Clinical benefit of early precut sphincintroterotomy for difficult biliary cannulation during endoscopic retrograde cholangiopancreatography.

OBJECTIVES: A precut procedure is sometimes required for difficult biliary cannulation during endoscopic retrograde cholangiopancreatography (ERCP). However, it is unclear whether the biliary access rate has improved for early precut procedures compared to conventional techniques. This study aimed to identify the benefit of early precut sphincterotomy in cases showing difficult biliary access. METHODS: Between April 2017 and August 2021, consecutive patients who underwent precutting for difficult biliary cannulation were retrospectively enrolled. The outcomes of early (≤ 10 min from start of cannulation) and delayed (> 10 min) precut groups were evaluated. All adverse events were defined according to Cotton criteria. RESULTS: A total of 70 patients were enrolled in this study. The biliary cannulation rate for a first ERCP was significantly higher in the early compared to delayed precut group (95% vs. 73.3%; P = 0.015). A difference in overall cannulation rate between the two groups was not observed (97.5% vs. 83.3%; P > 0.05). Significantly higher rates of prophylactic pancreatic stents were described in the delayed compared to early precut group (36.7% vs. 12.5%; P = 0.009). Significant differences in the frequency of pancreatitis, bleeding, penetration, and perforation were not noted between the two groups. Overall, the success rate was statistically significant between the experienced and less experienced endoscopists (87.2% vs. 63.9%; P = 0.017). CONCLUSIONS: Early precutting within 10 min from the start of cannulation in ERCP is safe and effective in cases with a difficult biliary cannulation, and can improve the biliary cannulation rate.

A comparative study between high ligation of the inter-sphincteric fistula tract via lateral Approach Versus Fistulotomy and primary sphincteroplasty in High Trans-Sphincteric Fistula-in-Ano: a randomized clinical trial.

BACKGROUND: Trans-sphincteric fistula management is very challenging and everyday new techniques are introduced to reach the safest and the most effective technique. In this study two of the most effective techniques are compared based on their post-operative outcomes. OBJECTIVE: To compare the efficacy of high ligation of the inter-sphincteric fistula tract by lateral approach (modified LIFT) and Fistulotomy and primary sphincteroplasty (FIPS) in the management of high trans-sphincteric fistula regarding their post-operative outcomes in the form of post-operative pain, time of wound healing in weeks, wound infection, incontinence and recurrence within one year. PATIENTS AND METHODS: The current study is single-blind, prospective, randomized, controlled, single-center trial conducted from June 2020 to June 2022 in the colorectal surgical unit of Ain Shams University Hospitals, which included 80 patients presented with high trans-sphincteric perianal fistula 55 (68.75%) males and 25 (31.25%) including a one-year follow-up postoperative. RESULTS: There were 80 patients in our study 40 patients in each group. The mean age of group (I) is 46.65 with standard deviation 6.6. while, in group (II) the mean age is 45.85 with standard deviation 6.07 (p = 0.576). From the included 80 patients 55(68.7%) were males and 25 (31.25%) were females (p = 0.469). Regarding, postoperative wound infection occurred in 2(5%) Patients in group (I) and 7(17.5%) patients in group (II) (p = 0.154). There were no cases of incontinence in group I. However, there were 6(15%) cases of incontinence to gases only scored by Wexner score 3/20 in group II (p = 0.026) and its significant difference between the two techniques. Postoperative pain was assessed for one week duration by the visual analogue score (VAS) from 0 to 10 in which, zero is the least and 10 is the maximum. In group (I) 18(45%) patients scored their pain mild from 1 to 3, 20(50%) patients scored their pain moderate from 4 to 6 and 2(5%) patients scored severe pain from 7 to 9. While, in group (II) 14(35%) patients scored their pain mild from 1 to 3, 22(55%) patients their pain moderate from 4 to 6 and 4(10%) patients scored their pain severe from 7 to 9 (p = 0.275). Recurrence in one-year follow-up occurred in 13(32.5%) patients in group (I) about 7 patients had recurrence in the form of inter-sphincteric fistula and 6 patients in the form of trans-sphincteric fistula. While, in group II recurrence occurred in 1 (2.5%) patient in the form of subcutaneous fistula at the healing site (p = 0.001). CONCLUSION: Fistulotomy and primary sphincteroplasty is an effective and preferred technique for the trans-sphincteric fistula repair with high statistically significant lower incidence of recurrence in one-year follow-up as compared to modified LIFT technique. Although, there is higher incidence regarding incontinence to gases only post-operative. This work recommends fistulotomy and primary sphincter reconstruction procedure in high trans-sphincteric perianal fistulas to be more popular, to be implemented as a corner stone procedure along various and classic operations for such cases as it's easy, feasible.

Success and Safety of Needle Knife Papillotomy and Fistulotomy Based on Papillary Anatomy: A Prospective Controlled Trial.

BACKGROUND: Needle knife papillotomy (NKP) and fistulotomy (NKF) are the two most commonly used rescue techniques for patients with difficult biliary cannulation (DBC). Anatomy of the major duodenal papillae (MDP) influences the optimal precut technique for biliary access. However, comparative studies of the success and safety of NKP and NKF based on the anatomy of MDP have been scarce. METHODS: Patients with intact MDPs for therapeutic endoscopic retrograde cholangio-pancreatography (ERCP) in our center were enrolled. Early needle knife precuts were uniformly applied to patients with DBC. Difficult MDPs were classified into one of five types based on their endoscopic anatomy. Each type of MDP was allocated to NKP or NKF treatment. Patients with types 1 and 2 papillae always received NKF, 3 and 4 received NKP, and 5 could receive either. The safety and efficacy were analyzed between NKP and NKF, and among different types of MDPs. RESULTS: A total of 188 out of 1674 patients undergoing ERCP satisfied the criteria for early precutting: 75 patients were assigned to the NKP group and 113 to the NKF group. The total initial success rate of biliary cannulation (ISRBC) of the precut techniques (both NKP and NKF) for patients with DBC was 91.5%. The ISRBC of patients of the NKP group was similar to that of the NKF group (90.7% vs 92.0%, P > 0.05). The ISRBC of the patients in the swollen MDP subgroup (96.1%) was higher than that of patients in the distorted MDP subgroup (81.8%, P = 0.030). The total and specific complications of the patients of the NKP group were similar to those of the NKF group (P > 0.05). CONCLUSIONS: NKP and NKF, as selected on the basis of MDP anatomy, are equally safe and highly efficient for patients with DBC to allow biliary cannulation. Patients with swollen MDPs had a higher ISRBC than patients with distorted MDPs. Selecting a precut method based on MDP anatomy is an effective and safe strategy for patients with DBC.

Needle knife fistulotomy in flat and diverticular papillae: Is it time for redemption?

BACKGROUND: European Society of Gastrointestinal Endoscopy (ESGE) recommends needle-knife fistulotomy (NKF) as the preferred precut technique in cases when standard cannulation techniques fail. Despite scarce scientific evidence, flat and diverticular papillae are thought not to be ideal for NKF, as they are associated with poor outcomes. The present study aimed to determine the outcomes of the use of NKF in relation to flat and intradiverticular papillae. METHODS: This prospective multicenter study enrolled consecutive patients, evidencing naïve flat (group A, n = 49) or diverticular papilla (group B, n = 28), who underwent NKF after failure of standard cannulation techniques. Diverticular morphology was subdivided into intradiverticular (group B1, n = 14) and diverticular border papillae (group B2, n = 14), using a previously validated endoscopic classification of the major papilla. The success of biliary cannulation at initial endoscopic retrograde cholangiopancreatography (ERCP), overall biliary cannulation, overall cannulation time, and the rate of adverse events were assessed in the study. RESULTS: The initial cannulation rates were 93.9%, 64.3% and 71.4% for group A, B1, and B2, respectively (P = 0.005); overall cannulation rates after a second ERCP were 98.0%, 92.9% and 85.7%, respectively (P = 0.134). Adverse events occurred in 11.7% of patients, with post-ERCP pancreatitis (PEP) being the most common adverse event (10.4%). Although there was a trend towards a higher incidence of PEP in flat papillae, univariate and multivariate analyses did not show any significant relationship between pancreatitis and trainee involvement, papillary morphology, nor overall cannulation time. CONCLUSIONS: Although flat papillae are associated with high success rates of biliary cannulation using NKF, the rate of PEP is not negligible. NKF is feasible in diverticular papillae, but it is associated with a modest success rate in the initial ERCP.

Outcomes of single-endoscopist-performed needle-knife fistulotomy for selective biliary access in 842 consecutive patients: learning curve and changes over a 14-year period in a retrospective study.

BACKGROUND AND AIMS: Needle-knife fistulotomy (NKF) has emerged as the preferred precut technique. From a late strategy, NKF has shifted to an early rescue technique and has been used recently as a primary method for biliary access. It is unknown how these changes have affected NKF outcomes. We analyzed the outcomes of NKF over time in a large cohort of patients. METHODS: Multicenter retrospective cohort study of 842 patients who underwent NKF for biliary access between 2006 and 2019. Patients were divided into four study periods according to a late or early cannulation strategy and to the use of post-ERCP pancreatitis prophylaxis (Period 1-Period 4). We assessed outcomes of NKF, learning curves and shifts over time. RESULTS: Bile duct access was obtained in 88.0% of the patients. The initial cannulation rate increased significantly from 77.5% in P1 to 92.0% in P4 (p < .001). An endoscopist can obtain 80% success rate after performing 100 NKF procedures (95% CI: 0.79-0.86) and a 95% success rate after 830 procedures (95% CI: 0.92-0.98). Adverse events and pancreatitis were observed in 6.5% and 4.9% of patients respectively. The rate of pancreatitis was not significantly different during the 4 periods (p = .190). A decline in the pancreatitis rate was observed from 2006 until 2016 (no trainees) and then an increase until 2019 (trainees involved). The presence of trainees increased the rate of pancreatitis in the last period by 9.9%. CONCLUSIONS: The success of NKF has increased significantly over the years, initially in a rapid manner and then more slowly. It is associated with a low rate of complications, which tend to decrease with experience. The involvement of trainees is associated with an increased rate of pancreatitis.

A meta-analysis of marsupialisation versus none in the treatment of simple fistula-in-ano.

INTRODUCTION: Marsupialisation of post-fistulotomy wounds results in a smaller raw surface area and may improve postoperative outcomes. However, it remains a variable practice. We performed a systematic review and meta-analysis to evaluate the effectiveness of marsupialisation in the treatment of simple fistula-in-ano. MATERIALS AND METHODS: PubMed, EMBASE and Cochrane databases were searched for relevant articles from inception until April 2020. All trials that reported on marsupialisation in anal fistula treatment were included. The primary outcome measure was time to complete healing, while secondary outcomes included recurrence, pain scores and incontinence. Random effects models were used to calculate pooled effect size estimates. A sensitivity analysis was performed. RESULTS: Six randomised controlled trials were included capturing 461 patients. The mean (SD) age of the cohort was 39.31 (± 8.71) years. There were 395 males (85.7%). All fistulae were of the cryptoglandular aetiology. On random effects analysis, marsupialisation was associated with a significantly shorter time to healing compared with no marsupialisation (SMD - 0.97 weeks, 95% CI = - 1.36 to - 0.58, p < 0.00001). However, there was no difference in recurrence (RD = - 0.00, 95% CI = - 0.02 to 0.02, p = 0.72), pain scores at 24 h (SMD - 0.03, 95% CI = - 0.56 to 0.50, p = 0.91) or incontinence (RD = - 0.01, 95% CI = - 0.05 to 0.02, p = 0.42). On sensitivity analysis, focusing exclusively on fistulotomy for simple fistula-in-ano, the results for time to healing, recurrence and incontinence remained similar. CONCLUSIONS: Marsupialisation of fistulotomy wounds for simple fistula-in-ano is associated with a significantly shorter healing time, but similar recurrence, pain scores at 24 h and incontinence rates, compared with omitting marsupialisation.

Surgery for anal fistulae: state of the art.

BACKGROUND AND AIM: Anal fistulae (AF) are considered a challenge for colorectal surgeons, as they recur if not properly operated. Being a septic disease, they are correlated with immunodeficiency and surgery may be followed by anal incontinence (AI). The aim of this paper is to suggest a state-of-the-art treatment of AF. METHODS: Pathogenesis, classification, diagnostic tools, intraoperative assessment, and surgeries proposed for AF have been reviewed, together with the results following conventional surgery and innovations aimed at sphincters' preservation. RESULTS: Stress causes immunodepression and favors anal sepsis, and heavy smoking facilitates AF recurrences. Evacuation fistulography, MRI, and transanal ultrasound may help the diagnosis. Fistulotomy allows high cure rate, up to 96.4%, but may cause up to 64% of AI in transsphincteric AF. Fistulectomy with rectal advancement flap is effective in 80% of these cases and avoids AI. Other options are either suturing of AF internal orifice or positioning a cutting seton. Ligation of intersphincteric fistula track (LIFT) is a costless alternative carrying a success of 57-99% with 0-23% AI. Costly innovations, i.e., autologous stem cells, porcine derma sheet (Permacol), video-assisted fistula excision (VAAFT), porcine matrix (PLUG), and laser closure (FiLaC), minimize AI, but may carry AF recurrence. Their grades of recommendation range between 2B and 2C in the Guidelines of the Italian Society of Colorectal Surgery. CONCLUSION: Postoperative incontinence in transsphincteric AF may be minimized by both costless and costly sphincter-saving procedures, the latter carrying higher recurrence rate. The success of surgery may be increased by a different lifestyle.

Is fistulotomy with immediate sphincter reconstruction (FISR) a sphincter preserving procedure for high anal fistula? A systematic review and meta-analysis.

AIM: This systematic review aimed to assess the outcomes of fistulotomy or fistulectomy and immediate sphincter repair (FISR) in relation to healing, incontinence and sphincter dehiscence both overall and in patients with high anal fistulae. METHODS: Medline, Embase and The Cochrane library were searched for studies of patients undergoing FISR for anal fistula. Data regarding healing, continence and sphincter dehiscence were extracted overall and for high anal fistulae. The DerSimonian-Laird random-effects method was used for pooled analysis, heterogeneity between studies was assessed based on the significance of between-study heterogeneity, and on the size of the I2  value. Risk of bias was assessed using the Cochrane risk of bias tool and the Newcastle-Ottawa scale. RESULTS: We identified 21 studies evaluating 1700 patients. Pooled analysis of healing reached 93% (95% CI: 91%-95%, I2  = 51% p-value for heterogeneity = 0.004), with continence disturbance and worsening continence reaching 11% (95% CI: 6%-18%, I2  = 87% p < 0.001) and 8% (95% CI: 4%-13%, I2  = 74% p < 0.001), respectively. Subgroup analysis according to fistula height could only be conducted on limited data. Pooled healing in high anal fistulae was 89% (95% CI: 84%-94%, I2  = 76% p < 0.001), 16% suffered disturbance of continence (95% CI: 7%-27%, I2  = 89% p < 0.001), 8% worsening continence from baseline (95% CI: 2%-16%, I2  = 80% p < 0.001) and 2% suffered sphincter dehiscence (95% CI: 0%-10%, I2  = 89% p < 0.001). CONCLUSION: The evidence suggests FISR is a safe, effective procedure. However, data are limited by inconsistencies in reporting of continence and definition of fistula height, particularly high anal fistulae. Significant heterogeneity means that outcomes in high fistulae remain uncertain.

Transanal opening of the intersphincteric space: a novel sphincter-sparing procedure to treat 325 high complex anal fistulas with long-term follow-up.

AIM: Sepsis in the intersphincteric plane behaves like an abscess in a closed space and is present in most complex fistulas. Ignoring this sepsis is a cause of recurrence. Complex fistulas can be successfully managed by transanal opening of the intersphincteric space (TROPIS) into the anal canal. The long-term efficacy of the TROPIS procedure was analysed in an exclusive cohort of high complex anal fistulas. METHODS: All consecutive patients operated for a high complex fistula-in-ano were included prospectively. Preoperative MRI scans were obtained for all the patients. The intersphincteric space and internal opening was laid open into the anal canal while preserving the external sphincter. The external tracts were thoroughly curetted and cleaned. Fistula healing rate and objective incontinence scores (preoperatively and during long-term follow-up) were analysed. RESULTS: A total of 325 patients (age 39.9 ± 10.9 years, 292 men) were operated with TROPIS and had a follow-up of 7-67 months (median 36 months). In the cohort, 67.4% (219) had recurrent fistulas, 82.8% (269) had multiple tracts, 36.3% (118) had horseshoe tracts, 37.5% (122) had associated abscesses and 24% (78) were supralevator fistulas. Nineteen patients were excluded. Fistulas healed completely in 78.4% (240/306) of patients and did not heal in 21.6% (66/306) of patients. 36/66 of these patients were operated again and the fistulas healed in 28 patients. Thus, the overall healing rate was 87.6% (268/306). The mean preoperative and postoperative incontinence scores were 0.085 ± 0.35 and 0.119 ± 0.48 respectively (P = 0.38). The healing rate of fistulas with associated acute abscesses was similar to the fistulas without abscesses (87% vs. 88%, P = 0.85). CONCLUSION: Transanal opening of the intersphincteric space is a safe and highly effective sphincter-sparing procedure to manage high complex fistulas-in-ano.

Combined strategies following surgical drainage for perianal fistulizing Crohn's disease: failure rates and prognostic factors.

AIM: The medico-surgical strategy for the treatment of perianal fistulizing Crohn's disease (CD) following surgical drainage remains challenging and debated. Our aims were to describe the failure rate of therapeutic interventions after drainage of the fistula tract and determine the factors associated with failure to optimize medico-surgical strategies. METHOD: All consecutive patients with perianal fistulizing CD who underwent surgical drainage with at least a 12-week follow-up were included. Failure was defined as the occurrence of at least one of the following items: abscess recurrence, purulent discharge from the tract, visible external opening and further drainage procedure(s). RESULTS: One hundred and sixty-nine patients were included. The median follow-up was 4.0 years. The cumulative failure rates were 20%, 30% and 36% at 1, 3 and 5 years, respectively. The cumulative failure rates in patients who had sphincter-sparing surgeries or seton removal were significantly higher than in those who had a fistulotomy. Anterior fistula [hazard ratio (HR) = 2.52 (1.13-5.61), P = 0.024], supralevator extension [HR = 20.78 (3.38-127.80), P = 0.001] and the absence or discontinuation of immunosuppressants after anal drainage [HR = 3.74 (1.11-12.5), P = 0.032] were significantly associated with failure in the multivariate analysis model. CONCLUSION: Combined strategies for perianal fistulizing CD lead to a failure rate of 36% at 5 years. Where advisable, fistulotomy may be preferred because it has a lower rate of recurrence. The benefits of immunosuppressants require a dedicated prospective randomized trial.

Cannulation procedure optimization for patients with duodenal papillary tumors.

BACKGROUND: The goal of this study was to compare the efficacy and safety of needle-knife fistulotomy (NKF) to that of conventional cannulation methods (CCMs) when used for primary biliary access in patients with duodenal papillary tumors. METHODS: Consecutive patients who had duodenal papillary tumors and who underwent endoscopic retrograde cholangiopancreatography (ERCP) were retrospectively enrolled. Successful cannulation rates, cannulation and procedure times, and the prevalence of adverse events were compared between the NKF and CCM groups. RESULTS: A total of 404 patients (NKF, n = 124; CCM, n = 280) with duodenal papillary tumors were included. The primary and overall cannulation rates were 92.1% (372/404) and 96.0% (388/404), respectively. Compared to CCMs, NKF was associated with a significantly higher successful cannulation rate (99.2% versus 88.9%, P < 0.001) and significantly lower cannulation times (2.1 ± 2.0 min versus 4.7 ± 5.2 min), procedure times (8.8 ± 3.8 min versus 12.9 ± 7.6 min), and unintentional pancreatic duct cannulation rates (1.6% versus 20%), with P < 0.001 for all. Overall adverse events occurred less frequently in the NKF group (3.2% versus 10.7%, P = 0.011). Of these adverse events, post-ERCP pancreatitis (PEP) was significantly lower in the NKF group than in the CCM group (1.6% versus 6.8%, P = 0.03). Bleeding and cholangitis rarely occurred with either cannulation method (0.8% versus 2.1%, P = 0.681, and 0.8% versus 1.7%, P = 0.671, respectively). CONCLUSION: NKF is a more effective and safer procedure than CCMs for patients with duodenal papillary tumors.

Sphincter damage during fistulotomy for perianal fistulae and its relationship with faecal incontinence.

BACKGROUND: The length of sphincter which can be divided during fistulotomy for perianal fistula is unclear. The aim was to quantify sphincter damage during fistulotomy and determine the relationship between such damage with symptoms and severity of faecal incontinence and long-term quality of life (QOL). METHODS: A prospective cohort study was performed over a 2-year period. Patients with intersphincteric and mid to low transsphincteric perianal fistulas without risk factors for faecal incontinence were scheduled for fistulotomy. All patients underwent 3D endoanal ultrasound (3D-EAUS) pre-operatively and 8 weeks postoperatively. Measurements were taken of pre- and postoperative anal sphincter involvement and division. Anal continence was assessed using the Jorge-Wexner scale and QOL scores pre, 6 and 12 months postoperatively. RESULTS: Forty-nine patients were selected. A strong correlation between pre- and postoperative measurements was found p < 0.001. A median length of 41% of the external anal sphincter and 32% of the internal anal sphincter was divided during fistulotomy. Significant differences in mild symptoms of anal continence were found with increasing length of external anal sphincter division. But there was no significant deterioration in continence, soiling, or quality of life scores at the 1-year follow-up. Division of over two-thirds of the external anal sphincter was associated with the highest incontinence rates. CONCLUSIONS: 3D-EAUS is a valuable tool for quantifying the extent of sphincter involvement pre- and postoperatively. Post-fistulotomy faecal incontinence is mild and increases with increasing length of sphincter division but does not affect long-term quality of life.

Simple fistula-in-ano: is it all simple? A systematic review.

BACKGROUND: Simple anal fistula is one of the most common causes of proctological surgery and fistulotomy is considered the gold standard. This procedure, however, may cause complications. The aim of this systematic review was to assess the surgical treatment of simple anal fistula with traditional and sphincter-sparing techniques. METHODS: A literature research was performed using PubMed, Cochrane, and Google Scholar to identify studies on the surgical treatment of simple anal fistulas. Observational studies and randomized clinical trials were included. We assessed the risk of bias of included studies using the Jadad scale for randomized controlled trials, and the MINORS Scale for the remaining studies. RESULTS: The search returned 456 records, and 66 studies were found to be eligible. The quality of the studies was generally low. A total of 4883 patients with a simple anal fistula underwent a sphincter-cutting procedure, mainly fistulotomy, with a weighted average healing rate of 93.7%, while any postoperative continence impairment was reported in 12.7% of patients. Sphincter-sparing techniques were adopted to treat 602 patients affected by simple anal fistula, reaching a weighted average success rate of 77.7%, with no study reporting a significant postoperative incontinence rate. The postoperative onset of fecal incontinence and the recurrence of the disease reduced patients' quality of life and satisfaction. CONCLUSIONS: Surgical treatment of simple anal fistulas with sphincter-cutting procedures provides excellent cure rates, even if postoperative fecal incontinence is not a negligible risk. A sphincter-sparing procedure could be useful in selected patients.

The complexity of cryptoglandular fistula-in-ano can be predicted by the distance of the external opening to the anal verge; implications for preoperative imaging?

BACKGROUND: Many surgeons believe that the distance from the external opening to the anal verge (DEOAV) predicts the complexity of a cryptoglandular fistulas-in-ano and, therefore, predicts the need for additional imaging. However, there is no evidence to support this. The primary aim of this study was to determine if DEOAV can predict the complexity of a fistula. Secondary aims were clinical outcome and identification of those patients that might not benefit from preoperative imaging. METHODS: All patients having surgery for cryptoglandular fistula-in-ano between January 2014 and December 2016 were evaluated. Preoperative imaging was used to classify fistulas as simple or complex. The DEAOV was measured preoperatively and was divided into categories ≤ 1 cm, 1-2 cm, or > 2 cm. The relationship between the DEOAV and complexity of the fistula was investigated. Clinical outcome was recorded and a group of patients that might not benefit from preoperative imaging was identified. RESULTS: A total of 103 patients [m:f = 65:38, median age 47 (range 19-79) years] were included. Magnetic resonance imaging identified 39 simple and 64 complex fistulas. The percentage of simple fistula was 88% in fistulas with DEAOV ≤ 1 cm, 48% in DEAOV 1-2 cm and 38% in > 2 cm. There was a significant difference between the complexity of the fistula and the distance to the anal verge (p < 0.001). The overall healing rate was 88%. CONCLUSIONS: The complexity of perianal fistula depends on the DEAOV. We propose that preoperative imaging should be performed in fistulas with external opening > 1 cm from the anal verge.

Fistulectomy and primary sphincteroplasty (FIPS) to prevent keyhole deformity in simple anal fistula: a single-center retrospective cohort study.

OBJECTIVE: Fistulotomy remains the gold standard for the surgical treatment of simple anal fistula, but may cause fecal incontinence and a characteristic anal 'keyhole' deformity. Although seemingly trivial, keyhole deformity may lead to bothersome symptoms such as anal pruritus and fecal soiling. This study aims to evaluate the efficacy of fistulectomy and primary sphincteroplasty (FIPS), a technique with immediate sphincter reconstruction, in the treatment of simple anal fistula and the prevention of keyhole deformity created by simple fistulotomy. METHODS: A retrospective study was performed on all consecutive patients who underwent FIPS for a simple anal fistula at our institution between January 2015 and August 2019. The primary outcome of the study was the rate of early postoperative wound dehiscence, which essentially transforms a FIPS into a simple fistulotomy and may lead to keyhole deformity. All patients received follow-up at regular intervals to evaluate fistula healing and the presence of keyhole deformity. RESULTS: FIPS was performed in 24 patients (median age: 52.8 years). After a median follow-up time of 3.0 (2.0, 6.3) months, the overall healing rate was 95.8% (23/24 patients). Six (25%) patients experienced early postoperative wound dehiscence resulting in the development of a keyhole deformity. Five of them were symptomatic (mainly soiling). Keyhole deformity was diagnosed at a median time of 6.0 (3.8, 7.5) months postoperatively. The occurrence of early wound dehiscence and subsequent keyhole deformity was associated with a posteriorly located fistula (p = .02). CONCLUSION: FIPS avoids the development of keyhole deformity in the majority of patients with simple anal fistula, but is less successful in posterior fistulas. Since FIPS is a very effective, fast and simple procedure, it should be considered a valid alternative for the treatment of every simple anal fistula.

Comparison between transpancreatic sphincterotomy and needle-knife fistulotomy in difficulty biliary access, a retrospective study in Taiwan.

BACKGROUND: Selective deep biliary cannulation is the first and the most important step before further biliary therapy. Transpancreatic sphincterotomy (TPS), and needle knife fistulotomy (NKF) were commonly used in patients with difficult cannulation, but few studies compare the outcome between TPS and NKF. METHODS: A total of 78 patients who met the criteria of difficult cannulation in the National Taiwan University hospital from October 2015 to October 2017 were retrospectively reviewed. Their baseline demographics, success rate of biliary cannulation, and the rate of adverse events were assessed. RESULTS: 31 patients and 47 patients underwent TPS and NKF for difficult biliary access, respectively. The characteristics of the 2 groups were similar, but patients in TPS group had more frequent pancreatic duct cannulation. Bile duct cannulation was successful in 23 patients (74.2%) in the TPS group and 39 (83.0%) in the NKF group (P = 0.34). There was no difference between the TPS and NKF in the rate of adverse events, including post-ERCP pancreatitis (PEP) (16.1% vs. 6.4%, p = 0.17), and hemorrhage (3.2% vs. 8.5%, p = 0.35). No perforation occurred. CONCLUSIONS: Both TPS and NKF have good biliary access rate in patient with difficult cannulation. TPS has acceptable successful rate and similar complication rate, compared with NKF.

A randomized controlled trial on the effect of topical phenytoin 2% on wound healing after anal fistulotomy.

AIM: Laying open fistulotomy is the standard treatment for simple anal fistula. However, healing of the resultant anal wound may be prolonged and may adversely affect a patient's lifestyle and work. This randomized trial aimed to assess the effect of topical phenytoin 2% powder spray on healing of the anal wound following fistulotomy. METHOD: Adult patients with simple anal fistula who underwent anal fistulotomy were divided into two equal groups: group I applied topical phenytoin 2% powder spray on the anal wound regularly with sitz baths until complete healing was confirmed clinically and group II had regular sitz baths only. The primary outcome of the study was time to complete wound healing. Secondary outcomes were postoperative pain, complications, time to return to work and impact on lifestyle. RESULTS: Sixty patients (50 of whom were men) with a mean age of 41.4 ± 12.5 years were included. Both groups had comparable pain scores at 1 week after surgery (1 ± 0.83 vs 0.86 ± 0.81; P = 0.51). The duration to complete wound healing was 41.2 ± 2.4 days in group I and 42 ± 2.5 days in group II (mean ± SD, P = 0.21). The time to return to work was 13.5 ± 2.8 days in group I and 14.1 ± 2.6 days in group II (mean ± SD, P = 0.39). No significant differences were noted between the two groups with regard to postoperative complications or impact on lifestyle. CONCLUSION: The use of topical phenytoin 2% powder spray did not promote wound healing, relieve postoperative pain or accelerate patient recovery after anal fistulotomy for simple anal fistula.

Comparison of efficacy and safety of transpancreatic septotomy, needle-knife fistulotomy or both based on biliary cannulation unintentional pancreatic access and papillary morphology.

BACKGROUND: Precut sphincterotomy has been widely performed to facilitate selective biliary access when standard cannulation attempts failed during endoscopic retrograde cholangiopancreatography (ERCP). However, scarce data are available on different precut techniques for difficult biliary cannulation. This study aimed to evaluate the efficacy and safety of transpancreatic septotomy (TPS), needle-knife fistulotomy (NKF) or both based on the presence of unintentional pancreatic access and papillary morphology. METHODS: Between March 2008 and December 2016, 157 consecutive patients undergoing precutting for an inaccessible bile duct during ERCP were identified. Precut techniques were chosen depending on repetitive inadvertent pancreatic cannulation and the papillary morphology. We retrospectively assessed the rates of cannulation success and procedure-related complications among three groups, namely TPS, NKF, and TPS followed by NKF. RESULTS: The baseline characteristics of the three groups were comparable. The overall success rate of biliary cannulation reached 98.1%, including 111 of 113 (98.2%) with TPS, 35 of 36 (97.2%) with NKF and 8 of 8 (100%) with NKF following TPS, without significant difference among groups. The incidences of total complications and post-ERCP pancreatitis were 9.6% and 7.6%, respectively. There was a trend towards less frequent post-ERCP pancreatitis after NKF (0%) compared with 11 cases (9.7%) after TPS and one case (12.5%) after NKF following TPS, but not significantly different (P = 0.07). No severe adverse event occurred during this study period. CONCLUSIONS: The choice of precut techniques by the presence of unintended pancreatic access and the papillary morphology brought about a high success rate without increasing risk in difficult biliary cannulation.

Fistulotomy and primary sphincteroplasty for anal fistula: long-term data on continence and patient satisfaction.

BACKGROUND: The aim of this study was to evaluate the safety and long-term efficacy of fistulotomy and primary sphincteroplasty (FIPS). Secondary endpoints were its impact on postoperative continence status and patients' satisfaction. METHODS: A retrospective study was conducted on patients with cryptoglandular anal fistula (AF) who had FIPS between June 2006 and May 2017. Patients were evaluated with standardized telephone interviews and clinical/instrumental assessment. Main outcome measures included fistula healing rate, continence status, and patient satisfaction. Incontinence was defined as an inability to hold either gas, liquid, or solid stools, as well as postdefecation soiling, and was measured by the Cleveland Clinic fecal incontinence score. Patient satisfaction was evaluated by an 11-point numeric rating scale. RESULTS: There were 203 patients (139 males; mean age: 48.7 years) who had FIPS. The overall healing rate was 93% (188 patients) with a mean follow-up period of 56 ± 31 months. Half of the total cohort (51%) had a complex fistula. Preoperatively, 8 (4%) patients complained of postdefecation soiling and 2 (1%) of gas incontinence. Postoperatively, 26 (13%) patients had continence impairment (de novo n = 24), mainly consisting of postdefecation soiling (10%). In univariate analysis, patients with recurrent (RR 6.153 95% CI 2.097-18.048; p = 0.002) or complex (RR 3.005 95% CI 1.203-7.506; p = 0.012) AF and those with secondary tracts (RR 8.190 95% CI 2.188-30.654; p = 0.004) or previous set on drainage (RR 5.286 95% CI 2.235-12.503; p = 0.0001) were at higher risk of incontinence. In multivariate analysis, no significant predictors were found, although fistula complexity approached statistical significance (RR 5.464 95% CI 0.944-31.623; p = 0.050). The mean patient satisfaction numeric rating scale was 9.3 ± 1.6. Lower satisfaction rates were found in patients with transphincteric (p = 0.011) or complex (p = 0.0001) AF, with secondary tracts (p = 0.041) or previous seton drainage (p = 0.008), and in those with postoperative continence impairment (p = 0.0001). Postoperative onset of incontinence was the only significant factor in multivariate analysis (p = 0.0001). CONCLUSIONS: FIPS should be considered a valid therapeutic option for selected AF. However, the risk of postoperative minor fecal incontinence exists, and should be discussed during preoperative patient counselling.

Fistulotomy versus fistulectomy for simple fistula in ano: a retrospective cohort study.

OBJECTIVE: To compare fistulotomy with fistulectomy for wound healing, duration of surgery, post-operative pain, incontinence and recurrence in patients with fistula in ano. METHODS: This retrospective cohort study was conducted at the Aga Khan University Hospital, Karachi, and comprised data of adults who had undergone fistulotomy/fistulectomy for simple fistula in ano from January 2007 to August 2012. Data collection was done in August 2013 using questionnaire and telephonic interviews. Outcome variables like duration of wound healing, recurrence, incontinence, duration of surgery and post-operative pain were compared in both the groups. SPSS 19 was used for data analysis. RESULTS: Of the 192 cases, there were 96(50%) in each group. The mean age was 40.51 years (range: 21-72 years) in the fistulotomy group and 41.14 years (range: 21-66 years) in the fistulectomy group (p=0.66). Both groups were comparable for baseline demographic variables. The median duration of wound healing was shorter in the fistulotomy group 15 days (Interquartile range: 7-20 days) compared to the fistulectomy group 30 days (Interquartile range: 15-42 days) (p<0.001). The incidence of recurrence was comparable in fistulotomy vs. fistulectomy (3[3.12%] vs. 4[4.16%]; p=0.70). The incidence of incontinence was higher in fistulotomy compared to fistulectomy (5[5.3%] vs. 12[12.5%]; p=0.07). The severity of incontinence was also compared but the difference was insignificant (p=0.06). The median duration of surgery was significantly shorter in fistulotomy group 17 minutes (Interquartile range: 12-25 minutes) compared to fistulectomy group 25 minutes Interquartile range: 20-35 minutes (p<0.001). The median post-operative pain in the surgical day care unit and at the first follow-up in clinic was zero for both groups. CONCLUSIONS: Fistulotomy yielded better results than fistulectomy since it significantly decreased the duration of wound healing and duration of surgery without increasing the incidence of recurrence, incontinence and post-operative pain.