Long-term Evaluation of Fistulotomy and Immediate Sphincteroplasty as a Treatment for Complex Anal Fistula

Abstract

BACKGROUND: Fistulotomy with immediate sphincteroplasty is a technique that can heal fistulas and decrease fecal incontinence more effectively than fistulotomy alone, in selected patients. OBJECTIVE: We aimed to perform a long-term evaluation of fecal incontinence after fistulotomy and immediate sphincteroplasty in patients with complex anal fistula. DESIGN: This prospective study included patients undergoing fistulotomy and immediate sphincteroplasty for complex anal fistula from January 2000 to December 2010. SETTINGS: The study was conducted by 2 colorectal surgeons in the coloproctology unit of the General Hospital of Elche. PATIENTS: We included patients aged ≥18 years with complex anal fistulas of cryptoglandular origin. MAIN OUTCOME MEASURES: Main outcomes were recurrence and continence after fistulotomy and immediate sphincteroplasty, according to fistula tract height and preoperative continence status. RESULTS: A total of 107 patients were included; 68.2% were men, with a mean age of 48 years and mean fistula duration of 12.8 months. The range and median follow-up period were 84 to 204 and 96 months. Thirty-seven fistulas were not primary. The overall healing rate was 84.1%. Primary fistulas healed by the end of follow-up in 58 (82.9%) of 70 patients; recurrent fistulas healed in 32 (86.5%) of 37; high tracts healed in 31 (83.8%) of 37, and nonhigh fistulas healed in 59 (84.3%) of 70. Male sex (OR = 0.66 (95% CI, 0.20–2.13); p > 0.05) and recurrent fistulas (OR = 0.43 (95% CI, 0.11–1.68); p > 0.05) could have a protective effect against postoperative fecal incontinence; however, more studies with larger sample sizes are necessary to confirm this result, whereas high fistulas showed a 4-fold increased risk of incontinence (range, 1.22–13.06; p < 0.01). One in 5 high-tracts patients experienced continence deterioration. LIMITATIONS: This was a prospective study, and randomized clinical trials with more patients and longer follow-up are needed to compare fistulotomy and immediate sphincteroplasty with other sphincter-preserving techniques. CONCLUSIONS: Fistulotomy and immediate sphincteroplasty are good options for treating complex anal fistulas, especially for recurrent fistulas, men, and patients with nonhigh tracts, with acceptable recurrence and incontinence rates. See Video Abstract at http://links.lww.com/DCR/B498. EVALUACIÓN A LARGO PLAZO DE LA FISTULOTOMÍA Y LA ESFINTEROPLASTIA INMEDIATA COMO TRATAMIENTO PARA LA FÍSTULA ANAL COMPLEJA ANTECEDENTES: La fistulotomía y la esfinteroplastia inmediata es una técnica que puede curar las fístulas y disminuir la incontinencia fecal de manera más efectiva que la fistulotomía sola, en pacientes seleccionados. OBJETIVO: Nuestro objetivo fue realizar una evaluación a largo plazo de la incontinencia fecal después de la fistulotomía y la esfinteroplastia inmediata en pacientes con fístula anal compleja. DISEÑO: Este estudio prospectivo incluyó pacientes sometidos a fistulotomía y esfinteroplastia inmediata por fístula anal compleja, desde enero d...

The Value of Transrectal Ultrasound in the Preoperative Diagnosis of Complex Anal Fistula (CAF): Based on a Retrospective Cohort Study

“…At present, there are many common preoperative examination methods of AF, such as physical examination, probe examination, Goodsall's law, and methylene blue test, which are mainly applicable to patients with simple AF, which can determine the course of fistula and the location of internal orifice, but when applied to patients with CAF, the diagnostic accuracy is low, and it may be misleading, resulting in postoperative recurrence [ 6 , 7 ]. The early methods employed in the diagnosis of AF include fistula X-ray and CT imaging, but the application of contrast media in CAF is difficult, has adverse reactions, and is difficult to distinguish between fibrotic fistula and sphincter complex and pelvic floor muscle and other shortcomings; clinical application is limited [ 8 , 9 ].…”

Is fistulotomy with immediate sphincter reconstruction (FISR) a sphincter preserving procedure for high anal fistula? A systematic review and meta‐analysis

“…Variable definitions were provided in the remaining six, with high fistulae involving >30% to >70% of the EAS. Four studies in which FISR was conducted on a heterogenous sample reported some outcomes of interest by fistula height [11,14,26,28]. Therefore, it was only possible to analyse data provided by these studies, in addition to the 8 in which FISR was only assessed in high fistulae (Table 3).…”

“…EAS is affected [14]. This is crucial since it is the highest fistulae for which options are limited.…”

“…Furthermore, outcomes by fistula aetiology were never reported and therefore these patients could not be excluded from analyses. There were 21 eligible studies, the majority conducted on European cohorts [5][6][7][8][9][10][11][12][13][14][15][16][17][18][19][20][21][22] with three studies conducted in Egypt [23], Thailand [24] and India [25]. There were 12 retrospective, seven prospective studies and two RCTs comparing the results of FISR to advancement flap [19] or over the scope clip (OTSC) [12].…”

“…Rates of postoperative continence disturbance ranged between 3% and 45% (Table 2). Two studies did not provide postoperative continence data [16,25] be analysed; however, the proportion of patients who suffered continence deterioration was reported [14]. Most studies utilised the Wexner scale; however, in seven studies the method used was unreported or unvalidated.…”