusion criteria were randomised into three groups: secondary healing (n=28), primary healing (n=27) and membrane-based primary healing (n=29). Digital panoramic radiographs were obtained preoperatively (T1) and three months postoperatively (T2). The distances between the cemento-enamel junctions and the alveolar bone crests on the distal aspects of the adjacent 2Ms were measured using calibrated radiograph measurement software. The pocket depth and plaque index measurements were performed preoperatively and three months postoperatively. The periodontal plaque index (PPI) scores were registered on the distal aspects of the 2Ms, and the mean values were used. Results: Three of the applied healing types positively affected periodontal pocket depth (PPD) and periodontal index values (p<0.05). In terms of the ABL of the adjacent 2Ms, primary 3-4N/healing (p=0.001) and membrane-based primary healing (p=0.000) had superior results to secondary healing. Conclusion: Membrane usage is promising for the distal bone gain and periodontal status of the adjacent 2M.

A method of reducing the frequency of local postoperative complications after laryngectomy incancer of the larynx T3N0M0

The problem of healing of postoperative wounds in oncologic patients remains relevant still the present time. After laryngectomy the percentage of primary healing of postoperative wounds does not exceed 40–60%. After surgical intervention there are favorable conditions for the activation of pathogenic microorganisms of the pharyngeal mucosa. The aim of our study was to develop preventive measures to reduce the percentage of healing of postoperative wounds by means of secondary intention after laryngectomy. The course of prevention consisted in daily treatment of the pharyngeal mucosa with successively freshly prepared ozonated saline solution with an ozone content of 0.15 g/l in an amount of 3 ml; and then with a bifidobacteria probiotic in in an amount of 2 ml. After this course of prevention, the number of pathogenic and opportunistic microorganisms decreased on the pharyngeal mucosa, bifidobacteria and lactobacilli appeared. Preoperative preparation for laryngectomy by irrigation of the pharyngeal mucosa with ozonated saline solution and probiotic helps to reduce the number of local complications of infectious origin by 16.7% of cases. There is no negative effect Bifidobacterium longum MC-42 on long – term oncological.