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Background and Aims: Perianal fistuliing Crohn's disease [PFCD] is an aggressive phenotype of Crohn's disease defined by frequent relapses and disabling symptoms. A novel consensus classification system was recently outlined by the TOpCLASS consortium, which seeks to unify disease severity with patient-centred goals but has not yet been validated. We aimed to apply this to a real-world cohort and to identify factors that predict transition between classes over time., Methods: We identified all patients with PFCD and at least one baseline and one follow-up pelvic MRI [pMRI]. TOpCLASS classification, disease characteristics, and imaging indices were collected retrospectively at time periods corresponding with respective MRIs., Results: We identified 100 patients with PFCD, of whom 96 were assigned TOpCLASS Classes 1-2c at baseline. Most patients [78.1%] started in Class 2b, but changes in classification were observed in 52.1% of all patients. Male sex [72.0%, 46.6%, 40.0%, p = 0.03] and prior perianal surgery [52.0% vs 44.6% vs 40.0%, p = 0.02] were more frequently observed in those with improved class compared to unchanged and worsened class. Baseline pMRI indices were not associated with changes in classification; however, greater improvements in mVAI, MODIFI-CD, and PEMPAC were seen among those who improved. Linear mixed effect modelling identified only male sex [-0.31, 95% CI -0.60 to -0.02] with improvement in class., Conclusion: The TOpCLASS classification highlights the dynamic nature of PFCD over time. However, our ability to predict transitions between classes remains limited and requires prospective assessment. Improvement in MRI index scores over time was associated with a transition to lower TOpCLASS classification., (© The Author(s) 2024. Published by Oxford University Press on behalf of European Crohn’s and Colitis Organisation. All rights reserved. For commercial re-use, please contact reprints@oup.com for reprints and translation rights for reprints. All other permissions can be obtained through our RightsLink service via the Permissions link on the article page on our site—for further information please contact journals.permissions@oup.com.)

Background: The Parks classification has been used for the classification of anal fistula for several years, but it does not allow for risk factors for failure after surgery., Objective: This study aimed to describe a modification of the Parks classification of anal fistula and examine its predictive validity in the assessment of the outcome of anal fistula in terms of failure of healing and fecal incontinence., Design: This is a retrospective review of a prospective database., Setting: This study was conducted in the Colorectal Surgery Unit, Mansoura University Hospitals., Patients: Adult patients with anal fistula who underwent surgery were included., Interventions: Five risk factors for failure after fistula surgery were identified from the literature and were examined by multivariate analysis of our patients. Four risk factors proved to be significant independent predictors of failure: secondary extensions, horseshoe fistula, previous fistula surgery, and anterior anal fistula in women. We modified the Parks classification by dividing the transsphincteric type into high and low and by grouping supra- and extrasphincteric anal fistulas into 1 group. The first 3 stages were subdivided according to the absence or presence of predictors of failure., Main Outcome Measures: The primary outcome measured was the validity of the modified Parks classification with regard to the rates of failure and fecal incontinence after surgical treatment of each stage of anal fistula., Results: A total of 665 patients with cryptoglandular anal fistula were included. Failure rates increased from 2.3% (95% CI, 0.9%-4.7%), to 17.4% (95% CI, 10.8%-25.9%), 19.5% (95% CI, 15%-24.6%), and 30.7% (95% CI, 9.1%-61.4%) across the 4 stages. The area under the receiver operating characteristic curve was 0.90 (95% CI, 0.85-0.94) indicating the strong discriminative ability of the final multivariable predictive model. The increase in failure and incontinence rates across the fistula stages was significant., Limitations: This is a retrospective, single-center study., Conclusion: Inclusion of predictors of poor outcome into the modified classification helped differentiate simple and complex fistulas within each stage and between the different stages, which can help in assessment and decision making for anal fistula. See Video Abstract at http://links.lww.com/DCR/B441., Modificacin De La Clasificacin De Parks De La Fstula Anal Criptoglandular: ANTECEDENTES:La clasificación de Parks se ha utilizado para la clasificación de la fístula anal durante varios años, sin embargo, no tuvo en cuenta los factores de riesgo de fracaso después de la cirugía.OBJETIVO:Describir una modificación de la clasificación de Parks de fístula anal y examinar su validez predictiva en la evaluación de los resultados de la fístula anal en términos de fracaso de la cicatrización e incontinencia fecal.DISEÑO:Revisión retrospectiva de la base de datos prospectiva.AJUSTE:Unidad de Cirugía Colorrectal, Hospital Universitario de Mansoura.PACIENTES:Pacientes adultos con fístula anal intervenidos quirúgicamente.INTERVENCIONES:Se identificaron cinco factores de riesgo de fracaso después de la cirugía de fístula de la literatura y se examinaron mediante análisis multivariante de nuestros pacientes. Cuatro factores de riesgo demostraron ser importantes predictores independientes de fracaso: extensiones secundarias, fístula en herradura, cirugía de fístula previa y fístula anal anterior en mujeres. Modificamos la clasificación de Parks dividiendo el tipo transesfinteriano en alto y bajo y agrupando la fístula anal supraesfinteriana y extraesfinteriana en un grupo. Las tres primeras etapas se subdividieron según la ausencia o presencia de predictores de fracaso.PRINCIPALES MEDIDAS DE RESULTADO:Validez de la clasificación de Parks modificada con respecto a las tasas de fracaso e incontinencia fecal después del tratamiento quirúrgico de cada etapa de la fístula anal.RESULTADOS:Se incluyeron 665 pacientes con fístula anal criptoglandular. Las tasas de fracaso aumentaron del 2,3% (IC del 95%: 0,9-4,7%), al 17,4% (IC del 95%: 10,8 al 25,9%), 19,5% (IC del 95%: 15-24,6%) y 30,7% (95% IC: 9,1- 61,4%) en las cuatro etapas. El área bajo la curva característica operativa del receptor fue 0,90 (IC del 95%: 0,85-0,94), lo que indica una fuerte capacidad discriminativa del modelo predictivo multivariable final. El aumento en las tasas de fracaso e incontinencia en las etapas de la fístula fue significativo.LIMITACIONES:Estudio retrospectivo, unicéntrico.CONCLUSIÓN:La inclusión de predictores de mal resultado en la clasificación modificada ayudó a diferenciar las fístulas simples y complejas dentro de cada etapa y entre las diferentes etapas, lo que puede ayudar en la evaluación y toma de decisiones para la fístula anal. Consulte Video Resumen en http://links.lww.com/DCR/B441., (Copyright © The ASCRS 2020.)

Objective: To validate the Martini staging system for postoperative rectourethral fistula (RUF) utilizing data from previous studies to determine whether it can accurately predict postoperative success rate., Methods: A systematic search of peer-reviewed studies was conducted through January, 2020. The primary inclusion criteria for the studies were studies that evaluated outcomes based on the etiology of the fistula (ie, radiotherapy/ablation [RA] vs nonradiotherapy/ablation [NRA]). Martini RUF classification was utilized for the subgroup analysis., Results: Out of 1948 papers, 7 studies with a total of 490 patients (251 in RA vs 239 NRA) were included in this study. Receiving RA increased the risk of permanent bowel diversion by 11.1 folds, eventual fistula recurrence by 9.1 folds, and post-op urinary incontinence (UI) by 2.6 folds. Similarly, compared to a Grade 0 fistula, a Grade I fistula increased the risk of permanent bowel diversion by 9.1 folds, fistula recurrence by 20 folds, and post-op UI by 2.7 folds. There were some valuable variables that were not captured by the Martini classification., Conclusion: Overall, the Martini classification system is efficacious in stratifying post-op complications from RUF repair based on the grade and etiology; however, it is limited in application. There is an opportunity for the development of more comprehensive staging systems in this domain., (Copyright © 2020 Elsevier Inc. All rights reserved.)

BACKGROUND An anal fistula plug is a sphincter-sparing procedure that uses biological substances to close an anorectal fistula. This study aimed to evaluate the long-term therapeutic effect of an anal fistula plug procedure in patients with trans-sphincteric fistula-in-ano and to determine the risk factors affecting fistula healing. MATERIAL AND METHODS A single-center retrospective study was performed assessing long-term treatment outcomes of patients with low trans-sphincteric anal fistulas who initially underwent anal fistula plug procedures between August 2008 and September 2012. Risk factors affecting fistula healing were identified using univariate and multivariate analyses. RESULTS A total of 135 patients who had low trans-sphincteric anal fistulas and underwent anal fistula plug procedures were analysed. The overall healing rate was 56% (75/135) with a median follow-up time of 8 years (range, 72-121 months). The primary reasons for treatment failure were plug extrusion (n=12, 20%) and surgical site infection (n=9, 15%), occurring within 30 days after surgery. Multiple logistic regression analysis showed that the duration of anal fistula ≥6 months was significantly associated with treatment failure using an anal fistula plug (OR=3.187, 95% CI: 1.361-7.466, P=0.008). Of the patients who failed initial treatment with an anal fistula plug, 6 (9%) had anal fistulas that healed spontaneously after 2-3 years without additional treatment. CONCLUSIONS As a sphincter-preserving procedure, the anal fistula plug can effectively promote healing of low trans-sphincteric anal fistulas. The long-term efficacy is good and the procedure warrants wider use in clinical practice.

Recommendations are advice that is given and considered to be beneficial; however, they are still suggestions and are therefore open to different interpretations. In this sense, the final objective of the review has been to try to homogenize, with the evidence available, the approach to the diagnosis and medical/surgical treatment of one of the most complex manifestations of Crohn's disease, such as simple and complex perianal fistulas., (Copyright © 2020 The Authors. Publicado por Elsevier España, S.L.U. All rights reserved.)

This article explains the pathogenesis of fistula-in-ano and details the different classifications of fistula encountered, describe their features on MR imaging, and explains how imaging influences subsequent surgical treatment and ultimate clinical outcome. Precise preoperative characterization of the anatomic course of the fistula and all associated infection via MR imaging is critical for surgery to be most effective. MR imaging is the preeminent imaging modality used to answer pertinent surgical questions., (Crown Copyright © 2019. Published by Elsevier Inc. All rights reserved.)

Aim: Several studies have evaluated the efficacy of preoperative MRI in fistula-in-ano. However, the evaluation of MRI after fistula-in-ano surgery has never been done. The aim was to evaluate the utility of MRI in postoperative period after fistula-in-ano surgery., Methods: Preoperative MRI was done in all the patients presenting with fistula-in-ano. Postoperative MRI was done to check radiological healing in clinically healed fistulas or when postoperative complication/healing problem was seen. The postoperative MRI was compared with preoperative MRI and correlated with the clinical picture., Results: A total of 1323 MRI were done in 1003 fistula-in-ano patients, out of which 702 patients underwent surgery. In 702 patients, there were 361 recurrent fistulas, 153 had associated abscess, 388 had multiple tracts, 146 had horseshoe tract, and 76 had supralevator fistula. In total, 320 postoperative MRI scans were done in 180/702 patients. The requirement of postoperative MRI was significantly higher in complex (grades III-V) than simple fistulas (grades I-II) [43.5% (136/313) vs. 11.3% (44/389), respectively, P < 0.0001]. In early postoperative period (8 weeks), healing (granulation) tissue was difficult to differentiate from active fistula tract/pus. The complete radiological healing took at least 10-12 weeks. So getting MRI scan for the assessment of healing was more accurate after 12 weeks. MRI was very accurate to identify postoperative complications like abscess, missed tract or non-healing of a tract. MRI detected such complications even in apparently clinically healed tracts. Closure/healing of internal opening and intersphincteric tract was assessed accurately by MRI and correlated well with the fistula healing., Conclusions: MRI is highly useful to assess healing and detect complications after fistula surgery.

Objective: to determine the role of endoscopic ultrasonography (EU) in comparison with nuclear magnetic resonance imaging (MRI) and examination under anesthesia (EUA) in the management of patients with perianal fistulizing Crohn's disease., Methods: we conducted a cross-sectional, observational study with patients with perianal Crohn's disease evaluated at a tertiary center in Curitiba, Paraná, Brazil, from February 2016 to March 2017. All patients underwent EU, MRI and EUA. We evaluated the degree of agreement between the three methods by obtaining the Kappa coefficient. A Kappa value of 0.7 or greater indicated good agreement. We used the Friedman's non-parametric test to compare the number of fistulous paths detected in each modality. We set the level of statistical significance at p<0.05., Results: we included 20 patients. There was agreement between the three exams in 11 patients. The level of Kappa agreement between the three exams was 0.53 (moderate - p<0.001). There was no statistically significant difference in relation to the number of fistulous trajectories detected in the three exams (p=0.641). EU failed to identify a fistulous pathway in three patients; MRI failed in three; and EUA failed in two., Conclusion: EU was comparable to MRI and EUA for the evaluation of perianal fistulizing Crohn's disease, and can be considered a valid exam for preoperative investigation of such patients.

Objective: To explore the diagnostic value of magnetic resonance imaging(MRI) in anal fistula., Methods: A total of 2160 patients were clinically diagnosed with anal fistula at the Sixth Affiliated Hospital of Sun Yat-sen University from March 2010 to September 2015. Among them, 232 cases with operative history at other hospital, 218 with Crohn's disease, 6 with rectum cancer and 8 with other disease were excluded, and 1696 patients were finally enrolled and retrospectively analyzed. The saggital FSE T2WI imaging was confirmed based on the midline of body, and then the coronal and axial scanning line were confirmed. The key point was that the coronal scanning line must parallel and the axial scanning line must be perpendicular to the major axis of anal canal. The characteristics of anal fistula were recorded, and anal fistula were classified as five types, including intersphincteric, transphincteric, suprasphincteric, extrasphincteric and superficial fistula according to the Parks classification and our experience. The distribution of internal opening was described by using lithotomy position clock method., Results: Of 1696 patients, 1456 were males and 240 females with median age of 26.5 (0.2 to 87.0) years. Age of 8.4% (143/1696) cases was under 20 years old, of 57.4%(973/1696) cases was between 20 to 40, of 28.4%(482/1696) cases was between 40 to 60, of 5.8%(98/1696) cases was over 60. The 1696 MR examinations included 1128 on 1.5T MR and 568 on 0.5T MR. Of all the anal fistulas was 29.0%(492) high position and 71.0%(1204) was low position. Among the 1696 patients, 1057 were intersphincteric fistulas(62.3%), 407 were transphincteric fistulas(24.0%), 68 were suprasphincteric fistulas(4.0%), 54 were extrasphincteric fistulas (3.2%), 67 were superficial fistulas(4.0%), and 43(2.5%) were difficult to classify. A total of 1996 internal openings were found and most of them were located around the dentate line of 5-7 o'clock in lithotomy position(47.7%, 952/1996)., Conclusions: Anal fistula mainly occur in young men, and the most common type is intersphincteric fistula. MRI can accurately classify anal fistulas and clearly demonstrate internal openings, and provide reliable evidence for clinical treatment and surgery.

Competing Interests: Competing interests: None declared.

Background: Fistula-in-ano are classified so as to grade them according to increasing complexity which can help guide their management. The classifications used are Parks, St James Hospital University (SJHU) and Standard Practice Task Force (SPTF). Laying open (fistulotomy) of the fistula tract is the most commonly done procedure for fistula-in-ano and has high success rate. The lower grade fistulas are supposed to have low risk of incontinence when laid open and vice-versa. The objective of the study was to evaluate the efficacy of the existing classifications., Materials & Methods: 440 consecutive fistula-in-ano patients operated over four years were analyzed on the basis of preoperative MRI scan and operative findings. It was assessed whether the amenability to fistulotomy (measurement of fistula simplicity) correlated with the fistula-in-ano grades in different classifications., Results: Out of 440 patients operated, 242 underwent fistulotomy whereas 198 underwent sphincter-sparing procedures for complex fistula. As per SJHU classification, the amenability to fistulotomy was 99.1% in Grade-I, 82.1% in Grade-II, 46.2% in Grade-III, 29.0% in Grade-IV and 5.4% in Grade-V. In Park's classification, the amenability to fistulotomy was 93.5% in Grade-I, 34.8% in Grade-II, 5.4% in Grade-III and 0% in Grade-IV. As per SPTF classification, 99.3% of simple and 32.1% of complex fistulas underwent fistulotomy. Even the higher grade fistula-in-ano in all three classifications had high rate of amenability to fistulotomy. Therefore none of the above classifications were accurate. A new classification is being proposed which divides fistula-in-ano in 5 grades in order of increasing complexity. Grade I & II are simple fistulas (fistulotomy be done conveniently) and Grade III-V are high complex fistulas (fistulotomy should not be attempted). The data was analyzed as per new classification and found it to be highly accurate., Conclusions: None of the existing classifications accurately correlated between the grade and the complexity of fistula. A new classification is being proposed., (Copyright © 2017 IJS Publishing Group Ltd. Published by Elsevier Ltd. All rights reserved.)

Purpose  Transperineal ultrasound (TPUS) is a practical tool for assessing perianal inflammatory lesions. We systematically review its accuracy for detecting and classifying perianal fistulae and abscesses. Method  The National Library of Medicine and Embase were searched for articles on TPUS for the assessment of idiopathic and Crohn's perianal fistulae and abscesses. Two reviewers independently reviewed eligible studies and rated them for quality using the QUADAS tool. The primary outcome measure was the accuracy of TPUS as measured by its sensitivity and positive predictive value (PPV) in detecting and classifying perianal fistulae, internal openings and perianal abscesses. Results  We included 12 studies (565 patients). Overall, the methodological quality of the studies was suboptimal. 3 studies were retrospective and 4 showed significant risks of bias in the application of the reference standard. The sensitivity of TPUS in detecting perianal fistulae on a per-lesion basis was 98 % (95 % CI 96 - 100 %) and the PPV was 95 % (95 % CI 90 - 98 %). The detection of internal openings had a sensitivity of 91 % (95 % CI 84 - 97 %) with a PPV of 87 % (95 % CI 76 - 95 %). The classification of fistulae yielded a sensitivity of 92 % (95 % CI 85 - 97 %) and a PPV of 92 % (95 % CI 83 - 98 %). TPUS had a sensitivity of 86 % (95 % CI 67 - 99 %) and PPV of 90 % (95 % CI 76 - 99 %) in the detection of perianal abscesses. Conclusion  The current literature on TPUS illustrates good overall accuracy in the assessment of perianal fistulae and abscesses. However, many studies had methodological flaws suggesting that further research is required., Competing Interests: Disclosure The authors report no conflicts of interest in this work., (© Georg Thieme Verlag KG Stuttgart · New York.)

This pictorial atlas provides a review of perianal fistulas with a brief description of the relevant anatomy, technique of imaging, and examples of various fistula types. Magnetic resonance imaging is highly accurate for depiction of both the primary tract and its secondary branches as well as abscesses. It is useful in the accurate preoperative classification of perianal fistulas and allows institution of the correct surgical procedure, thereby reducing the chances of recurrence or complications from occurring.

Perianal fistulas and other inflammatory diseases of the anus and perianal soft tissues are a cause of substantial morbidity, and are a major part of the practice of any colorectal surgeon. Magnetic resonance imaging (MRI) has a key role in the assessment of patients for the extent of fistulizing Crohn disease, complications related to fistulas, and to assist in confirming the diagnosis or proposing an alternative. Technique is critical and in particular, the selection of sequences for diagnosis and characterization of abnormalities with the main choices being between standard anatomical sequences (T1 or T2), assessing for edema (FS T2 or STIR), assessing abnormal contrast enhancement (FS T1), and assessing for abnormal diffusion or a combination of these. Guidance on MRI sequence selection, classification of fistulas, the current guidance on the role of MRI in assessing patients, and advice on how to provide useful structured reports, as well as how to detect complications of perianal sepsis are included., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Perianal fistulas in Crohn's disease are common and difficult to treat. Their aetiology is poorly understood. Assessment is clinical, endoscopic and radiological, and management is undertaken by a multidisciplinary team of gastroenterologists, surgeons and radiologists. Surgical drainage of the fistula tract system with the placement of loose setons precedes combined therapy with immunosuppressant and anti-TNFα agents in most patients. Proctitis should be rigorously eliminated where possible. Definitive surgical repair is sometimes possible and diversion or proctectomy are occasionally required. Combined medical and surgical management represents a promising avenue for the future.

Perianal sepsis is a common condition ranging from acute abscess to chronic fistula formation. In most cases, the source is considered to be a non-specific cryptoglandular infection starting from the intersphincteric space. The key to successful treatment is the eradication of the primary track. As surgery may lead to a disturbance of continence, several sphincter-preserving techniques have been developed. This consensus statement examines the pertinent literature and provides evidence-based recommendations to improve individualized management of patients.

The course of the fistula tract in relation to the anal sphincter is identified by clinical examination under general anaesthesia using a fistula probe and injection of fluid into the external fistula opening. In the event of a complex fistula or in the case of fistula recurrence, this should be supplemented with an endoluminal ultrasound scan and/or an MRI scan. St. Mark's fistula chart should be used for the description. Simple fistulas are amenable to fistulotomy, whereas treatment of complex fistulas requires special expertise and management of all available treatment modalities to tailor the right operation to the individual patient. The given levels of evidence and grades of recommendations are according to the Oxford Centre for Evidence-based Medicine (www.cemb.net).

Anal fistulas require surgical treatment to cure the fistula. Fistulotomy is the treatment of choice because of its high success rate, but it also carries a risk of postoperative incontinence. Different methods have been proposed to overcome the need for dividing part or all of the sphincter, so-called "sphincter saving techniques" (SST), such as flap advancement, intrafistular injection of glue, or the insertion of a bio-prosthesis (collagen plug). However, the success rate of SSTs is lower than that of fistulotomy. Ligation of the Intersphincteric Fistula Tract (LIFT) is one of the most recent SSTs. It aims to ligate and transect the fistula by an approach through the intersphincteric space. The methodological quality of most published studies has been only average, but several studies have reported attractive success rates of 70 to 95% without postoperative incontinence. Other techniques such as endo-anal clip or injection of autologous stem cells are still anecdotal., (Copyright © 2014. Published by Elsevier Masson SAS.)

The experience of the examination and treatment of 646 patients for different forms of complex rectal fistula (CRF) summarized. A working classification of the CRF with regard to their complication was developed and implemented. A differentiated approach has allowed greater use sphincter-preserving methods to improve functional outcome, quality of life, reduce the duration of the disability period and frequency of patients disability.

Anal fistula is a common benign condition that typically describes a miscommunication between the anorectum and the perianal skin, which may present de novo, or develop after acute anorectal abscess. Athough anal fistulae are benign, the condition can still negatively influence a patient's quality of life by causing minor pain, social hygienic embarrassment, and in severe cases, frank sepsis. Despite its long history and prevalence, anal fistula management remains one of the most challenging and controversial topics in colorectal surgery today. The end goals of treatment include draining the local infection, eradicating the fistulous tract, and minimizing recurrence and incontinence rates. The goal of this review is to ensure surgeons and physicians are aware of the different imaging and treatment choices available, and to report expected outcomes of the various surgical modalities so they may select the most suitable treatment.

Periproctal inflammations related to the anus are characterized by the rapid spread of the infection to the surrounding tissue, which is determined by the anatomical characteristics and infectious agents. Inflammation, which starts as a phlegmon, quickly forms boundaries and an abscess develops in most cases. Up to 80-90% of anorectal abscesses develop according to the crypto-glandular theory on the basis of infection of the anal glands, spilling into the Morgagni crypts in the anal canal. Up to two-thirds of such abscesses are associated with the emergence of anorectal fistulas. Anorectal abscesses can be divided into marginal and subcutaneous perianal abscesses, submucosal, intersphincteric, ischiorectal and supralevator abscesses. Their diagnosis is based on thorough physical examination, sometimes also with the help of imaging methods such as computed tomography, magnetic resonance imaging and endoanal ultrasound. What is decisive for the successful treatment of anorectal abscessess is their early and adequate surgical drainage. Adjuvant antibiotic therapy is necessary only when the overall signs of sepsis are present and for patients with a comorbidity such as diabetes, valvular heart disease, or immunodeficiency.

Objective: The purpose of this article is to provide an overview of pelvic MRI for the evaluation of perianal fistulas, with a description of the technique, illustration of relevant normal anatomy, and examples of various fistula types., Conclusion: MRI evaluation of perianal fistulas can be challenging, and knowledge of relevant pelvic anatomy and fistula classification remains crucial in the diagnosis. MRI is highly accurate for fistula depiction and, by providing an accurate assessment of disease status and extension, can help surgical planning to minimize recurrence and detect clinically unapparent disease.

Perianal fistula is a very unpleasant condition. It is also quite difficult to be solved without recurrence or with complete preservation of sphincter function. This paper summarizes the etiology, classification of fistulas along with the long-term surgical experiences in the approach and the treatment of this condition.

Anal fistulae are common and debilitating; they are characterized by severe pain and discharge. They arise following infection near the anal canal, or as a primary event from an abscess in the abdomen, fistulating into the vagina or perianal skin. The term 'cryptoglandular' is given to abscesses arising from the anal glands.For many years, the treatment of choice was to lay open the fistula; however, this risks causing incontinence with potentially devastating consequences. Alternative surgical treatments include setons, fibrin glue, collagen plugs and flaps to cover the internal fistula opening. These have achieved varying degrees of success, as will be discussed. The present review also discusses anal fistulae in light of much recently published literature. Currently, anal fistulae remain challenging and require specialist expertise; however, new treatment options are on the horizon.

Background: Several techniques have been described for the management of fistula-in-ano, but all carry their own risks of recurrence and incontinence. We conducted a prospective study to assess type of presentation, treatment strategy and outcome over a 5-year period., Methods: Between 1st January 2005 and 31st March 2011,247 patients presenting with anal fistulas were treated at the University Hospital Tor Vergata and were included in the present prospective study. Mean age was 47 years (range 16-76 years); minimum follow-up period was 6 months (mean 40, range 6-74 months).Patients were treated using 4 operative approaches: fistulotomy, fistulectomy, seton placement and rectal advancement flap. Data analyzed included: age, gender, type of fistula, operative intervention, healing rate, postoperative complications, reinterventions and recurrence., Results: Etiologies of fistulas were cryptoglandular (n = 218), Crohn's disease (n = 26) and Ulcerative Colitis (n = 3). Fistulae were classified as simple -intersphincteric 57 (23%), low transphincteric 28 (11%) and complex -high transphicteric 122 (49%), suprasphincteric 2 (0.8%), extrasphinteric 2 (0.8%), recto-vaginal 7 (2.8%) Crohn 26 (10%) and UC 3 (1.2%).The most common surgical procedure was the placement of seton (62%), usually applied in case of complex fistulae and Crohn's patients.Eighty-five patients (34%) underwent fistulotomy, mainly for intersphincteric and mid/low transphincteric tracts. Crohn's patients were submitted to placement of one or more loose setons.The main treatment successfully eradicated the primary fistula tract in 151/247 patients (61%). Three cases of major incontinence (1.3%) were detected during the follow-up period; Furthermore, three patients complained minor incontinence that was successfully treated by biofeedback and permacol injection into the internal anal sphincter., Conclusions: This prospective audit demonstrates an high proportion of complex anal fistulae treated by seton placement that was the most common surgical technique adopted to treat our patients as a first line. Nevertheless, a good outcome was achieved in the majority of patients with a limited rate of faecal incontinence (6/247 = 2.4%). New technologies provide promising alternatives to traditional methods of management particularly in case of complex fistulas. There is, however, a real need for high-quality randomized control trials to evaluate the different surgical and non surgical treatment options.

Background: We describe our 20-year experience with a posterior transrectal approach (York-Mason procedure) to treat recto-urinary fistula (RUF). Most RUFs are secondary to lower urinary or intestinal tract surgery. Spontaneous closure is infrequent, and operative treatment is often mandatory. Several surgical approaches have been proposed., Methods: We reviewed retrospectively the medical records of 14 patients presenting with RUF in our Department between 1988 and 2010. In 10 patients, RUFs developed after radical retropubic prostatectomy (RRP); in the other 4 patients, RUFs resulted after other surgical interventions. All patients were treated with the York-Mason approach. A temporary colostomy and suprapubic cystostomy were performed in all patients except one., Results: All patients were treated successfully. After fistulectomy, colostomies were closed after 4 mo, and patients reported fecal continence and no postoperative anal strictures. The colostomy was left in place permanently in 1 patient due to the simultaneous presence of Crohn's disease, in another with ulcerative rectocolitis, and in a third scheduled for adjuvant radiotherapy for relapse after RRP. In 1 patient, daily medications were essential because of wound infection. In the patient with Crohn's disease, the fistula recurred 11 years after first repair. Two patients died of metastatic prostate cancer 1 year after repair of the RUF., Conclusion: The posterior sagittal transrectal approach allows easy access and good surgical exposure, facilitating identification of the fistulous tract. In our opinion, the York-Mason approach guarantees the greatest success rate with the least morbidity., (Crown Copyright © 2011. Published by Mosby, Inc. All rights reserved.)

Background: The aim of the study was a cross-sectional investigation into the types of anal fistulae in patients with Crohn's disease using 3-dimensional endoanal ultrasonography., Methods: The study population consisted of 45 patients with established Crohn's disease referred in a 2-year period for treatment of anal fistula. The fistulae were classified according to the presence of three criteria: 1. bifurcation or secondary extension; 2. cross-sectional width ≥ 3 mm; and 3. content of hyperechoic secretions., Results: The fistulae of 24 patients (53%) satisfied two or three criteria and were classified as true Crohn's fistulae, while the fistulae of 21 patients satisfied one or none of the criteria and were the cryptoglandular type. The fistulae in the two or three criteria group had been in existence for 8.4 years on average and those in the cryptoglandular group for 4.5 years on average (P = 0.283). The corresponding numbers of previous operations for fistula were 5.7 (range 0-32) and 1.5 (range 0-6), respectively (P = 0.0211). The presence of colitis or proctitis was similar across the groups, but the perianal Crohn's disease activity index was higher with a Crohn's type of fistula (P = 0.0097). Also, a larger proportion had been treated with anti-TNF-monoclonal antibody (0.0169)., Conclusions: Endoanal ultrasonography was capable of discerning two subgroups of fistula in Crohn's patients. These groups were clinically different indicating that the prospect of surgical cure is also different.

Fistula-in-ano is a difficult problem that physicians have struggled with for centuries. Appropriate treatment is based on 3 central tenets: (1) control of sepsis; (2) closure of the fistula; and (3) maintenance of continence. Treatment options continue to evolve - as a result, it is important to review old and new options on a regular basis to ensure that our patients are provided with up to date information and options. This paper will briefly cover some of the traditional approaches that have been used as well as some newer promising procedures.

Purpose: The aims of this study were to determine the frequencies of the perianal fistula subtypes according to the Parks and St. James's University Hospital (SJUH) classification systems and to evaluate the adequacy of these two systems for classifying and reporting perianal fistulas., Materials and Methods: Magnetic resonance imaging examinations of 52 patients (44 men, 8 women) with perianal fistula were reviewed retrospectively. The fistulas were classified according to the Parks and SJUH classification systems., Results: According to the Parks system, 13 patients had intersphincteric (25%), 36 had transsphincteric (69.23%), and 2 had (3.84%) extrasphincteric fistulas. Only one fistula (a subsphincteric fistula) (1.92%) could not be classified. According to the SJUH system, 10 patients had grade 1 (19.23%), 2 patients had grade 2 (3.84%), 13 patients had grade 3 (25%), 21 patients had grade 4 (40.38%), and 5 patients had grade 5 (9.61%) perianal fistulas. The one (and only) subsphincteric fistula was left unclassified., Conclusion: The most common types are transsphincteric and intersphincteric fistulas. Although the two most commonly used classification systems are adequate for describing most perianal fistulas, there is a small percentage that is left unclassified.

Background: Fistula in ano is a rather common condition, but the disease process is not yet fully understood. The aim of our study was to determine how the distribution of anal glands contributes to the variable occurrence of fistula-in-ano in the perineum., Methods: we conducted a blinded two-phase prospective study. In the first phase, the perineum of the patients with primary fistulae was anatomically divided into right upper and lower and left upper and lower quadrants in the lithotomy position. The fistulae were classified according to what quadrant the external and internal openings and the tract pathway were in. In the second phase, using 10 human cadaver specimens, full thickness tissue samples were taken from each quadrant of the anus. Samples were histologically evaluated for the volume fractions of the anal glands in each quadrant., Results: The new classification system we propose revealed that the largest number of fistulae 43% (17/39) were in the right lower quadrant, and 22% (9/39), 12% (5/39) and 8% (3/39) were in the left lower, right upper and left upper quadrants, respectively. It was also observed that 14% (5/39) of fistulae were in more than one quadrant. The volume fractions of each quadrant showed that the largest volume fraction of the anal glands was in the right lower quadrant (right lower quadrant: 0.64, left lower quadrant: 0.35, right upper quadrant: 0.26 and left upper quadrant: 0.22, P = 0.001)., Conclusions: To the best of our knowledge, this is the first study that has objectively shown that the distribution of the anal glands is variable, and the highest density of anal glands is in the right lower quadrant of the anus. This variable distribution may be associated with the variable occurrence in fistula in ano.

The most common cause of anal fistula is anal gland sepsis, resulting in formation of anorectal abscess, particularly if the latter allowed bursting spontaneously or has been inadequately opened at operation. Surgical treatment of the fistula must intent to its healing or simply its drainage or its transformation to a simpler one. Superficial, low transsphincteric and intersphincteric fistulas are treated by the lay-open technique. The use of a loose seton allows time for any sepsis and induration to settle before a decision about further treatment is made. Also, the use of a tight seton in the management of complex fistula may avoid an early muscle division before any tissue scarring happened. The patient with a perianal fistula must have a steady trustful relationship with his surgeon and must be fully informed on the therapeutic plan and reassured for a favourable outcome.

Traditionally the distance between the inner opening and the anal verge is considered when making the decision to lay open an anal fistula or not. In contrast to this, the score presented here includes the distance to the upper border of the puborectalis muscle or to the external sphincter (anteriorly). In addition this score also takes various aspects of bowel function into consideration.

Background: Approximately one third of patients with Crohn's disease develop perianal fistulas. This study was conducted to determinate outcome predictors in patients treated at a specialized multidisciplinary unit., Patients and Methods: Between May 2005 and May 2008, all patients with perianal Crohn's fistulas were treated by the same surgeon and a gastroenterologist specialized in managing patients with Crohn's disease. Deep fistulas were treated by fistulotomy. For high fistulas, a noncutting seton was placed followed by maintenance treatment with azathioprine and/or infliximab. "Optimal outcome" was recorded when (a) there was no need for diverting stoma, (b) complete healing was achieved by fistulotomy, or (c) fistula symptoms were under control, i.e. there was no need for treatment extension during follow-up., Results: Thirty-four male and 32 female patients underwent 100 surgical interventions. The most frequent types of fistula were high trans-sphincteric (62%) and high intersphincteric (15%). Eleven of the 32 females presented with rectovaginal fistulae. At the study end, complete healing was observed in 12 patients and 32 had good control of fistula symptoms. Seven required proctectomy, fistula symptoms were not under control in 12, and three required diverting stoma. Altogether 44 patients (67%) achieved optimal outcome. The following factors were predictors of nonoptimal outcome by multivariate analysis: presence of Crohn's colitis (P=0.01), age at the onset of Crohn's disease <20 years (P=0.02), and types of fistula not suitable for fistulotomy (P=0.05)., Conclusions: The multidisciplinary approach at specialized units will lead to successful outcome in >60% of patients with Crohn's perianal fistulas. The presence of Crohn's colitis, young age at disease onset, and presence of high fistulas are indicators of poor prognosis.

Introduction: High transsphincteric fistulas are difficult to treat because fistulotomy of involved sphincter muscle results in incontinence. We compare our outcomes for anal fistula plug, fibrin glue, advancement flap closure, and seton drain insertion., Methods: This is a retrospective study of patients treated for high transsphincteric anal fistulas. The primary outcome was full healing at 12 weeks postoperatively., Results: Between 1997 and 2008, 232 patients with anal fistula were identified in the St. Paul's Hospital Anal Fistula Database. Postoperative healing rates at the 12-week follow-up for the fistula plug, fibrin glue, flap advancement, and seton drain groups were 59.3%, 39.1%, 60.4%, and 32.6%, respectively (P < .0001)., Conclusions: Closure of the primary fistula opening using a biological anal fistula plug and anal flap advancement result in similar fistula healing rates in patients with high transsphincteric fistulae. These 2 strategies are superior to seton placement and fibrin glue. Given the low morbidity and relative simplicity of the procedure, the anal fistula plug is a viable alternative treatment for patients with high transsphincteric anal fistulas.

Cryptoglandular anal fistulae are the most frequently occurring form of perianal sepsis. Characteristically they have an endoanal primary opening, a fistula track and an abscess and/or an external purulent opening. Antibiotic therapy is not of use in initial management except in special cases. Treatment of an abscess, if present, is required urgently and when possible, consists of its incision under local anaesthesia. Treating the fistula track occurs afterwards and aims to dry up the purulent discharge and avoid recurrence of the abscess by means of surgical fistulotomy. These techniques are very effective in terms of eradication of the problem but there is sometimes a risk of anal incontinence. This explains the increasing interest in sphincter preserving techniques using the advancement of a covering flap of rectal mucosa and the injection of fibrin glue.

Fistula in ano is a frequent disease, which often has a difficult diagnosis and mapping, and comports significant morbidity. Today, Magnetic Resonance (MRI) allows a rapid, simple and precise mapping of peri anal fistula, which leads to a correct surgical treatment. In this paper, the authors review its pathology and MRI role in diagnosis and mapping. The authors also report a retrospective and descriptive study on the MRI results for the mapping of fistula in ano performed in Hospital Fernando Fonseca for a 38-month period.

Objective: The purpose of this study was to evaluate the role of transcutaneous perianal ultrasonography in evaluation of fistulas in ano and to assess its possible role as a first-line investigation, for follow-up, and as a possible substitute for magnetic resonance imaging., Methods: Transcutaneous perianal ultrasonography was performed in 30 patients with fistulas in ano with the use of a 3- to 6-MHz sector probe, a 7- to 11-MHz linear probe, and a 5- to 7-MHz endocavitary probe. Patients were followed clinically and at surgery to assess the accuracy of transcutaneous perianal ultrasonography., Results: A total of 43 fistulas, sinus tracts, or both were found in 26 patients. They appeared as hypoechoic tracts. Eleven of 30 patients had the presence of a collection or abscess, which appeared as hypoechoic areas. Twenty-four of 29 patients with positive findings underwent surgery. In these, 35 of 39 tracts were surgically confirmed (positive predictive value, 90%). The positive predictive value for demonstration of an internal opening was 85% (22/26) when compared with direct visualization or probing. Sensitivity for detection of tracts was 100%, and that for demonstration of an internal opening was 96% (26/27). The negative predictive value for sinus/fistulous tracts was nearly 100%. Transcutaneous perianal ultrasonography could not adequately evaluate suprasphincteric-type fistulas. However, it is a good, inexpensive modality in the evaluation of patients with fistulas in ano and also helps in follow-up of these patients. It can also be used to select patients who need magnetic resonance imaging., Conclusions: Transcutaneous perianal ultrasonography has the potential to become the first investigation in patients with perianal fistulas and abscesses.

Unlabelled: There are different names: perianal abscesses and fistulae, periproctitis, paraproctitis, pararectal inflammatory and fistulous processes, etc. It is our opinion that the name perianal and anal fistulae does not correspond to the origin of the fistulae from an abscess of the rectal wall, although it is fairly common., Objective: To offer a name, based on the patophysiological mechanism and anatomic localization of the inflammatory process in the pararectal area through study of the origin and the way of development of ano - rectal abscesses and fistulae., Material and Methods: A group of 430 (4%) patients with recto - perineal abscesses and fistulae has been analyzed out of a total of 10 726 hospitalized patients for the 1986 - 2005 period. Of them 241 patients (56,1 %) have been with recto - perineal fistulae, and 189 (43,9%) with recto - perineal abscesses., Conclusion: The process starts in the rectal wall, in the Morgan's crypts - cryptitis, after which the process transits to the perineal connective tissue. This succession in the development of the inflammatory process allows us to put the term " rectum" before "perineum" in the name adopted by us "recto - perineal abscesses and fistulae". It is our opinion that it is more appropriate to consider fistulae as a consequence from the abscesses, united in a single name recto - perineal abscesses and fistulae.

Background: Several new therapies, including advancement flaps and fibrin glue, have been proposed for fistula in ano, with conflicting results. Most colorectal surgeons continue to use classic methods, e.g. fistulotomy, fistulectomy, a combined method, loose or cutting seton, and rubber loop. The aim of the present study is to report the outcome of our patients, operated on by such methods., Methods: We retrospectively reviewed the clinical records of 844 patients treated for anal fistula over a 30-year period, and assessed fistula morphology, surgical procedure and healing period. For patients treated 2 or more years prior to this study, we evaluated rates of persistent fistula and relapse, as well as prevalence of incontinence and patient satisfaction., Results: The majority of patients had trans-sphincteric fistulae (58.3%). We observed 274 secondary extensions (32.5%); these were common in all fistula types except for intrasphincteric fistulae. Most patients were treated by fistulotomy alone (594 patients, 70.4%) or by the combined fistulectomy-fistulotomy method (237 patients, 28.1%), with or without loose seton. All patients with trans-, supra- and extrasphincteric fistulae were re-examined in the operations theatre. Follow-up data were available for 652 (87%) of 751 patients at least two years after surgery. The anal fistula persisted in 3.2% and recurred in 2.1% of cases. A second procedure lowered the initial rate of unsuccessful operations from 5.3% to 2.5%. Continence disorders were reported in 6.9% of patients: 4.0% complained of incontinence to gas, 2.6% to liquid and 0.3% to solid feces., Conclusions: Fistulotomy and fistulectomy with loose seton supported by preoperative anal manometry and postoperative evaluation under anaesthesia are followed by good clinical and functional results.

Objective: To investigate the diagnostic value of the distance between external opening of perianal fistula and anal verge and to evaluate its relation to the type of fistula. Preoperative identification of complex fistulae is important for proper planning of treatment., Patients and Methods: One hundred and fifteen consecutive patients operated for perianal fistula were studied prospectively. The distance between the external opening and the anal verge was measured. Location of the external opening, demographic and medical history data were correlated with characteristics of the fistulae. Data analysis was performed using the SPSS statistical package. The association between categorical variables was examined using the chi(2)-test or Fisher's exact test for small sample. Comparison of continuous variables between two groups was analysed by t-test., Results: The mean distance between external opening and anal verge in simple fistulae was 2.8 cm (range 1.5-4.3, SD 0.689) and in complex fistulae it was 4.4 cm (range 3.5-6.0, SD 0.526). This difference was statistically significant -P < 0.0001. Age and previous operations (particularly attempted definitive operations) were also significantly related to the complexity of the fistula. Data concerning location and direction of the fistulous tracts confirm the validity of Goodsall's rule., Conclusion: Simple preoperative clinical examination may reliably predict the complexity of a perianal fistula. Identification of these patients permits to select the cases that should have specific sophisticated preoperative work-up. The first definitive operation is most important to assure a successful outcome, thus such preoperative triage may also permit selective referral to a specialized colorectal team.

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.