End-to-end stapled technique for Kono-S anastomosis.

PURPOSE: Our aim was to develop a Kono-S anastomotic technique using surgical staplers. METHODS: Two patients underwent stapled Kono-S anastomosis, one via abdominal and one transanal approach. RESULTS: The approach for an abdominal and transanal stapled Kono-S anastomosis is detailed. CONCLUSION: The Kono-S anastomosis can be safely configured using common surgical staplers.

Increasing experience with the LIFT procedure in Crohn's disease patients with complex anal fistula.

BACKGROUND: Surgical management of anal fistulas in Crohn's disease (CD) is associated with high failure rates, and treatment options are limited due to ongoing proctitis, multiple tracts, and concern for incontinence and non-healing wounds. The aim of this study was to investigate the healing rate of ligation of the inters-sphincteric fistula tract (LIFT) for anal fistulas in Crohn's disease and identify prognostic factors for healing. METHODS: This prospective analysis compared long-term healing rates of CD patients undergoing LIFT for anal fistulas. Consecutive patients with CD who underwent LIFT procedure at our institution, in the period from March 2012 to September 2019 were included. The main outcome was anal fistula healing rate. RESULTS: The study cohort of 46 patients (mean age of 34.2 ± 13.0 years, 18 (40%) males). After a mean follow-up time of 33 ± 28 months, fistula healing was seen in 30 (65%) patients. A total of 8 patients were noted to have inter-sphincteric recurrence and 8 patients had trans-sphincteric recurrence. Smoking at the time of surgery was significantly associated with LIFT failure (HR 3.18, 95% CI 1.18-8.61, p = 0.02). Other factors, such as age, sex, race, disease duration and location, type of fistula history of proctitis, preoperatively use of biologics or a seton, and previous repair attempts, did not appear to influence LIFT healing. Although not statistically significant, there was a trend toward increase in failure among patients with active proctitis at the time of surgery (HR 1.97, 95% CI 0.71-5.42, p = 0.19). CONCLUSION: Our increasing experience with LIFT for anal fistula in CD demonstrates a higher rate of healing (65%) than previously reported (48%). Smoking appears to negatively influence healing of LIFT in CD.

Long-term healing after complex anal fistula repair in patients with Crohn's disease.

BACKGROUND: Complex anal fistula in Crohn's disease (CD) poses a challenging problem. We sought to evaluate long-term surgical healing of complex anal fistula in CD through the two robust repair options-ligation of the intersphincteric fistula tract (LIFT) and advancement flap (AF). METHODS: A single-center retrospective study was conducted evaluating long-term healing rates in patients with CD with complex anal fistula undergoing LIFT or AF in 2008-2018. Fistula healing was defined as closure of external wounds, cessation of drainage and absence of pain. Short-term and long-term healing rates were compared. Cox proportional hazards model was performed to identify independent predictors of fistula healing. RESULTS: The study cohort included 60 CD patients undergoing LIFT (n = 38) or AF (n = 22). The AF group included 8 dermal flaps. Patients having LIFT were younger (35 years vs 43 years; p = 0.007), more likely to have a seton at the time of repair (92% vs 68%; p = 0.03) and less likely to have had prior repair attempts (34% vs 68%; p = 0.02). Short-term fistula healing occurred in 65% (n = 39) of the overall study cohort. However, at final follow-up, median 36 months (range 6-192 months), only 46% (n = 28) of repaired fistulas were healed. Considering the overall status of the cohort's perianal health at final follow-up, including both repaired, secondary or novel anal fistulas, only 50% (n = 30) of all patients in the cohort had all fistula sites healed and maintained bowel continuity at final follow-up. On Cox proportional hazards analysis, LIFT independently predicted long-term fistula healing (hazard ratio 2.3; 95% confidence interval 1.1-4.9; p = 0.03). Only a small number of patients (n = 5; 8%) required fecal diversion (n = 3) and/or proctectomy (n = 2). CONCLUSIONS: Repair of complex anal fistula in CD results in modest healing rates. LIFT independently predicts long-term healing. However, these results must be taken in context, considering differences in patient and fistula characteristics between groups. These results ought to be kept in mind when counseling CD patients with complex anal fistula.

Technical variations and feasibility of transanal ileal pouch-anal anastomosis for ulcerative colitis and inflammatory bowel disease unclassified across continents.

PURPOSE: Initial reports of transanal ileal pouch-anal anastomosis (taIPAA) suggest safety and feasibility compared with transabdominal IPAA. The purpose of this study was to evaluate differences in technique and results of taIPAA in three centers performing taIPAA across two continents. METHODS: Prospective IPAA registries from three institutions in the US and Europe were queried for patients undergoing taIPAA. Demographic, preoperative, intraoperative, and postoperative data were compiled into a single database and evaluated. RESULTS: Sixty-two patients (median age 38 years; range 16-68 years, 43 (69%) male) underwent taIPAA in the three centers (USA 24, UK 23, Italy 15). Most patients had had a subtotal colectomy before taIPAA [n = 55 (89%)]. Median surgical time was 266 min (range 180-576 min) and blood loss 100 ml (range 10-500 ml). Technical variations across the three institutions included proctectomy plane of dissection (intramesorectal or total mesorectal excision plane), specimen extraction site (future ileostomy site vs. anus), ileo-anal anastomosis technique (stapled vs. hand sewn) and use of fluorescence angiography. Despite technical differences, anastomotic leak rates (5/62; 8%) and overall complications (18/62; 29%) were acceptable across the three centers. CONCLUSIONS: This is the first collaborative report showing safety and feasibility of taIPAA. Despite technical variations, outcomes are similar across centers. A large multi-institutional, international IPAA collaborative is needed to compare technical factors and outcomes.

Increasing experience of ligation of the intersphincteric fistula tract for patients with Crohn's disease: what have we learned?

AIM: Ligation of the intersphincteric fistula tract (LIFT) has been proposed as a treatment of trans-sphincteric fistula in perianal Crohn's disease (CD). The aim of this study was to look at our experience of the LIFT procedure in CD patients on long-term follow-up. Specifically, we aimed to determine the fistula healing rate after the LIFT procedure after more than 12 months follow-up and to identify any prognostic factors. METHOD: Retrospective study of patients with trans-sphincteric Crohn's fistula tracts treated with the LIFT procedure between January 2011 and October 2015. Complete fistula healing as well as clinical outcomes were analysed. RESULTS: Data were available for 23 patients. After a median follow-up of 23 months, LIFT site healing was 48%. Patients with healed LIFT had a median follow-up time of 10.5 months, while patients with failed LIFT had a median follow-up time of 31 months (P = 0.04). Median time to failure was 9 months for patients with follow-up > 1 year. Most patients failed within 1 year (9/12; 75%) of the procedure. In multi-site CD, the LIFT procedure was more likely to be successful in those with small bowel disease (P = 0.04) compared with colonic disease (P = 0.02). Other factors such as preoperative use of biological therapies, presence of a seton, previous repair attempts, fistula position, type or number of fistulas, multiple fistula tracts, smoking status and other associated perianal disease did not appear to influence LIFT healing rates. CONCLUSION: The LIFT procedure offers reasonable long-term success in the treatment of perianal trans-sphincteric fistulas associated with CD. LIFT is more likely to fail in patients with concurrent colonic CD than in patients with small bowel CD.

Can three-dimensional high-resolution anorectal manometry detect anal sphincter defects in patients with faecal incontinence?

AIM: Endoanal ultrasound (EAUS) is the gold standard for detecting anal sphincter defects in patients with faecal incontinence (FI), while anorectal manometry evaluates sphincter function. Three-dimensional high-resolution anorectal manometry (3D HRAM) is a newer modality with the potential to assess both sphincter function and anatomy. The purpose of the present study was to compare 3D HRAM with 3D EAUS for the detection of anal sphincter defects in patients with FI. METHOD: A linkage analysis was performed between the 3D HRAM and 3D EAUS databases of a tertiary referral centre to identify patients with FI who underwent both 3D EAUS and 3D HRAM. With 3D HRAM, a defect was defined as any pressure measurement below 25 mmHg at rest with at least 18° of continuous expansion. The 3D HRAM findings were compared with those of 3D EAUS. RESULTS: The study cohort included 39 patients with a mean age of 64.7 ± 15.2 years (SD); and 31 (79%) were female. Eight (21%) patients had an anal sphincter defect on EAUS with a median size of 93° (range 40°-136°). Fourteen (36%) had a defect shown by 3D HRAM with a median size of 144° (36°-180°). The sensitivity, specificity and positive and negative predictive values of 3D HRAM in detecting a sphincter defect were 75%, 74%, 43% and 92%, respectively. CONCLUSION: With a negative predictive value of 92%, 3D HRAM may be a useful screening method for ruling out a sphincter defect in patients with FI, thereby avoiding both EAUS and manometry in selected patients.

The anal fistula plug in Crohn's disease patients with fistula-in-ano: a systematic review.

AIM: This study aimed to review, consolidate and analyse the findings of studies investigating the efficacy of anal fistula plugs (AFPs) in treating fistula-in-ano in patients with Crohn's disease. METHOD: A literature review was conducted via Pubmed, Embase, Medline, Scopus and the Cochrane Library for the period 1995-2015. Articles were selected and reviewed based on specific inclusion and exclusion criteria. RESULTS: A total of 16 studies were extracted, of which 12 were included in the systematic review. In total, 84 patients (n = 1-20 per study) with a median age of 45 (18-72) years and a median follow-up time of 9 (3-24) months were analysed. The total success rate, defined as closure of the fistula tract, was 49/84 (58.3%, 95% CI 47-69). Success in patients with recurrent anal fistulae was 2/5 (40%, 95% CI 5-85). Overall, the success rates of Surgisis and GORE BIO-A brand plugs were 48/80 (60%, 95% CI 48-71) and 1/4 (25%, 95% CI 1-81). The recurrence rate of fistula-in-ano in the five studies that reported recurrence was 3/22 (13.6%). In two comparative studies, inferior overall success rates were found in patients who received preoperative immunomodulators vs. those who did not [3/11 (27.3%) vs. 17/23 (73.9%)]. CONCLUSION: The studies suggest that the use of an AFP in patients with Crohn's disease is a safe procedure with reasonable success, little morbidity and a low risk of incontinence. The current literature is limited by a number of factors, including small study cohorts, grouping of fistulae in Crohn's disease with other types of anal fistula, short and highly variable follow-up times and multiple confounding factors such as number of fistula tracts, use of preoperative steroids or immunosuppressants, previous use of setons and variation in surgical technique.