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      Surgical technique: an improvisation in application of the technique of core-cut fistulectomy for fistula-in-ano

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          Abstract

          Cryptoglandular fistula-in-ano is a chronic inflammatory condition of the perianal region attributed to the obstruction of the glands, located chiefly at the dentate line and their subsequent infection. Anal fistulae are difficult to treat, and minimally invasive procedures are evolving with promises. We present an improvised application of core-cut technique of fistulectomy. It is a minimally invasive, simple, effective and easy to perform procedure with minimal risk of incontinence and recurrence in simple cryptoglandular fistulae-in-ano. We performed 47 cases with good results and present this procedure to emphasize the procedural modification used.

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          A classification of fistula-in-ano.

          A classification of anal fistulas is presented, which is the result of an analysis of 400 cases treated over the past 15 years, based on the pathogenesis of the disease and the normal muscular anatomy of the pelvic floor. Four main types were found but numerous variations of each occur, which are described. It is hoped that this will alert the surgeon to the various complex situations that he may encounter.
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            The use of the loose seton technique as a definitive treatment for recurrent and persistent high trans-sphincteric anal fistulas: a long-term outcome.

            The loose seton technique (suggested to avoid any external anal division following seton placement, to ensure anal continence) was assessed as the ultimate approach for primary as well as recurrent and persistent anal fistula. Between 2000 and 2006, 97 patients were operated for trans-sphincteric anal fistula, 41 patients of whom (42.3%) underwent the loose seton technique. The outcome was assessed periodically at the outpatient colorectal clinic and finally by detailed telephonic questionnaire. Mean age was 45.3 years. Thirty one operations were elective (75.6%). Fifteen (36.5%) patients had concomitant diseases, of whom three suffered from Crohn's disease. Twenty nine patients had previous anal operations. The time from seton placement to its removal ranged from 3 to 7 months. At short-term follow-up, early complications were noted in five patients (bleeding in one and abscess formation in four). Late complications included liquid stool soiling in one patient (2.4%), solid soiling in two, and mucous discharge in three. Post-operative clinical assessment of incontinence according to Cleveland Clinic Incontinence Score revealed scoring ranging from 2 to 6 in those six patients. Neither gross stool nor flatus incontinence was noted. Fistula recurrence (persistence) was noted in eight (19.5%) patients and successfully treated by the same loose seton technique. The loose seton technique for trans-sphincteric anal fistula carries favorable results and can be safely applied while preserving the external sphincter function. We also recommend repeating the technique in case of post-operative fistula recurrence or persistence.
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              New Techniques for Treating an Anal Fistula

              Surgery for an anal fistula may result in recurrence or impairment of continence. The ideal treatment for an anal fistula should be associated with low recurrence rates, minimal incontinence and good quality of life. Because of the risk of a change in continence with conventional techniques, sphincter-preserving techniques for the management complex anal fistulae have been evaluated. First, the anal fistula plug is made of lyophilized porcine intestinal submucosa. The anal fistula plug is expected to provide a collagen scaffold to promote tissue in growth and fistula healing. Another addition to the sphincter-preserving options is the ligation of intersphincteric fistula tract procedure. This technique is based on the concept of secure closure of the internal opening and concomitant removal of infected cryptoglandular tissue in the intersphincteric plane. Recently, cell therapy for an anal fistula has been described. Adipose-derived stem cells have two biologic properties, namely, ability to suppress inflammation and differentiation potential. These properties are useful for the regeneration or the repair of damaged tissues. This article discusses the rationales for, the estimated efficacies of, and the limitations of new sphincter-preserving techniques for the treatment of anal fistulae.
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                Author and article information

                Contributors
                Journal
                J Surg Case Rep
                J Surg Case Rep
                jscr
                Journal of Surgical Case Reports
                Oxford University Press
                2042-8812
                March 2021
                29 March 2021
                29 March 2021
                : 2021
                : 3
                : rjab032
                Affiliations
                Department of General Surgery , All India Institute of Medical Sciences , Bhopal Madhya Pradesh, India
                Department of General Surgery , All India Institute of Medical Sciences , Bhopal Madhya Pradesh, India
                Department of General Surgery , Rajeev Gandhi Medical College , Mumbai, Maharashtra, India
                Department of General Surgery , All India Institute of Medical Sciences , Bhopal Madhya Pradesh, India
                Author notes
                Correspondence address. General Surgery, AIIMS, Bhopal, Madhya Pradesh, India. E-mail: bharati_pandya@ 123456rediffmail.com
                Author information
                https://orcid.org/0000-0002-1743-9728
                https://orcid.org/0000-0002-9574-3688
                Article
                rjab032
                10.1093/jscr/rjab032
                8007175
                d3aee286-98a1-4574-bb89-d255ec1d092a
                Published by Oxford University Press and JSCR Publishing Ltd. All rights reserved. © The Author(s) 2021.

                This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( http://creativecommons.org/licenses/by-nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact journals.permissions@oup.com

                History
                : 11 December 2020
                : 18 January 2021
                : 25 January 2021
                Page count
                Pages: 4
                Categories
                Surgical Technique
                AcademicSubjects/MED00910
                jscrep/040

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