External validation of the MAGNIFI-CD index in patients with complex perianal fistulising Crohn's disease.

BACKGROUND: There is an increasing need for objective treatment monitoring in perianal fistulising Crohn's disease (pfCD). Therefore, the magnetic resonance novel index for fistula imaging in CD (MAGNIFI-CD) index has been designed and internally validated on the ADMIRE-CD trial cohort. The aim of this study was to externally validate the MAGNIFI-CD index to monitor response to medical and surgical treatment regimens in pfCD. METHODS: A retrospective longitudinal cohort was established of consecutive patients with complex pfCD treated with surgical and/or medical therapy and a baseline and follow-up MRI between January 2007 and May 2021. The MAGNIFI-CD index was scored by two independent, abdominal radiologists blinded for time points and clinical outcomes. Responsiveness, reliability, and test accuracy regarding clinically important improvement were assessed. Cut-offs for response and remission were selected classified on fistula drainage assessment and physician global assessment. RESULTS: A total of 65 patients (51% female, median age 32 years) were included. A clinically relevant responsiveness of the MAGNIFI-CD was shown, with a significant decrease in clinical remitters and responders with a median MAGNIFI-CD of 18.0 [7.5-20.0] to 9.0 [0.8-16.0] (p < 0.001) and non-significant change in non-responders with a median MAGNIFI-CD of 20.0 [12.0-23.0] to 18.0 [13.0-21.0] (p = 0.22). There was an 'almost perfect' interobserver agreement (ICC = 0.87; 95% CI 0.80-0.92) for the MAGNIFI-CD index. An optimal cut-off value was defined as a decrease of 2 points for clinical response, and a MAGNIFI-CD ≤ 6 for remission at follow-up MRI. CONCLUSION: The MAGNIFI-CD index is a responsive and reliable MRI scoring instrument for treatment monitoring in perianal fistulising Crohn's disease. CLINICAL RELEVANCE STATEMENT: The MAGNIFI-CD index is a well-structured, responsive scoring instrument to assess fistula severity and activity that allows quantitative detection of changes in therapy response in patients with perianal fistulising Crohn's disease, thereby facilitating endpoints in clinical trials. KEY POINTS: Well-defined cut-offs for response and remission are needed for objective treatment monitoring of perianal fistulising Crohn's disease (pfCD). Cut-off values for remission and for response at 6 months follow-up were defined. Interobserver agreement was good. The MAGNIFI-CD index is responsive and reliable for treatment monitoring and is suitable for use in clinical trials.

Posterior median surgical approach to anterior sacral meningocele complicated by rectothecal fistula.

In this case report, we aimed to describe the clinical presentation, surgical approach, and follow-up of a patient with rare anterior meningocele associated with rectothecal fistula. An 17-year-old female patient was admitted to the emergency department with meningitis. On further examinations, an anterior sacral meningocele accompanied by rectothecal fistula was detected. Appropriate antibiotic treatment was arranged and surgical plan was made with the pediatric surgery clinic. The patient underwent meningocele repair via posterior approach and colostomy operation. The patient did not experience any neurological issues after the surgery. The colostomy was reversed 3 months later, and third-month follow-up MRI showed complete regression of the meningocele sac with no neurological complications. Anterior meningocele accompanied by a rectothecal fistula is a rare and complicated case. Only seven cases of coexisting ASM and RTF have been reported in literature. Although both anterior and posterior approaches have been used for the treatment of ASM, the choice of treatment is essentially based on the patient's clinical and imaging findings.

An Asymptomatic Sigmoid Colonic Fistula Arising from a Large Aneurysm of the Internal Iliac Artery Was Discovered during a Medical Examination.

The rupture of an internal iliac artery aneurysm in the colon is a rare but potentially fatal complication. We report a rectal fistula of an asymptomatic internal iliac artery aneurysm that was discovered incidentally during a medical examination. A 77-year-old man presented at a local hospital for a general medical examination. Although the blood reports revealed severe anemia, the patient did not complain of any associated symptoms including dizziness and hematochezia. Moreover, there was no palpable mass in the patient's abdomen, and there was no evidence of hematochezia, as the patient had been using a bidet. Interestingly, computed tomography (CT) revealed a large right internal iliac artery aneurysm. There was a suspicious finding of a fistula within the colon in the CT, but it was undetected in the preoperative sigmoidoscopy. Furthermore, operative findings showed a protruding retroperitoneal mass adhering to the mesentery of the sigmoid colon. During aneurysm resection, the presence of a fistula was unclear. However, a fistula tract, devoid of any infectious bacteria such as tuberculosis, was found in the specimen after colon resection. After a recovery period of approximately one week, the patient was discharged from the hospital without any unusual findings on the post-operative CT. Sigmoid colonic fistulas arising from iliac artery aneurysms are rare. Also, diagnosis may be delayed in special circumstances wherein a patient routinely uses a bidet.

Three-dimensional modelling as a novel interactive tool for preoperative planning for complex perianal fistulas in Crohn's disease.

AIM: The aim of this study is to demonstrate the added value of three-dimensional (3D) reconstruction models and artificial intelligence for preoperative planning in complex perianal Crohn's disease. MRI is the gold standard for diagnosis of complex perianal fistulas and abscess due to its high sensitivity, but it lacks high specificity values. This creates the need for better diagnostic models such as 3D image processing and reconstruction (3D-IPR) with artificial intelligence (AI) algorithms. METHOD: This is a prospective study evaluating the utility of 3D reconstruction models from MRI in four patients with perineal Crohn's disease (pCD). RESULTS: Four pCD patients had 3D reconstruction models made from pelvic MRI. This provided a more visual representation of perianal disease and made possible location of the internal fistula orifice, seton placement in fistula tracts and abscess drainage. CONCLUSION: Three-dimensional reconstruction in CD-associated complex perianal fistulas can facilitate disease interpretation, anatomy and surgical strategy, potentially improving preoperative planning as well as intraoperative assistance. This could probably result in better surgical outcomes to control perianal sepsis and reduce the number of surgical procedures required in these patients.

State-of-the-art surgery for Crohn's disease: part III-perianal Crohn's disease.

PURPOSE: Diagnosis and treatment of perianal Crohn's disease is challenging and requires its own domain of therapy. Different types of perianal disease require a spectrum of treatment strategies. Treatment options range from conservative therapy, including immunosuppressives, biologics, or stem cell therapy, to surgical treatment with specific indications depending on the underlying lesion. This is part III of the series "state-of-the-art surgery for Crohn's disease," focusing on the management of perianal disease. We discuss the definition and diagnosis of perianal Crohn's disease, the treatment of perianal lesions, and specific surgical indications and techniques. RESULTS AND CONCLUSION: Pitfalls and complications play a substantial role in the treatment of perianal Crohn's disease, and surgical therapy may fail. Realistic treatment goals and an individual patient-oriented treatment approach are crucial in the treatment of perianal Crohn's disease.

Distalization of perianal fistulas after loose silicone seton drainage is a myth.

BACKGROUND: It is often stated that loose seton drainage results in distal migration of a fistula tract in perianal fistula. The aim of the present study was to assess this distalization of trans- and suprasphincteric perianal fistulas after a silicone seton has been inserted. METHODS: Consecutive patients who underwent loose seton placement for the management of a transsphincteric or suprasphincteric fistula between January 2016 and December 2021 with a pre- and postoperative magnetic resonance imaging (MRI) were included in the present retrospective study. The height of the external anal sphincter (EAS) and the level of penetration of perianal fistula through the EAS or puborectal muscle (PRM) were determined on MRI. Primary outcome was migration of the fistula tract through the EAS and PRM. RESULTS: Thirty-eight patients with perianal fistulas were included. Median height of the EAS was 28 (IQR 25-34) mm before seton placement and 27 (IQR 24-33) mm afterward. Median level of perforation was 32 (IQR 17-40) mm before seton placement and 28 (IQR 17-40) mm afterward (p = 0.37). One fistula (3%) was downgraded from mid to low transsphincteric and was laid open after 14.9 months of loose seton drainage. CONCLUSIONS: No statistically significant distalization of complex fistula tracts after loose silicone seton drainage was found. Some complex fistulas may downgrade to a less complex fistula after long-term seton drainage. However, loose silicone seton drainage should not be offered to patients as a treatment option to downgrade a complex fistula to a simple one or even have the hope to heal it.

Pneumorrhachis Secondary to a Locally Advanced Rectal Cancer with Pre-Sacral Abscess-Case Report and Review.

The occurrence of pneumorrhachis (PR), defined as the presence of air within the spinal canal, presents a complex clinical picture with diverse etiological factors. We report an exceedingly rare case of PR arising from locally advanced rectal cancer accompanied by a pre-sacral abscess. This report aims to enhance awareness and understanding of rare causes of PR within the medical community, particularly among surgeons engaged in emergency procedures. The patient survived the acute phase of the disease through multiple surgical interventions and admission to the intensive care unit, but succumbed to cardiovascular complications three weeks later. We also offer a brief review of the literature concerning PR originating from the colorectal lumen.

Loss of seton in patients with complex anal fistula: a retrospective comparison of conventional knotted loose seton and knot-free seton.

BACKGROUND: Loose setons are often utilized. Replacements after seton loss are frequent, but the exact incidence of this loss of seton (LOS) in patients is unknown. The aim of the present study was to assess the incidence of LOS in a population with complex anal fistula, comparing the knot-free loose seton with the conventional knotted loose seton. METHODS: All consecutive patients treated with a loose seton for complex anal fistula in two large teaching hospitals in the Netherlands between January 2017 and December 2019 were included in the present study. The incidence of loss of a conventional knotted loose seton was compared with the loss of commercially available knot-free setons. RESULTS: There were 212 patients. Fifty-two patients were included in the knotted loose group and 160 patients were included in the knot-free seton group. Sixteen patients who were treated with both a knotted and a knot-free loose seton were included in both groups. The incidence of LOS was 12% in the knotted seton group and 28% in the knot-free loose seton group (p = 0.02). Median time to LOS was 36 days for the knotted loose seton and 89 days for the knot-free loose seton (p = 0.36). Sex (p = 0.61), age at the time of seton placement (p = 0.60), and presence of inflammatory bowel disease (p = 0.28) were not significantly associated with LOS. CONCLUSIONS: LOS occurs frequently in patients treated for complex anal fistulas. The incidence of LOS is significantly higher in patients treated with a knot-free loose seton. Further developments in seton manufacturing should be focussed on optimisation of the closure mechanism.

Late-onset anorectal disease and psychosocial impact in survivors of childhood cancer: A report from the Childhood Cancer Survivor Study.

BACKGROUND: The prevalence and associated psychosocial morbidity of late-onset anorectal disease after surgery and radiotherapy for the treatment of childhood cancer are not known. METHODS: A total of 25,530 survivors diagnosed between 1970 and 1999 (median age at cancer diagnosis, 6.1 years; age at survey, 30.2 years) and 5036 siblings were evaluated for late-onset anorectal disease, which was defined as a self-reported fistula-in-ano, self-reported anorectal stricture, or pathology- or medical record-confirmed anorectal subsequent malignant neoplasm (SMN) 5 or more years after the primary cancer diagnosis. Piecewise exponential models compared the survivors and siblings and examined associations between cancer treatments and late-onset anorectal disease. Multiple logistic regression with generalized estimating equations was used to evaluate associations between late-onset anorectal disease and emotional distress, as defined by the Brief Symptom Inventory 18 (BSI-18), and health-related quality of life, as defined by the Medical Outcomes Study 36-Item Short Form Health Survey (SF-36). RESULTS: By 45 years after the diagnosis, 394 survivors (fistula, n = 291; stricture, n = 116; anorectal SMN, n = 26) and 84 siblings (fistula, n = 73; stricture, n = 23; anorectal neoplasm, n = 1) had developed late-onset anorectal disease (adjusted rate ratio [RR] for survivors vs siblings, 1.2; 95% confidence interval [CI], 1.0-1.5). Among survivors, pelvic radiotherapy with ≥30 Gy within 5 years of the cancer diagnosis was associated with late-onset anorectal disease (adjusted RR for 30-49.9 Gy vs none, 1.6; 95% CI, 1.1-2.3; adjusted RR for ≥50 Gy vs none, 5.4; 95% CI, 3.1-9.2). Late-onset anorectal disease was associated with psychosocial impairment in all BSI-18 and SF-36 domains. CONCLUSIONS: Late-onset anorectal disease was more common among childhood cancer survivors who received higher doses of pelvic radiotherapy and was associated with substantial psychosocial morbidity.

Modified York Mason technique for repair of iatrogenic recto-urinary fistula: 20 years of the Montsouris experience.

PURPOSE: Iatrogenic recto-urinary fistulas are a disastrous complication of therapeutic interventions on the prostate. Many surgical approaches have been described to repair recto-urinary fistulas and no consensus has been reached regarding the better approach. The objective of this study is to present the results of our updated 20-year experience in the surgical management of recto-urinary fistula using a modified York Mason procedure. METHODS: We proceed to a retrospective single-institution review of surgically treated patients for iatrogenic recto-urinary fistulas between 1998 and 2017 by the modified York Mason technique. Descriptive analysis of our population was performed. Continuous and categorical variables were compared using Mann-Whitney and Fischer tests, respectively. All tests were two-sided with a significance level set at p value < 0.05. RESULTS: We included 30 consecutive patients treated for iatrogenic recto-urinary fistula. The median follow-up was 76 months (2-195). The median size of the fistula was 5 mm (2-20). Successful healing of the recto-urinary fistula was observed in 80, 97, and 100% of patients after 1, 2, or 3 York Mason procedure. During the study period, no one single case of acquired urinary incontinence or durable fecal incontinence has been observed. CONCLUSIONS: Our modified York Mason technique is a reliable and effective procedure with a 100% success rate for the repair of small iatrogenic recto-urinary fistulas in non-irradiated patients. It has a very low morbidity rate, and no case of postoperative urine or fecal incontinence has been observed.

Human Amniotic Membrane Effect on Perianal Fistula Healing in Rabbits: An Experimental Study.

BACKGROUND: Perianal fistula is a complicated disorder and most difficult to manage. New treatment methods would help surgeons to achieve a better outcome in patients with perianal fistula. Human amniotic membrane (HAM) has positive effects on wound healing in several conditions. The present study aimed to further determine the effect of HAM on wound healing of perianal fistula in rabbits. METHODS: In a prospective experimental study, 14 male rabbits (aged 4-6 months and weighing 3-4 kg) were randomly divided into 2 groups. After 12 weeks, the high type perianal fistula was repaired with endorectal flap (ERF) and ERF plus HAM in the control and case groups, respectively. In all rabbits of the case group, a 1×1 cm width wrap of HAM was applied and fixed around the ERF site. Three weeks later, the repaired site of the perianal fistula was sent for pathologic wound healing scoring. The results were analyzed with the SPSS 21.0 software using Mann-Whitney test. RESULTS: Six rabbits of each group survived the study period. There was a statistically significant difference in wound healing between the case and control groups (P<0.001). Wound healing process in the case group occurred better and faster than the control group. CONCLUSION: HAM has an effective role in enhancing the ERF procedure and considered appropriate. A combination of HAM with other methods is recommended.

Anoperineal disease in Hidradenitis Suppurativa : MR imaging distinction from perianal Crohn's disease.

OBJECTIVE: To determine whether Hidradenitis suppurativa (HS)-related anoperineal disease can be distinguished from Crohn's disease (CD) using MRI. METHODS: Pelvic MRI of 23 HS and 46 CD patients with anoperineal disease between 2007 and 2014 were independently analysed by two radiologists. For diagnosis of HS, sensitivity, specificity and positive likelihood ratios (LRs) of inflammatory features and of their anatomical distribution were calculated and compared to those of CD. RESULTS: In HS, fistulae were less present (P = .033) and less frequently involved the sphincters (P = .001) than in CD. Granulomas were more frequent (P = .0005). For anterior/inguinal and posterior localizations, sensitivity, specificity and LR for diagnosis of HS were 70% (49.1, 84.4), 87% (74.3, 93.9), 5.3 (2.41, 11.79) and 57% (36.8, 74.4), 93% (82.5, 97.8), 8.67 (2.74, 27.41), respectively. Combination of signs including posterior involvement, absence of rectal wall thickening and bilaterality of features yielded specificity of 100% (95% CI: 92.3-100) for HS. CONCLUSION: Although MRI presentations of anoperineal disease may overlap between CD and HS, specific diagnosis of HS is possible with a combination of three features: absence of features' predominance in perianal area, absence of rectal wall thickening and bilaterality of features. KEY POINTS: • Spectrum of MRI features of HS-related anoperineal disease is wide. • Specific diagnosis of HS-related anoperineal disease is possible using MR imaging. • A combination of three MR signs allows distinction between HS and CD.

Multi Detector Computed Tomography Fistulography In Patients of Fistula-in-Ano: An Imaging Collage.

Fistula-in-ano, or perianal fistula, is a challenging clinical condition for both diagnosis and treatment. Imaging modalities such as fistulography, anal endosonography, perineal sonography, magnetic resonance imaging (MRI), and computed tomography (CT) are available for its evaluation. MRI is considered as the modality of choice for an accurate delineation of the tract in relation to the sphincter complex and for the detection of associated complications. However, its availability and affordability is always an issue. Moreover, the requirement to obtain multiple sequences to depict the fistula in detail is cumbersome and confusing for the clinicians to interpret. The inability to show the fistula in relation to normal anatomical structures in a single image is also a limitation. Multi detector computed tomography fistulography (MDCTF) is an underutilized technique for defining perianal fistulas. Acquisition of iso-volumetric data sets with instillation of contrast into the fistula delineates the tract and its components. Post-processing with thin sections allows for a generation of good quality images for presentation in various planes (multi-planar reconstructions) and formats (volume rendered technique, maximum intensity projection). MDCTF demonstrates the type of fistula, its extent, whether it is simple or complex, and shows the site of internal opening and associated complications; all in easy to understand images that can be used by the surgeons. Its capability to represent the entire pathology in relation to normal anatomical structures in few images is a definite advantage. MDCTF can be utilized when MRI is contraindicated or not feasible. This pictorial review shares our initial experience with MDCT fistulography in evaluating fistula-in-ano, demonstrates various components of fistulas, and discusses the types of fistulas according to the standard Parks classification.

Proactive rectal warming during total-gland prostate cryoablation.

PURPOSE: Proactive rectal warming (PRW), as a modification of prostate cryoablation, was assessed in terms of rectal complications and therapeutic outcomes. MATERIALS AND METHODS: A cohort of 166 patients cumulatively treated between September, 2009 and November, 2012 qualified for study, each undergoing total-gland cryoablation (TGC) for prostate cancer. The initial 100 patients accrued submitted to TGC alone. PRW was administered to the final 66 patients. Preemptive warming is achieved by inserting a cryoprobe midline through perineal skin into anterior rectal wall under ultrasound guidance. The activated probe generates warmth as the ice ball encroaches on rectum. Prospective, post-ablative grading of rectal pain was measured at weeks 1, 2, 4, 8, 12, and 24 by using the Common Terminology Criteria for Adverse Events. Recurrent prostate cancer was gauged by Phoenix criterion (nadir+2 ng/ml). The Mann-Whitney U test and Chi-square test were used to compare clinical characteristics of therapeutic subsets. The Cox proportional hazard model was applied for comparison of cancer recurrence risk by group. RESULTS: Rectal pain (all grades) was experienced by patients treated with (62%) and without (74%) PRW. Although such pain typically resolved with time, it was milder (general lineal model, p=0.023) and less prolonged (median: 0.75 vs 1.5 months; log-rank test, p=0.002) in patients receiving PRW than in controls. Of note, PRW did not heighten cancer recurrence risk (hazard ratio=1.3 [95% CI, 0.3-5.0]). CONCLUSIONS: PRW helps to protect the rectum from freeze injury during prostate cryoablation, significantly reducing post-ablative rectal pain without compromising therapeutic outcomes.

[Management of rectourethral fistulas with the York Mason procedure: surgical techniques and outcomes]. / Traitement des fistules uréthro-rectales par voie trans-anorectale de York Mason: technique et résultats.

OBJECTIVE: To report our experience for the management of urethro-rectal fistula by the York Mason technique. PATIENTS AND METHODS: We retrospectively analyzed the data of patients treated surgically for FUR by the technique of York Mason, between 2000 and 2012. RESULTS: Seventeen patients were included in the study. All patients had a bowel diversion before surgery. We observed four recurrences of FUR (23.5%). Recurrences occurred in a radiation field for two patients and in a oncologic recurrence for 1 patient. The fourth recurrence was treated by a second procedure of York Mason successfully. CONCLUSION: In our study, the York Mason technique was safe and reproducible for the treatment of FUR. The main factor of failure was a history of pelvic radiotherapy.

Our Experience with MR Imaging of Perianal Fistulas.

Magnetic resonance imaging (MRI) depicts infectious foci in the perianal region better than any other imaging modality. MRI allows definition of the fistula, associated abscess formation and its secondary extensions. Accurate information is necessary for surgical treatment and to obtain a decrease in the incidence of recurrence and complications. Radiologists should be familiar with anatomical and pathological findings of perianal fistulas and classify them using the MRI - based grading system. The purpose of this article was to provide an overview for evaluation of perianal fistulas, examples of various fistula types and their classification.

Immediate sphincter repair following fistulotomy for anal fistula: does it impact the healing rate and septic complications?

PURPOSE: Fistulotomy is considered the most effective treatment for anal fistula; however, it carries a risk of incontinence. Sphincteroplasty in the setting of fistulotomy is not standard practice due to concerns regarding healing and potential infectious complications. We aimed to compare the outcomes of patients who underwent fistulotomy with primary sphincteroplasty to those who did not undergo repair. METHODS: This was a retrospective review of consecutive patients who underwent fistulotomy for cryptoglandular anal fistula. All operations were performed by one colorectal surgeon. Sphincteroplasty was performed for patients perceived to be at higher risk for continence disturbance. The main outcome measures were the healing rate and postoperative septic complications. RESULTS: In total, 152 patients were analyzed. Group A (fistulotomy with sphincteroplasty) consisted of 45 patients and group B (fistulotomy alone) included 107 patients. Both groups were similar in age (P=0.16) and sex (P=0.20). Group A had higher proportions of multiple fistulas (26.7% vs. 6.5%, P<0.01) and complex fistulas (mid to high transsphincteric, 37.8% vs. 10.3%; P<0.01) than group B. The median follow-up time was 8 weeks. The overall healing rate was similar in both groups (93.3% vs. 90.6%, P=0.76). No significant difference between the 2 groups was noted in septic complications (6.7% vs. 3.7%, P=0.42). CONCLUSION: Fistulotomy with primary sphincter repair demonstrated a comparable healing rate to fistulotomy alone, without an increased risk of postoperative septic complications. Further prospective randomized studies are needed to confirm these findings and to explore the functional outcomes of patients who undergo sphincteroplasty.

Optimum management for complex anal fistula: A network meta-analysis of randomized controlled trials.

Background: Complex anal fistula has a high recurrence rate and disturbing surgical complications, which are frustrating for patients and challenging for surgeons. Although single or combined management methods have produced positive outcomes, no trials have simultaneously compared these therapies. Therefore, this study aimed to determine the management method for complex anal fistula with the lowest failure and complication rates. Methods: This network meta-analysis (NMA) was registered in the international prospective register of systematic reviews (PROSPERO; CRD42023393349). Randomized controlled trials that analyzed complex anal fistula management were obtained from Medline, Scopus, and Cochrane using representative keywords. The primary outcome was the failure of anal fistulas to heal (including recurrences) after 6 to 12 months. The secondary outcome was fecal incontinence. All statistical analysis was conducted within the Bayesian framework using BUGSnet 1.1.0 in R Studio. A forest plot and league table were used to present the results. Results: A total of 19 studies containing 15 interventions, 1844 subjects, and 104 pairwise comparisons were analyzed quantitatively. The lowest failure rates occurred with ligation of the intersphincteric fistula tract (LIFT) + Plug (RR 0.2; 95 % CI 0.01-2.65), LIFT + platelet-rich plasma (PRP) (RR 0.22; 95 % CI 0.01-2.89), and FSR (RR 0.26; 95 % CI 0.02-2.12) relative to drainage seton. LIFT combined with other management methods showed lower fecal incontinence rates than the other treatments. Conclusion: The combination of LIFT with plug or PRP resulted in lower failure and complication rates in the management of complex anal fistula compared to the other methods tested.

Recent advances in the diagnosis and treatment of complex anal fistula.

Anal fistula can be a challenging condition to manage, with complex fistulas presenting even greater difficulties. The primary concerns in treating this condition are a risk of damage to the anal sphincters, which can compromise fecal continence, and refractoriness to treatment, as evidenced by a high recurrence rate. Furthermore, the treatment of complex anal fistula involves several additional challenges. Satisfactory solutions to many of these obstacles remain elusive, and no consensus has been established regarding the available treatment options. In summary, complex anal fistula has no established gold-standard treatment, and the quest for effective therapies continues. This review discusses and highlights groundbreaking advances in the management of complex anal fistula over the past decade.

Study on the effect and mechanism of Yanghe decoction Huacai on tissue repair ofsyndrome after anal fistula surgery.

OBJECTIVE: To observe the clinical efficacy and safety of Yanghe decoction Huacai for the repair of Yin syndrome wounds with slow-healing after anal fistula surgery. METHODS: A total of 120 patients with slow-healing negative wounds with after low-grade anal fistula surgery who met the inclusion criteria were divided into a treatment group and a control group based on a random number table method, with 60 patients in the treatment group and 60 patients in the control group. The treatment group was given Yanghe decoction Huacai in combination with routine treatment; the control group was only given routine treatment, in which the wound surface was disinfected with iodine, and then covered with sterile gauze. The course of treatment in both groups was 10 d. After treatment, the wound secretion score, wound granulation tissue score, the expression levels of basic fibroblast growth factor (bFGF), transforming growth factor ß1 (TGF-ß1), and epidermal growth factor (EGF) in the wound, wound healing time and clinical efficacy were compared. RESULTS: There was no significant difference in age or gender between the two groups (P > 0.05). On the 10th and 15th days after the surgery, the wound secretion scores were higher in the treatment group than in the control group (P < 0.01). Comparing the two groups at the 10th and 15th day after surgery, the granulation tissue growth scores in the treatment group were better than the in control group (P < 0.01). On the 10th and 15th day after operation, the expression levels of bFGF, TGF-ß1 and EGF factors in the treatment group were stronger than those in the control group. The healing time of the wounds in the treatment group was significantly shorter than in the control group (P < 0.01). The clinical efficacy of the two groups after treatment was compared, and the overall efficacy of the treatment group was significantly higher than that of the control group (P < 0.01). CONCLUSIONS: Yanghe decoction Huacai have significant efficacy in the treatment of slow-healing wounds with Yin syndrome after anal fistula surgery. It improves wound secretions, promotes the growth of wound granulation tissue, and shortens wound healing time. Its mechanism of action may be related to the control of wound inflammation. It is related to increasing the expression of bFGF, TGF-ß1 and EGF in wound tissue, and promoting wound angiogenesis and fibroblast proliferation.