Subtotal fistulectomy and sliding anoderm flap: A new sphincter-sparing technique for anal fistula.

AIM: The underlying causes of failure or recurrence after ligation of the intersphincteric fistula tract are postulated to be refistulization, breakdown of the closure wound in the intersphincteric plane and faecal contents entering the internal opening, thereby causing recurrent infection. The aim of this study is to demonstrate the outcomes of subtotal fistulectomy with sliding anoderm flaps to prevent refistulization. METHOD: This retrospective study used prospectively collected data. Patients with transsphincteric or intersphincteric fistulas were enrolled between August 2021 and July 2023. An anal manometric study was performed before and after surgery. Faecal incontinence was evaluated using the faecal incontinence severity index (FISI). Failure was defined as nonhealing of the surgical wound or fistula. RESULTS: Fifty-one patients who underwent subtotal fistulectomy with a sliding anoderm flap were included. After a median follow-up of 12 months (range 4-27 months), primary healing was achieved in 49 patients (96%). Two patients experienced treatment failure, while none developed postoperative recurrence. The median healing time was 10 weeks (range 6-24 weeks). The FISI scores did not change significantly after the surgery. The median resting pressure significantly reduced after surgery [125 cmH2O (range 59-204 cmH2O) vs. 99 cmH2O (range 36-176 cmH2O); p = 0.0001]. The median squeeze pressure significantly decreased after surgery [356 cmH2O (range 137-579 cmH2O) vs. 329 cmH2O (range 72-594 cmH2O; p = 0.005)]. CONCLUSION: Subtotal fistulectomy with a sliding anoderm flap showed excellent healing rates with no postoperative deterioration of anal function.

Safety and efficacy of preauricular fistulectomy with fascia-anchoring suture technique: A large case series.

OBJECTIVE: This study aimed to analyze the safety and efficacy of preauricular fistulectomy with fascia-anchoring suture technique through large case series. In addition, differences in surgical outcomes according to preoperative status and age were investigated. METHODS: In this retrospective study, 380 patients (450 ears) with preauricular fistula (PAF) who underwent preauricular fistulectomy with fascia-anchoring suture technique by a single surgeon (E.P) were enrolled. Patients were divided into fresh, previous incision and drainage (I&D), and the revision surgery groups according to the preoperative status. Additionally, they were divided into adult and pediatric groups according to age. Patient's demographics, postoperative infections, and recurrence rates were analyzed. RESULTS: The mean age of the patients was 28.3 years, and there were 119 males and 261 females. Out of 450 PAFs (n = 281 in the fresh groups, n = 119 in the previous I&D groups, and n = 50 in the revision groups), 21 (4.7 %) cases had postoperative infections and 12 (2.7 %) cases had recurrence. There was no difference in postoperative infections, regardless of the preoperative condition (I&D group, p = 0.701; revision group, p = 0.658). The recurrence rate was higher in the revision group than in the fresh and I&D groups (p = 0.004). There was no significant difference in postoperative infection (p = 0.221) or recurrence (p = 0.161) between adults and children. CONCLUSIONS: The study found that performing preauricular fistulectomy with a fascia-anchoring suture technique led to low rates of postoperative infections and recurrences. These positive outcomes were consistent across different patient groups categorized by preoperative status and age, indicating the technique's safety and effectiveness for all patients with preauricular fistulas.

Management of Rectal Wall Abscess: A Rare Case Report.

A 34-year-old male presented with spontaneous rectal pain. He was diagnosed with a posterior rectal wall abscess 7 cm proximal to the anal verge that was confirmed on an MRI (magnetic resonance imaging) pelvis. This abscess was drained through a transrectal route. Rectal wall abscess is an exceedingly rare pathology compared to perianal abscess; therefore, this case highlights the key aspects of its management.

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.

Cutting of sphincter in fistulectomy with primary closure in complex fistula-in-ano: is it feasible?

Introduction: Treatment of complex fistulas such as inter- or transsphincteric, recurrent, and high fistulae have high rate of recurrence or incontinence. Fistulectomy with primary sphincter reconstruction might represent an effective and safe alternative to reduce rate of recurrence and incontinence. The aim of this study is to assess incontinence and recurrence after fistulectomy with primary sphincter reconstruction for management of complex fistulas. Material and Methods: There were 60 patients with complex fistulae involving the sphincter, with 56 male and 4 female, mean age 40.6 years, operated by fistulectomy and primary sphincter repair over a period of 7 years. Patients were followed up for 6months for any complications, recurrence, and incontinence. Results: The majority of patients (50, 83.3%) had complete wound healing in 2 weeks, while 4 (6.6%) patients had hematoma and superficial wound dehiscence, which were managed conservatively and healed in 4 weeks. There was one recurrence. All patients had good continence postoperatively, except for mild fecal incontinence (FI, score 3), seen in 6 (10%) patients. However, all these patients regained continence within 6 weeks. Conclusions: Primary reconstruction of anal sphincter with fistulectomy is a safe option for complex fistula-in-ano. (AU)

[Full-wall semi-circular mobilization of posterior wall of the lower ampullar rectum for complex recurrent anorectal fistula]. / Polnostennaya polutsirkulyarnaya mobilizatsiya zadnei stenki nizhneampulyarnogo otdela pryamoi kishki kak metod lecheniya slozhnykh retsidivnykh anorektal'nykh svishchei.

OBJECTIVE: To describe a new technique for closure of sphincter complex defects after excision of recurrent high rectal fistulas and compare with other traditional techniques. MATERIAL AND METHODS: We retrospectively analyzed patients operated on for recurrent posterior rectal fistula. All patients underwent fistulectomy and one of the methods for defect closure after excision of the fistula: sphincter suturing, muco-muscular flap or full-wall semicircular mobilization of the lower ampullar rectum. The last method implemented the principle of inter-sphincter resection in rectal cancer. We developed this method as an alternative to muco-muscular flap in patients with fibrosis of anal canal to form a full-thickness well-vascularized flap without tissue tension. RESULTS: Between 2019 and 2021, 6 patients underwent fistulectomy with sphincter suturing, 5 patients - closure with muco-muscular flap, 3 males underwent full-wall semicircular mobilization of the lower ampullar rectum. There was a tendency to better continence after a year (1 (0, 1.5), 1 (0, 1.5) and 3 (1, 3) points, respectively). Postoperative follow-up period was 12.5 (10, 15), 12 (9, 15) and 16 (12, 19) months, respectively. None patient had signs of recurrence throughout the follow-up period. CONCLUSION: Original technique can be considered as an alternative to standard approaches in patients with high recurrent posterior anorectal fistulas, when traditional displaced endorectal flap is ineffective or impossible due to excessive scarring and anatomical changes in the anal canal.

Primary sphincter repair after fistulectomy: A simple and safe option for complex fistula-in-ano.

Complete tract excision for complex fistula-in-ano, where the sphincter, is divided is increasingly being followed by immediate sphincter repair. We concluded, by a prospective study conducted on 60 consecutive patients, that this procedure is feasible and safe, and polydioxanone and polyglactin 910 in repair result in a comparable outcome.

Surgery of Simple and Complex Anal Fistulae in Adults: A Review of the Literature for Optimal Surgical Outcomes.

Anal fistulas are common anorectal conditions, and surgery is the primary treatment option. In the last 20 years of literature, there exist a large number of surgical procedures, especially for the treatment of complex anal fistulas, as they present more recurrences and continence problems than simple anal fistulas. To date, there are no guidelines for choosing the best technique. We conducted a recent literature review, mainly the last 20 years, based on the PubMed and Google Scholar medical databases, with the goal of identifying the surgical procedures with the highest success rates, lowest recurrence rates, and best safety profiles. Clinical trials, retrospective studies, review articles, comparative studies, recent systematic reviews, and meta-analyses for various surgical techniques, as well as the latest guidelines of the American Society of Colon and Rectal Surgeons, the Association of Coloproctology of Great Britain and Ireland, and the German S3 guidelines on simple and complex fistulas were reviewed. According to the literature, there is no recommendation for the optimal surgical technique. The etiology, complexity, and many other factors affect the outcome. In simple intersphincteric anal fistulas, fistulotomy is the procedure of choice. In simple low transsphincteric fistulas, the patient's selection is crucial in order to perform a safe fistulotomy or another sphincter-saving technique. The healing rate in simple anal fistulas is higher than 95% with low recurrence and without significant postoperative complications. In complex anal fistulas, only sphincter-saving techniques should be used; the optimal outcomes are obtained by the ligation of the intersphincteric fistulous tract (LIFT) and rectal advancement flaps. Those techniques assure high healing rates of 60-90%. The novel technique of the transanal opening of the intersphincteric space (TROPIS) is under evaluation. The novel sphincter-saving techniques of fistula laser closure (FiLac) and video-assisted anal fistula treatment (VAAFT) are safe, with reported healing rates ranging from 65% to 90%. Surgeons should be familiar with all sphincter-saving techniques in order to face the variability of the fistulas-in-ano. Currently, there is no universally superior technique that can treat all fistulas.

The efficacy of Ksharsutra, Fistulectomy and Ligation of Intersphincteric Fistula Tract (LIFT) procedure in management of Fistula in ano a prospective observational study.

BACKGROUND: Fistula in ano is always a troublesome condition for the clinician and the patients owing to its complexity, recurrences, and high morbidity since ancient times. There is no gold standard treatment modality to date documented in the literature for complex fistula in ano. MATERIAL AND METHODS: We enrolled 60 consecutive adult patients attending the surgical outpatient department of a tertiary care centre in India, diagnosed with complex fistula in ano. Among them, 20 each in the Ligation of intersphincteric fistula tract (LIFT), Fistulectomy andKsharsutra(Special medicated seton) group were respectively recruited randomly. A prospective observational study was conducted. The primary outcomes were postoperative recurrence and morbidity. Post-operative morbidity is measured in terms of postoperative pain, postoperative bleeding, pus discharge and post-operative incontinence. The result of the study were analysed after 6 months of follow-up by clinical examination at outpatient department and at 18 months follow up done telephonically. RESULTS: At 6 months of follow-up, 2 patients (10%) had a recurrence in the Ligation of intersphincteric fistula tract procedure group, 3 patients (15%) in the fistulectomy group and 6 patients (30%) in Ksharsutra group, however 3(15%), 4(20%) and 9(45%) patients developed recurrence in Ligation of Intersphincteric fistula tract, Fistulectomy and Ksharsutra group respectively at 18 month of follow-up. The differences in the recurrence were not statistically significant.The mean Visual analogue score for postoperative pain after 24 h as well as after 48 h were statistically significant in Ligation of intersphincteric fistula tract versus Ksharsutra group (p < 0.05). The Visual analogue score for post-operative pain was also significant in the Ligation of the intersphincteric fistula tract versus the Fistulectomy group (p < 0.05). The patients treated via Fistulectomy and Ksharsutra had a higher proportion of bleeding (15%) as compared to the Ligation of intersphincteric fistula tract procedure. Postoperative morbidity was statistically significant between the Ligation of intersphincteric fistula tract versus the Ksharsutra and the Ligation of intersphincteric fistula tract versus Fistulectomy. CONCLUSION: Ligation of intersphincteric fistula tract had less postoperative morbidity compared to Fistulectomy and Ksharsutra procedure; although recurrence was less compared to other methods it was statistically not significant.

Fistulectomy and primary sphincteroplasty in complex anal fistula treatment: a hospital-based long-term follow-up study.

BACKGROUND: Currently, there is no agreement on the best treatment for complex anal fistulas with the least recurrence and lowest complication rate. The aim of this study was to evaluate the long-term recurrence and incontinence after fistulectomy and primary sphincteroplasty (FIPS) in a group of patients with complex perianal fistula. METHODS: This prospective observational study was done at the colorectal ward of Taleghani Hospital of Tehran from January 2010 to December 2020. Patients with anal fistula who underwent FIPS were studied. After surgery, patients were evaluated regularly by a colorectal surgeon for fistula recurrence and incontinence. Recurrence was described as a new fistula tract formation after the initial cure and failure of healing in the operation site or any purulent discharge from the fistula tract and openings. In addition, the patient's continence was assessed based on the Wexner score. RESULTS: There were 335 patients (66 men and 269 women, mean age 42.74 ± 12.44 years), 191 of them with low fistula and 144 with high fistula. Thirteen patients (3.90%) experienced recurrence (all had a low fistula). Thirty-nine patients (11.64%), 19 patients with high and 20 patients with low fistula, had a Wexner score ≥ 3 during the follow-up. Fifteen patients were lost to follow-up. Male patients (OR = 2.67, 95% CI 0.84, 8.45, p = 0.094, adjusted OR = 4.41, 95% CI 1.05, 18.48, p = 0.042), patients with low fistula (p = 0.001), and recurrent cases had a significantly higher rate of recurrence (OR = 10.38, 95% CI 3.24-33.20 p ≤ 0.001, adjusted OR = 23.36, 95% CI 4.35-125.39, p ≤ 0.001). A significant correlation between body mass index > 35 kg/m2 and incontinence was found (OR = 4.40, 95% CI 1.35, 14.33, p = 0.014). CONCLUSIONS: In the present study, an acceptable healing rate and a low percentage of complications following FIPS were seen in patients with complex anal fistula. Randomized clinical trials with appropriate follow-up duration and sample size comparing different surgical methods in these patients are needed to confirm these results.

Complex Fistula-in-Ano Extending From the Anal Canal to Mid-Thigh Treated With Combine Fistulectomy and Video-Assisted Anal Fistula Treatment (VAAFT): A Case Report.

An anal fistula is abnormal, chronic epithelial-lined communication between the anorectal lumen and the skin of the perineum or buttock. A complex fistula-in-ano is difficult to diagnose and treat; it requires careful approaches because of the high risk of complications and recurrences. We report a case of a 60-year-old male who presented with a discharging sinus on the posteromedial aspect of his left thigh for the past two years. On examination, there were two external openings on the posteromedial aspect of the left thigh, 20 cm away from the anal verge, extending toward the left buttock, with an internal opening on the right side of the anal canal at 11 o'clock in the lithotomy position. The MRI showed a fluid-filled marginally enhancing tract ascending obliquely from the skin of the posterior left thigh, passing through the left gluteus maximus to the bilateral ischioanal fossae. The distal 7 cm tract was excised, as the rest of the tract was deep, passing through the gluteus maximus. Therefore, a video-assisted anal fistula treatment (VAAFT) procedure was done for the remaining tract. The wound was left open for healing by secondary intention. The patient was monitored for six months during which time the wound healed completely.

Treatment of Nine Patients with Refractory Plasma Cell Mastitis by Fistulectomy Combined with Nipple Correction / 临床外科杂志

Objective To investigate the clinical treatment of patients with refractory plasma cell mastitis by fistulectomy combined with nipple correction,observe its clinical efficacy,and analyze its clinical practicability.Methods Nine patients with refractory plasma cell mastitis were treated from August in 2020 to March in 2022.Before operation,fistulectomy and nipple correction were performed after the local inflammation was controlled by oral Chinese medicine.After operation,routine surgical dressing changes were performed,and the clinical efficacy,satisfaction evaluation of postoperative breast appearance and recurrence rate were observed.Results All the nine patients were cured after operation and they were satisfied with their breast shape,and there was no recurrence within one year after operation.Conclusion Fistulectomy combined with nipple correction is a safe and effective method for the treatment of patients with refractory plasma cell mastitis.

Effects of video-assisted anal fistula treatment on stress indicators and anal function in patients with anal fistula / 中国基层医药

Objective:To investigate the effects of video-assisted anal fistula treatment (VAAFT) on stress indicators and anal function in patients with anal fistula.Methods:Ninety-nine patients with anal fistula who received treatment in Lishui City People's Hospital from March 2020 to February 2022 were included in this study. They were randomly divided into a control group ( n = 48, undergoing fistulotomy) and an observation group ( n = 51, undergoing VAAFT). Clinical efficacy and the levels of various indexes during the perioperative period were compared between the two groups. Anal function [anal maximal contraction pressure, anal canal rest pressure, anal longest contraction time, anal incontinence Wexner score], and the levels of serum stress indicators [norepinephrine (NE), β-endorphin (β-EP), nerve growth factor (NGF), substance P (SP), and cortisol (Cor)] were determined before and after treatment. Postoperative complications were recorded. All patients were followed up for 3 months after surgery. Recurrence of anal fistula was compared between the two groups. Results:The total effective rate in the observation group was 94.12% (48/51), which was significantly higher than 79.17% (38/48) in the control group ( χ2 = 4.84, P < 0.05). The operative time, intraoperative blood loss, wound healing time, and length of hospital stay in the observation group were (34.78 ± 4.01) minutes, (34.48 ± 3.86) mL, (19.46 ± 2.05) days, and (12.76 ± 1.50) days, which were significantly shorter or less than those in the control group [(54.86 ± 6.05) minutes, (36.88 ± 4.01) mL, (25.61 ± 2.92) days, (21.05 ± 2.46) days, t = -19.57, -3.03, -12.18, -20.67, all P < 0.05). On the first day after surgery, the Visual Analogue Scale score in the observation was (1.88 ± 0.28) points, which was significantly lower than (3.55 ± 0.41) points in the control group ( t = -23.78, P < 0.05). At 3 months after surgery, anal maximal contraction pressure and Wexner scores in the observation group were (171.86 ± 18.68) mmHg and (0.39 ± 0.07) points, which were significantly lower than (180.37 ± 19.56) mmHg and (0.52 ± 0.09) points in the control group ( t = -2.21, -8.04, both P < 0.05). Anal canal rest pressure in the observation group was (50.77 ± 5.68) mmHg, which was significantly higher than (48.34 ± 5.23) mmHg in the control group ( t = 2.21, P < 0.05). There was no significant difference in anal longest contraction time between the two groups before and after treatment (both P > 0.05). At 3 days after surgery, NE and Cor levels in each group increased compared with those before surgery (both P < 0.05). At 3 days after surgery, NE and Cor levels in the observation group were (252.67 ± 29.16) μg/L and (281.34 ± 31.27) nmol/L, respectively, which were significantly lower than (304.03 ± 32.28) μg/L and (308.72 ± 34.18) nmol/L in the control group ( t = -8.31, -4.16, both P < 0.05). At 3 days after surgery, β-EP, SP, and NGF in each group were decreased compared with those before treatment (all P < 0.05). At 3 days after surgery, β-EP, SP, and NGF in the observation group were (62.37 ± 6.83) ng/L, (1.87 ± 0.23) ng/L, (30.82 ± 4.03) mg/L], respectively, which were significantly higher than (51.09 ± 5.74) ng/L, (2.59 ± 0.51) ng/L, and (38.19 ± 4.24) mg/L in the control group ( t = 8.86, 8.95, 8.85, all P < 0.05). There was no significant difference in the incidence of complications between the two groups ( P > 0.05). The recurrence of anal fistula in the observation group was 1.96% (1/51), which was significantly lower than 12.50% (6/48) in the control group ( χ2 = 4.18, P < 0.05). Conclusion:VAAFT exhibits a significant therapeutic effect on anal fistula, with a small surgical incision and minimal intraoperative bleeding. This procedure greatly shortens operative time and the length of hospital stay, alleviates postoperative pain, improves anal function, reduces postoperative stress response indicators, and has a low postoperative recurrence rate.

Fistulotomy versus Fistulectomy for Fistula-in-Ano: A Randomized Prospective Study.

Background Fistula-in-ano is common surgical ailment yet challenging to treat. Current management remains majorly dependent on two conventional surgical options (fistulotomy and fistulectomy), surgeon's preference, and their experience. Methods This prospective, randomized study was conducted to compare fistulotomy with fistulectomy in the management of patients with simple fistula-in-ano. Fifty patients were recruited and randomized into two groups each containing 25 patients: group I was managed by fistulotomy and group II was managed by fistulectomy. The outcomes of the study include operating time, postsurgery hospital stay, wound healing time, postoperative pain, and postoperative complications. Results Of the 50 patients, 11 (22%) were female and 39 (78%) were male with a mean age of 40.62 ± 12.86 years. The operating time in patients in the fistulotomy group was 21.96 ± 1.90 minutes and in the fistulectomy group was 31.32 ± 2.99 minutes ( p ≤ 0.001). The mean postsurgical hospital stay in the fistulotomy group was 1.32 ± 0.47 days and in the fistulectomy group was 2.32 ± 0.69 days ( p ≤ 0.001), respectively. Mean Visual Analog Scale score was higher in fistulectomy when compared with the fistulotomy at 6 hours and at discharge ( p ≤ 0.05). Postoperative complications were also found to be less in fistulotomy patients compared with patients who underwent fistulectomy. Conclusion In comparison to a fistulectomy, fistulotomy has a slight edge in terms of operating time, postsurgery hospital stay, wound healing time, postoperative pain, and postoperative complications. Fistulotomy yielded better results than fistulectomy and we recommend fistulotomy procedure as a treatment of choice in patients with simple low lying fistula-in-ano.

Fistulectomy and incontinence: do we really need to worry?

Background: Anal fistula is often considered to be a dilemma because of the need to maintain a fine balance between postoperative incontinence and recurrence. We tried to find whether apprehension of causing incontinence should stop us from performing fistulectomy. The aim of this study was to determine whether fistulectomy was associated with increased rate of fecal incontinence and recurrence, compared to other procedures used for the treatment of anal fistula. Methods: It was a prospective, single center, observational study. All patients with anal fistula operated at a tertiary care teaching institute over a period of two years were included in the study. Recurrence rates and fecal incontinence were compared between patients subjected to fistulectomy and other procedures for treatment of fistula in ano. Results: A total of 124 patients with anal fistula were included. 92.8% patients were ≤ 60 years of age with high male preponderance (89.5%). Perineal discharge was the commonest complaint (95.96%). Intersphincteric (47.58%) followed by transphincteric fistulas (45.16%) accounted for the majority of fistulas. Fistulectomy was the most common procedure, performed in 90 (72.58%) patients. Incontinence occurred in 8/90 (8.88%) from the fistulectomy group and 2/34 (5.9%) patients in other surgery group, p=0.726. Recurrence occurred in 8/90 (8.88%) from the fistulectomy group and 8/34 (23.5%) patients from other surgery group, p=0.038. Overall rates of incontinence and recurrence were 8.1% and 12.9% respectively. Conclusion: Fistulectomy, as compared to other procedures, results in less chances of recurrence without compromising continence.

Sphincter-Preserving Fistulectomy Is an Effective Minimally Invasive Technique for Complex Anal Fistulas.

Background: The optimal treatment of complex anal fistulas remains unclear, though many different sphincter-preserving procedures have been described. A minimally invasive technique with a better outcome is desired. The purpose of this study was to present a new technique-sphincter-preserving fistulectomy (SPF) and its clinical outcomes. Materials and Methods: A retrospective study was performed to compare the efficacy and outcomes of SPF with ligation of the intersphincteric fistula tract (LIFT) in the management of complex anal fistulas in regards to postoperative pain, complications, wound healing time, recurrence, overall success rate, fecal continence function, and quality of life. Continence function was evaluated using the Wexner incontinence scale and anal manometry. The fecal incontinence quality of life (FIQL) scale was used to assess patients' quality of life. Results: From June 2020 to July 2021, 41 patients with 43 SPF procedures and 35 patients with 35 LIFT procedures were included. Postoperative pain was comparable between two groups. The morbidity rate and the mean wound healing time in the SPF group were lower than those in the LIFT group (2.3% vs. 48.6%, p < 0.001; 1.4 ± 0.3 vs. 1.7 ± 0.4 months, p = 0.001). At a mean follow-up duration of 11.4 ± 3.5 months in the SPF group and 10.7 ± 4.3 months in the LIFT group, SPF achieved a better overall success rate than LIFT (97.7% vs. 77.1%, p = 0.014). Three patients in the SPF group and 4 patients in the LIFT group who all underwent a simultaneous fistulotomy procedure complained new incontinence of flatus. There was no statistical difference between the two groups in regards to the Wexner scores (p = 0.790), the maximum resting anal canal pressure (p = 0.641), the maximum squeeze pressure (p = 0.289), and the FIQL scores including lifestyle (p = 0.188), coping (p = 0.188), depression (p = 0.850), and embarrassment (p = 0.910). Conclusions: SPF is a novel, safe, and effective minimally invasive technique for the management of complex anal fistulas, with a promising success rate and negligible impairment on continence. Future prospective studies are needed to evaluate the long-term outcomes of SPF.

A PILOT STUDY on the Clinical and Functional Outcomes of an Improvised Technique of Core-cut Fistulectomy for Fistula-in-ano.

BACKGROUND: Anal fistulae are difficult to treat entities and minimally invasive procedures are evolving with promises. Our improvised technique is a simple and easy day-care procedure for simple fistulae. AIM: To evaluate the outcomes of a technical modification in the procedure of core-cut fistulectomy in simple cryptoglandular fistula-in-ano. METHODS: 47 patients of fistula-in-ano presenting to the out-patient of the General Surgery department at All India Institute of Medical Sciences, Bhopal, from November 2018 to March 2020 were selected. A complete history, physical examination followed by relevant investigations were meticulously performed and recorded. They were operated using an improvised core-cut technique, under a pudendal nerve block. Patients were kept on follow-up for a minimum of 6 months period to note the outcome of the surgery. RESULTS: The mean age was 37 ± 13.17 years with a male: female ratio of 5.1:1. The most common clinical presentation was perianal discharge in 96% of patients followed by pain and pruritus ani in 45% and 32%, respectively. 93.62% were inter-sphincteric, and 6.38% were trans-sphincteric. Extra-sphincteric and supra-levator fistulae were excluded from the study. The mean operative time was 17 ± 10.19 minutes. The mean healing time was 19.21 ± 5.99 days. The success rate of this novel technique of core-cut was calculated to be 89.37%. The rate of recurrence was calculated to be 10.63% (5 out of 47 patients). None of our patients developed incontinence. CONCLUSION: Our pilot study results for simple fistulae-in-ano had less morbidity, postoperative pain, better wound healing, patient satisfaction, and compliance with low risk of recurrence, and no incontinence. It could hence be recommended for larger groups and more complicated fistulae in the future.

Coring-out fistulectomy for perianal cryptoglandular fistula: a retrospective cohort study on 20 years of experience at a single center.

Purpose: Cryptoglandular fistula is one of the common anal diseases requiring surgical treatment. Various surgical techniques have been introduced; however, there is no known standard technique. Coring-out fistulectomy is a surgical technique that accurately resects only the fistula tract. However, only a few cases of this procedure have been reported. We aimed to analyze the surgical outcomes of coring-out fistulectomy for cryptoglandular anal fistulas. Methods: We retrospectively reviewed the medical records of patients who underwent coring-out fistulectomy for a cryptoglandular fistula between 1999 and 2019. Primary outcomes were the treatment success rate (recurrence and healing rates) and incidence of fecal incontinence. Results: A total of 184 patients were included in our study. The average age of the patients was 44 years (range, 16-75 years), and 88.0% were male. Twenty-four (13.0%), 13 (7.1%), and 68 patients (37.0%) underwent operation for recurrent fistula, multiple tracts, and complex type fistula, respectively. The healing rate was 92.4%, and recurrence occurred in 15 of 170 healed patients (8.8%). Thus, the treatment success rate was 84.2%. There was no fecal incontinence except in 1 patient who had preoperative fecal incontinence because of cauda equine syndrome. In multivariable analysis of the factors affecting the treatment success rate, the complex fistula (odds ratio [OR], 14.2; 95% confidence interval [CI], 4.7-43.0; P < 0.001) and undetected internal opening during the operation (OR, 4.0; 95% CI, 1.4-11.6; P = 0.012) were significant factors. Conclusion: Coring-out fistulectomy is a simple and feasible technique for sphincter-preserving anal fistula surgery.

The effect of lacrimal drainage abnormality on the surgical outcomes of congenital lacrimal fistula and vice versa.

PURPOSE: To evaluate the various surgical modalities of congenital lacrimal fistula and assess the mutual effect of lacrimal fistula and lacrimal drainage abnormality on the individual surgical outcomes. METHODS: In this retrospective cohort and case-control study, 74 eyes from 63 patients with lacrimal fistula who underwent surgical management between 2000 and 2015 at three medical centers were enrolled. The data collected included sex, age, preoperative symptoms, presence of concurrent lacrimal drainage abnormality, surgical methods, and surgical outcomes. The main outcome measures were treatment outcomes based on lacrimal drainage patency and symptom improvement, surgical outcome of fistulectomy according to the presence of lacrimal drainage abnormality, and surgical outcome of lacrimal drainage abnormality according to the presence of fistula. RESULTS: The mean age at the time of surgery was 9.2 (SD, ±8.8) years and the mean follow-up duration was 14.4 (SD, ±19.5) months. All eyes (37/37) with fistula without lacrimal drainage abnormality demonstrated surgical success after simple fistulectomy. Patients with concurrent lacrimal drainage abnormalities showed more frequent surgical failure than those with fistula alone (p = 0.009). However, the presence of fistula did not affect the outcomes of surgery for lacrimal drainage abnormality (p = 0.179). CONCLUSION: Simple fistulectomy is sufficient for sole asymptomatic or pauci-symptomatic lacrimal fistula. Symptomatic fistula as well as those accompanied with lacrimal drainage abnormality underwent fistulectomy and lacrimal drainage system surgery. Patients with accompanying lacrimal drainage system abnormalities showed less favorable outcomes. Meticulous preoperative examination of the lacrimal drainage system is critical for surgical planning and prognosis prediction.