ObjectiveTo summarize the occurrence of anal fistula in Crohn disease (CDAF) accompanying with preoperative rectal stenosis and analyze its influencing factors. Meanwhile to explore the effect of improved anal sphincter retention virtual-hanging (hereafter this text will be abbreviated as virtual-hanging) for treatment of CDAF. MethodsThe CDAF patients admitted to the Third People’s Hospital of Bengbu from January 2019 to June 2021 were retrospectively collected, who were treated with virtual-hanging. Meanwhile the multivariable logistic regression analysis was used to identify the risk factors for accompanying with preoperative rectal stenosis and which were used to establish a decision tree model by Chi squared automatic interaction detection method. ResultsA total of 234 patients with CDAF were collected, and the incidence of accompanying with preoperative rectal stenosis was 22.2% (52/234). The multivariate logistic regression analysis found that the patients with preoperative proctitis, Montreal subtype B2, fistula located above the musculi levator ani (MLA), single fistula accompanied by branches or multiple fistulas, lymphocyte count (Lym) ≥6.03×109/L, platelet count (PLT) ≥0.61×109/L, erythrocyte sedimentation rate (ESR) ≥39.11 mm/h, C-reactive protein (CRP) ≥5.13 mg/L, and brain natriuretic peptide (BNP) ≥313.26 ng/L had higher probability of accompanying with preoperative rectal stenosis (P<0.05). For the patients with or without preoperative rectal stenosis, the CD activity index score and perianal CD activity index score, and anal resting pressure all showed decreasing trends after treatment with the virtual-hanging, and the anal maximal contraction pressure showed a increasing trend as compared to before treatment. The decision tree consisted 18 nodes and 9 terminal nodes. The gain map of the decision tree model gradually increased from 0% to 100%; The index chart maintained a high level starting from 198% and then rapidly decreased to 100%. The area under the receiver operating characteristic curve of the decision tree model was 0.852 [95%CI (0.821, 0.908)], with a sensitivity of 84.35% and a specificity of 82.33%. ConclusionsThe incidence of accompanying with preoperative rectal stenosis in patients with CDAF is relatively higher. The effect of virtual-hanging for treatment of CDAF is better. For patients with preoperative proctitis, Montreal subtype B2, fistula above the MLA, single fistula accompanied by branches or multiple fistulas, and higher Lym, PLT, ESR, CRP, and BNP, attention should be paid to their accompanying with preoperative rectal stenosis. The decision tree model based on these factors to distinguish whether accompanying with preoperative rectal stenosis is better.
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 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 the long-term efficacy of intersphincter approach combined with virtual solid and hanging line in the treatment of posterior high complex anal fistulas and risk factors for recurrence. Methods A total of 167 patients with posterior high complex anal fistula treated in our hospital from April 2020 to June 2023 were retrospectively included. According to different treatment methods, the patients were divided into observation group (n=88) and control group (n=79). The observation group was treated with the combination of virtual solid and hanging line via intersphincter approach, while the control group was treated with cutting and wire hanging drainage. The general clinical data, the height of the internal fistula opening and the anorectal pressure before and after 1, 2 and 3 months were compared between the two groups. The patients were divided into recurrence group (n=50) and non-recurrence group (n=117) according to the recurrence situation during the follow-up period. Univariate and multivariate logistic regression were used to analyze the risk factors of postoperative anal fistula recurrence, and Kaplan-Meier method was ued to draw relapse-free curve. ResultsCompared with the control group, the observation group had longer operative time, shorter wound healing time and shorter hospital stay (P<0.05). At 1, 2 and 3 months after operation, the anal resting pressure and maximum anal retraction pressure in the observation group were significantly increased, while the height of the inner mouth was significantly decreased, with statistical significance (P<0.05). There were statistically significant differences in age, body mass index, gender, regular dressing change to hospital after discharge, history of anal fistula surgery, clarity of internal opening and treatment methods between the recurrence group and the non-recurrence group (P<0.05). The results of multivariate logistic regression analysis showed that the independent risk factors for postoperative recurrence of patients with posterior high complicated anal fistula were that they didn’t regularly go to the hospital for dressing change after discharge, had a history of anal fistula operation, had unclear internal orifice and underwent thread-drawing drainage (P<0.05). The cumulative relapse-free rate of patients in the observation group and the control group was 84.58% and 67.73% respectively, and the difference was statistically significant (P<0.05). ConclusionsThe treatment of posterior high complex anal fistulas by intersphincter approach combined with virtual solid and hanging line has a good effect in protecting anal function and promoting wound healing. After discharge, the factors affecting postoperative recurrence in patients with posterior high complex anal fistula are not regularly changed dressing, history of anal fistula surgery, unclear internal mouth, cutting and wire hanging drainage, which should be paid attention to.
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.
ObjectiveTo analyze the effect of anal fistula clip (AFC) in the treatment of anal fistula, and to evaluate its safety. MethodsA historical cohort study method was conducted. Eighty-three patients with glandular transsphincteric anal fistula in the Xuzhou Central Hospital from September 2018 to May 2021 were collected, of which 42 patients underwent the AFC treatment (AFC group), 41 patients underwent the endorectal advancement flap (ERAF) treatment (ERAF group). The operation time, intraoperative blood loss, visual analogue scale (VAS) score of anus pain on postoperative day 1, 3, and 7, wound healing time, Wexner incontinence score of anal function on postoperative month 6, and clinical efficacy (healing and failure) were compared between the two groups. ResultsThe operation was successfully completed in both groups. The operation time and intraoperative blood loss in the AFC group were shorter or less than those in the ERAF group (P<0.05). No complications such as internal opening infection and bleeding occurred in the two groups. There were no statistical differences in the VAS score of postoperative anus pain at all time point between the two groups (P>0.05). The median follow-up time was 22 months. There was no statistical difference in the wound healing time between the two groups (P>0.05). The Wexner score of anal function in the AFC group was lower than that in the ERAF group (P<0.05), and there was no statistical difference between after operation and before operation (Z=–1.751, P=0.089) in the AFC group, while that in the ERAF group after operation was higher than before operation (Z=–1.859, P=0.014). The healing rate had no statistical difference between the AFC group and ERAF group (85.7% versus 77.5%, χ2=0.925, P=0.336). Conclusion From the results of this study, the AFC is safe and effective in treatment of anal fistula, with the advantages of relatively simple operation, less bleeding during operation, lighter postoperative pain, and good protection of anal function.
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.
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.
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 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.