Outcomes of anal fistula surgery in patients with inflammatory bowel disease

doi:10.1016/j.amjsurg.2010.01.007

The American Journal of Surgery

Volume 199, Issue 5, May 2010, Pages 609-613

https://doi.org/10.1016/j.amjsurg.2010.01.007 Get rights and content

Abstract

Background

Anal fistulas in patients with Crohn's disease are especially difficult to manage because of nonhealing and incontinence. We reviewed our outcomes for the newer sphincter-preserving techniques of anal fistula plug and fibrin glue compared with standard treatments of advancement flap closure and seton drain insertion.

Methods

This was a retrospective study of patients with inflammatory bowel disease treated for high transsphincteric anal fistulas. The primary outcome was healing and continence at 12 weeks postoperatively.

Results

Between 1997 and 2009, 51 patients with anal fistulas and inflammatory bowel disease were identified in the St Paul's Hospital Anal Fistula Database. Postoperative healing rates at 12 weeks for the fistula plug, fibrin glue, flap advancement, and seton drain groups were 75%, 0%, 20%, and 28%, respectively. Continence scores were not altered by these procedures.

Conclusions

Closure of the primary fistula opening in patients with inflammatory bowel disease using a biologic anal fistula plug had improved healing compared with fibrin glue, seton drain, and flap advancement. Given its low morbidity and relative simplicity, the anal fistula plug should be considered for treating high transsphincteric anal fistulas in patients with inflammatory bowel disease.

Section snippets

Methods

All IBD patients treated for anal fistulas by a single colorectal surgeon at St Paul's Hospital, University of British Columbia, from January 1997 to January 2009, were identified from a database.

Simple fistulas were defined as low fistulas including subcutaneous, intersphincteric, and low transsphincteric fistulas. Low transsphincteric fistulas involved the lower third of the external anal sphincter mechanism. Conversely, complex anal fistulas were defined as Crohn's fistulas, low compromised

Results

Fifty-one patients with high transsphincteric fistulas concomitant with IBD were included. Table 1 shows demographic information. The median age was 39 years (range, 21–66 y). There was no significant difference in age or sex between the treatment groups.

Healing rates at week 12 in patients with IBD are reported in Table 2 and range from 0% for fibrin glue to 75% for the fistula plug. Healing rates were not statistically significantly different between the 4 treatment groups. Healing rates at

Comments

Complex fistulas are notoriously difficult to manage and particularly so in patients with Crohn's disease. The tendency for nonhealing and nonsphincterotomy strategies including long-term seton drains results in a poor chance of permanent fistula closure in these patients. We retrospectively evaluated healing of high transsphincteric anal fistulas in IBD patients using the newer treatment techniques (fistula plug and fibrin glue), comparing them with conventional treatments (flap advancement

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Cited by (39)

Surgical options for perianal fistula in patients with Crohn's disease: A comparison of seton placement, fistulotomy, and stem cell therapy
2021, Asian Journal of Surgery
Citation Excerpt :
CD patients with perianal fistulas have high primary non-healing, morbidity, and recurrence rates. Closure rates following treatment have also been reported to vary.7 For example, the closure rate of seton placement alone was 17%, whereas the closure rate following combined treatment with seton placement and an anti-TNF agent was 45%.8
This study was designed to assess the demographic characteristics of patients with Crohn's perianal fistula (CPF) who were treated at a tertiary referral institution. Surgical outcomes were compared in groups of patients who underwent seton placement, fistulotomy, and stem cell therapy.
Patients who underwent surgery for CPF between 2015 and 2017 at Asan Medical Center, Seoul, Korea, were retrospectively evaluated. Patients were divided into groups who underwent seton placement, fistulotomy, and stem cell therapy. Their clinical variables and closure rates were compared.
This study included 156 patients who underwent a total of 209 operations. More than half of the operations consisted of seton placement (67%), followed by stem cell therapy (18%) and fistulotomy (15%) patients. Of the 209 fistulas, 153 (73%) were complex, with an overall closure rate of 38% during a median follow-up of 29 months. Closure rates following fistulotomy, stem cell therapy, and seton placement were 90%, 70%, and 18%. Seton placement was more significantly frequently used than the other procedures in patients with complex fistula and those with abscesses. Of the 79 fistulas that achieved complete closure, 11 (14%) recurred. The recurrence rates did not differ among the various techniques.
Surgical treatment of CPF is dependent on lesion type. Seton placement was the primary draining procedure for complex fistulas and abscesses, resulting in low closure rates. Fistulotomy was the definite procedure for low type and simple fistula. Stem cell therapy showed high closure rates as definitive treatment, even for complex fistulas.
Advances in Perianal Disease Associated with Crohn's Disease-Evolving Approaches
2019, Gastrointestinal Endoscopy Clinics of North America
Assessment of fistulectomy combined with sphincteroplasty in the treatment of complicated anal fistula
2017, Journal of Coloproctology
Citation Excerpt :
Insertion of cutting seton was evaluated in many studies, in which healing rate was reported between 80% and 100% and impaired continence rates after the surgery were between 0% and 92%.23–25 Besides, endorectal advancement flap was evaluated with the healing rate between 33% and 100% and incontinence rate between 0% and 71%.26–31 Recently, the newer techniques such as fibrin glue and collagen plug are offered.
The ideal method of treating the complex anal fistula is to eradicate the sepsis and preserve the anal sphincter; since there is no definite consensus on the surgical method of treating it. Recent studies show that fistulectomy and immediate sphincteroplasy are a safe and appropriate way to treat the fistula-in-ano. The aim of this study was to evaluate the long term outcomes of fistulectmy and sphincteroplasty in the treatment of complex perianal fistula.
In this prospective study, we have analyzed the data of 80 patients who underwent fistulectomy and sphincteroplasty from May 2013 to May 2016. Preoperative information included physical examination, preoperative fecal incontinence evaluation and taking a complete history about underlying diseases and past related surgeries were collected.
Of all 80 patients with complex fistula, 57.5% (46 patients) were male. 70-Patients were presented with high transsphincteric fistula (87.5%) and anterior fistula was diagnosed in 10 of them (12.5%). 9 patients (11.3%) suffered from hypertension and 43 patients (53.75%) had recurrent fistula after previous surgeries. During the follow-up period, the overall success rate was 98.8% (98.8%) and fistulectomy and sphincteroplasty failed in only one patient (failure rate: 1.3%). preoperative and post-operative scoring showed mild fecal incontinence in 8 patients (10%). We have found no significant relation between the age, gender, hypertension, previous surgery and post-operative recurrence.
Fistulectomy and sphincteroplasty is a safe surgical procedure in the treatment of anterior anal fistula in females and high transsphincteric fistulas.
o método ideal para tratar a fístula anal complexa consiste em erradicar a sepse e preservar o esfíncter anal, uma vez que não existe consenso definitivo com relação ao método cirúrgico para tratamento desse problema. Estudos recentes demonstram que a fistulectomia, seguida imediatamente pela esfincteroplastia, é procedimento seguro e apropriado no tratamento da fístula perianal. O objetivo deste estudo foi avaliar os resultados em longo prazo da fistulectomia e da esfincteroplastia no tratamento da fístula perianal complexa.
Neste estudo prospectivo analisamos os dados de 80 pacientes tratados por fistulectomia e esfíncteroplastia no período de maio de 2013 até maio de 2016. Foram coletadas as seguintes informações pré-operatórias: exame físico, avaliação pré-operatória de incontinência fecal e história completa sobre doenças subjacentes e cirurgias prévias afins.
De todos os 80 pacientes com fístula complexa, 57,5% (46 pacientes) pertenciam ao gênero masculino. Setenta pacientes se apresentaram com fístula trans-esfinctérica alta (87,5%); em 10 desses pacientes (12,5%), foi diagnosticada fístula anterior. Nove pacientes (11,3%) sofriam de hipertensão (HT), tendo sido observada recorrência de fístula após cirurgias prévias em 43 pacientes (53,75%). Durante o período de seguimento, o percentual de sucesso global foi de 98,8%, e em apenas um paciente os procedimentos de fistulectomia e esfincteroplastia não obtiveram sucesso (percentual de falha: 1,3%). Os escores pré-operatórios e pós-operatórios revelaram incontinência fecal leve em 8 pacientes (10%). Não observamos nenhuma relação significativa entre idade, gênero, HT, cirurgia prévia e recorrência pós-operatória.
Fistulectomia e esfincteroplastia constituem procedimento cirúrgico seguro no tratamento de fístulas anais anteriores em mulheres e de fístulas trans-esfinctéricas altas.
Anal abscess and fistula
2013, Gastroenterology Clinics of North America
Citation Excerpt :
Fistulas can occur at any age but the average age is 39 years.18 Perianal fistulizing disease affects up to 30% of patients with Crohn disease.19 A fistula is defined as an abnormal communication between 2 epithelialized surfaces; anal fistula represents a communication between the anorectal canal and the perianal skin.20
Perianal fistulas in Crohn’s disease (review)
2023, Koloproktologia
Flap techniques—still state of the art today?
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The North Pacific Surgical AssociationOutcomes of anal fistula surgery in patients with inflammatory bowel disease

Abstract

Background

Methods

Results

Conclusions

Section snippets

Methods

Results

Comments

Gastroenterology

Am J Surg

Gastroenterology

Perianal Crohn's disease

Br J Surg

Closing fistulas in Crohn's disease—should the accent be on maintenance or safety?

N Engl J Med

The North Pacific Surgical Association
Outcomes of anal fistula surgery in patients with inflammatory bowel disease