There is no satisfactory treatment of complex fistula-in-ano to date. A fistula-in-ano is termed “ complex ” when the track crosses > 30 % -50 % of the external sphincter ( high-transsphincteric, suprasphincteric and extrasphincteric ), is anterior in a female, is perennial, has multiple tracks, or the patient has preexisting dissoluteness, local anesthetic radiotherapy or Crohn ’ s disease [ 1 – 4 ]. In hurt of several new procedures, such as anal fistulous withers plug [ 5, 6 ], ligation of intersphincteric fistulous withers tract ( LIFT ) [ 7 ], video assisted anal fistula treatment ( VAAFT ) [ 8 ], laser-FiLaC [ 9 ] and the OTSC proctology procedure [ 10 ] tried in the last ten, the challenge of successfully treating complex anal fistulous withers remains integral. The two chief issues in managing such fistulas are to minimize the recurrence rate and prevent any deterioration in continence levels. The clean process was done four times a day. For the first 10 vitamin d, the patient was called to the outpatient clinic for supervised clean once or twice a day depending upon the complexity of the fistula. After this, the affected role could do the clean march at home plate. The scavenge march entailed cleaning the cauterized wound in the anal canal and even houseclean and vacate of the curetted tracts. The former was done by pacify rub of the scent by doing a per rectal finger insertion. The latter was done by a cotton swab mounted on an artery forceps. No povidine iodine, hydrogen peroxide or any liquid was injected in to the tract during the clean process as this would have prevented the internal open from close. The clean was done by a educate nurse, a aesculapian attendant or a relative. In our set, teaching a relative was an economic and preferable option. postoperative cleanse aimed at healing two areas : the cauterized wind in the anal duct ( around the home opening ) and the curetted tracts. The former was pivotal as the closing of the internal open depended upon it and by and large took about 10-12 five hundred to heal. The latter was besides needed for the complete closing of the fistula and took a variable star time ( 4-8 wk ) depending on the fistula characteristics ( number, length and complexity of the tracts ) and the affected role co-morbidities ( diabetes, anemia, hypoproteinemia etc. ). The patient was discharged on the operation sidereal day ( if done under curtly general anesthesia ) or the first postoperative day ( if done under saddle or spinal anesthesia ). He/she could resume all his/her normal activities on the same day. The patient was encouraged to walk briskly for 5 km every day. This helped to keep the tracts empty. After this, the tracts were curetted in accordance with the MRI diagram and the tract line was scraped out angstrom much as possible with a dull curette. While doing then, a finger was kept in the rectum so as to ensure that the curette did not incidentally perforate the rectum. Proximal superficial cautery ( Figure ) was carried out with electrocautery around the internal open, cauterizing only the mucous membrane and superficial part of the inner sphincter. The crypt glands, the internal afford and the tissue around it were cauterized. This normally resulted in an ellipse area, approximately 1 cm ( wide ) and 2 cm ( long ), with the inner open at the center of the injure ( Figure ). After cautery, the injure was left as such and no try was made to close the inner open with any suture, stapler, glue or hack. To ensure proper clean of the tracts, the play along steps ( one or multiple depending upon the prerequisite and fistulous withers characteristics ) could be done in a patient : ( 1 ) multiple holes were made along the straight or the horseshoe tract ( Figures, ,, and ) in such a direction that the farthest corner of the tract could be cleaned with ease ; ( 2 ) the external first step was widened and the scarred pucker clamber ( if present ) was excised. The purpose was to make the open bigger than 1 curium × 1 centimeter ( Figure ). This facilitated houseclean of the tracts for a longer duration ; and ( 3 ) idle seton or tube were put in the tracts to prevent the previous blockage of the external open. These were removed 10-12 d after the operation ( Figures, ,, and ). The PERFACT routine had three steps ( calculate ) : ( 1 ) proximal superficial cautery : the area around the inner afford was freshened and de-epithelized by electrocautery ( Figure ) and the wound was encouraged to heal by secondary purpose ( granulation tissue ). This normally closed the inner possibility in about 10-12 d ; ( 2 ) curettage of tracts : all the tracts were thoroughly curetted and debrided of their line with a curette ; and ( 3 ) emptying regularly fistulous withers tracts : the curetted tracts were keep open clean and evacuate of any serous fluid then as to ensure that the tracts healed ( closed ) by granulation tissue. Keeping all the tracts clean until they healed completely was a challenge tax and the most necessitate step of the routine. It took 4-8 wk ( occasionally even longer ) for all the tracts to heal amply. Until that time, even cleaning of the tracts was done. All types of building complex fistula-in-ano including : ( 1 ) fistula associated with multiple tracts ; ( 2 ) horse shoe fistulas ; ( 3 ) perennial fistulous withers ; ( 4 ) anterior fistulous withers in females ; ( 5 ) fistulous withers with long tracts ( any tract distance > 10 curium ) ; ( 6 ) fistulous withers with supralevator subterfuge extension ( not with high rectal open ) ; ( 7 ) fistula where internal possibility can not be localized ; and ( 8 ) fistulous withers associated with abscess/pus collections. It was used as a first lineage definitive procedure in patients with anal fistulas presenting with ischiorectal or perianal abscess. Fifty-one patients with complex fistula-in-ano were prospectively enrolled. The medial follow-up was 9 moment ( 5-14 molybdenum ). The hateful age was 42.7 ± 11.3 years. male : female proportion was 43:8. The fistulous withers characteristics were perennial in 76.5 % ( 39/51 ), horseshoe in 50.1 % ( 26/51 ), multiple tracts in 52.9 % ( 27/51 ), associated abscess in 41.2 % ( 21/51 ) and anterior fistula in 33.3 % ( 17/51 ). The internal open could not be decidedly traced intraoperatively in 15.7 % ( 8/51 ) and there was associated supralevator elongation in 9.8 % ( 5/51 ) ( table ). seven patients were excluded from the analysis ( 5 lost to follow-up, 2 had biopsy test mycobacteria tuberculosis ). The fistulous withers and all the associated tracts healed wholly in 79.5 % ( 35/44 ) of patients and there was recurrence of symptoms in 20.5 % ( 9/44 ) of patients. Out of these, three undergo reoperation ( two PERFACT procedure, one fistulotomy ) and all three were successful ( table ). The subgroup analysis showed that although the presence of multiple tracts and an abscess reduced the bring around rate, it was not statistically meaning ( Fisher demand test P > 0.05 ) ( board ). The only complication was a non-healing tract in 9.1 % ( 4/44 ) of patients. There was no significant change in objective dissoluteness scores after the operation. The pain was minimal, with all patients resuming their normal activities within 72 h of the mathematical process .
The PERFACT procedure is a novel concept to treat building complex fistula-in-ano. It is simple to perform and easy to reproduce. The results ( initial 79.5 %, overall 86 % ) are quite impressive considering that all these patients had highly complicated fistula-in-ano ( Table ). The concept behind the PERFACT procedure was identical simple. It aimed to close the home opening by proximal superficial cautery in the anal duct ( Figure ). In the postoperative period, it was ensured that the weave healed by junior-grade purpose so that the inner opening was sealed by granulation weave.
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The second gradation was curettage of the tracts. This ensured that the infect epithelium was removed and the refresh raw wound in the tracts led to the coevals of the granulation weave which would facilitate the closure of the tracts. however, the serous discharge of the granulation weave needed to be thoroughly cleaned/removed from the tracts as otherwise the dead discharge would become infect, leading to a collection. The latter would not entirely lead to the rapid re-epithelialization of the tracts but would besides flow into inner open, preventing its closure. The postoperative management was quite meaning. It had two components : to keep the cauterize anal wind clean and to keep the tracts clean and empty. Any insufficiency in this care was damaging to the final consequence. The cautery of the inner possibility had been tried earlier without much success. The reason for the success of the same step in the PERFACT procedure needs explanation. undoubtedly, the inner open is the prime perpetrator in a fistula-in-ano by allowing entrance of the bacteria from the anal duct into the fistulous withers tracts. however, once the tracts are formed and are lined by the infect epithelium, then it is a mutually propagate position. The patent internal open keeps the tracts infected and the infect collection in the tracts keep the internal hatchway patent. Therefore, an isolated undertake to close the inner opening would fail until it is accompanied by the meticulous cleaning, emptying and curative of all the associated tracts. This possibly explains the rigorous motivation for regular tract clean in the postoperative period. The concept behind this procedure was undoubtedly simple but to achieve good results in complex anal fistula, it required detail analysis of the MRI scan, careful plan and map of the tracts ( preoperatively ), meticulous curettage and scavenge of all the tracts ( intraoperatively ), and disciplined postoperative care ( postoperatively ). The main benefit of this procedure was minimal morbidity and the least gamble of dissoluteness. The morbidity was minimal as no extensive weave cut was done. aside from a small superficial wound in the anal canal, the external open was widened ( Figure ) or a few holes were made in the perianal region ( to drain accessory tracts ) ( Figures, ,, and ). The anal wound was normally minor and low as the inner open was located by and large at the dentate line ( Figure ). then, the result wound was normally about 2 cm long and 1 curium wide. due to the small wound and little pain, the patients were able to resume all their normal day by day activities from the first postoperative day. The patients were encouraged to walk briskly for 4-5 kilometers from the first postoperative day as it facilitated keeping the tracts empty. second major advantage was that as the external sphincter was completely spared, the negative affect on dissoluteness was minimal. The routine worked quite well in all types of complex fistulous withers : fistulous withers associated with multiple tracts, sawhorse shoe fistulas, perennial fistulas, front tooth fistulous withers in females, fistula with long tracts, fistulous withers with supralevator blind extension ( not with high rectal open ), fistula associated with abscess/pus collections and fistulous withers where no definite inner opening could be localized intraoperatively ( Figures, ,, and ). The PERFACT procedure was quite effective in horseshoe fistulous withers and fistula with multiple tracts. About half of the fistulous withers ( 50.1 % ) in our series had a horseshoe fistulous withers and the remedy rate was 76.2 % ( 16/21 ) ( table ) ( Figures and ). In fact, one of the patients presented with a double horseshoe intersphincteric abscess which encircled the rectum circumferentially. This affected role was besides cured by this routine ( Figure ). About 53 % of patients had multiple tracts and the achiever rate in this subgroup was 71.4 % ( 15/21 ). One of the patients had eight external openings and he underwent this operation successfully ( Figure ). In fistula with an consort abscess, the abscess was drained and the PERFACT procedure was carried out as described. There was no need to make a big incision as the setons and regular clean of the cavity in the postoperative time period ensured that there was no remembrance and estimable curative ensued. In our series, 41.2 % patients presented with an abscess or had an associated significant abscess ( Table ). The PERFACT procedure was done as the definitive first gear line procedure and the remedy rate was 72 % ( table ; Figures, and ). The PERFACT procedure was effective in fistula cases where no definite internal orifice could be localized intraoperatively. failure to identify the inner opening during the operation possibly happens because of the irregular closing of the inner opening due to debris or the devious run of the collapsible tract through the sphincters. As in the literature, this can happen in up to 15-20 % of cases [ 8 ]. In our series, this happened in 15.7 % ( 8/44 ) of cases ( Table ). This routine worked quite successfully in 87.5 % ( 7/8 ) of such cases in our series ( Figure ) ( table ). As the MRI was done preoperatively in every case, it helped to localize the tracts in the majority of cases and gave a fair theme of where the tract was coursing towards the rectum. This information along with the intraoperative examination findings ( sclerosis of the sphincter complex in the region of inner opening ) helped to determine the potential web site of the internal open. At that place, the superficial cautery was done. In two patients, the MRI video created doubt that the tracts could be going both anteriorly and posteriorly and hence superficial cautery was done at both places ( figure ). superficial cautery was a safe tone to do. Although it created a wound, it was not associated with any risk of dissoluteness as the wound was quite superficial. therefore, in subject of confusion/doubt, superficial cautery can be done at two places. This procedure was besides effective in fistulous withers with supralevator extension ( blind ). The operation was carried out as described. The position of the supralevator tract was carefully assessed on MRI and intraoperatively this nerve pathway was cautiously curetted while keeping a finger in the rectum ( to avoid injuring the rectal wall ). During the postoperative dressings, the supralevator nerve pathway was regularly cleaned for at least 2-3 wk ( or as needed ). While doing therefore, a finger was inserted in the rectum to avoid any injury. In our series, it was effective in providing cure in 75 % of patients ( 3/4 ) with supralevator extension ( Figure ). With careful postoperative management, most of the fistulas healed between 4-10 wk. In 9 ( 20.5 % ) patients, the operation failed. The home open did not close up and one or multiple tracts failed to heal. The probable reason was inability to regularly clean all the tracts postoperatively, leading to a collection in one of the tracts. This possibly prevented the tracts deoxyadenosine monophosphate well as the inner opening from healing. Four ( 9 % ) of the patients had persistent serous/watery discharge for a prolong menstruation ( 10-16 wk ). This happened in cases with long fistula tracts. The callous wound in the anal canal and the home open healed quite well in these cases, leading to the cessation of plutonium geological formation. however, the serous drain was possibly due to the re-epithelialization of the outer dowry of the nerve pathway. We did aristocratic curettage of the tract in the office under topical anesthesia ( lidocaine gelatin ) and it helped to close the recalcitrant tract. however, multiple curettings were needed in two cases. There are certain patients in whom the internal hatchway is enlarged/widened ascribable to previous surgical interventions ( like tightening setons ). In these patients, proximal superficial cautery fails or takes much longer to heal. In this subgroup, an progress flap plus the intensify mechanical clean of the fistula tract could be a better choice. The PERFACT procedure adds a potentially useful treatment option to our armamentarium against complex fistula-in-ano. It complements the mucosal promotion beat, anal fistula plug, OTSC proctology, LIFT, VAAFT and glue procedures. The PERFACT operation is dim-witted and associated with lower unwholesomeness and minimal risk of dissoluteness. Compared to a mucosal progress beat, the PERFACT operation is technically less demanding. Unlike an anal fistula plug, laser-FiLaC and OTSC proctology procedure [ 9, 10 ], the PERFACT operation can be done as a authoritative routine in fistula patients presenting with an acute abscess or collection. Unlike early existing procedures, the PERFACT routine can be done in patients where the internal open can not be decidedly localized. last, unlike fistulotomy and cutting tightening setons, the PERFACT routine is associated with a minimal gamble of dissoluteness.
The PERFACT procedure has certain clear-cut advantages. It is associated with the least risk of incontinence, morbidity is minimal, pain is not much and the patient is able to resume normal activities within 1-2 vitamin d of the operation. It has a high achiever rate in all types of complex fistula-in-ano, including horseshoe fistula, perennial fistulous withers and fistulous withers with multiple tracts. It is effective in highly complicated cases where the other procedures do not work well, such as fistulous withers with supralevator extension, fistulous withers with consort abscess and fistula where the home hatchway can not be localized. furthermore, the PERFACT routine can be done as the first base line authoritative procedure in fistulas presenting with an anorectal or ischiorectal abscess ( quite than doing an incision and drain initially and a authoritative procedure later ). Another advantage of this procedure is its cost effectiveness. No expensive equipment/gadget is required, operation duration is 15-30 min and hospital stay is only 12-24 h ( can be done as a day care procedure ). As there is minimal incision/cutting, there is very little scar and distortion of the anatomy. stopping point but not the least, this operation is quite bare to do and reproduce. The procedure has its limitations. The PERFACT routine is not effective in cases where a supralevator tract has a high rectal opening. It is besides not indicated in humble fistulous withers where there is no sphincter engagement. second, meticulous postoperative concern is required, particularly for the first gear two weeks. Although most of the patients are back to their normal routine the inaugural day after the operation, they need to come for doubly daily follow-up for at least ten days. active participation/cooperation is needed from a relative/acquaintance. In our area, teaching a proportional ( spouse in the majority of cases ) was an economically viable and acceptable option. third, the problem of prolong serous discharge adds to the unwholesomeness in few patients. last, the long condition follow-up ( > 3 years ) results are awaited. To conclude, the PERFACT procedure is a simple novel method acting to treat complex and highly complex anal fistulous withers. This includes fistula-in-ano with multiple tracts, horse shoe fistulas, perennial fistulas, anterior fistula in females, supralevator fistula, fistula where inner opening can not be localized and as a first base line authoritative procedure in patients with fistula-in-ano presenting with ischiorectal or perianal abscess. however, long term multicenter trials are needed with larger numbers of patients to substantiate these findings .