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Fistulotomy with end-to-end primary sphincteroplasty for anal fistula: results from a prospective study.
MedLine Citation:
PMID:  23303152     Owner:  NLM     Status:  In-Data-Review    
Abstract/OtherAbstract:
BACKGROUND: : Fistulotomy plus primary sphincteroplasty for complex anal fistulas is regarded with scepticism, mainly because of the risk of postoperative incontinence.
OBJECTIVES: : The aim of this study was to evaluate safety and effectiveness of this technique in medium-term follow up and to identify potential predictive factors of success and postoperative continence impairment.
DESIGN AND SETTING: : This was a prospective observational study conducted at a tertiary care university hospital in Italy.
PATIENTS: : A total of 72 patients with complex anal fistula of cryptoglandular origin underwent fistulotomy and end-to-end primary sphincteroplasty; patients were followed up at 1 week, 1 and 3 months, 1 year, and were invited to participate in a recent follow-up session.
MAIN OUTCOME MEASURES: : Success regarding healing of the fistula was assessed with 3-dimensional endoanal ultrasound and clinical evaluation. Continence status was evaluated using the Cleveland Clinic fecal incontinence score and by patient report of post-defecation soiling.
RESULTS: : Of the 72 patients, 12 (16.7%) had recurrent fistulas and 29 patients (40.3%) had undergone seton drainage before definitive surgery. At a mean follow-up of 29.4 (SD, 23.7; range, 6-91 months, the success rate of treatment was 95.8% (69 patients). Fistula recurrence was observed in 3 patients at a mean of 17.3 (SD, 10.3; range, 6-26) months of follow-up. Cleveland Clinic fecal incontinence score did not change significantly (p = 0.16). Eight patients (11.6% of those with no baseline incontinence) reported de novo postdefecation soiling. None of the investigated factors was a significant predictor of success. Patients with recurrent fistula after previous fistula surgery had a 5-fold increased probability of having impaired continence (relative risk = 5.00, 95% CI, 1.45-17.27, p = 0.02).
LIMITATIONS: : The study was limited by potential single-institution bias, lack of anorectal manometry, and lack of quality of life assessment.
CONCLUSIONS: : Fistulotomy with end-to-end primary sphincteroplasty can be considered to be an effective therapeutic option for the treatment of complex anal fistulas, with low morbidity, a high rate of success even at long-term follow-up, and a very low rate of postoperative major fecal incontinence, although minor impairment of continence (postdefecation soiling) may occur. Caution should be used in selecting patients with a history of recurrent fistula and fecal incontinence.
Authors:
Carlo Ratto; Francesco Litta; Angelo Parello; Giuseppe Zaccone; Lorenza Donisi; Veronica De Simone
Publication Detail:
Type:  Journal Article    
Journal Detail:
Title:  Diseases of the colon and rectum     Volume:  56     ISSN:  1530-0358     ISO Abbreviation:  Dis. Colon Rectum     Publication Date:  2013 Feb 
Date Detail:
Created Date:  2013-01-10     Completed Date:  -     Revised Date:  -    
Medline Journal Info:
Nlm Unique ID:  0372764     Medline TA:  Dis Colon Rectum     Country:  United States    
Other Details:
Languages:  eng     Pagination:  226-33     Citation Subset:  IM    
Affiliation:
Department of Surgical Sciences, Catholic University, Rome, Italy.
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