Complex anal fistulas are difficult to treat.The main reasons for this are a higher recurrence rate and the risk of disrupting the continence mechanism because of sphincter involvement.Due to this,several sphincter-sp...Complex anal fistulas are difficult to treat.The main reasons for this are a higher recurrence rate and the risk of disrupting the continence mechanism because of sphincter involvement.Due to this,several sphincter-sparing procedures have been developed in the last two decades.Though moderately successful in simple fistulas(50%-75%healing rate),the healing rates in complex fistulas for most of these procedures has been dismal.Only two procedures,ligation of intersphincteric fistula tract and transanal opening of intersphincteric space have been shown to have good success rates in complex fistulas(60%-95%).Both of these procedures preserve continence while achieving high success rates.In this opinion review,I shall outline the history,compare the pros and cons,indications and contraindications and future application of both these procedures for the management of complex anal fistulas.展开更多
Management of the complex anal fistula represents a perennial challenge to surgeons.Conventional approaches often upset the balance between recurrence prevention and continence preservation with their high failure rat...Management of the complex anal fistula represents a perennial challenge to surgeons.Conventional approaches often upset the balance between recurrence prevention and continence preservation with their high failure rates and significant associated morbidity.The emergence of minimally invasive treatment in recent years,however,offers a promising paradigm shift.Regenerative solutions like autologous stem cell therapy or fistula plugs with extracellular and synthetic matrices represent new frontiers in anal fistula treatment,harnessing physiological regenerative capacities and avoiding the traditional postoperative burden of open wounds,drains,or setons in situ.Together with novel techniques like fistula laser closure,video-assisted fistula treatment,or over-the-scope clip burgeoning over the last decade,these state-of-the-art approaches have been touted for their total sphincter-sparing nature,preserving functional outcomes and quality of life.Despite gaining much scientific and clinical momentum,do these newer modalities live up to their promise?This review aims to critically appraise the latest evidence surrounding minimally invasive approaches,providing up-todate insights into the constantly evolving landscape of anal fistula management.Further long-term and comparative studies will nevertheless be needed to supplement the significantly heterogenous,retrospective analyses consolidated.展开更多
Anal fistula is among the most common illnesses affecting man.Medical literature dating back to 400 BC has discussed this problem.Various causative factors have been proposed throughout the centuries,but it appears th...Anal fistula is among the most common illnesses affecting man.Medical literature dating back to 400 BC has discussed this problem.Various causative factors have been proposed throughout the centuries,but it appears that the majority of fistulas unrelated to specific causes (e.g.Tuberculosis,Crohn’s disease) result from infection (abscess) in anal glands extending from the intersphincteric plane to various anorectal spaces.The tubular structure of an anal fistula easily yields itself to division or unroofing (fistulotomy) or excision (fistulectomy) in most cases.The problem with this single,yet effective,treatment plan is that depending on the thickness of sphincter muscle the fistula transgresses,the patient will have varying degrees of fecal incontinence from minor to total.In an attempt to preserve continence,various procedures have been proposed to deal with the fistulas.These include: (1) simple drainage (Seton);(2) closure of fistula tract using fibrin sealant or anal fistula plug;(3) closure of primary opening using endorectal or dermal flaps,and more recently;and (4) ligation of intersphincteric fistula tract (LIFT).In most complex cases (i.e.Crohn’s disease),a proximal fecal diversion offers a measure of symptom-atic relief.The fact remains that an "ideal" procedure for anal fistula remains elusive.The failure of each sphincter-preserving procedure (30%-50% recurrence) often results in multiple operations.In essence,the price of preservation of continence at all cost is multiple and often different operations,prolonged disability and disappointment for the patient and the surgeon.Nevertheless,the surgeon treating anal fistulas on an occasional basis should never hesitate in referring the patient to a specialist.Conversely,an expert colorectal surgeon must be familiar with many different operations in order to selectively tailor an operation to the individual patient.展开更多
Fistula-in-ano is a difficult problem that physicians have struggled with for centuries.Appropriate treatment is based on 3 central tenets: (1) control of sepsis;(2) closure of the fistula;and (3) maintenance of conti...Fistula-in-ano is a difficult problem that physicians have struggled with for centuries.Appropriate treatment is based on 3 central tenets: (1) control of sepsis;(2) closure of the fistula;and (3) maintenance of continence.Treatment options continue to evolve-as a result,it is important to review old and new options on a regular basis to ensure that our patients are provided with up to date information and options.This paper will briefly cover some of the traditional approaches that have been used as well as some newer promising procedures.展开更多
文摘Complex anal fistulas are difficult to treat.The main reasons for this are a higher recurrence rate and the risk of disrupting the continence mechanism because of sphincter involvement.Due to this,several sphincter-sparing procedures have been developed in the last two decades.Though moderately successful in simple fistulas(50%-75%healing rate),the healing rates in complex fistulas for most of these procedures has been dismal.Only two procedures,ligation of intersphincteric fistula tract and transanal opening of intersphincteric space have been shown to have good success rates in complex fistulas(60%-95%).Both of these procedures preserve continence while achieving high success rates.In this opinion review,I shall outline the history,compare the pros and cons,indications and contraindications and future application of both these procedures for the management of complex anal fistulas.
文摘Management of the complex anal fistula represents a perennial challenge to surgeons.Conventional approaches often upset the balance between recurrence prevention and continence preservation with their high failure rates and significant associated morbidity.The emergence of minimally invasive treatment in recent years,however,offers a promising paradigm shift.Regenerative solutions like autologous stem cell therapy or fistula plugs with extracellular and synthetic matrices represent new frontiers in anal fistula treatment,harnessing physiological regenerative capacities and avoiding the traditional postoperative burden of open wounds,drains,or setons in situ.Together with novel techniques like fistula laser closure,video-assisted fistula treatment,or over-the-scope clip burgeoning over the last decade,these state-of-the-art approaches have been touted for their total sphincter-sparing nature,preserving functional outcomes and quality of life.Despite gaining much scientific and clinical momentum,do these newer modalities live up to their promise?This review aims to critically appraise the latest evidence surrounding minimally invasive approaches,providing up-todate insights into the constantly evolving landscape of anal fistula management.Further long-term and comparative studies will nevertheless be needed to supplement the significantly heterogenous,retrospective analyses consolidated.
文摘Anal fistula is among the most common illnesses affecting man.Medical literature dating back to 400 BC has discussed this problem.Various causative factors have been proposed throughout the centuries,but it appears that the majority of fistulas unrelated to specific causes (e.g.Tuberculosis,Crohn’s disease) result from infection (abscess) in anal glands extending from the intersphincteric plane to various anorectal spaces.The tubular structure of an anal fistula easily yields itself to division or unroofing (fistulotomy) or excision (fistulectomy) in most cases.The problem with this single,yet effective,treatment plan is that depending on the thickness of sphincter muscle the fistula transgresses,the patient will have varying degrees of fecal incontinence from minor to total.In an attempt to preserve continence,various procedures have been proposed to deal with the fistulas.These include: (1) simple drainage (Seton);(2) closure of fistula tract using fibrin sealant or anal fistula plug;(3) closure of primary opening using endorectal or dermal flaps,and more recently;and (4) ligation of intersphincteric fistula tract (LIFT).In most complex cases (i.e.Crohn’s disease),a proximal fecal diversion offers a measure of symptom-atic relief.The fact remains that an "ideal" procedure for anal fistula remains elusive.The failure of each sphincter-preserving procedure (30%-50% recurrence) often results in multiple operations.In essence,the price of preservation of continence at all cost is multiple and often different operations,prolonged disability and disappointment for the patient and the surgeon.Nevertheless,the surgeon treating anal fistulas on an occasional basis should never hesitate in referring the patient to a specialist.Conversely,an expert colorectal surgeon must be familiar with many different operations in order to selectively tailor an operation to the individual patient.
文摘Fistula-in-ano is a difficult problem that physicians have struggled with for centuries.Appropriate treatment is based on 3 central tenets: (1) control of sepsis;(2) closure of the fistula;and (3) maintenance of continence.Treatment options continue to evolve-as a result,it is important to review old and new options on a regular basis to ensure that our patients are provided with up to date information and options.This paper will briefly cover some of the traditional approaches that have been used as well as some newer promising procedures.
