Academic literature on the topic 'Anal fistula'

BACKGROUND Fistula-in-ano or anal fistulas are documented since ancient times and their management has always been a challenge. Various modalities of treatment are available and newer ones are being added each day. The aim of this retrospective study is to analyse the outcome of the video assisted anal fistula treatment (VAAFT), one of the modalities of treatment for complex anal fistulas done at our centre. METHODS Records of patients who had been treated through VAAFT by single senior consultant surgeon of Minimal Access Surgery unit between April 2013 and March 2019, were collected and analysed. RESULTS Altogether, records of 48 (forty-eight) patients who had undergone VAAFT during the period were analysed. Data revealed that 38 male (79.17 %) and 10 female (20.83 %) patients with mean age of 49.96 ± 12.22 years were operated. Most commonly, trans sphincteric followed by inter sphincteric type of fistulae were encountered. In 3 cases, internal opening couldn’t be visualised. Six patients were documented to have a recurrence within 6 months of the procedure and in the rest were cured except in a small subset of patients who did not follow up. CONCLUSIONS Amongst the wide range of armamentarium available today for the treatment of complex anal fistulas, video assisted anal fistula treatment (VAAFT) is a novel sphincter saving technique. The recurrence rate at our centre was at par with other studies and with zero incontinence rate, however further RCTs are required. KEYWORDS Complex Anal Fistula, Fistula-in-Ano, MEINERO Fistuloscope, VAAFT

Objective: To analyze the accuracy of DWI-MRI combined with conventional MRI sequence in the diagnosis and classification of anal fistula, and to explore its application value. Methods: The clinical and imaging data of 56 patients with anal fistula confirmed by surgery were collected. All patients underwent conventional MR scans (axial T1WI, T2WI and axial, coronary, sagittal T2WI fat suppression) and axial DWI. With the surgical pathology results as the gold standard, the diagnostic compliance rate of anal fistula inside and outside mouth, main fistula, branch fistula, and abscess were observed and relied on both conventional sequence and conventional sequence combined with DWI. At the same time, the patients in this group were classified according to Parks classification of anal fistula, and the results were compared with the surgical results. Results: Fifty-six patients with anal fistula were confirmed to have 7 simple anal fistulas and 49 complicated anal fistulas. According to Parks anal fistula classification, MRI diagnosed 7 cases of intersphincteric fistula, 24 cases of trans sphincteric type fistula, 16 cases of superior sphincteric type fistula, and included 9 cases of rectal vaginal/scrotal fistula into the scope of extra-sphincteric fistula. The overall coincidence rate of scores was 87.5% (49/56). Conclusion: In preoperative MRI examination of anal fistula, compared with relying only on conventional sequences, the combined use of DWI sequences has higher accuracy in displaying the inner, outer and branch fistulas, and provides more detailed images before clinical operation. Anatomical information should be applied as a routine examination sequence for preoperative diagnosis of anal fistula.

Objective Horseshoe anal fistula is a common anorectal disease, and there is no standard procedure for its treatment. In this study, we performed a modified surgical procedure for the treatment of horseshoe anal fistula and investigated its efficacy and adverse effects. Methods We retrospectively analyzed the outcomes of video-assisted anal fistula treatment combined with an anal fistula plug (VAAFT-Plug) in 26 patients with a horseshoe anal fistula. The follow-up period ranged from 6 to 18 months. Preoperative and postoperative data were collected to analyze the cure rate, anal sphincter function, and incidence of complications. Results The surgeries were successfully performed in all patients, 23 of whom were cured (effective cure rate of 88.46%). Three patients developed recurrence and were cured after traditional surgery. No patients developed severe complications or postoperative anal incontinence. The VAAFT-Plug protocol was performed with a small incision in the fistula that subsequently promoted fistula healing and preserved sphincter function. Conclusion Although randomized controlled trials will be needed to fully validate these findings, our results suggest that VAAFT-Plug represents a promising treatment strategy for horseshoe anal fistulas. This technique preserves normal anal function and achieves satisfactory outcomes in most patients.

Background/Aim. There are limited data examining variations in the local expression of inflammatory mediators in anal fistulas where it is anticipated that an improved understanding of the inflammatory milieu might lead to the potential therapeutic option of instillation therapy in complicated cases. The aim of the present study was to examine prolactin receptors (PRLR) as inflammatory markers and to correlate their expression with both the complexity of anal fistulas and the likelihood of fistula recurrence. Methods. Microarray was used to screen the differentially expressed gene profile of anal fistula using anal mucosa samples with hemorrhoids with ageand sex-matched patients as controls and then a prospective analysis of 65 patients was conducted with anal fistulas. PRLR immunohistochemistry was performed to define expression in simple, complex and recurrent anal fistula cases. The quantitative image comparison was performed combining staining intensity with cellular distribution in order to create high and low score PRLR immunohistochemical groupings. Results. A differential expression profile of 190 genes was found. PRLR expression was 2.91 times lower in anal fistula compared with control. Sixty-five patients were assessed (35 simple, 30 complex cases). Simple fistulas showed significantly higher PRLR expression than complex cases with recurrent fistulae showing overall lower PRLR expression than de novo cases (p = 0.001). These findings were reflected in measurable integrated optical density for complex and recurrent cases (complex cases, 8.31 ? 4.91 x 104 vs simple cases, 12.30 ? 6.91 x 104; p < 0.01; recurrent cases, 7.21 ? 3.51 x 104 vs primarily healing cases, 8.31 ? 4.91 x 104; p < 0.05). In univariate regression analysis, low PRLR expression correlated with fistula complexity; a significant independent effect maintained in multivariate analysis odds ratio [(OR) low to high PRLR expression = 9.52; p = 0.001)]. Conclusion. PRLR expression inversely correlates with anal fistula complexity. Further work must define the specificity of this finding and its relationship to other conventional mediators of inflammation.

Abstract Background Magnetic resonance imaging (MRI) is the standard for evaluating perianal fistulae. Perianal fistula can be the first manifestation of CD, and needs to be differentiated from non-CD associated perianal fistula. This study sought to identify the variations in MRI characteristics of perianal fistulas in patients with and without inflammatory bowel disease (IBD), considering the potential implications for treatment decisions. Methods This was a single-center cross-sectional analysis of patients who underwent pelvic MRI for assessment of perianal fistula between January 2021 and June 2022 at Dayanand Medical College and Hospital (DMCH), Ludhiana, India. Patients who underwent dedicated MRI fistula protocol were included. Patients with prior anal resection or anastomosis, anorectal tumor, or equivocal imaging findings that could not be definitely assessed as a fistula were excluded. The following features were assessed: anatomic type of fistula (Parks classification), luminal origin (hour clock position), anal verge distance, signs of acute inflammation, circumference of anus involved by inflammation, presence of rectal inflammation, and abscess. Results Between January 2022 and December 2022, a total of 287 MRI scans were conducted to assess for perianal fistulae. Out of these, 119 MRI scans met the eligibility criteria and 32(26.89%) were associated with an established clinical diagnosis of CD. A higher proportion of females had CD-associated perianal fistula compared to non-CD perianal fistula. A significantly greater percentage of CD-associated perianal fistulas exhibited supra-levator extension, multiple and branched fistula tracts, and ≥2 internal and external openings. Patients with CD had higher prevalence of concurrent perianal abscess, proctitis, anorectal strictures, and a greater number of clock hours of inflamed anal circumference, compared to patients with cryptoglandular fistula. (Table 1) On multivariate logistic regression analysis, female sex, ≥2 internal openings, proctitis and height of the mucosal origin of the fistula from the anal verge >1.85 cm independently predicted the perianal fistula to be associated with CD. We constructed the DMCH index as follows: DMCH index: (3xfemale sex) + (3x≥2 internal openings of the fistula tract) + (6xrectal wall thickening) + (2xheight of mucosal origin of the fistula from anal verge >1.85 cm) The DMCH index greater than 7 identified the perianal fistulae associated with CD with a sensitivity of 84% and specificity of 91% [Area under curve 0.91; 95% CI 0.85-0.97; P< 0.0001].(Figure 1) Conclusion The DMCH index identifies CD associates perianal fistula with a high level of accuracy. These findings require validation and confirmation in independent, multi-reader studies.

Introduction: Laser treatment for fistula-in-ano, also known as FiLaC (fistula laser closure) or LAFT (laser ablation of fistula tract), has gained increasing attention in the last decade. The procedure consists of delivering laser energy at 360° within the lumen of fistulas by means of a radial fiber which is slowly withdrawn from the external orifice. Material & Methods: The study analysed 40 patients treated for anal fistulae in Sapthagiri Institute of Medical Sciences, Bangalore between November 2020 to June 2021. Fistulae were classified in accordance with the Parks’ classification system, and all patients were preoperatively assessed by clinical examination and proctosigmoidoscopy and classified using three-dimensional (3D) endoanal ultrasonography performed by a sonographer experienced in endoanal ultrasound. Results: Of the 40 patients, 26 were female and 14 were male (overall median age 46 years; range 17–82 years). The median period of follow-up was 11 months, follow up was scheduled in the outpatient at 1 and 2 weeks and 1, 3, 6 and 11 months postoperatively. However, patients were instructed to return to the outpatient at any time should symptoms recur. In the cohort, 39 fistulae (97.5%) were cryptoglandular in origin and 1 (2.5%) were Crohn’s related. 97.5% had previously undergone surgery including abscess drainage and prior fistula operations. The mean number of operations before FiLaC treatment was 2.4 (±1.7) with a range of 1–9 previous operations. Discussion: The use of FILAC for the treatment of anorectal fistula has shown encouraging. The technique is easy to learn and fast to perform, allows exploration of curved paths and any size since the fiber is very flexible and long. The destruction of the epithelialized path and sealing is carried out by laser emission radially 360◦, thereby allowing the application of energy across the path homogeneous in a controlled manner. Conclusion: The FILAC, sphincter preservation minimally invasive surgery in the treatment of anal fistulas, looks promising although prospective and long-term follow-up studies should be conducted.

Background: The aim of this study is to evaluate our experience in the management of complex anal fistulae by combined technique approach. Ideal surgical treatment for complex anal fistula should aim to eradicate the source of infection and promote healing of the tract, while preserving the sphincters and the mechanism of anal continence. Even with the evolving newer techniques complex anal fistulae have higher rates of recurrence and functional disability as anal incontinence. The requirement of multiple surgeries for recurrence and the newer techniques like anal fistula plug are expensive and will become a burden for patients living in developing countries like ours. Thus, apart from Ligation of Intersphincteric fistula tract, the use of cutting seton is the main surgical method practiced here. This article focuses on the approach to the complex anal fistula management through evidence-based treatment strategies.Methods: Author conducted a prospective study of 35 complex anal fistulae patients undergoing combined technique approach with cutting Seton, Ligation of Intersphincteric Fistula tract and fistulotomy. Results: All patients recovered well with no complications in postoperative period. After 2 years of follow up patients are recurrence free and only 2 patients had partial incontinence with improving trend.Conclusions: The use of cutting Seton in high anal fistula is an effective technique. LIFT technique is good for Transphincteric tracts without previous scarring; it can be easily learned and applied. We can conclude that combined technique was an effective procedure and valid alternative for complex anal fistula management.

Background: Association of tuberculosis (TB) with anal fistulas can make its treatment quite difficult. The main challenge is timely detection of TB in anal fistulas and its proper management. There is little data available on diagnosis and management of TB in anal fistulas.
 Objective: To detect TB in fistula-in-ano patients were analyzed in different methods utilized. Methods: It was a prospective study conducted in Department of Colorectal Surgery, Bangabandhu Sheikh Mujib Medical University and Department of Surgery & Pathology, Sir Salimullah Medical College Mitford Hospital, Dhaka. Total 258 cases were included in this study during the period January 2018 to December 2020.The sampling was done for tissue (fistula tract lining) and pus (when available). The detection rate of various tests to detect TB and prevalence rate of TB in simple vs complex fistulae were studied.
 Results: This study shows 84.1% were non TB fistula and 15.9% were TB fistula. Majority were male between non TB fistula and TB fistula which was 87.1% and 85.4% respectively. TB fistulas were more complex than non-tuberculous fistulas (68.3% vs 44.2%) respectively. TB was detected in (7.4%) samples tested by PCR-tissue, 23.6% samples tested by PCR-pus, (1.6%) samples tested with HPE-tissue and 0.8% samples tested by GeneXpert.
 Conclusion: This study shows the detection of TB by polymerase chain-reaction was higher than by histopathology and GeneXpert. Amongst polymerase chain-reaction, pus had a higher detection rate than tissue. TB fistulas were more complex than non-tuberculous fistulas but aggressive diagnosis and meticulous treatment led to comparable overall success rates in both groups.
 Sir Salimullah Med Coll J 2021; 29(2): 121-123

A fistula of the anus is a chronic inflammatory process in the pararectal cell, intersphincter space and anal crypt with the presence of a formed fistula passage, where the affected anal crypt is the internal opening of the fistula. The urgency of surgical treatment of rectal fistulas is due to unsatisfactory results because of frequent anal incontinence and relapses of the disease. In this regard, most authors emphasize that the treatment of anal fistulas, as before, remains an urgent problem of colorectal surgery, and the search for new methods is a priority task of colorectal surgery. Literature analysis performed using the Elsevier, PubMed, eLIBRARY.RU, CyberLeninka, Google Scholar databases showed that the currently used technologies and methods of surgical treatment of anal fistulas do not allow us to determine their “gold standard”. In this regard, further analysis of the effectiveness and safety of their use, an assessment of the complications of surgical intervention and the frequency of relapses of the disease is necessary.

BACKGROUND Perianal fistulas account for a substantial discomfort and morbidity to the patient thus affecting productive man hours and quality of life. Accurate pre-operative assessment of course of the primary fistulous track and secondary extension or abscesses is required for successful surgical management of anal fistulas. The purpose of this study was to diagnose and classify pre-operative perianal fistulas. METHODS This is a cross-sectional study at Department of Radiodiagnosis in a tertiary level hospital of southern Rajasthan from November 2018 to November 2020. The study included a total of 50 patients referred to department of radiology for magnetic resonance imaging (MRI). Statistical analysis was done using chi square test and student t test. RESULTS Out of these patients, 56 % were having secondary tract on MRI, 12 % patients were having abscess and 4 % were having horseshoe abscess on MRI. The commonest type of ano-rectal fistula encountered in the study was Grade -II seen in 32 %. CONCLUSIONS MRI is a highly accurate, rapid and non-invasive tool in pre-operative evaluation of the perianal and anal fistulas. MRI evaluation and classification of perianal fistulae has a high degree of diagnostic accuracy. The use of MRI for the diagnosis and classification of perianal fistula can provide reliable information which has both pre-operative and prognostic value. St James University Hospital classification, which is an MR imaging-based grading system for perianal fistula is very useful for effective radiological-surgical communication thus contributing to improved patient care and reduced rate of recurrence. KEYWORDS MR Fistulogram, Perianal Fistula, Anal Fistula, Fistula Classification, Fistulography