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Techniques in Coloproctology
Published in: Techniques in Coloproctology 8/2019

Open Access 01-08-2019 | Magnetic Resonance Imaging | Original Article

Contemporary surgical practice in the management of anal fistula: results from an international survey

Authors: C. Ratto, U. Grossi, F. Litta, G. L. Di Tanna, A. Parello, V. De Simone, P. Tozer, D. DE Zimmerman, Y. Maeda

Published in: Techniques in Coloproctology | Issue 8/2019

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Abstract

Background

Management of anal fistula (AF) remains challenging with many controversies. The purpose of this study was to explore current surgical practice in the management of AF with a focus on technical variations among surgeons.

Methods

An online survey was conducted by inviting all surgeons and physicians on the membership directory of European Society of Coloproctology and American Society of Colon and Rectal Surgeons. An invitation was extended to others via social media. The survey had 74 questions exploring diagnostic and surgical techniques.

Results

In March 2018, 3572 physicians on membership directory were invited to take part in the study 510 of whom (14%) responded to the survey. Of these respondents, 492 (96%) were surgeons. Respondents were mostly colorectal surgeons (84%) at consultant level (84%), age ≥ 40 years (64%), practicing in academic (53%) or teaching (30%) hospitals, from the USA (36%) and Europe (34%). About 80% considered fistulotomy as the gold standard treatment for simple fistulas. Endorectal advancement flap was performed using partial- (42%) or full-thickness (44%) flaps. Up to 38% of surgeons performed ligation of the intersphincteric fistula tract (LIFT) sometimes with technical variations. Geographic and demographic differences were found in both the diagnostic and therapeutic approaches to AF. Declared rates of recurrence and fecal incontinence with these techniques were variable and did not correlate with surgeons’ experience. Only 1–4% of surgeons were confident in performing the most novel sphincter-preserving techniques in patients with Crohn’s disease.

Conclusions

Profound technical variations exist in surgical management of AF, making it difficult to reproduce and compare treatment outcomes among different centers.
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Literature
1.
2.
Zanotti C, Martinez-Puente C, Pascual I, Pascual M, Herreros D, Garcia-Olmo D (2007) An assessment of the incidence of fistula-in-ano in four countries of the European Union. Int J Colorectal Dis 22(12):1459–1462CrossRefPubMed
3.
4.
Kotze PG, Shen B, Lightner A, Yamamoto T, Spinelli A, Ghosh S et al (2018) Modern management of perianal fistulas in Crohn’s disease: future directions. Gut 67(6):1181–1194CrossRefPubMed
5.
Lee MJ, Heywood N, Adegbola S, Tozer P, Sahnan K, Fearnhead NS et al (2017) Systematic review of surgical interventions for Crohn’s anal fistula. BJS Open 1(3):55–66CrossRefPubMedPubMedCentral
6.
Atkin GK, Martins J, Tozer P, Ranchod P, Phillips RK (2011) For many high anal fistulas, lay open is still a good option. Tech Coloproctol 15(2):143–150CrossRefPubMed
7.
Hall JF, Bordeianou L, Hyman N, Read T, Bartus C, Schoetz D et al (2014) Outcomes after operations for anal fistula: results of a prospective, multicenter, regional study. Dis Colon Rectum 57(11):1304–1308CrossRefPubMed
8.
Abramowitz L, Soudan D, Souffran M, Bouchard D, Castinel A, Suduca JM et al (2016) The outcome of fistulotomy for anal fistula at 1 year: a prospective multicentre French study. Colorectal Dis 18(3):279–285CrossRefPubMed
9.
Bokhari S, Lindsey I (2010) Incontinence following sphincter division for treatment of anal fistula. Colorectal Dis 12(7):e135–e139PubMed
10.
Gottgens KW, Janssen PT, Heemskerk J, van Dielen FM, Konsten JL, Lettinga T et al (2015) Long-term outcome of low perianal fistulas treated by fistulotomy: a multicenter study. Int J Colorectal Dis 30(2):213–219CrossRefPubMed
11.
Ozuner G, Hull TL, Cartmill J, Fazio VW (1996) Long-term analysis of the use of transanal rectal advancement flaps for complicated anorectal/vaginal fistulas. Dis Colon Rectum 39(1):10–14CrossRefPubMed
12.
Oh C (1983) Management of high recurrent anal fistula. Surgery 93(2):330–332PubMed
13.
Hjortrup A, Moesgaard F, Kjaergard J (1991) Fibrin adhesive in the treatment of perineal fistulas. Dis Colon Rectum 34(9):752–754CrossRefPubMed
14.
Johnson EK, Gaw JU, Armstrong DN (2006) Efficacy of anal fistula plug vs. fibrin glue in closure of anorectal fistulas. Dis Colon Rectum 49(3):371–376CrossRefPubMed
15.
Heydari A, Attina GM, Merolla E, Piccoli M, Fazlalizadeh R, Melotti G (2013) Bioabsorbable synthetic plug in the treatment of anal fistulas. Dis Colon Rectum 56(6):774–779CrossRefPubMed
16.
Garcia-Olmo D, Garcia-Arranz M, Herreros D (2008) Expanded adipose-derived stem cells for the treatment of complex perianal fistula including Crohn’s disease. Expert Opin Biol Ther 8(9):1417–1423CrossRefPubMed
17.
Rojanasakul A, Pattanaarun J, Sahakitrungruang C, Tantiphlachiva K (2007) Total anal sphincter saving technique for fistula-in-ano; the ligation of intersphincteric fistula tract. J Med Assoc Thai 90(3):581–586PubMed
18.
Meinero P, Mori L (2011) Video-assisted anal fistula treatment (VAAFT): a novel sphincter-saving procedure for treating complex anal fistulas. Tech Coloproctol 15(4):417–422CrossRefPubMedPubMedCentral
19.
Wilhelm A (2011) A new technique for sphincter-preserving anal fistula repair using a novel radial emitting laser probe. Tech Coloproctol 15(4):445–449CrossRef
20.
Prosst RL, Ehni W (2012) The OTSC(R) Proctology clip system for anorectal fistula closure: the ‘anal fistula claw’: case report. Minim Invasive Ther Allied Technol 21(4):307–312CrossRefPubMed
21.
Williams G, Williams A, Tozer P, Phillips R, Ahmad A, Jayne D et al (2018) The treatment of anal fistula: second ACPGBI Position Statement—2018. Colorectal Dis 20(Suppl 3):5–31CrossRefPubMed
22.
Vogel JD, Johnson EK, Morris AM, Paquette IM, Saclarides TJ, Feingold DL et al (2016) Clinical practice guideline for the management of anorectal abscess, fistula-in-ano, and rectovaginal fistula. Dis Colon Rectum 59(12):1117–1133CrossRef
23.
Ommer A, Herold A, Berg E, Furst A, Post S, Ruppert R et al (2017) German S3 guidelines: anal abscess and fistula (second revised version). Langenbecks Arch Surg 402(2):191–201CrossRefPubMed
24.
Lichtenstein GR, Loftus EV Jr, Isaacs KL, Regueiro MD, Gerson LB, Sands BE (2018) Correction: ACG clinical guideline: management of Crohn’s disease in adults. Am J Gastroenterol 113(7):1101CrossRefPubMed
25.
Lichtenstein GR, Loftus EV, Isaacs KL, Regueiro MD, Gerson LB, Sands BE (2018) ACG clinical guideline: management of Crohn’s disease in adults. Am J Gastroenterol 113(4):481–517CrossRefPubMed
26.
Brazilian Study Group of Inflammatory Bowel, D (2010) Consensus guidelines for the management of inflammatory bowel disease. Arq Gastroenterol 47(3):313–325CrossRef
27.
Sadowski DC, Bernstein CN, Bitton A, Croitoru K, Fedorak RN, Griffiths A et al (2009) Canadian Association of Gastroenterology Clinical Practice Guidelines: the use of tumour necrosis factor-alpha antagonist therapy in Crohn’s disease. Can J Gastroenterol 23(3):185–202CrossRefPubMedPubMedCentral
28.
Hvas CL, Dahlerup JF, Jacobsen BA, Ljungmann K, Qvist N, Staun M et al (2011) Diagnosis and treatment of fistulising Crohn’s disease. Dan Med Bull 58(10):C4338PubMed
29.
Gionchetti P, Dignass A, Danese S, Magro Dias FJ, Rogler G, Lakatos PL et al (2017) 3rd European evidence-based consensus on the diagnosis and management of Crohn’s disease 2016: Part 2: surgical management and special situations. J Crohns Colitis 11(2):135–149CrossRefPubMed
30.
Bouchard D, Abramowitz L, Bouguen G, Brochard C, Dabadie A, de Parades V et al (2017) Anoperineal lesions in Crohn’s disease: French recommendations for clinical practice. Tech Coloproctol 21(9):683–691CrossRefPubMed
31.
Gecse KB, Bemelman W, Kamm MA, Stoker J, Khanna R, Ng SC et al (2014) A global consensus on the classification, diagnosis and multidisciplinary treatment of perianal fistulising Crohn’s disease. Gut 63(9):1381–1392CrossRefPubMed
32.
Yamamoto-Furusho JK, Bosques-Padilla F, Paula J, Galiano MT, Ibanez P, Juliao F et al (2017) Diagnosis and treatment of inflammatory bowel disease: First Latin American Consensus of the Pan American Crohn’s and Colitis Organisation. Rev Gastroenterol Mex 82(1):46–84PubMed
33.
Bouchard D, Pigot F, Staumont G, Siproudhis L, Abramowitz L, Benfredj P et al (2018) Management of anoperineal lesions in Crohn’s disease: a French National Society of Coloproctology national consensus. Tech Coloproctol 22(12):905–917CrossRefPubMed
34.
de Groof EJ, Cabral VN, Buskens CJ, Morton DG, Hahnloser D, Bemelman WA et al (2016) Systematic review of evidence and consensus on perianal fistula: an analysis of national and international guidelines. Colorectal Dis 18(4):O119–O134CrossRefPubMed
35.
Eysenbach G (2004) Improving the quality of Web surveys: the Checklist for Reporting Results of Internet E-Surveys (CHERRIES). J Med Internet Res 6(3):e34CrossRefPubMedPubMedCentral
36.
Dykema J, Jones NR, Piche T, Stevenson J (2013) Surveying clinicians by web: current issues in design and administration. Eval Health Prof 36(3):352–381CrossRefPubMed
37.
Sahlqvist S, Song Y, Bull F, Adams E, Preston J, Ogilvie D et al (2011) Effect of questionnaire length, personalisation and reminder type on response rate to a complex postal survey: randomised controlled trial. BMC Med Res Methodol 11:62CrossRefPubMedPubMedCentral
38.
Oliver I, Lacueva FJ, Perez Vicente F, Arroyo A, Ferrer R, Cansado P et al (2003) Randomized clinical trial comparing simple drainage of anorectal abscess with and without fistula track treatment. Int J Colorectal Dis 18(2):107–110PubMed
39.
Sahnan K, Askari A, Adegbola SO, Tozer PJ, Phillips RKS, Hart A et al (2017) Natural history of anorectal sepsis. Br J Surg 104(13):1857–1865CrossRefPubMed
40.
Matos D, Lunniss PJ, Phillips RK (1993) Total sphincter conservation in high fistula in ano: results of a new approach. Br J Surg 80(6):802–804CrossRefPubMed
41.
Ye F, Tang C, Wang D, Zheng S (2015) Early experience with the modificated approach of ligation of the intersphincteric fistula tract for high transsphincteric fistula. World J Surg 39(4):1059–1065CrossRefPubMed
42.
McCulloch P, Altman DG, Campbell WB, Flum DR, Glasziou P, Marshall JC et al (2009) No surgical innovation without evaluation: the IDEAL recommendations. Lancet 374(9695):1105–1112CrossRefPubMed
43.
Sahnan K, Tozer PJ, Adegbola SO, Lee MJ, Heywood N, McNair AGK et al (2019) Developing a core outcome set for fistulising perianal Crohn’s disease. Gut 68(2):226–238CrossRefPubMed
Metadata
Title
Contemporary surgical practice in the management of anal fistula: results from an international survey
Authors
C. Ratto
U. Grossi
F. Litta
G. L. Di Tanna
A. Parello
V. De Simone
P. Tozer
D. DE Zimmerman
Y. Maeda
Publication date
01-08-2019
Publisher
Springer International Publishing
Published in
Techniques in Coloproctology / Issue 8/2019
Print ISSN: 1123-6337
Electronic ISSN: 1128-045X
DOI
https://doi.org/10.1007/s10151-019-02051-5

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