BACKGROUND: Sphincter-preserving operations have been increasingly used for treating anal fistula. However, their success rates remain modest in complex anal fistulas. OBJECTIVE: This study aimed to report outcomes of video-assisted ligation of intersphincteric fistula tract (a procedure combining video-assisted anal fistula treatment and ligation of intersphincteric fistula tract) for treating complex anal fistulas and to compare its results with conventional ligation of intersphincteric fistula tract. DESIGN: A review of prospectively collected data from October 2014 to December 2017 was performed. SETTINGS: The study was conducted at a large tertiary hospital in Thailand. PATIENTS: All patients with primary or recurrent complex anal fistulas undergoing video-assisted ligation of intersphincteric fistula tract were included. Patients with anal fistula related to malignancy, Crohn’s disease, tuberculosis, or acute abscess were excluded. MAIN OUTCOME MEASURES: Healing as defined by an absence of fistula or drainage from an external opening and complete epithelialization of the external opening were measured. RESULTS: This study included 103 patients with a median age of 47 years. The primary healing rate was 84.5% at a median follow-up of 28 months (range, 15–38 mo). Primary healing rates of anterior high transsphincteric fistula, semi-horseshoe fistula, and horseshoe fistula were 88% (44 of 50 cases), 77% (30 of 39 cases), and 93% (13 of 14 cases). Median time to healing was 4 weeks (range, 4–8 wk). Accordingly, the overall failure rate was 15.5%. None reported worse fecal incontinence postoperatively. Video-assisted ligation of intersphincteric fistula tract had a higher rate of primary healing for complex anal fistula than ligation of intersphincteric fistula tract (84.5% vs 63.4%; p < 0.001). LIMITATIONS: This study is limited by its small sample size. CONCLUSIONS: The outcomes of video-assisted ligation of intersphincteric fistula tract for complex anal fistulas are quite good. This technique has the potential to become another viable option of sphincter-preserving operation for complex anal fistulas. See Video Abstract at http://links.lww.com/DCR/B373. LIGADURA ASISTIDA POR VIDEO DEL TRACTO DE LA FÍSTULA INTERESFINTÉRICA PARA LA FÍSTULA ANAL COMPLEJA: TÉCNICA Y RESULTADOS PRELIMINARIES ANTECEDENTES: Las operaciones de preservación del esfínter se han utilizado cada vez más para tratar la fístula anal. Sin embargo, sus tasas de éxito siguen siendo modestas en las fístulas anales complejas. OBJETIVO: Este estudio tuvo como objetivo informar los resultados de la ligadura asistida por video del tracto de la fístula interesfintérica (un procedimiento que combina el tratamiento de la fístula anal asistida por video y la ligadura del tracto de la fístula interesfintérica) para el tratamiento de las fístulas anales complejas y comparar sus resultados con la ligadura convencional de la fístula interesfintérica tracto. DISEÑO: Se realizó una revisión de los datos recolectados prospectivamente desde Octubre de 2014 hasta Diciembre de 2017. MARCO: El estudio se realizó en un gran hospital terciario en Tailandia. PACIENTES: Se incluyeron todos los pacientes con fístulas anales complejas primarias o recurrentes sometidas a ligadura asistida por video del tracto de la fístula interesfintérica. Se excluyeron los pacientes con fístula anal relacionada con malignidad, enfermedad de Crohn, tuberculosis o absceso agudo. MEDIDAS DE RESULTADOS PRINCIPALES: Curación definida por la ausencia de fístula o drenaje de la abertura externa y la epitelización completa de la abertura externa. RESULTADOS: Este estudio incluyó 103 pacientes con una mediana de edad de 47 años. La tasa de curación primaria fue del 84,5% con una mediana de seguimiento de 28 meses (rango 15-38). La tasa de curación primaria de la fístula transesfintérica alta anterior, la fístula semi-herradura y la fístula de herradura fue del 88% (44 de 50 casos), 77% (30 de 39 casos) y 93% (13 de 14 casos), respectivamente. El tiempo mediano hasta la curación fue de 4 semanas (rango 4-8). En consecuencia, la tasa de fracaso general fue del 15,5%. Ninguno informó peor incontinencia fecal después de la operación. La ligadura asistida por video del tracto de la fístula interesfintérica tuvo una mayor tasa de curación primaria para la fístula anal compleja que la ligadura del tracto de la fístula interesfintérica (84.5% vs 63.4%; p <0.001). LIMITACIONES: Este estudio está limitado por su pequeño tamaño de muestra. CONCLUSIONES: Los resultados de la ligadura asistida por video del tracto de la fístula interesfintérica para fístulas anales complejas son bastante buenos. Esta técnica tiene el potencial de convertirse en otra opción viable de operación de preservación del esfínter para fístulas anales complejas. Consulte Video Resumen en http://links.lww.com/DCR/B373. (Traducción—Dr Yesenia Rojas-Khalil).

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Background: Modified fundus-down cholecystectomy is a surgical procedure used to treat patients diagnosed with benign gallbladder disease. This technique begins with Calot’s triangle dissection and attempts to identify key structures such as the cystic artery and duct. Subsequently, fundus-down dissection is performed to separate the gallbladder from the cystic plate. The cystic artery and duct are the final structures that are clipped and cut. In this study, the authors discuss the success and complication rates of this treatment based on their 10-year experience at a tertiary hospital in southern Thailand. Objectives: This study aimed to compare the operative outcomes of conventional laparoscopic cholecystectomy (LC) and modified fundus-down techniques regarding postoperative complications and consequences. Methods: A retrospective analysis of single-centre data from 2010 to 2022 was conducted at our hospital. All patients with gallstone disease who underwent conventional LC or modified fundus-down cholecystectomy were included in the study. The primary outcomes of this study were the incidence of major bile duct injury and the need for further intervention or surgical correction. Results: From a total of 1993 patients who were surveyed, 1612 patients underwent conventional LC and 381 underwent laparoscopic modified fundus-down cholecystectomy. In terms of conversion rate, estimated blood loss, length of hospital stay, and complication rate, there were no differences between the conventional LC and the modified fundus-down approach. However, modified fundus-down cholecystectomy reduced the operative time. The authors collected data from each patient’s sign-in to extubation time (P<0.001). The postoperative complications (P=0.120) and conversion rates (P=0.904) were similar. Conclusion: Laparoscopic modified fundus-down cholecystectomy can be performed in simple and complex cases, including cases of severe fibrosis of the hepatocystic triangle. The study showed that this alternative technique could reduce operative time compared to the conventional technique with no difference in complications, especially common bile duct injury, postoperative common bile duct stones, and postoperative pancreatitis.