BACKGROUND A complex anal fistula is a challenging disease to manage. AIM To review the experience and insights gained in treating a large cohort of patients at an exclusive fistula center. METHODS Anal fistulas operated on by a single surgeon over 14 years were analyzed. Preoperative magnetic resonance imaging was done in all patients. Four procedures were performed: fistulotomy; two novel sphincter-saving procedures, proximal superficial cauterization of the internal opening and regular emptying and curettage of fistula tracts (PERFACT) and transanal opening of intersphincteric space (TROPIS), and anal fistula plug. PERFACT was initiated before TROPIS. As per the institutional GFRI algorithm, fistulotomy was done in simple fistulas, and TROPIS was done in complex fistulas. Fistulas with associated abscesses were treated by definitive surgery. Incontinence was evaluated objectively by Vaizey incontinence scores. RESULTS A total of 1351 anal fistula operations were performed in 1250 patients. The overall fistula healing rate was 19.4% in anal fistula plug ( n = 56), 50.3% in PERFACT ( n = 175), 86% in TROPIS ( n = 408), and 98.6% in fistulotomy ( n = 611) patients. Continence did not change significantly after surgery in any group. As per the new algorithm, 1019 patients were operated with either the fistulotomy or TROPIS procedure. The overall success rate was 93.5% in those patients. In a subgroup analysis, the overall healing rate in supralevator, horseshoe, and fistulas with an associated abscess was 82%, 85.8%, and 90.6%, respectively. The 90.6% healing rate in fistulas with an associated abscess was comparable to that of fistulas with no abscess (94.5%, P = 0.057, not significant). CONCLUSION Fistulotomy had a high 98.6% healing rate in simple fistulas without deterioration of continence if the patient selection was done judiciously. The sphincter-sparing procedure, TROPIS, was safe, with a satisfactory 86% healing rate for complex fistulas. This is the largest anal fistula series to date.

BACKGROUND The association of tuberculosis (TB) with anal fistulas can make its treatment quite difficult. The main challenge is timely detection of TB in anal fistulas and its proper management. There is little data available on diagnosis and management of TB in anal fistulas. AIM To detect TB in fistula-in-ano patients were analyzed in different methods utilized. METHODS A retrospective analysis of different methods, polymerase chain-reaction (PCR), GeneXpert and histopathology (HPE), utilized to detect tuberculosis in fistula-in-ano patients, treated between 2014-2020, was performed. The sampling was done for tissue (fistula tract lining) and pus (when available). The detection rate of various tests to detect TB and prevalence rate of TB in simple vs complex fistulae were studied. RESULTS In 1336 samples (776 patients) tested, TB was detected in 133 samples (122 patients). TB was detected in 52/703 (7.4%) samples tested by PCR-tissue, in 77/331 (23.2%) samples tested by PCR-pus, 3/197 (1.5%) samples tested with HPE-tissue and 1/105 (0.9%) samples tested by GeneXpert. To detect TB, PCR-tissue was significantly better than HPE-tissue (52/703 vs 3/197 respectively) ( P = 0.0012, significant, Fisher’s exact test) and PCR-pus was significantly better than PCR-tissue (77/331 vs 52/703 respectively) ( P < 0.00001, significant, Fisher’s exact test). TB fistulas were more complex than non-tuberculous fistulas [78/113 (69%) vs 278/727 (44.3%) respectively] ( P < 0.00001, significant, Fisher’s exact test) but the overall healing rate was similar in tuberculous and non-tuberculous fistula groups [90/102 (88.2%) vs 518/556 (93.2%) respectively] ( P = 0.10, not significant, Fisher’s exact test). CONCLUSION This is the largest study of anorectal TB to be published. The detection of TB by polymerase chain-reaction was significantly higher than by histopathology and GeneXpert. Amongst polymerase chain-reaction, pus had a higher detection rate than tissue. TB fistulas were more complex than non-tuberculous fistulas but aggressive diagnosis and meticulous treatment led to comparable overall success rates in both groups.

Magnetic resonance imaging (MRI) is considered the gold standard for the evaluation of anal fistulas. There is sufficient literature available outlining the interpretation of fistula MRI before performing surgery. However, the interpretation of MRI becomes quite challenging in the postoperative period after the surgery of fistula has been undertaken. Incidentally, there are scarce data and no set guidelines regarding analysis of fistula MRI in the postoperative period. In this article, we discuss the challenges faced while interpreting the postoperative MRI, the timing of the postoperative MRI, the utility of MRI in the postoperative period for the management of anal fistulas, the importance of the active involvement and experience of the treating clinician in interpreting MRI scans, and the latest advancements in the field.

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Aim Complex fistula‐in‐ano can recur even after complete clinical healing has occurred. ‘Radiological healing’ of fistula on MRI correlates well with long‐term healing rates but no study has yet objectively quantified this. The aim of this study was to assess the accuracy of anal fistula healing as documented on MRI and to correlate it with long‐term healing as evidenced on long‐term follow‐up. Methods Patients with clinically healed anal fistulas who also had radiological healing checked by postoperative MRI were included in the study. Results Three hundred and twenty‐five patients operated for high complex fistula‐in‐ano were followed up for 14–68 months (median 38 months). Postoperative MRI was done to assess radiological healing of the fistula in 151 patients, and they were included in the study. The mean age was 39.4 ± 10.5 years (116 men). Five patients were lost to follow‐up. The fistulas did not heal radiologically (on MRI) in 20 patients and recurred in all these patients. The fistulas healed radiologically (on MRI) in 126 patients. On long‐term follow‐up, 124/126 patients remained healed while 2/126 had a recurrence. In the first patient, the fistula recurred 40 months after complete radiological healing. In the second patient, the fistula recurred 10 months after complete radiological healing but pus from the fistula tested positive for tuberculosis (by real‐time polymerase chain reaction) and he was excluded from the analysis. Thus, there was only one (1/125) recurrence on long‐term follow‐up. Conclusions Radiological healing on MRI correlates well with long‐term healing in complex fistula‐in‐ano.

Video abstractPoint your SmartPhone at the code above. If you have a QR code reader the video abstract will appear. Or use: https://youtu.be/ScO76Q8nEOYBackground: Gallbladder hydatid cyst (GBHC) is highly uncommon with an incidence of 0.3-0.4% of all atypically located hydatid cysts. Our personal experience of one case of primary GBHC (PGBHC) managed laparoscopically motivated this systematic review. This study aimed to analyze the demographic characteristics, types [whether primary GBHC (PGBHC) or secondary GBHC (SGBHC)], clinical presentation, laboratory investigations, imaging studies, operative procedure, hospital stay, follow-up and recurrence. Methods: A systematic review was performed using preferred reporting items for systematic reviews and meta-analyses guidelines.Results: Twenty studies, including 22 cases plus one more case managed by us, were included in the review. For PGBHC, the mean age was 48.61 years while for SGBHC it was 47.9 years. PGBHC was more common in females (69.23%) while SGBHC was more common in males (55.55%). Overall, GBHC was more common in females (56.52%). The most common presentation overall was abdominal pain (100%) followed by nausea/vomiting (43.47%). The other common symptoms were nausea/vomiting (61.53%) and Murphy's sign (38.46%) in PGBHC, but jaundice (50%) and fever (30%) in SGBHC. In PGBHC, 50% patients had normal liver function while this was deranged in 66.66% patients with SGBHC. Serology was positive in 50% of PGBHC and 100% in SGBHC. Ultrasonography was positive in 50%, while CT-scan showed 70%. CT-scan was better at detection of SGBHC (100%). The most common operation was open cholecystectomy (78.26%) either isolated or combined. Isolated open cholecystectomy was commonly done in PGBHC (69.23%). Overall, only 56.52% of patients received albendazole, but no recurrence was reported. The average hospital stay was 7.25 days and follow-up ranged from 1 month to 10 years. Conclusion: GBHC mostly affects females with abdominal pain being the most common symptom. Ultrasonography is expedient though CT-scan is more sensitive. Albendazole monotherapy has questionable value. Open cholecystectomy is the most common operation. However, laparoscopy is safe in experienced hands.

Background Anal fistulas cause great uncertainty and anxiety in patients and surgeons alike. This is largely because of the inability to accurately confirm postoperative fistula healing, especially long-term healing. There is no scoring system available that can objectively assess cryptoglandular anal fistulas for postoperative healing and can also accurately predict long-term healing. Methods Several parameters that could indicate anal fistula healing were assessed. Out of these, six parameters (four MRI-based and two clinical) were finalized, and a weighted score was given to each parameter. A novel scoring system (NSS) was developed. A minimum possible score (zero) indicated complete healing whereas the maximum weighted score (n = 20) indicated confirmed non-healing. Scoring was done with postoperative MRI (at least 3 months post-surgery), then compared with the actual healing status, and subsequently correlated with the final long-term clinical outcome. Results The NSS was validated in 183 operated cryptoglandular fistula-in-ano patients over a 3-year period in whom 283 MRIs (preoperative plus postoperative) were performed. The postoperative follow-up was 12–48 months (median-30 months). The NSS was found to have a very high positive predictive value (98.2%) and moderately high negative predictive value (83.7%) for long-term fistula healing. Additionally, its sensitivity and specificity in predicting healing were 93.9% and 94.7%, respectively. Conclusion Thus, this new scoring system is highly accurate and would be a useful tool for surgeons and radiologists managing anal fistulas. By objectivizing the assessment of postoperative healing, it can both ease and streamline management. Moreover, reliable prediction of recurrence-free long-term healing will greatly allay the apprehensions associated with this dreaded disease.

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