Original scientific article
Fistulotomy with Primary Sphincter Reconstruction in the Management of Complex Fistula-in-Ano: Prospective Study of Clinical and Manometric Results

https://doi.org/10.1016/j.jamcollsurg.2004.12.015Get rights and content

Background

Complex fistula-in-ano is a frequent source of concern for both patients and surgeons, because of its high rate of recurrence and postoperative anal incontinence. The objective of this study was to assess the results of fistulotomy with sphincter reconstruction in terms of recurrence and anal function.

Study design

We conducted a prospective study of 35 patients undergoing fistulotomy with sphincter reconstruction for complex fistula-in-ano. Preoperative and postoperative evaluation included physical examination, anal ultrasonography, and anal manometry, with a 32-month followup. Fecal continence was assessed using the Wexner Continence Grading Scale (0 to 20).

Results

Fistulas were classified as high trans-sphincteric in 30 patients (85.7%), suprasphincteric in 4 patients (11.4%), and extrasphincteric in 1 patient (2.9%). Eleven patients (31.4%) reported varying degrees of earlier fecal incontinence. Their mean continence scores decreased from 7.2 to 2.0 (p=0.008) after operation, and all patients improved except for 2, whose scores remained unchanged. On anal manometry, there were significant differences between continent and incontinent patients before operation (maximum resting pressure: 89.2 versus 65.5mmHg, p=0.013; maximum squeeze pressure: 203.6 versus 148mmHg, p=0.008) that disappeared after operation (maximum resting pressure: 81.9 versus 70.6mmHg, p=0.21; maximum squeeze pressure: 199.1 versus 154.8mmHg, p=0.052). There were neither clinical nor manometric differences between pre- and postoperative values in fully continent patients, although 3 patients (12.5%) reported minor alterations of continence (Wexner<4). Two female patients had recurrences (5.7%), 3 and 6 months after operation, respectively.

Conclusions

Fistulotomy with sphincter reconstruction is an effective resource in the management of complex fistula-in-ano. It improves both anal continence and manometric values in incontinent patients without compromising them in fully continent ones.

Section snippets

Methods

We conducted a prospective study of 35 patients undergoing fistulotomy and primary sphincter reconstruction for complex fistula-in-ano, from October 2000 to July 2002 in the Coloproctology Unit, Department of Surgery, University Hospital of Elche. Mean followup was 32±4.8months (range 24 to 42 months). We included fistulas with high trans-sphincteric, suprasphincteric, and extrasphincteric tracks according to Park’s classification for fistula-in-ano.1 Patients suffering from acute anal sepsis

Results

The mean age of the patients was 51.4±9.5 years (range 31 to 73years), 23 were men (65.7%), and 12 women (34.3%). Sixteen patients (45.7%) presented with recurrent fistulas, in 4 of whom (25%) the fistula had recurred twice or more. Seven of the 16 recurrent fistulas (43.8%) had been treated by a cutting seton and 2 (12.5%) with an advancement flap; 4 patients (25%) had their fistula laid-open, all suffering from varying degrees of anal incontinence. The techniques applied in the remaining 3

Discussion

Surgery for complex fistula-in-ano is marked by a high rate of disturbances of anal continence. This may vary from 0% to 25% for flatus control, 0% to 17% for stools, and reach as high as 40% for passive incontinence of any amount (soiling)2 depending on the complexity of the fistula, the presence of associated risk factors for incontinence, and the type of operation. Recurrence is the other great pitfall, oscillating from 0% to 32%. Both have been identified as the factors most markedly

References (17)

  • A.G. Parks et al.

    A classification of fistula-in-ano

    Br J Surg

    (1976)
  • The American Society of Colon and Rectal Surgeons. Practice parameters for treatment of fistula-in-ano

    Dis Colon Rectum

    (1996)
  • J. García-Aguilar et al.

    Patient satisfaction after surgical treatment for fistula-in-ano

    Dis Colon Rectum

    (2000)
  • W.F. Van Tets et al.

    Continence disorders after anal fistulotomy

    Dis Colon Rectum

    (1994)
  • J. García-Aguilar et al.

    Anal fistula surgery. Factors associated with recurrence and incontinence

    Dis Colon Rectum

    (1996)
  • P.J. Lunniss et al.

    Factors affecting continence after surgery for anal fistula

    Br J Surg

    (1994)
  • K.P. Hamalainen et al.

    Cutting seton for anal fistulashigh risk of minor control defects

    Dis Colon Rectum

    (1997)
  • J.G. Williams et al.

    Seton treatment of high anal fistulae

    Br J Surg

    (1991)
There are more references available in the full text version of this article.

Cited by (0)

Competing Interests Declared: None.

View full text