Anorectal fistula is a common condi

Anorectal fistula is a common condition defined by an abnormal perianal track that connects two epithelialized surfaces, usually the anal canal to the perianal skin but occasionally to another organ, such as the vagina. (Changhu Liang et al., 2014)

Although the etiology of fistulas is clear and less controversial, the exact incidence and prevalence of fistulas is not known due to poor data available from outpatient treatment centers. The incidence of fistulae developing from an anal abscess ranges from 26 to 38 percent. The mean age for presentation of anal abscess and fistula disease is 40 years (range 20 to 60).The disease predominates in adults with a male to female ratio of 2:1. Soon after diagnosis (R.L. Nelson et al., 2014)

Fistulae in the overwhelming majority of cases arise from prior abscesses. Anorectal fistulas are associated with preexisting abscesses in the majority of cases. In a study of 100 recurrent anorectal abscesses, an underlying fistula was demonstrated in the operating room in 68 % of the patients (Elsa Limura et al., 2015)
Other causes such as hemorrhoidectomy, foreign body perforation, and trauma are of less frequency. Inflammatory bowel disease, more commonly Crohn’s dis- ease, has been known to be associated with anorectal fistulas. Specific diseases such as tuberculosis and actinomycosis are much less frequent in the Western world. Tubercular fistulas are covered in a separate section (R.L. Nelson et al., 2014)


. It is interesting to note that the highest number of concomitant fistulas (47 %) was found in intersphincteric abscesses where the branches of anal glad terminate. With unroofing of abscess and primary fistulotomy when deemed appropriate and safe, the incidence of recurrent infection was only 3.7 % [1]. This is in stark contrast of the 68 % incidence of fistulas found in 100 patients with recurrent anorectal abscesses (R.L. Nelson et al., 2014)


Classification:
There are two main classification systems for perianal fistulas: the Parks classification and the St James’s University Hospital classification. (Jaime de Miguel et al., 2012)

Parks Classification:
Several classification systems have been proposed in the published literature. In 1976, the Parks’ classification of perianal fistulas was introduced. It is an anatomical classification of perianal fistulas based on the relation of the fistula tract and the external sphincter muscle, Parks et al described fistulas in the coronal plane according to the course of the fistula and its relationships to the internal and external sphincters. Fistulas were classified into four groups: inter- sphincteric, transsphincteric, suprasphincteric, and extrasphincteric. In the Parks classification, the external sphincter is used as the keystone. (Jaime de Miguel et al., 2012)

St James’s University Hospital Classification:
Nowadays, the most commonly used grading system is the St. James University Hospital classification, with five subtypes The classification grades fistulas into five groups: grade 1, simple linear intersphincteric fistula; grade 2, intersphincteric with abscess or secondary track; grade 3, transsphincteric; grade4, transsphincteric with abscess or secondary track in ischiorectal or ischioanal fossa; grade 5, supralevator and translevator (Jaime de Miguel et al., 2012)


The history of an anal fistula is often quite typical. The patient gives a history of a prior episode of perianal swelling and pain (low abscess) or deep rectal pain with fever and systemic symptoms (high abscess). The abscess either ruptures spontaneously and drainage of pus and blood is followed by resolution of acute pain or alternately the abscess may be drained by a surgeon to relieve the symptoms and prevent spreading sepsis. The spontaneously or surgically drained abscess will take one of three courses: (1) complete healing and no recurrence (less likely), (2) non-healing and continuous drainage (more likely), or (3) healing and recurrence of the abscess (most likely) (Peter Glen et al., 2014)

The first landmark is often readily visible to the secondary opening of the fistula, is often open and draining or has a telltale granulation tissue protruding from the opening. If a fistula opening is sealed, whether healed or temporarily closed with an epithelial layer, it is often seen as a small depression especially in chronic fistulas with fibrosis and retraction of the external opening ( F. Pigot et al.,2014)

The next step is to palpate the fistula tract , Palpation of the soft tissue between the secondary opening and the anal canal often feels like a firm cord (much like the extensor tendons of the fingers) connecting the two (F. Pigot et al.,2014)
Anoscopy, using an Anoscopy with side opening (e.g., Vernon-David or Ives) will allow visualization of the primary opening, which is often seen as a small dimple. Gentle pressure on the fistula track may result in discharge of pus from the primary opening, which confirms the diagnosis (Robert D. Fry et al., 2014).

Examination under anesthesia (EUA) is undertaken with plans to address the fistula with curative intent. Due to the cost associated with EUA, this procedure should not be used routinely to clinically assess the fistula tract (R.L. Nelson et al., 2014)

Ordinarily, a fistula being treated for the first time requires very little if any additional imaging. However with multiple operations resulting in scarring and distortion of the fistula tract, and in cases where there is more than one fistula encountered imaging might be helpful. (Hall JF1 et al., 2014)
Consist of the following:
1. Fistulography, which was popularized in the 1970s and 1980s but has fallen out of favor with advent of other imaging modalities. There were publications pro and con of fistulography but currently this procedure is rarely utilized (Hall JF1 et al., 2014)

2. Endoanal ultrasonography without or with injection of peroxide in the fistula tract. This modality is helpful not only in delineating the fistula tract and other potential associated tracts or abscess cavity but also as a road map for identification of fistula tracts during surgery. (Hall JF1 et al., 2014)

3. Computerized tomography of pelvis and perineum with administration of contrast intravenously, intrarectally, orally, or injection through the fistula tract is helpful but more reserved for “high” fistulas originating in the pelvis or supralevator space. (Changhu Liang et al., 2014)
4. Magnetic resonance imaging is quite helpful in diagnosing fistula and assessing the closure of the fistula after seemingly successful procedures, especially in Crohn’s disease. (Changhu Liang et al., 2014)

The purpose of the clinical assessment of fistula is twofold
.1. Identification of primary and secondary openings and the fistula tract itself which is described above.
2. Assessment of the complexity of fistula including clinical classification and the thickness of sphincter muscle involved
(M. Khanbhai et al., 2014)


Frederic Salmon in 1847 founded a specialty unit for proctology, i.e., the St. Mark’s Hospital for Fistulae, etc. in City Road, London. Many surgeons studied and worked at St. Marks and the specialty spread through Europe and across the Atlantic. Joseph P. Matthews studied under Allingham in the UK prior to establishing the first proctology section and unit at the University of Kentucky in Louisville. The specialty gained recognition in the US leading to the incorporation of the American Proctologic Society in Columbus Ohio in 1899 with Dr. Matthews as its first President. Surgical texts were published on the sole subject of proctology and preceptorships led to propagation the specialty in the US. Over the ensuing decades St. Marks’ remained a Mecca for education of surgeons in proctology and despite many successes in treatment of many proctologic condition, cure of fistulas remained much more elusive than any other condition (Robert D et al., 2014)



For simple anal fistulas, fistulotomy with or without marsupialization is recommended. In the presence of an abscess with anal fistula, incision and drainage along with fistulotomy may be considered. This is associated with decreased recurrence (relative risk, 0.17; 95% confidence interval, 0.09-0.32; P < .001) but increased risk of continence disturbance. Fibrin glue has also been studied, with the advantage of less risk of incontinence. However, success rates have been reported lower than those for fistulotomy (41.7%). (Ratto C et al., 2012)
For complex fistulas, debridement and fibrin glue or fistula plug may be used. Success rates for fibrin glue range from 10-67%. Although it has a relatively low success rate, recent guidelines suggest that fibrin glue may be used as first-line therapy. Likewise, variable success has been reported with fistula plugs. One small trial described a success rate of 72.7% with the use of the Gore Bio-A fistula plug. Endoanal advancement flaps also have variable success rates for the treatment of complex fistulas. (Liu WY et al., 2013)
Ligation of intersphincteric fistula tract (LIFT) has also been described, with long-term success rates (>12 months) of 62%. In this small study, fistula tract lengths greater than 3 cm were noted to have a higher rate of failure with LIFT (odds ratio, 0.55; 95% confidence interval, 0.34-0.88). In some cases, staged surgery is needed to repair an anal fistula. . ( Liu WY et al., 2013)

Initial studies on fibrin glue injection for the management of complex anal fistulae were promising. The first of these was published in 1991 by Hjortrup et al [65] and was the result of a pioneering series of treatments for perianal fistulae with fibrin glue (Elsa Limura et al., 2015)

The use of laser in the treatment of anal fistula was initially described in 2011 in a pilot study by Wilhelm [73]. This novel sphincter-saving technique uses an emitting laser probe [Fistula laser closure (FiLaC™), Biolitec, Germany], which d

النتائج (الإنجليزية) 1:

Anorectal fistula is a common condition defined by an abnormal perianal track that connects two epithelialized surfaces, usually the anal canal to the perianal skin but occasionally to another organ, such as the vagina. (Changhu Liang et al., 2014)Although the etiology of fistulas is clear and less controversial, the exact incidence and prevalence of fistulas is not known due to poor data available from outpatient treatment centers. The incidence of fistulae developing from an anal abscess ranges from 26 to 38 percent. The mean age for presentation of anal abscess and fistula disease is 40 years (range 20 to 60).The disease predominates in adults with a male to female ratio of 2: 1. Soon after diagnosis (R.L. Nelson et al., 2014) Fistulae in the overwhelming majority of cases arise from prior abscesses. Anorectal fistulas are associated with preexisting abscesses in the majority of cases. In a study of 100 recurrent anorectal abscesses, an underlying fistula was demonstrated in the operating room in 68% of the patients (Elsa Limura et al., 2015) Other causes such as hemorrhoidectomy, foreign body perforation, and trauma are of less frequency. Inflammatory bowel disease, more commonly Crohn's dis-ease, has been known to be associated with anorectal fistulas. Specific diseases such as tuberculosis and actinomycosis are much less frequent in the Western world. Tubercular fistulas are covered in a separate section (R.L. Nelson et al., 2014). It is interesting to note that the highest number of concomitant fistulas (47%) was found in intersphincteric abscesses where the branches of anal glad terminate. With unroofing of abscess and primary fistulotomy when deemed appropriate and safe, the incidence of recurrent infection was only 3.7% [1]. This is in stark contrast of the 68% incidence of fistulas found in 100 patients with recurrent anorectal abscesses (R.L. Nelson et al., 2014)Classification: There are two main classification systems for perianal fistulas: the Parks classification and the St James's University Hospital classification. (Jaime de Miguel et al., 2012)Parks Classification:Several classification systems have been proposed in the published literature. In 1976, the Parks ' classification of perianal fistulas was introduced. It is an anatomical classification of perianal fistulas based on the relation of the fistula tract and the external sphincter muscle, Parks et al described fistulas in the coronal plane according to the course of the fistula and its relationships to the internal and external sphincters. Fistulas were classified into four groups: inter-sphincteric, transsphincteric, suprasphincteric, and extrasphincteric. In the Parks classification, the external sphincter is used as the keystone. (Jaime de Miguel et al., 2012)St James's University Hospital Classification:Nowadays, the most commonly used grading system is the St. James University Hospital classification, with five subtypes The classification grades fistulas into five groups: grade 1, simple linear intersphincteric fistula; grade 2, intersphincteric with abscess or secondary track; grade 3, transsphincteric; grade4, transsphincteric with abscess or secondary track in ischiorectal or ischioanal fossa; grade 5, supralevator and translevator (Jaime de Miguel et al., 2012)The history of an anal fistula is often quite typical. The patient gives a history of a prior episode of perianal swelling and pain (low abscess) or deep rectal pain with fever and systemic symptoms (high abscess). The abscess either ruptures spontaneously and drainage of pus and blood is followed by resolution of acute pain or alternately the abscess may be drained by a surgeon to relieve the symptoms and prevent spreading sepsis. The spontaneously or surgically drained abscess will take one of three courses: (1) complete healing and no recurrence (less likely), (2) non-healing and continuous drainage (more likely), or (3) healing and recurrence of the abscess (most likely) (Peter Glenn et al., 2014)The first landmark is often readily visible to the secondary opening of the fistula, is often open and draining or has a telltale granulation tissue protruding from the opening. If a fistula opening is sealed, whether healed or temporarily closed with an epithelial layer, it is often seen as a small depression especially in chronic fistulas with fibrosis and retraction of the external opening (F. Pigott et al., 2014)The next step is to palpate the fistula tract, Palpation of the soft tissue between the secondary opening and the anal canal often feels like a firm cord (much like the extensor tendons of the fingers) connecting the two (F. Pigott et al., 2014)Anoscopy, using an Anoscopy with side opening (e.g., Vernon-David or Ives) will allow visualization of the primary opening, which is often seen as a small dimple. Gentle pressure on the fistula track may result in discharge of pus from the primary opening, which confirms the diagnosis (Robert D. Fry et al., 2014).Examination under anesthesia (EUA) is undertaken with plans to address the fistula with curative intent. Due to the cost associated with EUA, this procedure should not be used routinely to clinically assess the fistula tract (R.L. Nelson et al., 2014)Ordinarily, a fistula being treated for the first time requires very little if any additional imaging. However with multiple operations resulting in scarring and distortion of the fistula tract, and in cases where there is more than one fistula encountered imaging might be helpful. (Hall JF1 et al., 2014) Consist of the following:1. Fistulography, which was popularized in the 1970s and 1980s but has fallen out of favor with advent of other imaging modalities. There were publications pro and con of fistulography but currently this procedure is rarely utilized (Hall JF1 et al., 2014)2. Endoanal ultrasonography without or with injection of peroxide in the fistula tract. This modality is helpful not only in delineating the fistula tract and other potential associated tracts or abscess cavity but also as a road map for identification of fistula tracts during surgery. (Hall JF1 et al., 2014) 3. Computerized tomography of pelvis and perineum with administration of contrast intravenously, intrarectally, orally, or injection through the fistula tract is helpful but more reserved for "high" fistulas originating in the pelvis or supralevator space. (Changhu Liang et al., 2014)4. Magnetic resonance imaging is quite helpful in diagnosing fistula and assessing the closure of the fistula after seemingly successful procedures, especially in Crohn's disease. (Changhu Liang et al., 2014)The purpose of the clinical assessment of fistula is twofold.1. Identification of primary and secondary openings and the fistula tract itself which is described above.2. Assessment of the complexity of fistula including clinical classification and the thickness of sphincter muscle involved(M. Khanbhai et al., 2014)Frederic Salmon in 1847 founded a specialty unit for proctology, i.e. the St. Marks Hospital for Fistulae, etc. in City Road, London. Many surgeons studied and worked at St. Marks and the specialty spread through Europe and across the Atlantic. Joseph P. Matthews studied under Allingham in the UK prior to establishing the first proctology section and unit at the University of Kentucky in Louisville. The specialty gained recognition in the US leading to the incorporation of the American Proctologic Society in Columbus Ohio in 1899 with Dr. Matthews as its first President. Surgical texts were published on the sole subject of proctology and preceptorships led to propagation the specialty in the US. Over the ensuing decades St. Marks ' remained a Mecca for education of surgeons in proctology and despite many successes in treatment of many proctologic condition, cure of fistulas remained much more elusive than any other condition (Robert D et al., 2014)For simple anal fistulas, fistulotomy with or without marsupialization is recommended. In the presence of an abscess with anal fistula, incision and drainage along with fistulotomy may be considered. This is associated with decreased recurrence (relative risk, 0.17; 95% confidence interval, 0.09-0.32; P <. 001) but increased risk of continence disturbance. Fibrin glue has also been studied, with the advantage of less risk of incontinence. However, success rates have been reported lower than those for fistulotomy (41.7c). (Ratto C et al., 2012)For complex fistulas, debridement and fibrin glue or fistula plug may be used. Success rates for fibrin glue range from 10-67%. Although it has a relatively low success rate, recent guidelines suggest that fibrin glue may be used as first-line therapy. Likewise, variable success has been reported with fistula plugs. One small trial described a success rate of 72.7c with the use of the Gore Bio-A fistula plug. Endoanal advancement flaps also have variable success rates for the treatment of complex fistulas. (Look it up WHY et al., 2013)Ligation of intersphincteric fistula tract (LIFT) has also been described, with long-term success rates (> 12 months) of 62%. In this small study, fistula tract lengths greater than 3 cm were noted to have a higher rate of failure with LIFT (odds ratio, 0.55; 95% confidence interval, 0.34-0.88). In some cases, staged surgery is needed to repair an anal fistula. . (Look it up WHY et al., 2013)Initial studies on fibrin glue injection for the management of complex anal fistulae were promising. The first of these was published in 1991 by Hjortrup et al [65] and was the result of a pioneering series of treatments for perianal fistulae with fibrin glue (Elsa Limura et al., 2015)The use of laser in the treatment of anal fistula was initially described in 2011 in a pilot study by Wilhelm [73]. This novel sphincter-saving technique uses an emitting laser probe [Fistula laser closure (FiLaC™), Biolitec, Germany], which d

النتائج (الإنجليزية) 3:

肛门直肠瘘是一种常见的疾病的一种不正常的肛周轨道连接两个上皮表面的定义，通常肛管肛周皮肤但偶尔到另一个器官，如阴道。（长亮等人。，2014）

虽然瘘管病因明确、争议较少，确切的发病率和患病率瘘不知道由于可以从门诊治疗中心的不良数据。瘘的肛门脓肿的范围从26到百分之38的开发率。对于肛周脓肿和瘘管疾病的症状的平均年龄为40岁（范围20至60）。该病主要在成年人的男性与女性的比例为2:1。诊断后不久（北京Nelson等人。，2014）

瘘在绝大多数情况下出现之前的脓肿。肛门直肠瘘伴脓肿是在大多数情况下，相关。100肛门直肠脓肿复发的研究，一个潜在的瘘病人中的68%个操作室显示（埃尔莎limura等人。，2015）