Anal fistulas are still a huge challenge for surgeons because of their high incidence, high recurrence rate, prolonged healing time and possible complications such as fecal incontinence. Even though many surgical options have been described, we still do not have the standardized procedure. Patients who suffered from this problem have a low quality of life because of constant anal pain and soiling from anal tracts. Aside from cryptoglandular etiology, fistulas associated with Crohn’s disease are separate entity that requires a multidisciplinary approach. This chapter will be an overview of modern approaches in anal fistula treatment regardless of etiology with special consideration on how to avoid adverse outcomes and to improve patients’ quality of life.

Complex anal fistulas present a challenge to even a seasoned colorectal surgeon due to high rate of recurrence and a real possibility of fecal incontinence if treated with conventional methods (e.g., fistulotomy, fistulectomy, seton placement). Although the illness is benign in nature, it can significantly decrease patient’s quality of life because of symptoms like pain and soiling. Given those facts, minimally invasive or sphincter preserving methods of treatment were introduced. Some of these include: Video-assisted anal fistula treatment (VAAFT), ligation of intersphincteric fistula tract (LIFT), Fistula-tract laser closure (FILAC), rectal advancement flap (RAF), treatment with platelet cells and combinations of techniques. This chapter would be an overview of these novel techniques with reference to latest clinical trials and meta-analyses.

Aim: The aim of this prospective, nonrandomized, observational study was to present our results in operative treatment of complex anal fistulas using video-assisted anal fistula treatment (VAAFT) procedure with a curative intent in 2 years follow-up period. Materials and Methods: Between March 2016 and March 2018, 73 patients underwent the VAAFT procedure. Postoperative follow-up was 2 years, up to March 2020. Only patients with complex cryptoglandular anal fistulas were included. All patients were referred for magnetic resonance imaging of the pelvis. Fecal incontinence severity index score was used to assess any continence disturbance prior operation and postoperatively. Result: Primary healing occurred in 52 cases (71.23%) after first operation. From 21 patients who had recurrence or who had persisting disease, 16 patients accepted reoperation with second VAAFT procedure and additionally 10 patients achieved healing. From a total number of 73 patients who were included in study healing ultimately occurred in 62 cases (84.93%). In the first operation internal opening was identified in 47 cases (64.38%) and was closed with mattress suture, rectal advancement flap or ligation of intersphincteric fistula tract technique depending on its extent and type of fistula. Median primary healing rate was 6 weeks. There were no serious intra- or postoperative complications. None of the patients reported any type of continence disturbance. Discussion: VAAFT has been shown to offer good rates of healing, low morbidities, possibilities of multiple attempts in case of first failure and this series adds to the literature.

This is a case of 45 year old female patient who was diagnosed with complex high transphincteric anal fistula. The patient also had problems with chronic constipation lasting for 6 months secondary to anal stenosis. A colonoscopy, which was performed 2 years earlier, was normal. She underwent a pelvic MRI that, apart from the fistula, showed no other pathology.

Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.

Zelic, Marko MD; Karlovic, Damir MD; Krsul, Dorian MD; Bacic, Ðordano MD Author Information

TEM is an endoscopic method of operating tumors up to 18 cm of the anal verge. It enables procedures from a simple mucosectomy to en-block excisions of the whole thickness of the rectal wall. We present a study in which we evaluated surgical morbidity, mortality and recurrence rate of rectal tumors in patients treated with TEM from July 2007, up to the end of March 2014. In our Department 129 patients were treated by TEM and 123 of them (74 men and 49 women) had rectal tumors: 55 adenomas, 36 cancers in situ (Tis), 15 T1, 9 T2, 4 T3 (3 palliative, and 1 underwent salvage operation) and 4 T4 (all palliative) rectal cancers. 6/123 patients were treated with TEM after the finding of metachronic recurrences that emerged after previously performing major surgery. In 3/123 cases (2.44%) the resection margins were positive. The overall local recurrence rate was 19(15.45%)--adenoma 6/55(10.91%), Tis 4/36 (11.11%), T1 0/15 (0%), T2 4/9 (44.44%), T3 1/4 (25%), T4 4/4 (100%), respectively. In 2 patients the illness was subsequently disseminated, and in 7 patients it was widespread at the time of surgery. Nine (7.31%) patients died during follow-up due to disease dissemination. Minor com plications occurred in 24 patients (19.51%) whereas we had no major complications and no early postoperative mortality. The average postoperative hospital stay is 2.3 days. TEM is a safe and appropriate surgical treatment option for benign rectal tumors and for early-stage rectal carcinomas. TEM is also good as a palliative method, and it's useful for elderly and unfit patients.

Natural killer T (NKT) and regulatory T cells (Tregs) play an important role in innate immune response. Natural killer (NK) and NKT cells are indispensable factors in the body's ongoing defense against tumor development, as well as viral infection. NKT cells are a subset of T cells that shares properties of natural killer cells and conventional T cells. They are involved in innate immune responses, tumor rejection, post transplantation immunotherapy, immune surveillance and control of autoimmune diseases. They may also play both protective and harmful roles in the progression of certain autoimmune diseases, such as diabetes, lupus, atherosclerosis, and allergen-induced asthma. Immune surveillance involves the process whereby precancerous and malignant cells are recognized by the host immune system as damaged and are consequently targeted for elimination. The pharmacological management of postoperative pain in patients with malignancies uses very different techniques whose possible cytotoxic functions we still known very poor. The present study compared effects of two different postoperative pain management techniques in patients undergoing colorectal cancer surgery on the innate immunity. Our data indicate that the patients with colorectal cancer have significantly increased the percentage of Tregs and NKT cells. The values were statistically higher during epidural analgesia in comparison with intravenous analgesia, indicating that epidural pain management technique ameliorate the immune suppression after surgery.

UNLABELLED Recent evidence suggests that decline of regulatory T cells (Tregs) play a critical role in the prevalence of autoimmune diseases inhibiting the maintenance of peripheral self tolerance, while its augmentation leads to insufficient antitumor response, accompanied with poor prognosis in various malignancies. Increased number of Tregs (CD4+CD25+FoxP3+) were noticed in peripheral blood mononuclear cells (PBMCs), tumor-infiltrating lymphocytes (TILs) and/or regional lymph nodes lymphocytes (LNLs) of patients with gastrointestinal tumors. The aim of our study was to investigate the correlation between the percentage of Tregs in peripheral blood of patients with colorectal carcinoma, using flow cytometric technique and tumor stages, classified as Dukes' A, B, C or D and by stage of differentiation. Peripheral blood venous samples were obtained from 92 patients with colorectal cancer and from 30 healthy adult volunteers. STATISTICAL ANALYSIS Linear regression equations were generated using a least-squares method and analyzed for differences of covariance. Statistical significance was calculated by Mann Whitney U-test. Our data has shown that 15% patients with colorectal cancer were classified as Dukes' A, 41% were Dukes' B, 35% were Dukes' C and 9% were Dukes' D. 54% patients with CRC were well differentiated, 11% were poorly differentiated, 20 were moderately differentiated, tage, 4% were mucinous carcinoma and rest of 11% were partly good differentiated with mucinous components. The increased percentage of Tregs in colorectal cancer patients correlates with tumor stage. These results indicate a possible involvement of regulatory T cells in disease progression. New strategies using inhibition or depletion of Tregs are necessary to elucidate the complexity of defective tumor immunity.