The evaluation of day surgery for simple low anal fistula: A case-control study based on PSM

BackgroundDelayed wound healing following anal fistula (AF) surgery remains a clinical challenge. This study endeavors to identify and validate key exosomal miRNAs that regulate postoperative inflammation after AF surgery by integrating multi-omics analyses with functional assays, and to elucidate the molecular mechanisms by which these miRNAs and their target genes influence macrophage M1/M2 polarization.Methods15 patients undergoing AF surgery were randomized to three groups. The negative control group received sterile Vaseline gauze dressings, the positive control cohort took Kangfuxin Solution, and the treatment cohort received Wugu Qilin Ointment. Wound exudates were collected postoperatively and exosomes were isolated via ultracentrifugation. Total RNA was extracted through the TRIzol method, followed by miRNA microarray analysis to identify differentially expressed miRNAs (DEMs). Candidate miRNAs were validated via qPCR to identify those significantly linked to the therapeutic efficacy of the traditional Chinese medicine (TCM) method of Euriching Pus for Tissue Growth. In vitro, the differentiation of THP-1 cells into macrophages was employed via PMA. The MP were verified by flow cytometry (FC), qPCR and Western blotting (WB). Potential miRNA target genes were predicted using TargetScan before Gene Ontology (GO) functional annotation and Kyoto Encyclopedia of Genes and Genomes (KEGG) pathway enrichment analysis. The direct interplay between miRNA and its target gene was verified through a dual-luciferase reporter (DLR) assay.ResultsMicroarray analysis and qPCR validation identified miR-93-3p as the most significantly DEMs. miR-93-3p overexpression markedly downregulated M1 macrophage marker CD86 and pro-inflammation cytokines IL-1β, IL-6, and TNF-α, while upregulating M2 markers Arg-1, CD206, and anti-inflammation cytokines IL-10 and TGF-β in functional assays. Conversely, miR-93-3p suppression exhibited the opposite effect. WB analysis confirmed that miR-93-3p bidirectionally regulated CD86, Arg-1, and CD206 protein expression. Bioinformatic analysis suggested that miR-93-3p possibly targets EIF4EBP1, thereby modulating biological processes like inflammatory response, cellular metabolism, and MP. This regulatory relationship was unveiled through DLR assays, proving that miR-93-3p specifically suppresses EIF4EBP1 expression.ConclusionThis study is the first to elucidate the molecular mechanism by which the TCM therapeutic approach of Euriching Pus for Tissue Growth promotes M2 MP through the exosomal miR-93-3p/EIF4EBP1 axis, and theoretically supports the formulation of new exosome-based miRNA treatment strategies for postoperative anti-inflammatory treatment in AF.

Conventional surgery for complex anal fistula (AF) is associated with continence disturbance and recurrence. In the hope of reducing these we developed a new mechanical device, the 'fistulectome', to excise the entire fistula tract. Between March 2001 and April 2011, 136 patients underwent surgery for a complex AF using the fistulectome. All fistulae were cryptoglandular in origin. Five patients were lost to follow up and were excluded from the analysis. Of the 131 fistulae, 76 were trans-sphincteric, 14 were suprasphincteric and 16 were extrasphincteric. Seven had a horseshoe extension and 18 were unclassified. Of the 131, 108 had recurred after conventional fistulotomy performed at another centre and 23 were primary. The mean duration of follow up was 34.6months, the mean hospital stay was 5days and the healing time was 14days. Recurrence, flatus incontinence and soiling occurred in 17 (12.9%), four (3.5%) and two (1.52%) patients. The results of this series suggest that coring-out of a fistula using a fistulectome may be a valid treatment for complicated anal fistula.

BackgroundHaemorrhoidal surgery and anal fistula surgery are two of the most common procedures in proctology. Currently, there is no definitive consensus on the need to administer a preoperative enema. The objective of this study was to evaluate the efficacy and benefits of preoperative enemas in anal surgical procedures.MethodsPatients diagnosed with grade III or IV haemorrhoids and anal fistulas at the Taipei Medical University Shuang-Ho Hospital, Taiwan, between 2022 and 2023, were enrolled in a randomized clinical study comparing the use of preoperative enema (intervention) versus no preoperative enema (control). The primary outcome measures included postoperative visual analogue scale scores and analgesic usage from postoperative day 0 to day 7. Secondary outcomes of interest were postoperative complications, including surgical site infection, postoperative bleeding and urinary retention. Subgroup analyses were performed according to the type of procedure for the same outcomes.ResultsA total of 266 patients were enrolled in this study, with 133 allocated to the enema group and 133 to the control group. No significant differences were observed in postoperative visual analogue scale scores, analgesic consumption and postoperative complications between the two groups. Subgroup analysis revealed that patients undergoing stapled haemorrhoidopexy and anal fistula surgery also showed no significant differences in postoperative visual analogue scale scores, analgesic consumption, and postoperative complications between the enema and control groups. However, in the subgroup of patients undergoing Milligan–Morgan haemorrhoidectomy, the mean(s.d.) visual analogue scale score was significantly higher in the control group than in the enema group on day 2 (5.69(2.14) versus 3.77(2.45), P = 0.021), day 3 (5.85(2.61) versus 3.92(2.73), P = 0.042) and day 4 (5.23(2.55) versus 3.42(2.18), P = 0.027).ConclusionPreoperative enema in anal surgery did not yield additional benefits or reduce complications when compared with patients who did not undergo enema before anal surgery. Based on the study findings, its use can be omitted in anal surgery, especially for patients undergoing stapled haemorrhoidopexy and anal fistula surgery.

Study on the effect and mechanism of Yanghe decoction Huacai on tissue repair ofsyndrome after anal fistula surgery.

The aim of fistula surgery is to eradicate the disease while preserving anal sphincter function. The efficacy of the Surgisis® anal fistula plug (Cook Medical, Bloomington, IN, USA) in the treatment of trans-sphincteric fistula-in-ano has been variably reported. To undertake a randomised comparison of the safety and efficacy of the Surgisis anal fistula plug in comparison with surgeon's preference for the treatment of trans-sphincteric anal fistulas. A randomised, unblinded, parallel-arm, prospective, multicentre clinical trial. Hospitals in the UK NHS involving colorectal surgeons accredited by the Association of Coloproctology of Great Britain and Ireland. Adult patients suffering from trans-sphincteric fistula-in-ano of cryptoglandular origin. Patients were randomised on a 1 : 1 basis to either the fistula plug or the surgeon's preference [e.g. fistulotomy, cutting seton, advancement flap or ligation of intersphincteric fistula tract (LIFT) procedure]. The primary outcome measure was quality of life as measured by the Faecal Incontinence Quality of Life (FIQoL) questionnaire at 12-month follow-up. Secondary outcome measures included clinical and radiological fistula healing rates, faecal incontinence rates, complications rates, reintervention rates and cost-effectiveness. Between May 2011 and March 2016, 304 participants were recruited (152 fistula plug vs. 152 surgeon's preference). No difference in FIQoL score between the two trial groups was seen at the 6-week, 6-month or 12-month follow-up. Clinical evidence of fistula healing was reported in 66 of 122 (54%) participants in the fistula plug group and in 66 of 119 (55%) participants in the surgeon's preference group at 12 months. Magnetic resonance imaging (MRI) showed fistula healing in 54 of 110 (49%) participants in the fistula plug group and in 63 of 112 (56%) participants in the surgeon's preference group. Variation in 12-month clinical healing rates was observed: 55%, 64%, 75%, 53% and 42% for fistula plug, cutting seton, fistulotomy, advancement flap and LIFT procedure, respectively. Faecal incontinence rates were low at baseline, with small improvement in both groups post treatment. Complications and reinterventions were frequent. The mean total costs were £2738 [standard deviation (SD) £1151] in the fistula plug group and £2308 (SD £1228) in the surgeon's preference group. The average total quality-adjusted life-years (QALYs) gain was much smaller in the fistula plug group (0.829, SD 0.174) than in the surgeon's preference group (0.790, SD 0.212). Using multiple imputation and probabilistic sensitivity analysis, and adjusting for differences in baseline EuroQol-5 Dimensions, three-level version utility, there was a 35-45% chance that the fistula plug was as cost-effective as surgeon's preference over a range of thresholds of willingness to pay for a single QALY of £20,000-30,000. Limitations include a smaller sample size than originally calculated, a lack of blinding that perhaps biased patient-reported outcomes and a lower compliance rate with MRI at 12-month follow-up. The Surgisis anal fistula plug is associated with similar FIQoL score to surgeon's preference at 12-month follow-up. The higher costs and highly uncertain and small gains in QALYs associated with the fistula plug mean that this technology is unlikely to be considered a cost-effective use of resources in the UK NHS. Further in-depth analysis should consider the clinical and MRI characteristics of fistula-in-ano in an attempt to identify predictors of fistula response to treatment. Current Controlled Trials ISRCTN78352529. This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 23, No. 21. See the NIHR Journals Library website for further project information.

The aim of treatment of anal fistula is to remove the track avoiding while ensuring faecal continence. We report the results of a technique that preserves the external anal sphincter in patients with complex anal fistulas. Between 2006 and 2009, 18 patients underwent surgery for a complex anal fistula using this technique. It involved initial identification and partial laying open of the fistulous tract including the internal sphincter distal to the dentate line without transecting the external sphincter. A loose-seton is placed around the external sphincter and is not removed until the internal orifice has migrated towards the perianal skin. Of the 18 patients [mean age 42 (31-65) years] 11 were female and the median follow-up was 16 months. The mean time for removal of the seton, after discharge had ceased, was 4 (3-12) months. The preoperative faecal incontinence Wexner score was 0 (0-9) and postoperatively 0 (0-8). The technique shows excellent results in the treatment of complex anal fistulas with conservation of fecal continence.

Aim: The laser method (FiLaCTM) has recently emerged as a minimally invasive treatment option in the treatment of anal fistula. Anal incontinence and fistula recurrence after anal fistula surgery are postoperative problems that complicate the treatment. In our study, we aimed to investigate the effectiveness of the film method in the treatment of anal fistula and in which cases it should be preferred in the treatment. Methods: Twelve patients who underwent FiLaCTM diode laser at Derik State Hospital between July 2017 and August 2018 were included in the study. Patients were analyzed retrospectively in terms of age, gender, development of incontinence, recovery and return to work, fistula types, MRI findings, and complications. Results: 11 of the patients included in the study were male and 1 female and the mean age was 46. Intraoperative complications were not observed in any of the patients. The mean follow-up period was 13.5 (7-19) months. Complete recovery was observed in 4 (33.3%) patients in the follow-ups of the patients, while no improvement was achieved in 8 (66.7%) patients. Conclusion: The FiLaCTM procedure for the treatment of anal fistula is a safe, minimally invasive, sphincter-sparing treatment option with low efficacy. However, it can be preferred as an initial treatment in high-level fistulas and in patients who want minimally invasive intervention.

Introduction: Anal fistula is a benign anorectal disease. Infection of Hermann and Desfosses anal glands is responsible for the formation of abscesses and/or fistulas. The main treatment is surgery but recurrence and sometimes incontinence are frequently observed. So to choose surgical methods of anal fistula treatment is very important. Aim: The aim of this retrospective study was to evaluate the reliability and feasibility of Video-assisted anal fistula treatment (VAAFT) at the anal fistula surgery. Materials and Methods: A retrospective analysis was performed on data collected during a 11-year period (2008-2019) from 52 patients who underwent fistulotomy with loose seton technique. The male to female ratio was 3:1 and the mean patient age was 48.34 years. Results: Mortality, recurrence, complications rate were 0%. Though the patients were scheduled as day-surgery cases, the average duration of hospital stay was 1.18 days. Quality of life index (QOLI) for these patients were often be improved by treating their fistula. Conclusion: The appropriate treatment for anal fistula is dependent upon the anatomy and the location of the fistula tract. Detection of the inner mouth is the touchstone in the treatment of anal fistula. It could be determined location of inner mouth of the anal fistula easily with transparent anoscope guideline. VAAFT seems to be a safe and effective technique for treating perianal fistula without recurrence and anal incontinence.

Objective To investigate the effect of auricular acupoint acupuncture therapy on postoperative pain in patients undergoing surgery for low anal fistula. Methods Totally 60 patients undergoing surgical treatment for low anal fistula were divided into the control group (n=30) and acupuncture group (n=30) by using the random number table method. In the control group, on the basis of conventional treatment, 20 mg of paracetamol and dihydrocodeine tartrate was taken orally 30 min before dressing change and going to bed in the evening every day. In the acupuncture group, after the patient returned to the ward after surgery, the acupuncture was applied to the four auricular acupoints of Zhichang, Gangmen, Jiaogan and Shenmen at 8 am every morning. The VAS scores of the two groups were observed after changing the dressing every day for five days after the operation, and the changes of β-EP and CRP concentration in the venous blood before and 5 days after the treatment were observed. Results VAS scores of patients in the acupuncture group were lower than those in the control group five days after surgery, and the difference was statistically significant (P＜0. 05). Compared with the control group, there was no significant difference in the levels of β-EP and CRP before treatment(P＞0. 05), and there was significant difference after 5 days of treatment(P＜0. 05). Conclusion Auricular acupoint acupuncture therapy can alleviate postoperative pain, promote the release of β-EP, inhibit the secretion of CRP, reduce inflammation, and improve the therapeutic effect of surgical treatment for low anal fistula. (目的 探讨耳穴揿针治疗对低位单纯性肛瘘患者术后疼痛的影响。方法 选取医院肛肠科2021年1月—6月收治的低位单纯性肛瘘术后患者60例, 采用随机数字表法将患者分为对照组(n=30)与揿针组(n=30)。对照组在常规治疗基础上, 于每日换药前30 min及晚上睡前口服氨酚双氢可待因20 mg; 揿针组在患者术毕安全返回病房后、术后每天上午8时使用揿针贴于耳穴直肠、肛门、交感、神门四穴。观察两组患者术后5 d内每天换药后疼痛评分情况, 以及治疗前、治疗5 d后静脉血血浆中β-内啡肽(β-EP)含量和C反应蛋白(CRP)浓度变化。结果 揿针组患者术后5 d换药后VAS评分均低于对照组, 差异有统计学意义(P＜0. 05)。揿针组与对照组相比, β-EP、CRP水平治疗前差异无统计学意义(P＞0. 05), 治疗5 d后差异有统计学意义(P＜0. 05)。结论 耳穴揿针治疗运用于肛瘘术后患者, 可以减轻患者疼痛感, 并促进β-EP的释放, 抑制CRP的分泌, 减轻炎症反应, 提高治疗效果。)

Background: An anal fistula is an abnormal connection between the anal canal and perianal tissue, often resulting from an infected anal crypt. In terms of surgical management, there remains ongoing debate about whether fistulectomy is preferable to fistulotomy for treating low-lying simple anal fistulas. This study aims to compare the efficacy of fistulotomy and fistulectomy in the management of low anal fistulas at a tertiary care center in Central India. Methods: This randomized controlled trial included 60 patients aged over 18 years with clinically diagnosed simple low anal fistulas. Patients were divided into two groups: Group I underwent fistulectomy, and Group II underwent fistulotomy. Demographic data, operative time, postoperative pain (measured using a Visual Analog Scale), complications, and follow-up assessments were recorded. Results: The mean age of participants was 38.54 ± 10.50 years, with no significant differences in demographic characteristics between groups. The fistulotomy group demonstrated significantly shorter operative time (15.15 ± 2.09 minutes vs. 26.12 ± 3.26 minutes, p < 0.001), reduced hospital stay (1.78 ± 0.62 days vs. 2.58 ± 0.54 days, p < 0.001), and faster wound healing (23.11 ± 2.85 days vs. 30.40 ± 4.14 days, p < 0.001). Pain levels were consistently lower in the fistulotomy group at all follow-ups (p < 0.001). Complications such as urinary retention and wound infection were not significantly different between groups. No cases of recurrence were observed. Conclusion: Fistulotomy is a superior treatment option for low anal fistulas compared to fistulectomy, offering shorter surgical duration, faster recovery, and fewer complications while maintaining similar recurrence rates.

The long-term recurrence rate of fibrin glue treatment was analysed in patients with trans-sphincteric cryptoglandular fistula operated by a two-phase procedure: (i) fistulectomy with seton placement; (ii) fibrin sealant (Tissucol Duo®, Baxter) insertion in the track. Clinical data were collected prospectively for all patients operated between 2004 and 2010. The statistical association of clinical variables and recurrence was analysed and a disease-free curve was constructed using the Kaplan-Meier method. Twenty-eight consecutive patients (mean age 48.3 ± 13.3 years; 22 men) were enrolled in the study. Middle and high trans-sphincteric fistulae were diagnosed in 20 (71.4%) and eight (28.6%) patients. Seven (25%) had secondary track formation. The mean interval between the first operation and the fibrin sealant treatment was 12.5 ± 7.6 months. There were no complications related to the procedure. Nine (32.1%, 95% CI 17.9-50.7%) patients developed recurrence between 3 and 27 months after fibrin sealant treatment. Disease-free curves showed that the highest probability of recurrence occurred in the first 2 years. No incontinence was found at a mean follow-up of 20.6 (3-60) months among the 67.8% patients with no evidence of recurrence. Fibrin sealant is safe and simple. The healing rate is satisfactory without the risk of incontinence.

PurposeA number of techniques have been described for the treatment of a transsphincteric anal fistula. In this report, we aimed to introduce a relatively new two-stage technique, application of advancement flap after loose seton placement, to present its technical aspects and to document our results.MethodsIncluded in this retrospective study were 13 patients (10 males, 3 females) with a mean age of 42 years who underwent a two-stage seton and advancement flap surgery for transsphincteric anal fistula between June 2008 and June 2013. In the first stage, a loose seton was placed in the fistula tract, and in the second stage, which was performed three months later, the internal and external orifices were closed with advancement flaps.ResultsAll the patients were discharged on the first postoperative day. The mean follow-up period was 34 months. Only one patient reported anal rigidity and intermittent pain, which was eventually resolved with conservative measures. The mean postoperative Wexner incontinence score was 1. No recurrence or complications were observed, and no further surgical intervention was required during follow-up.ConclusionThe two-stage seton and advancement flap technique is very efficient and seems to be a good alternative for the treatment of a transsphincteric anal fistula.

Background Perianal abscess management varies between the French and Anglo-Saxon schools, with the former advocating immediate fistula treatment to prevent recurrence, while the latter suggests simple incision due to a purported low recurrence rate. This study aimed to evaluate the outcomes and predictive factors associated with perianal abscess management in our department. Methods In 2019, 109 patients presenting with a first perianal abscess were included in the study, excluding those with specific criteria. Treatment involved incision under local anesthesia, possibly combined with antibiotic therapy using amoxicillin/clavulanic acid for five days. Patients with obvious signs of fistula were scheduled for immediate surgery. The primary objective was to assess the rate of patients requiring surgical management of fistula and/or experiencing abscess recurrence, with secondary objectives including the identification of predictive factors. Results Among the 336 patients who consulted for an abscess, 109 were included, with a mean age of 43 years and 74% being men. Of these, 55 underwent incision alone, while 54 had anal fistula surgery after incision. The mean follow-up for patients with incision alone was approximately 30 months, during which 18% experienced abscess recurrence. Univariate logistic regression analysis revealed smoking and absence of antibiotic therapy post-incision as predictive of recurrence. Gender, age, BMI, diabetes, Crohn's disease, HIV infection, prior NSAID use, and abscess location were not predictive. Multivariate analysis was not conducted due to insufficient data. Conclusions This study demonstrates that 41% of patients who underwent incision for a first perianal abscess did not experience recurrence during the follow-up period. Additionally, the administration of antibiotic therapy post-incision was associated with a reduced likelihood of recurrence. However, randomized trials are warranted to validate these findings and specify the optimal antibiotic regimen.

The aim of this study was to determine the prevalence of tuberculosis (TB) in anal fistulas at a referral hospital in Cape Town, and to document the clinical features and course of patients with tuberculous anal fistulas. This was a prospective study of all patients who underwent surgery for anal fistulas at the Colorectal Surgery Unit at Groote Schuur Hospital, Cape Town, from 2004 to 2006. Tissue was submitted for histopathological examination, Ziehl-Neelsen (ZN) staining and TB culture. The patients with proven TB were followed up until January 2008. During the 3-year study period, 117 operations were performed on 96 patients. TB was diagnosed in 7 of the 96 patients (7.3%). In 5 of these 7 cases, the diagnosis of TB could be proven on histological examination and ZN staining, while in 2 cases the diagnosis could only be made on TB culture. None of the 7 patients had systemic features suggestive of TB, and only 1 had evidence of TB on a chest radiograph, Five patients were HIV-negative, and 2 declined testing. After a median follow-up of 2 years, 5 of 7 patients had evidence of recurrent or persistent fistulas, despite having completed 6 months of TB treatment. At a referral hospital in an endemic area, TB was present in 7.3% of anal fistulas. Histopathological examination including ZN staining was inadequate to make the diagnosis in a third of these patients. Tissue from anal fistulas should therefore routinely be sent for TB culture as well as histopathological examination and ZN staining in areas where TB is prevalent.

Surgical treatment of high anal fistulas is associated with the potential risk of faecal incontinence and recurrence. The primary aim of this study was to determine the accuracy of three-dimensional endoanal ultrasound (3D-EAUS) in the assessment of height and type of anal fistulas, compared to the intra-operative findings (gold standard). The secondary aim was to evaluate the inter-observer reproducibility of 3D-EAUS. The study design was a prospective analysis of retrospective data. 299 patients (202 men), mean age 45.3years, who underwent surgery for anal fistulas, were included. All patients were preoperatively assessed by 3D-EAUS. Two readers independently reviewed the volumes to determine the type and height of fistulas. Sensitivity, specificity, positive and negative predictive values, proportion of agreements and Cohen's kappa coefficient (κ) were calculated for both examiners. Ultrasound findings were compared with intra-operative data (reference standard), evaluated blindly by the surgeons. At surgery, 201 (67%) were transsphincteric, 49 (16%) suprasphincteric, 47 (16%) intersphincteric and two (1%) extrasphincteric fistulas. Intra-operatively, 177 (59%) were low and 122 (41%) high fistulas. The overall accuracy of 3D-EAUS was 91% for fistula type (271/299 fistulas: 97% transsphincteric, 100% intersphincteric, 57% suprasphincteric, 0% extrasphincteric) and 92% for fistula height (275/299 fistulas: 80% high and 100% low). Both readers reported very good agreement with surgery in the assessment of fistula type (proportion of agreement 0.88, κ=0.89) and height (proportion of agreement 0.90, κ=0.91). 3D-EAUS is an accurate and reproducible modality for the assessment of type and height of anal fistulas.