ANAL AND PERIANAL FISTULAS

An anal fistula is an infection that spreads through the perirectal soft tissue, starting from a perianal abscess, taking on the appearance of a tunnel which follows the weakest structural route, i.e. through the perirectal fat. It can affect the perianal sphincter muscles, and in its most advanced state it can cross the pelvic floor and end up in the rectal ampulla, above the first valve of Houston.

It is also possible for fistulas to occur between the intestine and other pelvic structures such as the vagina, bladder, prostate, rectum, intestines, gastric colon etc.

The fistulas of interest to the field of proctology, however, are the lower fistulas (known as perianal) located below or slightly above the levator ani muscle between the first and second valves of Houston.

The tunnelling that differentiates the fistula from a perianal abscess (from which it originates) is caused by the intervention of the immune system, which creates a wall of neutrophils (macrophages), lymphocytes and plasma cells around the infection. The lymphocytes produce antibodies, while the neutrophils ingest the pyogenic bacteria. The pus therefore invades the tissues within this tunnel due to its lithic qualities, and searches for oxygen-free tissues.

Fistulas originate, for the most part, from perianal microabscesses formed in the swallow's nest glands or Morgagni glands of the dentate line (also known as the pectineal line). Here, the accumulation of faeces causes an infection - the infected crypt, prone to inflammation, is identifiable by a small white cone at the height of the anal edge of the swallow's nest; if allowed to develop over time, this formation can become a hypertrophied anal papilla that can reach the size of a large olive.

Another very common origin of anal fistulas is anal fissures where the exposure of deep tissue to faeces can cause an infection which may lead to fistulas. Sebaceous cysts on the perianal skin are another cause of fistulas - these can lead to abscesses and give rise to fistulas starting from the perianal skin. Anal fistulas can also be caused by Chron's disease, a chronic inflammatory disorder caused by the body's own antibodies. These typically originate in the higher sections of the rectum, between the colon and the small intestine, between different loops of the colon itself or between the colon and the bladder, prostate, ovaries etc. These fistulas can only be treated with surgery in exceptional cases, and treatment is generally medication-based.

ANATOMICAL CLASSIFICATION OF ANAL FISTULAS

Fistulas in this case are classified according to the anatomical route they follow:

  1. Superficial : the simplest type - subcutaneous, submucosal, does not affect muscular structures, does not reach the dentate line. Can sometimes be horseshoe-shaped and exit through the skin after travelling completely under the skin and mucosa. Often originates from injuries caused by scratching infected anal skin in patients with pinworm infections (once I found pinworms within a fistula), proctitis or anal fissures.
  2. Intersphincteric : originates from the crypts or an anal fissure and after passing through the internal sphincter, follows the path of the intersphincteric groove heading down toward the skin (descending) or upwards (ascending). It rarely proceeds upwards, in most cases arriving at the aponeurosis of the levator ani and deviating downwards towards the perisphincteric fat, becoming a descending perisphincteric fistula and exiting at the height of the buttock skin.
  3. Transsphinteric : Originates from a crypt or anal fissure, and having crossed the anal sphincter at its thickest point, reaches the perisphincteric fat, where it can take several routes, such as climbing upwards and very occasionally piercing the levator ani, finishing up above the first valve of Houston. Alternatively, it can follow the lower outline and emerge into the rectum above the anorectal junction, or bend back on itself and descend towards the perianal skin.
  4. Supra-sphincteric : Already discussed with regard to intersphincteric fistulas as the least favourable development of the latter.
  5. Extra-sphincteric : Typically originates from a subcutaneous or gluteus perianal abscess, climbs to the perisphincteric fat to emerge into the rectum above the puborectal sling of the levator ani.
  6. This schematic classification considers the fistulas as if they had a linear path, but they often follow tortuous paths and feature scattergun routes that branch off, becoming more and more complex. Fistulas can be classified with a number from 1 upwards based on their number of branches.

 

    The unpredictable number of branches that a fistula can present accounts for the fact that without an adequate preoperative diagnosis and an up-to-date surgical procedure, recurrences are almost the rule with the old systems. This is true even in the case of the most simple fistulas, which are often considered by experienced surgeons as a minor anorectal disorder and are still treated today with techniques from the days of Napoleon. Thus, when patients experience a recurrence, they turn to other surgeons and nothing out of the ordinary has happened as far as they are concerned.

    CAUSES OF ANAL FISTULAS


    Anal fistulas are unreliable in the sense that they only show themselves once they emerge from the skin and therefore become obvious; but before this event (which I call the Epiphany of the Fistula ) occurs, a silent story has already been developing, often for months.

    As mentioned before, in most cases the fistula originates from a gland infection in the Crypt of Morgagni, located at the bottom of the swallow's nest. This event is often symptomless or concealed by other conditions, and is only discovered by chance during a rectoscopy carried out when other disorders are suspected, although often the patient's discomfort is specifically due to the fistula that is developing.

    Originating in the swallow's nest glands and positioned against the direction of faecal discharge, the infection may not be spotted by a proctoscopy, especially if the patient is suffering from haemorrhoids. But when the white cone appears, we must immediately think of cryptitis and remove it using simple band ligation of the mucosa in which it lies.

    The removal of the infected crypt together with the Morgagni gland can prevent the anal fistula if it has not already formed and has not passed through the internal sphincter.

    SYMPTOMS OF ANAL FISTULAS

    Anal fistulas are an unreliable disorder which for most stages of their development have no or only minimal symptoms. These are often not noticed by patients, or considered as such minor ailments that they do not merit a visit to the doctor. Only when an infected tunnel appears through the skin (in the "Epiphany of the Fistula") do we suddenly take note of this serious issue. The reasons why fistulas develop in such a way are as follows:

    1. For most of its path, the fistula passes through tissues free of nerve endings, such as the perianal fat. Here the patient only exhibits a borderline fever (37°), and from the point of view of a laboratory analysis an increase in ESR and CPR, which as non-specific markers of inflammation are often attributed in the absence of other specific symptoms to a decaying tooth, a touch of cystitis etc.
    2. Often the patient has urinary problems that do not get linked to the fistula; however when he/she has repeated cystitis, we must think of a potential fistula as in its path through the fat of both the rectovesical lymphatic tissue and the venous circulation system it transfers bacteria to the bladder (especially E. coli), which multiply if they come into contact with alkaline urine, causing repeated cystitis.
    3. Local ailments are often wrongfully attributed to haemorrhoids, proctitis etc. rather than a fistula, and the patient self medicates with ointments and pills instead of seeking medical help
    4. And when the Epiphany of the Fistula finally occurs by chance with its classic trio of symptoms - a lesion in the skin (although it can also be located inside the rectum), pus leakage and unbearable pain - the diagnosis becomes completely obvious, and finally the patient turns to a doctor.
    5. Often after one of the traditional treatments for anal fistulas, the patient is convinced that he/she is cured - and unfortunately, so is the surgeon. But after months, or less commonly years, once the patient has forgotten the pain suffered, this divine condemnation returns more serious than ever before, throwing the patient into turmoil. In these cases the classical surgical treatment becomes even more painful and the risk of relapse increases exponentially, as in the meantime the fistula has branched out even more, and without the right diagnosis and the right operation it is unlikely that the patient will be cured of this divine plague.

    The most frequent symptoms are pain, the feeling of painful swelling, skin which may appear warm and flushed, and a possible increase in pain when touching the inflamed area. Sometimes the swelling can open up in a small point and allow yellow and possibly foul-smelling liquid (pus) to spill out, occasionally along with blood. The amount of liquid can vary (from small leakages to abundant discharges of pus and blood). Once this event has occurred, the pain (if present) tends to be reduced and the fever also tends to die down, but this does not mean that the fistula has healed - only that the release of tension eases symptoms and can lead to the closure of the fistula, which remains ready to reopen if the oxygen that has penetrated it has not been exhausted.

     

    DIAGNOSIS OF ANAL FISTULAS

    The Salmon-Goodsall rule helps us to make a fairly accurate and highly likely deduction about the direction of an anal fistula's course based on its external opening. We must remember that this rule actually includes the following three propositions:

    External openings located in the anterior perianal quadrant (i.e. "above the equator" as defined by a horizontal plane passing across the anus) correspond, in general, to a direct fistulous track, with an internal opening positioned at the same "hour" as the external opening

    External openings located in the posterior quadrant (i.e. "below the horizon" according to the definition described above) correspond to a curved fistulous track which is convex, with an internal opening found below the anal verge under the midline

    Anterior external openings located farther than 3 cm from the anal verge should lead us to suspect and search for a fistulous track with an internal opening in the posterior region.

    However, we must remember that this is a simplification that can serve as the starting point of the diagnosis, but not as a confirmation of the anatomical form of the fistula.

    Today the correct diagnosis is based on a single, comprehensive examination which identifies the course and possible branches of the fistula and the connections it has with nearby organs: a CT FISTULOGRAPHY, infiltration of the fistula with a contrast medium, with 3D reconstruction and possible 3D printing of the anatomical section in question.

    This examination, which can nowadays be carried out in almost all radiological centres, renders all other types of tests outdated and useless. Used preoperatively, it allows the operation to be thoroughly planned out, taking into account the actual path of the fistula and its stereoscopic shape.

    After the operation, if the fistula is modelled in 3D it is possible to compare the resected fistula with the polymer printout to confirm the complete anatomical removal of the fistula, allowing us to provide a well-founded prognosis to the patient, not one based on the feelings or hopes of the surgeon.

    Finally, this technique is also important from a legal medicine standpoint, for both the surgeon and the patient.

    This diagnostic technique was first adopted by me, but it would be a good thing for it to become a routine procedure for all surgeons who deal with fistulas, as this could drastically reduce the recurrence of this disorder.

     

    Today the correct diagnosis is based on a single, comprehensive examination which identifies the course and possible branches of the fistula and the connections it has with nearby organs: a CT FISTULOGRAPHY, infiltration of the fistula with a contrast medium, with 3D reconstruction and possible 3D printing of the anatomical section in question.

    This examination, which can nowadays be carried out in almost all radiological centres, renders all other types of tests outdated and useless. Used preoperatively, it allows the operation to be thoroughly planned out, taking into account the actual path of the fistula and its stereoscopic shape.

    After the operation, if the fistula is modelled in 3D it is possible to compare the resected fistula with the polymer printout to confirm the complete anatomical removal of the fistula, allowing us to provide a well-founded prognosis to the patient, not one based on the feelings or hopes of the surgeon.

    Finally, this technique is also important from a legal medicine standpoint, for both the surgeon and the patient.

    This diagnostic technique was first adopted by me, but it would be a good thing for it to become a routine procedure for all surgeons who deal with fistulas, as this could drastically reduce the recurrence of this disorder.

    TREATMENT OF ANAL FISTULAS

    Anal fistulas are the proctological surgeon's downfall, as they have a high recurrence rate with the techniques available to the vast majority of those operating in the field. In fact, more than 70% of fistulas treated worldwide today are recurrences, and of these another 70% will recur again.

    Why do fistulas have such a high recurrence rate? The causes are as follows:

    1. Surgeons consider them a minor anorectal disorder and treat them with this in mind; that is until they themselves are affected by this 'divine condemnation' (as the Schola Medica Salernitana described it), at which point they understand that it is by no means a minor issue.
    2. Lack of a correct preoperative diagnostic tool: CT fistulography with 3D reconstruction , which allows us to identify all the branches of the fistula's structure, and thus to plan out an accurate and complete resection of the fistula.
    3. Lack of appropriate surgical techniques to treat the branches of fistulas, which are unpredictable in their course. Lacking a thorough preoperative diagnosis, surgeons treat the main tunnel leaving in place internal branches that the fistula can restart from, more serious than before because in these cases the patient cannot experience the 'epiphany of the fistula', and therefore remains convinced that he/she is healed, when in fact a ravenous worm is proceeding unhindered, with the risk of finding it when there is no longer anything to be done to preserve full rectal functionality. The possible consequences are a irreversible colostomy, amputation of the rectum and even rectal cancer.
    4. We will now give an overview of the techniques used by my colleagues who deal with anal fistulas, before I discuss my own personal technique.

    5. Advancement flap procedure (endorectal/endoanal): The area is cleaned out precisely by 'scraping' the tissue that makes up the fistula, and a flap of vascularised tissue is taken from elsewhere to occupy the space taken up by the fistula. This procedure involves a high risk of incontinence (35%)
    6. Fistulotomy : This surgery involves cutting along the entire length of the fistula, from the internal opening to the external orifice. This type of operation is preferred for simple fistulas. With this procedure the risk of complications leading to incontinence is quite limited. This technique is not recommended for high transphincteric fistulas or other complex fistulas due to the high risk of incontinence caused by cutting the sphincter muscles. It also has a very high recurrence rate, due to the possibility that some fistulous residue, however partial or minimal, may remain in place after the operation, allowing the disease to recur.
    7. Seton techniques : This procedure is used when infection is present, and also for transphincteric fistulas. It is only a temporary measure that prepares the area for other definitive operations. Furthermore, the seton only passes through the main tunnel of the fistula and not any branches. It can only be used in cases where the fistula has both an internal and external opening. I use it as an outpatient procedure to keep the fistula open while waiting to carry out the CT fistulography with 3D reconstruction, and to drain it while waiting to carry out a cryo-guided resection.
    8. LIFT (ligation of intersphinteric fistula tract) : An incision is made to reach the fistula in the intersphincteric space, and once it has been isolated it is bound. Although the LIFT technique allows for the functionality of the sphincter to be preserved, its functional results do not confirm the theoretical assumptions.
    9. Fibrin glue : A compound, known as fibrin glue for simplicity's sake, is injected into the main channel of the fistula, with the aim of sealing it. This procedure has some interesting premises given its simplicity, the preservation of the sphincter region, its lack of invasiveness and a particularly straightforward post-operative recovery. However, this technique does not preclude the recurrence of the fistula, nor its reopening shortly after treatment, since the glue often does not reach the branches due to its density. Furthermore, it does not eliminate the structural element, from whose walls other branches can develop. Clinical studies have sadly confirmed the inefficiency of this treatment in healing anal fistulas.
    10. VAAFT (Video Assisted Anal Fistula Treatment): A new technique proposed in line with the trend for endoscopic/minimally invasive surgery. It consists of identifying and following the course of the fistula using a small endoscope and treating the fistula channel using diathermocoagulation under direct vision. The internal opening is then closed. From a technical and conceptual point of view, it is extremely interesting and convincing. The results observed and discussed during specialist conferences and seminars do not provide acceptable proof, for now, in terms of positive results. Given time, and with the necessary adjustments, it could be a technique for the future. The miniature endoscope is costly and must be handled delicately because of its very small optics. Furthermore, even if the technique allows us to treat the inside of the fistula, it does not guarantee the removal of the macrophagal gemmae full of bacteria found on the tissue side of the fistula wall, from which further branches can develop, and this is perhaps the real reason for its unconvincing results.
    11. Absorbable plug : This technique involves an approach which aims to minimise the disadvantages of surgical procedures that preserve the anal sphincter (i.e. inserting a seton). It uses a system consisting of a totally absorbable apparatus which allows both drainage (like a seton) and the stimulation of the healing process, therefore helping the fistula to close without causing pain or aggravating the patient's suffering. This technique works for Grade 1 fistulas with a single channel, no branches and no abscesses in its path. In other cases, closing the main channel and leaving other branches in place is doomed to fail, even if the branch is only millimetres in length. In addition, the apparatus is very expensive, and in this period of cuts to health services I don't know what future it could have, if not a very niche usage. The adoption of a CT fistulography with 3D reconstruction (designed by the writer) during the preoperative diagnosis might help to reduce unnecessary costs, allowing us to discard the cases in which the technique cannot be used, destined as it is to fail because of the presence of branches or abscesses along the fistula's path. We could thus direct our spending towards cases that can be successfully treated.

     

    TREATMENT OF ANAL FISTULAS

    Anal fistulas are the proctological surgeon's downfall, as they have a high recurrence rate with the techniques available to the vast majority of those operating in the field. In fact, more than 70% of fistulas treated worldwide today are recurrences, and of these another 70% will recur again.

    Why do fistulas have such a high recurrence rate? The causes are as follows:

    Surgeons consider them a minor anorectal disorder and treat them with this in mind; that is until they themselves are affected by this 'divine condemnation' (as the Schola Medica Salernitana described it), at which point they understand that it is by no means a minor issue.

    Lack of a correct preoperative diagnostic tool: CT fistulography with 3D reconstruction, which allows us to identify all the branches of the fistula's structure, and thus to plan out an accurate and complete resection of the fistula.

    Lack of appropriate surgical techniques to treat the branches of fistulas, which are unpredictable in their course. Lacking a thorough preoperative diagnosis, surgeons treat the main tunnel leaving in place internal branches that the fistula can restart from, more serious than before because in these cases the patient cannot experience the 'epiphany of the fistula', and therefore remains convinced that he/she is healed, when in fact a ravenous worm is proceeding unhindered, with the risk of finding it when there is no longer anything to be done to preserve full rectal functionality. The possible consequences are a irreversible colostomy, amputation of the rectum and even rectal cancer.

    We will now give an overview of the techniques used by my colleagues who deal with anal fistulas, before I discuss my own personal technique.

    Advancement flap procedure (endorectal/endoanal): The area is cleaned out precisely by 'scraping' the tissue that makes up the fistula, and a flap of vascularised tissue is taken from elsewhere to occupy the space taken up by the fistula. This procedure involves a high risk of incontinence (35%)

    Fistulotomy: This surgery involves cutting along the entire length of the fistula, from the internal opening to the external orifice. This type of operation is preferred for simple fistulas. With this procedure the risk of complications leading to incontinence is quite limited. This technique is not recommended for high transphincteric fistulas or other complex fistulas due to the high risk of incontinence caused by cutting the sphincter muscles. It also has a very high recurrence rate, due to the possibility that some fistulous residue, however partial or minimal, may remain in place after the operation, allowing the disease to recur.

    Seton techniques: This procedure is used when infection is present, and also for transphincteric fistulas. It is only a temporary measure that prepares the area for other definitive operations. Furthermore, the seton only passes through the main tunnel of the fistula and not any branches. It can only be used in cases where the fistula has both an internal and external opening. I use it as an outpatient procedure to keep the fistula open while waiting to carry out the CT fistulography with 3D reconstruction, and to drain it while waiting to carry out a cryo-guided resection.

    LIFT (ligation of intersphinteric fistula tract): An incision is made to reach the fistula in the intersphincteric space, and once it has been isolated it is bound. Although the LIFT technique allows for the functionality of the sphincter to be preserved, its functional results do not confirm the theoretical assumptions.

    Fibrin glue: A compound, known as fibrin glue for simplicity's sake, is injected into the main channel of the fistula, with the aim of sealing it. This procedure has some interesting premises given its simplicity, the preservation of the sphincter region, its lack of invasiveness and a particularly straightforward post-operative recovery. However, this technique does not preclude the recurrence of the fistula, nor its reopening shortly after treatment, since the glue often does not reach the branches due to its density. Furthermore, it does not eliminate the structural element, from whose walls other branches can develop. Clinical studies have sadly confirmed the inefficiency of this treatment in healing anal fistulas.

    VAAFT (Video Assisted Anal Fistula Treatment): A new technique proposed in line with the trend for endoscopic/minimally invasive surgery. It consists of identifying and following the course of the fistula using a small endoscope and treating the fistula channel using diathermocoagulation under direct vision. The internal opening is then closed. From a technical and conceptual point of view, it is extremely interesting and convincing. The results observed and discussed during specialist conferences and seminars do not provide acceptable proof, for now, in terms of positive results. Given time, and with the necessary adjustments, it could be a technique for the future. The miniature endoscope is costly and must be handled delicately because of its very small optics. Furthermore, even if the technique allows us to treat the inside of the fistula, it does not guarantee the removal of the macrophagal gemmae full of bacteria found on the tissue side of the fistula wall, from which further branches can develop, and this is perhaps the real reason for its unconvincing results.

    Absorbable plug: This technique involves an approach which aims to minimise the disadvantages of surgical procedures that preserve the anal sphincter (i.e. inserting a seton). It uses a system consisting of a totally absorbable apparatus which allows both drainage (like a seton) and the stimulation of the healing process, therefore helping the fistula to close without causing pain or aggravating the patient's suffering. This technique works for Grade 1 fistulas with a single channel, no branches and no abscesses in its path. In other cases, closing the main channel and leaving other branches in place is doomed to fail, even if the branch is only millimetres in length. In addition, the apparatus is very expensive, and in this period of cuts to health services I don't know what future it could have, if not a very niche usage. The adoption of a CT fistulography with 3D reconstruction (designed by the writer) during the preoperative diagnosis might help to reduce unnecessary costs, allowing us to discard the cases in which the technique cannot be used, destined as it is to fail because of the presence of branches or abscesses along the fistula's path. We could thus direct our spending towards cases that can be successfully treated.

      CRYO-GUIDED FISTULECTOMY (DR BIUNDO'S PERSONAL TECHNIQUE)

      During my time at university I carried out several surgical internships where I observed the suffering of patients with anal fistulas, and the various treatments that were used, in most cases unsuccessfully, in an attempt to cure this disorder. This gave me the desire to find a system that could overcome the failures of the surgeries used at the time.

      In 1980 I begin to investigate the pathophysiology of anal fistulas, and to devote my time to patients hospitalised with this condition in the department where I was an intern. I looked for reasons why so many, in fact too many, different techniques had been tried out over the centuries to overcome what the Schola Medica Salernitana called a divine condemnation.

      After graduating, I started practising cryotherapy of haemorrhoids and anal fissures. I noticed straight away that this technique, while being too painful for haemorrhoid sufferers, producing an iatrogenic thrombosis that required around a month to heal, was a target technique for anal fissures - a procedure that has given me a lot of satisfaction in my career of over thirty years.

      From my experience in the treatment of anal fissures with cryotherapy, I developed the idea of ​​using this method to carry out a minimally invasive fistulectomy that would prevent recurrences for 3 reasons:

      1. By isolating the fistula and enclosing it in ice, I could make an accurate resection using the ice block as a guideline, meaning I did not need to expand into the tissue to avoid leaving residues of the fistula in situ. This meant leaving a very neat and linear recess which lent itself to being sutured to heal by primary intention;
      2. The walls of the resulting recess were exposes to temperatures of - 36°, so they were automatically sterilised, allowing for a state of asespis unthinkable with traditional techniques. They could therefore be sutured to heal by primary intention, free from infections that could complicate the surgery.
      3. By precisely defining the structure of the fistula before operating and using cryotherapy, I was able to make modular resections that simplified the excision of complex fistulas, so that intrasphincteric sections could also be removed without harming the integrity of the sphincter around the fistula. By freezing the path of the fistula from the inside, I could resect it using the ice block as a guide, without interrupting the continuity of the sphincters around the fistula.

      Drawing on those considerations, born from my observations, I fine-tuned a neat and consistent surgical technique, which allows the fistula to be sutured to heal quickly by primary intention: Cryo-Guided Fistulectomy after 3D CT Reconstruction

      • A visit to the proctologist during which the traditional diagnosis is performed and the fistula discovered. The internal and external openings are identified,with the aid of methylene blue if necessary. If the fistula has been previously treated with antibiotics, l insert a woven cotton lace (similar to a shoe lace) to prevent the external orifice from closing up, and clean the channel, since the subsequent forced opening might open up erroneous paths created by the device. The tube emerges from the internal orifice and the two ends are tied together outside the anus. At this point antibiotics are prescribed.
      • CT fistulography with 3D reconstruction and possible 3D printing : At the radiologist, once the lace has been removed, the fistula is injected with the contrast medium normally used for haematic purposes, diluted 50% with saline solution. After that, we proceed to a CT scan of the area. After the images have been taken, the fistula is reconstructed on paper in 3D. Where it is particularly complex, we 3D print it using polymer. With this system, we can create a copy of the fistula as it is in reality, and plan out the operation correctly.
      • Operation : Once the lace has been removed, we begin to cut the free cells of the fistula using a grooved probe, via an incision in the tissues parallel to the path. We freeze the channel in sections and following the outline of the ice block with the cutting edge of the scalpel which scrapes along the ice, we remove the structure while it is enclosed in the ice at intervals of 5 cm at a time. At this point we suture the resulting cavity with absorbable material in separate stitches, and proceed to remove the next section using the same method.

      CRYO-GUIDED EXCISION OF PERIANAL ABSCESSES

      Perianal abscesses can also benefit from this method to be removed painlessly and without recurrence, with a simple local anaesthetic in an outpatient procedure.

      • Firstly, the abscess is drained and the pus is removed;
      • The tip of the cryo-scalpel is inserted into the drainage breach, and the gas is activated;
      • When the ice block has filled the entire abscess, the gas is turned off;
      • By manipulating the handle of the cryo-scalpel, the various sides of the frozen abscess are exposed and resected following the ice block;
      • Once the entire abscess has been removed, we can suture the resulting cavity in two layers to heal by primary intention.
      • They are removed in stages over 10-15 days.
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