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Fistula: Coloproctology

Treatment of perianal fistulas in Crohn's disease by local injection of antibody to TNF-alpha accounts for a favourable clinical response in selected cases: A pilot study.
Asteria CR, Ficari F, Bagnoli S, Milla M, Tonelli F
Scand J Gastroenterol. 2006 Sep;41(9):1064-72.

Objective. Intravenously administered infliximab, a monoclonal antibody directed against tumor necrosis factor-alpha, has been proven to be efficacious in the treatment of fistulas in patients with Crohn's disease. It has recently been suggested that local injections of infliximab might be beneficial as well. The aim of this study was to assess whether infliximab could play an effective role in the local treatment of perianal fistulas in Crohn's disease. Material and methods. Local infliximab injections were administered to 11 patients suffering from Crohn's disease complicated by perianal disease. Eligible subjects included Crohn's disease patients with single or multiple draining fistulas, regardless of status of luminal disease at baseline. Patients, however, were excluded from the study if they had perianal or rectal complications, such as abscesses or proctitis or if they had previously been treated with infliximab. Twenty-milligram doses of infliximab were injected along the fistula tract and around both orifices at baseline and then every 4 weeks for up to 16 weeks or until complete cessation of drainage. No further doses were administered to patients who did not respond after three injections. Efficacy was measured in terms of response (a reduction in fistula drainage of 50% or more) and remission (complete cessation of fistula drainage for at least 4 weeks). Time to loss of response and health-related quality of life were also evaluated. Results. Overall, 8/11 patients (72.7%) responded to the therapy and 4/11 (36.4%) reached remission, whereas 3/11 patients (27.2%) showed no response. Response or remission was very much dependent on the location of the fistulas, and time to loss of response was generally longer for patients who reached remission compared to patients in response. Changes in health-related quality of life, as assessed by the Inflammatory Bowel Disease Questionnaire (IBDQ), also reflected response or remission, with more marked improvements associated with remission. After a mean 10.5 months' follow-up (range 7-18 months), 6/11 patients (54.5%) are in response and 4/11 patients (36.4%) are in remission. No adverse events have been observed in this cohort of patients. Conclusions. Local injections of infliximab along the fistula tract seem to be an effective and safe treatment of perianal fistulas in Crohn's disease. However, further controlled clinical investigations are warranted.

Clinical and manometric results of endorectal advancement flaps for complex anal fistula.
Uribe N, Millan M, Minguez M, Ballester C, Asencio F, Sanchiz V, Esclapez P, Del Castillo JR
Int J Colorectal Dis. 2006 Aug 2;.e-pub

BACKGROUNDS AND AIM: Endorectal advancement flap repair is a well-recognized method for the treatment of complex anorectal fistula. The purpose of this study was to prospectively assess the clinical and functional results of endorectal advancement flaps for complex anorectal fistula and to identify factors that affect outcome. MATERIALS AND METHODS: A prospective study of 56 patients was performed. Clinical and functional results were studied using the Wexner continence scale and anal manometry before and after surgery. Factors associated with recurrence and incontinence were analyzed by univariate and multivariate regression analysis. RESULTS: Sixty endorectal flaps were constructed in 56 patients. Mean age was 49 years (range 24-74). The fistula was of cryptoglandular origin in 91.1% cases. Mean follow-up was 43.8 months. The technique was repeated in four patients because of recurrence (7.1%), with subsequent healing in all cases. There were significant reductions in maximum resting pressure 3 months after surgery (83.6+/-33.2 vs 45.6+/-18.3, p<0.001) and maximum squeeze pressure (208.8+/-91.5 vs 169.5+/-75, p<0.001). Before surgery, five patients (8.9%) reported incontinence symptoms. After surgery, 78.6% patients had normal continence, seven patients (12.5%) complained of minor incontinence, and five (9%) had major continence disturbances. None of the variables studied (age, sex, previous fistula surgery, rectovaginal fistula, and Crohn's disease) affected the outcome of the procedure in multivariate analysis. CONCLUSIONS: Endorectal advancement flap repair is an effective technique for complex anal fistula, with a low recurrence rate (7.1%). Patients (21.4%) reported disturbed anal continence. It is still not possible to identify factors that are predictive of failure or incontinence.

Transperineal Repair of Persistent Rectovaginal Fistulas Using an Acellular Cadaveric Dermal Graft (AlloDerm((R))).
Shelton AA, Welton ML
Dis Colon Rectum. 2006 Aug 4;.

A number of surgical techniques have been described to treat rectovaginal fistulas. Recurrent or persistent fistulas after previous repair can be particularly difficult to treat. We report a novel technique used to successfully repair rectovaginal fistulas after failed mucosal advancement flap procedures using a transperineal-layered closure with an interposed graft of acellular cadaveric dermis (Alloderm((R))).

Novel Biomaterials in the Management of Anal Fistulas.
Hammond TM, Lunniss PJ
Dis Colon Rectum. 2006 Aug 11;.

The Authors Reply.
Dis Colon Rectum. 2006 Sep 4;.

[Perianal abscess and anal fistula in infancy and childhood : A congenital etiology?]
Meyer T, Weininger M, Hocht B
Chirurg. 2006 Sep 1;.

BACKGROUND: Perianal abscess and anal fistula in childhood are commonly treated in the same way as abscess and fistula in adults. We questioned whether they represent a cryptoglandular infection, as in adults, or two different diseases with the same symptoms.MATERIALS AND METHODS: We retrospectively analyzed all medical records of 80 children (seven male, 73 female) who underwent surgical treatment for primary perianal abscess or primary anal fistula during a 10-year period. The records were analyzed concerning age at appearance of lesion, sex, diagnosis (fistula and/or abscess), and anatomic localization of the lesion.RESULTS: Of all the children, 67.5% were treated during their 1st year of life and another 10% during their 2nd year (group 1: 77.5%, n=62). Only 22.5% were 3 or older (group 2, n=18). Group 1 contained significantly more male infants (m:f 30:1). However, much more balanced sex distribution was detected in group 2 (m:f 2.6:1), similarly to adults. Analyzing anatomic localization, a second important difference could be found: in contrast to group 2, almost two thirds of all anal fistulas/abscesses in group 1 were localized horizontally between 3:00 and 9:00 o'clock in crown-rump position.CONCLUSIONS: Divergences in preference of age, sex, and localization suggest a congenital etiology for anal fistulas and perianal abscesses in children.

Randomized clinical trial of local gentamicin-collagen treatment in advancement flap repair for anal fistula.
Gustafsson UM, Graf W
Br J Surg. 2006 Sep 4;.

BACKGROUND:: Endoanal advancement flap repair is widely used in sphincter-preserving surgery for anal fistula, but the high recurrence rate is a major problem. A possible cause of non-healing is local infection of the flap. The aim of this study was to evaluate whether local antibiotic treatment with gentamicin-collagen improves healing after endoanal advancement flap repair for anal fistula. METHODS:: Eighty-three patients (52 men and 31 women; mean age 47 (range 17-71) years) who had endoanal advancement flap repair for anal fistula between September 1998 and January 2004 were randomized to surgery with (42 patients) or without (41 patients) application of gentamicin-collagen beneath the flap. Patients were evaluated at 1-3 and 12 months after surgery for healing and/or recurrence. RESULTS:: The overall healing rate with no recurrence at 1 year after surgery was 57 per cent (47 of 83). Twenty-six of 42 patients randomized to gentamicin-collagen healed primarily compared with 21 of 41 patients randomized to surgery only. There were no overall differences in healing rate according to sex, previous fistula surgery, complexity of fistula, smoking habit or body mass index. CONCLUSION:: Endoanal advancement flap repair for anal fistula has a fairly high primary recurrence rate. Healing was not significantly improved by local application of gentamicin-collagen. Copyright (c) 2006 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.


A diverticular 'pain in the bottom'.
Bardhan SK, Morgan E, Daniels IR, Mortensen NJ
Ann R Coll Surg Engl. 2006 Jul;88(4):W 1-2.

This is the case of a 40-year-old man with a gluteal abscess as the first presentation of diverticular disease. As well as the unusual site, imaging revealed the lack of a connective tract between the abscess and the abdominal cavity or retroperitoneum. In addition, a lack of gastrointestinal symptoms made this case very unusual. Hence, this highlights the need for a high index of clinical suspicion when the usual clinical pointers that guide to the diagnosis of diverticulitis are absent.

Computer-assisted evaluation of perianal fistula activity by means of anal ultrasound in patients with Crohn's disease.
Caprioli F, Losco A, Vigano C, Conte D, Biondetti P, Forzenigo LV, Basilisco G
Am J Gastroenterol. 2006 Jul;101(7):1551-8.

OBJECTIVES: Assessment of the activity of perianal fistulas may be of clinical relevance in patients with Crohn's disease. Fistula activity is currently evaluated by means of magnetic resonance imaging; anal ultrasound can also be used, but its diagnostic performance in this setting remains to be defined. Our aims were to evaluate the agreement between clinical examination, magnetic resonance imaging, and anal ultrasound in assessing perianal fistula activity, and to apply computerized analysis to improve the assessment of ultrasound images. METHODS: Thirty-one consecutive patients with Crohn's perianal fistulas underwent clinical examination, and magnetic resonance and anal ultrasound imaging. Active fistulas were defined as the presence of active drainage or signs of local inflammation on clinical examination, and the definition was confirmed by surgical examination. Activity was assessed on the basis of T2 hyperintensity on magnetic resonance imaging and the degree of hypoechogenicity on anal ultrasound; the anal ultrasound images were also analyzed using dedicated computer image-analysis software. RESULTS: Twenty-five patients had an active fistula at clinical examination. The agreement between clinical examination and magnetic resonance imaging was good (k-value = 0.739), whereas that with anal ultrasound was only fair (k-value = 0.266-0.294); computer-assisted analysis of the anal ultrasound images improved the agreement from fair to good (k-value = 0.608-0.670). CONCLUSIONS: Anal ultrasound can be used to assess fistula track activity in patients with Crohn's disease. The diagnostic performance of the technique can be improved to values comparable with those of magnetic resonance imaging by using a computer-assisted evaluation of the anal ultrasound images.

Implantation of rectal cancer in an anal fistula: report of a case.
Ishiyama S, Inoue S, Kobayashi K, Sano Y, Kushida N, Yamazaki Y, Yanaga K
Surg Today. 2006;36(8):747-9.

A 53-year-old man who had had an anal fistula for 20 years was admitted to our hospital with a large intestinal obstruction. Barium enema and colonoscopy confirmed advanced rectal cancer and we palpated a soft tumor, 3 cm in diameter, with inflammatory induration on the right side of the rectum. After draining a perianal abscess caused by the anal fistula, we performed low anterior resection. Histological examination of the perianal necrotic tissue obtained during resection of the perianal tumor encompassing the anal fistula revealed adenocarcinoma. Since the histology of the perianal lesion was identical to that of the rectal cancer, a diagnosis of cancer implantation rather than carcinoma originating in the anal fistula was entertained. Although the recurrence of rectal cancer by mucosal implantation is not uncommon, the coincidental implantation of rectal cancer in an anal fistula is extremely rare.

Ethanol injection for ablation of an intractable digestive tract fistula: report of a case.
Matsuyama S, Sato S, Yoda Y, Kai K, Mitsuno M, Nakafusa Y, Miyazaki K
Surg Today. 2006;36(8):744-6.

We successfully occluded an intractable digestive tract fistula by injecting it with absolute ethanol after all other treatments failed. A 48-year-old man suffered from a complex and relapsing digestive tract fistula after curative surgery for advanced colon cancer invading the pancreas and duodenum. After conservative management by fasting, drainage, and irrigation failed, fibrin glue infusion achieved only transient occlusion. We performed surgical repair and he was discharged from hospital, at which time fistulography showed no fistula. However, 1 month later fistulography showed that the fistula had recurred and involved the transverse colon, stomach, and intrahepatic bile duct via the jejunum. Finally, we gave five injections of absolute ethanol into the fistula, which resulted in complete occlusion within 6 months. Considering its clinical efficacy, safety, and cost efficiency, we think that ethanol sclerotherapy is a feasible treatment for intractable digestive tract fistula when conservative therapy fails.


How should complex perianal Crohn's disease be treated in the Remicade era.
Poritz LS
J Gastrointest Surg. 2006 May;10(5):633-4.

Role of fibrin glue in the management of simple and complex fistula in ano.
Dietz DW
J Gastrointest Surg. 2006 May;10(5):631-2.

Treatment of pilonidal disease with laser epilation.
Schulze SM, Patel N, Hertzog D, Fares LG 2nd
Am Surg. 2006 Jun;72(6):534-7.

Pilonidal disease is a debilitating, chronic disease of the natal cleft. It mainly involves the sacrococcygeal region and the presentation varies from asymptomatic pits to painful draining abscesses. Treatment options vary from observation to wide excision. Unfortunately, surgical treatment often results in recurrence. The etiologic agent remains in question, as does the optimal treatment. Our objective was to assess the efficacy of laser epilation as an adjunctive therapy to surgical excision of the pilonidal sinus. Eighteen men and five women were treated with laser epilation in our office from 2001 to 2004. All patients had experienced recurrent folliculitis and had undergone some form of drainage procedure or prior excision. After surgical excision of the affected area, a Vasculite Plus laser was used for the epilation treatments. Each session involved 9 to 12 treatments and the patients underwent an average of two sessions. All 19 of the patients that remain in follow-up report no recurrence of their folliculitis or need for further surgical procedures. During treatment, six of the men and one of the women experienced a superficial wound dehiscence. All healed with local wound care and continued laser treatments. Laser epilation is an effective adjunctive therapy for the treatment of pilonidal disease. Although not curative in and of itself, the removal of hair allows better healing and decreases the chance of recurrence by removal of a significant etiology of pilonidal disease.

Randomized clinical and manometric study of advancement flap versus fistulotomy with sphincter reconstruction in the management of complex fistula-in-ano.
Perez F, Arroyo A, Serrano P, Sanchez A, Candela F, Perez MT, Calpena R
Am J Surg. 2006 Jul;192(1):34-40.

BACKGROUND: The goal of this study was to compare the outcomes of advancement flap (AF) versus fistulotomy with sphincter reconstruction (FSR) for primary complex fistula-in-ano in terms of recurrence and anal function. METHODS: A randomized clinical trial was conducted to compare AF with FSR. Preoperative and postoperative evaluation included physical examination, anal ultrasonography, and anal manometry, with a minimum follow-up period of 24 months. Anal continence was evaluated using the Wexner Continence Grading Scale (scale, 0-20). RESULTS: Sixty patients were randomized to AF (group 1, N = 30) or FSR (group 2, N = 30). Three patients from group 1 and 2 patients from group 2 were excluded from the study because of active sepsis at surgery. Fistulas were classified as high transsphincteric in 44 patients (80%) and suprasphincteric in 11 patients (20%). Demographic and clinical features showed no differences between the 2 groups. The mean Wexner Continence Grading Scale did not vary significantly after surgery in either group, and there was no difference between the groups. On anal manometry there was a significant decrease in the maximum resting pressure after surgery in both groups, and in the maximum squeeze pressure in the AF group, but neither the maximum resting pressure nor the maximum squeeze pressure differed significantly between groups, either before or after surgery. Two fistulas from each group recurred after surgery (7.4% and 7.1%, respectively). The mean follow-up period was 36 months (range, 24-52 mo). CONCLUSIONS: FSR compares with AF in terms of postoperative continence and recurrence. Anal continence and manometric values are not jeopardized in either technique.

Complex perirectal sepsis: clinical classification and imaging.
Zbar AP, Armitage NC
Tech Coloproctol. 2006 Jun;10(2):83-93. Epub 2006 Jun 19.

BACKGROUND: The use of specialized imaging to assess cryptogenic fistula-in-ano is selective, aimed at delineation of the site of the internal fistula opening and the relationship of the primary and secondary tracks and collections to the main levator plate. Advanced imaging also permits definition of the destructive effects of perirectal sepsis (e.g. internal or external anal sphincter damage, perineal body destruction and an ano- or rectovaginal fistula), which may require secondary reconstructive surgery.METHODS: We performed a PubMed search of outcomes for fistula management in the English and non-English literature, and summarized results regarding the accuracy of internal opening and horseshoe detection as well as the operative correlation for cryptogenic and non-cryptogenic fistula-in-ano using endoanal ultrasound (EAUS) and magnetic resonance (MR) imaging. Only literature defining these characteristics was included.RESULTS: The advantages and limitations of the main forms of imaging are discussed in this review with emphasis on EAUS and endoanal or pelvic phased-array MR fistulography. The new technique of transperineal sonography is highlighted. A small but important group of patients with complex fistula-in-ano require specialized imaging. There are specific limitations of endoanal ultrasound (EAUS) which necessitate pelvic phased-array MR imaging. Initial work suggests that EAUS may have a role in intraoperative use for image-guided drainage of recurrent abscesses where operative interpretation can be difficult. The coloproctologist in a tertiary referral center must acquire the skills of ultrasound performance in order to successfully treat fistulous disease, suggesting a role for formal imaging accreditation as part of coloproctological training.CONCLUSION: Future studies should determine both what sequential imaging algorithms for imaging are cost-effective as well as predictive of fistula cure.

CT-guided percutaneous pelvic abscess drainage in Crohn's disease.
Golfieri R, Cappelli A, Giampalma E, Rizzello F, Gionchetti P, Laureti S, Poggioli G, Campieri M
Tech Coloproctol. 2006 Jun;10(2):99-105. Epub 2006 Jun 19.

BACKGROUND: Percutaneous abscess drainage (PAD) is the current therapy for abdominal or pelvic collections. PAD has poorer curative rate for abscesses in Crohn's disease (CD), commonly complicated by wide fistulas and multiloculations.METHODS: We retrospectively evaluated abscess cure rate, complications and final outcome in 87 CD patients, 70 with spontaneous and 17 with postoperative pelvic abscesses, all treated with CT-guided PAD during the last 7 years.RESULTS: A 77% primary success rate and an 84.3% secondary success rate were obtained without major complications. The higher success rate for PAD was for postoperative (88.2%) rather than spontaneous abscesses (74.2%). Seventy-two percent of treated patients did not develop recurrent abscesses and underwent elective surgery up to 40 months later.CONCLUSION: PAD in pelvic abscess complicating CD is an effective alternative to early surgery with satisfactory curative success rates. In unsuccessful cases, due to wide fistulas or postoperative anastomotic dehiscence, PAD helped in planning elective surgery, reducing surgical complications.


Colovesical fistula complicating diverticular disease: one-stage resection.
Carvajal Balaguera J, Camunas Segovia J, Pena Gamarra L, Oliart Delgado de Torres S, Martin Garcia-Almenta M, Viso Ciudad S, Fernandez IP, Gomez Maestro P, Cerquella Hernandez C
Int Surg. 2006 Jan-Feb;91(1):17-23.

Colonic diverticular disease is common in developed countries, and its prevalence increases with age. Most affected individuals remain asymptomatic throughout their lives, and relatively few patients require surgical intervention for obstructive or inflammatory complications. Colovesical fistula is the most common type (65%) of fistula associated with colonic diverticular disease. Primary resection of sigmoid colon with colorectal anastomosis performed as a one-stage procedure is its definitive treatment and can be performed safely--as simple closure, using an omental flap, or through resection and closure of bladder defect--in 90% of the patients. We report our experience with four patients suffering from colovesical fistula who were treated with primary resection of sigmoid colon and colorectal anastomosis performed as a one-step procedure. In our experience, diverting colostomy or Hartmann intervention is not recommended because of the lack of fistula definitive resolution and the possibility of additional complications.

Management of a congenital H-type anorectal fistula by anterior sagittal anorectovaginoplasty (ASARVP).
Meyer T, Hocht B
Int J Colorectal Dis. 2006 May 18;.

Autologous fibroblasts transplant after infliximab administration: a new approach in Crohn's perianal fistulas? : Brief Clinical Report.
Ascanelli S, de Tullio D, Gregorio C, Azzena G, Occhionorelli S
Int J Colorectal D is. 2006 May 30;.


The use of muscle flaps for the management of recalcitrant gastrointestinal fistulas.
Cohen M, Grevious M
Clin Plast Surg. 2006 Apr;33(2):295-302.

Enterocutaneous fistulas can result from various conditions. Although some heal spontaneously, others persist or recur. This article describes how using muscle flaps may aid in managing recalcitrant gastrointestinal fistulas. Specific cases are cited.

Anal Tumor Diagnosed After the Recovery of Fournier Gangrene.
Elgin Y, Demirkasimoglu T, Kucukplakci B, Altundag MB, Altundag K, Misirlioglu C, Sanri E, Erkal H, Ugur I, Kara P, Ozgen A, Ozdamar N
Dig Dis Sci. 2006 Apr 27;.

Cyanoacrylate glue in the treatment of ano-rectal fistulas.
Barillari P, Basso L, Larcinese A, Gozzo P, Indinnimeo M
Int J Colorectal Dis. 2006 Apr 20;.

BACKGROUND AND AIMS: The management of anal fistula is debatable. Although several procedures have been described, none of them is free from complications, such as anal incontinence and anal pain. The purpose of this study was to evaluate the employment of a glue composed of N-butil-2-cyanoacrylate and methacryloxysulfolane (Glubran 2) to treat fistula-in-ano. PATIENTS AND METHODS: Twenty-one patients (14 men and 7 women) with cryptoglandular anal fistula were enrolled in the study and treated as day-cases. Fistulas were assessed both clinically and by trans-rectal endosonography with a rotating 10-MHz 360 degrees endoscopic probe. Assessment of continence was also performed. The fistula tract was identified, curetted and washed-out with normal saline and hydrogen peroxide; then the glue was injected from the syringe nozzle through a catheter previously inserted into the fistula. Additional treatments were performed when the first failed. RESULTS: Five of seven simple fistulas (71.4%) healed with primary glue treatment; the other two needed second and third injections, and both healed. Ten of 14 (71.4%) complex fistulas healed with primary treatment; of the other four patients, one showed signs of intolerance to cyanoacrylate, which required re-intervention to remove the applied glue. In the second patient, treatment was successful after a second session; in the third case, three glue injections were required; while the fourth patient was lost at follow-up after three unsuccessful sessions. The ratio of cumulative healing with only one treatment was 15/21 (71.4%), and the ratio of overall healing after more than one session was 19/21 (90.2%). There was no sign of recurrence of the disease after 18 months of follow-up. CONCLUSION: Cyanoacrylate glue seems to be ideal to treat fistula-in-ano, as it is a safe, cost-effective, repeatable and muscle-sparing technique. The incidence of recurrence is low, and post-procedure complicated fistulas or perianal abscesses were not reported.


Imaging of fistula in ano.
Halligan S, Stoker J
Radiology. 2006 Apr;239(1): 18-33.

Fistula in ano is a common condition that often recurs despite seemingly adequate surgery, usually because of infection that was missed at surgery. It is now increasingly recognized that preoperative imaging can help identify infection that would have otherwise gone unidentified. In particular, magnetic resonance (MR) imaging findings have been shown to influence surgery and markedly diminish the chance of recurrence; thus, preoperative imaging will become increasingly routine in the future. In this article, the authors describe the pathogenesis, classification, and imaging of fistula in ano, with an emphasis on MR imaging. Most important, the authors describe how the radiologist is well placed to answer the surgical riddles that must be solved for treatment to be effective.

Etanercept: effective in the management of hidradenitis suppurativa.
Cusack C, Buckley C
Br J Dermatol. 2006 Apr;154(4):726-9.

BACKGROUND: Hidradenitis suppurativa (HS) is a chronic suppurative condition which is poorly responsive to treatment and is characterized by significant morbidity. Successful treatment of HS in patients treated with infliximab for concomitant Crohn's disease has been reported. More recent reports of positive responses to infliximab [an antitumour necrosis factor (TNF)-alpha agent] in patients who have HS but not Crohn's disease are encouraging. OBJECTIVES: TNF-alpha is implicated in many inflammatory disorders and we wished to determine the efficacy of subcutaneous etanercept, a competitive inhibitor of TNF-alpha in the control of HS symptoms. METHODS: We commenced six patients with severe, recalcitrant HS on etanercept (25 mg subcutaneously twice weekly in all cases). All patients had a normal chest X-ray and negative purified protein derivative test prior to treatment and were closely monitored throughout the treatment period for signs of infection. Patients self-assessed their disease activity and completed Dermatology Life Quality Index (DLQI) questionnaires immediately before the introduction of therapy and 24 weeks later in the case of four patients, and 12 weeks later in the case of two others. All patients were asked to estimate the time lapse between commencement of treatment and initial response. RESULTS: Treatment was well tolerated by all patients with no reported adverse reactions. A marked reduction in self-reported disease activity (mean reduction of 61% at 24 weeks), in DLQI scores (mean reduction of 64% at 24 weeks) and in relapse rates occurred. All patients rated etanercept as their most effective treatment to date. CONCLUSIONS: Our results show the effectiveness of etanercept in this group of patients with particularly challenging disease. Etanercept, unlike infliximab, may be administered subcutaneously, rendering costly day-case admissions unnecessary.

Therapeutic Effects of Gelatin-Resorcin-Formal Glue in the Treatment of Postoperative Fistula Following a Low Anterior Resection: Report of a Case.
Sato S, Suzuki Y, Shiozaki T
Dis Colon Rectum. 2006 Mar 23;.

Postoperative fistulas are among the most difficult and distressing of surgical problems. We describe a case of a discharging fistula that developed after low anterior resection and was successfully treated with a new biologic adhesive agent, gelatin-resorcin-formal glue. To our knowledge, this is the first reported case of a postoperative fistula after colorectal surgery successfully treated with gelatin-resorcin-formal glue. In conclusion, gelatin-resorcin-formal glue is useful for uncontrollable postoperative fistula.

Microbiological analysis and endoanal ultrasonography for diagnosis of anal fistula in acute anorectal sepsis.
Toyonaga T, Matsushima M, Tanaka Y, Shimojima Y, Matsumura N, Kannyama H, Nozawa M, Hatakeyama T, Suzuki K, Yanagita K, Tanaka M
Int J Colorectal Dis. 2006 Apr 7;.

BACKGROUND AND AIMS: Treatment of anorectal sepsis requires prompt surgical drainage, but it is important to identify any associated anal fistula for preventing recurrence. We evaluated whether microbiological analysis and/or endoanal ultrasonography could be used to predict anal fistula in patients with acute anorectal sepsis. METHODS: Five hundred fourteen consecutive patients with acute anorectal sepsis were studied. Clinical data, digital examination findings, endosonographic findings, and results of microbiological analysis were compared with definitive surgical findings of the presence or absence of anal fistula. RESULTS: Anorectal abscess with anal fistula was found in 418 patients, and anorectal abscess without anal fistula was found in 96 patients. Microbiological examination showed that Escherichia coli, Bacteroides, Bacillus, and Klebsiella species were significantly more prevalent in patients with fistula (P<0.01), and coagulase-negative Staphylococci and Peptostreptococcus species were significantly more prevalent in patients without fistula (P<0.01). Results of endoanal ultrasonography were concordant with the definitive surgical diagnosis in 421 (94%) of 448 patients studied. CONCLUSION: Acute anorectal sepsis due to colonization of "gut-derived" microorganisms rather than "skin-derived" organisms is more likely to be associated with anal fistula. When the microbiological analysis yields gut-derived bacteria, but no fistula has been found in the initial drainage operation, repeat examinations during a period of quiescence, including careful digital assessment and meticulous endosonography, are warranted to identify a potentially missed anal fistula.

Guideline proposal to reconstructive surgery for complex perineal sinus or rectal fistula.
Oomen JW, Spauwen PH, Bleichrodt RP, van Goor H
Int J Colorectal Dis. 2006 Mar 22;.

AIM: To evaluate a guideline approach of reconstructive surgery for complex perineal sinus or rectal fistula. METHODS: pre-, per-, and postoperative data of 28 patients undergoing transposition of rectus abdominis muscle (TRAM), gracilis muscle (GM), gluteal thigh flap (GTF), or omentoplasty (OP) for complex perineal sinus or rectal fistula were analyzed. A fistula higher than 10 cm and a sinus with a length of >10 cm were treated with TRAM or OP. If <8 cm, the first choice was GM or GTF. The operative team made choice between 8 and 10 cm. Vacuum assisted closure (VAC) therapy was used as adjunct therapy before and after muscle transposition in huge sinus. Success was defined as no residual or recurrent sinus or fistula within 6 months, postoperatively. Long-term complaints of perineum and muscle donor site were assessed. RESULTS: Twenty-five out of 28 patients (90%) were treated according to the guideline. VAC therapy was done in six. Three patients died during mean follow up of 40 months (6-90). Initial success rate was 61% (17/28). After secondary surgery in seven, four (57%) were successful. Overall success rate, including VAC therapy, was 79% (22/28). Success was highest with GM and GTF and in small sinus or fistula. CONCLUSION: A guideline approach to complex perineal sinus or fistula based on length or height of the sinus or rectal fistula, respectively, is successful in about 80% of cases. Large defects may best be downsized by VAC therapy, followed by muscle flap. Long-term complaints are acceptable.

Long-term outcome following mucosal advancement flap for high perianal fistulas and fistulotomy for low perianal fistulas Recurrent perianal fistulas: failure of treatment or recurrent patient disease?
van der Hagen SJ, Baeten CG, Soeters PB, van Gemert WG
Int J Colorectal Dis. 2006 Mar 15;.

BACKGROUND: In this study, we determined the long-term outcome of perianal fistulas treated with mucosal advancement flap (MF) or fistulotomy (FT). METHODS: One hundred three patients with perianal fistulas were treated by MF for high fistulas or FT for low fistulas and were retrospectively assessed by case-note review and examined at the out-patient clinic. The localization and time of recurrence of the fistula were recorded. RESULTS: Forty-one patients [median follow-up of 72 months (range 48-99)] were treated by an MF, and 62 patients [median follow up of 75 months (range 48-99)] were treated by FT. After 12, 48, and 72 months, the fistula had recurred in 9 (22%), 26 (63%), and 26 (63%) patients of the MF group and in 4 (7%), 16 (26%), and 24 (39%) patients of the FT group, respectively. Eighteen (69%) of the recurrences in the MF group and ten (33%) of the FT group occurred within 24 months after surgery (p=0.01). Four (15%) of the recurrences in the MF group and 13 (54%) of the recurrences in the FT group were present in a different localization (p=0.007). CONCLUSION: The success rate of both FT and MF techniques decreases with time. Recurrence appears to be caused by failure of treatment and by recurrent patient disease.

Mucinous adenocarcinoma associated with fistula in ano: report of a case.
Sierra EM, Villanueva Saenz E, Martinez PH, Rocha JR
Tech Coloproctol. 2006 Mar 15;.

We present a case of the rare occurrence of a mucus-secreting adenocarcinoma originating in an anal gland. A 37-year-old diabetic man had an anal fistulotomy 16 years before. He had four ischiorectal abscesses in a 6- month period. A seton was inserted in a complex fistula tract in the left anterior lateral aspect. Due to delayed healing, a new surgical exploration was carried out; pathological analysis of the curetted mucinous tissue revealed a mucoid adenocarcinoma. Surgical resection is the first choice of curative treatment, and additional treatments include chemotherapy, radiotherapy and brachytherapy.


Perianal actinomycosis: diagnostic and management considerations: a review of six cases.
Bauer P, Sultan S, Atienza P
Gastroenterol Clin Biol. 2006 Jan;30(1):29-32.

INTRODUCTION: Primary anal actinomycosis of cryptoglandular origin, mainly due to Actinomyces israelii, a specific and rare cause of anal suppurative disease, needs to be recognized because it can be cured using specific treatments. METHOD: Data were reviewed from 6 patients with actinomycotic anal abscesses of obvious cryptoglandular origin observed in a single proctology unit between 1983 and 2000. Therapeutic management included conventional surgical treatment of anal sepsis followed by a specific oral antibiotic therapy maintained until the surgical wound had completely healed. RESULTS: All but one of the patients were men (median age, 53 years). All abscesses, except one, were indolent. No patient presented macroscopic "sulphur granules" in the pus, but one presented "watery pus". The diagnosis was established by histological study of the surgically excised tissue or by anaerobic culture of the pus. In the one HIV-positive patient, an uncommon organism was isolated: Actinomyces meyeri. Two cases of recurrence were observed without evidence of Actinomyces infection. CONCLUSION: Actinomycosis should be suspected particularly in indolent anal suppuration. The absence of macroscopic "sulphur granules" does not mean this diagnosis can be ruled out. Careful histological examination of the excised tissue and appropriate anaerobic cultures of pus should be carried out to achieve complete eradication of this rare, but easily curable disease.

Lithopedion presenting as intra-abdominal abscess and fecal fistula: report of a case and review of the literature.
Odom SR, Gemer M, Muyco AP
Am Surg. 2006 Jan;72(1):77-8.

A rare case of unrecognized and long-standing lithopedion ("stone baby") with erosion into the bowel with fecal fistula formation is described. A literature review is also presented.

Intraoperative physical diagnosis in the management of anal fistula.
Gonzalez-Ruiz C, Kaiser AM, Vukasin P, Beart RW Jr, Ortega AE
Am Surg. 2006 Jan;72(1):11-5.

This report reviews a prospective database applying a systematic fistulomy technique in 101 patients requiring surgery for fistula in ano at LAC+USC Medical Center during a 15-month period. Data were collected for the reliability of primary crypt palpation, success of tract injection with peroxide/methylene blue, and the accuracy of Goodsall's rule. Time to healing, recurrence, and incontinence according to type of procedure were also recorded. Palpation of the primary crypt was possible in 93 per cent. Hydrogen peroxide/methylene blue injection successfully delineated the tract in 83 per cent. Goodsall's rule was correct in 81 per cent. Each fistula was categorized as intersphincteric (n = 72), transphincteric (n = 33), extrasphincteric (n = 1), or submucosal (n = 6). At a mean follow-up period of 44 weeks, 89.2 per cent of patients were cured. Reasons for recurrence included wound bridging (n = 6), misdiagnosis of the tract (n = 3), and two blind-ended fistulae (n = 2). Time to healing in weeks was (mean, range): simple fistulotomy (12, 3-21), seton (16, 4-28), Hanley procedure (28, 8-48). Patients with a marsupialized tract healed at an average of 6 weeks (range 4-8). Four (3.9%) patients reported postoperative incontinence (1 gas, 3 liquid, 0 solids).

Stapled Endorectal Mucosectomy for High Extrasphincteric Fistula-in-Ano: Preliminary Report.
Perez F, Arroyo A, Candela F, Calpena R
Dis Colon Rectum. 2006 Feb 13;.

PURPOSE: There is no optimum surgical method of repair for high extrasphincteric fistula-in-ano. We describe a relatively simple procedure for surgery of extrasphincteric fistula, which entirely preserves the anal sphincter, does not interfere with anal function, and does not preclude the possibility of further surgery, if necessary. METHODS: Five patients have been treated for high extrasphincteric fistula with a stapled endorectal flap by using a circular hemorrhoidal stapler gun. The procedure involved two 180 degrees pursestrings placed above the dentate line and 3 cm apart, proximal and distal to the internal opening. On firing, the result was the excision of a 180 degrees rectal flap, containing the internal ostium, and including rectal mucosa and submucosa. RESULTS: No perioperative complications were encountered. There was some temporary difficulty in controlling flatus and/or defecatory urgency in two patients, which spontaneously reversed with no treatment within the first two postoperative months. The mean Cleveland Clinic Score of Incontinence did not vary significantly after surgery. Overall anal manometry did not register any significant differences between preoperative and postoperative values. With up to 26 months of follow-up, none of the fistulas recurred. CONCLUSIONS: These preliminary promising results suggest that the stapled endorectal flap could have a role in the management of high extrasphincteric fistula-in-ano.

Carbon dioxide laser ablation of perianal fistulas in patients with Crohn's disease: experience with 27 patients.
Moy J, Bodzin J
Am J Surg. 2006 Mar;191(3):424-7.

BACKGROUND: Perianal fistula disease (PAD) occurs in up to 40% of patients with Crohn's disease (CD). Medical therapy is often unsuccessful, and, with surgical therapy, healing is unreliable and management is frequently painful and unsatisfactory. Outpatient CO(2) laser ablation of PAD has emerged as an alternative. METHODS: Twenty-seven patients were evaluated by chart review. The severity of PAD based on a 5 category scoring system was collected. Scores were recorded at the time of surgery and at each subsequent postoperative visit. RESULTS: Differences between PAF severity scores were significant for the initial operation versus postoperative visit 1 (P < .001) and for the initial operation versus the final visit (P < .001). Variation in the postoperative PAD score was affected by the score in the operating room and colonic involvement of CD. CONCLUSION: CO(2) laser ablation therapy successfully treats PAD; many fistulas are completely healed and others are converted into a single, minimally draining fistula with this well-tolerated outpatient procedure.

Characteristics of perianal abscess and fistula-in-ano in healthy children.
Serour F, Gorenstein A
World J Surg. 2006 Mar;30(3):467-72.

BACKGROUND: Probably because of the low frequency, perianal abscess (PA) and fistula-in-ano (FIA) in children older than 2 years have not been investigated except in those with a predisposing condition such as Crohn's disease. This study aims to summarize our experience about the characteristics and treatment of PA and FIA in healthy children. METHODS: The charts of all children older than 24 months of age treated for PA and/or FIA from 1990 to 2003 were reviewed. RESULTS: We found 40 patients, 37 of them boys (92.5%), ranging from 2 to 14 years of age (average: 7.19 years). At the first examination, the diagnosis was PA in 36 patients (mean age: 6.8 years; range: 2.3-13 years), and FIA in 4 patients (mean age: 10.8 years; range: 6-14 years). The primary local treatment of PA was drainage (needle aspiration in 26 patients, and incision and drainage in 4 patients) and local care in 6 patients. All patients received antibiotics. Overall, 29 children (80.6%) had primary cure of the abscess. Evolution included recurrent abscess in 3 patients (8.3%) and FIA in 4 patients (11.1%). Crohn's disease was diagnosed in only one boy with an abscess of long duration. No patient developed a new PA in another location or a recurrent FIA. Four male patients aged 6 to 14 years (range: 7.1 years) had a FIA of long duration. One patient underwent a fistulectomy. Crohn's disease was found in three other children and treated conservatively. CONCLUSION: Drainage of PA by needle aspiration associated with antibiotics is effective in children older than 2 years of age with a low rate of evolution toward FIA. Associated pathology must be ruled out in children with FIA.


Efficacy of Anal Fistula Plug vs. Fibrin Glue in Closure of Anorectal Fistulas.
Johnson EK, Gaw JU, Armstrong DN
Dis Colon Rectum. 2006 Jan 20;.

PURPOSE: Long-term closure rates of anorectal fistulas using fibrin glue have been disappointing, possibly because of the liquid consistency of the glue. A suturable bioprosthetic plug (Surgisis(R), Cook Surgical, Inc.) was fashioned to close the primary opening of fistula tracts. A prospective cohort study was performed to compare fibrin glue vs. the anal fistula plug. METHODS: Patients with high transsphincteric fistulas, or deeper, were prospectively enrolled. Patients with Crohn's disease or superficial fistulas were excluded. Age, gender, number and type of fistula tracts, and previous fistula surgeries were compared between groups. Under general anesthesia and in prone jackknife position, the tract was irrigated with hydrogen peroxide. Fistula tracts were occluded by fibrin glue vs. closure of the primary opening using a Surgisis((R)) anal fistula plug. RESULTS: Twenty-five patients were prospectively enrolled. Ten patients underwent fibrin glue closure, and 15 used a fistula plug. Patient's age, gender, fistula tract characteristics, and number of previous closure attempts was similar in both groups. In the fibrin glue group, six patients (60 percent) had persistence of one or more fistulas at three months, compared with two patients (13 percent) in the plug group (P < 0.05, Fisher exact test). CONCLUSIONS: Closure of the primary opening of a fistula tract using a suturable biologic anal fistula plug is an effective method of treating anorectal fistulas. The method seems to be more reliable than fibrin glue closure. The greater efficacy of the fistula plug may be the result of the ability to suture the plug in the primary opening, therefore, closing the primary opening more effectively. Further prospective, long-term studies are warranted.

"Elliptical rotation flap for pilonidal sinus".
Yazicioglu B, Polat C, Gokce O
Am J Surg. 2006 Jan;191(1):142; author reply 142.

The Use of Fibrin Glue in the Treatment of Fistula-In-Ano: A Prospective Study.
Maralcan G, Baskonus I, Aybasti N, Gokalp A
Surg Today. 2006 Feb;36(2):166-170.

PURPOSE: This prospective study was done to analyze the efficacy of commercial fibrin glue application in the healing of patients with fistulas-in-ano. METHODS: This clinical trial of 36 patients was performed during the period from November 2003 to May 2004. Thirty men and six women were treated for a fistula-in-ano with commercial fibrin glue application. None of the patients had undergone prior attempts to correct fistulas-in-ano surgically. All patients received preoperative mechanical bowel preparation and prophylactic intravenous antibiotics. In the operating room, the patients underwent an anorectal examination under spinal anesthesia. The external and internal fistula tract openings were then identified. The fistula tract was curetted. Fibrin glue was injected into the external fistula opening until fibrin glue could be seen coming from the internal opening. No dressing was applied over the external opening. Thereafter, the patient was discharged. A 1-week course of oral antibiotics was prescribed. The patients were followed up for 70 weeks with a mean of 54 weeks (range 40-70 weeks). RESULTS: The cause of the fistula-in-ano was cryptoglandular in all patients. The overall initial success rate was 77.8% (28/36). No complications were encountered related to the application. Two patients underwent a reapplication with fibrin glue and the fistulas of these patients were all closed. The overall success rate was 83.3% (30/36). CONCLUSION: Fibrin glue application was thus found to be an easy, safe, effective, and useful alternative treatment in the management of fistulas-in-ano. However, our findings need substantiation by increasing the number of patients and prolonging the follow-up duration, as well as carrying out comparative studies.