Cutting of Sphincter in Fistulectomy with Primary Closure in Complex Fistula-in-Ano: Is it Feasible?

Amrendra Verma; Reena Kothari; Dhananjaya Sharma; Pawan Agarwal

doi:10.1055/s-0043-1774726

Journal of Coloproctology, Table of Contents

CC BY-NC-ND 4.0 · Journal of Coloproctology 2023; 43(03): e204-e207
DOI: 10.1055/s-0043-1774726

Original Article

Cutting of Sphincter in Fistulectomy with Primary Closure in Complex Fistula-in-Ano: Is it Feasible?

Authors

Amrendra Verma

¹Department of General Surgery, Netaji Subhash Chandra Bose Medical College and Hospital, Jabalpur, Madhya Pradesh, India
Reena Kothari

²Departament of Emergency Medicine, Department of General Surgery, Division of Surgery, NSCB Medical College, Netaji Subhash Chandra Bose Medical College and Hospital, Jabalpur, Madhya Pradesh, India
Dhananjaya Sharma

²Departament of Emergency Medicine, Department of General Surgery, Division of Surgery, NSCB Medical College, Netaji Subhash Chandra Bose Medical College and Hospital, Jabalpur, Madhya Pradesh, India
Pawan Agarwal

²Departament of Emergency Medicine, Department of General Surgery, Division of Surgery, NSCB Medical College, Netaji Subhash Chandra Bose Medical College and Hospital, Jabalpur, Madhya Pradesh, India

Abstract

Introduction Treatment of complex fistulas such as inter- or transsphincteric, recurrent, and high fistulae have high rate of recurrence or incontinence. Fistulectomy with primary sphincter reconstruction might represent an effective and safe alternative to reduce rate of recurrence and incontinence. The aim of this study is to assess incontinence and recurrence after fistulectomy with primary sphincter reconstruction for management of complex fistulas.

Material and Methods There were 60 patients with complex fistulae involving the sphincter, with 56 male and 4 female, mean age 40.6 years, operated by fistulectomy and primary sphincter repair over a period of 7 years. Patients were followed up for 6months for any complications, recurrence, and incontinence.

Results The majority of patients (50, 83.3%) had complete wound healing in 2 weeks, while 4 (6.6%) patients had hematoma and superficial wound dehiscence, which were managed conservatively and healed in 4 weeks. There was one recurrence. All patients had good continence postoperatively, except for mild fecal incontinence (FI, score 3), seen in 6 (10%) patients. However, all these patients regained continence within 6 weeks.

Conclusions Primary reconstruction of anal sphincter with fistulectomy is a safe option for complex fistula-in-ano.

Keywords

anal sphincter - fistulectomy - complex fistula-in-ano - primary sphincteroplasty

Full Text

References

References
1 Soltani A, Kaiser AM. Endorectal advancement flap for cryptoglandular or Crohn's fistula-in-ano. Dis Colon Rectum 2010; 53 (04) 486-495
2 Parks AG, Gordon PH, Hardcastle JD. A classification of fistula-in-ano. Br J Surg 1976; 63 (01) 1-12
3 Arroyo A, Pérez-Legaz J, Moya P. et al. Fistulotomy and sphincter reconstruction in the treatment of complex fistula-in-ano: long-term clinical and manometric results. Ann Surg 2012; 255 (05) 935-939
4 Sultan AH, Monga AK, Kumar D, Stanton SL. Primary repair of obstetric anal sphincter rupture using the overlap technique. Br J Obstet Gynaecol 1999; 106 (04) 318-323
5 Rasmussen OØ. Fecal incontinence. Studies on physiology, pathophysiology and surgical treatment. Dan Med Bull 2003; 50 (03) 262-282
6 Lestár B, Asztalos I, László S. et al. [Possibilities in the preservation and restoration of anal continence]. Magy Seb 2001; 54 (03) 168-173
7 Fitzpatrick M, Behan M, O'Connell PR, O'Herlihy C. A randomized clinical trial comparing primary overlap with approximation repair of third-degree obstetric tears. Am J Obstet Gynecol 2000; 183 (05) 1220-1224
8 Jorge JM, Wexner SD. Etiology and management of fecal incontinence. Dis Colon Rectum 1993; 36 (01) 77-97
9 Vasilevsky CA, Gordon PH. The incidence of recurrent abscesses or fistula-in-ano following anorectal suppuration. Dis Colon Rectum 1984; 27 (02) 126-130
10 Loungnarath R, Dietz DW, Mutch MG, Birnbaum EH, Kodner IJ, Fleshman JW. Fibrin glue treatment of complex anal fistulas has low success rate. Dis Colon Rectum 2004; 47 (04) 432-436
11 Garcia-Aguilar J, Belmonte C, Wong WD, Goldberg SM, Madoff RD. Anal fistula surgery. Factors associated with recurrence and incontinence. Dis Colon Rectum 1996; 39 (07) 723-729
12 Cadeddu F, Salis F, Lisi G, Ciangola I, Milito G. Complex anal fistula remains a challenge for colorectal surgeon. Int J Colorectal Dis 2015; 30 (05) 595-603
13 Parkash S, Lakshmiratan V, Gajendran V. Fistula-in-ano: treatment by fistulectomy, primary closure and reconstitution. Aust N Z J Surg 1985; 55 (01) 23-27
14 Ratto C, Litta F, Donisi L, Parello A. Fistulotomy or fistulectomy and primary sphincteroplasty for anal fistula (FIPS): a systematic review. Tech Coloproctol 2015; 19 (07) 391-400
15 Stelzner F. The morphological principles of anorectal continence. Prog Pediatr Surg 1976; 9: 1-6
16 Roig JV, García-Armengol J, Jordán JC, Moro D, García-Granero E, Alós R. Fistulectomy and sphincteric reconstruction for complex cryptoglandular fistulas. Colorectal Dis 2010; 12 (7 Online): e145-e152
17 Lewis A. (1996) Core out. In: Phillips RKS, Lunniss PJ. eds. Anal fistula: surgical evaluation andmanagement. London, UK: Chapman & Hall; 81-6
18 Seyfried S, Bussen D, Joos A, Galata C, Weiss C, Herold A. Fistulectomy with primary sphincter reconstruction. Int J Colorectal Dis 2018; 33 (07) 911-918
19 Farag AFA, Elbarmelgi MY, Mostafa M, Mashhour AN. One stage fistulectomy for high anal fistula with reconstruction of anal sphincter without fecal diversion. Asian J Surg 2019; 42 (08) 792-796
20 Iqbal N, Dilke SM, Geldof J. et al. Is fistulotomy with immediate sphincter reconstruction (FISR) a sphincter preserving procedure for high anal fistula? A systematic review and meta-analysis. Colorectal Dis 2021; 23 (12) 3073-3089
21 Maqbool J, Mehraj A, Shah ZA. et al. Fistulectomy and incontinence: do we really need to worry?. Med Pharm Rep 2022; 95 (01) 59-64