w w w . j c o l . o r g . b r
Journal
of
Coloproctology
Original
Article
Assessment
of
fistulectomy
combined
with
sphincteroplasty
in
the
treatment
of
complicated
anal
fistula
Fakhrolsadat
Anaraki
a,
Omid
Etemad
b,
Elham
Abdi
c,∗,
Gholamreza
Bagherzadeh
a,
Roubik
Behboo
daShahidBeheshtiUniversityofMedicalSciences,TaleghaniHospital,DepartmentofColorectalSurgery,Tehran,Iran
bTehranUniversityofMedicalSciences,PlasticandReconstructiveSurgeryWard,Tehran,Iran
cShahidBeheshtiUniversityofMedicalSciences,Tehran,Iran
dIranUniversityofMedicalSciences,RasoulAkramHospital,DepartmentofColorectalSurgery,Tehran,Iran
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Articlehistory:
Received1April2017 Accepted14May2017 Availableonline5July2017
Keywords:
Fistulectomy Sphincteroplasty Analfistula
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Introduction:Theidealmethodoftreatingthecomplexanalfistulaistoeradicatethesepsis andpreservetheanalsphincter;sincethereisnodefiniteconsensusonthesurgicalmethod oftreatingit.Recentstudiesshowthatfistulectomyandimmediatesphincteroplasyarea safeandappropriatewaytotreatthefistula-in-ano.Theaimofthisstudywastoevaluate thelongtermoutcomesoffistulectmyandsphincteroplastyinthetreatmentofcomplex perianalfistula.
Methods:Inthisprospectivestudy,wehaveanalyzedthedataof80patientswhounderwent fistulectomyandsphincteroplastyfromMay2013toMay2016.Preoperativeinformation includedphysicalexamination,preoperativefecalincontinenceevaluationandtakinga completehistoryaboutunderlyingdiseasesandpastrelatedsurgerieswerecollected.
Results:Ofall80patientswithcomplexfistula,57.5%(46patients)weremale.70-Patients werepresentedwithhightranssphinctericfistula(87.5%)andanteriorfistula was diag-nosedin10ofthem(12.5%).9patients(11.3%)sufferedfromhypertensionand43patients (53.75%)hadrecurrentfistulaafterprevioussurgeries.Duringthefollow-upperiod,the over-allsuccessratewas98.8%(98.8%)andfistulectomyandsphincteroplastyfailedinonlyone patient(failurerate:1.3%).preoperativeandpost-operativescoringshowedmildfecal incon-tinencein8patients(10%).Wehavefoundnosignificantrelationbetweentheage,gender, hypertension,previoussurgeryandpost-operativerecurrence.
Conclusion:Fistulectomyandsphincteroplastyisasafesurgicalprocedureinthetreatment ofanterioranalfistulainfemalesandhightranssphinctericfistulas.
©2017SociedadeBrasileiradeColoproctologia.PublishedbyElsevierEditoraLtda.This isanopenaccessarticleundertheCCBY-NC-NDlicense(http://creativecommons.org/ licenses/by-nc-nd/4.0/).
∗ Correspondingauthor.
E-mail:elhammabdi1993@gmail.com(E.Abdi).
http://dx.doi.org/10.1016/j.jcol.2017.05.003
Avaliac¸ão
de
fistulectomia
combinada
com
esfincteroplastia
no
tratamento
de
fístula
anal
complicada
Palavras-chave:
Fistulectomia Esfincteroplastia Fístulaanal
r
e
s
u
m
o
Introduc¸ão: ométodoidealparatratarafístulaanalcomplexaconsisteemerradicarasepse epreservaroesfíncteranal,umavezquenãoexisteconsensodefinitivocomrelac¸ãoao métodocirúrgicoparatratamentodesseproblema.Estudosrecentesdemonstramquea fistulectomia,seguidaimediatamentepelaesfincteroplastia,éprocedimentoseguroe apro-priadonotratamentodafístulaperianal.Oobjetivodesteestudofoiavaliarosresultados emlongoprazodafistulectomiaedaesfincteroplastianotratamentodafístulaperianal complexa.
Métodos: Nesteestudoprospectivoanalisamososdadosde80pacientestratadospor fis-tulectomiaeesfíncteroplastianoperíododemaiode2013atémaiode2016.Foramcoletadas asseguintesinformac¸õespré-operatórias:examefísico,avaliac¸ãopré-operatóriade incon-tinênciafecalehistóriacompletasobredoenc¸assubjacentesecirurgiaspréviasafins.
Resultados: Detodosos80pacientescomfístulacomplexa,57,5%(46pacientes)pertenciam aogêneromasculino.Setentapacientesseapresentaramcomfístulatrans-esfinctéricaalta (87,5%);em10dessespacientes(12,5%),foidiagnosticadafístulaanterior.Novepacientes (11,3%)sofriamdehipertensão(HT),tendosidoobservadarecorrênciadefístulaapós cirur-gias préviasem 43 pacientes(53,75%).Duranteoperíodode seguimento, opercentual desucessoglobalfoide98,8%,eemapenasumpacienteosprocedimentosde fistulec-tomiae esfincteroplastianãoobtiveramsucesso(percentualdefalha:1,3%).Osescores pré-operatóriosepós-operatóriosrevelaramincontinênciafecalleveem8pacientes(10%). Nãoobservamosnenhumarelac¸ãosignificativaentreidade,gênero,HT,cirurgiapréviae recorrênciapós-operatória.
Conclusão: Fistulectomiaeesfincteroplastiaconstituemprocedimentocirúrgicosegurono tratamentodefístulasanaisanterioresemmulheresedefístulastrans-esfinctéricasaltas. ©2017SociedadeBrasileiradeColoproctologia.PublicadoporElsevierEditoraLtda.Este ´eumartigoOpenAccesssobumalicenc¸aCCBY-NC-ND(http://creativecommons.org/ licenses/by-nc-nd/4.0/).
Introduction
Anal fistulas are mostly cryptogenic in which the main methodoftreatmentistoeradicatetheinfection,and pre-servetheanalsphincterfunction.1Thestandardcommittee
ofAmericanSocietyofColorectalSurgeons(ASCRS)classified “Complex” fistulas as all intersphincteric, transsphincteric andsuprasphinctericfistulas.2,3
Thereare manysphincter-savingmethodsforthe treat-mentofcomplexanalfistula,but becauseofpost-operative fecalincontinence(FI)orrecurrence,thereisnodefinite con-sensus about the surgical treatment ofit.4,5 Cutting seton
placementhasupto67%incontinencerate6;sinceendorectal
advancementflaphasupto35%riskofFI,and30–60%failure rate.7,8Newertechniquessuchasligationofintersphincteric
fistulatracthavetherecurrencerateof30–60%andanalfistula plughasthefailurerateof70–80%.9,10
20yearsago,fistulectomyandimmediatesphinctroplasty wassuggestedtoreducethepost-operativeFIandthenmany surgeonsemployedthiscombinedtechniquefortreating com-plexanalfistula.11–14Thistechniqueisdefinedasasafeand
appropriatewayfortreatmentoffistula-in-anoandalsohasa highhealingrate,15buttherearesomeconcernsanddoubts
abouttheresultsofthisprocedure.16
Theaimofthisstudyisevaluationthelongtermresultsof fistulectmywithsphincteroplastyontreatmentofComplex perianalfistula.
Materials
and
methods
Inourprospectivestudy,wehaveanalyzedandevaluated80 patientswhounderwentfistulectomyandimmediate sphinc-teroplastyfromMay2013toMay2016.Allpatientssuffered fromcomplexanalfistula(hightranssphinctericandanterior fistulainfemale).Thepatientswithcomplexfistulasecondary toradiationorIBDwereexcludedinthisstudy.
All patientswere physicallyexamined bycolorectal sur-geonto identifythetype offistulaandmakesure that no abscesshasoccurred.Wehaveassessedallpatientsinorder to find out if they had past surgeries related to abscess drainageorhealingthefistulaorunderlyingdiseasesuchas Hypertension. Pre-operative assessmentsalso included the examinationoffecalincontinencebyusingClevelandClinic Floridafecalincontinencescoring(CCF-FIS)whichistabulated inSupplementaryMaterial.
Fig.1–Excisionoffistuloustract.
regionalanesthesia.Allpatientswerepositionedinthe litho-tomyposition. Two distinctstepsoftheprocedure were as follows:
First,weexcisedthefistuloustractinischioanalfossaup tothe lateral border ofexternal sphincterand opened the transsphincteric portion ofthe tract and internalopening, asyoucanseeinFig.1.Aftercuttingtheskinoverlyingthe sphincter,wecutthesphincteroverthetract,andthenthe granulationtissueofthetractwasexcisedmeticulously.
Then,afterirrigationofthewoundwithsalinesolution,we approximatedthetwoedgesofexternalandinternal sphinc-ter usingVicryl2/o sutures(Fig.2).Theskin andanoderm overlyingthewoundwasleftopenfordrainage(Fig.3).
Firstpost-opday,wekeptallpatientsNPOandprescribed them2dosesofintravenous(i.v.)Ceftriaxoneand Metronida-zole.
Fig.2–Approximationoftwoedgesofexternaland
internalsphincterusingVicryl2/osutures.
Fig.3–Theskinandanodermoverlyingthewoundwas
leftopenfordrainage.
Onthe seconddayafterthe surgery,onlyfluiddietwas startedforthemandoralantibioticsincludedciprofloxacin, 500BIDandMetronidazole,250mgTDSwereprescribedfor oneweek.Ontheendofsecondday,wetaughtthepatients howtobaththewound,anddischargedthem.Allthepatients were visited 1 week after the surgery in colorectal clinic. They were also examined 1, 3, 6, 12, 24, 36 months after thesurgeryforevaluationofwoundhealingandcontinence status.
Results
Statistical analysis was conducted by using SPSS software packageVer.21.Baselinecharacteristiclikemean±standard deviation or the median were calculated according to the statistical distribution for continues parameters, and the numberofpatientsandassociatedpercentagesforcategorical parameters.Thevariablesanalyzedwereage,gender,weight, underlyingdisease,previousassociatedsurgeries,Pre-opand Post-opFI,andrecurrence.Follow-upwasperformedforall patients in3, 6,12, 24,36 monthsafterthe surgery. Of80 patientswithcomplexfistula,57.5%(46patients)weremale, and42.5%(34patients)werefemale(Fig.4).
Themedianagewas40-years-old. Theyoungestpatient was17yearsold,andtheoldestwas70yearsold.Themedian weightwas78kg(mean=77.6).
70patientshadhightranssphinctericfistula(87.5%)and10 ofthemwhowerefemale,hadanteriorfistula(12.5%)(Fig.5). The9patients(11.3%)sufferedfromhypertension(HTN) and43patients(53.75%)hadrecurrentfistulaafterprevious surgeries.25patients(31.25%)hadundergoneprevious oper-ationonce,15patients(18.75%)hadexperiencedtheprevious surgerytwiceorthreetimes,and3patients(3.75%)hadthe operationsmorethanthreetimes.
57.5
Female
Male
Fig.4–Genderdistribution.
12.5
High transsphincteric fistula
Anterior fistula
Fig.5–Typeoffistula.
Infollowupperiod,theoverallsuccessratewas98.8%,and recurrencewasseeninonlyonepatient(failurerate:1.2%) whohadpastanalfistulasurgery(Fig.6).
Thepreoperativeandpost-operativeincontinencescoring showedmildfecalincontinencein8(10%)patients.Thescore ofincontinencewas2/20intwopatients,4/20intwopatients, 6/20inonepatient,7/20inonepatient,8/20inonepatientand therewasfecalsoilageinonlyonepatient.Anotherpatient withpreoperativescoreof8/20improvedtothepostoperative scoreof6/20.
120
98.8%
1.2%
Success Failure
100
80
60
40
20
0
Fig.6–Successandfailurerate.
The SPSS calculation detected no significant relation between the age, gender, HTN, previous surgery and post-operativerecurrenceorfecalincontinence.
Discussion
Perianalfistulashavethemeanincidenceof10per10,1000 intheworld.Itisafrequentconditionthatneedscolorectal interventionfortreatment.17Inspiteofhighincidenceof
peri-analfistulaandmanyadvancesinsurgeryandtechniques,the treatmentofperianalfistulaisstillachallengebecauseofhigh rateofrecurrenceandfecalincontinenceafterthesurgery.4,18
Thedisturbancesofanalcontinencemayvaryfrom0%to25% forflatuscontrol,0%to17%forstools,andupto40%for pas-siveincontinencewhichdependonthetypeoftheprocedure, the typeandcomplexity offistula,and associatedrisk fac-torsforincontinencesuchasage,gender,previoussurgeryfor perianalfistulaandetc.6,19–21
For a long time, fistulotomy was the definitechoicefor managementofanalfistulabecauseofthebestresultsof suc-cesshealingratewhichwasbetween74%and100%,butin manyliteratures,thehighriskofrecurrenceandfecal incon-tinenceinthetreatmentofcomplexanalfistulasVisscheretal. wasreported.In2015,anevaluationon141patientswith sim-pleandcomplexperianalfistulawhounderwentfistulotomy wasperformed.Themedianfollow-upwas7.8years.34%of thepatientsexperiencedfecalincontinence,whichwasworse inpatientswithcomplexfistulaincomparisonwithsimple fistula.4BoththeAmericanandEuropeanguidelinessuggest
usingthisprocedureonlyforlow,“simple”fistulas.3,16
Informeryears,fistulectomyhasbeenperformedtobethe standardsurgeryformanagementofcomplexperianalfistula. However,theincontinenceaftersurgeryleadtheproctologists toproposeand evaluatesomeprocedureswiththe mecha-nismofsphinctersaving.5,22 Insertionofcuttingseton was
evaluatedinmanystudies,inwhichhealingratewasreported between80%and100%andimpairedcontinenceratesafter thesurgerywerebetween0%and92%.23–25Besides,
endorec-tal advancement flap was evaluated with the healing rate between 33% and100% and incontinencerate between0% and 71%.26–31 Recently,thenewertechniquessuchasfibrin
glueandcollagenplugareoffered.Thestudiesshowedthat thehealingrateoffibringlueisrangedfrom0%to86%,32–35
andanalcollagenplugisbetween14%and100%.17,36–38Also
recentliteraturesshowedthatthelong-termresultsofanal collagenplugwerepoor,soperformingthismethodseemsto bedoubtful.39,40
In1985,Parkashetal.publishedtheirresultofresearches onprimaryclosureandreconstructionofanalsphincterafter fistulectomy. They introduced this procedure as a wayfor reducingthehealingtimeandpreventinganaldeformity.After that,thisprocedurewasperformedforthetreatmentof com-plexanalfistula.11
wasdonetoevaluatethehealingrateandFIin50patients with high transsphincteric fistulawho underwent fistulec-tomywithprimarysphincterreconstruction.15 Duringtheir
follow-upperiod,thehealingratewas88%,andtherecurrence was10%.Threepatientshadlowgradefecalincontinence con-sequentthesurgeryandonepatientwith2scoreincontinence improved.
Roig et al., analyzed the data of 31 patients with high trans-sphincteric,lowtrans-sphinctericandsuprasphincteric fistulawhounderwentfistulectomywithsphincteroplastyin themean24monthsfollow-up.41Therecurrencewas9.7%,
perianal soiling was 20%,and flatus incontinence was 4%. Thisstudyalsoshowedthatthisprocedureallowsbothrapid recoveryandthepreservationofanalsphincter.
Wealsoassessedthefactorssuchasage,gender, Hyperten-sion,previoussurgery,andtypeoffistulathatmayaffecton theresultsofthisprocedureandfoundoutthatthesefactors hadthemeaninglesseffectsontheoutcomeofthesurgery.
In some studies,previous surgerywas announced as a probable factor affecting the post-operative continence,6,42
butwedidnotfindarelationbetweenprevioussurgeriesand post-operativeFIaswhatAbcarianhadpublishedinFebruary, 2013.14Thatstudyshowedthatnoneoftheinvestigated
fac-tors(age,gender,smoking,previoussurgery)canpredictthe successofsurgery.
In previous studies, fistulectomy with sphincteroplasty wasmostlyperformedinthetreatmentofhigh transsphinc-tericfistula,butweemployedthisoperationtechniqueforthe patientswithhightranssphincteric fistula,andthe women withanteriorfistula.Thesuccessrateofthisprocedurewas high(100%)inpatientswithanteriorfistulawhichleadusto saythatfistulectomywithsphincterreconstructionisasafe andeffectiveprocedurefortranssphinctericfistulaand Ante-riorfistulainfemalepatients,aswellasrecurrentfistulas.
Conclusion
Fistulectomyandimmediatesphincterreconstructionisasafe surgicalproceduretotreattheanterioranalfistulainwomen andhightranssphinctericfistulas.Theprimaryhealingrateis highandtherecurrencerate(failurerate)isverylow.
Conflicts
of
interest
Theauthorsdeclarenoconflictsofinterest.
Appendix
A.
Supplementary
data
Supplementarydataassociatedwiththisarticlecanbefound, intheonlineversion,atdoi:10.1016/j.jcol.2017.05.003.
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