Current Therapy of Cryptoglandular Anal Fistula: Gold Standards and Alternative Methods. / Therapie der kryptograndulären Analfisteln: aktuelle Goldstandards und Alternativen.

Cryptoglandular anal fistulas are one of the most common colorectal diseases and occur with an incidence of about 20/100,000. Anal fistulas are defined as an inflammatory junction between the anal canal and the perianal skin. They develop from an abscess or chronic infection of the anorectum. Surgical treatment of the disease is the method of choice. Even when treating an acute abscess, its cause should be sought at the same time. If there is a connection to the anal canal without affecting relevant parts of the sphincter muscles, primary fistulotomy should be performed. If larger parts of the sphincter muscle are involved, the insertion of a seton drain is usually useful. There are essentially two recommendations for the elective treatment of cryptoglandular anal fistulas. Distal fistulas should be excised, with the proviso that as little sphincter muscle as possible is sacrificed. In the case of highly proximally located and complex fistulas, sphincter-preserving surgical techniques should be used. In this case, the method of choice is the mucosal or advancement flap. Alternatively, clips, fibrin injections, fistula plugs, fistula ligatures, or laser-based procedures are described in the literature. In the case of intermediate fistulas, a fistulectomy with primary sphincter reconstruction can be useful. Every operation is carried out as a compromise between definitive healing of the fistula and a potential risk to the patient's continence. It is often difficult to make a reliable prognosis about the continence function to be expected postoperatively. In addition to the fistula morphology, particular attention should be paid to whether previous proctological operations have already been performed, the gender of the patient, and whether there are pre-existing sphincter dysfunctions. Since the surgeon's expertise plays a decisive role in the success of the treatment, the procedure should be carried out in a specialist proctological centre, especially in the case of complex fistulas or in the case of a condition after previous operations. In addition to the classic procedures, such as fistulectomy or the plastic fistula closure, this article examines alternative methods and their areas of application.

Enteral resorbable diet versus standard diet in primary sphincter reconstruction: a prospective randomised trial.

AIM: Bowel movements after reconstructive anorectal surgery may negatively affect surgical outcome. This study was aimed to assess any differences between a standard diet (SD) and the enteral resorbable diet (ED) in terms of operative outcomes and patient tolerance after fistulectomy with primary sphincter reconstruction. METHOD: Adult patients undergoing elective fistulectomy with primary sphincter reconstruction for anorectal and rectovaginal fistulas were eligible for inclusion. Patients were intraoperatively randomised to receive either the ED and peristalsis-inhibiting medication (ED) or a SD. The primary endpoint was the healing rate. Secondary endpoints included continence scores, complications and quality of life. Sample size calculation resulted in the analysis of 60 patients to detect a difference in fistula recurrence of 30% with 70% power and a 5% significance level. RESULTS: Sixty-six patients (24 women) were prospectively and randomly assigned to the ED (n = 34: 51%) or a SD (n = 32; 48%); mean age was 47 (18-74) years. The primary healing rate was 64 out of 66 patients (96%). No statistical difference in healing rate was seen between the groups. However, patient satisfaction was significantly higher in the SD group (P < 0.0001). CONCLUSIONS: Fistulectomy with primary sphincter reconstruction is a safe method with low complication rates. Postoperative stool behaviour has no significant influence on the healing rate but has a significant negative impact on patient satisfaction. Therefore, maintaining a standard diet seems to be preferable following reconstructive anal surgery. TRIAL REGISTRATION: The trial was registered with the German Clinical Trials Register ( DRKS00020524 ).

Retrospective analysis of mepivacaine, prilocaine and chloroprocaine for low-dose spinal anaesthesia in outpatient perianal procedures.

PURPOSE: Perianal procedures are carried out in an outpatient setting regularly. The purpose of this retrospective analysis was to investigate the impact of different local anaesthetics (LA) for spinal anaesthesia (SPA) on operating room (OR) efficiency (perioperative process times, turnaround times) and postoperative recovery. This study aims on the determination of the optimal LA for low-dose SPA in the specific setting of a high-volume day-surgery centre. METHODS: Anaesthesia records of all patients undergoing perianal outpatient surgery under saddle-block SPA at the Mannheim University Medical Centre from 2008 until 2017 were analysed. Patients were categorized as having received prilocaine, mepivacaine or chloroprocaine. RESULTS: Two thousand seven hundred forty-six patients were included. Postoperative recovery was faster for chloroprocaine 1% compared with both other LAs. Preoperative processes but not process times in the OR were shorter for chloroprocaine. In contrary, turnaround times were significantly prolonged when chloroprocaine had been used, leading to reduction of OR efficiency. CONCLUSION: Low-dose SPA provides reliable blocks for perianal surgery. Considerations on the choice of LA for SPA must include not only the recovery profile, but also the impact on OR efficiency. Due to shorter turnaround times and a manageable prolonged duration of stay, prilocaine is the preferable LA for low-dose SPA in perianal outpatient surgery at a high-volume day-surgery centre.

Management of retrorectal supralevator abscess-results of a large cohort.

PURPOSE: Proximal intersphincteric fistulas with proximal extension causing supralevatoric, retrorectal abscesses are a rare disease. There is only very limited experience, with small groups, and the limited published literature confirms the complexity of diagnostics and treatment. The aim of this study was to evaluate transrectal internal abscess drainage as planned definitive treatment. METHODS: We retrospectively studied medical records of all patients with the diagnosis of retrorectal abscesses that underwent transrectal internal abscess drainage in the Department of Colo-proctology of the University Medical Centre Mannheim (2003-2012). RESULTS: One hundred nine patients were operated on retrorectal abscesses, 70 (64.2%) men and 39 (35.8%) women. Mean age was 45.3 years (18-81). In 96 cases (88.1%), only a transrectal internal abscess drainage was performed as planned definitive treatment. Primary healing occurred in 60 patients (62.5%). A second transrectal internal drainage procedure was necessary in 27 cases (28.1%) to assure complete internal drainage. All secondary procedures led to subsequent healing. A combined surgical treatment due to coexisting fistula tracts to the perianal skin or additional ischioanal abscesses was required in 13 patients (11.9%), and an additional seton placement was performed. Nine patients (9.4%) underwent one or more reoperations due to previously unidentified complex coexisting fistulas. Most of these patients were immunosuppressed due to Crohn's disease. Internal drainage alone was successful in 90.6% with an overall healing rate of 94.5% for the entire population of complex fistulas. CONCLUSIONS: Transrectal internal abscess drainage is a safe and highly successful procedure for treatment of retrorectal abscess, with very low risk of postoperative fecal incontinence. Inflammatory bowel disease and immunosuppressives have a negative impact on the healing process.

Fistulectomy with primary sphincter reconstruction.

AIM: Despite modern medical techniques, anatomically proximal (high) anal fistulas are still a challenge in colorectal surgery. In previous years, the standard of care was complete fistulectomy with a high rate of continence disorders. Over the past 20 to 30 years, sphincter-saving procedures have gained wide acceptance. They represent the technique used in these cases. Additionally, many patients received indefinite treatment, namely the placement of a seton to maintain surgical drainage. The main problem with all fistula surgical possibilities is the high recurrence rate of 30 to 50% in flap procedures and 100% persistence in seton treatments. In recent years, a direct repair (primary reconstruction) in distal fistulas was instigated and shows excellent results. It allowed our technique for proximal (high) anal fistulas to evolve. METHOD: All patients who underwent surgery at the University Medical Center Mannheim, Department of Colo-proctology (from 06/2003 to 11/2015), were retrospectively evaluated using a prospective database. Patients who underwent fistulectomy with primary sphincter reconstruction were all included. RESULTS: The primary healing rate, after a mean follow-up of 11 months (7 to 200 months), was 88.2% (374 of 424). Taking into account revisionary surgeries with secondary sphincter repair, this rate reaches 95.8% (406 of 424). Factors such as gender and fistula location as related to the sphincter had significant influence on the study outcome, whereas variables such as the amount of reconstructed muscle (in mm), number of revisions, patient age, other anal operations, and concomitant medication did not. The incontinence of a subgroup of 148 patients was evaluated in detail by way of a questionnaire. Even at a preoperative baseline, 9.6% of those patients reported some minor degree of continence disorders. After the procedure, incontinence disorders were observed in 34 patients (23.0%), with 23 of these patients suffering from flatus incontinence (15.5%), 10 patients from liquid incontinence (6.8%), and 1 patient from solid fecal incontinence. CONCLUSION: Fistulectomy with primary sphincter reconstruction is a feasible procedure resulting in a low recurrence rate. No other procedure has shown better results in transsphincteric fistulas. Continence disorders seem to be of minor relevance/consequence for these patients.

Randomised clinical trial of pilonidal sinus operations performed in the prone position under spinal anaesthesia with hyperbaric bupivacaine 0.5 % versus total intravenous anaesthesia.

PURPOSE: The aim of this randomised clinical trial was to determine whether spinal anaesthesia (SPA) is superior to total intravenous anaesthesia (TIVA) in patients undergoing pilonidal sinus (PS) operations in the prone position. METHODS: After approval of the local ethics committee, suitable patients aged 19-49 years were randomised to SPA (7.5 mg hyperbaric bupivacaine) or TIVA (Propofol and Fentanyl). Cumulative consumption of analgesics, postoperative recovery, complications and patient satisfaction were evaluated. RESULTS: A total of 50 patients were randomised within a 24-month period. Median monitoring time in the recovery room was 0 (0-11) min for SPA versus 40 (5-145) min for TIVA (p < 0.0001). Patients in the SPA group were able to drink (40.5 (0-327) min versus TIVA 171 (72-280) min, p < 0.0001) and eat (55 (0-333) min versus TIVA 220 (85-358), p < 0.0001) earlier. More patients with a TIVA needed analgesics in the recovery room (SPA n = 0 versus TIVA n = 6, p = 0.0023) and suffered more frequently from a sore throat (SPA n = 0 versus TIVA n = 11, p = 0.0001). Two patients with a TIVA suffered from nausea and vomiting. Patients of both groups were equally satisfied with the anaesthesia technique offered. CONCLUSIONS: SPA with 7.5 mg hyperbaric bupivacaine is superior to TIVA in patients undergoing PS operations in the prone position in terms of analgesia consumption in the recovery room, recovery times and postoperative complications.

Efficacy and safety of sclerotherapy with polidocanol foam in comparison with fluid sclerosant in the treatment of first-grade haemorrhoidal disease: a randomised, controlled, single-blind, multicentre trial.

PURPOSE: Sclerotherapy is the treatment of choice for first-grade haemorrhoidal disease. Numerous studies have shown that sclerotherapy with foamed sclerosants is more efficacious than liquid in the treatment of varicose veins. The aim of this study was to assess the efficacy and safety of polidocanol foam in comparison with liquid for haemorrhoidal disease. METHODS: A total of 130 patients were randomised to foam or liquid sclerotherapy (polidocanol 3%). Patients with first-grade haemorrhoidal disease were included and blinded to treatment assignment. The primary endpoint was the stopping of perianal bleeding after one sclerotherapy session. Sclerotherapy was repeated until patients were free of bleeding (2-week intervals). The final follow-up was 12 weeks after the last sclerotherapy session. RESULTS: In the foam group, significantly more patients (88%) were treated successfully after one sclerotherapy session compared to the liquid group (69%; p = 0.01). There was high patient satisfaction in both groups, but significantly more patients were satisfied with their treatment in the foam group than in the liquid group (99 vs. 84%; p = 0.009). Additionally, in the foam group, significantly less treatment sessions were required (p < 0.001), and the total amount of injected polidocanol was reduced (p < 0.001). CONCLUSION: In the therapy of first-grade haemorrhoidal disease, polidocanol 3 % foam is more effective and equally safe compared to liquid polidocanol. The results of this trial show that foam sclerotherapy is a new, innovative, effective and safe non-surgical treatment option for haemorrhoidal disease.

Influence of the pre-operative time in upright sitting position and the needle type on the incidence of post-dural puncture headache (PDPH) in patients receiving a spinal saddle block for anorectal surgery.

BACKGROUND: A spinal saddle block can be a safe method for anorectal surgery with a low rate of complications when performed with the right technique. A dreaded complication is the post-dural puncture headache (PDPH), which can be decreased by the use of non-cutting spinal needles. Regrettably, cutting Quincke (Q)-type needles are still widely used for economic reasons. Besides size and design of a spinal needle, the pre-operative time in upright sitting position may also influence the incidence of PDPH after spinal saddle block. METHODS: Within 4 months, 363 patients undergoing anorectal surgery in saddle block technique were randomised to receive either a 27-gauge (G) pencil-point (PP) or a 27-G Q spinal needle and were pre-operatively left in upright sitting position for 10 or 30 min, respectively. The incidence of PDPH was assessed 1 week after the operation via a telephone interview. RESULTS: Three hundred sixty three patients (219 males/144 females) were analysed. Fifteen patients (4.1%) developed PDPH. Patients receiving spinal anaesthesia with a Q needle suffered significantly more frequently from PDPH [Q: n = 12 (6.6%) vs. PP: n = 3 (1.7%), p = 0.02], but there was no association between PDPH and pre-operative time in the upright position (p = 0.20). CONCLUSIONS: These data prove that using 27-G PP needles is the method with the fewest side effects caused by spinal saddle block, and suggest that the time spent sitting in the upright position is not clinically relevant.

Influence of the vascular endothelial growth factor on the development of severe pre-eclampsia or HELLP syndrome.

PURPOSE: The aim of this study was to compare the maternal serum concentrations of the vascular endothelial growth factor (VEGF) in patients whose pregnancies were complicated by pre-eclampsia or HELLP syndrome with those of healthy pregnant controls and to study its relationship with the hormonal and nutritive function of the placenta. METHODS: The study group consisted of 30 primaparae who suffered from either severe pre-eclampsia (n = 16) or from HELLP syndrome (n = 14). 30 healthy pregnant woman of the same gestational age served as control group. Maternal serum VEGF concentrations were determined by using a commercially available Sandwich immunoassay (Quantikine(®), R&D Systeme, Wiesbaden, Germany). Estradiol, estriol and progesterone serum levels were measured by performing a radioimmunoassay (Biermann, Bad Nauheim, Germany). RESULTS: The mean serum VEGF concentration of the study group (172.0 ± 98.9 pg/ml) was significantly increased, compared with the mean serum VEGF concentration of the control group (41.4 ± 30.5 pg/ml) (U test: P < 0.001). In the subgroup of the study patients with HELLP syndrome, significantly lower VEGF levels were measured than in patients suffering from severe pre-eclampsia (109.2 ± 68.5 pg/ml vs. 219.0 ± 72.9. U test: P < 0.05). In all study and control patients, a significantly positive correlation between serum estradiol and VEGF concentration could be found (Spearman's rank correlation: P < 0.05). CONCLUSIONS: An increased placental expression due to local hypoxia and an increased extraplacental production, e.g., in endothelial cells of the fetal or maternal vascular system, in macrophages or in smooth muscle cells, could be discussed as causes for the raised serum VEGF concentration in patients suffering from severe pre-eclampsia or HELLP syndrome.

High incidence of post-dural puncture headache in patients with spinal saddle block induced with Quincke needles for anorectal surgery: a randomised clinical trial.

PURPOSE: Spinal saddle block represents nearly the ideal anaesthesia technique for anorectal surgery. Post-dural puncture headache (PDPH) is a dreaded complication but can be decreased by the use of non-cutting spinal needles to rates less than 1%. Though, cutting Quincke type needles are still widely used for economic reasons, leading to a higher rate of PDPH. We performed this study to demonstrate a reduction of PDPH by the use of very small 29-G compared with commonly used 25-G Quincke type spinal needles. METHODS: Two hundred sixteen adult patients (male/female, 19-83 years, ASA status I-III) were randomised 1:1 to groups, in which either a 25-G or a 29-G Quincke type spinal needle was used for a spinal saddle block. The incidence of PDPH was assessed during 1 week after surgery. RESULTS: Thirty-nine of 216 patients developed PDPH but there was no difference between the two needle sizes (25-G, n = 18/106 vs. 29-G, n = 21/110, p = 0.6870). Women suffered significantly more from PDPH than men (23/86 vs. 16/130, p = 0.0069). Ambulatory patients had a later onset of PDPH than in-patients (24 h [0.5-72] vs. 2 h [0.2-96], p = 0.0002) and the headache was more severe in these patients (NRS 7 [2-10] vs. NRS 3 [1-8], p = 0.0009). CONCLUSIONS: The use of 29-G compared with 25-G Quincke needles led to no reduction of PDPH and is considerably higher compared with data from pencil-point needles. The use of non-cutting or pencil-point spinal needles should become the standard for performing spinal saddle block.

Influence of sedation on patients' perceptions and recovery in patients undergoing minor perianal procedures under spinal saddle block.

OBJECTIVES: Additional intra-operative sedation may help improve acceptability and comfort of anaesthesia in patients undergoing minor anorectal (perianal) procedures under spinal saddle block. This observational study was done to determine which patients request sedatives and to what extent sedatives affect the patients' recovery. SUBJECTS AND METHODS: During a 6-month period, 500 patients undergoing minor perianal procedures received 1.0 ml hyperbaric bupivacaine (0.5%). On request, a light sedation with propofol in bolus application was provided. Patients were evaluated postoperatively using a standardized questionnaire about their perceptions before, during and 48 h after the administration of anaesthesia. RESULTS: More female (91/143, 63.6%) than male (136/259, 52.5%) patients (p = 0.0312) received sedation. Patients with sedation were significantly younger (46.7 +/- 13.8 vs. 50 +/- 13.8 years, p = 0.0171) and had a lower body mass index (BMI; 25.6 +/- 4.3 vs. 27.5 +/- 5.1, p < 0.0001). Time to mobilization and first micturition was significantly longer in patients with sedation (4.8 vs. 4.4 h, p = 0.0194 and 5.8 vs. 5.4 h, p = 0.0188), which was associated with a higher incidence of nausea (7.5 vs. 1.7%, p = 0.0083). CONCLUSIONS: Female gender, younger age, lower body weight and lower BMI were associated with higher subjective requirements for sedation. The use of sedation showed prolongation of time to first mobilization and micturition and a higher incidence of nausea.

Practicability and patients' subjective experiences of low-dose spinal anaesthesia using hyperbaric bupivacaine for transanal surgery.

PURPOSE: The safety, effectiveness and long lasting post-operative analgesia make spinal anaesthesia in saddle block technique an "ideal" method for transanal surgery. To improve patient satisfaction and offer reliable operation conditions to surgeons, this study quantifies practicability and patients' subjective experiences with this technique. METHODS: Within a 5-month period, 400 consecutive patients undergoing transanal surgery in saddle block technique were evaluated by a standardised questionnaire. RESULTS: The success rate of spinal anaesthesia was 99.5%. Side effects occurred far less frequently as mentioned in the literature. The duration of the sensory block was about twice as long as the time until first mobilisation and micturition. Despite some negative experiences during the procedure, 92% of the investigated patients would choose a saddle block again. CONCLUSIONS: Both from reasons of practicability and from patients' view, spinal anaesthesia in saddle block technique can be thoroughly recommended for transanal surgery. Patients undergoing a stapler haemorrhoidectomy should receive additional opioids.

Severe pyomyositis caused by Panton-Valentine leucocidin-positive methicillin-sensitive Staphylococcus aureus complicating a pilonidal cyst.

BACKGROUND: To our best knowledge, Panton-Valentine leucocidin (PVL)-positive methicillin-sensitive Staphylococcus aureus (MSSA) has not been described yet as cause for severe pyomyositis. CASE REPORT: We present a 23-year-old apparently healthy male patient without any typical predisposing findings who developed severe pyomyositis secondary to an operated pilonidal cyst. In the follow-up, the patient showed signs of immunocompromisation. The causative agent for purulent infection of multiple muscles was a MSSA strain harbouring PVL toxin. RESULTS: In the reported case, aggressive antibiotic and surgical treatment with additional application of immunoglobulins has lead to recovery from the disease without relapse. CONCLUSIONS: PVL-positive S. aureus are associated with skin diseases, multiple abscesses and often complicated by severe sepsis and necrotising pneumonia. Under such circumstances, the mortality rate can reach up to 75%. In addition, the PVL toxin can cause immunocompromisation and might be therefore involved in the aetiology of pyomyositis. Aggressive antibiotic and surgical treatment with additional application of immunoglobulins is recommended for treatment.

Endoscopic ultrasound-guided transrectal biopsies of pelvic tumors.

The aim of this study was to evaluate the feasibility, safety, and diagnostic accuracy of endorectal ultrasound-guided biopsies in patients with extrarectal lesions. Data from all patients with suspicious pelvic pathology who underwent endorectal ultrasound-guided biopsies were collected prospectively. To evaluate the accuracy of the diagnosis, all patients with benign histology but primary suspicion of a malignant lesion were followed up for at least 12 months. A total of 48 patients whose median age was 66 years were evaluated. Apart from one postbiopsy hemorrhage, which was managed conservatively, no other complications were encountered. Sufficient tissue was removed to allow histologic examination in all cases. A large variety of diagnoses including primary and secondary malignancies (n = 25) as well as benign pathologies (n = 23) could be established. There were no false positive but three false negative histologies in patients with proven local recurrence of a malignant tumor during the follow-up period. This results in a sensitivity of 88%, specificity of 100%, positive predictive value of 100%, and negative predictive value of 89%. It is concluded that endoscopic ultrasound-guided transrectal biopsy is a safe method with a high diagnostic accuracy in the assessment of pelvic tumors.

DeloRes trial: study protocol for a randomized trial comparing two standardized surgical approaches in rectal prolapse - Delorme's procedure versus resection rectopexy.

BACKGROUND: More than 100 surgical approaches to treat rectal prolapse have been described. These can be done through the perineum or transabdominally. Delorme's procedure is the most frequently used perineal, resection rectopexy the most commonly used abdominal procedure. Recurrences seem more common after perineal compared to abdominal techniques, but the latter may carry a higher risk of peri- and postoperative morbidity and mortality. METHODS/DESIGN: DeloRes is a randomized, controlled, observer-blinded multicenter trial with two parallel groups. Patients with a full-thickness rectal prolapse (third degree prolapse), considered eligible for both operative methods are included. The primary outcome is time to recurrence of full-thickness rectal prolapse during the 24 months following primary surgery. Secondary endpoints are time to and incidence of recurrence of full-thickness rectal prolapse during the 5-year follow-up, duration of surgery, morbidity, hospital stay, quality of life, constipation, and fecal incontinence. A meta-analysis was done on the basis of the available data on recurrence rates from 17 publications comprising 1,140 patients. Based on the results of a meta-analysis it is assumed that the recurrence rate after 2 years is 20% for Delorme's procedure and 5% for resection rectopexy. Considering a rate of lost to follow-up without recurrence of 30% a total of 130 patients (2 x 65 patients) was calculated as an adequate sample size to assure a power of 80% for the confirmatory analysis. DISCUSSION: The DeloRes Trial will clarify which procedure results in a smaller recurrence rate but also give information on how morbidity and functional results compare. TRIAL REGISTRATION: German Clinical Trial Number DRKS00000482.