Treating highly complex anal fistula with a new method of combined intraoperative endoanal ultrasonography (IOEAUS) and transanal opening of intersphincteric space (TROPIS).

Huang, Baolei; Xu, Weihua; Zhou, Dongxu; Chen, Si; Li, Bai; Wang, Yilin; Tai, Jiandong

doi:10.5114/wiitm.2021.104368

Cited by 27 publications

(39 citation statements)

References 24 publications

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“…TROPIS provides a ray of hope, as it has been shown to have satisfactory results in these fistulas[ 2 , 3 , 16 , 24 , 41 ]. In the TROPIS procedure, the intersphincteric space is laid open in the anal canal and the resultant wound is allowed to heal by secondary intention[ 16 , 24 ].…”

Section: Management Guidelinesmentioning

confidence: 99%

“…In the TROPIS procedure, the intersphincteric space is laid open in the anal canal and the resultant wound is allowed to heal by secondary intention[ 16 , 24 ]. The transsphincteric tracts (tracts lateral to the EAS in the ischiorectal fossa) are thoroughly curetted and cleaned[ 3 , 41 ]. Thus, the tracts on both sides of the EAS are managed separately (tracts inner to the EAS are laid open into the anal canal and tracts outside the EAS in the ischiorectal fossa are curetted and cleaned) and the EAS is not cut or damaged at all[ 16 , 24 ].…”

Section: Management Guidelinesmentioning

confidence: 99%

“…The reason for the higher success rate of the TROPIS procedure could be that, unlike other procedures, TROPIS adequately tackles the sepsis in the intersphincteric space[ 3 , 41 ]. It is now understood that the pus/sepsis in the intersphincteric part of the fistula tract is like an abscess in a closed space[ 24 ].…”

Section: Management Guidelinesmentioning

confidence: 99%

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Guidelines to diagnose and treat peri-levator high-5 anal fistulas: Supralevator, suprasphincteric, extrasphincteric, high outersphincteric, and high intrarectal fistulas

Garg¹,

Yagnik²,

Dawka³

et al. 2022

WJG

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Supralevator, suprasphincteric, extrasphincteric, and high intrarectal fistulas (high fistulas in muscle layers of the rectal wall) are well-known high anal fistulas which are considered the most complex and extremely challenging fistulas to manage. Magnetic resonance imaging has brought more clarity to the pathophysiology of these fistulas. Along with these fistulas, a new type of complex fistula in high outersphincteric space, a fistula at the roof of ischiorectal fossa inside the levator ani muscle (RIFIL), has been described. The diagnosis, management, and prognosis of RIFIL fistulas is reported to be even worse than supralevator and suprasphincteric fistulas. There is a lot of confusion regarding the anatomy, diagnosis, and management of these five types of fistulas. The main reason for this is the paucity of literature about these fistulas. The common feature of all these fistulas is their complete involvement of the external anal sphincter. Therefore, fistulotomy, the simplest and most commonly performed procedure, is practically ruled out in these fistulas and a sphincter-saving procedure needs to be performed. Recent advances have provided new insights into the anatomy, radiological modalities, diagnosis, and management of these five types of high fistulas. These have been discussed and guidelines formulated for the diagnosis and treatment of these fistulas for the first time in this paper.

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Section: Management Guidelinesmentioning

confidence: 99%

Section: Management Guidelinesmentioning

confidence: 99%

See 1 more Smart Citation

Guidelines to diagnose and treat peri-levator high-5 anal fistulas: Supralevator, suprasphincteric, extrasphincteric, high outersphincteric, and high intrarectal fistulas

Garg¹,

Yagnik²,

Dawka³

et al. 2022

WJG

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show abstract

“…In the present study, the abscesses in the outer-sphincteric space were drained externally through the ischiorectal fossa, while the fistula tract in the intersphincteric space was managed by TROPIS (transanal opening of intersphincteric space) procedure. [6][7][8] TROPIS is a modification of LIFT (ligation of intersphincteric tract) in which the intersphincteric tract is opened up into the anal canal so that it heals by secondary intention. [6][7][8][9] The ischioanal or ischiorectal abscess should not be drained into the anal canal as this will risk injuring the external anal sphincter (EAS).…”

Section: Implications Of the Newly Described ("Outer-sphincteric") Anatomical Space In Clinical Managementmentioning

confidence: 99%

“…[6][7][8] TROPIS is a modification of LIFT (ligation of intersphincteric tract) in which the intersphincteric tract is opened up into the anal canal so that it heals by secondary intention. [6][7][8][9] The ischioanal or ischiorectal abscess should not be drained into the anal canal as this will risk injuring the external anal sphincter (EAS). However, drainage of supralevator abscess into the anal canal is the preferred method as it would entail incising the internal anal sphincter (IAS) only and thus prevent injury to the external anal sphincter.…”

Section: Implications Of the Newly Described ("Outer-sphincteric") Anatomical Space In Clinical Managementmentioning

confidence: 99%

A New Anatomical Pathway of Spread of Pus/Sepsis in Anal Fistulas Discovered on MRI and Its Clinical Implications

Garg¹,

Kaur²,

Yagnik³

et al. 2021

CEG

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Background: In the anal sphincter complex, the intersphincteric space between the internal and external sphincters is the only conventionally recognized pathway for the spread of sepsis. However, there is another unrecognized space discovered on MRI, the "outersphincteric space", between the external anal sphincter and its lateral fascia along which pus can spread. An abscess in the intersphincteric space is easily drained into the rectum via the transanal route and is more likely to spread into the supralevator space. Conversely, an abscess in the outer-sphincteric space is difficult to drain transanally into the rectum and is more likely to become a transsphincteric abscess/fistula. Methods: The MRIs of anal fistula patients operated over four years on intersphincteric abscesses were analyzed. The pattern of spread into the ischiorectal fossa and/or supralevator space and ease of drainage into the rectum through the transanal route were studied. Results: Thirty-six patients were operated on to drain their intersphincteric abscesses through the anal canal. Two distinct patterns were noted. Twenty patients had abscesses in the intersphincteric space, which were easily drained into the rectum. Of them, 6/20 had supralevator extension, while only 1/20 had spread to the ischiorectal fossa. In 16/36 patients, the abscess was in the outer-sphincteric space and could not be drained into the rectum. In 9/16 of these patients, pus spread into the ischiorectal fossa but supralevator spread did not happen in any patient. Conclusion: Apart from the intersphincteric space, there is perhaps another unrecognized anatomical space -the outer-sphincteric space -discovered on MRI, through which pus can spread in anal fistulas or abscesses.

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Recent Advances in Benign Anorectal Disorders

Garg

2022

GI Surgery Annual

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Treating highly complex anal fistula with a new method of combined intraoperative endoanal ultrasonography (IOEAUS) and transanal opening of intersphincteric space (TROPIS).

Cited by 27 publications

References 24 publications

Guidelines to diagnose and treat peri-levator high-5 anal fistulas: Supralevator, suprasphincteric, extrasphincteric, high outersphincteric, and high intrarectal fistulas

Guidelines to diagnose and treat peri-levator high-5 anal fistulas: Supralevator, suprasphincteric, extrasphincteric, high outersphincteric, and high intrarectal fistulas

A New Anatomical Pathway of Spread of Pus/Sepsis in Anal Fistulas Discovered on MRI and Its Clinical Implications

Recent Advances in Benign Anorectal Disorders

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