*Małgorzata Kołodziejczak1, 2, Przemysław Ciesielski1, 2
Treatment of anal fistula – a review of recent 2023/2024 reports
Leczenie przetok odbytu – przegląd najnowszych doniesień 2023/2024
1Warsaw Proctology Centre, Saint Elizabeth’s Hospital in Warsaw
2Department of General Surgery, Hospital in Ostrów Mazowiecka
Streszczenie
Sposób leczenia przetok odbytu, szczególnie wysokich, skomplikowanych, od lat wywołuje dyskusje i kontrowersje. Pojawiają się liczne doniesienia i algorytmy leczenia przetok, często ze sobą sprzeczne.
W pierwszej części artykułu autorzy dokonali przeglądu najciekawszych doniesień dotyczących leczenia przetok odbytu z ostatnich 2 lat. Druga część poświęcona jest omówieniu wytycznych Europejskiego Towarzystwa Chirurgów Kolorektalnych z 2023 roku dotyczących diagnostyki i leczenia ropni i przetok odbytu. Uzupełnienie stanowi autorski komentarz praktyczny.
W podsumowaniu zwrócono uwagę na fakt, że żadna z aktualnych prac nie zawiera zaleceń dotyczących kontroli pooperacyjnych po operacjach przetok. Jest to ważny element leczenia pacjenta z przetoką, w dużym stopniu pozwalający zapobiec nawrotom choroby. Większość rekomendacji jest spójnych z wydanymi w ostatnich latach, jakkolwiek kilka zaleceń jest nowatorskich.
Autorzy zachęcają do śledzenia aktualnego postępu wiedzy w pojawiających się corocznie Wytycznych Kolorektalnych Towarzystw Naukowych, zwracając jednak uwagę, że należy dostosowywać zalecenia do możliwości danego ośrodka oraz przy wyborze metody leczenia brać pod uwagę własne doświadczenia zawodowe.
Summary
The treatment of anal fistulas, high complicated ones in particular, has been generating debate and controversy for years. Many reports and algorithms for the treatment of fistula-in-ano, often contradicting each other, have been published.
The first part of the article is a review of the most interesting reports on the management of anal fistula published in the last 2 years. The second part discusses the 2023 guidelines of the European Society of Coloproctology for the diagnostic and therapeutic management of anal abscess and fistula. This section includes our practical commentary.
It was concluded that none of the recent papers offers recommendations for postoperative follow-up in anal fistula, although this is an important element of the management of patients with anal fistula, which largely allows for preventing recurrence. Most recommendations are consistent with those published in recent years, although there are a few novel propositions.
We encourage keeping up with current advances in the annual Guidelines of Colorectal scientific societies, noting, however, that the recommendations should be tailored to the capabilities of the individual centres, whose professional experience should be considered when choosing the therapeutic strategy.
Introduction
The treatment of anal fistulas, high complicated ones in particular, has been generating debate and controversy for years. Many papers on the management of anal abscess and fistula were published in 2023.
In this article, we present those we found most interesting. Some of the conclusions and recommendations discussed in the 2023 reports do not significantly deviate from the previous practice. In their 2023 article, Jimenez and Mandava recommend (1):
– incision and drainage for anal abscesses,
– fistulotomy for simple and low fistulas,
– ligation of intersphincteric fistula tract (LIFT) or advancement flap for high and complex fistula-in-ano.
The authors recommend a separate management for fistulas in Crohn’s disease.
Comment: This is consistent with previous recommendations; the actual procedure is generally preceded by loose seton drainage in high fistulas.
Another paper dedicated only to Crohn’s fistulas confirms that steroids and/or infliximab should only be used after successful drainage of the infection site using a seton. Similarly, antibiotic therapy should be preceded by seton drainage in tuberculosis- or hidradenitis-related fistulas (2).
Comment: It is not new that infection should be limited, fluid collections opened and fistulous tracts drained before immunosuppressive treatment or steroids are used.
In our opinion, a very interesting novel paper on Crohn’s fistulas was presented by Perez and Eisenstein (3). They showed that a chronic fistula can undergo malignant transformation in patients with Crohn’s disease. Histopathological verification is particularly important if a properly draining fistula suddenly starts to “misbehave”. The authors pointed out that this may indicate malignancy, not necessarily squamous cell carcinoma, but sometimes adenocarcinoma. The authors recommend extending the diagnosis with MRI for differentiation (3).
Comment: Fistulous carcinoma is described occasionally; however, persistent inflammation (such as hidradenitis or anorectal Crohn’s disease) predisposes to skin cancer.
Intraoperative biopsy specimens are obligatory, but the authors’ recommendation to verify histopathology during long-term drainage is innovative and requires attention.
A paper on fistulous bacteriology was also published in 2023. Yang et al. (4) showed that mainly cutaneous bacteria are found in fistulae, i.e. from the external outlet area, rather than from the bowel (the internal outlet). This fact may have implications for future planning of antibiotic treatment in the case of inflammatory infiltration or abscess.
Comment: our experience showed that most cultures from fistulous tracts and abscesses grew Escherichia coli and anaerobic Bacteroides spp. (5). The results of the authors from the cited paper are surprising.
A unique and interesting paper was written during the 2020-2022 COVID pandemic, when patients with transsphincteric fistulae had no access to surgery. These patients were treated with silicone cutting setons. After 4 months, up to 91.5% of patients were cured without significant complications, including faecal incontinence (6).
Comment: Cutting seton has been accepted as treatment method for low transsphincteric fistulas for many years. It should be assumed that the patients treated in the cited study had low fistulas involving less than 30% of the sphincter mass, otherwise the absence of postoperative complications in the form of incontinence would be surprising. In our opinion, fistulotomy with immediate sphincter repair provides better cosmetic and functional outcomes and is associated with better healing.
An interesting meta-analysis of many studies involving more than 2,200 patients with complicated fistula was presented by An et al (7). The authors compared three treatment methods: fistulotomy, fistulectomy with sphincter repair and LIFT. They concluded that fistulectomy is the most effective and safest treatment method.
Comment: Since the above 3 methods are used in different types of fistula, it is difficult to compare the treatment outcomes. For example, “isolated fistulectomy” may lead to incontinence in high complicated fistula.
We have similar doubts about another paper presented by Huang et al. (8), which compared transanal opening of the intersphincteric space (TROPIS), stem cell transplantation (SCT) and LIFT. The authors of this paper showed:
– the highest cure rate in patients with complex anal fistula treated with TROPIS,
– the lowest recurrence rate in SCT,
– the least postoperative complications in LIFT.
Comment: Since each of the above methods is used in a different type of fistula (with a different anatomical course), it is difficult to compare them. In 2024, Luo et al. (9) published the outcomes of stapler-assisted transvaginal repair of rectovaginal fistula. The authors showed a higher success rate for this procedure (less recurrences and postoperative complications) compared to advancement flap (9).
In 2023, ESCP Guidelines for the diagnosis, classification and preoperative investigation of anal abscess and fistula were published (10). More recent classifications for anal fistulas (e.g. Garg) were not included in the recommendations (11, 12).
The following are the key recommendations for the treatment of anal abscess included in the Guidelines:
– Immediate fistulotomy at abscess incision is not recommended.
– Routine packing at abscess incision is not recommended.
– Empirical antibiotics following abscess incision and drainage are not recommended to prevent fistula development.
– Antibiotic therapy following abscess incision may be considered in septic and immunodeficient patients.
Comment: These guidelines are consistent with previous recommendations. For many years, most surgeons have emphasised that rapid incision and drainage rather than antibiotic therapy is an appropriate treatment for an abscess. Full antibiotic therapy is used for specific patients with immune deficits.
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Piśmiennictwo
1. Jimenez M, Mandava N: Anorectal Fistula. 2023 Feb 2. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan–. PMID: 32809492.
2. Nottingham JM, Rentea RM: Anal Fistulotomy. 2023 Aug 8. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan–. PMID: 32310458.
3. Perez S, Eisenstein S: Cancer in Anal Fistulas. Clin Colon Rectal Surg 2023; 37(1): 41-45.
4. Yang J, Li L, Su W et al.: Microbiomic signatures of anal fistula and putative sources of microbes. Front Cell Infect Microbiol 2024; 14: 1332490.
5. Kesler M, Koch A, Rychlik M et al.: Ocena zasadności stosowanej profilaktyki antybiotykowej (klindamycyny) u pacjentów operowanych z powodu przetoki odbytu w materiale własnym. Nowa Med 2021; 1: 5-11.
6. Tomasicchio G, Giove C, Dezi A et al.: The management of low trans-sphincteric anal fistula during the COVID-19 pandemic: revisiting the role of the seton. Updates Surg 2024; 76(1): 163-167.
7. An Y, Gao J, Xu J et al.: Efficacy and safety of 13 surgical techniques for the treatment of complex anal fistula, non-Crohn CAF: a systematic review and network meta-analysis. Int J Surg 2024; 110(1): 441-452.
8. Huang H, Ji L, Gu Y et al.: Efficacy and Safety of Sphincter-Preserving Surgery in the Treatment of Complex Anal Fistula: A Network Meta-Analysis Front Surg 2022; 9: 825166.
9. Luo MY, Chen WP, Chen HX et al.: Stapled transperineal rectovaginal fistula repair for low- and mid-level rectovaginal fistulas: A comparison study with rectal mucosal advancement flap repair. Asian J Surg 2024: S1015-9584(24)00002-2.
10. Reza L, Gottgens K, Kleijnen J et al.: Guidelines European Society of Coloproctology: Guidelines for diagnosis and treatment of cryptoglandular anal fistula. Colorectal Dis 2024; 26: 145-196.
11. Garg P: Garg classification for anal fistulas: I sit better than existing classification? – a review. Indian J Surg 2018; 80(6): 606-608.
12. Garg P: Assessing validity of existing fistula-in-ano classification In a cohort of 848 operated and MRI-assessed anal fistula patient: Cohort study. Ann Med Surg (Lond) 2020; 59: 122-126.
