Assessment of fistulectomy combined with sphincteroplasty in the treatment of complicated anal fistula

Avaliação de fistulectomia combinada com esfincteroplastia no tratamento de fístula anal complicada

Abstract

Introduction

The ideal method of treating the complex anal fistula is to eradicate the sepsis and preserve the anal sphincter; since there is no definite consensus on the surgical method of treating it. Recent studies show that fistulectomy and immediate sphincteroplasy are a safe and appropriate way to treat the fistula-in-ano. The aim of this study was to evaluate the long term outcomes of fistulectmy and sphincteroplasty in the treatment of complex perianal fistula.

Methods

In this prospective study, we have analyzed the data of 80 patients who underwent fistulectomy and sphincteroplasty from May 2013 to May 2016. Preoperative information included physical examination, preoperative fecal incontinence evaluation and taking a complete history about underlying diseases and past related surgeries were collected.

Results

Of all 80 patients with complex fistula, 57.5% (46 patients) were male. 70-Patients were presented with high transsphincteric fistula (87.5%) and anterior fistula was diagnosed in 10 of them (12.5%). 9 patients (11.3%) suffered from hypertension and 43 patients (53.75%) had recurrent fistula after previous surgeries. During the follow-up period, the overall success rate was 98.8% (98.8%) and fistulectomy and sphincteroplasty failed in only one patient (failure rate: 1.3%). preoperative and post-operative scoring showed mild fecal incontinence in 8 patients (10%). We have found no significant relation between the age, gender, hypertension, previous surgery and post-operative recurrence.

Conclusion

Fistulectomy and sphincteroplasty is a safe surgical procedure in the treatment of anterior anal fistula in females and high transsphincteric fistulas.

Keywords
Fistulectomy; Sphincteroplasty; Anal fistula

Resumo

Introdução

o método ideal para tratar a fístula anal complexa consiste em erradicar a sepse e preservar o esfíncter anal, uma vez que não existe consenso definitivo com relação ao método cirúrgico para tratamento desse problema. Estudos recentes demonstram que a fistulectomia, seguida imediatamente pela esfincteroplastia, é procedimento seguro e apropriado no tratamento da fístula perianal. O objetivo deste estudo foi avaliar os resultados em longo prazo da fistulectomia e da esfincteroplastia no tratamento da fístula perianal complexa.

Métodos

Neste estudo prospectivo analisamos os dados de 80 pacientes tratados por fistulectomia e esfíncteroplastia no período de maio de 2013 até maio de 2016. Foram coletadas as seguintes informações pré-operatórias: exame físico, avaliação pré-operatória de incontinência fecal e história completa sobre doenças subjacentes e cirurgias prévias afins.

Resultados

De todos os 80 pacientes com fístula complexa, 57,5% (46 pacientes) pertenciam ao gênero masculino. Setenta pacientes se apresentaram com fístula trans-esfinctérica alta (87,5%); em 10 desses pacientes (12,5%), foi diagnosticada fístula anterior. Nove pacientes (11,3%) sofriam de hipertensão (HT), tendo sido observada recorrência de fístula após cirurgias prévias em 43 pacientes (53,75%). Durante o período de seguimento, o percentual de sucesso global foi de 98,8%, e em apenas um paciente os procedimentos de fistulectomia e esfincteroplastia não obtiveram sucesso (percentual de falha: 1,3%). Os escores pré-operatórios e pós-operatórios revelaram incontinência fecal leve em 8 pacientes (10%). Não observamos nenhuma relação significativa entre idade, gênero, HT, cirurgia prévia e recorrência pós-operatória.

Conclusão

Fistulectomia e esfincteroplastia constituem procedimento cirúrgico seguro no tratamento de fístulas anais anteriores em mulheres e de fístulas trans-esfinctéricas altas.

Palavras-chave
Fistulectomia; Esfincteroplastia; Fístula anal

Introduction

Anal fistulas are mostly cryptogenic in which the main method of treatment is to eradicate the infection, and preserve the anal sphincter function.¹ The standard committee of American Society of Colorectal Surgeons (ASCRS) classified “Complex” fistulas as all intersphincteric, transsphincteric and suprasphincteric fistulas.^2,3

There are many sphincter-saving methods for the treatment of complex anal fistula, but because of post-operative fecal incontinence (FI) or recurrence, there is no definite consensus about the surgical treatment of it.^4,5 Cutting seton placement has up to 67% incontinence rate⁶; since endorectal advancement flap has up to 35% risk of FI, and 30-60% failure rate.^7,8 Newer techniques such as ligation of intersphincteric fistula tract have the recurrence rate of 30-60% and anal fistula plug has the failure rate of 70-80%.^9,10

20 years ago, fistulectomy and immediate sphinctroplasty was suggested to reduce the post-operative FI and then many surgeons employed this combined technique for treating complex anal fistula.^11-14 This technique is defined as a safe and appropriate way for treatment of fistula-in-ano and also has a high healing rate,¹⁵ but there are some concerns and doubts about the results of this procedure.¹⁶

The aim of this study is evaluation the long term results of fistulectmy with sphincteroplasty on treatment of Complex perianal fistula.

Materials and methods

In our prospective study, we have analyzed and evaluated 80 patients who underwent fistulectomy and immediate sphincteroplasty from May 2013 to May 2016. All patients suffered from complex anal fistula (hightranssphincteric and anterior fistula in female). The patients with complex fistula secondary to radiation or IBD were excluded in this study.

All patients were physically examined by colorectal surgeon to identify the type of fistula and make sure that no abscess has occurred. We have assessed all patients in order to find out if they had past surgeries related to abscess drainage or healing the fistula or underlying disease such as Hypertension. Pre-operative assessments also included the examination of fecal incontinence by using Cleveland Clinic Florida fecal incontinence scoring (CCF-FIS) which is tabulated in Supplementary Material.

Bowel preparation was done by using suppository Bisacodil for all patients the day before surgery. Antibiotics (IV Cephtriaxon 1 g and Metronidazol 500 mg) were given on induction of regional anesthesia. All patients were positioned in the lithotomy position. Two distinct steps of the procedure were as follows:

First, we excised the fistulous tract in ischioanal fossa up to the lateral border of external sphincter and opened the transsphincteric portion of the tract and internal opening, as you can see in Fig. 1. After cutting the skin overlying the sphincter, we cut the sphincter over the tract, and then the granulation tissue of the tract was excised meticulously.

Fig. 1
Excision of fistulous tract.

Then, after irrigation of the wound with saline solution, we approximated the two edges of external and internal sphincter using Vicryl 2/o sutures (Fig. 2). The skin and anoderm overlying the wound was left open for drainage (Fig. 3).

Fig. 2
Approximation of two edges of external and internal sphincter using Vicryl 2/o sutures.

Fig. 3
The skin and anoderm overlying the wound was left open for drainage.

First post-op day, we kept all patients NPO and prescribed them 2 doses of intravenous (i.v.) Ceftriaxone and Metronidazole.

On the second day after the surgery, only fluid diet was started for them and oral antibiotics included ciprofloxacin, 500 BID and Metronidazole, 250 mg TDS were prescribed for one week. On the end of second day, we taught the patients how to bath the wound, and discharged them. All the patients were visited 1 week after the surgery in colorectal clinic. They were also examined 1, 3, 6, 12, 24, 36 months after the surgery for evaluation of wound healing and continence status.

Results

Statistical analysis was conducted by using SPSS software package Ver. 21. Baseline characteristic like mean ± standard deviation or the median were calculated according to the statistical distribution for continues parameters, and the number of patients and associated percentages for categorical parameters. The variables analyzed were age, gender, weight, underlying disease, previous associated surgeries, Pre-op and Post-op FI, and recurrence. Follow-up was performed for all patients in 3, 6, 12, 24, 36 months after the surgery. Of 80 patients with complex fistula, 57.5% (46 patients) were male, and 42.5% (34 patients) were female (Fig. 4).

Fig. 4
Gender distribution.

The median age was 40-years-old. The youngest patient was 17 years old, and the oldest was 70 years old. The median weight was 78 kg (mean = 77.6).

70 patients had high transsphincteric fistula (87.5%) and 10 of them who were female, had anterior fistula (12.5%) (Fig. 5).

Fig. 5
Type of fistula.

The 9 patients (11.3%) suffered from hypertension (HTN) and 43 patients (53.75%) had recurrent fistula after previous surgeries. 25 patients (31.25%) had undergone previous operation once, 15 patients (18.75%) had experienced the previous surgery twice or three times, and 3 patients (3.75%) had the operations more than three times.

Most of the patients had no complaint of FI before this surgery (n = 79, 98.8%) and only one person had fecal incontinence with the score of 8/20 according to CCF-FIS.

In follow up period, the overall success rate was 98.8%, and recurrence was seen in only one patient (failure rate: 1.2%) who had past anal fistula surgery (Fig. 6).

Fig. 6
Success and failure rate.

The preoperative and post-operative incontinence scoring showed mild fecal incontinence in 8 (10%) patients. The score of incontinence was 2/20 in two patients, 4/20 in two patients, 6/20 in one patient, 7/20 in one patient, 8/20 in one patient and there was fecal soilage in only one patient. Another patient with preoperative score of 8/20 improved to the postoperative score of 6/20.

The SPSS calculation detected no significant relation between the age, gender, HTN, previous surgery and post-operative recurrence or fecal incontinence.

Discussion

Perianal fistulas have the mean incidence of 10 per 10, 1000 in the world. It is a frequent condition that needs colorectal intervention for treatment.¹⁷ In spite of high incidence of perianal fistula and many advances in surgery and techniques, the treatment of perianal fistula is still a challenge because of high rate of recurrence and fecal incontinence after the surgery.^4,18 The disturbances of anal continence may vary from 0% to 25% for flatus control, 0% to 17% for stools, and up to 40% for passive incontinence which depend on the type of the procedure, the type and complexity of fistula, and associated risk factors for incontinence such as age, gender, previous surgery for perianal fistula and etc.^6,19-21

For a long time, fistulotomy was the definite choice for management of anal fistula because of the best results of success healing rate which was between 74% and 100%, but in many literatures, the high risk of recurrence and fecal incontinence in the treatment of complex anal fistulas Visscher et al. was reported. In 2015, an evaluation on 141 patients with simple and complex perianal fistula who underwent fistulotomy was performed. The median follow-up was 7.8 years. 34% of the patients experienced fecal incontinence, which was worse in patients with complex fistula in comparison with simple fistula.⁴ Both the American and European guidelines suggest using this procedure only for low, “simple” fistulas.^3,16

In former years, fistulectomy has been performed to be the standard surgery for management of complex perianal fistula. However, the incontinence after surgery lead the proctologists to propose and evaluate some procedures with the mechanism of sphincter saving.^5,22 Insertion of cutting seton was evaluated in many studies, in which healing rate was reported between 80% and 100% and impaired continence rates after the surgery were between 0% and 92%.^23-25 Besides, endorectal advancement flap was evaluated with the healing rate between 33% and 100% and incontinence rate between 0% and 71%.^26-31 Recently, the newer techniques such as fibrin glue and collagen plug are offered. The studies showed that the healing rate of fibrin glue is ranged from 0% to 86%,^32-35 and anal collagen plug is between 14% and 100%.^17,36-38 Also recent literatures showed that the long-term results of anal collagen plug were poor, so performing this method seems to be doubtful.^39,40

In 1985, Parkash et al. published their result of researches on primary closure and reconstruction of anal sphincter after fistulectomy. They introduced this procedure as a way for reducing the healing time and preventing anal deformity. After that, this procedure was performed for the treatment of complex anal fistula.¹¹

In our series of 80 patients, healing rate was 98.8%, and FI rate was 10%. Among the patients with FI, one patient suffers from soilage or passive incontinence. Another patient with preoperative score of 8/20 has improved to the postoperative score of 6/20. Most of the previous studies had the same results as we had. One follow-up study by Hirschburger et al. was done to evaluate the healing rate and FI in 50 patients with high transsphincteric fistula who underwent fistulectomy with primary sphincter reconstruction.¹⁵ During their follow-up period, the healing rate was 88%, and the recurrence was 10%. Three patients had low grade fecal incontinence consequent the surgery and one patient with 2 score incontinence improved.

Roig et al., analyzed the data of 31 patients with high trans-sphincteric, low trans-sphincteric and suprasphincteric fistula who underwent fistulectomy with sphincteroplasty in the mean 24 months follow-up.⁴¹ The recurrence was 9.7%, perianal soiling was 20%, and flatus incontinence was 4%. This study also showed that this procedure allows both rapid recovery and the preservation of anal sphincter.

We also assessed the factors such as age, gender, Hypertension, previous surgery, and type of fistula that may affect on the results of this procedure and found out that these factors had the meaningless effects on the outcome of the surgery.

In some studies, previous surgery was announced as a probable factor affecting the post-operative continence,^6,42 but we did not find a relation between previous surgeries and post-operative FI as what Abcarian had published in February, 2013.¹⁴ That study showed that none of the investigated factors (age, gender, smoking, previous surgery) can predict the success of surgery.

In previous studies, fistulectomy with sphincteroplasty was mostly performed in the treatment of high transsphincteric fistula, but we employed this operation technique for the patients with high transsphincteric fistula, and the women with anterior fistula. The success rate of this procedure was high (100%) in patients with anterior fistula which lead us to say that fistulectomy with sphincter reconstruction is a safe and effective procedure for transsphincteric fistula and Anterior fistula in female patients, as well as recurrent fistulas.

Conclusion

Fistulectomy and immediate sphincter reconstruction is a safe surgical procedure to treat the anterior anal fistula in women and high transsphincteric fistulas. The primary healing rate is high and the recurrence rate (failure rate) is very low.

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Publication Dates

• Publication in this collection
  Jul-Sep 2017

History

• Received
  1 Apr 2017
• Accepted
  14 May 2017