w w w . j c o l . o r g . b r
Journal
of
Coloproctology
Original
Article
Retrospective
analysis
of
patients
submitted
to
surgical
treatment
of
perianal
fistula
in
Santa
Marcelina
Hospital,
São
Paulo
夽
Isaac
José
Felippe
Corrêa
Neto
a,b,∗,
Janaína
Wercka
a,
Diego
Palmeira
Rangel
a,
Eduardo
Augusto
Lopes
a,b,
Hugo
Henriques
Watté
a,b,
Rogério
Freitas
Lino
Souza
a,
Alexander
Sá
Rolim
a,b,
Laercio
Robles
a,baHospitalSantaMarcelina,DepartamentodeCirurgiaGeral,Servic¸odeColoproctologia,SãoPaulo,SP,Brazil
bSociedadeBrasileiradeColoproctologia,Brazil
a
r
t
i
c
l
e
i
n
f
o
Articlehistory:
Received16February2017 Accepted27March2017 Availableonline11May2017
Keywords:
Perianalfistula Demographicdata Relapse
Analincontinence
a
b
s
t
r
a
c
t
Introduction:Perianalfistulaisaconditioncommonlyfoundinsurgicalpractice,withan
incidenceofapproximately1in10,000individuals,withapredispositionforthemalegender, occurringmainlyinpatientsbetween30and50yearsandin80%ofthecasesoriginating frominfectionintheglandularcrypts(cryptoglandular).
Objective:To perform a retrospective analysis using electronic medical record data of
patientssubmittedtosurgicaltreatmentforperianalfistulainSantaMarcelinaHospital inSãoPaulo,aswellastoverifytheincidenceofrelapseandanalcontinencedisorders,in additiontothecomplexityandtypesoffistulasandpatientcharacterization.
Results:Twohundredpatientsweresubmittedtosurgicaltreatmentofperianalfistulawere
analyzed.Amongmen,therewasahigherincidenceofpatientswithlowereducationallevel (p=0.02),hypertension(0.03),diabetes(0.05),olderage(p=0.001),whereasamongwomen previousperianalabscesspredominated(0.001).Therewasnostatisticaldifferenceinanal continencebetweenpatientssubmittedtofistulotomywithorwithoutseton.
Conclusion: Weobservedapredominanceofmalepatientsandalowincidenceofrecurrence
andsymptomsofanalcontinencedisorders,inadditiontoapredominanceofcomplex fistulas.
©2017SociedadeBrasileiradeColoproctologia.PublishedbyElsevierEditoraLtda.This isanopenaccessarticleundertheCCBY-NC-NDlicense(http://creativecommons.org/ licenses/by-nc-nd/4.0/).
夽
StudycarriedoutinHospitalSantaMarcelina,DepartamentodeCirurgiaGeral,ProgramadeResidênciaMédicadeColoproctologia, SãoPaulo,SP,Brazil.
∗ Correspondingauthor.
E-mail:[email protected](I.J.Neto). http://dx.doi.org/10.1016/j.jcol.2017.03.008
Análise
retrospectiva
de
pacientes
submetidos
à
tratamento
cirúrgico
de
fístula
perianal
no
Hospital
Santa
Marcelina,
São
Paulo
Palavras-chave:
Fístulaperianal Dadosdemográficos Recidiva
Incontinênciaanal
r
e
s
u
m
o
Introduc¸ão: Fístulaperianaléumacondic¸ãocomumenteencontradanapráticacirúrgica
comincidênciadecerca1em10000indivíduoscompredisposic¸ãoparaosexomasculino, ocorrendofundamentalmenteempacientesentre30e50anoseem80%doscasostem origememinfecc¸ãonascriptasglandulares(criptoglandular).
Objetivo: Realizar análise retrospectiva através de dados de prontuário eletrônico de
pacientessubmetidosatratamentocirúrgicodefístulaperianalnoHospitalSantaMarcelina SãoPaulo,alémdeverificaraincidênciaderecidivaedesordensdacontinênciaanal,além dacomplexidadeetiposdasfístulasecaracterizac¸ãodospacientes.
Resultados:Duzentospacientesforamsubmetidosatratamentocirúrgicodefístulaperianal.
Entreoshomenshouvemaiorincidênciadepacientescommenorescolaridade(p=0,02), hipertensos(0,03),diabéticos(0,05),maioridade(p=0,001)enasmulherespredominou abscessoperianalprévio(p=0,001).Nãohouvediferenc¸aestatísticanacontinênciaanal entreospacientessubmetidosafistulotomiacomousemsedenho.
Conclusão: Verifica-sepredomíniodepacientesdosexomasculinoeumabaixaincidência
derecidivaesintomasdedesordensdacontinênciaanal,alémdeumpredomíniodefístulas complexas.
©2017SociedadeBrasileiradeColoproctologia.PublicadoporElsevierEditoraLtda.Este ´eumartigoOpenAccesssobumalicenc¸aCCBY-NC-ND(http://creativecommons.org/ licenses/by-nc-nd/4.0/).
Introduction
Perianalfistula isa condition commonlyfound in surgical practice1andcanbedefinedasanabnormalcommunication
betweentwoepithelializedsurfaces,usuallytheanal canal withthe perianal region.2–4 Ithas anincidenceof
approx-imately 1 in 10,000 individuals, with a predisposition for the male gender(2–7:1), occurringmainly inpatients aged between30and50 years5,6 and in80% ofcasesoriginating
frominfectionintheglandularcrypts(cryptoglandular).6
Clinically, it manifests as persistent or intermittent drainageofperianalsecretionassociatedwithpruritusand eventualbleeding.7Therefore,thediagnosisisbasedonthe
anamnesisandphysicalexamination,duringwhichthe exter-nalfistulaorifice,itslocationanddistancefromtheanalverge mustbeobserved,insearchofapalpabletrajectory.Afterthat, thedigitalexaminationofthedistalrectumand analcanal isperformed,payingattentiontothetonusoftheanorectal sphinctercomplex,lookingfortumorsand,eventually, palpa-tionoftheinternalfistulousorifice,whichcanbevisualized throughtheanoscopy.
Subsequently, complementary propaedeutic actions should be continued, especially in cases of complex and recurrent fistulas,7 with the aid of computed tomography
ofthepelvis,butmainlymagneticresonanceandendoanal ultrasonography.6,8However,thefistulacanbeconsideredas
simple,iftheexternalorificeisclosetotheanalverge,with ashorttrajectory,afterrulingoutthehypothesisofCrohn’s disease.9
Once the complexity has been defined, those of low transsphincteric location or the intersphincteric ones with involvementoftheexternalanalsphincterlessthan30%are
classifiedassimple.6Ontheotherhand,complexfistulasare
the onesthathave hightranssphincteric, suprasphincteric, andextrasphincterictrajectories,aswellashorseshoe fistu-las.Additionally,thoseassociatedwithinflammatorybowel disease, previous pelvic radiation,associated symptomsof analincontinence,andthosewithchronicdiarrhea,aswellas anteriorfistulasinwomenarealsoconsideredcomplex.10,11
Thetreatment oftheperianal fistulaismainly surgical, with the objective oferadicating the fistulous trajectory,12
identifyingtheinternalfistulaorificeandsearchingfor adja-cent collections, without lesionstothe anorectalsphincter complex.7,12,13However,thisidealproposalmaybedifficultto
achieve,withriskofanalincontinenceandfistularecurrence, whichcanoccurinupto18%ofcases.1,14
Objectives
Theprimaryobjectivewastoperformaretrospective analy-sisusingelectronicmedicalrecorddataofpatientssubmitted tosurgical treatmentofperianalfistulainSanta Marcelina Hospital, SãoPaulo,SP.Asecondaryobjective wastoverify theincidenceofrecurrenceandanalcontinencedisorders,in additiontothecomplexityandtypesoffistulasand charac-terizationofthepatients.
Materials
and
methods
SãoPaulo,betweenJanuary2010andJuly2015,afterexcluding patientswithinflammatoryboweldisease.
ThedataweretabulatedinanExcelworksheetwith anal-ysis of gender, age, body mass index, level of schooling, comorbidities,historyofperianalabscess,symptomatology, classification and location of the perianal fistula, type of surgery,postoperativecomplications,andrecurrence.
Statisticalanalysis
Dataweredescribedasmean±standarddeviation(extremes) orabsolutefrequency(percentage).Fischer’sexact testand RelativeRisk(RR)calculation(95%ConfidenceInterval)were usedtostudytheassociationbetweenqualitativevariables. Student’sttestforindependentsampleswasusedtostudy thedifference betweenquantitative variables.Binary logis-tic regression was used to study the association between preoperativeorintraoperativefactors.Thelevelofstatistical significancewassetat95%.
Results
DuringtheperiodfromJanuary2010toJuly2015,302 surger-ieswereperformedtotreatperianalfistulas.Thefinalsample consistedof200patientssubmittedtosurgicaltreatment.The flowchartofpatientinvolvementwiththestudyisdescribed inFig.1.
The socio-demographic characteristics and medical-obstetrichistorystratifiedbygenderofpatientsreferredfor surgicaltreatmentofperianalfistulasofcryptoglandular eti-ologyaredescribedinTable1.Amongmen,therewasahigher incidenceofpatientswithlowereducationallevel(p=0.02), hypertension(0.03),diabetes(0.05),andolderage(p=0.001),
Perianal fistulas n=302
Criptoglandular fistulas n=200
Fistulotomy n=48
Male n=34
Female n=14
Fistulotomy with seton n=152
Male n=98
Female n=54 Excluded: Trauma, iatrogenic (urological,
colorectal or gynecological causes) neoplasias, inflammatory bowel disease.
n=102
Fig.1–Flowchartofpatientinvolvementinthestudy.
whereas previous perianal abscess was predominant in women(p=0.001).
Thecomplaintsreportedbythepatientsundergoing preop-erativeevaluationaredescribedinTable2,withthepresence ofsecretionbeingthemostfrequentcomplaint,followedby perianallesionperceivedbythepatient,withnostatistically significant differenceregarding thesymptomsbetween the genders.
Intheintraoperativeperiod,thefistulaswereclassifiedin relationtothe anal sphincterand positionusing Goodsal’s rule. Thehighestincidencewas ofintersphinctericfistulas (140patients).Regardingtheposition,therewasnodifference betweenanteriorandposteriorfistulas,with97and103cases (greater than200),respectively.Theanalysisisstratifiedby
Table1–Sociodemographiccharacteristicsandhistoryofpatientsinvolvedinthestudy.
General n=200
Male n=132
Female n=68
p
Age(years) 43.3±14 46.4±14 37.3±11.9 0.001
(15–82) (15–82) (20–75)
BMI(kg/m2) 28.5±5.9 29±6.0 27.6±5.6 0.12
(16.6–55.3) (16.6–55.3) (16.9–40.9) Levelofschooling
Illiterate 19(9.5%) 15(11.4%) 4(6%) 0.02
Elementaryschool 72(36%) 55(41.7%) 17(25%)
Highschool 92(46%) 51(38.6%) 41(60%)
College/University 17(8.5%) 11(8.3%) 6(9%)
Hypertension 44(22%) 35(26%) 9(13%) 0.03
Diabetesmellitus 13(6.5%) 13(9.8%) 0(0%) 0.05
HIV 6(3.0%) 6(4.5%) 0(0%) 0.09
Smoking 42(21%) 31(23%) 11(16%) 0.27
Previousorificesurgery 61(30.5%) 36(27.3%) 25(36.8) 0.19 Previousabscess 113(57%) 63(47.7%) 50(70.3%) 0.001
Previouspregnancy 40(58.8%)
Vaginaldelivery 26(38.2%)
Forceps 8(11.8%)
Episiotomy 11(16%)
Meanpregnancies 1.4±1.6(0–7)
Table2–Preoperativesignsandsymptomsreportedbypatientsundergoingsurgicaltreatmentofperianalfistula.
General n=200
Male n=132
Female n=68
p
Secretion 164(82%) 105(79.5%) 59(86.8%) 0.24
Perceivedlesion 147(73.5%) 94(71.2%) 53(77.9%) 0.39
Pain 103(51.5%) 66(50%) 37(54.4%) 0.65
Soiling 3(1.5%) 1(0.8%) 2(2.9%) 0.27
36 31
48 20
2 1
67 66
92 36
5 2
Anterior Posterior Intersphincteric Transsphincteric Extrasphincteric Suprasphincteric
Male (n=132) Female (n=68)
Fig.2–Characteristicsofperianalfistulasin200patients submittedtosurgeryregardingtypeandlocation.
genderinFig.2.Onewomanandtwomenhadtwofistulas thatweretreatedatthesamesurgicalprocedure.
Mostpatients(50%)toleratedpostoperativefistulototomy withoutreportinganycomplaintstothesurgeon.However,the fivemostfrequentcomplaintsreportedduringthe postopera-tivefollow-upamongthesepatientswerepain(25%),soiling (20%),useofclothingprotectors(14%)anddifficultyinhygiene (12%).
Ontheotherhand,amongthepatientssubmittedto fistu-lotomywiththeuseofseton,only25.7%wereasymptomatic at the postoperative period. The complaints in this group were seton loss in 32% of cases, pain (25%), difficulty in hygiene(18%)andsoiling(15%),inadditiontotheneedfor reoperation in the second phase ofsurgical treatment for theremovalorpassageofanewsetonwhentheresultwas
notsatisfactory.Furthermore,therewasnostatistically sig-nificantdifferenceregardingthesepostoperativecomplaints whencomparingthedifferentsurgicaltechniques,asshown inTable3,althoughitwasobservedthatthegroupofpatients submitted to fistulotomy without seton showed a higher percentageofasymptomaticpatients,withastatistically sig-nificantdifference(50%×25.7%;p=0.002).
Afterperformingthebinarylogisticregressionanalysisof the preoperativeconditions, typeofsurgeryperformedand location of the fistula,which were analyzedin association withsymptomsofincontinenceand diseaserecurrence,an association was demonstrated between disease recurrence andintersphincteric(p=0.03),transsphincteric(p=0.044)and extrasphincteric(p=0.005)positions.Regardingcomplaintsof anal incontinence, evenif transient,therewas an associa-tionwithpreviousabscess(p=0.034),numberofpregnancies (p=0.019)andanteriororificesurgery(p=0.021).
Therecurrencerateinpatientsthatwereinitially submit-tedtofistulotomywasfourpatients(8.3%),whereasinthose submitted tofistulotomy withseton, this ratewas verified in22patients(14.5%),withnodifferenceintheincidenceof recurrence betweenpatientssubmitted toeithertechnique (8.3% and 14.5%) for fistulotomy without and with seton, respectively;p=0.33;RR0.61(CI:0.24–1.5).
Thepatientshadanaverageof4.4(±2.6)postoperative con-sultationsandmeanfollow-uptimewas10.2(±8.7)months; attheendoffollow-up,perianalfistularesolutionwith sur-gicaltreatmentwasattainedby184(92%)patients.Atotalof 85.4%(41patients)ofthosesubmittedtofistulotomyreported absence ofprevious symptoms, whereas 94.1% (143 cases) of patients submitted to fistulotomy with seton reported improvementwithtreatment;p=0.07;RR:1.38(CI:0.89–2.0).
Table3–Occurrenceofsignsandsymptomsreferredbythepatientsinthepostoperativeperiodoffistulotomywithout andwiththeuseofseton.
Fistulotomy n=48
Seton n=152
p RRand(95%CI)
Acutepain 12(25%) 35(23%) 0.84 0.61(0.62–1.92)
Difficultyinhygiene 6(12.5%) 28(18.4%) 0.39 0.60(0.32–1.50)
Lossofseton 50(32.9%)
Infection 4(8.3%) 8(5.3%) 0.48 1.4(0.61–3.3)
Nocomplaints 24(50%) 39(25.7%) 0.002 2.2(1.3–3.5) Reoperation 5(10.4%) 62(40.8%) 0.0001 1.4(1.2–1.6)
Soiling 10(20.8%) 24(15.8%) 0.51 1.3(0.71–2.3)
Gasleakage 3(6.3%) 5(3.3%) 0.40 1.6(0.63–4.0)
Fluidleakage 1(2.1%) 10(6.6%) 0.46 0.35(0.1–2.4)
Solidleakage 3(6.3%) 4(2.6%) 0.36 1.8(0.75–4.5)
Discussion
Perianalfistulaisadiseasewithanincidenceofaround1to 2.3per10,000inhabitantsperyear15withapredispositionfor
the malegender, mainly affectingindividuals intheir pro-ductiveyears,aroundthe3rdtothe5thdecades.16Ahigher
incidencewasalsoobservedinmales,thatis,1.95:1withan oldermeanageof43.3±14years,bothconsistentwithdata fromtheliterature.
Clinically, it is mainly characterizedby the presence of tumoror swelling, secretion and pain.17 Additionally, it is
knownthatapproximately30–50%ofpatientswithanorectal abscesswilldevelopapersistenttrajectoryoranorectalfistula withcommunicationfromtheanalcanaltotheperinealskin, beingimpossibletopredictorpreventthisevolution.7Inour
study,113patients(57%)hadaprevioushistoryofanorectal abscess,andahigherincidenceofthisprevioushistorywas observedinfemales(70.3%–p=0.001).
Regarding the surgicaltreatment oftheperianal fistula, it is known that it isbased on the eradication of the fis-tuloustrajectorywithmaintenanceofanalcontinence. For thispurpose,fistulasthatinvolvelessthanone-thirdofthe externalanalsphinctermuscle areusuallytreatedthrough fistulotomy,whereascomplexones,withsignificant involve-mentoftheinternalandexternalanalsphinctermusclesare treatedthroughmorecomplextechniques,amongwhichis thefistulotomywiththeuseofseton.18,19
Theuseofthesetoninthesurgicalplanningofthe peri-analfistulaisoneofthe mostcommonlyusedtechniques, especially incases ofcomplex disease, and it isbased on thechronicinflammatoryreaction,withconsequentfibrosis causedbytheforeign body thathelpsinthe preventionof sphincterretractionwhenitsdivisionisperformed,reducing, butnoteliminatingmajordamages,amongthemtheriskof analincontinence.4,20
Subhasetal.18analyzed24patientswithtranssphincteric
fistulas,25%ofwhichhadCronh’sdisease,andinallofthem thefistulotomywasperformedwiththesetonpassage,with progressivetractionandtherapeuticsuccessachievedby75% ofthe patients. Moreover,there was an index of satisfac-tionwiththetechniqueand90%ofthepatientsconsidered theywouldrepeatthetreatmentwithasetonincaseof dis-easerecurrence.Similarly,otherstudiesintheliteraturehave shownarecurrencerateof0–6%withtheuseofseton.21We,on
theotherhand,foundarateofrecurrenceof8.3%inpatients submittedtofistulotomyand14.5%inpatientssubmittedto fistulotomywithseton.
Regardingtheincidenceofanalincontinenceaftersurgery forperianalfistula,itisknownthatitcanoccur,evenif tran-siently,inupto18%ofpatients1,14;inourstudy,anassociation
ofthis morbiditywasdemonstrated withpreviousperianal abscess,numberofpregnanciesandhistoryoforifice surger-ies,leadingustobelieve thatinthese situationsanorectal manometryshouldberoutinelyrequested.
Conclusion
A retrospective analysis of cases of perianal fistula sub-mitted to surgery in Santa Marcelina Hospital showed a
predominance of male patients, more than half related to previous perianal abscess,especiallyinfemales,and alow incidenceofrecurrenceandsymptomsofanalcontinence dis-orders,inadditiontoapredominanceofcomplexfistulas.
Conflicts
of
interest
Theauthorsdeclarenoconflictsofinterest.
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