Current State-of-the Art of Anal Fistula Surgery in Germany.

Document Type : Review Article

Authors

1 Department of Proctological Surgery, Park-Klinik, Kiel, Germany

2 Privatpraxis für Beckenboden-Kontinenzstörungen und Koloproktologie, Düsseldorf, Germany

Abstract

Surgery for anal fistula and abscess is as old as mankind. More than 2000 years ago already procedures were performed and described in old manuscripts. In modern times anal fistula is still a big issue for colorectal surgeons. Only surgery has the ability to heal the patient. The cryptoglandular aetiology: in these glands a septic process starts and this leads to the formation of abscess and fistula. The abscess is the acute, the anal fistula the chronic manifestation of the same disease. Patients with recurrent abscess will have only relieve, when the underlying fistula has been dealt with. Most fistulas are superficial: fistulotomy results in a low recurrence rate and only minor problems concerning faecal continence. The complex fistulas are those, in which fistulotomy produces faecal incontinence. Therefor sphincter saving procedures have been developed. These techniques are described and the pros and cons are discussed. In Germany rectal advancement flap and fistulectomy with primary anal sphincter repair have found their place in the German guideline. In the last 30 years many new techniques have been developed, some are still being used, some are abandoned.
Surgery for anal fistula is demanding: recurrence and faecal incontinence rates should be low. On the other hand: the more recurrences a patient had, the higher the chance of a new recurrence AND the higher the chance of faecal incontinence. Every new septic process in the anal region does not improve anal and pelvic floor function. The colorectal surgeon dealing with complex anal fistula should have more than one option to offer and discuss these with the patient.

Keywords

References

  1. Amir Hossein Faghihi Kashani GH, 2,* Seyde Sedighe Yousefi,3 Rasool Choopani,2, Mohamad Kamalinejad SKV, 5 and Seyed Hamdollah Mosavat6. Effects of “Satureja hortensis L.” on Improving Adult Gastroesophageal

Reflux Disease: A Double-Blinded, Randomized, Controlled Clinical

Trial. Iran Red Crescent Med J. 2018;20(2).

  1. Lunniss PJ, Sheffield JP, Talbot IC, Thomson JP, Phillips RK. Persistence of idiopathic anal fistula may be related to epithelialization. The British journal of surgery. 1995;82(1):32-3.
  2. van Koperen PJ, ten Kate FJ, Bemelman WA, Slors JF. Histological identification of epithelium in perianal fistulae: a prospective study. Colorectal disease : the official journal of the Association of Coloproctology of Great Britain and Ireland. 2010;12(9):891-5.
  3. Ratto C, Litta F, Lucchetti D, Parello A, Boninsegna A, Arena V, et al. Immunopathological characterization of cryptoglandular anal fistula: a pilot study investigating its pathogenesis. Colorectal disease : the official journal of the Association of Coloproctology of Great Britain and Ireland. 2016;18(12):O436-o44.
  4. Shahbaz M, Musa O, Ansari NA. Study on Comparative Analysis on Fistulotomy and Fistulectomy in the Management of Low Anal Fistula %J Iranian Journal of Colorectal Research. 2023;11(1):-.
  5. Bennett RC. A review of the results of orthodox treatment for anal fistulae. Proceedings of the Royal Society of Medicine. 1962;55(9):756-7.
  6. S K. Continence following splitting of an anorectal fistula. Chirurg. 1966;37(2):64-6.
  7. Litta F, Parello A, De Simone V, Grossi U, Orefice R, Ratto C. Fistulotomy and primary sphincteroplasty for anal fistula: long-term data on continence and patient satisfaction. Techniques in coloproctology. 2019;23(10):993-1001.
  8. García-Botello S, Garcés-Albir M, Espi-Macías A, Moro-Valdezate D, Pla-Martí V, Martín-Arevalo J, et al. Sphincter damage during fistulotomy for perianal fistulae and its relationship with faecal incontinence. Langenbeck's archives of surgery. 2021;406(7):2497-505.
  9. Ommer A, Herold A, Berg E, Farke S, Fürst A, Hetzer F, et al. S3-Leitlinie: Kryptoglanduläre Analfisteln. coloproctology. 2017;39(1):16-66.
  10. Soltani A, Kaiser AM. Endorectal advancement flap for cryptoglandular or Crohn's fistula-in-ano. Diseases of the colon and rectum. 2010;53(4):486-95.
  11. García-Olmo D, Gómez-Barrera M, de la Portilla F. Surgical management of complex perianal fistula revisited in a systematic review: a critical view of available scientific evidence. BMC surgery. 2023;23(1):29.
  12. Chaveli Diaz C, Esquiroz Lizaur I, Marzo Virto J, Oteiza Martínez F, Gonzalez Álvarez G, de Miguel Velasco M, et al. Fistulectomy and endorectal advancement flap repair for cryptoglandular anal fistula: recurrence and functional outcome over 10 years of follow-up. International journal of colorectal disease. 2021;36(4):841-6.
  13. Kumar P, Sarthak S, Singh PK, Mishra TS, Sasmal PK. Ligation of Intersphincteric Fistulous Tract vs Endorectal Advancement Flap for High-Type Fistula in Ano: A Randomized Controlled Trial. Journal of the American College of Surgeons. 2023;236(1):27-35.
  14. Bondi J, Avdagic J, Karlbom U, Hallböök O, Kalman D, Šaltytė Benth J, et al. Randomized clinical trial comparing collagen plug and advancement flap for trans-sphincteric anal fistula. The British journal of surgery. 2017;104(9):1160-6.
  15. Zimmerman DD, Gosselink MP, Mitalas LE, Delemarre JB, Hop WJ, Briel JW, et al. Smoking impairs rectal mucosal bloodflow--a pilot study: possible implications for transanal advancement flap repair. Diseases of the colon and rectum. 2005;48(6):1228-32.
  16. Ellis CN, Clark S. Effect of tobacco smoking on advancement flap repair of complex anal fistulas. Diseases of the colon and rectum. 2007;50(4):459-63.
  17. Mei Z, Wang Q, Zhang Y, Liu P, Ge M, Du P, et al. Risk Factors for Recurrence after anal fistula surgery: A meta-analysis. International journal of surgery (London, England). 2019;69:153-64.
  18. Sørensen KM, Möller S, Qvist N. Video-assisted anal fistula treatment versus fistulectomy and sphincter repair in the treatment of high cryptoglandular anal fistula: a randomized clinical study. BJS open. 2021;5(5).
  19. Farag AFA, Elbarmelgi MY, Mostafa M, Mashhour AN. One stage fistulectomy for high anal fistula with reconstruction of anal sphincter without fecal diversion. Asian journal of surgery. 2019;42(8):792-6.
  20. Ratto C, Litta F, Donisi L, Parello A. Fistulotomy or fistulectomy and primary sphincteroplasty for anal fistula (FIPS): a systematic review. Techniques in coloproctology. 2015;19(7):391-400.
  21. De Hous N, Van den Broeck T, de Gheldere C. Fistulectomy and primary sphincteroplasty (FIPS) to prevent keyhole deformity in simple anal fistula: a single-center retrospective cohort study. Acta chirurgica Belgica. 2021;121(5):308-13.
  22. Rojanasakul A, Pattanaarun J, Sahakitrungruang C, Tantiphlachiva K. Total anal sphincter saving technique for fistula-in-ano; the ligation of intersphincteric fistula tract. Journal of the Medical Association of Thailand = Chotmaihet thangphaet. 2007;90(3):581-6.
  23. Bleier JI, Moloo H, Goldberg SM. Ligation of the intersphincteric fistula tract: an effective new technique for complex fistulas. Diseases of the colon and rectum. 2010;53(1):43-6.
  24. Wallin UG, Mellgren AF, Madoff RD, Goldberg SM. Does ligation of the intersphincteric fistula tract raise the bar in fistula surgery? Diseases of the colon and rectum. 2012;55(11):1173-8.
  25. Aboulian A, Kaji AH, Kumar RR. Early result of ligation of the intersphincteric fistula tract for fistula-in-ano. Diseases of the colon and rectum. 2011;54(3):289-92.
  26. Liu WY, Aboulian A, Kaji AH, Kumar RR. Long-term results of ligation of intersphincteric fistula tract (LIFT) for fistula-in-ano. Diseases of the colon and rectum. 2013;56(3):343-7.
  27. Emile SH, Garoufalia Z, Aeschbacher P, Horesh N, Gefen R, Wexner SD. Endorectal advancement flap compared to ligation of inter-sphincteric fistula tract in the treatment of complex anal fistulas: A meta-analysis of randomized clinical trials. Surgery. 2023;174(2):172-9.
  28. Madbouly KM, El Shazly W, Abbas KS, Hussein AM. Ligation of intersphincteric fistula tract versus mucosal advancement flap in patients with high transsphincteric fistula-in-ano: a prospective randomized trial. Diseases of the colon and rectum. 2014;57(10):1202-8.
  29. Vander Mijnsbrugge GJH, Felt-Bersma RJF, Ho DKF, Molenaar CBH. Perianal fistulas and the lift procedure: results, predictive factors for success, and long-term results with subsequent treatment. Techniques in coloproctology. 2019;23(7):639-47.
  30. Wilhelm A, Fiebig A, Krawczak M. Five years of experience with the FiLaC™ laser for fistula-in-ano management: long-term follow-up from a single institution. Techniques in coloproctology. 2017;21(4):269-76.
  31. Frountzas M, Stergios K, Nikolaou C, Bellos I, Schizas D, Linardoutsos D, et al. Could FiLaC™ be effective in the treatment of anal fistulas? A systematic review of observational studies and proportional meta-analysis. Colorectal disease : the official journal of the Association of Coloproctology of Great Britain and Ireland. 2020;22(12):1874-84.
  32. Lauretta A, Falco N, Stocco E, Bellomo R, Infantino A. Anal Fistula Laser Closure: the length of fistula is the Achilles' heel. Techniques in coloproctology. 2018;22(12):933-9.
  33. Elfeki H, Shalaby M, Emile SH, Sakr A, Mikael M, Lundby L. A systematic review and meta-analysis of the safety and efficacy of fistula laser closure. Techniques in coloproctology. 2020;24(4):265-74.
  34. Adegbola SO, Sahnan K, Pellino G, Tozer PJ, Hart A, Phillips RKS, et al. Short-term efficacy and safety of three novel sphincter-sparing techniques for anal fistulae: a systematic review. Techniques in coloproctology. 2017;21(10):775-82.
  35. Pommaret E, Benfredj P, Soudan D, de Parades V. Sphincter-sparing techniques for fistulas-in-ano. Journal of visceral surgery. 2015;152(2 Suppl):S31-6.
  36. Queralto M, Portier G, Bonnaud G, Chotard JP, Cabarrot P, Lazorthes F. Efficacy of synthetic glue treatment of high crypoglandular fistula-in-ano. Gastroenterologie clinique et biologique. 2010;34(8-9):477-82.
  37. Vollebregt PF, Vander Mijnsbrugge GJ, Molenaar CBH, Felt-Bersma RJF. Efficacy of Permacol injection for perianal fistulas in a tertiary referral population: poor outcome in patients with complex fistulas. Colorectal disease : the official journal of the Association of Coloproctology of Great Britain and Ireland. 2021;23(8):2119-26.
  38. de la Portilla F, Muñoz-Cruzado MVD, Maestre MV, García-Cabrera AM, Reyes ML, Vázquez-Monchul JM, et al. Platelet-rich plasma (PRP) versus fibrin glue in cryptogenic fistula-in-ano: a phase III single-center, randomized, double-blind trial. International journal of colorectal disease. 2019;34(6):1113-9.
  39. Meinero P, Mori L. Video-assisted anal fistula treatment (VAAFT): a novel sphincter-saving procedure for treating complex anal fistulas. Techniques in coloproctology. 2011;15(4):417-22.
  40. Chase TJG, Quddus A, Selvakumar D, Cunha P, Cuming T. VAAFT for complex anal fistula: a useful tool, however, cure is unlikely. Techniques in coloproctology. 2021;25(10):1115-21.
  41. Zarin M, Khan MI, Ahmad M, Ibrahim M, Khan MA. VAAFT: Video Assisted Anal Fistula Treatment; Bringing revolution in Fistula treatment. Pakistan journal of medical sciences. 2015;31(5):1233-5.
  42. Emile SH, Elfeki H, Shalaby M, Sakr A. A Systematic review and meta-analysis of the efficacy and safety of video-assisted anal fistula treatment (VAAFT). Surgical endoscopy. 2018;32(4):2084-93.
  43. Tian Z, Li YL, Nan SJ, Xiu WC, Wang YQ. Video-assisted anal fistula treatment for complex anorectal fistulas in adults: a systematic review and meta-analysis. Techniques in coloproctology. 2022;26(10):783-95.
  44. Moreno-Serrano A, García-Díaz JJ, Ferrer-Márquez M, Alarcón-Rodríguez R, Álvarez-García A, Reina-Duarte Á. Using autologous platelet-rich plasma for the treatment of complex fistulas. Revista espanola de enfermedades digestivas. 2016;108(3):123-8.
  45. Pérez Lara FJ, Hernández González JM, Ferrer Berges A, Navarro Gallego I, Oehling de Los Reyes H, Oliva Muñoz H. Can Perianal Fistula Be Treated Non-surgically with Platelet-Rich Fibrin Sealant? Journal of gastrointestinal surgery : official journal of the Society for Surgery of the Alimentary Tract. 2019;23(5):1030-6.
  46. Eberspacher C, Mascagni D, Ferent IC, Coletta E, Palma R, Panetta C, et al. Mesenchymal Stem Cells for Cryptoglandular Anal Fistula: Current State of Art. Frontiers in surgery. 2022;9:815504.
  47. Cwaliński J, Hermann J, Paszkowski J, Banasiewicz T. ASSESSMENT OF RECURRENT ANAL FISTULAS TREATMENT WITH PLATELET-RICH PLASMA. Arquivos de gastroenterologia. 2021;58(2):185-9.
  48. Wang Y, Rao Q, Ma Y, Li X. Platelet-rich plasma in the treatment of anal fistula: a systematic review and meta-analysis. International journal of colorectal disease. 2023;38(1):70.
  49. Prosst RL, Joos AK, Ehni W, Bussen D, Herold A. Prospective pilot study of anorectal fistula closure with the OTSC Proctology. Colorectal disease : the official journal of the Association of Coloproctology of Great Britain and Ireland. 2015;17(1):81-6.
  50. Mascagni D, Pironi D, Grimaldi G, Romani AM, La Torre G, Eberspacher C, et al. OTSC® Proctology vs. fistulectomy and primary sphincter reconstruction as a treatment for low trans-sphincteric anal fistula in a randomized controlled pilot trial. Minerva chirurgica. 2019;74(1):1-6.
  51. Prosst RL, Joos AK. Short-term outcomes of a novel endoscopic clipping device for closure of the internal opening in 100 anorectal fistulas. Techniques in coloproctology. 2016;20(11):753-8.
  52. Attaallah W, Uprak TK, Kara B, Sen A, Tuney D, Yegen C. Chemical Ablation for Treating Anal Fistulas without Surgical Intervention: Long-Term Results. Surgical innovation. 2021;28(6):731-7.
  53. Jacob TJ, Perakath B, Keighley MR. Surgical intervention for anorectal fistula. The Cochrane database of systematic reviews. 2010(5):Cd006319.
  54. Placer-Galán C, Enriquez-Navascués JM, Lopetegui AE, Ansorena YS. An analysis of randomized controlled trials on anal fistula conducted between 2000 and 2020 based on the Fragility Index and Reverse Fragility Index. Colorectal disease : the official journal of the Association of Coloproctology of Great Britain and Ireland. 2023;25(8):1572-7.
  55. Iqbal N, Machielsen A, Kimman ML, Kane G, Woodcock R, Grossi U, et al. AFCOS: The Development of a Cryptoglandular Anal Fistula Core Outcome Set. Annals of surgery. 2022;277(5):e1045-50.
  56. Sainio P, Husa A. Fistula-in-ano. Clinical features and long-term results of surgery in 199 adults. Acta chirurgica Scandinavica. 1985;151(2):169-76.
  57. Garcia-Aguilar J, Belmonte C, Wong WD, Goldberg SM, Madoff RD. Anal fistula surgery. Factors associated with recurrence and incontinence. Diseases of the colon and rectum. 1996;39(7):723-9.
  58. Sygut A, Zajdel R, Kedzia-Budziewska R, Trzciński R, Dziki A. Late results of treatment of anal fistulas. Colorectal disease : the official journal of the Association of Coloproctology of Great Britain and Ireland. 2007;9(2):151-8.
  59. ML C. Colon and Rectal Surgery. In: Lippincott WW, Philadelphia., editor. 5th ed2005. p. 295.
  60. Bordeianou L. Bad news on glues: fibrin glue success rates in the treatment of anal fistulas. Inflammatory bowel diseases. 2008;14(1):134-5.
Iranian Journal of Colorectal Research
Volume 11, Issue 2
June 2023
Pages 55-64

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