Introduction

"Complex" anal fistulas are characterized by a tract that cannot be laid open by fistulotomy without risking significant incontinence due to the depth of the tract and/or the patient's condition. Over the past 20 years, several techniques known as "sphincter-saving" have been proposed to address this surgical challenge. Among these techniques, FiLaC™ is one of the most recent. It involves closing the fistula tract by coagulation. The aim of our work is to evaluate the results of this technique in terms of healing of anal fistulas through a series of cases.

Aims & Methods

This is a descriptive prospective study conducted between May 2023 and March 2024 involving 14 patients who underwent treatment for anal fistula using the FiLaC™ technique. All patients underwent an initial surgical intervention to identify the fistula tract, place a loose seton, drain any abscess, and/or lay open any diverticula. The type of fistula tract was determined by the proctologist during this first operation. In cases of doubt about the quality of drainage, multi-operated fistula, and/or Crohn's disease, an MRI was performed. The procedure was performed under spinal anesthesia, and all patients received perioperative antibiotic prophylaxis. We used a 1.2 mm diameter radial fiber powered by the Leonardo Duel© diode laser platform. The primary outcome measure was fistula healing, clinically defined by closure of the internal and external openings and absence of pain and discharge.

Results

Fourteen patients were included, with a mean age of 45.1 +/- 2.1 years. Among our patients, 12 (85%) had cryptogenic fistulas, 1 case had a fistula as part of ano-perineal manifestations of Crohn's disease (CD), and one anal fistula was secondary to perianal tuberculosis. The fistula was classified as Parks 1 in 14.2% of cases, Parks 2 in 57.14% of cases, Parks 3 in 14.2% of cases, and Parks 4 in 14.2% of cases. The internal opening was tight in 64.28% of patients and gaping in 35.72%. The mean operative time before laser closure was 2.07. All patients had a seton drain placed. The mean time for drain removal was 124.90 seconds, and the mean delivered energy was 799.88 Joules. No cases of postoperative complications were reported. The mean follow-up was 2.21 months. Healing was achieved in 78.5% of cases, while in 21.5% of patients, closure of the internal and/or external opening was not achieved, and surgical revision was proposed. No cases of recurrence were reported.

Conclusion

The treatment of complex fistulas still presents a challenge: achieving fistula healing while preserving anal continence. Laser coagulation appears as a promising technique that can meet this challenge.

Introduction

Anal fissure is a common reason for consultation in proctology. Surgery is proposed in cases of chronic, complicated, or recurrent anal fissure. Fissurectomy can be performed alone (FS) or combined with anoplasty (F+A). The benefit of the latter compared to fissurectomy alone has never been demonstrated. The objective of the study was to compare the effectiveness and tolerance of the two techniques.

Aims & Methods

This was a retrospective descriptive and analytical study conducted over a period of 18 years from January 2005 to August 2023, involving 2070 patients surgically treated for anal fissure. We included all patients without a proctological surgical history who were operated on for a single, non-infected idiopathic anal fissure. We evaluated postoperative pain, early postoperative complications (bleeding, dysuria, constipation, superinfection), and healing time. Statistical analysis was performed using SPSS 20.0 software. Qualitative variables were compared using the Chi-square test. Predictive factors for healing were identified using a binary logistic regression model in univariate and multivariate analysis.

Results

The overall prevalence of anal fissures compared to other reasons for proctology consultation was 55.9%. The median age of the patients was 40 [21-69], with a female-to-male ratio of 0.85. The anal fissure was posterior in 1493 (72.1%) patients and anterior in 577 (27.9%) patients. Other proctological pathologies (anal fistula, hemorrhoidal disease) were associated in 358 cases (17.3%). FS was performed in 1304 patients (62.9%) and F+A in 766 patients (37%). Sphincterotomy was associated in 357 patients (17.24%). The median postoperative follow-up was 2 [1-3.9] months. Continence was respected in all patients. The time to disappearance of postoperative pain was the same for both procedures: 1.1 +/- 0.5 months vs. 1.0 +/- 1.2 months, p=0.51, respectively for FS and F+A. The overall rate of early complications was 5.29%, with them being more frequent in cases of F+A: 7.1% vs. 2.3%, p=0.031. The healing rate was similar in both procedures: 92.9% vs. 97.7%, p=0.31. The median healing time was shorter in patients who underwent F+A: 1.5 +/- 0.2 months vs. 2.8 +/- 0.4 months, p = 0.0003. In multivariate analysis, independent risk factors associated with delayed healing were age ≥ 40 years [OR = 3.1; 95% CI [1.1 to 14.1] p = 0.004) and a history of diabetes [OR 6.5, 95% CI [1.7 to 43.2] p <0.001. The postoperative recurrence rate was similar in both procedures: 2.1% in the case of FS vs. 3.2% in the case of F+A, p=0.1.

Conclusion

Fissurectomy remains an effective procedure in the management of anal fissures. Our study showed that fissurectomy with anoplasty has the advantage of accelerating healing. However, at present, no technique is consensual, hence the importance of multicenter randomized studies evaluating both surgical techniques.

Introduction

Hemorrhoidal disease (HD) is the most common pathology in proctology, with an estimated prevalence of between 4.4% and 39%. It can be managed in a variety of ways: hygienic-dietary measures, medical, instrumental or surgical treatment. The latter is considered especially after failure of medical and instrumental treatment.

Aims & Methods

Aims : The aim of our study is to report our experience with Milligan and Morgan technique in the management of hemorrhoidal disease.

Materials and methods: This was a monocentric retrospective descriptive-analytical study conducted over a 12-year period: from January 2011 to January 2023. The data studied were age, sex, clinical manifestations, stage of HD on proctological examination and therapeutic data. All patients who underwent Milligan and Morgan hemorrhoidectomy (MMH) and presented with stage IV and III hemorrhoids (after failure of instrumental treatment) were included in our study. Excluded were asymptomatic patients, patients with surgical contraindications and other stages treated by non-surgical means. The statistical study was carried out using IBM-SPSS 20.0 software. The chi-2 test was used to compare categorical variables.

Results

468 patients were enrolled during the study period. The mean age of this population was 41 years (22-71). The sex ratio M/F was 2,1. Clinical expression was dominated by rectal discharge in 246 patients (74%), proctalgia in 132 patients (28%), anal pruritus in 119 patients (25%) and anal oozing in 56 patients (12%). Proctological examination revealed stage IV haemorrhoids in 201 patients (43%) and stage III haemorrhoids in 267 patients (57%). 25 patients (5.3%) had an associated anal fissure. Anemia was present in 341 patients (72.8%), with a mean hemoglobin value of 7.8 g/dl. Transfusion was required in 65 patients (14%) who presented with severe anemia of less than 7g/dl. Colonoscopy was indicated in 87 patients (18.5%) over the age of 45 with rectal bleeding, and in 42 patients (9%) with a history of digestive cancer. Milligan and Morgan's indication was stage III hemorrhoids with severe anemia in 65 patients (14%), after failure of infrared photocoagulation in 194 patients (41.4%); after failure of HAL-RAR treatment n=8 (1.7%) and stage IV hemorrhoids in 201 patients (43%). The procedure performed was a hemorrhoidectomy.An open pedicle MMH type was performed. Patients with an associated anal fissure (5.3%) underwent the Bellan procedure in addition to hemorrhoidectomy. Immediate post-operative complications included post-operative pain in all our patients, urinary retention in 31 patients (6.6%), significant post-operative bleeding in 2 patients (0.5%) treated by electrocoagulation in the OR, and minimal post-operative bleeding in 117 patients (25%) treated by compression bandaging. The latter was reported in 43 patients (36.7%) with stage III hemorrhoids and 74 patients (63.2%) with stage IV hemorrhoids. This difference was statistically significant (p<0.001). Late complications included delayed healing in 9 patients (1.9%), 4 of whom were diabetic, anal stenosis in 5 patients (1%), requiring sphincterotomy combined with anoplasty in 3 patients, and finger dilatation in 2 patients. Anal stenosis was reported in 4 patients who did not undergo postoperative digital rectal examination and 1 patient who did. This difference is statistically significant p=0.03.

Conclusion

MMH remains the gold standard for the treatment of hemorrhoidal disease. The results are satisfactory, especially in the long term. Post-hemorrhoidectomy anal stenosis remains the most serious complication.

Introduction

Anal fistulas are the most common clinical forms of ano-perineal suppurations. They are defined by the initial infection of an anal gland of Hermann and Desfosses opening in the middle part of the anal canal. A specific origin is possible. The treatment is surgical and has two objectives: to treat the suppuration definitively and to preserve fecal continence, but also to have histological evidence for specific fistulas.

Aims & Methods

The aim of our work is to collect epidemiological, clinical, paraclinical, therapeutic and evolutionary data of this condition.
This is a retrospective, descriptive study over a period of 6 years: January 2015-December 2021, including 640 patients with anal fistula collected at the proctology unit, all patients with anal fistula and who received surgical treatment or biopsy for diagnostic purposes were included in our study. This work allowed to collect epidemiological, clinical, paraclinical, therapeutic and evolutionary data of this condition.

Results

640 patients were included presenting with anal fistula. The average age was 39 years [25-59], with a male predominance of 570 patients (89%). Clinically, the predominant symptomatology was chronic purulent discharge in 416 cases (65%), 128 cases (20%) had an inaugural anal abscess, 77 cases (12%) had proctalgia, 19 cases (3%) had anal pruritus and 13 cases (2%) had diarrhea.
The proctological examination revealed: simple anal fistula in 575 patients (90%) and 65 patients had complex anal fistula (10%).
Out of 640 patients recruited for anal fistula, 45 patients (7%) had specific anal fistula and 595 patients (93%) had cryptoglandular anal fistula.
After a digestive, phtysiological and radiological assessment we concluded :
- 26 cases (58%) anal fistula occurring in patients followed for Crohn's disease or inaugural ano-perineal Crohn's disease having benefited from a seton drainage and put under combotherapy.
- 16 cases (36%) in favour of anal tuberculosis put on anti bacillary treatment.
- 2 cases (4%) of neoplastic fistulas that benefited from oncological management.
- 1 case (2%) in favor of anal sarcoidosis treated with corticotherapy.

Conclusion

Anal fistulas are a fairly common pathology. The diagnosis of anal fistulas is clinical. Cryptoglandular anal fistula remains the most frequent entity, requiring surgical treatment, while the management of specific anal fistula depends on the etiology.

Disclosure

No conflict of interest

Clinical Case Summary

A 29-year-old man was admitted to the hospital with complaints of rectal tenesmus, a sensation of incomplete evacuation, diarrhea occurring 6-8 times daily, and occasional constipation. Digital rectal examination revealed a hard, immovable mass 5 cm from the anus, with an upper margin that could not be palpated. Laboratory tests showed a C-reactive protein (CRP) level of 4.68 mg/L and an erythrocyte sedimentation rate (ESR) of 28.0 mm/h. The tuberculosis-interferon gamma release assay and fecal occult blood test were positive. Computed tomography (CT) and rectal endoscopic ultrasound (EUS) showed a 6 cm mass in the lower rectum, thickened rectal walls with uneven enhancement, multiple enlarged lymph nodes and a solid perianal nodule measuring 5.0×4.0 mm. Endoscopy revealed irregular thickening of rectal wall, nodular lesions with erythema and erosion from 10 cm proximal to the anal canal, and intestinal stenosis with a fistula. Multiple biopsies from the colonoscopy showed chronic mucosal inflammation with hyperplastic glandular epithelial cells and mucus, but no malignancy was detected.
The patient received sequential treatments of metronidazole, mesalazine, and diagnostic antitubercular drugs, but showed no improvement. Finally, an endoscopic mucosal resection (EMR) was performed. Biopsy findings revealed crypt branching and distortion, reactive epithelial hyperplasia, a few chronic inflammatory cells in the lamina propria, and fibrosis of the submucosa, consistent with mucosal prolapse.
Rectal mucosal prolapse syndrome (RMPS) poses significant diagnostic challenges due to its overlapping clinical, endoscopic, and histopathological features with other rectal disorders, such as Crohn' disease, intestinal tuberculosis, and colorectal carcinoma^1-3. Detailed endoscopic evaluation and deep histopathological analysis is essential. In patients with a long history of abnormal defecation habits, RMPS should be considered in the differential diagnosis of rectal masses.

References

1. Hayasaka J, Hoteya S, Tomizawa K, et al. The Long-term Efficacy of Endoscopic Submucosal Dissection in the Treatment of Symptomatic Mucosal Prolapse Syndrome. Intern Med 2021;60:1005-1009.
2. Tang X, Han C, Sheng L, et al. Rectal mucosal prolapse with an emphasis on endoscopic ultrasound appearance. Dig Liver Dis 2021;53:427-433.
3. Chiang JM, Changchien CR, Chen JR. Solitary rectal ulcer syndrome: an endoscopic and histological presentation and literature review. Int J Colorectal Dis 2006;21:348-56.

Introduction

Incidence of squamous cell carcinoma (SCC) of the anal canal is increasing. SCC arises from anal intraepithelial neoplasia (AIN) and condylomas. However, destruction of these anal lesions with standard techniques carries a high risk of recurrence and potential functional impairment. Endoscopy can be used to detect and treat colorectal lesions by endoscopic mucosal resection (EMR) or endoscopic submucosal dissection (ESD), but its value in the management of anal lesions has been poorly studied. The aim of this study was to assess the feasibility, efficacy and safety of endoscopic management of AIN and condylomas.

Aims & Methods

We conducted a retrospective study including all patients who had undergone endoscopic resection either by EMR or DSM of anal lesion (AIN or condylomas). The following criteria were evaluated: the rate of residual lesion at the end of endoscopic treatment, the rate of monobloc resection, the rate of complication per procedure and within 30 days after the procedure, the rate of new anal lesion and the rate of SCC during follow-up.

Results

From May 2015 to November 2024, 33 patients were included. Twenty-six (78.8%) were women. Mean age was 62.8 (±11.1) years. Two (6.1%) patients were HIV-positive. Eleven (33.3%) patients had a history of anal lesions, including one (3.0%) case of SCC. The median number of lesions per patient was 1 (IQR 1 - 2), with multifocal involvement in 15 (45.5%) patients. Thirteen (39.4%) patients had anal involvement reaching more than one hemi-circumference. Seven patients (21.2%) underwent ESD, and 26 (78.2%) underwent EMR. At the end of endoscopic treatment, no residual lesions were visible in 31 (93.9%) patients. Lesions were intentionally left in the remaining two patients. Resections were monobloc and macroscopically complete in 19 (57.6%) patients. Intra-procedural hemorrhage was visualized in 18 (54.5%) patients and was treated endoscopically during the same anesthesia without recurrence or clinical impact. One case of anal stenosis occurred 27 days after circumferential ESD treated with 4 sessions of digital dilatations and one corticosteroid injection. No other complications occurred within 30 days after the procedures. Mean length of hospital stay was 1.12 (+/- 0.33) days. Pathological findings were: condyloma in 6 (18.2%) patients, AIN1 in 8 (24.2%) patients, AIN2 in 5 (15.2%) patients, AIN3 in 10 (30.3%) patients, and SCC in 4 (12.1%) patients (two SCC T1 R0, one of which required additional radiotherapy, and two in situ SCC). Follow-up data were available for 29 patients. Mean follow-up time was 34.4 (+/- 35.7) months. Of these 29 patients, 8 (27.6%) cases of a new AIN or condyloma (outside the resection scar) were detected during follow-up after an average duration of 4 (+/- 2.1) months, 7 of which were treated by endoscopy. Two (6.9%) cases of scar recurrence were detected 4 and 13 months after treatment. During follow-up, three (10.3%) cases of SCC ≥ T1 were diagnosed, including one case of recurrence at one year of a SCC pre-existing endoscopic treatment. The other two cases were diagnosed at one and 6 years.

Conclusion

Endoscopic management (EMR or DSM) of AIN and condylomas is a safe and effective. It should be part of the therapeutic arsenal in the management of these lesions. Increased surveillance is essential, given the high risk of new lesions.

References

Deshmukh AA, Suk R, Shiels MS, et al. Recent Trends in Squamous Cell Carcinoma of the Anus Incidence and Mortality in the United States, 2001-2015. J Natl Cancer Inst 2020; 112: 829–838.
Palefsky JM, Lee JY, Jay N, et al. Treatment of Anal High-Grade Squamous Intraepithelial Lesions to Prevent Anal Cancer. N Engl J Med 2022; 386: 2273–2282.
Borch-Johnsen P, Nygren J, Schmidt PT. Endoscopic underwater detection and resection of anal squamous intraepithelial lesions in non-anesthetized patients - a feasibility study and comparison with standard surgical treatment. Scand J Gastroenterol 2024; 59: 232–238.