Przemysław Ciesielski1, 2, Mateusz Sala2, *Małgorzata Kołodziejczak1
Proctology – an overview of new reports
Proktologia – nowe doniesienia
1Warsaw Proctology Centre, St. Elizabeth’s Hospital, Warsaw
2Hospital of Our Lady of Perpetual Help in Wołomin
Co roku w publikacjach medycznych pojawiają się nowe doniesienia dotyczące leczenia chorób proktologicznych lub pokrewnych dla tego zagadnienia problemów. Autorzy dokonali przeglądu piśmiennictwa proktologicznego z ostatnich kilku lat. Wybrali i przedstawili kilka z nich wraz z własnym komentarzem praktycznym. Publikacje w wysoko indeksowanych czasopismach poddawane są ostrym kryteriom kwalifikacji oraz recenzji, dzięki czemu informacje w nich zawarte są bardzo wiarygodne. Mimo to często obserwuje się sprzeczne doniesienia na temat podobnych lub nawet tych samych metod operacyjnych czy leków. Czas i praktyka kliniczna weryfikują wartość tych prac. Autorzy omówili: doniesienia na temat zastosowania setonu chemicznego w leczeniu przetok odbytu, metody FiXcision w operacjach przetok, przeciwwskazania do metody LIFT, najnowsze opinie dotyczące leczenia przetok komórkami macierzystymi i leczenia botoksem szczelin odbytu, a także zastosowanie nowych narzędzi w operacjach proktologicznych. Autorzy konkludują, że wprowadzenie „nowości” do własnej praktyki zawodowej wymaga zachowania pewnej rezerwy, gdyż czas i odległe wyniki weryfikują wartość tych prac.
Every year, reports are published in medical journals to present new developments in the treatment of proctological diseases or related problems. The authors of this paper have reviewed the literature in the field of proctology spanning the last few years. A few publications have been selected and presented together with the authors’ practice-oriented comments. Research papers published in highly indexed scientific journals are subject to rigorous evaluation and review criteria, which makes them very credible. Nevertheless, there are often conflicting reports on similar or even the same surgical or pharmaceutical therapies. Time and clinical practice verify the value of these studies. The authors discuss reports on the application of chemical seton in the treatment of anal fistulas, FiXcision method in fistulectomy, outline contraindications to performing the LIFT procedure, and present the latest developments in stem cell therapy for fistulas and Botox treatment of anal fissures, as well as the application of new tools in proctological surgery. It is concluded that incorporating novel solutions into one’s own professional practice must be done with a certain amount of reserve, as their value is ultimately verified by time and distant outcomes of treatment.
Each year brings new reports on the diagnosis and treatment of proctological disorders. Research papers published in highly indexed medical journals are subject to rigorous evaluation and review criteria, which makes their findings very credible. Yet there are often conflicting reports on similar or even the same surgical or pharmaceutical therapies. Occasionally, methods come to be regarded as obsolete, only to return after some time in a new – often very innovative – versions. This has happened recently with the treatment of anal fistulas using the Hippocratic method (seton drainage). Currently, it has become an indispensable preliminary stage of a number of definitive methods of anal fistula treatment, such as FiLaC or LIFT.
The authors review literature reports published in recent years, and provide them with practice-oriented comments based on their own professional experience and the results of reputable clinical trials.
Chemical seton in the treatment of fistula-in-ano
The Hippocratic technique of anal fistula treatment has a long history. The original method proposed by Hippocrates involved the placement of a cutting seton in the fistulous tract. In recent years, a new application of the method has been proposed – as a preparatory step before sphincter-sparing fistula surgery (FiLaC, LIFT, etc.). The cutting seton method is not very popular now. The technique involves mechanical cutting through the muscle tissue as the seton is gradually tightened on the fistula. When a seton is used as a preparatory step for other procedures (e.g. LIFT), a loose seton is used in order to drain purulent material and reduce infection in the tissues surrounding the fistula. One of the less commonly used methods of fistula-in-ano treatment, both in Poland and globally, is the chemical seton, also known as the Ayurvedic seton or Ksharasutra seton. The mechanism of action of chemical setons is based on the effect produced by chemical substances (chiefly of natural origin) on the tissues. The seton is woven from a dozen or so thin cotton threads soaked in various herbs (including Apamarga, Euphorbia nerifolia, and Curcuma) and has a pH of 9.7. Ksharasutra setons are replaced on a weekly basis. The substances listed above have cleansing and antibacterial properties, and accelerate the cutting of tissues, promoting open wound healing (1). In addition to fistula-in-ano, other indications to using Ksharasutra setons mentioned by the Indian authors include haemorrhoids (medicated setons are used for haemorrhoidal ligation), and pilonidal sinus (Ksharasutra threads are used for fistula drainage). The method enjoys the greatest popularity in India, where studies are published to compare classic surgery with the application of Ksharasutra setons. Based on these published findings, the method appears to be both simpler and less expensive to use, the suggestion being that it can be performed in primary healthcare facilities without a need for hospitalisation. The authors of publications on the subject point out a lower percentage of complications associated with the technique, as it allows to eliminate an extensive postoperative wound (2, 3). There are reports of the use of the chemical seton in ancient Greece and in the 14th century (4).
There are few clinical reports describing the method. The studies that have been accessed by the authors confirm high rates of therapeutic success (2). The authors of the study highlight that the method represents a low-cost treatment option and produces no complications. However, researchers also draw attention to poorer tolerance and more severe pain experienced by patients during the first few days after seton placement.
FiXcision device in anal fistulectomy
A novel device designed for optimised fistulectomy, called FiXcision, has recently become available on the medical market. While fistulectomy is not a new technique, the device, which is claimed to be of benefit in fistula surgery, is an innovative one. The design is based on a flexible steel probe (guidewire). After inserting the guidewire into the fistula, a circular cut is made around the tract by pushing forward the cutting sleeve with rotary motions along the guiding rods against the stopper. This mechanism of action enables a clean excision of the entire inner layer of the fistula tract after removing the cutting sleeve, leaving only healthy tissues. The procedure ends with the closure of the fistula’s internal opening.
There are currently no randomised studies confirming the therapeutic efficacy of the device in a larger group of patients. The only paper is the 2019 study (5) whose authors report no significant differences between the use of the FiXcision device and classic surgery in terms of early postoperative complications. However, both the authors of the paper and reviewers highlight the ethical and moral aspects, and a possible conflict of interests, involved in the application of the technique (6). It also appears that patient eligibility criteria might be a factor limiting the applicability of the method, as FiXcision can only be used in cases where the fistulous tract is straight, without any side tracts or segmental dilations, so that all pathological tissues can be effectively removed. Overall, it seems that a longer time perspective is needed to reliably verify the benefit of the FiXcision device in fistula therapy.
Contraindications to LIFT?
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