European Society of Coloproctology: Guidelines for diagnosis and treatment of cryptoglandular anal fistula.

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.

[Long-term results of surgical correction of H-type fistula in girls with a normal anus]. / Otdalennye rezul'taty khirurgicheskoi korrektsii H-fistul u devochek pri normal'no sformirovannom anuse.

OBJECTIVE: To evaluate the long-term results of surgical correction of H-type fistula in girls with a normal anus. MATERIAL AND METHODS: There were 7 patients with rectovestibular fistula and 3 patients with rectovaginal fistula with a normal anus were observed from 2014 to 2019 in the Surgical Department No. 1 of the Russian Children's Clinical Hospital. Upon admission, all patients underwent genital examination, vaginoscopy, rectal examination and probing the fistulous canal, irrigography, abdominal and retroperitoneal ultrasound. They were also examined by a gynecologist and genital smears were obtained. Surgical treatment was determined depending on the height and diameter of the fistula for each child. One patient underwent perineal fistulectomy, three patients - anterior anorectoplasty. Invaginated fistula extirpation, abdominoperineal proctoplasty and perineal fistulectomy using a pad flap between the defects were used in two cases, respectively. Patients were followed-up for the period from 6 months to 1 year after the last recurrence. Follow-up examination, irrigography and functional examination of sphincter were performed. RESULTS: Two (20%) patients did not require redo surgery. In 6 (60%) cases, recurrences didn't occur within a year after the second surgery, in 2 (20%) cases - after 3 operations. Recurrent H-type fistula appeared after 3 of 4 perineal fistulectomy procedures, 3 of 9 anterior anorectoplasty, 2 of 2 abdominoperineal proctoplasty and 2 of 3 invaginated fistula extirpation. Hypotension of internal anal sphincter and neo-rectal ampulla, recurrent vulvovaginitis were diagnosed in 2 patients in 6 months after anterior anorectoplasty. CONCLUSION: We recommend anterior anorectoplasty and perineal fistulectomy using a pad flap between the defects for the treatment of H-type fistula to minimize the risk of recurrence.

Perianal Crohn's Disease.

CASE SUMMARY: A 22-year-old man presents to your office with a perianal abscess and occasional mild crampy abdominal pain. You take him to the operating room for an examination under anesthesia (EUA) with incision and drainage of the abscess and note a transphincteric fistula tract through which you place a seton and 2 large skin tags. The anal canal and rectum are without ulceration, but there are mild proctitis and nonprolapsing internal hemorrhoids. Because of a concern for Crohn's disease (CD), he undergoes magnetic resonance enterography and colonoscopy. The magnetic resonance enterography shows inflammation in 20 cm of the distal terminal ileum, and colonoscopy reveals approximately 10 ulcers <5 mm in the terminal ileum without significant narrowing. He is seen in consultation for the initiation of a monoclonal antibody and returns to see you in the office after his first 3 infusions. He is feeling well, has significantly decreased drainage from the perianal fistula, but would really like his seton and skin tags removed while you are there.

Understanding and Treating Supralevator Fistula-in-Ano: MRI Analysis of 51 Cases and a Review of Literature.

BACKGROUND: Supralevator fistulas are highly complex. The delineation of the supralevator fistula has become accurate because of MRI. OBJECTIVE: The aim of the study was to analyze the pathophysiology and treatment of different types of supralevator fistulas. DESIGN: This was a prospective study. SETTINGS: The study was conducted at a specialized fistula treatment center in North India. PATIENTS: All of the patients with fistula-in-ano who presented in the outpatient department were assessed with a physical examination and MRI scan. The patients in whom the supralevator extension was confirmed on MRI were included in the study. MAIN OUTCOME MEASURES: The MRI scans of patients included in the study were analyzed in detail to assess the types of supralevator fistulas and other characteristics of these fistulas. The patients who were operated on were followed for cure rate and deterioration in incontinence. RESULTS: Of 702 patients with fistula-in-ano who were analyzed by MRI over a period of 3 years, 51 patients with supralevator fistula-in-ano were identified. The mean age was 44.3 ± 12.1 years and the male:female ratio was 16:1. The incidence of supralevator fistulas was 7.26% (51 of 702). In supralevator fistulas, the supralevator extension (upper part) was found to be in the intersphincteric plane in all of the patients. This upper part could be successfully managed by laying it open through the transanal route. The infralevator (lower) part could be of 3 types: intersphincteric (n = 13), low transsphincteric (n = 3), or high transsphincteric (n = 35). The lower part could be managed conventionally. There were no extrasphincteric fistulas. An extensive review of the literature revealed only 2 studies (total fistulas = 16) in which supralevator fistula was studied. LIMITATIONS: This was a retrospective study. CONCLUSIONS: The upper supralevator extension in all of the supralevator fistulas is almost always in the intersphincteric plane. This upper part could be laid open through the transanal route. The lower infralevator part could be of 3 types, intersphincteric, low transsphincteric, or high transsphincteric, which could be managed conventionally. Thus, supralevator fistulas could be managed successfully and easily. See Video Abstract at http://links.lww.com/DCR/A630.

A global consensus on the classification, diagnosis and multidisciplinary treatment of perianal fistulising Crohn's disease.

OBJECTIVE: To develop a consensus on the classification, diagnosis and multidisciplinary treatment of perianal fistulising Crohn's disease (pCD), based on best available evidence. METHODS: Based on a systematic literature review, statements were formed, discussed and approved in multiple rounds by the 20 working group participants. Consensus was defined as at least 80% agreement among voters. Evidence was assessed using the modified GRADE (Grading of Recommendations Assessment, Development, and Evaluation) criteria. RESULTS: Highest diagnostic accuracy can only be established if a combination of modalities is used. Drainage of sepsis is always first line therapy before initiating immunosuppressive treatment. Mucosal healing is the goal in the presence of proctitis. Whereas antibiotics and thiopurines have a role as adjunctive treatments in pCD, anti-tumour necrosis factor (anti-TNF) is the current gold standard. The efficacy of infliximab is best documented although adalimumab and certolizumab pegol are moderately effective. Oral tacrolimus could be used in patients failing anti-TNF therapy. Definite surgical repair is only of consideration in the absence of luminal inflammation. CONCLUSIONS: Based on a multidisciplinary approach, items relevant for fistula management were identified and algorithms on diagnosis and treatment of pCD were developed.

Retrorectal dermoid cyst manifested as an extrasphincteric perianal fistula - case report.

Retrorectal tumors are very rare but well defined pathological entities in the literature. Also, an extrasphincteric fistula is a very rare form of perianal fistula which makes our case a very unusual and rare one, especially by the fact that it was successfully treated with the first operation and without protective stoma formation. The patient was first treated in hospital for a retrorectal abscess that had spontaneously ruptured in the postanal space. Because of the constant drainage of the suppurative content from the postanal opening in the following months, MRI and fistulography were performed, registering cystic formation in the retrorectal space with fistulous communication with the rectum above and completely separate from the sphincter mechanism. After that the patient was admitted for definitive treatment. The operation was performed with the patient in a prone jack-knife position. Complete excision of the cyst with the fistulous communication was performed and the rectum was sutured in two layers with separate slowly absorbable sutures. The wound was laid open and the patient was discharged on the 5th post operative day. After about ten months the defecation is normal, the wound is sealed and there are no signs of inflammation and secretion locally.

Strategies to Distinguish Perianal Fistulas Related to Crohn's Disease From Cryptoglandular Disease: Systematic Review With Meta-Analysis.

BACKGROUND: Management of perianal fistulas differs based on fistula type. We aimed to assess the ability of diagnostic strategies to differentiate between Crohn's disease (CD) and cryptoglandular disease (CGD) in patients with perianal fistulas. METHODS: We performed a diagnostic accuracy systematic review and meta-analysis. A systematic search of electronic databases was performed from inception through February 2021 for studies assessing a diagnostic test's ability to distinguish fistula types. We calculated weighted summary estimates with 95% confidence intervals for sensitivity and specificity by bivariate analysis, using fixed effects models when data were available from 2 or more studies. The Quality Assessment of Diagnostic Accuracy Studies tool was used to assess study quality. RESULTS: Twenty-one studies were identified and included clinical symptoms (2 studies; n=154), magnetic resonance imaging (MRI) characteristics (3 studies; n=296), ultrasound characteristics (7 studies; n=1003), video capsule endoscopy (2 studies; n=44), fecal calprotectin (1 study; n=56), and various biomarkers (8 studies; n=440). MRI and ultrasound characteristics had the most robust data. Rectal inflammation, multiple-branched fistula tracts, and abscesses on pelvic MRI and the Crohn's ultrasound fistula sign, fistula debris, and bifurcated fistulas on pelvic ultrasonography had high specificity (range, 80%-95% vs 89%-96%) but poor sensitivity (range, 17%-37% vs 31%-63%), respectively. Fourteen of 21 studies had risk of bias on at least 1 of the Quality Assessment of Diagnostic Accuracy Studies domains. CONCLUSIONS: Limited high-quality evidence suggest that imaging characteristics may help discriminate CD from CGD in patients with perianal fistulas. Larger, prospective studies are needed to confirm these findings and to evaluate if combining multiple diagnostic tests can improve diagnostic sensitivity.

Differentiating between perianal fistulas related to cryptoglandular disease and Crohn's disease is essential to guide disease-specific management. A variety of imaging characteristics from magnetic resonance imaging and ultrasound had high specificity but relatively low sensitivity for predicting perianal fistulas associated with Crohn's disease.

Gluteal and Presacral Abscess Due to Crohn's Disease with Multiple Fistulas.

The abscess is a common complication of Crohn's disease (CD), with the perianal form more frequent than gluteal or presacral which is relatively rare. There are few case reports of gluteal abscess combined with presacral abscess caused by CD and the treatment has not been established. A 21-year-old male was admitted with right buttock and lower back pain with a duration of 3 months. He had a history of CD in the small intestine diagnosed 10 months previously. He had poor compliance and had not returned for follow-up care during the previous 6 months. Abdominopelvic CT indicated newly developed multiple abscess pockets in right gluteal region, including piriformis muscle and presacral space. Additionally, fistula tracts between small bowel loops and presacral space were observed. Patient's CD was moderate activity (273.12 on the Crohn's Disease Activity Index [CDAI]). Treatment was started with piperacillin/ tazobactam antibiotic but patient developed a fever and abscess extent was aggravated. Therefore, surgical incision and drainage was performed and 4 Penrose drains were inserted. Patient's pain and fever were resolved following surgery. Infliximab was then administered for the remaining fistulas. After the induction regimen, multiple fistula tracts improved and patient went into remission (CDAI was -0.12).

Diagnosis and treatment of fistulising Crohn's disease.

A fistula is defined as a pathological connection between the intestine and an inner (bladder or other intestine) or outer (vagina or skin) epithelial surface. Fistulas are discovered in up to 25% of all Crohn's disease patients during long-term follow-up examinations. Most are perianal fistulas, and these may be classified as simple or complex. The initial investigation of perianal fistulas includes imaging (MRI of the pelvis and rectum), examination under anaesthesia (EUA) with digital imaging, endoscopy, probing and anal ultrasound. Non-perianal fistulas require contrast imaging and/or CT/MRI for complete anatomical definition. Any abscess should be drained, and the disease extent throughout the entire gastrointestinal tract should be evaluated. Treatment goals for perianal fistulas include reduced fistula secretion or none, evaluated by clinical examination; the absence of abscesses; and patient satisfaction. MR imaging is required to demonstrate definitive fistula closure. Fistulotomy is considered for simple perianal fistulas. In complex perianal fistulas, antibiotics and azathioprine or 6-mercaptopurine, which are often combined with a loose seton, constitute the first-line medical therapy. In cases with persistent secretion, infliximab at 5 mg/kg is given at weeks 0, 2, and 6 and subsequently every 8 weeks. Adalimumab may improve fistula response in both infliximab-naïve patients and following infliximab treatment failure. Local therapy with fibrin glue or fistula plugs is rarely effective. Definitive surgical closure of perianal fistulas using an advancement flap may be attempted, but this procedure is associated with a high risk of relapse. Colostomy and proctectomy are the ultimate surgical treatment options for fistulas. Intestinal resection is almost always needed for the closure of symptomatic non-perianal fistulas.

[Consensus of Chinese experts on the diagnosis and treatment of anal fistula (2020)].

Anal fistula is one of the most common diseases in colorectal and anal surgery. Most of them are formed after the abscess of perianal space reptures. Due to the complexity and diversity of pathological changes, the clinical efficacy of some patients is not optimistic, and there may even be serious surgical complications, including delayed healing of anal fistula or varying degrees of fecal incontinence, which significantly affect the quality of life of patients and even lead to disability. The Working Committee of Clinical Guidelines of Anorectal Physicians Branch of Chinese Medical Association organized some domestic experts to discuss and prepare this expert consensus. It is suggested that comprehensive evaluation of anal fistula, including detailed medical history, physical examination and necessary auxiliary examination should be conducted before treatment. Auxiliary examinations include fistulography, ultrasound, CT or MRI. The purpose of the auxiliary examination is to accurately determine the position of the internal orifice of the anal fistula, the direction of the fistula and its relationship with the anal sphincter. Adenogenic anal fistula needs surgical treatment after diagnosis. The operation methods can be divided into two types: operations breaching sphincter and operations preserving sphincter function. The former includes anal fistulectomy, anal fistulotomy and seton placement; the latter includes ligation of intersphincteric fistula (LIFT), rectal mucosal muscle flap advancement repair, anal fistula laser closure, video-assisted anal fistula treatment, etc. It is suggested to select or combine the application according to the specific condition of patients. Bioabsorbable materials include anal fistula plug and fibrin glue. Due to the characteristics of retaining sphincter function and reusability, it is recommended to be used selectively by qualified and experienced doctors. Proper wound management after anal fistula surgery can reduce the pain of patients, promote healing and reduce the recurrence of anal fistula. Because there is a certain risk of recurrence and fecal incontinence after anal fistula surgery, for some patients with complex condition, repeated operations or impaired anal function, we must be careful when choosing reoperation, and weigh the benefits of patients and the risk of fecal incontinence.

Optimized timing of using infliximab in perianal fistulizing Crohn's disease.

Infliximab (IFX), as a drug of first-line therapy, can alter the natural progression of Crohn's disease (CD), promote mucosal healing and reduce complications, hospitalizations, and the incidence of surgery. Perianal fistulas are responsible for the refractoriness of CD and represent a more aggressive disease. IFX has been demonstrated as the most effective drug for the treatment of perianal fistulizing CD. Unfortunately, a significant proportion of patients only partially respond to IFX, and optimization of the therapeutic strategy may increase clinical remission. There is a significant association between serum drug concentrations and the rates of fistula healing. Higher IFX levels during induction are associated with a complete fistula response in these patients. Given the apparent relapse of perianal fistulizing CD, maintenance therapy with IFX over a longer period seems to be more beneficial. It appears that patients without deep remission are at an increased risk of relapse after stopping anti-tumor necrosis factor agents. Thus, only patients in prolonged clinical remission should be considered for withdrawal of IFX treatment when biomarker and endoscopic remission is demonstrated, especially when the hyperintense signals of fistulas on T2-weighed images have disappeared on magnetic resonance imaging. Fundamentally, the optimal timing of IFX use is highly individualized and should be determined by a multidisciplinary team.

[Fistulas and fissures. Part I: perianal fistulas]. / Fisteln und Fissuren. Teil I: Perianale Fisteln.

Perianal abscesses are caused by cryptoglandular infections at the dentate line between the anal sphincters. Acute therapy will relieve the pain but not the development of perianal fistulas. The challenge in therapy of perianal fistulas balances between the best possible cure and the preservation of continence. Local treatment with fibrin glue is a first step whenever continence might be endangered by operative procedures. First results with fistula "plugs" are promising but need further critical observation. Lower, intersphincteric fistulas can be treated by fistulotomy without risking a substantial loss in continence, but higher, suprasphincteric or complex fistula systems might be treated as a first step with a seton--followed by surgery as a second step. Excision of the external fistula tract, closure of the internal opening, and a local advancement flap are now competing with fistulotomy, curettage, and immediate reconstruction.

[Perianal fistulas: developments in the classification and diagnostic techniques, and a new treatment strategy]. / Perianale fistels: veranderde inzichten met betreklking tot classificatie en diagnostiek, en een nieuwe behandelstrategie.

The aim of surgical treatment of perianal fistulas is to treat the patient's symptoms, with low recurrence rates and risk of incontinence. In recent years there have been developments regarding the classification and diagnosis ofperianal fistulas. MRI is the most appropriate diagnostic tool. In the hands of an experienced operator anal endosonography is a suitable, less expensive and readily-available alternative. As a result of developments in fistula surgery it is now more practical to classify perianal fistulas as low or high fistulas, as this has implications for the further treatment. Low perianal fistulas are defined as fistulas of which the fistula tract is located in the lower third of the external anal sphincter. High fistulas are fistulas in which the fistula tract runs through the upper two-thirds of the external sphincter muscle. Low perianal fistulas can be treated safely by fistulotomy. At present, rectal advancement is the gold standard for the surgical treatment of high transsphincteric perianal fistulas. The anal fistula plug might be an alternative for the treatment of high transsphincteric perianal fistulas.

[The treatment of an acute paraproctitis].

The results of surgical treatment of an acute paraproctitis in 708 patients, in 9 (1.27%) of whom gangrenous -- putrificated form of paraproctitis was diagnosed, are adduced. In 187 (42.6%) patients the abscess disclosure with intraintestinal purulent fistula, going into intestinal lumen, excision was performed, together with cryptectomy -- in 182 (41.4%), the ligature method was applied in 18 (4.1%) with subsequent fistula excision and its internal orifice plasty using mucosal-submucosal flap. For extrasphincteric or transsphincteric purulent tunnel the abscess was opened and drained, its internal orifice sutured, using 'distant" removable suture. It internal orifice was not revealed there was accomplished procedure of disclosure and draining of purulent cavity, the wound sanation with insufflation of ozone-oxygen mixture. In anaerobic paraproctitis the procedure consisted of disclosure and draining of purulent cavities with necrectomy was performed. To all the patients antibacterial therapy was conducted. In 20 (4.5%) patients an acute paraproctitis recurrence had occurred, in 9 (2%) -- pararectal fistula, and in 5 (1.1%) -- the anal sphincter stage I insufficiency.

Treatment of anal fistula and abscess.

The glands of Hermann and Desfosses, located in the thickness of the anal canal, drain into the canal at the dentate line. Infection of these anal glands is responsible for the formation of abscesses and/or fistulas. When this presents as an abscess, emergency drainage of the infected cavity is required. At the stage of fistula, treatment has two sometimes conflicting objectives: effective drainage and preservation of continence. These two opposing constraints explain the existence of two therapeutic concepts. On one hand the laying-open of the fistulous tract (fistulotomy) in one or several operative sessions remains the treatment of choice because of its high cure rates. On the other hand surgical closure with tract ligation or obturation with biological components preserves sphincter function but suffers from a higher failure rate.

Complex anal fistula surgery: personal experience.

Personal experience with the treatment cryptogenic complex anal fistulas over the 10-year period from 1993 to 2002 is reported. Such fistulas accounted for 54 out of 255 fistulas observed (21.1%). Accurate anatomo-pathological classification, based on the connections between the fistulas and the sphincter and the musculature of the pelvic floor, is mandatory, as is thorough preoperative evaluation of ano-rectal function and of the risk of faecal incontinence. The surgical strategies used, in relation to the different kinds of complex fistulas treated, are schematically reported. A mixed technique consisting in fistulectomy-fistulotomy with setons was particularly preferred, because of the risk related to immediate dissection of the sphincter, especially when concurrent risk factors are present. As regards the results obtained, the surgical outcome consisted in healing in 49/54 cases (90.7%) as against recurrence or persistence of the fistula in 5/54 (9.3%). Minor complications occurred in 6/54 (11.1%); no major complications were observed and no cases of permanent faecal incontinence were reported. In conclusion, the surgical choice in cases of complex fistulas must lead to definitive, radical treatment of the lesion, at the same time avoiding irreversible anal incontinence due to severe lesions to the sphincter.

[Daily aspects of proctology]. / La proctologie au quotidien.

Revue of the commonest anal diseases encountered in the daily practice of general medicine. Hemorrhoids share their symptoms with a whole series of other diseases, and it is this lack of specificity that always calls for a thorough examination to reach a precise diagnosis. The most usual and accessible methods of treatment are described. Anal fissures: their diagnosis and, mostly, their prompt conservative treatment lead to frequent therapeutic success. Anal fistulas: if their description and origins are interesting, it is mostly the prompt incision and drainage of the abscess, by the general practitioner, without use of antibiotics, that will prevent the formation of fistulas. Pilonidal sinuses must be recognized as incurable without the help of surgery. Condylomas can often be treated at the office.