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Zhou H, Bao C, Li Y, Wang G, Zhou W, Guo C. A Mendelian Randomization Study of the Connection Between Exogenous Hormones and Perianal Abscess in Pediatric Patients. Surg Infect (Larchmt) 2025; 26:150-157. [PMID: 39436832 DOI: 10.1089/sur.2024.229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2024] Open
Abstract
Background: Recent years have witnessed the hypothesis that bioavailable testosterone (BT) might be closely related to the development of inflammatory diseases, especially anal abscess (AA), a common inflammatory ailment with unclear pathogenesis. Given that AA is more prevalent among males, this study investigates the causal relationship between BT and AA. Objective: To explore the causal link between BT and AA, a Mendelian randomization (MR) study was conducted using large-scale genomic data. Materials and Methods: Utilizing genomic data from the UK Biobank and IEU OpenGWAS databases, a two-sample MR analysis was executed. Twenty-six genetic variants strongly associated with BT were selected as instrumental variables (IVs) to assess their link with AA risk. Various MR methods were employed for consistency checks, including sensitivity analyses for heterogeneity and horizontal pleiotropy. Results: Using a combination of MR methods, we identified a significant causal relationship between BT and the risk of AA. Specifically, the MR analysis revealed that higher levels of BT were associated with an increased risk of AA. Sensitivity analyses, including heterogeneity tests and assessments for horizontal pleiotropy, confirmed the robustness of these findings. The IVs used in the analysis demonstrated a strong association with BT and showed no evidence of significant heterogeneity or horizontal pleiotropy, indicating the validity of the causal inference. Conclusion: This study, employing two-sample MR for the first time, confirms a causal relationship between BT levels and the risk of AA. These findings provide preliminary evidence of the causal relationship between BT and AA and may offer new insights into the pathophysiological mechanism of AA and future therapeutic strategies.
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Affiliation(s)
- Hai Zhou
- Department of Pediatrics, Women's and Children's Hospital, Chongqing Medical University, Chongqing, P.R. China
- Department of Pediatrics, Children's Hospital, Chongqing Medical University, Chongqing, P.R. China
| | - Chunli Bao
- Department of Pediatrics, Women's and Children's Hospital, Chongqing Medical University, Chongqing, P.R. China
- Department of Fetus and Pediatrics, Chongqing Health Center for Women and Children, Chongqing, P.R. China
| | - Yao Li
- Department of Pediatrics, Women's and Children's Hospital, Chongqing Medical University, Chongqing, P.R. China
- Department of Pediatrics, Children's Hospital, Chongqing Medical University, Chongqing, P.R. China
| | - Guoyong Wang
- Department of Pediatrics, Women's and Children's Hospital, Chongqing Medical University, Chongqing, P.R. China
- Department of Pediatrics, Children's Hospital, Chongqing Medical University, Chongqing, P.R. China
| | - Wei Zhou
- Department of Fetus and Pediatrics, Chongqing Health Center for Women and Children, Chongqing, P.R. China
- Department of Obstetrics and Gynecology, Chongqing Maternal and Child Health Hospital, Chongqing Medical University, Chongqing, P.R. China
| | - Chunbao Guo
- Department of Pediatrics, Women's and Children's Hospital, Chongqing Medical University, Chongqing, P.R. China
- Department of Fetus and Pediatrics, Chongqing Health Center for Women and Children, Chongqing, P.R. China
- Department of Obstetrics and Gynecology, Chongqing Maternal and Child Health Hospital, Chongqing Medical University, Chongqing, P.R. China
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Karmakar R, Gupta D, Mukundan A, Wang HC. Hydrogen peroxide-enhanced magnetic resonance imaging: A novel approach for diagnosing anorectal-fistula. World J Radiol 2025; 17. [DOI: https:/doi.org/10.4329/wjr.v17.i3.105777] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/02/2025] Open
Abstract
In this editorial, a commentary on the article by Chang et al has been provided, the course of treatment of anorectal fistulas, especially complex and recurring ones, require accurate diagnostic procedures for determining ideal surgical procedures. Conventional ways of imaging sometimes fall short, offering insufficient insights in aggravated instances. In this editorial, a novel application of hydrogen peroxide-enhanced magnetic resonance imaging (HP-MRI) that promises significant improvements in the imaging of anorectal fistula. Study is based on a retrospective investigation of 60 patients, contrasts the new HP-MRI with conventional diagnostic techniques such as physical examination, trans-perineal ultrasonography and poor spatial resolution MRI. The findings demonstrate HP-MRI's incredible diagnostic performance, with sensitivity and specificity rates of 96.08% and 90.91%, respectively, and unparalleled interobserver agreement (Kappa values ranging from 0.80 to 0.89). It has been a significant advancement for assessment of anorectal fistulas providing a better roadmap for surgical planning, lowering recurrence rates as well as reduced personal and financial burden on patients by reducing the need for repeated treatment and extended hospital stays. The remaining funds can be utilized for treatment of other medical need. Ultimately HP-MRI provides us a healthier & more efficient society by improvising patients well-being & optimized healthcare infrastructure.
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Karmakar R, Gupta D, Mukundan A, Wang HC. Hydrogen peroxide-enhanced magnetic resonance imaging: A novel approach for diagnosing anorectal-fistula. World J Radiol 2025; 17:105777. [PMID: 40176955 PMCID: PMC11959619 DOI: 10.4329/wjr.v17.i3.105777] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2025] [Revised: 03/11/2025] [Accepted: 03/17/2025] [Indexed: 03/27/2025] Open
Abstract
In this editorial, a commentary on the article by Chang et al has been provided, the course of treatment of anorectal fistulas, especially complex and recurring ones, require accurate diagnostic procedures for determining ideal surgical procedures. Conventional ways of imaging sometimes fall short, offering insufficient insights in aggravated instances. In this editorial, a novel application of hydrogen peroxide-enhanced magnetic resonance imaging (HP-MRI) that promises significant improvements in the imaging of anorectal fistula. Study is based on a retrospective investigation of 60 patients, contrasts the new HP-MRI with conventional diagnostic techniques such as physical examination, trans-perineal ultrasonography and poor spatial resolution MRI. The findings demonstrate HP-MRI's incredible diagnostic performance, with sensitivity and specificity rates of 96.08% and 90.91%, respectively, and unparalleled interobserver agreement (Kappa values ranging from 0.80 to 0.89). It has been a significant advancement for assessment of anorectal fistulas providing a better roadmap for surgical planning, lowering recurrence rates as well as reduced personal and financial burden on patients by reducing the need for repeated treatment and extended hospital stays. The remaining funds can be utilized for treatment of other medical need. Ultimately HP-MRI provides us a healthier & more efficient society by improvising patients well-being & optimized healthcare infrastructure.
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Affiliation(s)
- Riya Karmakar
- Department of Mechanical Engineering, National Chung Cheng University, Chiayi 62102, Taiwan
| | - Devansh Gupta
- Department of Computer Science & Engineering, Thapar Institute of Engineering & Technology, Patiala 147001, Punjab, India
| | - Arvind Mukundan
- Department of Mechanical Engineering, Center for Innovative Research on Aging Society, National Chung Cheng University, Chiayi 621, Taiwan
| | - Hsiang-Chen Wang
- Department of Mechanical Engineering, National Chung Cheng University, Chiayi 62102, Taiwan
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Chang CC, Qiao LH, Zhang ZQ, Tian X, Zhang Y, Cheng WW, Wang X, Yang Q. High-resolution direct magnetic resonance imaging fistulography with hydrogen peroxide for diagnosing anorectal fistula: A preliminary retrospective study. World J Radiol 2025; 17:101221. [PMID: 39876881 PMCID: PMC11755908 DOI: 10.4329/wjr.v17.i1.101221] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2024] [Revised: 12/05/2024] [Accepted: 01/14/2025] [Indexed: 01/21/2025] Open
Abstract
BACKGROUND Fistula-in-ano is an abnormal tunnel formation linking the anal canal with the perineum and perianal skin. Multiple imagining methods are available to evaluate it, among which magnetic resonance imaging (MRI) is the most advanced noninvasive preoperative method. However, it is limited in its visualization function. AIM To investigate the use of intraluminal MRI for perianal fistulas via a novel direct MRI fistulography method. METHODS We mixed 3% hydrogen peroxide (HP) with gadolinium for HPMRI fistulography, retrospectively analyzing 60 cases of complex/recurrent fistula-in-ano using physical examination, trans-perineal ultrasonography (TPUS), low-spatial-resolution MRI, and high-resolution direct HPMRI fistulography. We assessed detection rates of fistula tracks, internal openings, their relationship with anal sphincters, and perianal abscesses using statistical analyses, including interobserver agreement (Kappa statistic), and compared results with intraoperative findings. RESULTS Surgical confirmation in 60 cases showed that high-resolution direct HPMRI fistulography provided superior detection rates for internal openings (153) and fistula tracks (162) compared to physical exams, TPUS, and low-spatial-resolution MRI (Z > 5.7, P < 0.05). The effectiveness of physical examination and TPUS was also inferior to that of our method for detecting perianal abscesses (54) (Z = 6.773, 3.694, P < 0.05), whereas that of low-spatial-resolution MRI was not significantly different (Z = 1.851, P = 0.06). High-resolution direct HPMRI fistulography also achieved the highest interobserver agreement (Kappa: 0.89, 0.85, and 0.80), while low-spatial-resolution MRI showed moderate agreement (Kappa: 0.78, 0.74, and 0.69). TPUS and physical examination had lower agreement (Kappa range: 0.33-0.63). CONCLUSION High-resolution direct HPMRI fistulography enhances the visualization of recurrent and complex fistula-in-ano, including branched fistulas, allowing for precise planning and improved surgical outcomes.
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Affiliation(s)
- Can-Can Chang
- Department of Medical Imaging, Bozhou Hospital of Traditional Chinese Medicine, Bozhou 236800, Anhui Province, China
| | - Long-Hu Qiao
- Department of Medical Imaging, Bozhou Hospital of Traditional Chinese Medicine, Bozhou 236800, Anhui Province, China
| | - Zhen-Qi Zhang
- Department of Medical Imaging, Bozhou Hospital of Traditional Chinese Medicine, Bozhou 236800, Anhui Province, China
| | - Xiao Tian
- Department of Medical Imaging, Bozhou Hospital of Traditional Chinese Medicine, Bozhou 236800, Anhui Province, China
| | - Yu Zhang
- Department of Medical Imaging, Bozhou Hospital of Traditional Chinese Medicine, Bozhou 236800, Anhui Province, China
| | - Wen-Wen Cheng
- Department of Medical Imaging, Bozhou Hospital of Traditional Chinese Medicine, Bozhou 236800, Anhui Province, China
| | - Xia Wang
- Department of Medical Imaging, Bozhou Hospital of Traditional Chinese Medicine, Bozhou 236800, Anhui Province, China
| | - Qing Yang
- Department of Medical Imaging, Anqing Hospital Affiliated to Anhui Medical University, Anqing 246000, Anhui Province, China
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Wu C, Mei Z, Wang Z. Curing cryptoglandular anal fistulas-Is it possible without surgery? Heliyon 2025; 11:e41297. [PMID: 39811351 PMCID: PMC11730242 DOI: 10.1016/j.heliyon.2024.e41297] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2024] [Revised: 12/15/2024] [Accepted: 12/16/2024] [Indexed: 01/11/2025] Open
Abstract
Background Empirical reviews suggested that cryptoglandular anal fistulas require surgical resolution. However, some reports have indicated the possibility of nonsurgical and conservative treatment, which is discussed in this review. Methods This review explores the potential of nonsurgical approaches for curing anal fistulas through bacterial inhibition and immunomodulation. The longstanding cryptoglandular theory has been a subject of controversy, prompting the reevaluation of conventional surgical interventions for anal fistulas. The review was conducted through database searches, including Medline, EMBASE, PubMed, and the Cochrane Library. Results Emerging evidence suggests that targeting the anaerobic environments present in anal fistulas and perianal abscesses and eradicating bacteria and their by-products may be critical for successful treatment. Immunomodulatory strategies show promise as a potential avenue for the nonsurgical management of anal fistulas. Conclusions Ongoing developments in pharmacological research offer opportunities for alternative treatment options, shedding light on the prospects of noninvasive anal fistula management.
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Affiliation(s)
- Chuang Wu
- Shanghai Baoshan District Hospital of Integrated Traditional Chinese and Western Medicine, Shanghai, 201999, China
| | - Zubing Mei
- Shuguang Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, 201203, China
| | - Zhenyi Wang
- Yueyang Hospital of Integrated Traditional Chinese and Western Medicine, Shanghai University of Traditional Chinese Medicine, Shanghai, 200437, China
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Wang YQ, Wang Y, Jia XF, Yan QJ, Zheng XP. High complex anal fistula managed by the modified transanal opening of the intersphincteric space via the inter-sphincteric approach: A case report. World J Radiol 2024; 16:552-560. [PMID: 39494138 PMCID: PMC11525834 DOI: 10.4329/wjr.v16.i10.552] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2024] [Revised: 09/08/2024] [Accepted: 09/13/2024] [Indexed: 10/28/2024] Open
Abstract
BACKGROUND High complex anal fistulas are epithelialized tunnels, with the main fistula piercing above the deep external sphincter and the internal opening approaching the dentate line. Conventional surgical procedures for high complex anal fistulas remove most of the external sphincter and damage the anorectal ring. Postoperative loss of anal function can cause physical and mental damage. Transanal opening of the intersphincteric space (TROPIS) is an effective procedure that completely preserves the external anal sphincter. However, its clinical application is limited by challenges in the localization of the internal opening of a fistula and the high risk of complications. On the basis of our clinical experience, we modified the TROPIS procedure for the treatment of treating high complex anal fistulas. CASE SUMMARY A patient with a high complex anal fistula located above the anorectal ring underwent modified TROPIS, which involved sepsis drainage and identification of the internal opening in the intersphincteric space. The patient with the high complex anal fistula recovered well postoperatively, without any postoperative complications or anal dysfunction. Anal function returned to normal after 17 months of follow-up. CONCLUSION The modified TROPIS procedure is the most minimally invasive surgery for anal fistulas that minimally impairs anal function. It allows the complete removal of infected anal glands and reduces the risk of postoperative complications. Modified TROPIS via the intersphincteric approach is an alternative sphincter-preserving treatment for high complex anal fistulas.
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Affiliation(s)
- Ya-Qun Wang
- Anorectal Disease Center, Jiangsu Province traditional Chinese Medicine Innovation Center for Anorectal Disease, Nanjing 211000, Jiangsu Province, China
- Department of Anorectal Surgery, Zhenjiang Hospital Affiliated to Nanjing University of Chinese Medicine (Zhenjiang Hospital of Traditional Chinese Medicine), Zhenjiang 212000, Jiangsu Province, China
| | - Yan Wang
- Anorectal Disease Center, Jiangsu Province traditional Chinese Medicine Innovation Center for Anorectal Disease, Nanjing 211000, Jiangsu Province, China
- Department of Anorectal Surgery, Yangzhou Jiangdu Hospital of Traditional Chinese Medicine, Yangzhou 225200, Jiangsu Province, China
| | - Xiao-Feng Jia
- Department of Imaging, Nanjing Hospital of Chinese Medicine Affiliated to Nanjing University of Chinese Medicine, Nanjing 211000, Jiangsu Province, China
| | - Qiao-Jing Yan
- Anorectal Disease Center, Jiangsu Province traditional Chinese Medicine Innovation Center for Anorectal Disease, Nanjing 211000, Jiangsu Province, China
- Colorectal Disease Center, Nanjing Hospital of Chinese Medicine affiliated to Nanjing University of Chinese Medicine, Nanjing 210000, Jiangsu Province, China
| | - Xue-Ping Zheng
- Anorectal Disease Center, Jiangsu Province traditional Chinese Medicine Innovation Center for Anorectal Disease, Nanjing 211000, Jiangsu Province, China
- Colorectal Disease Center, Nanjing Hospital of Chinese Medicine affiliated to Nanjing University of Chinese Medicine, Nanjing 210000, Jiangsu Province, China
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Yi H, Zheng Y, Yan Z. Efficacy of radial incision combined with tunnel floating line drainage in the treatment of high posterior horseshoe anal fistula and perianal flora: Randomized control trial. Medicine (Baltimore) 2024; 103:e39947. [PMID: 39465802 PMCID: PMC11479427 DOI: 10.1097/md.0000000000039947] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2024] [Accepted: 09/13/2024] [Indexed: 10/29/2024] Open
Abstract
BACKGROUND Due to the high prevalence of posterior horseshoe anal fistula and causing numerous complications, this study aimed to investigate the clinical effect of radial incision combined with tunnel floating line drainage (RCTD) and arc incision internal drainage in the treatment of the disease and the influence on perianal flora. METHODS Ninety-six subjects treated with high posterior horseshoe anal fistula were stochastically assigned to a joint group (RCTD), and control group (arc incision internal drainage). The operation-related conditions, complication rate, anal function, and recurrence rate of 6 months after operation were compared, and perianal secretions were collected before operation and 1 day after operation to detect the changes of microbial flora. RESULTS After operation, it was corroborated notable difference between joint group and control group in operation time, intraoperative blood loss, wound healing time, visual analogue scale score 6 hours after operation and phase I cure rate. Chi square test analysis showed notable difference between control group (27.08%) and joint group (10.40%) in incidence of complications, in terms of number of pathogens detected around anus, significantly smaller of the incremental change for the joint subgroup versus the control subgroup 1 day after operation. CONCLUSION RCTD can be the best choice for patients with high posterior horseshoe anal fistula. This operation method has the advantages of short operation time, less trauma, fewer complications, fast recovery of anal function, and can also reduce perianal pathogenic bacteria infection.
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Affiliation(s)
- Hang Yi
- Huazhong Agricultural University Hospital, Wuhan, Hubei, P. R. China
| | - Yong Zheng
- Department of Anorectal Surgery, Wuhan Hospital of Traditional Chinese Medicine, Wuhan, Hubei, P. R. China
| | - Zhengqing Yan
- Department of Surgery, Wuhan University of Technology Hospital, Wuhan, Hubei, P. R. China
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Yang M, Mei Z, Wang Q, Han Y, Zheng D. Evaluating the efficacy of multi-incision and tube-dragging therapy combined with laser closure for high horseshoe-shaped anal fistula: Protocol of a prospective, randomized, controlled trial. PLoS One 2024; 19:e0307653. [PMID: 39331594 PMCID: PMC11432866 DOI: 10.1371/journal.pone.0307653] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Accepted: 07/03/2024] [Indexed: 09/29/2024] Open
Abstract
INTRODUCTION High horseshoe-shaped anal fistula (HHAF) is a complicated and challenging condition that presents considerable obstacles in treatment. We are presently investigating a novel surgical technique involving a combination of multi-incision and tube-dragging therapy, and laser closure (MITD-LaC) for the management of HHAF. Due to the current scarcity of rigorous evidence evaluating this approach, it is essential to perform a well-designed randomized controlled trial to compare the effectiveness of this new method with incision and thread-drawing therapy. METHODS AND ANALYSIS This trial is a prospective, randomized, controlled and interventional study. After preliminary screening of qualified outpatients, a total of 64 adult patients will be enrolled in the trial and randomly allocated to either the MITD-LaC group or the control group (n = 32 per group). These patients will receive either MITD-LaC or incision and thread-drawing therapy. The design aims to allow for a robust comparison between the two treatment modalities. The primary endpoint is the wound healing time, while secondary endpoints include postoperative anal pain at 1, 3, and 5 days (measured with visual analogue scale), fecal incontinence score within 30 days after operation (measured with Cleveland Clinic Florida incontinence score), and the occurrence of postoperative complications within 1 month after surgery, and quality of life up to six months postoperatively (evaluated by The Quality of Life in patients with Anal Fistula Questionnaire Score). DISCUSSION This study represents the first randomized controlled trial evaluating the short-term outcomes of MITD-LaC, thereby aiming to contribute high-quality evidence to guide clinical practice. Moreover, this trial incorporates comprehensive outcome measures assessing both subjective and objective dimensions. Because of this multidimensional assessment, MITD-LaC offers a promising potential for broader application in the treatment of HHAF. Consequently, obtaining more definitive and authoritative evidence through scientifically rigorous clinical trials is of utmost importance in further validating this treatment approach. ETHICS AND DISSEMINATION We have submitted the clinical study protocol to the Ethics Committee, and it has been approved under ethical approval number 2021-1036-111-01. The results of the trial will be disseminated through peer-reviewed academic journals and presentations at professional conferences. REGISTRATION NUMBER ChiCTR2100053556.
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Affiliation(s)
- Min Yang
- Department of Anorectal Surgery, Shuguang Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Zubing Mei
- Department of Anorectal Surgery, Shuguang Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, China
- Anorectal Disease Institute of Shuguang Hospital, Shanghai, China
| | - Qingming Wang
- Department of Anorectal Surgery, Shuguang Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Ye Han
- Department of Anorectal Surgery, Shuguang Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - De Zheng
- Department of Anorectal Surgery, Shuguang Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, China
- Anorectal Disease Institute of Shuguang Hospital, Shanghai, China
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Zhang D, Gu J, Xu Y, Yu X, Jin H. Exploring the mechanism of Huanglian ointment in alleviating wound healing after anal fistula surgery through metabolomics and proteomics. Heliyon 2024; 10:e29809. [PMID: 38699024 PMCID: PMC11064137 DOI: 10.1016/j.heliyon.2024.e29809] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2023] [Revised: 03/23/2024] [Accepted: 04/15/2024] [Indexed: 05/05/2024] Open
Abstract
Anal fistula is a common anal and intestinal disease. The wound of anal fistula surgery is open and polluting, which is the most difficult to heal among all surgical incisions. To investigate the mechanism of Huanglian ointment (HLO) on wound healing after anal fistula incision. The S. aureus infected wound in SD rats were used to imitate poor healing wound after anal fistula surgery. SD rats with wound sites (n = 24) were randomly divided into four groups (Control group, Model group, Potassium permanganate (PP) treatment group, and HLO treatment group). The wound healing rate was evaluated, HE staining was used to evaluate the pathological changes of each group, ELISA was used to detect the secretion of inflammatory factors in each group, and the mechanism was explored through metabolomics and proteomics in plasma rat. Compared to other groups, the rate of wound healing in the HLO group was higher on days 7 and 14. Histological analysis showed that collagen and fibroblast in HLO rats were significantly increased, inflammatory cells were reduced, and vascular endothelial permeability was increased. ELISA results showed that the secretion of inflammatory factors in HLO rats was significantly lower. Significant proteins and metabolites were identified in the wound tissues of the infected rats and HLO-treated rats, which were mainly attributed to Cdc42, Ctnnb1, Actr2, Actr3, Arpc1b, Itgam, Itgb2, Cttn, Linoleic acid metabolism, d-Glutamine and d-glutamate metabolism, Phenylalanine, tyrosine and tryptophan biosynthesis, Phenylalanine metabolism, alpha-Linolenic acid metabolism, and Ascorbate and aldarate metabolism. In conclusion, this study showed that HLO can promote S. aureus infected wound healing, and the data provide a theoretical basis for the treatment of wounds after anal fistula surgery with HLO.
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Affiliation(s)
- Dongliang Zhang
- Nanjing University of Chinese Medicine, Nanjing, 210023, China
- Department of Colorectal and Anal Surgery, Zhenjiang Hospital Affiliated to Nanjing University of Chinese Medicine (Zhenjiang Hospital of Traditional Chinese Medicine), Zhenjiang, 212001, China
| | - Jiabo Gu
- Nanjing University of Chinese Medicine, Nanjing, 210023, China
- Department of Colorectal and Anal Surgery, The Second Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing, 210011, China
| | - Yanyan Xu
- Department of Colorectal and Anal Surgery, The Second Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing, 210011, China
| | - Xiaowen Yu
- Department of Colorectal and Anal Surgery, Zhenjiang Hospital Affiliated to Nanjing University of Chinese Medicine (Zhenjiang Hospital of Traditional Chinese Medicine), Zhenjiang, 212001, China
| | - Heiying Jin
- Department of Colorectal and Anal Surgery, The Second Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing, 210011, China
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Włodarczyk M, Włodarczyk J, Maryńczak K, Waśniewska-Włodarczyk A, Dziki Ł, Fichna J. The impact of adipose fat tissue on the pathogenesis of crypto-glandular anal fistula. POLISH JOURNAL OF SURGERY 2024; 96:12-17. [PMID: 39465628 DOI: 10.5604/01.3001.0054.4682] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/29/2024]
Abstract
<b>Indroduction:</b> Cryptoglandular perianal fistula represents a prevalent benign anorectal condition, primarily addressed through surgical interventions, occasionally posing considerable therapeutic challenges. The associated decline in patient quality of life underscores the significance of effective management. However, the lack of a fully understood pathogenesis complicates the treatment approach. Recent research has proposed the involvement of adipose fat tissue in the inflammatory response and pathogenesis of cryptoglandular anal fistula.<b>Aim:</b> The study aims to characterize the role of adipose fat tissue in the pathogenesis of cryptoglandular anal fistula, with a specific focus on understanding the potential involvement of proinflammatory cytokines in the development of chronic inflammation.<b>Materials and methods:</b> This study involved the characterization of serum levels of inflammatory cytokines and adipose tissue hormones. A total of 35 samples from both simple and complex cryptoglandular perianal fistula cases were collected during surgical procedures.<b>Results:</b> Serum levels of leptin, resistin, IL-1β, and IL-8 were significantly elevated in patients operated on due to complex cryptoglandular perianal fistula when compared to patients with simple fistula. Adiponectin was significantly lowered in samples from complex perianal fistula in comparison to simple fistula.<b>Conclusions:</b> Complex perianal cryptoglandular fistula has a reduced level of anti-inflammatory adipokines i.e. adiponectin, and an increased level of proinflammatory resistin, leptin, IL-1β, and IL-8.
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Affiliation(s)
- Marcin Włodarczyk
- Department of General and Oncological Surgery, Faculty of Medicine, Medical University of Lodz, Poland
| | - Jakub Włodarczyk
- Department of General and Oncological Surgery, Faculty of Medicine, Medical University of Lodz, Poland, Department of Biochemistry, Faculty of Medicine, Medical University of Lodz, Poland
| | - Kasper Maryńczak
- Department of General and Oncological Surgery, Faculty of Medicine, Medical University of Lodz, Poland
| | | | - Łukasz Dziki
- Department of General and Oncological Surgery, Faculty of Medicine, Medical University of Lodz, Poland
| | - Jakub Fichna
- Department of Biochemistry, Faculty of Medicine, Medical University of Lodz, Poland
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Yu Z, Su X. Clinical study of electro-coagulation tunneling method based on oligopolistic technique for the treatment of low single anal fistula. Asian J Surg 2024; 47:1182-1183. [PMID: 37973479 DOI: 10.1016/j.asjsur.2023.11.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Accepted: 11/03/2023] [Indexed: 11/19/2023] Open
Affiliation(s)
- Zhihan Yu
- Department of Plastic Surgery, Dalian University Affiliated Xinhua Hospital, Dalian, 116021, China
| | - Xiaowei Su
- Department of Plastic Surgery, Dalian University Affiliated Xinhua Hospital, Dalian, 116021, China.
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Ghasemlouei A, Naseri A, Ashjaei A, Sadeghi S, Keshvari A. Evaluation surgical strategies in perianal fistulas treatment: Efficacy draining seton compared to other surgical approaches; a case-control study. Health Sci Rep 2024; 7:e1911. [PMID: 38410496 PMCID: PMC10894753 DOI: 10.1002/hsr2.1911] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2023] [Revised: 12/12/2023] [Accepted: 01/21/2024] [Indexed: 02/28/2024] Open
Abstract
Background and Aims Perianal fistula is a prevalent anorectal condition originating from an infectious crypt extending to the external opening. Multiple surgical methods exist for treating perianal fistulas; however, selecting the appropriate options is still controversial. Our study aims to evaluate seton replacement versus other surgical methods in treating perianal fistula. Methods This study recruited 72 patients presenting with perianal discharge and diagnosed with perianal fistula through intra-sphincteric, trans-sphincteric, and supra-sphincteric examinations at Imam Reza and Besat Hospitals from July 2022 up to March 2023. Regarding case-control design, patients were divided into two groups: the first group (n = 36) underwent seton insertion, while the control group (n = 36) received alternative surgical methods. Follow-up was conducted for 1 month post-discharge, with monthly visits for 6 months. Patients were evaluated for fistula tract healing, seton loosening, and daily secretion rate (based on infected pads) during each visit. Finally, the two groups were compared in terms of improvement rates. Results In the seton group, approximately 94.4% of patients showed improvement. However, the difference between the groups was insignificant (p = 0.494). Seton replacement was performed in 52% of patients, with the majority requiring replacement twice (61%). Improvement rates were highest among cases with two seton replacements, although the difference was not statistically significant (p = 0.073). Following seton replacement, the most common treatment methods were endoanal flap and fistulotomy, with observed improvement in 10 cases for each procedure. Conclusion This study highlights that draining seton remains a primary choice for intermediate treatment due to its satisfactory improvement rate and lower requirement for replacement, especially up to two times.
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Affiliation(s)
- Amir Ghasemlouei
- Department of SurgeryAja University of Medical SciencesTehranIran
| | | | - Ali Ashjaei
- Department of SurgeryAja University of Medical SciencesTehranIran
| | - Shahryar Sadeghi
- Division of Colorectal Surgery, Department of Surgery, Imam‐Khomeini Hospital ComplexUniversity of Medical SciencesTehranIran
| | - Amir Keshvari
- Division of Colorectal Surgery, Department of Surgery, Imam‐Khomeini Hospital ComplexUniversity of Medical SciencesTehranIran
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Włodarczyk M, Włodarczyk J, Maryńczak K, Waśniewska-Włodarczyk A, Doboszewska U, Wlaź P, Dziki Ł, Fichna J. Role of Adipose Tissue Hormones in Pathogenesis of Cryptoglandular Anal Fistula. Int J Mol Sci 2024; 25:1501. [PMID: 38338780 PMCID: PMC10855462 DOI: 10.3390/ijms25031501] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Revised: 11/21/2023] [Accepted: 01/23/2024] [Indexed: 02/12/2024] Open
Abstract
The cryptoglandular perianal fistula is a common benign anorectal disorder that is managed mainly with surgery and in some cases may be an extremely challenging condition. Perianal fistulas are often characterized by significantly decreased patient quality of life. Lack of fully recognized pathogenesis of this disease makes it difficult to treat it properly. Recently, adipose tissue hormones have been proposed to play a role in the genesis of cryptoglandular anal fistulas. The expression of adipose tissue hormones and epithelial-to-mesenchymal transition (EMT) factors were characterized based on 30 samples from simple fistulas and 30 samples from complex cryptoglandular perianal fistulas harvested during surgery. Tissue levels of leptin, resistin, MMP2, and MMP9 were significantly elevated in patients who underwent operations due to complex cryptoglandular perianal fistulas compared to patients with simple fistulas. Adiponectin and E-cadherin were significantly lowered in samples from complex perianal fistulas in comparison to simple fistulas. A negative correlation between leptin and E-cadherin levels was observed. Resistin and MMP2 levels, as well as adiponectin and E-cadherin levels, were positively correlated. Complex perianal cryptoglandular fistulas have a reduced level of the anti-inflammatory adipokine adiponectin and have an increase in the levels of proinflammatory resistin and leptin. Abnormal secretion of these adipokines may affect the integrity of the EMT in the fistula tract. E-cadherin, MMP2, and MMP9 expression levels were shifted in patients with more advanced and complex perianal fistulas. Our results supporting the idea of using mesenchymal stem cells in the treatment of cryptoglandular perianal fistulas seem reasonable, but further studies are warranted.
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Affiliation(s)
- Marcin Włodarczyk
- Department of General and Oncological Surgery, Faculty of Medicine, Medical University of Lodz, Pomorska 251, 92-213 Lodz, Poland
| | - Jakub Włodarczyk
- Department of General and Oncological Surgery, Faculty of Medicine, Medical University of Lodz, Pomorska 251, 92-213 Lodz, Poland
- Department of Biochemistry, Faculty of Medicine, Medical University of Lodz, Mazowiecka 6/8, 92-215 Lodz, Poland
| | - Kasper Maryńczak
- Department of General and Oncological Surgery, Faculty of Medicine, Medical University of Lodz, Pomorska 251, 92-213 Lodz, Poland
| | - Anna Waśniewska-Włodarczyk
- Department of Normal and Clinical Anatomy, Medical University of Lodz, Żeligowskiego 7/9, 90-752 Lodz, Poland
| | - Urszula Doboszewska
- Department of Pharmacobiology, Jagiellonian University Medical College, Medyczna 9, 30-688 Kraków, Poland
| | - Piotr Wlaź
- Department of Animal Physiology and Pharmacology, Institute of Biological Sciences, Maria Curie-Skłodowska University, Akademicka 19, 20-033 Lublin, Poland
| | - Łukasz Dziki
- Department of General and Oncological Surgery, Faculty of Medicine, Medical University of Lodz, Pomorska 251, 92-213 Lodz, Poland
| | - Jakub Fichna
- Department of Biochemistry, Faculty of Medicine, Medical University of Lodz, Mazowiecka 6/8, 92-215 Lodz, Poland
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14
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Yang J, Li L, Su W, Zhang S, Xu H, Wang M, Shen W. Microbiomic signatures of anal fistula and putative sources of microbes. Front Cell Infect Microbiol 2024; 14:1332490. [PMID: 38312743 PMCID: PMC10834682 DOI: 10.3389/fcimb.2024.1332490] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Accepted: 01/02/2024] [Indexed: 02/06/2024] Open
Abstract
Anal fistula is a common perianal disease that typically develops from an abscess caused by in-flammation in the area. It has long been believed that intestinal microbes play a significant role in its development, considering its close relation to the intestinal environment. This work attempts to identify the microbiomic signatures of anal fistula, and putative sources of microbes by analyzing microbiomes of 7 anal fistula-associated sites in 12 patients. This study found that microbes in anal fistulas may originate from the skin surface in addition to the intestinal tract. This finding was further validated by NMDS analysis, which also indicated that the microbial communities in the inner and outer openings of the fistula were more similar to their surrounding environments. Using MaAslin2, the characteristics of the microbiome were examined, demonstrating a higher similarity between the abundant bacteria in the anal fistula samples and those found on the skin surface. Moreover, pin-to-pair analysis conducted on all subjects consistently showed a higher abundance of skin-sourced bacteria in anal fistulas. This study identifies the microbiomic signatures of anal fistula, and provides novel insights into the origin of microorganisms in anal fistulas.
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Affiliation(s)
- Jun Yang
- Department of Anorectal Surgery, Qilu Hospital of Shandong University (Qingdao), Qingdao, Shandong, China
| | - Ling Li
- State Key Laboratory of Microbial Technology, Microbial Technology Institute, Shandong University, Qingdao, China
| | - Wenya Su
- State Key Laboratory of Microbial Technology, Microbial Technology Institute, Shandong University, Qingdao, China
| | - Shuqin Zhang
- Department of Anorectal Surgery, Yinan Hospital of Traditional Chinese Medicine, Linyi, Shandong, China
| | - Hai Xu
- State Key Laboratory of Microbial Technology, Microbial Technology Institute, Shandong University, Qingdao, China
| | - Mingyu Wang
- State Key Laboratory of Microbial Technology, Microbial Technology Institute, Shandong University, Qingdao, China
| | - Wenlong Shen
- Department of Anorectal Surgery, Qilu Hospital of Shandong University (Qingdao), Qingdao, Shandong, China
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15
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Reza L, Gottgens K, Kleijnen J, Breukink S, Ambe PC, Aigner F, Aytac E, Bislenghi G, Nordholm-Carstensen A, Elfeki H, Gallo G, Grossi U, Gulcu B, Iqbal N, Jimenez-Rodriguez R, Leventoglu S, Lisi G, Litta F, Lung P, Millan M, Ozturk E, Sackitey C, Shalaby M, Stijns J, Tozer P, Zimmerman D. European Society of Coloproctology: Guidelines for diagnosis and treatment of cryptoglandular anal fistula. Colorectal Dis 2024; 26:145-196. [PMID: 38050857 DOI: 10.1111/codi.16741] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Revised: 07/11/2023] [Accepted: 08/03/2023] [Indexed: 12/07/2023]
Abstract
AIM The primary aim of the European Society of Coloproctology (ESCP) Guideline Development Group (GDG) was to produce high-quality, evidence-based guidelines for the management of cryptoglandular anal fistula with input from a multidisciplinary group and using transparent, reproducible methodology. METHODS Previously published methodology in guideline development by the ESCP has been replicated in this project. The guideline development process followed the requirements of the AGREE-S tool kit. Six phases can be identified in the methodology. Phase one sets the scope of the guideline, which addresses the diagnostic and therapeutic management of perianal abscess and cryptoglandular anal fistula in adult patients presenting to secondary care. The target population for this guideline are healthcare practitioners in secondary care and patients interested in understanding the clinical evidence available for various surgical interventions for anal fistula. Phase two involved formulation of the GDG. The GDG consisted of 21 coloproctologists, three research fellows, a radiologist and a methodologist. Stakeholders were chosen for their clinical and academic involvement in the management of anal fistula as well as being representative of the geographical variation among the ESCP membership. Five patients were recruited from patient groups to review the draft guideline. These patients attended two virtual meetings to discuss the evidence and suggest amendments. In phase three, patient/population, intervention, comparison and outcomes questions were formulated by the GDG. The GDG ratified 250 questions and chose 45 for inclusion in the guideline. In phase four, critical and important outcomes were confirmed for inclusion. Important outcomes were pain and wound healing. Critical outcomes were fistula healing, fistula recurrence and incontinence. These outcomes formed part of the inclusion criteria for the literature search. In phase five, a literature search was performed of MEDLINE (Ovid), PubMed, Embase (Ovid) and the Cochrane Database of Systematic Reviews by eight teams of the GDG. Data were extracted and submitted for review by the GDG in a draft guideline. The most recent systematic reviews were prioritized for inclusion. Studies published since the most recent systematic review were included in our analysis by conducting a new meta-analysis using Review manager. In phase six, recommendations were formulated, using grading of recommendations, assessment, development, and evaluations, in three virtual meetings of the GDG. RESULTS In seven sections covering the diagnostic and therapeutic management of perianal abscess and cryptoglandular anal fistula, there are 42 recommendations. CONCLUSION This is an up-to-date international guideline on the management of cryptoglandular anal fistula using methodology prescribed by the AGREE enterprise.
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Affiliation(s)
| | | | - Jos Kleijnen
- KSR Ltd & Maastricht University Medical Center (MUMC+) -CAPHRI, Maastricht, Netherlands
| | | | | | | | | | | | | | | | | | - Ugo Grossi
- Treviso Regional Hospital, Treviso, Italy
| | | | | | | | | | | | | | | | - Monica Millan
- La Fe University and Polytechnic Hospital, Valencia, Spain
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16
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Skovgaards DM, Perregaard H, Dibbern CB, Nordholm-Carstensen A. Fistula development after anal abscess drainage-a multicentre retrospective cohort study. Int J Colorectal Dis 2023; 39:4. [PMID: 38093036 PMCID: PMC10719138 DOI: 10.1007/s00384-023-04576-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/29/2023] [Indexed: 12/17/2023]
Abstract
PURPOSE Anal abscesses are common and, despite correct treatment with surgical drainage, carry the risk of developing fistulas. Studies identifying risk factors for the development of anal fistulas are sparse. This study aimed to identify the risk factors for anal fistulas after anal abscess surgery. METHODS This was a multicentre, retrospective cohort study of patients undergoing acute surgery for anal abscesses in the Capital Region of Denmark between 2018 and 2019. The patients were identified using ICD-10 codes for anal abscesses. Predefined clinicopathological factors and postoperative courses were extracted from patient records. RESULTS A total of 475 patients were included. At a median follow-up time of 1108 days (IQR 946-1320 days) following surgery, 164 (33.7%) patients were diagnosed with an anal fistula. Risk factors for developing fistulas were low intersphincteric (OR 2.77, 95CI 1.50-5.06) and ischioanal (OR 2.48, 95CI 1.36-4.47) abscesses, Crohn's disease (OR 5.96, 95CI 2.33-17.2), a history of recurrent anal abscesses (OR 4.14, 95CI 2.47-7.01) or repeat surgery (OR 5.96, 95CI 2.33-17.2), E. coli-positive pus cultures (OR 4.06, 1.56-11.4) or preoperative C-reactive protein (CRP) of more than 100 mg/L (OR 3.21, 95CI 1.57-6.71). CONCLUSION Several significant clinical risk factors were associated with fistula development following anal abscess surgery. These findings are clinically relevant and could influence the selection of patients for specialised follow-up, facilitate expedited diagnosis, and potentially prevent unnecessarily long treatment courses.
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Affiliation(s)
- Daniel Mark Skovgaards
- Digestive Disease Center, Bispebjerg Hospital, University of Copenhagen, Copenhagen, Denmark.
| | - Helene Perregaard
- Surgical Department, Nordsjællands Hospital, University of Copenhagen, Hillerød, Denmark
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17
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Varsamis N, Kosmidis C, Chatzimavroudis G, Apostolidou Kiouti F, Efthymiadis C, Lalas V, Mystakidou CM, Sevva C, Papadopoulos K, Anthimidis G, Koulouris C, Karakousis AV, Sapalidis K, Kesisoglou I. Preoperative Assessment of Perianal Fistulas with Combined Magnetic Resonance and Tridimensional Endoanal Ultrasound: A Prospective Study. Diagnostics (Basel) 2023; 13:2851. [PMID: 37685389 PMCID: PMC10486944 DOI: 10.3390/diagnostics13172851] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2023] [Revised: 08/29/2023] [Accepted: 08/31/2023] [Indexed: 09/10/2023] Open
Abstract
BACKGROUND we designed a prospective study of diagnostic accuracy that compared pelvic MRI and 3D-EAUS with pelvic MRI alone in the preoperative evaluation and postoperative outcomes of patients with perianal fistulas. METHODS the sample size was 72 patients and this was divided into two imaging groups. MRI alone was performed on the first group. Both MRI and 3D-EAUS were performed in parallel on the second group. Surgical exploration took place after two weeks and was the standard reference. Park's classification, the presence of a concomitant abscess or a secondary tract, and the location of the internal opening were recorded. All patients were re-evaluated for complete fistula healing and fecal incontinence six months postoperatively. All of the collected data were subjected to statistical analysis. RESULTS the MRI group included 36 patients with 42 fistulas. The MRI + 3D-EAUS group included 36 patients with 46 fistulas. The adjusted sensitivity and negative predictive value were 1.00 for most fistula types in the group that underwent combined imaging. The adjusted specificity improved for intersphincteric fistulas in the same group. The adjusted balanced accuracy improved for all fistula types except rectovaginal. The combination of imaging methods showed improved diagnostic accuracy only in the detection of a secondary tract. The healing rate at six months was 100%. Fecal incontinence at six months did not present a statistically significant difference between the two groups (Fisher's exact test p-value > 0.9). Patients with complex perianal fistulas had a statistically significant higher probability of undergoing a second surgery (x2 test p-value = 0.019). CONCLUSIONS the combination of pelvic MRI and 3D-EAUS showed improved metrics of diagnostic accuracy and should be used in the preoperative evaluation of all patients with perianal fistulas, especially those with complex types.
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Affiliation(s)
- Nikolaos Varsamis
- Third Surgical Department, “AHEPA” University Hospital, Medical Faculty, Aristotle University of Thessaloniki, 1 Kiriakidi Street, 54636 Thessaloniki, Greece; (C.K.); (C.S.); (K.P.); (C.K.); (A.V.K.); (K.S.); (I.K.)
| | - Christoforos Kosmidis
- Third Surgical Department, “AHEPA” University Hospital, Medical Faculty, Aristotle University of Thessaloniki, 1 Kiriakidi Street, 54636 Thessaloniki, Greece; (C.K.); (C.S.); (K.P.); (C.K.); (A.V.K.); (K.S.); (I.K.)
| | - Grigorios Chatzimavroudis
- Second Surgical Department, “G. Gennimatas” University Hospital, Medical Faculty, Aristotle University of Thessaloniki, 41 Eth. Aminis Steet, 54635 Thessaloniki, Greece;
| | - Fani Apostolidou Kiouti
- Biostatistics Unit, Medical Faculty, Aristotle University of Thessaloniki, 54124 Thessaloniki, Greece;
| | | | - Vasilis Lalas
- Radiology Department, “Euromedica” Diagnostic Center, 35 Gr. Lampraki & Ag. Dimitriou Street, 54638 Thessaloniki, Greece;
| | | | - Christina Sevva
- Third Surgical Department, “AHEPA” University Hospital, Medical Faculty, Aristotle University of Thessaloniki, 1 Kiriakidi Street, 54636 Thessaloniki, Greece; (C.K.); (C.S.); (K.P.); (C.K.); (A.V.K.); (K.S.); (I.K.)
| | - Konstantinos Papadopoulos
- Third Surgical Department, “AHEPA” University Hospital, Medical Faculty, Aristotle University of Thessaloniki, 1 Kiriakidi Street, 54636 Thessaloniki, Greece; (C.K.); (C.S.); (K.P.); (C.K.); (A.V.K.); (K.S.); (I.K.)
| | - George Anthimidis
- Surgical Department, European Interbalkan Medical Center, 10 Asklipiou Street, 55535 Thessaloniki, Greece;
| | - Charilaos Koulouris
- Third Surgical Department, “AHEPA” University Hospital, Medical Faculty, Aristotle University of Thessaloniki, 1 Kiriakidi Street, 54636 Thessaloniki, Greece; (C.K.); (C.S.); (K.P.); (C.K.); (A.V.K.); (K.S.); (I.K.)
| | - Alexandros Vasileios Karakousis
- Third Surgical Department, “AHEPA” University Hospital, Medical Faculty, Aristotle University of Thessaloniki, 1 Kiriakidi Street, 54636 Thessaloniki, Greece; (C.K.); (C.S.); (K.P.); (C.K.); (A.V.K.); (K.S.); (I.K.)
| | - Konstantinos Sapalidis
- Third Surgical Department, “AHEPA” University Hospital, Medical Faculty, Aristotle University of Thessaloniki, 1 Kiriakidi Street, 54636 Thessaloniki, Greece; (C.K.); (C.S.); (K.P.); (C.K.); (A.V.K.); (K.S.); (I.K.)
| | - Isaak Kesisoglou
- Third Surgical Department, “AHEPA” University Hospital, Medical Faculty, Aristotle University of Thessaloniki, 1 Kiriakidi Street, 54636 Thessaloniki, Greece; (C.K.); (C.S.); (K.P.); (C.K.); (A.V.K.); (K.S.); (I.K.)
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18
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Cai P, Rong H, Zhu Q, Dai X, Zhao J. The potential roles of gut microbiome in anal fistula. AMB Express 2023; 13:58. [PMID: 37301777 DOI: 10.1186/s13568-023-01560-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2023] [Accepted: 05/14/2023] [Indexed: 06/12/2023] Open
Abstract
Anal fistula is a common proctological disease, but the thorough mechanisms of the anal fistula formation are still unclear. An increasing number of studies have revealed the crucial role of gut microbiota in intestinal diseases. We used 16S rRNA gene sequencing to analyze the intestinal microbiome in order to determine whether there are differences in the microbiome between anal fistula patients and healthy individuals. The microbiome samples were extracted by repeatedly wiping the rectal wall with intestinal swab. Before this operation, the whole intestine of all participants was irrigated and the score of the Boston bowel preparation scale reached 9. The biodiversity of gut microbiome of rectum revealed significant difference between anal fistula patients and healthy individuals. 36 discriminative taxa were identified by LEfSe analysis between two groups. At the phylum level, Synergistetes was enriched in anal fistula patients, while Proteobacteria was higher in healthy individuals. We also found that at the genus level, Blautia, Faecalibacterium, Ruminococcus, Coprococcus, Bacteroides, Clostridium, Megamonas and Anaerotruncus were highly enriched in anal fistula patients, while the microbiome of healthy individuals was enriched with Peptoniphilus and Corynebacterium. Spearman correlations showed the extensive and close association among genera and species. Finally, a diagnostic prediction model was constructed by random forest classifier, and the area under curve (AUC) reached 0.990. This study gave an important hint for analyzing gut microbiome of rectum in anal fistula patient.Keypoints.We use the 16S rRNA gene sequencing to test the microbiome samples extracted from the intestinal swab. This is the first study to explore the gut microbiome of rectum using this workflow. We also found the distinct gut microbiome of rectum differences between anal fistula patients and healthy individuals.
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Affiliation(s)
- Ping Cai
- Ningbo No.2 Hospital, Ningbo, 315000, China
- Ningbo Institute of Life and Health Industry, University of Chinese Academy of Sciences, Ningbo, 315000, China
- Key Laboratory of Diagnosis and Treatment of Digestive System Tumors of Zhejiang Province, Ningbo, 315000, China
| | - Hao Rong
- Ningbo No.2 Hospital, Ningbo, 315000, China.
- The Affiliated Hospital of Medical School of Ningbo University, Ningbo, 315000, China.
- Department of Preventive Medicine, Zhejiang Provincial Key Laboratory of Pathological and Physiological Technology, School of Medicine, Ningbo, 315211, China.
| | - Qiaoqiao Zhu
- Ningbo No.2 Hospital, Ningbo, 315000, China
- Ningbo Institute of Life and Health Industry, University of Chinese Academy of Sciences, Ningbo, 315000, China
- Key Laboratory of Diagnosis and Treatment of Digestive System Tumors of Zhejiang Province, Ningbo, 315000, China
| | - Xiaoyu Dai
- Ningbo No.2 Hospital, Ningbo, 315000, China
- Ningbo Institute of Life and Health Industry, University of Chinese Academy of Sciences, Ningbo, 315000, China
- Key Laboratory of Diagnosis and Treatment of Digestive System Tumors of Zhejiang Province, Ningbo, 315000, China
| | - Jianpei Zhao
- Ningbo No.2 Hospital, Ningbo, 315000, China
- Ningbo Institute of Life and Health Industry, University of Chinese Academy of Sciences, Ningbo, 315000, China
- Key Laboratory of Diagnosis and Treatment of Digestive System Tumors of Zhejiang Province, Ningbo, 315000, China
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Schwandner O. [Stem Cell Therapy for Complex Anal Fistula in Crohn`s Disease: Current Evidence and Future Perspectives]. Zentralbl Chir 2023; 148:220-227. [PMID: 37267976 DOI: 10.1055/a-2063-3673] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
Despite progress in multidisciplinary diagnostic and therapeutic strategies, complex anal fistulas associated with Crohn's disease remain a challenge for both medical and surgical management. Conventional surgical techniques such as flap procedures or LIFT are still associated with considerable persistence and recurrence rates. Based on this background, results of stem cell therapy for Crohn's anal fistula have shown promising results and are a sphincter-preserving technique. In particular, adipose-derived, allogeneic stem cell therapy (Darvadstrocel) has shown encouraging healing rates within the randomised controlled ADMIRE-CD trial, which were reproducible in "real world" data of limited clinical studies. The current evidence has led to the integration of allogeneic stem cell therapy into international guidelines. To date, the definitive status of allogeneic stem cells in the multidisciplinary treatment algorithm for complex anal fistulas associated with Crohn's disease cannot be evaluated.
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Affiliation(s)
- Oliver Schwandner
- Abteilung für Proktologie, Krankenhaus Barmherzige Brüder, Regensburg, Deutschland
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20
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Fritz S, Reissfelder C, Bussen D. Current Therapy of Cryptoglandular Anal Fistula: Gold Standards and Alternative Methods. Zentralbl Chir 2023; 148:209-219. [PMID: 37267975 DOI: 10.1055/a-2049-9722] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
Cryptoglandular anal fistulas are one of the most common colorectal diseases and occur with an incidence of about 20/100,000. Anal fistulas are defined as an inflammatory junction between the anal canal and the perianal skin. They develop from an abscess or chronic infection of the anorectum. Surgical treatment of the disease is the method of choice. Even when treating an acute abscess, its cause should be sought at the same time. If there is a connection to the anal canal without affecting relevant parts of the sphincter muscles, primary fistulotomy should be performed. If larger parts of the sphincter muscle are involved, the insertion of a seton drain is usually useful. There are essentially two recommendations for the elective treatment of cryptoglandular anal fistulas. Distal fistulas should be excised, with the proviso that as little sphincter muscle as possible is sacrificed. In the case of highly proximally located and complex fistulas, sphincter-preserving surgical techniques should be used. In this case, the method of choice is the mucosal or advancement flap. Alternatively, clips, fibrin injections, fistula plugs, fistula ligatures, or laser-based procedures are described in the literature. In the case of intermediate fistulas, a fistulectomy with primary sphincter reconstruction can be useful. Every operation is carried out as a compromise between definitive healing of the fistula and a potential risk to the patient's continence. It is often difficult to make a reliable prognosis about the continence function to be expected postoperatively. In addition to the fistula morphology, particular attention should be paid to whether previous proctological operations have already been performed, the gender of the patient, and whether there are pre-existing sphincter dysfunctions. Since the surgeon's expertise plays a decisive role in the success of the treatment, the procedure should be carried out in a specialist proctological centre, especially in the case of complex fistulas or in the case of a condition after previous operations. In addition to the classic procedures, such as fistulectomy or the plastic fistula closure, this article examines alternative methods and their areas of application.
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Affiliation(s)
- Stefan Fritz
- Deutsches End- und Dickdarmzentrum Mannheim, Mannheim, Deutschland
- Chirurgische Klinik, Universitätsmedizin Mannheim, Medizinische Fakultät Mannheim, Universität Heidelberg, Mannheim, Mannheim, Deutschland
| | - Christoph Reissfelder
- Chirurgische Klinik, Universitätsmedizin Mannheim, Medizinische Fakultät Mannheim, Universität Heidelberg, Mannheim, Mannheim, Deutschland
| | - Dieter Bussen
- Deutsches End- und Dickdarmzentrum Mannheim, Mannheim, Deutschland
- Chirurgische Klinik, Universitätsmedizin Mannheim, Medizinische Fakultät Mannheim, Universität Heidelberg, Mannheim, Mannheim, Deutschland
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21
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Charalampopoulos A, Papakonstantinou D, Bagias G, Nastos K, Perdikaris M, Papagrigoriadis S. Surgery of Simple and Complex Anal Fistulae in Adults: A Review of the Literature for Optimal Surgical Outcomes. Cureus 2023; 15:e35888. [PMID: 36911578 PMCID: PMC9993441 DOI: 10.7759/cureus.35888] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/08/2023] [Indexed: 03/11/2023] Open
Abstract
Anal fistulas are common anorectal conditions, and surgery is the primary treatment option. In the last 20 years of literature, there exist a large number of surgical procedures, especially for the treatment of complex anal fistulas, as they present more recurrences and continence problems than simple anal fistulas. To date, there are no guidelines for choosing the best technique. We conducted a recent literature review, mainly the last 20 years, based on the PubMed and Google Scholar medical databases, with the goal of identifying the surgical procedures with the highest success rates, lowest recurrence rates, and best safety profiles. Clinical trials, retrospective studies, review articles, comparative studies, recent systematic reviews, and meta-analyses for various surgical techniques, as well as the latest guidelines of the American Society of Colon and Rectal Surgeons, the Association of Coloproctology of Great Britain and Ireland, and the German S3 guidelines on simple and complex fistulas were reviewed. According to the literature, there is no recommendation for the optimal surgical technique. The etiology, complexity, and many other factors affect the outcome. In simple intersphincteric anal fistulas, fistulotomy is the procedure of choice. In simple low transsphincteric fistulas, the patient's selection is crucial in order to perform a safe fistulotomy or another sphincter-saving technique. The healing rate in simple anal fistulas is higher than 95% with low recurrence and without significant postoperative complications. In complex anal fistulas, only sphincter-saving techniques should be used; the optimal outcomes are obtained by the ligation of the intersphincteric fistulous tract (LIFT) and rectal advancement flaps. Those techniques assure high healing rates of 60-90%. The novel technique of the transanal opening of the intersphincteric space (TROPIS) is under evaluation. The novel sphincter-saving techniques of fistula laser closure (FiLac) and video-assisted anal fistula treatment (VAAFT) are safe, with reported healing rates ranging from 65% to 90%. Surgeons should be familiar with all sphincter-saving techniques in order to face the variability of the fistulas-in-ano. Currently, there is no universally superior technique that can treat all fistulas.
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Affiliation(s)
- Anestis Charalampopoulos
- Third Department of Surgery, "Attikon" University General Hospital/National and Kapodistrian University of Athens, School of Medicine, Athens, GRC
| | - Dimitrios Papakonstantinou
- Third Department of Surgery, "Attikon" University General Hospital/National and Kapodistrian University of Athens, School of Medicine, Athens, GRC
| | - George Bagias
- Third Department of Surgery, "Attikon" University General Hospital/National and Kapodistrian University of Athens, School of Medicine, Athens, GRC
| | - Konstantinos Nastos
- Third Department of Surgery, "Attikon" University General Hospital/National and Kapodistrian University of Athens, School of Medicine, Athens, GRC
| | - Markos Perdikaris
- Third Department of Surgery, "Attikon" University General Hospital/National and Kapodistrian University of Athens, School of Medicine, Athens, GRC
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22
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Tang X, He T, Li X, Liu Y, Wu Y, You G, Li J, Yun Y, Wu L, Li L, Kang J. Clinical features and independent predictors of postoperative refractory trauma to anal fistula combined with T2DM: A propensity score-matched analysis-retrospective cohort study. Front Surg 2023; 10:1119113. [PMID: 36911620 PMCID: PMC9998506 DOI: 10.3389/fsurg.2023.1119113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Accepted: 01/31/2023] [Indexed: 02/26/2023] Open
Abstract
Background Refractory wound is a common postoperative complication in anal fistula surgery, when combined with type 2 diabetes mellitus (T2DM) it presents a slower recovery time and more complex wound physiology. The study aims to investigate factors associated with wound healing in patients with T2DM. Materials and methods 365 T2DM patients who underwent anal fistula surgery at our institution were recruited from June 2017 to May 2022. Through propensity score-matched (PSM) analysis, multivariate logistic regression analysis was applied to determine independent risk factors affecting wound healing. Results 122 pairs of patients with no significant differences were successfully established in matched variables. Multivariate logistic regression analysis revealed that uric acid (OR: 1.008, 95% CI: 1.002-1.015, p = 0.012), maximal fasting blood glucose (FBG) (OR: 1.489, 95% CI: 1.028-2.157, p = 0.035) and random intravenous blood glucose (OR: 1.130, 95% CI: 1.008-1.267, p = 0.037) elevation and the incision at 5 o'clock under the lithotomy position (OR: 3.510, 95% CI: 1.214-10.146, p = 0.020) were independent risk factors for impeding wound healing. However, neutrophil percentage fluctuating within the normal range can be considered as an independent protective factor (OR: 0.906, 95% CI: 0.856-0.958, p = 0.001). After executing the receiver operating characteristic (ROC) curve analysis, it was found that the maximum FBG expressed the largest under curve area (AUC), glycosylated hemoglobin (HbA1c) showed the strongest sensitivity at the critical value and maximum postprandial blood glucose (PBG) had the highest specificity at the critical value. To promote high-quality healing of anal wounds in diabetic patients, clinicians should not only pay attention to surgical procedures but also take above-mentioned indicators into consideration.
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Affiliation(s)
- Xiao Tang
- Department of Proctology, Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, China.,School of Clinical Medicine, Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Taohong He
- Department of Proctology, Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Xinyi Li
- Department of Proctology, Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, China.,School of Clinical Medicine, Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Ya Liu
- Department of Endocrinology, Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Yuqi Wu
- Department of Proctology, Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, China.,School of Clinical Medicine, Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Gehang You
- Department of Proctology, Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, China.,School of Clinical Medicine, Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Jie Li
- Department of Proctology, Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, China.,School of Clinical Medicine, Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Yu Yun
- Department of Proctology, Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, China.,School of Clinical Medicine, Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Lei Wu
- Department of Proctology, Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, China.,School of Clinical Medicine, Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Li Li
- Department of Proctology, Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, China.,School of Clinical Medicine, Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Jian Kang
- Department of Proctology, Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, China
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23
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Litta F, Papait A, Lucchetti D, Farigu S, Parello A, Tenore CR, Campennì P, Silini AR, Giustiniani MC, Parolini O, Sgambato A, Ratto C. The pathogenesis of cryptoglandular anal fistula: New insight into the immunological profile. Colorectal Dis 2022; 24:1567-1575. [PMID: 35916639 PMCID: PMC10087133 DOI: 10.1111/codi.16290] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2022] [Revised: 07/08/2022] [Accepted: 07/27/2022] [Indexed: 01/07/2023]
Abstract
AIM The aetiology of cryptoglandular anal fistula (AF) is poorly understood. Evidence suggests that persistence and/or recurrence of the disease is more related to inflammatory than infectious factors. The aim of this study was to investigate the immune profile of cryptoglandular AF and to perform a histopathological characterization. METHOD Fistulectomy was performed in all patients; healthy ischioanal fat from the same patients was used as a control. Samples were evaluated by the Luminex xMAP system for the detection of 27 analytes. AF tissues were analysed using immunofluorescence. Staining was performed using primary antibodies to identify M1 inflammatory and M2 anti-inflammatory macrophages. Selective staining of total T lymphocytes and different T lymphocyte subsets was performed. RESULTS Twenty patients with AF underwent a fistulectomy. Specific cytokine pathways differentiated AF from healthy tissue: pro-inflammatory cytokines interleukin (IL)-1β, IL-4, IL-8 and IL-17 and the anti-inflammatory cytokine IL-10 were overexpressed in AF compared with controls. Chemokines involved in macrophage recruitment (CCL2, CCL3, CCL4) were higher in AF than in healthy fatty tissue. Moreover, we showed that Tc17 cells characterize AF patients, thus confirming the enzyme-linked immunosorbent assay data. Furthermore, elevated infiltration of CD68+ myeloid cells and a reduction of the M1/M2 ratio characterize AF patients. CONCLUSION A combination of inflammatory cytokines, chemokines and growth factors reside in the wound microenvironment of AF patients. For the first time an important prevalence of Tc17 cells and a reduction in the M1/M2 ratio was observed, thus suggesting new insights into the immunological characterization of AF patients.
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Affiliation(s)
- Francesco Litta
- Proctology Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Andrea Papait
- Dipartimento di Scienze della Vita e Sanità Pubblica, Università Cattolica del Sacro Cuore, Rome, Italy.,Fondazione Policlinico Universitario 'Agostino Gemelli' IRCCS, Rome, Italy
| | - Donatella Lucchetti
- Dipartimento Universitario di Medicina e Chirurgia Traslazionale, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Serafina Farigu
- Centro di Ricerca E. Menni, Fondazione Poliambulanza, Brescia, Italy
| | - Angelo Parello
- Proctology Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Claudio Ricciardi Tenore
- Dipartimento Universitario di Medicina e Chirurgia Traslazionale, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Paola Campennì
- Proctology Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | | | | | - Ornella Parolini
- Dipartimento di Scienze della Vita e Sanità Pubblica, Università Cattolica del Sacro Cuore, Rome, Italy.,Fondazione Policlinico Universitario 'Agostino Gemelli' IRCCS, Rome, Italy
| | - Alessandro Sgambato
- Dipartimento Universitario di Medicina e Chirurgia Traslazionale, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Carlo Ratto
- Proctology Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
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24
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Newton K, Dumville J, Briggs M, Law J, Martin J, Pearce L, Kirwan C, Pinkney T, Needham A, Jackson R, Winn S, McCulloch H, Hill J. Postoperative Packing of Perianal Abscess Cavities (PPAC2): randomized clinical trial. Br J Surg 2022; 109:951-957. [PMID: 35929816 PMCID: PMC10364677 DOI: 10.1093/bjs/znac225] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Revised: 05/16/2022] [Accepted: 05/31/2022] [Indexed: 08/02/2023]
Abstract
BACKGROUND Perianal abscess is common. Traditionally, postoperative perianal abscess cavities are managed with internal wound packing, a practice not supported by evidence. The aim of this randomized clinical trial (RCT) was to assess if non-packing is less painful and if it is associated with adverse outcomes. METHODS The Postoperative Packing of Perianal Abscess Cavities (PPAC2) trial was a multicentre, RCT (two-group parallel design) of adult participants admitted to an NHS hospital for incision and drainage of a primary perianal abscess. Participants were randomized 1:1 (via an online system) to receive continued postoperative wound packing or non-packing. Blinded data were collected via symptom diaries, telephone, and clinics over 6 months. The objective was to determine whether non-packing of perianal abscess cavities is less painful than packing, without an increase in perianal fistula or abscess recurrence. The primary outcome was pain (mean maximum pain score on a 100-point visual analogue scale). RESULTS Between February 2018 and March 2020, 433 participants (mean age 42 years) were randomized across 50 sites. Two hundred and thirteen participants allocated to packing reported higher pain scores than 220 allocated to non-packing (38.2 versus 28.2, mean difference 9.9; P < 0.0001). The occurrence of fistula-in-ano was low in both groups: 32/213 (15 per cent) in the packing group and 24/220 (11 per cent) in the non-packing group (OR 0.69, 95 per cent c.i. 0.39 to 1.22; P = 0.20). The proportion of patients with abscess recurrence was also low: 13/223 (6 per cent) in the non-packing group and 7/213 (3 per cent) in the packing group (OR 1.85, 95 per cent c.i. 0.72 to 4.73; P = 0.20). CONCLUSION Avoiding abscess cavity packing is less painful without a negative morbidity risk. REGISTRATION NUMBER ISRCTN93273484 (https://www.isrctn.com/ISRCTN93273484). REGISTRATION NUMBER NCT03315169 (http://clinicaltrials.gov).
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Affiliation(s)
- Katy Newton
- Correspondence to: Katy Newton, Department of Surgery, Manchester Royal Infirmary, Oxford Road, Manchester, M14 9WL, UK (e-mail: )
| | - Jo Dumville
- School of Midwifery, Nursing and Social Work, University of Manchester, UK
| | - Michelle Briggs
- School of Midwifery, Nursing and Social Work, University of Manchester, UK
| | | | | | - Lyndsay Pearce
- Department of General Surgery, Salford Royal NHS Foundation Trust, UK
| | - Cliona Kirwan
- Department of Academic Surgery, Wythenshawe Hospital, Manchester University NHS Foundation Trust, UK
| | - Thomas Pinkney
- Academic Department of Surgery, University of Birmingham, UK
| | | | | | | | | | - James Hill
- Department of General Surgery, Manchester Royal Infirmary, Manchester University NHS Foundation Trust, UK
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25
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Zhang C, Zhang X, Zhao X, Zhu Y, Zhang D, Li H. The Value of Transrectal Ultrasound in the Preoperative Diagnosis of Complex Anal Fistula (CAF): Based on a Retrospective Cohort Study. COMPUTATIONAL AND MATHEMATICAL METHODS IN MEDICINE 2022; 2022:6411935. [PMID: 35685902 PMCID: PMC9173950 DOI: 10.1155/2022/6411935] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Revised: 03/04/2022] [Accepted: 04/09/2022] [Indexed: 11/17/2022]
Abstract
Objective A case-control study was employed to retrospectively analyze the value of transrectal ultrasound in the preoperative diagnosis of complex anal fistula (CAF). Methods The clinical data of 128 patients with CAF treated in our hospital from March 2019 to June 2021 were analyzed retrospectively. All patients were examined by transrectal ultrasound and MRI with Hitachi HI Vision Ascendus ultrasound diagnostic apparatus and MRI. The general data of the patients (age, sex, course of disease, complications, and previous operation history) and ultrasonic image characteristics were recorded. The consistency of internal orifice, head, branch/abscess, and abscess detected by ultrasound, MRI, and ultrasound combined with MRI were compared, and the sensitivity, accuracy, and specificity of ultrasound, MRI, and the combination of ultrasound and MRI (ultrasound+MRI) in the diagnosis of different Parks classification of anal fistula (AF) were compared. Results The ultrasound images of the rectal probe in typical cases were compared with the MRI images. The characteristics of the ultrasound images were as follows: the outer orifice of AF was a thin strip of mixed echo or low echo leading to the skin side, and the inner orifice showed local dilated low echo, mixed echo, or interruption of mucosal continuity. The following are the MRI image features: abnormal long bar signal shadow from the dorsal side of the end of the coccyx to the S5 plane, low signal on T1WI, high signal on T2WI, blurred boundary, uneven signal, bifurcation in the lower end of the tail for "Y" shape, one branch opening at the body surface at about 6 o'clock, the other walking horizontally, passing through the levator ani muscle to the right posterior position of the rectum at about 6:00 o'clock, and penetrating the inner mouth of the rectum at 6 o'clock. The detection of internal orifice, head, branch/abscess, and abscess were compared by three examination methods. There was significant difference in the detection rate of internal orifice and branch/purulent cavity among the three methods (P < 0.05). The detection rates of internal mouth and branch/abscess cavity by ultrasound and MRI (94.77% and 94.94%) were higher than those by single ultrasound (75.16% and 79.78%) and MRI (81.05% and 83.15%) (P < 0.05). There was no significant difference in the detection rate of ultrasound, MRI internal orifice, and branch/purulent cavity (P > 0.05). There was no significant difference in the detection rate of supervisor and abscess among the three methods (P > 0.05). The results of operation included transsphincter type (n = 53), intersphincter type (n = 45), and superior sphincter type (n = 30). Analysis of transsphincter type AF detected by three methods: 42 cases of transsphincter type AF and 86 cases of nonsphincter type AF were detected by ultrasound, 36 cases of transsphincter type AF and 92 cases of nontranssphincter type AF were detected by MRI, 57 cases of transsphincter type AF and 71 cases of nonsphincter type AF were detected by ultrasound and MRI. The comparison of the efficacy of the three methods in the diagnosis of transsphincter AF and the sensitivity of the three methods in the diagnosis of transsphincter AF showed significant difference (P < 0.05). The sensitivity of ultrasound and MRI in the diagnosis of transsphincter AF (96.23%) was higher than those of single ultrasound (67.92%) and MRI (64.15%) (P < 0.05). There was no significant difference in the accuracy and specificity of the three methods in the diagnosis of transsphincter AF (P > 0.05). There were 41 cases of intersphincter type AF and 87 cases of nonsphincter type AF detected by ultrasound, 38 cases of intersphincter type AF and 90 cases of nonsphincter intersphincter type AF detected by MRI, and 45 cases of intersphincter type AF and 83 cases of nonsphincter intersphincter type AF detected by ultrasound and MRI. The sensitivity and accuracy of the three methods in the diagnosis of intersphincter AF were statistically significant (P < 0.05). The sensitivity and accuracy (100.00% and 100.00%) of ultrasound and MRI in the diagnosis of intersphincter AF were higher than those of single ultrasound (66.67% and 79.69%) and MRI (71.11% and 85.16%) (P < 0.05). There was no significant difference in the specificity of the three methods in the diagnosis of intersphincter AF (P > 0.05). The results of three methods were compared, including 24 cases of superior sphincter type AF and 89 cases of nonsuperior sphincter type AF, 21 cases of superior sphincter type AF, and 107 cases of nonsuperior sphincter type AF detected by MRI and 93 cases of superior sphincter type AF and 128cases of nonsuperior sphincter type AF detected by ultrasound and MRI. There was no significant difference in the sensitivity, accuracy, and specificity of the three methods in the diagnosis of superior sphincter AF (P > 0.05). Conclusion The sphincter, anorectal, and surrounding tissues were clearly demonstrated by transrectal ultrasound. The internal orifice, head, branch/abscess, abscess, and the relationship between abscess and sphincter in the diagnosis of CAF were in good agreement with the surgical results. Ultrasound+MRI can take into account the advantages of ultrasound and MRI, make up for each other, and improve the detection rate of internal orifice and branch/abscess. It can improve the sensitivity of diagnosis of transsphincter AF and the sensitivity and accuracy of intersphincter AF, which can provide intuitive and valuable imaging information for surgical intervention.
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Affiliation(s)
- Chen Zhang
- Department of Ultrasonography, Wangjing Hospital, China Academy of Chinese Medical Sciences, Beijing 100102, China
| | - Xu Zhang
- Department of Ultrasonography, Wangjing Hospital, China Academy of Chinese Medical Sciences, Beijing 100102, China
| | - Xiaoqi Zhao
- Department of Ultrasonography, Wangjing Hospital, China Academy of Chinese Medical Sciences, Beijing 100102, China
| | - Yongtao Zhu
- Department of Ultrasonography, Wangjing Hospital, China Academy of Chinese Medical Sciences, Beijing 100102, China
| | - Dingding Zhang
- Department of Ultrasonography, Wangjing Hospital, China Academy of Chinese Medical Sciences, Beijing 100102, China
| | - Hexia Li
- Department of Ultrasonography, Wangjing Hospital, China Academy of Chinese Medical Sciences, Beijing 100102, China
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26
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Perianal fistulas: A review with emphasis on preoperative imaging. Adv Med Sci 2022; 67:114-122. [PMID: 35134600 DOI: 10.1016/j.advms.2022.01.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2021] [Revised: 11/24/2021] [Accepted: 01/14/2022] [Indexed: 02/06/2023]
Abstract
PURPOSE We aim to present a comprehensive literature review which focuses on the preoperative imaging of perianal fistulas. MATERIAL/METHODS Pelvic magnetic resonance imaging (MRI) and endoanal ultrasound (EAUS) are the two first-line imaging modalities for the preoperative evaluation of patients with perianal fistulas. We conducted a search in PubMed, Scopus and Google Scholar concerning articles comparing pelvic MRI with EAUS, which were published from 1994 until 2019. RESULTS In most articles, pelvic MRI is superior to EAUS for the evaluation of perianal fistulas (especially for supralevator and extrasphincteric ones). Preoperative pelvic MRI is associated with statistically significant better results and prognosis after surgical treatment of the disease. Preoperative EAUS poses high sensitivity and specificity in identifying intersphincteric and transsphincteric perianal fistulas, as well as the internal opening of a fistula-in-ano. There is only one meta-analysis which compares the diagnostic accuracy of the two mentioned imaging modalities in preoperative fistula detection. Sensitivity of both - pelvic MRI and EAUS, is acceptably high (0.87). Specificity of pelvic MRI is 0.69 in comparison to EAUS (0.43), but both values are considered low. CONCLUSIONS Future well-designed prospective studies are needed to investigate the diagnostic accuracy of pelvic MRI and EAUS in the preoperative assessment of patients with perianal fistulas. Moreover, the combination of pelvic MRI and EAUS should also be studied, since several published articles suggest that it could lead to improved diagnostic accuracy. A novel treatment algorithm for perianal fistulas could arise from this study.
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27
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Adegbola SO, Sarafian M, Sahnan K, Ding NS, Faiz OD, Warusavitarne J, Phillips RKS, Tozer PJ, Holmes E, Hart AL. Differences in amino acid and lipid metabolism distinguish Crohn's from idiopathic/cryptoglandular perianal fistulas by tissue metabonomic profiling and may offer clues to underlying pathogenesis. Eur J Gastroenterol Hepatol 2021; 33:1469-1479. [PMID: 33337668 DOI: 10.1097/meg.0000000000001976] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
INTRODUCTION Few studies have investigated perianal fistula etiopathogenesis, and although the cryptoglandular theory is widely accepted in idiopathic cases, in Crohn's disease, it is thought to involve the interplay between microbiological, immunological and genetic factors. A pilot study was conducted to assess for metabolic variations in Crohn's perianal fistula tissue that might differ from that of idiopathic (cryptoglandular) perianal fistula tissue as a comparator. The goal was to identify any potential biomarkers of disease, which may improve the understanding of pathogenesis. AIMS AND METHODS Fistula tract biopsies were obtained from 30 patients with idiopathic perianal fistula and 20 patients with Crohn's anal fistula. Two different assays were used in an ultra-high-performance liquid chromatography system coupled with a mass spectrometric detector to achieve broad metabolome coverage. Univariate and multivariate statistical data analyses were used to identify differentiating metabolic features corresponding to the perianal fistula phenotype (i.e. Crohn's disease vs. idiopathic). RESULTS Significant orthogonal partial least squares discriminant analysis predictive models (validated with cross-validated-analysis of variance P value <0.05) differentiated metabolites from tissue samples from Crohn's vs. idiopathic anal fistula patients using both metabolic profiling platforms. A total of 41 metabolites were identified, suggesting alterations in pathways, including amino acid, carnitine and lipid metabolism. CONCLUSION Metabonomics may reveal biomarkers of Crohn's perianal fistula. Further work in larger numbers is required to validate the findings of these studies as well as cross-correlation with microbiome work to better understand the impact of host-gut/environment interactions in the pathophysiology of Crohn's and idiopathic perianal fistulas and identify novel therapeutic targets.
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Affiliation(s)
- Samuel O Adegbola
- Robin Phillips Fistula Research Unit, St Mark's Hospital and Academic Institute, Harrow, Middlesex
- Department of Surgery and Cancer
| | - Magali Sarafian
- Computational Systems Division, Imperial College London, South Kensington Campus, London, UK
| | - Kapil Sahnan
- Robin Phillips Fistula Research Unit, St Mark's Hospital and Academic Institute, Harrow, Middlesex
- Department of Surgery and Cancer
| | - Nik S Ding
- Department of Gastroenterology, St Vincent's Hospital, Melbourne, Australia
| | - Omar D Faiz
- Robin Phillips Fistula Research Unit, St Mark's Hospital and Academic Institute, Harrow, Middlesex
- Department of Surgery and Cancer
| | - Janindra Warusavitarne
- Robin Phillips Fistula Research Unit, St Mark's Hospital and Academic Institute, Harrow, Middlesex
- Department of Surgery and Cancer
| | - Robin K S Phillips
- Robin Phillips Fistula Research Unit, St Mark's Hospital and Academic Institute, Harrow, Middlesex
- Department of Surgery and Cancer
| | - Phil J Tozer
- Robin Phillips Fistula Research Unit, St Mark's Hospital and Academic Institute, Harrow, Middlesex
- Department of Surgery and Cancer
| | - Elaine Holmes
- Computational Systems Division, Imperial College London, South Kensington Campus, London, UK
| | - Ailsa L Hart
- Robin Phillips Fistula Research Unit, St Mark's Hospital and Academic Institute, Harrow, Middlesex
- Department of Surgery and Cancer
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Effectiveness and Prognosis: Drainage Skin-Bridge Sparing Surgery Combined with Fistulotomy versus Fistulotomy Only in the Treatment of Anal Fistula. JOURNAL OF HEALTHCARE ENGINEERING 2021; 2021:6940072. [PMID: 34876965 PMCID: PMC8645410 DOI: 10.1155/2021/6940072] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Revised: 08/28/2021] [Accepted: 09/04/2021] [Indexed: 02/07/2023]
Abstract
Objective This study intends to analyze the difference in the efficacy of drainage skin-bridge sparing surgery combined fistulotomy (DSCF) and fistulotomy alone. Methods 125 patients with anal fistula were enrolled as study subjects and randomly divided into control group (CG) and observation group (OG) by double-blind lottery. The CG received drainage skin-bridge sparing surgery with fistulotomy and the OG received fistulotomy only. Results The VAS scores of the trauma in the OG were lower than those in the CG on 1st day of surgery and 7 days after surgery (P < 0.05). The length of hospital stay and time to wound healing were shorter in the OG than in the CG (P < 0.05). The incidence of postoperative bleeding in the OG was 9.52%, which was lower than 22.58% in the CG (P < 0.05). The rectal examination scores were lower in the OG than in the CG at 3 and 5 days postoperatively (P < 0.05). The Wexner scores of solid incontinence (0 to 4), liquid incontinence (0 to 4), gas incontinence (0 to 4), pad wearing (0 to 4), and lifestyle alteration (0 to 4) in the OG were lower than those of the CG at 5 days postoperatively (P < 0.05). Voiding function scores were lower in the OG than in the CG at 2 and 3 days postoperatively (P < 0.05). Conclusions The efficacy of drainage skin-bridge sparing surgery combined fistulotomy is better than that of fistulotomy alone, which can accelerate postoperative healing, enhance urinary function, reduce postoperative bleeding, and improve anal function.
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29
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Treatments for the amelioration of persistent factors in complex anal fistula. Biotechnol Lett 2021; 44:23-31. [PMID: 34799826 DOI: 10.1007/s10529-021-03207-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Accepted: 11/12/2021] [Indexed: 10/19/2022]
Abstract
Anal fistulae are abnormal hollow connections between the wall of the anal canal and the perianal skin around the anus that have remained a burden on the medical sector for centuries. The complexity of this disease is attributed to a number of factors such as the degree of associated sphincter muscle, concomitant illnesses, existence of multiple fistulous tracts and the number of previous interventions. Persistence of a complex anal fistula can cause a decline in patient's physical quality of life as well as impact on the psychological status of patients who often suffer from anxiety and depression. Surgical intervention remains the gold standard for treatment, however; the risk of incontinence and high recurrence potential has led to interest into developing alternative treatment approaches such as the use of biologics, bioactives and biomaterials. One potential reason for these varied outcomes could be the multifactorial interplay between genetic, immune-related, environmental, and microbial persistence factors on tissue regeneration. Recent observations have proposed that adverse inflammatory mediators may contribute more than microbial factors. The moderate to high success rates of biotechnological advances (mesenchymal stem cells and biomaterial scaffolds) show promise as therapies for the amelioration of adverse persistent factors while facilitating a means to closing the fistula tract. The purpose of this review is to outline recent advances in biologics and combination therapies to treat persistent factors associated with complex anal fistula.
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Tsai L, McCurdy JD, Ma C, Jairath V, Singh S. Epidemiology and Natural History of Perianal Crohn's Disease: A Systematic Review and Meta-Analysis of Population-Based Cohorts. Inflamm Bowel Dis 2021; 28:1477-1484. [PMID: 34792604 PMCID: PMC9527611 DOI: 10.1093/ibd/izab287] [Citation(s) in RCA: 49] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Indexed: 12/26/2022]
Abstract
BACKGROUND AND AIMS Perianal Crohn's disease (pCD) is a potentially severe phenotype of CD. We conducted a systematic review with meta-analysis to estimate cumulative incidence, risk factors, and outcomes of pCD in population-based cohort studies. METHODS Through a systematic literature review through March 1, 2021, we identified population-based inception cohort studies reporting cumulative incidence of perianal disease (primarily abscess and/or fistula) in patients with CD. We estimated the cumulative incidence of pCD at presentation and 1-, 5-, and 10-year follow-up, and risk factors for perianal disease and outcomes including risk of major (bowel resection, proctectomy, ostomy) and minor perianal (incision and drainage, seton placement, etc.) surgery. RESULTS In 12 population-based studies, prevalence of pCD was 18.7% (95% confidence interval [CI], 12.5%-27.0%) with 1-, 5-, and 10-year risk of perianal disease being 14.3% (95% CI, 7.9%-24.6%), 17.6% (95% CI, 11.3%-26.5%), and 18.9% (95% CI, 15.0%-23.4%), respectively. Approximately 11.5% of patients (95% CI, 6.7%-19.0%) had perianal disease at or before CD diagnosis. Colonic disease location and rectal involvement were associated with higher risk of pCD. Overall, 63.3% of patients (95% CI, 53.3-72.3) required minor perianal surgery and 6.4% of patients (95% CI, 1.8%-20.6%) required major abdominal surgery for pCD. Use of biologic therapy for pCD is common and has steadily increased throughout the years. CONCLUSIONS Approximately 1 in 5 patients with CD develops perianal disease within 10 years of CD diagnosis, including 11.5% who have perianal disease at presentation. Approximately two-thirds of patients require perianal surgery, with a smaller fraction requiring major abdominal surgery.
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Affiliation(s)
- Lester Tsai
- Division of Gastroenterology, Department of Medicine, University of California San Diego, La Jolla, CA, USA
| | - Jeffrey D McCurdy
- Division of Gastroenterology, Department of Medicine, University of Ottawa, Ottawa, ON, Canada,Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Christopher Ma
- Division of Gastroenterology and Hepatology, Departments of Medicine and Community Health Sciences, University of Calgary, Calgary, AB, Canada
| | - Vipul Jairath
- Department of Epidemiology and Biostatistics, Western University, London, Ontario, Canada,Division of Gastroenterology, Western University, London, ON, Canadaand the
| | - Siddharth Singh
- Address correspondence to: Siddharth Singh, MD, MS, Assistant Professor of Medicine, Division of Gastroenterology, and Division of Biomedical Informatics, University of California San Diego, 9452 Medical Center Drive, ACTRI 1W501, La Jolla, CA 92093, USA ()
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31
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Gomez ME, Trencheva K, Symer M, Garrett K, Milsom JW, Shukla PJ. Evaluating the Efficacy of Cutting Setons for the Treatment of Anal Fistulas. Indian J Surg 2021. [DOI: 10.1007/s12262-021-03162-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
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32
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Fistelexzision mit Schließmuskelrekonstruktion. COLOPROCTOLOGY 2021. [DOI: 10.1007/s00053-021-00569-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Efficacy and safety of autologous adipose-derived stromal vascular fraction enriched with platelet-rich plasma in flap repair of transsphincteric cryptoglandular fistulas. Tech Coloproctol 2021; 25:1301-1309. [PMID: 34606026 PMCID: PMC8580893 DOI: 10.1007/s10151-021-02524-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Accepted: 09/07/2021] [Indexed: 12/26/2022]
Abstract
Background Transanal advancement flap repair of transsphincteric fistulas is a sphincter-preserving procedure, which frequently fails, probably due to ongoing inflammation in the remaining fistula tract. Adipose-derived stromal vascular fraction (SVF) has immunomodulatory properties promoting wound healing and suppressing inflammation. Platelet-rich plasma (PRP) reinforces this biological effect. The aim of this study was to evaluate the efficacy and safety of autologous adipose-derived SVF enriched with PRP in flap repair of transsphincteric cryptoglandular fistulas. Methods A prospective cohort study was conducted including consecutive patients with transsphincteric cryptoglandular fistula in a tertiary referral center. During flap repair, SVF was obtained by lipoharvesting and mechanical fractionation of adipose tissue and combined with PRP was injected around the internal opening and into the fistulous wall. Endpoints were fistula healing at clinical examination and fistula closure on postoperative magnetic resonance imaging (MRI). Adverse events were documented. Results Forty-five patients with transsphincteric cryptoglandular fistula were included (29 males, median age 44 years [range 36–53 years]). In the total study population, primary fistula healing was observed in 38 patients (84%). Among the 42 patients with intestinal continuity at time of surgery, primary fistula healing was observed in 35 patients (84%). In one patient, the fistula recurred, resulting in a long-term healing rate of 82%. MRI, performed in 37 patients, revealed complete closure of the fistula tract in 33 (89.2%). In the other patients, the tract was almost completely obliterated by scar tissue. During follow-up, none of these patients showed clinical signs of recurrence. The postoperative course was uneventful, except for three cases; venous thromboembolism in one patient and bleeding under the flap, necessitating intervention in two patients. Conclusions Addition of autologous SVF enriched with PRP during flap repair is feasible, safe and might improve outcomes in patients with a transsphincteric cryptoglandular fistula. Trial registration Dutch Trial Register, Trial Number: NL8416, https://www.trialregister.nl/
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Vollebregt PF, Vander Mijnsbrugge GJ, Molenaar CBH, Felt‐Bersma RJF. Efficacy of Permacol injection for perianal fistulas in a tertiary referral population: poor outcome in patients with complex fistulas. Colorectal Dis 2021; 23:2119-2126. [PMID: 33955138 PMCID: PMC8453864 DOI: 10.1111/codi.15696] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2020] [Revised: 03/13/2021] [Accepted: 04/10/2021] [Indexed: 12/17/2022]
Abstract
AIM Injection of Permacol collagen paste can be used as a sphincter-sparing treatment for perianal fistulas. In a tertiary referral population we aimed to evaluate the efficacy of Permacol injection and the clinical and fistula-related factors associated with recurrence. METHOD This was a retrospective analysis of consecutive patients with perianal fistulas treated with Permacol injection at a specialist centre between June 2015 and April 2019. Endoanal ultrasonography was systematically reanalysed, blinded to treatment outcome. Rectovaginal, anovaginal and Crohn's disease fistulas were excluded. Healed fistulas were defined as absent anal symptoms and a closed external opening on physical examination at a minimum follow-up of 6 months. Regression analyses were performed to identify factors associated with unhealed fistulas. RESULTS A total of 90 patients (51 men; median age 45 years) were analysed. Seventy-two (80.0%) patients had complex perianal fistulas (greater than one-third sphincter involvement or multiple tracts). After a single Permacol injection, fistulas were healed in 20 (22.2%) patients at 3 months follow-up and in 18 (20.0%) patients at a median follow-up of 30 months (interquartile range 17-37). Eight (11.1%) patients with unhealed fistulas had significant improvement in their symptoms. Complex fistulas were significantly associated with unhealed status [OR 3.53 (95% CI 1.12-11.09); p = 0.031]. Twenty patients underwent subsequent Permacol injections, which were successful in six (30.0%) patients after one (n = 3) or two (n = 3) additional injections. CONCLUSION This largest study to date in patients with mainly complex perianal fistulas, demonstrated that the efficacy of a single Permacol injection was only 20%. Complex fistulas were associated with a poor outcome.
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Affiliation(s)
- Paul F. Vollebregt
- Department of Gastroenterology and HepatologyAmsterdam UMCAmsterdam Gastroenterology Endocrinology MetabolismVrije Universiteit AmsterdamAmsterdamThe Netherlands
| | | | | | - Richelle J. F. Felt‐Bersma
- Department of Gastroenterology and HepatologyAmsterdam UMCAmsterdam Gastroenterology Endocrinology MetabolismVrije Universiteit AmsterdamAmsterdamThe Netherlands,Proctos KliniekBilthovenThe Netherlands
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Włodarczyk M, Włodarczyk J, Sobolewska-Włodarczyk A, Trzciński R, Dziki Ł, Fichna J. Current concepts in the pathogenesis of cryptoglandular perianal fistula. J Int Med Res 2021; 49:300060520986669. [PMID: 33595349 PMCID: PMC7894698 DOI: 10.1177/0300060520986669] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Cryptoglandular perianal fistula is a common benign anorectal disorder that is managed mainly with surgery. A fistula is typically defined as a pathological communication between two epithelialized surfaces. More specifically, perianal fistula manifests as an abnormal tract between the anorectal canal and the perianal skin. Perianal fistulas are often characterized by significantly decreased patient quality of life. The cryptoglandular theory of perianal fistulas suggests their development from the proctodeal glands, which originate from the intersphincteric plane and perforate the internal sphincter with their ducts. Involvement of proctodeal glands in the inflammatory process could play a primary role in the formation of cryptoglandular perianal fistula. The objective of this narrative review was to investigate the current knowledge of the pathogenesis of cryptoglandular perianal fistula with the specific aims of characterizing the potential role of proinflammatory factors responsible for the development of chronic inflammation. Further studies are crucial to improve the therapeutic management of cryptoglandular perianal fistulas.
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Affiliation(s)
- Marcin Włodarczyk
- Department of General and Colorectal Surgery, Medical University of Lodz, Lodz, Poland.,Department of Biochemistry, Medical University of Lodz, Lodz, Poland
| | - Jakub Włodarczyk
- Department of General and Colorectal Surgery, Medical University of Lodz, Lodz, Poland.,Department of Biochemistry, Medical University of Lodz, Lodz, Poland
| | - Aleksandra Sobolewska-Włodarczyk
- Department of Biochemistry, Medical University of Lodz, Lodz, Poland.,Department of Gastroenterology, Medical University of Lodz, Lodz, Poland
| | - Radzisław Trzciński
- Department of General and Colorectal Surgery, Medical University of Lodz, Lodz, Poland
| | - Łukasz Dziki
- Department of General and Colorectal Surgery, Medical University of Lodz, Lodz, Poland
| | - Jakub Fichna
- Department of Biochemistry, Medical University of Lodz, Lodz, Poland
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Fugita FR, Santos CHMD, Ribeiro CODS. Epidemiological profile of patients with fistula in ano. JOURNAL OF COLOPROCTOLOGY 2021. [DOI: 10.1016/j.jcol.2019.09.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Abstract
Rationale There is a lack of consistent national data on the evaluation of the epidemiological profile of patients with anal fistula.
Objective To evaluate the epidemiological profile of patients with anal fistula at a center specialized in coloproctology.
Method A cross-sectional, retrospective study was carried out between 2016 and 2018 of patients who underwent surgical procedures for the treatment of fistula in ano by the Department of Coloproctology of the Regional Hospital of Mato Grosso do Sul. Age, gender, disease duration, number of procedures, association with Crohn's disease and other comorbidities were evaluated. The data were tabulated and submitted to statistical treatment considering p < 0.05.
Results 93.2% of the patients were less than 60 years old, 66.7% were male, 88.9% had the disease less than one year, the most frequent procedures were fistulotomy (55.6%) and fistulectomy (36.8%), with a greater percentage of patients having undergone only one procedure (74.4%), 8.5% had Crohn’s disease, 7.7% systemic hypertension and 3.4% had diabetes mellitus.
Conclusion In the studied group, there was a predominance of anal fistulae in men under 60 years old and without comorbidities, diagnosed for up to one year, most of them submitted to fistulotomy or fistulectomy at one time. Patients operated after one year of illness and also those with Crohn’s disease were submitted mainly to curettage + seton and multiple procedures.
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Affiliation(s)
- Fabiano Roberto Fugita
- Hospital Regional de Mato Grosso do Sul, Serviço de Coloproctologia, Campo Grande, MS, Brazil
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37
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Tao Y, Zheng Y, Han JG, Wang ZJ, Cui JJ, Zhao BC, Yang XQ. Long-Term Clinical Results of Use of an Anal Fistula Plug for Treatment of Low Trans-Sphincteric Anal Fistulas. Med Sci Monit 2020; 26:e928181. [PMID: 33279927 PMCID: PMC7727077 DOI: 10.12659/msm.928181] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND An anal fistula plug is a sphincter-sparing procedure that uses biological substances to close an anorectal fistula. This study aimed to evaluate the long-term therapeutic effect of an anal fistula plug procedure in patients with trans-sphincteric fistula-in-ano and to determine the risk factors affecting fistula healing. MATERIAL AND METHODS A single-center retrospective study was performed assessing long-term treatment outcomes of patients with low trans-sphincteric anal fistulas who initially underwent anal fistula plug procedures between August 2008 and September 2012. Risk factors affecting fistula healing were identified using univariate and multivariate analyses. RESULTS A total of 135 patients who had low trans-sphincteric anal fistulas and underwent anal fistula plug procedures were analysed. The overall healing rate was 56% (75/135) with a median follow-up time of 8 years (range, 72-121 months). The primary reasons for treatment failure were plug extrusion (n=12, 20%) and surgical site infection (n=9, 15%), occurring within 30 days after surgery. Multiple logistic regression analysis showed that the duration of anal fistula ≥6 months was significantly associated with treatment failure using an anal fistula plug (OR=3.187, 95% CI: 1.361-7.466, P=0.008). Of the patients who failed initial treatment with an anal fistula plug, 6 (9%) had anal fistulas that healed spontaneously after 2-3 years without additional treatment. CONCLUSIONS As a sphincter-preserving procedure, the anal fistula plug can effectively promote healing of low trans-sphincteric anal fistulas. The long-term efficacy is good and the procedure warrants wider use in clinical practice.
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Affiliation(s)
- Yu Tao
- Department of General Surgery, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China (mainland)
| | - Yi Zheng
- Department of General Surgery, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China (mainland)
| | - Jia Gang Han
- Department of General Surgery, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China (mainland)
| | - Zhen Jun Wang
- Department of General Surgery, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China (mainland)
| | - Jin Jie Cui
- Department of General Surgery, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China (mainland)
| | - Bao Cheng Zhao
- Department of General Surgery, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China (mainland)
| | - Xin Qing Yang
- Department of General Surgery, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China (mainland)
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Frountzas M, Stergios K, Nikolaou C, Bellos I, Schizas D, Linardoutsos D, Kontzoglou K, Vaos G, Williams AB, Toutouzas K. Could FiLaC™ be effective in the treatment of anal fistulas? A systematic review of observational studies and proportional meta-analysis. Colorectal Dis 2020; 22:1874-1884. [PMID: 32445614 DOI: 10.1111/codi.15148] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2020] [Accepted: 04/30/2020] [Indexed: 02/08/2023]
Abstract
AIM Fistula Laser Closure (FiLaC™) is a novel sphincter-preserving technique that is based on new technologies and shows promising results in repairing anal fistulas whilst maintaining external sphincter function. The aim of the present meta-analysis is to present the efficacy and the safety of FiLaC™ in the management of anal fistula disease. METHOD The present proportional meta-analysis was designed using the PRISMA and AMSTAR guidelines. We searched MEDLINE, Scopus, clinicaltrials.gov, Embase, Cochrane Central Register of Controlled Trials CENTRAL and Google Scholar databases from inception until November 2019. RESULTS Overall, eight studies were included that recruited 476 patients. The pooled success rate of the technique was 63% (95% CI 50%-75%). The pooled complication rate was 8% (95% CI 1%-18%). Sixty-six per cent of patients had a transsphincteric fistula and 60% had undergone a previous surgical intervention, mainly the insertion of a seton (54%). The majority had a cryptoglandular fistula. Operation time and follow-up period were described for each study. CONCLUSION FiLaC™ seems to be an efficient therapeutic option for perianal fistula disease with an adequate level of safety that preserves quality of life. Nevertheless, randomized trials need to be designed to compare FiLaC™ with other procedures for the management of anal fistulas such as ligation of intersphincteric fistula tract, anal advancement flaps, fibrin glue, collagen paste, autologous adipose tissue, fistula plug and video-assisted anal fistula treatment.
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Affiliation(s)
- M Frountzas
- Laboratory of Experimental Surgery and Surgical Research, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece.,First Propaedeutic Department of Surgery, School of Medicine, Hippocration General Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - K Stergios
- Laboratory of Experimental Surgery and Surgical Research, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - C Nikolaou
- Laboratory of Experimental Surgery and Surgical Research, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - I Bellos
- Laboratory of Experimental Surgery and Surgical Research, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - D Schizas
- First Department of Surgery, School of Medicine, Laikon General Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - D Linardoutsos
- First Propaedeutic Department of Surgery, School of Medicine, Hippocration General Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - K Kontzoglou
- Laboratory of Experimental Surgery and Surgical Research, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - G Vaos
- Department of Paediatric Surgery, School of Medicine, Attikon University General Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - A B Williams
- Department of Colorectal Surgery, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - K Toutouzas
- First Propaedeutic Department of Surgery, School of Medicine, Hippocration General Hospital, National and Kapodistrian University of Athens, Athens, Greece
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Yzet C, Sabbagh C, Loreau J, Turpin J, Brazier F, Dupas JL, Nguyen-Khac É, Fumery M. Inflammatory bowel disease symptoms at the time of anal fistula lead to the diagnosis of Crohn's disease. Clin Res Hepatol Gastroenterol 2020; 44:968-972. [PMID: 32336615 DOI: 10.1016/j.clinre.2020.03.027] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2019] [Revised: 03/25/2020] [Accepted: 03/27/2020] [Indexed: 02/04/2023]
Abstract
INTRODUCTION Most anal fistulas are crypto-glandular. Nevertheless, anal fistulas can reveal Crohn's disease (CD). The aim of our study was to evaluate the risk of developing CD in patients undergoing surgery for anal fistula. PATIENTS AND METHODS All patients undergoing surgery for anal fistula in our center between January 1, 2008 and January 31, 2017 were identified through a prospective administrative database. Demographic, clinical, and laboratory data were retrospectively collected. RESULTS Ninety-three patients underwent anal exploration under general anesthesia. The median age at diagnosis of fistula was 43 years (IQR, 34-56) and 27% (n=29) were women. Twenty-seven percent (n=16) had had at least one previous fistula episode. After a median follow-up of 16.8 months (IQR, 7.2-42.0), seven (7.4%) patients were diagnosed with CD. The median time between the diagnosis of fistula and that of CD was 7.6 months (IQR, 2.7, 26.1). Chronic diarrhea (P=0.0003), weight loss (P=0.001), and chronic abdominal pain (P=0.002) were associated with the diagnosis of CD. Characteristics of the fistulas (number, simple/complex, abscess), smoking, extra-digestive manifestations of CD, or a family history of IBD were not associated with the diagnosis of CD. CONCLUSION A medical history of anal fistula surgery resulted in the diagnosis of CD in 7% of cases. Weight loss and the presence of digestive symptoms were associated with the diagnosis of CD. These elements could be used to select patients requiring endoscopic exploration after anal fistula.
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Affiliation(s)
- Clara Yzet
- Department of Gastroenterology, Amiens University Hospital, Picardie University, Amiens, France.
| | - Charles Sabbagh
- Department of Digestive Surgery, Amiens University Hospital, Picardie University, Amiens, France
| | - Julien Loreau
- Department of Gastroenterology, Amiens University Hospital, Picardie University, Amiens, France
| | - Justine Turpin
- Department of Gastroenterology, Amiens University Hospital, Picardie University, Amiens, France
| | - Franck Brazier
- Department of Gastroenterology, Amiens University Hospital, Picardie University, Amiens, France
| | - Jean-Louis Dupas
- Department of Gastroenterology, Amiens University Hospital, Picardie University, Amiens, France
| | - Éric Nguyen-Khac
- Department of Gastroenterology, Amiens University Hospital, Picardie University, Amiens, France
| | - Mathurin Fumery
- Department of Gastroenterology, Amiens University Hospital, Picardie University, Amiens, France
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40
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Dong X, Jia Z, Yu B, Zhang X, Xu F, Tan L. Effect of intersphincteric fistula tract ligation versus anal fistulectomy on pain scores and serum levels of vascular endothelial growth factor and interleukin-2 in patients with simple anal fistulas. J Int Med Res 2020; 48:300060520949072. [PMID: 32967495 PMCID: PMC7521059 DOI: 10.1177/0300060520949072] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2019] [Accepted: 07/21/2020] [Indexed: 12/29/2022] Open
Abstract
OBJECTIVE This study was performed to explore the effects of ligation of the intersphincteric fistula tract (LIFT) on pain scores and serum levels of vascular endothelial growth factor (VEGF) and interleukin (IL)-2 in patients with simple anal fistulas. METHODS Ninety patients with simple anal fistulas were evenly randomized into a study group (treated with LIFT) and a control group (treated with traditional anal fistulectomy) according to a random number table. The surgical outcomes, basic operation conditions (operation time, hospital stay, and anal continence), and postoperative wound healing rates were compared between the two groups. RESULTS The study group had significantly better operation conditions (better anal continence and shorter length of hospital stay), a higher postoperative wound healing rate, lower pain scores, higher VEGF and IL-2 levels, and higher overall efficacy rate than the control group. However, the incidence of postoperative complications was not significantly different between the two groups. CONCLUSIONS Patients who underwent LIFT had better surgical outcomes, higher wound healing rates, better anal continence, a shorter length of hospital stay, and less severe postoperative pain than those who underwent simple anal fistulectomy. Increased levels of VEGF and IL-2 after surgery may promote wound healing.
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Affiliation(s)
| | - Zhanbo Jia
- Zhanbo Jia, Anorectal Department, Dongying People’s Hospital, No. 317 Nanyi Road, Dongying District, Dongying City, Shandong Province 257091, China.
| | - Bianfang Yu
- Anorectal Department, Dongying People’s Hospital, Dongying, Shandong, China
| | - Xuebin Zhang
- Anorectal Department, Dongying People’s Hospital, Dongying, Shandong, China
| | - Fagang Xu
- Anorectal Department, Dongying People’s Hospital, Dongying, Shandong, China
| | - Longtao Tan
- Anorectal Department, Dongying People’s Hospital, Dongying, Shandong, China
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Sahnan K, Adegbola S, Iqbal N, Twum-Barima C, Reza L, Lung P, Warusavitarne J, Hart A, Tozer P. Managing non-IBD fistulising disease. Frontline Gastroenterol 2020; 12:524-534. [PMID: 34712471 PMCID: PMC8515280 DOI: 10.1136/flgastro-2019-101234] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Revised: 06/03/2020] [Accepted: 06/07/2020] [Indexed: 02/04/2023] Open
Affiliation(s)
- Kapil Sahnan
- Department of Surgery and Cancer, Imperial College London, London, UK
- Robin Phillip’s Fistula Research Unit, St Mark's Hospital and Academic Institute, Harrow, London, UK
| | - Samuel Adegbola
- Department of Surgery and Cancer, Imperial College London, London, UK
- Robin Phillip’s Fistula Research Unit, St Mark's Hospital and Academic Institute, Harrow, London, UK
| | - Nusrat Iqbal
- Department of Surgery and Cancer, Imperial College London, London, UK
- Robin Phillip’s Fistula Research Unit, St Mark's Hospital and Academic Institute, Harrow, London, UK
| | - Charlene Twum-Barima
- Department of Surgery and Cancer, Imperial College London, London, UK
- Robin Phillip’s Fistula Research Unit, St Mark's Hospital and Academic Institute, Harrow, London, UK
| | - Lillian Reza
- Department of Surgery and Cancer, Imperial College London, London, UK
- Robin Phillip’s Fistula Research Unit, St Mark's Hospital and Academic Institute, Harrow, London, UK
| | - Phillip Lung
- Robin Phillip’s Fistula Research Unit, St Mark's Hospital and Academic Institute, Harrow, London, UK
| | - Janindra Warusavitarne
- Department of Surgery and Cancer, Imperial College London, London, UK
- Robin Phillip’s Fistula Research Unit, St Mark's Hospital and Academic Institute, Harrow, London, UK
| | - Ailsa Hart
- Robin Phillip’s Fistula Research Unit, St Mark's Hospital and Academic Institute, Harrow, London, UK
- IBD Unit, St Mark's Hospital, Harrow, UK
| | - Phil Tozer
- Department of Surgery and Cancer, Imperial College London, London, UK
- Robin Phillip’s Fistula Research Unit, St Mark's Hospital and Academic Institute, Harrow, London, UK
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Assaraf J, Lambrescak E, Lefèvre JH, de Parades V, Bourguignon J, Etienney I, Taouk M, Atienza P, Zeitoun JD. Increased Long-term Risk of Anal Fistula After Proctologic Surgery: A Case-Control Study. Ann Coloproctol 2020; 37:90-93. [PMID: 32054251 PMCID: PMC8134930 DOI: 10.3393/ac.2019.06.18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2019] [Accepted: 06/18/2019] [Indexed: 11/02/2022] Open
Abstract
PURPOSE Anal fistula is a common condition in proctology, usually requiring surgical treatment. Few risk factors have been clearly identified based on solid evidence. Our research objective was to determine whether history of anal surgery was a risk factor for subsequent anal fistula. METHODS We conducted a case-control study from January 1, 2012 through December 31, 2013 in our tertiary center, comprising 280 cases that underwent surgery for anal fistula and 123 control patients seeking a consultation for upper gastrointestinal symptoms. Patients with inflammatory bowel disease were excluded. For both cases and controls, the following variables were recorded: sex, any prior anal surgery, diabetes mellitus, infection with human immunodeficiency virus, and smoking status. For each variable, confidence interval and odds ratio (OR) were calculated. RESULTS In univariate analysis, male sex (73.2% vs. 31.7%, P < 0.0001), active smoking (38.1% vs. 22%, P = 0.0015), and prior anal surgery (16.0% vs. 4.1%, P = 0.0008) were associated with higher risk of anal fistula. In multivariate analysis, only male sex (OR, 5.5; 95% confidence interval [CI], 5.42 to 9.10; P < 0.0001) and previous anal surgery (OR, 4.48; 95% CI, 1.79 to 13.7; P = 0.0008) remained independently associated with anal fistula occurrence. CONCLUSION The epidemiology of anal fistula is poorly assessed despite the high frequency at which it is diagnosed. Our findings suggest that history of any kind of anal surgery is a risk factor for further onset of anal fistula. Surgeons and patients must be informed of this issue.
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Affiliation(s)
- Julie Assaraf
- Proctologic Surgery, Groupe Hospitalier Diaconesses Croix Saint-Simon, Paris, France
| | - Elsa Lambrescak
- Proctologic Surgery, Groupe Hospitalier Diaconesses Croix Saint-Simon, Paris, France
| | - Jérémie H Lefèvre
- General and Digestive Surgery, Saint-Antoine Hospital, APHP, Paris, France.,Department of Digestive Surgery, University Paris VI, Paris, France
| | - Vincent de Parades
- Proctologic Surgery, Groupe Hospitalier Paris Saint-Joseph, Institut Léopold Bellan, Paris, France
| | - Josée Bourguignon
- Proctologic Surgery, Groupe Hospitalier Diaconesses Croix Saint-Simon, Paris, France
| | - Isabelle Etienney
- Proctologic Surgery, Groupe Hospitalier Diaconesses Croix Saint-Simon, Paris, France
| | - Milad Taouk
- Proctologic Surgery, Groupe Hospitalier Diaconesses Croix Saint-Simon, Paris, France
| | - Patrick Atienza
- Proctologic Surgery, Groupe Hospitalier Diaconesses Croix Saint-Simon, Paris, France
| | - Jean-David Zeitoun
- Proctologic Surgery, Groupe Hospitalier Diaconesses Croix Saint-Simon, Paris, France.,Gastroenterology and Nutrition, Saint-Antoine Hospital, APHP, Paris, France
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Yan J, Ma L. Clinical Effect of Tunnel-Like Fistulectomy Plus Draining Seton Combined with Incision of Internal Opening of Anal Fistula (TFSIA) in the Treatment of High Trans-Sphincteric Anal Fistula. Med Sci Monit 2020; 26:e918228. [PMID: 31929499 PMCID: PMC6977603 DOI: 10.12659/msm.918228] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Background The aim of this study was to investigate the clinical effect of tunnel-like fistulectomy plus draining seton combined with incision of internal opening of anal fistula (TFSIA) in the treatment of high transsphincteric anal fistula. Material/Methods There were 80 patients with high transsphincteric anal fistula randomly divided into TFSIA group and control group, 40 cases in each group. The control group was treated with cutting seton, and the seton was tightened weekly after discharge from the hospital until the seton dropped off. In the TFSIA group, the anal fistula was dissected and resected in tunnel-like form through the external opening to the intersphinceteric space, drained with seton through the tunnel, and cut open the internal opening of the anal fistula and the intersphincteric space and expanded the drainage. The operative time, blood loss, postoperative uroschesis, anal wound pain score, healing time, Wexner anal incontinence score, keyhole-like deformity, and recurrence rate were compared between the 2 groups. Results The differences of the blood loss, operative time, anal wound pain score at 6 hours after operation, postoperative uroschesis and the recurrence rate after operation were not statistically significant (P>0.05), but the TFSIA were better than the control group in the anal wound pain score at 1 week after operation, healing time, Wexner anal incontinence score, and anal keyhole-like deformity rate (P<0.05). Conclusions TFSIA is effective in treating high transsphincteric anal fistula, and it can reduce adverse complications after operation.
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Affiliation(s)
- Jifu Yan
- Department of Colorectal Surgery, Yuyao People's Hospital of Zhejiang Province, Zhejiang, Yuyao, China (mainland)
| | - Li'an Ma
- Department of Colorectal Surgery, Yuyao People's Hospital of Zhejiang Province, Zhejiang, Yuyao, China (mainland)
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Prevalence of Anal Fistulas in Europe: Systematic Literature Reviews and Population-Based Database Analysis. Adv Ther 2019; 36:3503-3518. [PMID: 31656013 PMCID: PMC6860471 DOI: 10.1007/s12325-019-01117-y] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2019] [Indexed: 12/12/2022]
Abstract
Introduction Despite the fact that perianal fistulas are associated with significant morbidity and impaired quality of life, their prevalence in Europe is unknown. The aim of this study was to estimate the prevalence of perianal fistulas in Europe, overall and according to etiology. Methods Two independent literature reviews were performed using different search strategies to maximize the identification of potentially relevant studies. Data from relevant articles were used to estimate the prevalence of perianal fistulas in Europe. The robustness of the estimate was evaluated using data from a large population-based database from the UK. Results A total of 26 studies provided epidemiological data on perianal fistulas, of which 16 provided suitable data to estimate the prevalence. Estimations using these data yielded a total prevalence of 1.69 per 10,000 population. Cryptoglandular infection and Crohn’s disease (CD) were the predominant etiologies, with prevalence rates at 0.86 and 0.76 per 10,000 population, respectively. Comparison of prevalence data from the UK population-based database with the European population resulted in a standardized prevalence estimate of all perianal fistulas of 1.83 per 10,000 population, confirming the robustness of the literature-based estimate. Conclusion Although in terms of incidence cryptoglandular fistulas were clearly predominant, the prevalence of fistulas in CD and cryptoglandular infection appeared more balanced. This is due to the longer duration and higher frequency of relapses of fistulas in CD. The estimated prevalence implies that perianal fistulas meet the criteria to be considered as a rare condition in Europe (prevalence less than 5 per 10,000 population). Funding This study was funded by Takeda Pharmaceutical U.S.A., Inc. and TiGenix SAU. Electronic Supplementary Material The online version of this article (10.1007/s12325-019-01117-y) contains supplementary material, which is available to authorized users.
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Galazzo G, Tedjo DI, Wintjens DSJ, Savelkoul PHM, Masclee AAM, Bodelier AGL, Pierik MJ, Jonkers DMAE, Penders J. Faecal Microbiota Dynamics and their Relation to Disease Course in Crohn's Disease. J Crohns Colitis 2019; 13:1273-1282. [PMID: 30810207 PMCID: PMC6764104 DOI: 10.1093/ecco-jcc/jjz049] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Microbial shifts have been associated with disease activity in Crohn's disease [CD], but findings on specific taxa are inconsistent. This may be due to differences in applied methods and cross-sectional study designs. We prospectively examined the faecal microbiota in adult CD patients with changing or stable disease course over time. METHODS Faeces were collected at two time-points from 15 healthy control individuals [HCs], 35 CD patients who were in remission and who maintained remission [RRs], and 22 CD patients during remission and also during subsequent exacerbation [RAs]. The microbial composition was assessed by 16S rRNA [V4] gene sequencing. RESULTS Compared with HCs, patients with CD had a lower microbial richness [p = 0.0002] and diversity [p = 0.005]. Moreover, the microbial community structure of a subset of patients, clustered apart from HCs, was characterized by low microbial diversity and Faecalibacterium abundance. Patients within this cluster did not differ with respect to long-term disease course compared with patients with a 'healthy-appearing' microbiota.Over time, microbial richness and diversity did not change in RR versus RA patients. Although the microbial community structure of both RR and RA patients was less stable over time compared with that of HCs, no differences were observed between the patient groups [p = 0.17]; nor was the stability impacted by Montreal classification, medication use, or surgery. CONCLUSION The altered microbiota composition and stability in CD was neither associated with disease activity nor long-term disease course, questioning its involvement in the development of an exacerbation. The aberrant microbiota composition in a subset of CD patients warrants further exploration of a more microbiota-driven etiology in this group.
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Affiliation(s)
- Gianluca Galazzo
- School of Nutrition and Translational Research in Metabolism [NUTRIM], Department of Medical Microbiology, Maastricht University Medical Center+, Maastricht, The Netherlands,School of Public Health and Primary Care [Caphri], Department of Medical Microbiology, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - Danyta I Tedjo
- School of Nutrition and Translational Research in Metabolism [NUTRIM], Department of Medical Microbiology, Maastricht University Medical Center+, Maastricht, The Netherlands,School of Nutrition and Translational Research in Metabolism [NUTRIM], Division Gastroenterology–Hepatology, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - Dion S J Wintjens
- School of Nutrition and Translational Research in Metabolism [NUTRIM], Division Gastroenterology–Hepatology, Maastricht University Medical Center+, Maastricht, The Netherlands,Department of Internal Medicine, Division of Gastroenterology and Hepatology, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - Paul H M Savelkoul
- School of Nutrition and Translational Research in Metabolism [NUTRIM], Department of Medical Microbiology, Maastricht University Medical Center+, Maastricht, The Netherlands,School of Public Health and Primary Care [Caphri], Department of Medical Microbiology, Maastricht University Medical Center+, Maastricht, The Netherlands,Department of Medical Microbiology & Infection control, Amsterdam UMC, Vrije Universiteit, Amsterdam, The Netherlands
| | - Ad A M Masclee
- School of Nutrition and Translational Research in Metabolism [NUTRIM], Division Gastroenterology–Hepatology, Maastricht University Medical Center+, Maastricht, The Netherlands,Department of Internal Medicine, Division of Gastroenterology and Hepatology, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | | | - Marie J Pierik
- School of Nutrition and Translational Research in Metabolism [NUTRIM], Division Gastroenterology–Hepatology, Maastricht University Medical Center+, Maastricht, The Netherlands,Department of Internal Medicine, Division of Gastroenterology and Hepatology, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - Daisy M A E Jonkers
- School of Nutrition and Translational Research in Metabolism [NUTRIM], Division Gastroenterology–Hepatology, Maastricht University Medical Center+, Maastricht, The Netherlands,Department of Internal Medicine, Division of Gastroenterology and Hepatology, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - John Penders
- School of Nutrition and Translational Research in Metabolism [NUTRIM], Department of Medical Microbiology, Maastricht University Medical Center+, Maastricht, The Netherlands,School of Public Health and Primary Care [Caphri], Department of Medical Microbiology, Maastricht University Medical Center+, Maastricht, The Netherlands,Corresponding authors: J. Penders, Department of Medical Microbiology, Maastricht University Medical Center+, PO 5800, 6202 AZ, Maastricht, The Netherlands. Tel: +31-(0)433875134; Fax: +31-(0)433676643;
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High prevalence of hidradenitis suppurativa in patients with perianal fistula. Int J Colorectal Dis 2019; 34:1337-1339. [PMID: 31093736 DOI: 10.1007/s00384-019-03313-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/02/2019] [Indexed: 02/04/2023]
Abstract
BACKGROUND Perianal fistula is an abnormal communication between the anal canal and perianal skin. Hidradenitis suppurativa (HS) is a chronic, auto-inflammatory skin disease in the intertriginous body areas, presenting with recurring abscesses, inflammatory nodules, and sinus tracts. The aim of this study was to determine the prevalence of HS in patients with a perianal fistula. METHODS All patients with perianal fistula visiting a specialized proctology clinic between July and September 2017 were included and asked a validated diagnostic question for HS. Subsequently, physical examination was performed to objectively assess the diagnosis and relevant patient characteristics. RESULTS In 6.6% (8/122) of patients, HS was diagnosed outside the perianal region. Four of these patients were newly diagnosed. The fistulas in HS patients were classified as a superficial fistula (three), a blind ending fistula (two), and a transsphincteric fistula (two). One patient had more than one type of fistula. CONCLUSION The prevalence of HS in patients with a perianal fistula is at least 6.6%. This is higher than the prevalence reported in the general European population (1%) suggesting an association between perianal fistulas and HS. We stress the importance to screen for HS in patients with perianal fistulas in order to start appropriate anti-inflammatory treatment to reduce symptoms and disease progression.
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Abstract
Anal fistulas are a common anorectal disease and are frequently associated with a perianal abscess. The etiology is based on a cryptoglandular infection in the intersphincteric space. Surgery remains the only definitive therapy. The primary goal of definitive fistula surgery is healing; however, success of fistula surgery is influenced by a variety of factors including the surgeon's experience, type of fistula, involvement of sphincter muscles, type of surgical procedure and patient-related factors. For the surgical treatment of a complex anal fistula, a variety of operative procedures have been described including fistulectomy with sphincterotomy, different flap procedures (e.g. mucosal flap and advancement flap) and finally so-called sphincter-preserving techniques, such as LIFT (ligation of intersphincteric fistula tract), VAAFT (video-assisted anal fistula treatment), the use of plugs of collagen or fibrin glue sealants as well as laser procedures or the clip. In the search for suitable quality indicators in anal fistula surgery there is a conflict between healing and preservation of continence. If potential quality indicators are identified the principles of anal fistula surgery must be adhered to and the appropriate selection of patients and procedures is of crucial importance to achieve high healing rates without compromising continence or inducing surgical revision due to abscesses or recurrence. Based on the available literature and guidelines, in the assessment of quality indicators considerable differences exist with respect to patient selection, etiology of anal fistulas and length of follow-up. Heterogeneity of treatment protocols lead to difficulties in a definitive assessment of which surgical treatment is the best option for complex anal fistulas.
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Affiliation(s)
- O Schwandner
- Abteilung für Proktologie, Krankenhaus Barmherzige Brüder Regensburg, Prüfeninger Str. 86, 93049, Regensburg, Deutschland.
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49
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Abstract
Anal fistula, or fistula-in-ano, is a condition involving the anal region that is common yet debilitating. Surgery is the mainstay of treatment for an anal fistula and the chances of recurrence are quite high even after corrective surgical procedures. The risk factors for recurrence can be broadly classified into four categories: 1) risk factors related to the fundamental anatomy of the fistula and presence of comorbidities, 2) lack of proper preoperative assessment of the fistula, which includes failure to recognize the internal opening and overall structure of the fistula and not supplementing the proctologic examination with sufficient imaging, 3) intraoperative loopholes that include improper procedure selection, inexperience of the surgeon, and failure to get rid of the entire tract along with its ramifications, and 4) lack of proper postoperative care in the early and late periods following the surgery. The aim of this paper, therefore, is to highlight the factors that could increase the risk of recurrence in different types of anal fistulae. Once surgeons know these risk factors, they can anticipate any complication and detect recurrence early.
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50
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Abstract
BACKGROUND The characteristics of patients who develop a fistula-in-ano after an anorectal abscess are unclear. OBJECTIVE Our study explored this relationship and patient factors associated with fistula development. DESIGN International Classification of Diseases, 10 Revision, and Classification of Interventions and Procedures, version 4, codes were used to identify all of the patients with a primary anorectal abscess. Multivariable analysis was used to identify factors predictive of fistula formation. SETTINGS The study was conducted in a district general hospital. PATIENTS Patients with anorectal abscess who were admitted to our institution (2004-2015) were included. MAIN OUTCOMES MEASURES The rate of subsequent fistula formation was measured. RESULTS A total of 1970 abscess patients were identified; 70.0% (n = 1379) were men, and 7.3% (n = 144) had Crohn's disease. Fistulas occurred in 16.2% (n = 319) at a median of 7 months (interquartile range, 3-7 mo). Patients with Crohn's disease were more than twice as likely to develop a fistula than patients without Crohn's disease (32.6% vs 14.9%; OR = 2.5 (95% CI, 1.7-3.7); p < 0.001). Patients with Crohn's disease with a fistula were more likely to be women (55.3% vs 34.6%; p = 0.007) and aged <30 years (51.1% vs 24.3%; p< 0.001) versus patients without Crohn's disease with a fistula. At multivariable analysis of the entire cohort, male sex (OR = 0.7 (95% CI, 0.5-0.9); p = 0.005) and diabetes mellitus (OR = 0.5 (95% CI, 0.3-0.9); p = 0.027) were associated with a reduced likelihood of developing a fistula after abscess formation. LIMITATIONS The study was limited by its single-center scope, retrospective analysis, and lack of a standardized definition for Crohn's disease. CONCLUSIONS Abscesses are more common in men, but progression to fistula is more likely in women. The rate of fistula progression in Crohn's disease is twice that in patients without Crohn's disease. Identification of patients at risk may help delineate those who will benefit from a more conservative surgical approach, enhanced follow-up, or investigation after abscess drainage. See Video Abstract at http://links.lww.com/DCR/A798.
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