Objective To investigate the safety and effectiveness of the operation of integrate subparagraph, fenestration, exclusion, cut expansion, seton, tube, and drainage (ISFECSTD) to cure complex anal fistula. Methods Using randomized comparison and multicenter parallel experiment, the total number was 240: 120 patients in study group treated by ISFECSTD, and 120 patients in control group treated by extended cutting and seton operation. Then compared the safety and effectiveness between two groups. Results The clinical recovery rate of the study group was significantly higher than that in the control group （Plt;0.05）. The operation time and wound healing time in study group were significantly less than those in control group, and the scar area after wound healing was smaller than that in control group （Plt;0.01）. The decreased extents of anorectal pressures and rectal capacity feeling function after operation in study group were smaller than those in control group (Plt;0.01). Rectal and anal reflex function and healing of the endostoma, stem, and branch in study group were better than those in control group (Plt;0.05, Plt;0.01). Incidence of anal incontinence after operation in study group was significantly less than that in of anus-rectum structure and function, and has the merits of higher cure rate, shorter time of healing, smaller scar, less pain, etc. The method of ISFECSTD is worth being a new standardized operation in the clinical application.
Objective To trace and review the treatment of complex anal fistula so as to consider whether current procedures and therapies might offer a better choice. Methods Through the literature collected, with the difficulties and contradictions of the treatment of complex anal fistula as the starting point, the currently widely used seton management, the development and deficiency of biological therapy and sphincter preserving surgery, and the change of treatment model of complex anal fistula were reviewed. The research progress and application prospect of intersphincteric fistula ligation was focus attented. Results The treatment of complex anal fistula would be not too much emphasis of healing or radical cure, and more attention to the anus function, shape, fine feeling, and quality of life, has become a consensus. The seton management remained an useful therapy for the treatment of complicated anal fistula through continuous improvement and development, in despite of it has postoperative relapse or mild to moderate anal incontinence. Biotherapy relied on its minimal invasion rising in recent years especially at abroad, but it is limited wider application in China because of its high cost, unstable efficacy, and high recurrence rate. Sphincter-preserving operation always attracts attentions particularly under the background of invasive treatment. It has been already established about efficacy and security of the ligation of intersphincteric fistula tract as a novel procedure, which possessed an excellent advantage for protecting anal continence. Conclusion The ligation of intersphincteric fistula tract is a promising procedure, which tends to be superior than fistulotomy and seton management, may become a first-line treatment of complex anal fistula.
Objective To summarize the research progression of video-assisted anal fistula treatment (VAAFT). Methods The related literatures in recent years were reviewed, and then the operation principle, operation process, advantages and disadvantages, matters needing attention, and clinical application of VAAFT were summarized. Results VAAFT is the treatment of fistulas by endoscopy. It don’t require the incision or resection of the fistula. It has the advantages of less surgical trauma, faster postoperative recovery, and less impact on the anal sphincter. The disadvantage of this method is relatively strict indications, fistula bending or horseshoe fistula is not suitable for this method. In addition, the endoscope using during the operation is a rigid mirror tube, and the operation is not convenient enough, so technical improvement is needed in the future. We should pay attention to distinguish true fistula and false fistula in clinical practice; the wall of the fistula should be adequately burned and the necrotic tissue should be cleaned; the treatment of the internal opening of anal fistula must be exact; the time of the first defecation should be appropriately delayed, and the incidence of infection should be reduced after operation. At present, the clinical reports of VAAFT are increasing gradually in foreign countries, and these reports have achieved good therapeutic effect. It is considered that this method maybe a safe and effective minimally invasive surgical treatment for anal fistula. However, there is few clinical reports on VAAFT in China, and it is still in the preliminary stage of exploration. Conclusion VAAFT is a new technology in the treatment of anal fistula, and it has advantages of minimally invasive, sphincter preservation, and so on, which is worthy of clinical application.
Objective To explore the effect of local injection of high concentration of glucose when removing setons of perianal fistulizing in Crohn’s disease (CD). Methods Thirty cases of CD combined with anal fistula admitted to the Affiliated Hospital of Nanjing University of Chinese Medicine from August 2015 to July 2017 were collected prospectively, 12 cases were divided into experimental group and 18 cases were divided into control group. Cases of the experimental group received demolition of drainage seton+IFX+local injection of high concentration of glucose treatment, cases of the control group received the drainage setons removing+IFX only. Before treatment, and at 6, 14, 22, and 30 weeks after IFX treatment, the laboratory indicators of the 2 groups were detected, and BMI, Crohn’s diseaseactivity index (CDAI), perianal disease activity index (PDAI), and clinical efficacy were evaluated. Results Therewas no significant difference on the group effect and interaction of group and time (P>0.05), but time (P<0.05). Both in the experimental group and the control group, compared with before treatment group, the counts of WBC and platelet, levels of C reaction protein (CRP) and erythrocyte sedimentation rate (ESR), CDAI, and PDAI at 6 months after IFX therapy decreased and maintained at the latter period, but the level of hemoglobin (Hb) and BMI increased at 6 weeks after IFX therapy and maintained at the latter period. On the clinical effect, there was no significant difference at the time points of 14, 22, and 30 weeks of IFX therapy (P>0.05). Conclusion The treatment of local injection of high concentration of glucose when removing setons has not shown any positive effect to CD combined with anal fistula, this conclusion needs to be further studied.
Objective To explore the clinical characteristics of Crohn’s disease (CD) with perianal fistula by analyzing the clinical data of them. Methods A total of 139 cases of CD with perianal fistula who got treatment from January 2010 to January 2017 in The Affiliated Hospital of Nanjing University of Traditional Chinese Medicine were analyzed retrospectively. Results The proportion of males and females in 139 patients was about 3.3∶1.0, the age was (28±8) years, and 47.5% of patients had perianal fistula before CD diagnosis. The percents of patients with perianal surgery history and medication history were 64.7% and 74.1%, respectively. The ratio of L3 type (diseased position) was 49.6%. The ratios of inflammatory type (B1 type) and stenotic type (B2 type) of the disease were 51.8% and 41.0%, respectively. The complex perianal fistula accounted for 90.6%, and 31.7% of patients combined analrectal stricture. Symptoms of diarrhea were found in 46.0% of patients and perianal lesions alone in 29.5% of patients; 54.0% of patients combined with abnormal BMI; 64.7% of patients were in the active stage of Crohn’s disease activity index (CDAI) and 94.2 % of patients were in the active period of perianal disease activity index (PDAI). The patients with erythrocyte sedimentation rate (ESR) higher than normal were 53.2%. The results of logistic showed that, age and degree of CDAI were influencing factors for CD with stenosis of perianal fistula. Conclusions Characteristics of patients with CD combined with perianal fistula include: young, men predominant, high prevalence of ileocolic position involvement, as well as inflammation and stenosis disease behavior. Fistula symptoms often preced the intestinal symptoms and diarrhea is the most common intestinal performance. History of perianal abscess and fistula operation are common. The anorectal stricture are complicated usually. Intestinal inflammation is active. Some patients show abnormal laboratory indicators of inflammation. This suggests that patients with perianal fistula with these clinical features should be alert to the possibility of CD, so as toavoid the consequences of blind surgery. The higher CDAI score and the older the diagnosis age, the higher the risk ofrectal stenosis.
ObjectiveTo investigate long-term efficacy of infliximab (IFX) combined with seton placement in treatment of perianal fistulizing Crohn disease (CD) and to analyze factors affecting its clinical healing and recurrence.MethodsThe patients with perianal fistulizing CD underwent the IFX combined with seton placement therapy from July 2010 to January 2017 were collected from the HIS database of the Affiliated Hospital of Nanjing University of Traditional Chinese Medicine. The healing and recurrence of perianal fistulizing CD were counted and their influencing factors were analyzed.ResultsA total of 103 patients with perianal fistulizing CD were included in the study. After a median follow-up of 36 months, 64 patients (62.1%) had a complete fistula healing, 34 patients (33.0%) relapsed. The cumulative recurrence rates of fistula in the 1, 3, and 5 years was 21.8%, 32.6%, and 37.4%, respectively. The multivariate analysis showed that the Montreal classification B1 ［HR=3.987, 95% CI (1.640, 9.694), P=0.023］ and without abscess ［HR=2.724, 95% CI (1.101, 6.740), P=0.030］ were positively associated with the long-term healing of fistula, and the IFX maintenance treatment >3 times ［HR=5.497, 95% CI (1.197, 25.251), P=0.028］ was a risk factor for the recurrence of the fistula.ConclusionsLong-term healing rate of fistula by IFX combined with seton placement therapy is higher. Montreal classification B1, without abscess, and IFX maintenance treatment less than 3 times are expected to have a better long-term efficacy.
ObjectiveTo understand progress of stem cell transplantation in treatment of complex anal fistula.MethodThe relevant literatures were searched in the PubMed, Web of Science, CNKI, Wanfang, and other databases and the clinical efficacy, advantages and problems of the therapy were analyzed and summarized.ResultsThe stem cells currently used in the field of complex anal fistula were mainly the adipose tissue-derived stem cells, which had the biological characteristics of regenerative differentiation, immune regulation, and repair of intestinal mucosal barrier, which could be used as the seed cells for the treatment of complex anal fistula, its effectiveness was worthy of recognition. But its long-term clinical efficacy remained to be seen due to its clinical treatment options were different and lack of uniform standards. The safety of treatment for complex anal fistula was payed a attention because the stem cells had the oncogene activation and tumor suppressor gene inactivation characteristics.ConclusionsStem cell transplantation, as an emerging therapy, has broad prospects for patients with complex anal fistula that are difficult to solve by surgery, but its long-term efficacy is still unsatisfactory. Due to current sample size, short observation time, and lack of randomized control, current clinical data is not convincing, and high cost also limits its development of technology.
ObjectiveTo explore the clinical efficacy and safety of ligation of intersphincteric fistula tract in the treatment of high simple anal fistula.MethodsA prospective collection of 72 patients diagnosed with high simple anal fistula, who admitted to the department of the author’s hospital between March 2015 and December 2017 was performed, and then the patients were divided into two groups according to the random number table method combined with the patients’ wishes: the ligation of intersphincteric fistula tract group (experimental group, 32 cases) and the low incision and high hanging group (control group, 40 cases). Comparison of indexes on the operative effect and physiological function of the sphincter in six months after operation was performed.ResultsCompared with the control group, the patients in the experimental group had short postoperative pain duration, short postoperative wound healing time, high cure rate, low recurrence rate, low initial sensory threshold, high anal resting pressure, and long anal high pressure band length, with statistically significant differences (P<0.05). However, there was no statistically significant difference between the two groups in the operation time, anal maximal contractive pressure, and rectal resting pressure (P>0.05). The results suggested that the physiological function of anus in the experimental group recovered well.ConclusionThe ligation of intersphincteric fistula tract is a safe and reliable method in the treatment of high simple anal fistula, which can be widely used in the clinic.
ObjectiveTo investigate effect of preoperative three-dimensional anorectal endosonography (3D-AREUS) in anal fistula surgery.MethodsA total of 100 patients with anal fistula who were admitted to the Chaoyang Central Hospital from December 2017 to December 2018 were included prospectively, then were randomly divided into ultrasound group and control group with 50 cases in each group. The preoperative examination was performed by 3D-AREUS in the ultrasound group, and preoperative routine examination, finger examination or probe exploration were performed in the control group. The postoperative recurrence and anal functions were compared between the two groups.ResultsThere were no statistically significant differences in the gender, age, body mass index, anal surgery history, preoperative anal function, etc. between the two groups (P>0.05). The detection rate of branch fistulas in the ultrasound group was significantly higher than that in the control group (P=0.025). For the patients with complex anal fistula, compared with the control group, the location accuracy rate of internal opening was higher (P=0.014), the change value of preoperative and postoperative fecal incontinence score was lower (P=0.039), anorectal pressure status (resting pressure of anal canal, anal systolic pressure, and length of anal high pressure zone) were lower (P<0.05) in the ultrasound group; For the patients with simple anal fistula, which had no significant differences between the ultrasound group and control group (P>0.05). There were 4 cases of recurrence in each group.ConclusionsFor complex anal fistula, preoperative 3D-AREUS could clarify position of internal opening, presence of branching fistula, and the relationship between fistula and sphincter, so as to make accurate surgical plans, reduce secondary injuries, and retain postoperative anal function of patients.
ObjectiveTo observe the effect of modified ligation of intersphincteric fistula tract (LIFT) combined with acellular anal fistula repair matrix packing in the treatment of high anal fistula, and to evaluate its clinical efficacy and safety.MethodsAll 86 patients who met the diagnostic criteria of high anal fistula in Beijing Anorectal Hospital from October 2018 to August 2019 were selected and randomly divided into observation group and control group. The observation group was treated with modified LIFT combined with acellular anal fistula repair matrix tamponade, while the control group was treated with traditional low incision and high thread drawing surgery. The curative effect, wound healing time, postoperative pain score, intraoperative blood loss, postoperative complications, hospitalization time, patient satisfaction and recurrence at 6 months after operation were compared between the two groups.ResultsThe effective rate of the observation group was 92.9% (39/42), and that of the control group was 86.4% (38/44), there was no significant difference between the two groups (Z=−1.251, P=0.211). The healing time of the observation group and the control group were (24.8±8.5) days and (32.1±10.9) days, respectively, the difference was statistically significant (t=3.472, P<0.001). Compared with the control group, the observation group had less intraoperative blood loss, less postoperative pain and shorter hospital stay (P<0.05). There was no anal incontinence after operation in the two groups, and the incidence of postoperative complications such as bloody stool, anal border edema and urinary retention were lower in the observation group (11.9%) compared with the control group (31.8%), with a statistically significant difference (P<0.05). The treatment satisfaction of the observation group was 90.5%, and that of the control group was 81.8%. There was no significant difference between the two groups (Z=−1.284, P>0.05).ConclusionModified LIFT combined with acellular anal fistula repair matrix in the treatment of high anal fistula has the advantages of small trauma, quick recovery and low incidence of complications.