Abstract
Aim
Despite modern medical techniques, anatomically proximal (high) anal fistulas are still a challenge in colorectal surgery. In previous years, the standard of care was complete fistulectomy with a high rate of continence disorders. Over the past 20 to 30 years, sphincter-saving procedures have gained wide acceptance. They represent the technique used in these cases. Additionally, many patients received indefinite treatment, namely the placement of a seton to maintain surgical drainage. The main problem with all fistula surgical possibilities is the high recurrence rate of 30 to 50% in flap procedures and 100% persistence in seton treatments. In recent years, a direct repair (primary reconstruction) in distal fistulas was instigated and shows excellent results. It allowed our technique for proximal (high) anal fistulas to evolve.
Method
All patients who underwent surgery at the University Medical Center Mannheim, Department of Colo-proctology (from 06/2003 to 11/2015), were retrospectively evaluated using a prospective database. Patients who underwent fistulectomy with primary sphincter reconstruction were all included.
Results
The primary healing rate, after a mean follow-up of 11 months (7 to 200 months), was 88.2% (374 of 424). Taking into account revisionary surgeries with secondary sphincter repair, this rate reaches 95.8% (406 of 424). Factors such as gender and fistula location as related to the sphincter had significant influence on the study outcome, whereas variables such as the amount of reconstructed muscle (in mm), number of revisions, patient age, other anal operations, and concomitant medication did not. The incontinence of a subgroup of 148 patients was evaluated in detail by way of a questionnaire. Even at a preoperative baseline, 9.6% of those patients reported some minor degree of continence disorders. After the procedure, incontinence disorders were observed in 34 patients (23.0%), with 23 of these patients suffering from flatus incontinence (15.5%), 10 patients from liquid incontinence (6.8%), and 1 patient from solid fecal incontinence.
Conclusion
Fistulectomy with primary sphincter reconstruction is a feasible procedure resulting in a low recurrence rate. No other procedure has shown better results in transsphincteric fistulas. Continence disorders seem to be of minor relevance/consequence for these patients.
This is a preview of subscription content, log in via an institution to check access.
Similar content being viewed by others
References
Ommer A, Herold A, Berg E et al (2011) Cryptoglandular anal fistulas. Dtsch Arztebl Int 108:707–713. https://doi.org/10.3238/arztebl.2011.0707
Herold A, Joos A, Hellmann U, Bussen D (2009) Treatment of high anal fistula: is fistulectomy with primary sphincter repair an option? Color Dis 11:15
Roig G-A, Jordán et al. (1999) Immediate reconstruction of the anal sphincter after fistulectomy in the management of complex anal fistulas. Colorectal Dis 1:137–140. https://doi.org/10.1046/j.1463-1318.1999.00021.x
Arroyo A, Pérez-Legaz J, Moya P et al (2012) Fistulotomy and sphincter reconstruction in the treatment of complex fistula-in-ano: long-term clinical and manometric results. Ann Surg 255:935–939. https://doi.org/10.1097/SLA.0b013e31824e9112
Ratto C, Litta F, Donisi L, Parello A (2015) Fistulotomy or fistulectomy and primary sphincteroplasty for anal fistula (FIPS): a systematic review. Tech Coloproctol 19:391–400. https://doi.org/10.1007/s10151-015-1323-4
Hirschburger M, Schwandner T, Hecker A et al (2014) Fistulectomy with primary sphincter reconstruction in the treatment of high transsphincteric anal fistulas. Int J Colorectal Dis 29:247–252. https://doi.org/10.1007/s00384-013-1788-4
Hull TL, El-Gazzaz G, Gurland B et al (2011) Surgeons should not hesitate to perform episioproctotomy for rectovaginal fistula secondary to cryptoglandular or obstetrical origin. Dis Colon Rectum 54:54–59. https://doi.org/10.1097/01.dcr.0000388926.29548.36
Christiansen J, Rønholt C (1995) Treatment of recurrent high anal fistula by total excision and primary sphincter reconstruction. Int J Colorectal Dis 10:207–209
Perez F, Arroyo A, Serrano P et al (2006) Prospective clinical and manometric study of fistulotomy with primary sphincter reconstruction in the management of recurrent complex fistula-in-ano. Int J Colorectal Dis 21:522–526. https://doi.org/10.1007/s00384-005-0045-x
Bernal-Sprekelsen J, Landente F, Morera F, Ripoll F, De Tursi L, Garcia-Granero MMJ (2008) Treatment of anal fistulae followed by sphincteroplasty. Color Dis Suppl 2:51
Lux N, Athanasiadis S (1991) Functional results following fistulectomy with primary muscle suture in high anal fistula. A prospective clinical and manometric study. Chirurg 62:36–41
Perez F, Arroyo A, Serrano P et al (2006) Randomized clinical and manometric study of advancement flap versus fistulotomy with sphincter reconstruction in the management of complex fistula-in-ano. Am J Surg 192:34–40. https://doi.org/10.1016/j.amjsurg.2006.01.028
Author information
Authors and Affiliations
Corresponding author
Ethics declarations
The study was approved by the local ethics committee (2017-819R-MA). All patients have given their informed consent to participate.
Rights and permissions
About this article
Cite this article
Seyfried, S., Bussen, D., Joos, A. et al. Fistulectomy with primary sphincter reconstruction. Int J Colorectal Dis 33, 911–918 (2018). https://doi.org/10.1007/s00384-018-3042-6
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s00384-018-3042-6