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Anorectal Abscess and Fistula
Published in Peter Sagar, Andrew G. Hill, Charles H. Knowles, Stefan Post, Willem A. Bemelman, Patricia L. Roberts, Susan Galandiuk, John R.T. Monson, Michael R.B. Keighley, Norman S. Williams, Keighley & Williams’ Surgery of the Anus, Rectum and Colon, 2019
Most intersphincteric fistulas have a simple low and linear tract, running downward in the intersphincteric plane to the anal verge. In most cases, appropriate treatment of these fistulas is fistulotomy, provided this does not involve a large segment of the internal anal sphincter. During this procedure, the entire fistulous tract is laid open from the external opening to the internal opening. This implies division of the lower part of the internal anal sphincter (Figure 11.45 in 3rd edition). This procedure is very effective at treating the fistula, and the risk of continence disturbances has in the past been considered to be minimal. This is true with regard to major incontinence, but not for minor incontinence. Toyonaga and co-workers conducted a prospective, observational study in 148 patients who underwent fistulotomy for an intersphincteric fistula.40 After a mean follow-up of 12 months, the healing rate was found to be 97 percent. One of every five patients encountered minor continence disturbances, mainly soiling and incontinence for gas. The authors demonstrated that maximum anal resting pressure was significantly decreased after fistulotomy, whereas maximum anal squeeze pressure was not affected. Multivariate analysis showed low maximum anal squeeze pressure and multiple previous drainage procedures to be independent risk factors for these post-operative minor continence disturbances.
The anus and anal canal
Published in Professor Sir Norman Williams, Professor P. Ronan O’Connell, Professor Andrew W. McCaskie, Bailey & Love's Short Practice of Surgery, 2018
Professor Sir Norman Williams, Professor P. Ronan O’Connell, Professor Andrew W. McCaskie
Management of acute anorectal sepsis is primarily surgical, including careful examination under anaesthesia, sigmoidoscopy and proctoscopy, and adequate drainage of the pus. For perianal and ischiorectal sepsis (with an incidence of 60% and 30%, respectively), drainage is through the perineal skin, usually through a cruciate incision over the most fluctuant point, with excision of the skin edges to deroof the abscess (Figure 74.39). Pus is sent for microbiological culture (Grace) and tissue from the wall is sent for histological appraisal to exclude specific causes. With a finger in the anorectum to avoid creation of a false opening, the cavity is carefully curetted. A gentle search may be made for an underlying fistula if the surgeon is experienced, and, if obvious, a loose draining seton may be passed; injudicious probing in the acute stage is, however, potentially dangerous and may lead to a much more difficult situation. Unless by highly experienced hands, immediate fistulotomy should not be performed. After irrigation of the cavity, the wound is lightly tucked; antibiotics are prescribed if there is surrounding cellulitis and especially in those less resistant to infection, such as diabetics. If the pus subsequently cultures skin-type organisms, there will be no underlying fistula and the patient can be reassured. If gut flora are cultured, it is likely, but not inevitable, that there is an underlying fistula.
Perianal sepsis
Published in S Asbury, A Mishra, KM Mokbel, M Fishman Jonathan, Principles of Operative Surgery, 2017
S Asbury, A Mishra, KM Mokbel, M Fishman Jonathan
It is important to identify the tract of the fistula. Those that run below the puborectalis are classified as low fistulas. Management of these has a lower risk of incontinence due to damage of the sphincter mechanism. Low fistulas – lay open with either fistulotomy or fistulectomy.High fistulas – require staged surgery to maintain continence, which may include the placement of a seton. A defunctioning colostomy may be required.
Higher anti-TNF serum levels are associated with perianal fistula closure in Crohn’s disease patients
Published in Scandinavian Journal of Gastroenterology, 2019
Anne S. Strik, Mark Löwenberg, Christianne J. Buskens, Krisztina B. Gecse, Cyriel I. Ponsioen, Willem A. Bemelman, Geert R. D’Haens
Perianal manifestations of Crohn’s disease (CD), such as fissures, fistulas and abscesses are invalidating complications, that are associated with a reduced quality of life [1,2]. Tumour necrosis factor (TNF) inhibitors are not only effective for the treatment of luminal inflammatory bowel disease (IBD), but also for perianal fistulas [3–5]. Before the introduction of anti-TNF agents, the management of perianal fistulas in CD patients was mainly surgical. Surgical options include chronic seton drainage, fistulotomy, ligation of the intersfincteric fistula tract (LIFT) or mucosal advancement flaps. Many patients also undergo (temporary) seton placement to facilitate drainage and to prevent abscess recurrence. The therapeutic efficacy of infliximab (IFX) in CD patients with perianal fistulizing disease was demonstrated in the ACCENT-2 trial [4]. IFX was effective in closing fistulas and during maintenance, the median duration of fistula closure was more than 3 months longer in responders receiving IFX compared to placebo.
Fistulectomy and primary sphincteroplasty (FIPS) to prevent keyhole deformity in simple anal fistula: a single-center retrospective cohort study
Published in Acta Chirurgica Belgica, 2021
Nicolas De Hous, Thomas Van den Broeck, Charles de Gheldere
Fistulotomy remains the gold standard for the surgical treatment of simple anal fistula, and healing is observed in over 90% of patients [1–3]. However, fistulotomies remain a source of concern because of two reasons. First, damaging the anal sphincter may lead to varying degrees of fecal incontinence, even for simple anal fistulas [1]. Second, the surgical wound is left to heal by secondary intention and has the tendency to form a scar groove. This condition is referred to as ‘keyhole deformity’ (Figure 1) [4]. Although seemingly trivial, keyhole deformity may lead to bothersome symptoms such as anal pruritus and fecal soiling [4].
Jump Technique versus Seton Method for Anal Fistula Repair: A Randomized Controlled Trial
Published in Journal of Investigative Surgery, 2022
Jalaluddin Khoshnevis, Roberto Cuomo, Farzaneh Karami, Terifeh Dashti, Alireza Kalantar Motamedi, Mohammadreza Kalantar Motamedi, Eznollah Azargashb, Negaar Aryan, Payam Sadeghi
The ultimate goal in the treatment of anal fistula is to eliminate the primary or any associated secondary openings and tracts with continence remaining intact [6, 7]. Fistulotomy is the “gold standard” approach for the treatment of anal fistula. For simple fistulae, the recurrence rate subsequent to fistulotomy is generally between 2–9% with a change in continence in 0–17% of patients [8, 9]. Fistulotomy wounds could last for prolonged healing periods, therefore causing significant discomfort, distress and contour defects around the anus in patients [10].