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Perianal fistül tedavisi: Geleneksel cerrahi yöntem ile yeni yaklaşımlarının sonuçlarının karşılaştırılması. Tek merkezli bir retrospektif kohort çalışması

Year 2020, Volume: 4 Issue: 7, 582 - 586, 01.07.2020
https://doi.org/10.28982/josam.684298

Abstract

Amaç: Anal fistül iyi tanımlanmış bir hastalıktır ancak kesin bir cerrahi teknik geliştirilmemiştir. Hastanemizde 2012-2018 yılları arasında perianal fistül nedeniyle cerrahi tedavi uygulanan hastaları değerlendirmek için tek merkezli, retrospektif bir kohort çalışması yürüttük. Çalışmanın amacı, farklı cerrahi tekniklerin (Fistülotomi / fistülektomi ve seton, Video Destekli Anal Fistül Tedavisi (VAAFT), Mikro-parçalanmış yağ dokusu enjeksiyonu, Lipogems®) sonuçlarını karşılaştırmaktı.
Yöntemler: Elektif cerrahi için uygun olan anal fistüllü 103 hastadan oluşan bir kohort, 2012 ve 2018 yılları arasında Ferrara'daki Sant’Anna Hastanesi’nde opere edildi. Tüm hastalara fistül traktını ve iç açıklığı belirlemek için ameliyat öncesi rektal tuşe ve manyetik rezonans görüntüleme (MRI) uygulandı. Hastalar, geçirdikleri her ameliyat için birer tane olmak üzere 4 gruba ayrıldı: Fistülotomi / fistülektomi ve seton, Video Destekli Anal Fistül Tedavisi (VAAFT), Mikro parçalı yağ dokusu enjeksiyonu, Lipogems®). Ameliyattan bir hafta sonra öznel ağrıyı değerlendirmek için sayısal derecelendirme ölçeği (NRS) kullanıldı ve sonuçlar kaydedildi. Puanlar, 0, hiç ağrı yok, ile 10, karşılaşılan en şiddetli ağrı, arasında değişmekteydi. Birincil sonlanım noktası, 1 yıllık takipte fistül rekürrensiydi. İkincil sonlanım noktası, ameliyat sonrası ağrının değerlendirilmesiydi.
Bulgular: Ortanca yaşı 50 olan (aralık 21-89 yaş) 71 erkek ve 32 kadın çalışmaya dahil edildi. Bunlardan 79 hastaya yeni teşhis konulmuş, diğer 24 hasta daha önce ameliyat olmuş ve nüksetmişti. Anal fistül için toplam 118 cerrahi operasyon yapıldı. Takip süresince VAAFT sonrası 13 hastada, Mikro parçalı yağ dokusu enjeksiyonu sonrası 3 hastada, fistülotomi sonrası 4 hastada, fistülotomi sonrası 12 hastada, seton yerleştirme sonrasında 10 hastada ve Lipogems® tekniğinden sonra 8 hastada anal fistül rekürrensi gözlendi. Ameliyattan bir hafta sonra ağrı tüm hastalar tarafından 0 ile 10 arasında bir ölçekte değerlendirildi. VAAFT, mikro parçalı yağ dokusu enjeksiyonu, fistülotomi, fistülektomi, seton yerleştirme ve Lipogems® tekniği uygulanan hastaların ortalama skorları sırasıyla 1 (0- 5), 1.5 (0-8), 5 (3-8), 6.8 (5-9), 4.2 (2-6) ve 0’dı (0-2).
Sonuç: Bu çalışma anal fistül yönetimindeki zorlukları ve çeşitli cerrahi seçenekleri sunmaktadır. VAAFT ve Mikro-parçalanmış yağ dokusu enjeksiyonu, anal fistül yönetiminde güvenli ve uygulanabilir seçenekler gibi görünmektedir ve kısa süreli iyileşme oranları, kontinans üzerinde kalıcı bir etki olmaksızın kabul edilebilirdir. Bununla birlikte, uzun vadeli sonuçları olan güvenilir veri yetersizliği olduğundan, bu teknikler, bu nedenle memnuniyetle karşılanmaktadır. Lipogems ® tekniği güvenli ve tekrarlanabilir bir işlemdir, ancak ne yazık ki deneyimlerimize göre, tekrarlayan sfinkterik anal fistülü olan hastalarda fistül iyileşmesini desteklememektedir. Bu tekniğin birinci basamak tedavi olarak kullanılmasını önermiyoruz.

References

  • 1. Sherief S, Steven DW. Idiopathic fistula-in-ano. World J Gastroenterol. 2011;17(28):3277-85.
  • 2. Sandborn WJ, Fazio VW, Feagan BG, Hanauer SB. AGA technical review on perianal Crohn’s disease. Gastroenterology. 2003;125(5):1508–30.
  • 3. Amato A, Bottini C, De Nardi P, Giamundo P, Lauretta A, Realis LA, et al Evaluation and managementof perianal abscess and anal fistula: a consensus statement developed by the Italian Society of Colorectal Surgery (SICCR). Tech Coloproctol. 2015;19(10):595–606.
  • 4. Limura E, Giordano P. Modern management of anal fistula. World J Gastroenterol. 2015;21(1):12-20.
  • 5. Dige A, Tarri EH, Agnholt J, Ginnerup BP, Tencerova M, Kassem M, et al. Efficacy of Injection of Freshly Collected Autologous Adipose Tissue Into Perianal Fistulas in Patients With Crohn’s Disease. Gastroenterology. 2019 Jun;156(8):2208-2216.e1.
  • 6. Naldini G, Sturiale A, Fabiani B, Giani I, Menconi C. Micro-fragmented adipose tissue injection for the treatment of complex anal fistula: a pilot study accessing safety and feasibility. Tech Coloproctol. 2018;22(2):107-13.
  • 7. Bubbers EJ, Cologne KG: Management of complex anal fistulas. Clin Colon Rectal Surg. 2016;29:43–9.
  • 8. Kontovounisios C, Tekkis P, Tan E, Rasheed S, Darzi A, Wexner SD. Adoption and success rates of perineal procedures for fistula-in-ano: a systematic review. Colorectal Dis. 2016;18(5):441–58.
  • 9. Adegbola SO, Sahnan K, Pellino G, Tozer JP, Hart A, Phillips RKS, et al. Short-term efficacy and safety of three novel sphincter-sparing techniques for anal fistulae: a systematic review. Tech in Coloproctol. 2017;21(10):775-82. doi: 10.1007/s10151-017-1699-4
  • 10. Atkin GK, Martins J, Tozer JP, Ranchod P, Phillips R. For many high anal fistulas, lay open is still a good option. Tech Coloproctol. 2011;15:143–50. doi:10.1007/s10151-011-0676-6
  • 11. Tozer P, Sala S, Cianci V, Kalmar K, Atkin GK, Rahbour G, et al. Fistulotomy in the tertiary setting can achieve high rates of fistula cure with an acceptable risk of deterioration in continence. J Gastrointest Surg. 2013;17:1960–5. doi:10.1007/s11605-013-2198-1
  • 12. Schwandner O. Video-assisted anal fistula treatment (VAAFT) combined with advancement flap repair in Crohn’s disease. Tech Coloproctol. 2013;17:221–5. doi:10.1007/s10151-012-0921-7
  • 13. Wałęga P, Romaniszyn M, Nowak W. VAAFT: a new minimally invasive method in the diagnostics and treatment of anal fistulas–initial results. Pol Przegl Chir. 2014;86:7–10. doi:10.2478/pjs- 2014-0002.
  • 14. Mohammad Z, Muhammad IK, Mukhtar A, Muhammad I, Muhammad AK. VAAFT: video assisted Anal fistula treatment; bringing revolution in Fistula treatment. Pak J Med Sci. 2015;31:716–21. doi:10.12669/pjms.315.6836
  • 15. Caplan AI. Adult mesenchymal stem cells for tissue engineering versus regenerative medicine. J Cell Physiol. 2007;213(2):341–7.
  • 16. Tremolada C, Colombo V, Ventura C. Adipose Tissue and mesenchymal stem cells: state of the art and Lipogems (R) technology development. Curr Stem Cell Rep. 2016;2:304–12.
  • 17. Panes J, Garcia-Olmo D, Van AG, Colombel JF, Reinisch W, Baumgart DC, et al. Expanded allogeneic adipose-derived mesenchymal stem cells (Cx601) for complex perianal fistulas in Crohn’s disease: a phase 3 randomised, double-blind controlled trial. Lancet. 2016;388(10051):1281–90.
  • 18. Kılıç A, Tilev SM, Başak F, Şişik A. Rectal Flap Experience in High Transsphincteric Cryptoglandular Anal Fistula. J Surg Med. 2019;3(10):746-8. doi: 10.28982/josam.636918

Treatment of fistula-in-ano: Outcome comparison between traditional surgery and novel approaches. A retrospective cohort study in a single center

Year 2020, Volume: 4 Issue: 7, 582 - 586, 01.07.2020
https://doi.org/10.28982/josam.684298

Abstract

Aim: Fistula-in-ano is a well described disease but no definitive surgical technique has been developed. We conducted a retrospective cohort study in a single center to evaluate patients who underwent surgical treatment of a perianal fistula from 2012 to 2018 in our hospital. The aim of the study was to compare the outcome of different surgical techniques (Fistulotomy/fistulectomy and seton, Video-Assisted Anal Fistula Treatment (VAAFT), Micro-fragmented adipose tissue injection, Lipogems®).
Methods: A cohort of 103 patients with anal fistula who qualified for elective surgery between 2012 and 2018 were recruited at Sant’Anna Hospital in Ferrara. All patients underwent a digital rectal examination and preoperative magnetic resonance imaging (MRI) to identify the fistula tract and internal opening. Patients were divided into 4 groups, one for each type of surgery they underwent: Fistulotomy/fistulectomy and seton, Video-Assisted Anal Fistula Treatment (VAAFT), Micro-fragmented adipose tissue injection, Lipogems®). Numerical rating scale (NRS) was used to assess subjective pain one week after surgery and documented. The scale ranged from 0 to 10, where 0 stands for no pain and 10 stands for worst pain ever faced. Primary end point was fistula recurrence at 1 year of follow-up. Secondary end point was evaluation of post-operative pain.
Results: There were 71 males and 32 females, with a median age of 50 years (range 21-89 years). Among them, 79 patients were newly diagnosed, the other 24 patients had undergone previous surgery and had recurrence. In total, 118 surgical operation were performed for anal fistula. During the follow-up period, anal fistula recurrence was observed in 13 patients after VAAFT, 3 patients after Micro-fragmented adipose tissue injection, 4 after fistulotomy, 12 after fistulectomy, 10 after seton placement and 8 after Lipogems® technique. One week after surgery, pain was evaluated by all patients on a scale from 0 to 10. The mean scores of patients who underwent VAAFT, micro-fragmented adipose tissue injection, fistulotomy, fistulectomy, seton placement and Lipogems® technique were 1 (0-5), 1.5 (0-8), 5 (3-8), 6.8 (5-9), 4.2 (2-6) and 0 (0-2), respectively.
Conclusion: This study presents the difficulties in managing anal fistulas and the variety of surgical options. VAAFT and Micro-fragmented adipose tissue injection appear to be safe and feasible options in the management of anal fistula, and short-term healing rates are acceptable with no sustained effect on continence. There is, however, a paucity of robust data with long-term outcomes. These techniques are thus welcome additions. Lipogems ® technique is a safe and reproducible procedure, unfortunately according to our experience, it does not promote fistula healing in patients with recurrent inter-sphincteric anal fistula. We do not suggest the use of this technique as a first-line treatment.

References

  • 1. Sherief S, Steven DW. Idiopathic fistula-in-ano. World J Gastroenterol. 2011;17(28):3277-85.
  • 2. Sandborn WJ, Fazio VW, Feagan BG, Hanauer SB. AGA technical review on perianal Crohn’s disease. Gastroenterology. 2003;125(5):1508–30.
  • 3. Amato A, Bottini C, De Nardi P, Giamundo P, Lauretta A, Realis LA, et al Evaluation and managementof perianal abscess and anal fistula: a consensus statement developed by the Italian Society of Colorectal Surgery (SICCR). Tech Coloproctol. 2015;19(10):595–606.
  • 4. Limura E, Giordano P. Modern management of anal fistula. World J Gastroenterol. 2015;21(1):12-20.
  • 5. Dige A, Tarri EH, Agnholt J, Ginnerup BP, Tencerova M, Kassem M, et al. Efficacy of Injection of Freshly Collected Autologous Adipose Tissue Into Perianal Fistulas in Patients With Crohn’s Disease. Gastroenterology. 2019 Jun;156(8):2208-2216.e1.
  • 6. Naldini G, Sturiale A, Fabiani B, Giani I, Menconi C. Micro-fragmented adipose tissue injection for the treatment of complex anal fistula: a pilot study accessing safety and feasibility. Tech Coloproctol. 2018;22(2):107-13.
  • 7. Bubbers EJ, Cologne KG: Management of complex anal fistulas. Clin Colon Rectal Surg. 2016;29:43–9.
  • 8. Kontovounisios C, Tekkis P, Tan E, Rasheed S, Darzi A, Wexner SD. Adoption and success rates of perineal procedures for fistula-in-ano: a systematic review. Colorectal Dis. 2016;18(5):441–58.
  • 9. Adegbola SO, Sahnan K, Pellino G, Tozer JP, Hart A, Phillips RKS, et al. Short-term efficacy and safety of three novel sphincter-sparing techniques for anal fistulae: a systematic review. Tech in Coloproctol. 2017;21(10):775-82. doi: 10.1007/s10151-017-1699-4
  • 10. Atkin GK, Martins J, Tozer JP, Ranchod P, Phillips R. For many high anal fistulas, lay open is still a good option. Tech Coloproctol. 2011;15:143–50. doi:10.1007/s10151-011-0676-6
  • 11. Tozer P, Sala S, Cianci V, Kalmar K, Atkin GK, Rahbour G, et al. Fistulotomy in the tertiary setting can achieve high rates of fistula cure with an acceptable risk of deterioration in continence. J Gastrointest Surg. 2013;17:1960–5. doi:10.1007/s11605-013-2198-1
  • 12. Schwandner O. Video-assisted anal fistula treatment (VAAFT) combined with advancement flap repair in Crohn’s disease. Tech Coloproctol. 2013;17:221–5. doi:10.1007/s10151-012-0921-7
  • 13. Wałęga P, Romaniszyn M, Nowak W. VAAFT: a new minimally invasive method in the diagnostics and treatment of anal fistulas–initial results. Pol Przegl Chir. 2014;86:7–10. doi:10.2478/pjs- 2014-0002.
  • 14. Mohammad Z, Muhammad IK, Mukhtar A, Muhammad I, Muhammad AK. VAAFT: video assisted Anal fistula treatment; bringing revolution in Fistula treatment. Pak J Med Sci. 2015;31:716–21. doi:10.12669/pjms.315.6836
  • 15. Caplan AI. Adult mesenchymal stem cells for tissue engineering versus regenerative medicine. J Cell Physiol. 2007;213(2):341–7.
  • 16. Tremolada C, Colombo V, Ventura C. Adipose Tissue and mesenchymal stem cells: state of the art and Lipogems (R) technology development. Curr Stem Cell Rep. 2016;2:304–12.
  • 17. Panes J, Garcia-Olmo D, Van AG, Colombel JF, Reinisch W, Baumgart DC, et al. Expanded allogeneic adipose-derived mesenchymal stem cells (Cx601) for complex perianal fistulas in Crohn’s disease: a phase 3 randomised, double-blind controlled trial. Lancet. 2016;388(10051):1281–90.
  • 18. Kılıç A, Tilev SM, Başak F, Şişik A. Rectal Flap Experience in High Transsphincteric Cryptoglandular Anal Fistula. J Surg Med. 2019;3(10):746-8. doi: 10.28982/josam.636918
There are 18 citations in total.

Details

Primary Language English
Subjects Surgery
Journal Section Research article
Authors

Nicolò Fabbri 0000-0001-7039-3717

Simona Ascanelli This is me 0000-0002-1423-8576

Francesco D'urbano This is me 0000-0001-9704-8980

Giuseppe Resta This is me 0000-0002-1649-2279

Giorgio Cavallesco This is me 0000-0003-3926-7020

Paolo Carcoforo This is me 0000-0003-1630-0174

Publication Date July 1, 2020
Published in Issue Year 2020 Volume: 4 Issue: 7

Cite

APA Fabbri, N., Ascanelli, S., D’urbano, F., Resta, G., et al. (2020). Treatment of fistula-in-ano: Outcome comparison between traditional surgery and novel approaches. A retrospective cohort study in a single center. Journal of Surgery and Medicine, 4(7), 582-586. https://doi.org/10.28982/josam.684298
AMA Fabbri N, Ascanelli S, D’urbano F, Resta G, Cavallesco G, Carcoforo P. Treatment of fistula-in-ano: Outcome comparison between traditional surgery and novel approaches. A retrospective cohort study in a single center. J Surg Med. July 2020;4(7):582-586. doi:10.28982/josam.684298
Chicago Fabbri, Nicolò, Simona Ascanelli, Francesco D’urbano, Giuseppe Resta, Giorgio Cavallesco, and Paolo Carcoforo. “Treatment of Fistula-in-Ano: Outcome Comparison Between Traditional Surgery and Novel Approaches. A Retrospective Cohort Study in a Single Center”. Journal of Surgery and Medicine 4, no. 7 (July 2020): 582-86. https://doi.org/10.28982/josam.684298.
EndNote Fabbri N, Ascanelli S, D’urbano F, Resta G, Cavallesco G, Carcoforo P (July 1, 2020) Treatment of fistula-in-ano: Outcome comparison between traditional surgery and novel approaches. A retrospective cohort study in a single center. Journal of Surgery and Medicine 4 7 582–586.
IEEE N. Fabbri, S. Ascanelli, F. D’urbano, G. Resta, G. Cavallesco, and P. Carcoforo, “Treatment of fistula-in-ano: Outcome comparison between traditional surgery and novel approaches. A retrospective cohort study in a single center”, J Surg Med, vol. 4, no. 7, pp. 582–586, 2020, doi: 10.28982/josam.684298.
ISNAD Fabbri, Nicolò et al. “Treatment of Fistula-in-Ano: Outcome Comparison Between Traditional Surgery and Novel Approaches. A Retrospective Cohort Study in a Single Center”. Journal of Surgery and Medicine 4/7 (July 2020), 582-586. https://doi.org/10.28982/josam.684298.
JAMA Fabbri N, Ascanelli S, D’urbano F, Resta G, Cavallesco G, Carcoforo P. Treatment of fistula-in-ano: Outcome comparison between traditional surgery and novel approaches. A retrospective cohort study in a single center. J Surg Med. 2020;4:582–586.
MLA Fabbri, Nicolò et al. “Treatment of Fistula-in-Ano: Outcome Comparison Between Traditional Surgery and Novel Approaches. A Retrospective Cohort Study in a Single Center”. Journal of Surgery and Medicine, vol. 4, no. 7, 2020, pp. 582-6, doi:10.28982/josam.684298.
Vancouver Fabbri N, Ascanelli S, D’urbano F, Resta G, Cavallesco G, Carcoforo P. Treatment of fistula-in-ano: Outcome comparison between traditional surgery and novel approaches. A retrospective cohort study in a single center. J Surg Med. 2020;4(7):582-6.