Modification of Parks Classification of Cryptoglandular Anal Fistula.

BACKGROUND: The Parks classification has been used for the classification of anal fistula for several years, but it does not allow for risk factors for failure after surgery. OBJECTIVE: This study aimed to describe a modification of the Parks classification of anal fistula and examine its predictive validity in the assessment of the outcome of anal fistula in terms of failure of healing and fecal incontinence. DESIGN: This is a retrospective review of a prospective database. SETTING: This study was conducted in the Colorectal Surgery Unit, Mansoura University Hospitals. PATIENTS: Adult patients with anal fistula who underwent surgery were included. INTERVENTIONS: Five risk factors for failure after fistula surgery were identified from the literature and were examined by multivariate analysis of our patients. Four risk factors proved to be significant independent predictors of failure: secondary extensions, horseshoe fistula, previous fistula surgery, and anterior anal fistula in women. We modified the Parks classification by dividing the transsphincteric type into high and low and by grouping supra- and extrasphincteric anal fistulas into 1 group. The first 3 stages were subdivided according to the absence or presence of predictors of failure. MAIN OUTCOME MEASURES: The primary outcome measured was the validity of the modified Parks classification with regard to the rates of failure and fecal incontinence after surgical treatment of each stage of anal fistula. RESULTS: A total of 665 patients with cryptoglandular anal fistula were included. Failure rates increased from 2.3% (95% CI, 0.9%-4.7%), to 17.4% (95% CI, 10.8%-25.9%), 19.5% (95% CI, 15%-24.6%), and 30.7% (95% CI, 9.1%-61.4%) across the 4 stages. The area under the receiver operating characteristic curve was 0.90 (95% CI, 0.85-0.94) indicating the strong discriminative ability of the final multivariable predictive model. The increase in failure and incontinence rates across the fistula stages was significant. LIMITATIONS: This is a retrospective, single-center study. CONCLUSION: Inclusion of predictors of poor outcome into the modified classification helped differentiate simple and complex fistulas within each stage and between the different stages, which can help in assessment and decision making for anal fistula. See Video Abstract at http://links.lww.com/DCR/B441. MODIFICACIN DE LA CLASIFICACIN DE PARKS DE LA FSTULA ANAL CRIPTOGLANDULAR: ANTECEDENTES:La clasificación de Parks se ha utilizado para la clasificación de la fístula anal durante varios años, sin embargo, no tuvo en cuenta los factores de riesgo de fracaso después de la cirugía.OBJETIVO:Describir una modificación de la clasificación de Parks de fístula anal y examinar su validez predictiva en la evaluación de los resultados de la fístula anal en términos de fracaso de la cicatrización e incontinencia fecal.DISEÑO:Revisión retrospectiva de la base de datos prospectiva.AJUSTE:Unidad de Cirugía Colorrectal, Hospital Universitario de Mansoura.PACIENTES:Pacientes adultos con fístula anal intervenidos quirúgicamente.INTERVENCIONES:Se identificaron cinco factores de riesgo de fracaso después de la cirugía de fístula de la literatura y se examinaron mediante análisis multivariante de nuestros pacientes. Cuatro factores de riesgo demostraron ser importantes predictores independientes de fracaso: extensiones secundarias, fístula en herradura, cirugía de fístula previa y fístula anal anterior en mujeres. Modificamos la clasificación de Parks dividiendo el tipo transesfinteriano en alto y bajo y agrupando la fístula anal supraesfinteriana y extraesfinteriana en un grupo. Las tres primeras etapas se subdividieron según la ausencia o presencia de predictores de fracaso.PRINCIPALES MEDIDAS DE RESULTADO:Validez de la clasificación de Parks modificada con respecto a las tasas de fracaso e incontinencia fecal después del tratamiento quirúrgico de cada etapa de la fístula anal.RESULTADOS:Se incluyeron 665 pacientes con fístula anal criptoglandular. Las tasas de fracaso aumentaron del 2,3% (IC del 95%: 0,9-4,7%), al 17,4% (IC del 95%: 10,8 al 25,9%), 19,5% (IC del 95%: 15-24,6%) y 30,7% (95% IC: 9,1- 61,4%) en las cuatro etapas. El área bajo la curva característica operativa del receptor fue 0,90 (IC del 95%: 0,85-0,94), lo que indica una fuerte capacidad discriminativa del modelo predictivo multivariable final. El aumento en las tasas de fracaso e incontinencia en las etapas de la fístula fue significativo.LIMITACIONES:Estudio retrospectivo, unicéntrico.CONCLUSIÓN:La inclusión de predictores de mal resultado en la clasificación modificada ayudó a diferenciar las fístulas simples y complejas dentro de cada etapa y entre las diferentes etapas, lo que puede ayudar en la evaluación y toma de decisiones para la fístula anal. Consulte Video Resumen en http://links.lww.com/DCR/B441.

Long-Term Clinical Results of Use of an Anal Fistula Plug for Treatment of Low Trans-Sphincteric Anal Fistulas.

BACKGROUND An anal fistula plug is a sphincter-sparing procedure that uses biological substances to close an anorectal fistula. This study aimed to evaluate the long-term therapeutic effect of an anal fistula plug procedure in patients with trans-sphincteric fistula-in-ano and to determine the risk factors affecting fistula healing. MATERIAL AND METHODS A single-center retrospective study was performed assessing long-term treatment outcomes of patients with low trans-sphincteric anal fistulas who initially underwent anal fistula plug procedures between August 2008 and September 2012. Risk factors affecting fistula healing were identified using univariate and multivariate analyses. RESULTS A total of 135 patients who had low trans-sphincteric anal fistulas and underwent anal fistula plug procedures were analysed. The overall healing rate was 56% (75/135) with a median follow-up time of 8 years (range, 72-121 months). The primary reasons for treatment failure were plug extrusion (n=12, 20%) and surgical site infection (n=9, 15%), occurring within 30 days after surgery. Multiple logistic regression analysis showed that the duration of anal fistula ≥6 months was significantly associated with treatment failure using an anal fistula plug (OR=3.187, 95% CI: 1.361-7.466, P=0.008). Of the patients who failed initial treatment with an anal fistula plug, 6 (9%) had anal fistulas that healed spontaneously after 2-3 years without additional treatment. CONCLUSIONS As a sphincter-preserving procedure, the anal fistula plug can effectively promote healing of low trans-sphincteric anal fistulas. The long-term efficacy is good and the procedure warrants wider use in clinical practice.

Recommendations of the Crohn's Disease and Ulcerative Colitis Spanish Working Group (GETECCU) for the treatment of perianal fistulas of Crohn's disease. / Recomendaciones del Grupo Español de Trabajo de Enfermedad de Crohn y Colitis Ulcerosa (GETECCU) para el tratamiento de las fístulas perianales de la enfermedad de Crohn.

Recommendations are advice that is given and considered to be beneficial; however, they are still suggestions and are therefore open to different interpretations. In this sense, the final objective of the review has been to try to homogenize, with the evidence available, the approach to the diagnosis and medical/surgical treatment of one of the most complex manifestations of Crohn's disease, such as simple and complex perianal fistulas.

Comparison of Preoperative and Postoperative MRI After Fistula-in-Ano Surgery: Lessons Learnt from An Audit of 1323 MRI At a Single Centre.

AIM: Several studies have evaluated the efficacy of preoperative MRI in fistula-in-ano. However, the evaluation of MRI after fistula-in-ano surgery has never been done. The aim was to evaluate the utility of MRI in postoperative period after fistula-in-ano surgery. METHODS: Preoperative MRI was done in all the patients presenting with fistula-in-ano. Postoperative MRI was done to check radiological healing in clinically healed fistulas or when postoperative complication/healing problem was seen. The postoperative MRI was compared with preoperative MRI and correlated with the clinical picture. RESULTS: A total of 1323 MRI were done in 1003 fistula-in-ano patients, out of which 702 patients underwent surgery. In 702 patients, there were 361 recurrent fistulas, 153 had associated abscess, 388 had multiple tracts, 146 had horseshoe tract, and 76 had supralevator fistula. In total, 320 postoperative MRI scans were done in 180/702 patients. The requirement of postoperative MRI was significantly higher in complex (grades III-V) than simple fistulas (grades I-II) [43.5% (136/313) vs. 11.3% (44/389), respectively, P < 0.0001]. In early postoperative period (8 weeks), healing (granulation) tissue was difficult to differentiate from active fistula tract/pus. The complete radiological healing took at least 10-12 weeks. So getting MRI scan for the assessment of healing was more accurate after 12 weeks. MRI was very accurate to identify postoperative complications like abscess, missed tract or non-healing of a tract. MRI detected such complications even in apparently clinically healed tracts. Closure/healing of internal opening and intersphincteric tract was assessed accurately by MRI and correlated well with the fistula healing. CONCLUSIONS: MRI is highly useful to assess healing and detect complications after fistula surgery.

Transperineal Ultrasound for Perianal Fistulas and Abscesses - A Systematic Review and Meta-Analysis.

Purpose Transperineal ultrasound (TPUS) is a practical tool for assessing perianal inflammatory lesions. We systematically review its accuracy for detecting and classifying perianal fistulae and abscesses. Method The National Library of Medicine and Embase were searched for articles on TPUS for the assessment of idiopathic and Crohn's perianal fistulae and abscesses. Two reviewers independently reviewed eligible studies and rated them for quality using the QUADAS tool. The primary outcome measure was the accuracy of TPUS as measured by its sensitivity and positive predictive value (PPV) in detecting and classifying perianal fistulae, internal openings and perianal abscesses. Results We included 12 studies (565 patients). Overall, the methodological quality of the studies was suboptimal. 3 studies were retrospective and 4 showed significant risks of bias in the application of the reference standard. The sensitivity of TPUS in detecting perianal fistulae on a per-lesion basis was 98 % (95 % CI 96 - 100 %) and the PPV was 95 % (95 % CI 90 - 98 %). The detection of internal openings had a sensitivity of 91 % (95 % CI 84 - 97 %) with a PPV of 87 % (95 % CI 76 - 95 %). The classification of fistulae yielded a sensitivity of 92 % (95 % CI 85 - 97 %) and a PPV of 92 % (95 % CI 83 - 98 %). TPUS had a sensitivity of 86 % (95 % CI 67 - 99 %) and PPV of 90 % (95 % CI 76 - 99 %) in the detection of perianal abscesses. Conclusion The current literature on TPUS illustrates good overall accuracy in the assessment of perianal fistulae and abscesses. However, many studies had methodological flaws suggesting that further research is required.

Evaluation and management of perianal abscess and anal fistula: a consensus statement developed by the Italian Society of Colorectal Surgery (SICCR).

Perianal sepsis is a common condition ranging from acute abscess to chronic fistula formation. In most cases, the source is considered to be a non-specific cryptoglandular infection starting from the intersphincteric space. The key to successful treatment is the eradication of the primary track. As surgery may lead to a disturbance of continence, several sphincter-preserving techniques have been developed. This consensus statement examines the pertinent literature and provides evidence-based recommendations to improve individualized management of patients.

Managing perianal Crohn's fistula in the anti-TNFα era.

Perianal fistulas in Crohn's disease are common and difficult to treat. Their aetiology is poorly understood. Assessment is clinical, endoscopic and radiological, and management is undertaken by a multidisciplinary team of gastroenterologists, surgeons and radiologists. Surgical drainage of the fistula tract system with the placement of loose setons precedes combined therapy with immunosuppressant and anti-TNFα agents in most patients. Proctitis should be rigorously eliminated where possible. Definitive surgical repair is sometimes possible and diversion or proctectomy are occasionally required. Combined medical and surgical management represents a promising avenue for the future.

[Acute periproctal abscesses]. / Akutní periproktální abscesy.

Periproctal inflammations related to the anus are characterized by the rapid spread of the infection to the surrounding tissue, which is determined by the anatomical characteristics and infectious agents. Inflammation, which starts as a phlegmon, quickly forms boundaries and an abscess develops in most cases. Up to 80-90% of anorectal abscesses develop according to the crypto-glandular theory on the basis of infection of the anal glands, spilling into the Morgagni crypts in the anal canal. Up to two-thirds of such abscesses are associated with the emergence of anorectal fistulas. Anorectal abscesses can be divided into marginal and subcutaneous perianal abscesses, submucosal, intersphincteric, ischiorectal and supralevator abscesses. Their diagnosis is based on thorough physical examination, sometimes also with the help of imaging methods such as computed tomography, magnetic resonance imaging and endoanal ultrasound. What is decisive for the successful treatment of anorectal abscessess is their early and adequate surgical drainage. Adjuvant antibiotic therapy is necessary only when the overall signs of sepsis are present and for patients with a comorbidity such as diabetes, valvular heart disease, or immunodeficiency.

[Tactic of surgical treatment of complex rectal fistula].

The experience of the examination and treatment of 646 patients for different forms of complex rectal fistula (CRF) summarized. A working classification of the CRF with regard to their complication was developed and implemented. A differentiated approach has allowed greater use sphincter-preserving methods to improve functional outcome, quality of life, reduce the duration of the disability period and frequency of patients disability.

TOpCLASS Expert Consensus Classification of Perianal Fistulising Crohn's Disease: A Real-world Application in a Serial Fistula MRI Cohort.

BACKGROUND AND AIMS: Perianal fistuliing Crohn's disease [PFCD] is an aggressive phenotype of Crohn's disease defined by frequent relapses and disabling symptoms. A novel consensus classification system was recently outlined by the TOpCLASS consortium, which seeks to unify disease severity with patient-centred goals but has not yet been validated. We aimed to apply this to a real-world cohort and to identify factors that predict transition between classes over time. METHODS: We identified all patients with PFCD and at least one baseline and one follow-up pelvic MRI [pMRI]. TOpCLASS classification, disease characteristics, and imaging indices were collected retrospectively at time periods corresponding with respective MRIs. RESULTS: We identified 100 patients with PFCD, of whom 96 were assigned TOpCLASS Classes 1-2c at baseline. Most patients [78.1%] started in Class 2b, but changes in classification were observed in 52.1% of all patients. Male sex [72.0%, 46.6%, 40.0%, p = 0.03] and prior perianal surgery [52.0% vs 44.6% vs 40.0%, p = 0.02] were more frequently observed in those with improved class compared to unchanged and worsened class. Baseline pMRI indices were not associated with changes in classification; however, greater improvements in mVAI, MODIFI-CD, and PEMPAC were seen among those who improved. Linear mixed effect modelling identified only male sex [-0.31, 95% CI -0.60 to -0.02] with improvement in class. CONCLUSION: The TOpCLASS classification highlights the dynamic nature of PFCD over time. However, our ability to predict transitions between classes remains limited and requires prospective assessment. Improvement in MRI index scores over time was associated with a transition to lower TOpCLASS classification.

Rectal imaging: part 2, Perianal fistula evaluation on pelvic MRI--what the radiologist needs to know.

OBJECTIVE: The purpose of this article is to provide an overview of pelvic MRI for the evaluation of perianal fistulas, with a description of the technique, illustration of relevant normal anatomy, and examples of various fistula types. CONCLUSION: MRI evaluation of perianal fistulas can be challenging, and knowledge of relevant pelvic anatomy and fistula classification remains crucial in the diagnosis. MRI is highly accurate for fistula depiction and, by providing an accurate assessment of disease status and extension, can help surgical planning to minimize recurrence and detect clinically unapparent disease.

Surgery for fistula-in-ano in a specialist colorectal unit: a critical appraisal.

BACKGROUND: Several techniques have been described for the management of fistula-in-ano, but all carry their own risks of recurrence and incontinence. We conducted a prospective study to assess type of presentation, treatment strategy and outcome over a 5-year period. METHODS: Between 1st January 2005 and 31st March 2011,247 patients presenting with anal fistulas were treated at the University Hospital Tor Vergata and were included in the present prospective study. Mean age was 47 years (range 16-76 years); minimum follow-up period was 6 months (mean 40, range 6-74 months).Patients were treated using 4 operative approaches: fistulotomy, fistulectomy, seton placement and rectal advancement flap. Data analyzed included: age, gender, type of fistula, operative intervention, healing rate, postoperative complications, reinterventions and recurrence. RESULTS: Etiologies of fistulas were cryptoglandular (n = 218), Crohn's disease (n = 26) and Ulcerative Colitis (n = 3). Fistulae were classified as simple -intersphincteric 57 (23%), low transphincteric 28 (11%) and complex -high transphicteric 122 (49%), suprasphincteric 2 (0.8%), extrasphinteric 2 (0.8%), recto-vaginal 7 (2.8%) Crohn 26 (10%) and UC 3 (1.2%).The most common surgical procedure was the placement of seton (62%), usually applied in case of complex fistulae and Crohn's patients.Eighty-five patients (34%) underwent fistulotomy, mainly for intersphincteric and mid/low transphincteric tracts. Crohn's patients were submitted to placement of one or more loose setons.The main treatment successfully eradicated the primary fistula tract in 151/247 patients (61%). Three cases of major incontinence (1.3%) were detected during the follow-up period; Furthermore, three patients complained minor incontinence that was successfully treated by biofeedback and permacol injection into the internal anal sphincter. CONCLUSIONS: This prospective audit demonstrates an high proportion of complex anal fistulae treated by seton placement that was the most common surgical technique adopted to treat our patients as a first line. Nevertheless, a good outcome was achieved in the majority of patients with a limited rate of faecal incontinence (6/247 = 2.4%). New technologies provide promising alternatives to traditional methods of management particularly in case of complex fistulas. There is, however, a real need for high-quality randomized control trials to evaluate the different surgical and non surgical treatment options.

Update on anal fistulae: surgical perspectives for the gastroenterologist.

Anal fistulae are common and debilitating; they are characterized by severe pain and discharge. They arise following infection near the anal canal, or as a primary event from an abscess in the abdomen, fistulating into the vagina or perianal skin. The term 'cryptoglandular' is given to abscesses arising from the anal glands.For many years, the treatment of choice was to lay open the fistula; however, this risks causing incontinence with potentially devastating consequences. Alternative surgical treatments include setons, fibrin glue, collagen plugs and flaps to cover the internal fistula opening. These have achieved varying degrees of success, as will be discussed. The present review also discusses anal fistulae in light of much recently published literature. Currently, anal fistulae remain challenging and require specialist expertise; however, new treatment options are on the horizon.

Endoanal ultrasonography may distinguish Crohn's anal fistulae from cryptoglandular fistulae in patients with Crohn's disease: a cross-sectional study.

BACKGROUND: The aim of the study was a cross-sectional investigation into the types of anal fistulae in patients with Crohn's disease using 3-dimensional endoanal ultrasonography. METHODS: The study population consisted of 45 patients with established Crohn's disease referred in a 2-year period for treatment of anal fistula. The fistulae were classified according to the presence of three criteria: 1. bifurcation or secondary extension; 2. cross-sectional width ≥ 3 mm; and 3. content of hyperechoic secretions. RESULTS: The fistulae of 24 patients (53%) satisfied two or three criteria and were classified as true Crohn's fistulae, while the fistulae of 21 patients satisfied one or none of the criteria and were the cryptoglandular type. The fistulae in the two or three criteria group had been in existence for 8.4 years on average and those in the cryptoglandular group for 4.5 years on average (P = 0.283). The corresponding numbers of previous operations for fistula were 5.7 (range 0-32) and 1.5 (range 0-6), respectively (P = 0.0211). The presence of colitis or proctitis was similar across the groups, but the perianal Crohn's disease activity index was higher with a Crohn's type of fistula (P = 0.0097). Also, a larger proportion had been treated with anti-TNF-monoclonal antibody (0.0169). CONCLUSIONS: Endoanal ultrasonography was capable of discerning two subgroups of fistula in Crohn's patients. These groups were clinically different indicating that the prospect of surgical cure is also different.

Validating the Martini Staging System for Rectourethral Fistula: A Meta-Analysis of Postoperative Outcomes.

OBJECTIVE: To validate the Martini staging system for postoperative rectourethral fistula (RUF) utilizing data from previous studies to determine whether it can accurately predict postoperative success rate. METHODS: A systematic search of peer-reviewed studies was conducted through January, 2020. The primary inclusion criteria for the studies were studies that evaluated outcomes based on the etiology of the fistula (ie, radiotherapy/ablation [RA] vs nonradiotherapy/ablation [NRA]). Martini RUF classification was utilized for the subgroup analysis. RESULTS: Out of 1948 papers, 7 studies with a total of 490 patients (251 in RA vs 239 NRA) were included in this study. Receiving RA increased the risk of permanent bowel diversion by 11.1 folds, eventual fistula recurrence by 9.1 folds, and post-op urinary incontinence (UI) by 2.6 folds. Similarly, compared to a Grade 0 fistula, a Grade I fistula increased the risk of permanent bowel diversion by 9.1 folds, fistula recurrence by 20 folds, and post-op UI by 2.7 folds. There were some valuable variables that were not captured by the Martini classification. CONCLUSION: Overall, the Martini classification system is efficacious in stratifying post-op complications from RUF repair based on the grade and etiology; however, it is limited in application. There is an opportunity for the development of more comprehensive staging systems in this domain.

Proposal: a score to select patients for fistulotomy.

Traditionally the distance between the inner opening and the anal verge is considered when making the decision to lay open an anal fistula or not. In contrast to this, the score presented here includes the distance to the upper border of the puborectalis muscle or to the external sphincter (anteriorly). In addition this score also takes various aspects of bowel function into consideration.

Perianal fistulas.

The most common cause of anal fistula is anal gland sepsis, resulting in formation of anorectal abscess, particularly if the latter allowed bursting spontaneously or has been inadequately opened at operation. Surgical treatment of the fistula must intent to its healing or simply its drainage or its transformation to a simpler one. Superficial, low transsphincteric and intersphincteric fistulas are treated by the lay-open technique. The use of a loose seton allows time for any sepsis and induration to settle before a decision about further treatment is made. Also, the use of a tight seton in the management of complex fistula may avoid an early muscle division before any tissue scarring happened. The patient with a perianal fistula must have a steady trustful relationship with his surgeon and must be fully informed on the therapeutic plan and reassured for a favourable outcome.

The distribution of the anal glands and the variable regional occurrence of fistula-in-ano: is there a relationship?

BACKGROUND: Fistula in ano is a rather common condition, but the disease process is not yet fully understood. The aim of our study was to determine how the distribution of anal glands contributes to the variable occurrence of fistula-in-ano in the perineum. METHODS: we conducted a blinded two-phase prospective study. In the first phase, the perineum of the patients with primary fistulae was anatomically divided into right upper and lower and left upper and lower quadrants in the lithotomy position. The fistulae were classified according to what quadrant the external and internal openings and the tract pathway were in. In the second phase, using 10 human cadaver specimens, full thickness tissue samples were taken from each quadrant of the anus. Samples were histologically evaluated for the volume fractions of the anal glands in each quadrant. RESULTS: The new classification system we propose revealed that the largest number of fistulae 43% (17/39) were in the right lower quadrant, and 22% (9/39), 12% (5/39) and 8% (3/39) were in the left lower, right upper and left upper quadrants, respectively. It was also observed that 14% (5/39) of fistulae were in more than one quadrant. The volume fractions of each quadrant showed that the largest volume fraction of the anal glands was in the right lower quadrant (right lower quadrant: 0.64, left lower quadrant: 0.35, right upper quadrant: 0.26 and left upper quadrant: 0.22, P = 0.001). CONCLUSIONS: To the best of our knowledge, this is the first study that has objectively shown that the distribution of the anal glands is variable, and the highest density of anal glands is in the right lower quadrant of the anus. This variable distribution may be associated with the variable occurrence in fistula in ano.

Magnetic Resonance Imaging of Fistula-In-Ano.

This article explains the pathogenesis of fistula-in-ano and details the different classifications of fistula encountered, describe their features on MR imaging, and explains how imaging influences subsequent surgical treatment and ultimate clinical outcome. Precise preoperative characterization of the anatomic course of the fistula and all associated infection via MR imaging is critical for surgery to be most effective. MR imaging is the preeminent imaging modality used to answer pertinent surgical questions.