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Video-assisted anal fistula treatment for complex anorectal fistulas in adults: a systematic review and meta-analysis

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Abstract

Background

Video-assisted anal fistula treatment (VAAFT) has gained increasing acceptance as a sphincter-sparing procedure for treating complex anorectal fistulas (CAF), but no unequivocal conclusions can yet be drawn regarding its ultimate effectiveness. We reviewed the literature and performed a meta-analysis to evaluate the efficacy and safety of VAAFT in CAF patients.

Methods

The study protocol was registered with the PROSPERO database (CRD42021279085). A systematic literature search was performed in the PubMed, Embase, and Cochrane Library databases up to June 2021 with no restriction on language based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We used the keywords video-assisted surgery, video-assisted anal fistula treatment, and complex anorectal fistula to identify relevant studies.

Results

Fourteen trials (7 prospective and 7 retrospective) with a total of 1201 patients (mean age 43.5 years) were included. The median follow-up duration was 16.5(8–48) months. Pooled analysis showed that the rates of success, recurrence and postoperative complication across the studies were 83% (95% CI 81–85%, I2 = 37.9%), 16% (95% CI 14–18%, I2 = 4.8%), 11% (95% CI 7–15%, I2 = 72.1%), respectively. The postoperative Jorge–Wexner score used to assess the level of anal incontinence was 1.09 (95% CI, 0.9–1.27, I2 = 74.6%). The internal opening detection rate was 97.6% (95% CI 96.1–99.6%, I2 = 48.2%). Recurrence rates varied according to the closure method of internal opening from 21.4% after using staplers, 18.7% after suturing, to 23.5% after advancement flap. The hospital stay was 3.15 days (95% CI 2.96–3.35, I2 = 49.7%). Subgroup analysis indicated that the risk of heterogeneity in the urine retention group was higher  compared with that of the overall group and that retrospective studies may be the source of heterogeneity for postoperative anal incontinence. r . Sensitivity analysis confirmed the stability of the pooled results. Begg's and Egger’s tests showed no evidence of publication bias.

Conclusions

According to the available evidence, VAAFT may be a valuable alternative to fistulotomy or seton in treating CAF and has the additional long-term benefits of reducing anal incontinence and surgical morbidity, permitting earlier healing and accelerated rehabilitation.

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There has been no significant financial support for this work that could have influenced its outcome.

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Authors and Affiliations

  1. Department of Anorectal Center, Qilu Hospital (Qingdao), Cheeloo College of Medicine, Shandong University, Qingdao, Shandong, China

    Z. Tian, S. J. Nan, W. C. Xiu & Y. Q. Wang

  2. The Affiliated Hospital of Qingdao University, Qingdao, Shandong, China

    Y. L. Li

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  4. W. C. Xiu
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Contributions

Conceptualization: ZT, YL, SN, WX, YW. Data curation: ZT, YL. Methodology: ZT, YLi. Statistical analysis: ZT. Quality control of data and algorithms: ZT, YL, SN, WX, YW. Supervision: ZT, YW. Validation: ZT, YL. Manuscript—original draft: ZT. Manuscript—review & editing: ZT, YL, SN, WX, YW.

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Correspondence to Y. Q. Wang.

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Tian, Z., Li, Y., Nan, S. et al. Video-assisted anal fistula treatment for complex anorectal fistulas in adults: a systematic review and meta-analysis. Tech Coloproctol 26, 783–795 (2022). https://doi.org/10.1007/s10151-022-02614-z

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