Assessment of microbiota and peptidoglycan in perianal fistulas.

Transanal advancement flap repair has been advocated as the treatment of choice for high transsphincteric perianal fistulas, but fails in 1 of every 3 patients. Persistence of the fistula after flap repair might be the result of ongoing disease in the remaining fistula tract. In 10 specimens of the distal part of the fistula, microbiota was assessed by means of conventional microbiological culture and 16S rRNA gene sequencing. Proinflammatory bacterial peptidoglycan and recognition proteins were assessed by immunohistochemistry. Bacterial species were bowel derived, skin derived, or a combination of both. No mycobacterium species were identified. 16S rRNA gene sequencing failed to identify bacteria in all but 1 specimen, most likely as a result of low numbers of organisms. Peptidoglycan was detected in 90% of the patients, and a host response to peptidoglycan in 60%. Therefore, we suggest that peptidoglycan might play a role in the ongoing inflammation in perianal fistulas.

Identification of epithelialization in high transsphincteric fistulas.

BACKGROUND: At present, transanal advancement flap repair (TAFR) is the treatment of choice for transsphincteric fistulas passing through the upper and middle third of the external anal sphincter. It has been suggested that epithelialization of the fistula tract contributes to the failure of the treatment. The aim of this study was to assess the prevalence of epithelialization of the fistula tract and to study its effect on the outcome of TAFR and TAFR combined with ligation of the intersphincteric fistula tract (LIFT). METHODS: Forty-four patients with a high transsphincteric fistula of cryptoglandular origin underwent TAFR. Nine of these patients underwent a combined procedure of TAFR with LIFT. In all patients the fistula tract was excised from the external opening up to the outer border of the external anal sphincter. In patients undergoing TAFR combined with LIFT an additional central part of the intersphincteric fistula tract was excised. A total of 53 specimens were submitted. Histopathological examination of the specimens was carried out by a pathologist, blinded for clinical data. RESULTS: Epithelialization of the distal and intersphincteric fistula tract was observed in only 25 and 22% of fistulas, respectively. There was no difference in outcome between fistulas with or without epithelialization. CONCLUSIONS: Epithelialization of high transsphincteric fistulas is rare and does not affect the outcome of TAFR and TAFR combined with LIFT.

Required length of follow-up after transanal advancement flap repair of high transsphincteric fistulas.

OBJECTIVE: Repair of high perianal fistulas presents a major surgical challenge. Transanal advancement flap repair (TAFR) provides a useful tool in the treatment of these fistulas. Initially promising results have been reported. More recent studies indicate that TAFR fails in one out of three patients. The aim of the present study was to determine the appropriate length of follow-up needed to assess the healing rate after TAFR of high transsphincteric fistulas. METHOD: Between 1992 and 2000 a consecutive series of 80 patients with a high transsphincteric fistula of cryptoglandular origin underwent TAFR. Medical records of all patients were studied. The initial healing rate and the median healing time were assessed. The initial outcome was successful in 54 patients. The medical records revealed that only one of these patients presented with a recurrent fistula after 28 months. The other 53 patients were sent a questionnaire in 2006 aimed to determine whether they had any complaints or signs of a recurrent fistula. RESULTS: The initial healing rate was 68%. The median healing time was 3.6 months. The completed questionnaire was returned by 48 patients. None of these patients reported any complaints or signs of a recurrent fistula. Median duration of follow-up in these patients was 92 months. CONCLUSION: At a median time interval of 3.6 months fistula healing was observed in 54 patients (68%). Only one patient (2%) encountered a recurrence. The length of follow-up can be restricted to the healing time.

Obliteration of the fistulous tract with BioGlue adversely affects the outcome of transanal advancement flap repair.

BACKGROUND: Transanal advancement flap repair (TAFR) is useful in the treatment of high transsphincteric fistulas. Initially, promising results were reported. More recent studies have indicated that TAFR fails in one out of three patients. In almost all of our patients with a failure, we have observed healing of the flap except at the site of the original internal opening. A possible explanation for this remarkable finding might be persistent inflammation in the fistulous tract, finding a way out through the original internal opening. The question is whether obliteration of the fistulous tract by local installation at a surgical adhesive, can prevent persistent inflammation to break through the original opening. The aim of this pilot study was to investigate whether concomitant instillation of BioGlue could improve the healing rate following TAFR for high transsphincteric fistulas. METHODS: Between March 2006 and April 2006 a consecutive series of eight patients (four men, four women; median age 46 years) with a high transsphincteric fistula underwent TAFR after instillation of BioGlue in the fistulous tract. All patients were seen in the outpatient department for postoperative evaluation. RESULTS: Fistula healing was observed in only one patient (12.5%). All other patients experienced one or more of the following complications: prolonged severe pain (n=5), discharge of great amounts of purulent liquid from the external opening (n=3) and abscess formation (n=2), necessitating incision and drainage. Because of this unexpected outcome we decided to terminate the study prematurely. CONCLUSIONS: Our findings indicate that obliteration of the fistulous tract with BioGlue adversely affects the outcome of TAFR for high transsphincteric fistulas.