Sphincter‐sparing surgery for complex anal fistulas: radiofrequency thermocoagulation of the tract is of no help

Abstract

Aim To compare the rate of failure of radiofrequency thermocoagulation for anal fistula with that of rectal advancement flap in a case‐matched study. Method Patients who underwent radiofrequency treatment were compared with age‐ and sex‐matched patients with Crohn's disease (CD) who underwent a rectal flap procedure. Fistula features, general characteristics and the main clinical events were recorded in a prospective database. Failure was defined by at least one of following: abscess, purulent discharge, visible external opening or further drainage procedure. Results A total of 62 patients [median age 45 (range 36.8–57.5) years; 22 women, 40 men; 22 with CD] were analysed. The failure rate of radiofrequency treatment was higher than that of rectal flap treatment (74.2% vs 32.2%; P = 0.004). The cumulative probabilities of failure of the radiofrequency treatment were 53.8% (38.8–68.3), 71.8% (55.3–84.0) and 87.4% (70.6–95.3) at 3, 6 and 12 months, respectively. Three patients in the radiofrequency group required drainage for an abscess and one had severe thermal ulceration. The Cox proportional hazards regression model (surgical procedure, obesity, CD) showed rectal flap treatment [3.48 (1.60–8.07); P = 0.001] and CD [2.60 (1.16–6.41); P = 0.02] to be the main independent predictors of healing. Conclusion Radiofrequency thermocoagulation is a less satisfactory sphincter‐sparing treatment for the management of anal fistula than a rectal flap procedure.

Prospective and multicentre study of radiofrequency treatment in anal fistula

“…These results are superior to a previous case-control retrospective study comparing radiofrequency treatment and advancement flap [32] which showed healing in 25.8% of the cases, with a median follow-up of 5 months. Postoperative complications were higher (three abscesses, a haematoma and a thermal ulceration with a rectovaginal fistula).…”

Optimizing electrode design to minimize thermal spread in radiofrequency-induced colonic anastomosis

“…Although using RF-induced thermofusion to create intestinal anastomosis represents a potentially important advance, it also poses new challenges with welded anastomoses by thermofusion including insufficient coagulation of proteins, necrosis and desquamation of parts of the circumference of the anastomotic zone, leading to dreaded complication of anastomotic leakage and causing failure of the operation. Therefore, technological research is needed to ensure reliable tissue connection and residual viability of the anastomotic zone until the tissue reconstruction is complete [19,20].…”

Radiofrequency thermocoagulation for high transphincteric fistulae, Merlini l'Héritier et al.

“…This month's Editor's Choice by Merlini l'Héritier et al . evaluated ablation of the tract by applying radiofrequency thermocoagulation . They used a control group, selected from a prospective database consisting of patients who underwent occlusion of the fistula tract by a rectal advancement flap, paired‐matched for sex, age and the presence of Crohn's disease.…”

“…Crohn's disease is thought to be caused by a failure of the intestinal mucosal immune system to tolerate commensal bacteria. The highest healing rates in the featured study were achieved in patients with Crohn's disease (overall success 64 percent) . All these patients were on anti‐tumour necrosis factor alpha therapy.…”

“…When managing Crohn's fistulae, combining a surgical procedure, which prevents entry of bacteria to the fistula, with immunotherapy seems to be the logical approach. The overall healing rate in patients with cryptoglandular fistulae was only 41% at 5 months follow‐up . The persistent inflammation in the anal crypt is nowadays believed to occur as a result of a defective local immune system.…”