J. Coloproctol. (Rio J.) vol.35 número1

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jcoloproctol(rioj).2015;35(1):42–45

w w w . j c o l . o r g . b r

Journal

of

Coloproctology

Original

Article

Anal

fistula

surgery

in

an

outpatient

setting:

the

Dubai

experience

Wessam

Hazim,

Labib

Al-Ozaibi

∗

_,

_Hadiel

_Azam,

_Alya

_Al-Mazrouei,

_Faisal

_Al-Badri

SurgicalDepartment,RashidHospital,DubaiHealthAuthority,Dubai,UnitedArabEmirates

a

r

t

i

c

l

e

i

n

f

o

Articlehistory:

Received8October2014

Accepted27November2014

Availableonline28January2015

Keywords:

Analfistula

Proctology

Ambulatorysurgery

Daycasesurgery

a

b

s

t

r

a

c

t

Aim:Todeterminewhethersurgeryfortranssphinctericandcomplexfistula-in-anocanbe

performedsafelyasadaycase.

Method:Thisisaretrospectivestudyof66patientswithtranssphinctericandcomplexanal

fistulas,initiallymanagedwithpreliminarylooseSetonfollowedbyfistulectomyand

sphinc-terrepair2–4monthslaterbetweenMarch2011andMarch2014.Patientswereseenatthe

clinic1week,3monthsand1yearpost-operativelyandwereobservedforcomplications

andrecurrences;incontinencewasnoteddownandwasgradedaccordingtotheCleveland

Clinicscore.

Result:Twenty-fivepatients(38%)hadhighorcomplexfistulasand32(48.5%)hadahistory

ofprevioussurgery.Allcasesweredoneinanoutpatientsetting.TheSetonwaskeptinsitu

for2–5months(2.6months)followedbyfistulectomyandsphincterrepair.Completehealing

wasachievedwithinapproximately3.6weeks(2–8weeks).Fifty-onepatientswerefollowed

upsuccessfullyforoneyear.Twopatientshadtemporaryflatusincontinencewhichhad

resolvedover2–3months.Recurrencehadoccurredin2(3.9%)patients.

Conclusion:Transsphinctericandcomplexfistulascansafelybeoperatedonasdaycase

surgerieswithhighpatientsatisfactionandlesscomplicationinthepopulationwestudied.

rightsreserved.

Cirurgia

de

fístula

anal

em

regime

ambulatorial:

a

experiência

Dubai

Palavras-chave:

Fístulaanal

Proctologia

Cirurgiaambulatorial

Cirurgiasempernoitehospitalar

r

e

s

u

m

o

Objetivo:Determinarsecirurgiasparafístulastransesfincterianaseparafistulaeinano

com-plexaspodemserrealizadascomseguranc¸aemambienteambulatorial,sempernoitedo

pacientenohospital.

Método:Trata-sedeumestudoretrospectivode66pacientescomfístulastransesfincterianas

efístulasanaiscomplexas,inicialmentetratadospreliminarmentecomsetondedrenagem,

seguidoporfistulectomiaereparodoesfíncter2–4mesesmaistarde,entremarc¸ode2011e

marc¸ode2014.Ospacientesforamreexaminadosnoambulatórioumasemana,trêsmeses

∗ _{Corresponding}_author_.

E-mail:[email protected](L.Al-Ozaibi).

http://dx.doi.org/10.1016/j.jcol.2015.01.005

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jcoloproctol(rioj).2015;35(1):42–45

43

eanoapósacirurgia,tendosidoobservadosparacomplicac¸õeserecorrências;casosde

incontinênciaforamanotadoseclassificadosdeacordocomoescoredaClevelandClinic.

Resultado: Vinteecincopacientes(38%)apresentaramfístulasaltas oucomplexase32

(48,5%)tinham históriadecirurgia prévia.Todosos casosforamtratadosem ambiente

ambulatorial.Osetonfoimantidoinsitudurante2–5meses(2,6meses),seguidopor

fis-tulectomiaereparodoesfíncter.Acuracompletaseconcretizouemcercade3,6semanas

(2–8semanas).Cinquentaeumpacientesforamacompanhadoscomsucessoaolongode

umano.Doispacientestiveramincontinênciatemporáriaparagases,resolvidaaolongode

2–3meses.Recorrênciaocorreuem2(3,9%)pacientes.

Conclusão: Fístulas transesfincterianas e fístulas complexas podem ser operadas com

seguranc¸acomocasosambulatoriais,sempermanênciahospitalarnoturna,comgrande

satisfaçãodopacienteemenoscomplicaçõesnapopulaçãoestudada.

Todososdireitosreservados.

Introduction

Most of the proctology cases nowadays are done as

day case surgeries without any significant complications.

Normally, ‘lay-open’ fistulotomies and fistulectomies for

inter-sphinctericfistulasaredoneasdaycases.High

trans-sphinctericandcomplicatedfistulas,whichrequireddivision

ofa large portion of the externalsphincter, were done as

inpatientsurgeries mainly due tothe fear of incontinence

andpostoperativepain.Theaimofsurgicaltreatmentofanal

fistulaistocurethediseasebypreventingrecurrencewhile

simultaneouslyensuringthatfecalcontinenceismaintained.

Theincidenceofpost-operativefecalincontinencefollowing

fistulectomyhas been reported to be 20.3%.1 _It_is _still _not

clearwhichapproachissafesttobeperformedasadaycase

surgeryintermsofriskofimmediateorearlypost-operative

complications,asthosecomplicationscouldaffect the

out-comeofthesurgery.Theoptimaltreatmentofanalfistulas

shouldincludeminimalcomplications,lowrecurrencerates,

nohospitaladmissionsandnegligiblepatientinconveniences.

Theaimofthisstudyistopresentanexperienceoftreating

fistula-in-anoinanoutpatientsetting.

Method

Datawerecollectedfromrecordsof66patientswho

under-wentpreliminarySeton placementfollowedbyfistulectomy

andsphincterrepair2–4monthslaterbetweenMarch2011and

March2014.FistulaswerecharacterizedusingParks’

Classifi-cation.Perianalfistulasweredefinedascomplexiftheyhad

multipleexternalopenings,highfistulasiftheyhadan

inter-nalopeningatthelevelofthedentatelineandlowfistulasif

theyhadaninternalopeningbelowthedentateline.Patients

withconcomitantanalpathologyorinflammatorybowel

dis-easewereexcludedfromthestudy.Lowfistulas,whichwere

treatedbythe lay open technique, were alsoexcluded. All

patientshadanASAphysicalstatusclassificationoflessthan

3.

Theprocedurewas performedundergeneralanesthesia

withthepatientinlithotomyposition.Afterinitialevaluation,

theexternalandinternalopeningswerelocatedusingaprobe

andairinjectionalongthetract.AlooseSetonwasinserted

under general anesthesia using 2 braided, non-absorbable

sutures(4/0prolene),whichwereloopedaroundthefistula

tract.Itwasnottightenedatanytimeduringthefollow-up

norwasitremoveduntilthetimeoffistulectomy.Twotofour

monthslaterthecompletefistulawasexcisedwith

immedi-aterepairofthesphinctersandthewoundwaskeptopen.

Setoninsertionandfistulectomyweredoneasdaycases.The

patientswereobservedfor4–6handwerethendischarged.

Patientswerereviewedattheclinic1week,3monthsand

1yearpostoperatively.Duringthefollow-upperiod,details

ofhealing(i.e.absenceofdischarge),recurrence,and

compli-cationswere gathered.Continencewasevaluatedaccording

totheClevelandClinicscore.2_The_excised_fistulas_were_sent

forhistopathologytoruleoutinflammatoryboweldiseaseand

cancer.

Finally,thedatawereanalyzedusingIBMSPSSSTATISTICS

BASE21.

Results

Afterobtainingtheethicalcommitteeapproval, 66patients

with transsphincteric and complex anal fistulaswho were

managed withpreliminarylooseSetonfollowedby

fistulec-tomyandsphincterrepair,werereviewed.Fifty-nine(89.4%)of

thepatientsweremaleand7(10.6%)werefemale.Theoverall

meanagewas38.5(range25–61)years.Thetypesoffistulas

aredepictedinTable1.

Thirty-two (48.5%) patients gave a history of previous

surgery, 27 ofwhichhad incision and drainageofperianal

abscessesand5ofwhichhadpreviousfistulasurgeries.The

Table1–Typeoffistulas.

Typeoffistula Number Percent

Lowtranssphincteric 41 62

Hightranssphincteric 13 20

Complex 12 18

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44

Setonwasinsertedandkeptinsitufor2–5months(average2.6

months).Thesecondprocedureconsistedoffistulectomyand

sphincterrepair;allcasesweredoneasdaycasesandwere

performedundergeneralanesthesia.

During the follow-up period there were no

signifi-cant complications. Four (6%) patients experienced

signifi-cant post-operativepain, which required oralnonsteroidal

anti-inflammatorymedications andacetaminophens.Three

patients(4.5%)hadminimal bleedingwhich wascontrolled

bypressuredressingalone.Thecompletehealingtimeofthe

woundwas between2and 8weeks(average 3.5weeks) in

whichnomoredressingwasrequired.

Fifty-one(77.3%)patientscompletedafollowupof12–24

months (mean 16 months); they were assessed for

recur-renceandpresenceofincontinence.Whiletwopatients(3.9%)

reported atransient incontinence ofgasin the immediate

postoperativeperiod(scores3and 4,respectivelyaccording

tothe Cleveland Incontinence Score), theyhad completely

recoveredby3monthspostoperative.Thefistulaswere

com-pletelycuredin49(96.1%)ofthepatients.Recurrenceoccurred

in only two patients (3.9%); one of them was re-operated

usingthesameprocedure–looseSetonfor4monthsfollowed

byfistulectomyandsphincterrepair–forwhichduringthe

follow-uphedidnothaveanyremainingsignsofrecurrence,

whiletheother patient wentthrough another fistulectomy

withoutpreliminarySetoninanotherhospitalandcontinued

tohaverecurrence.

Patientswereinterviewedfortheirsatisfactionofthe

pro-cedurebeingdone asadaycaseand 64outofthe66were

satisfied.Twopatientspreferredthesurgerytobedoneinan

inpatientsettinginordertoreceivepostoperativeanalgesia

andrest.

Discussion

Inabusy hospitalwheretheshortage ofbeds isthe main

issue,the admissionofsuchcaseswasincreasingtheload

andthecostonhospitalresources.Inaddition,thenumberof

casesthatwouldhavebeenoperatedonwouldhavebeenfar

lessduetothelongwaitinglistforadmission.Before2011,all

casesoffistulasweredoneasinpatientandbetweenJanuary

2010andFebruary2011;only8fistulacaseswereadmittedand

operatedon.Thenumberofadmissiondaysvariesbetween2

and5days(ameanof3days).

Thestrategytooperatetranssphinctericandcomplexanal

fistulasasdaycasesstartedinMarch2011,andupuntilMarch

2014the numberofcasesdone onanoutpatientbasishad

increasedto66cases. Thisstrategyhad aidedthe hospital

managementtoimprovethebedoccupancyrateandinturn,

thecosteffectiveness.

A day care clinic is defined as an institution in which

patientsundergoelectiveoperationsonthedayoftheir

admis-sionandaredischargedwithin24hofthesurgery.3

Nowadays,proctologic conditions are increasingly

man-agedonanoutpatientbasis.Thishasbeenassociatedwitha

successfulpostoperativeoutcome.Severalfactorsplayarole

inthisrecentincrease,suchasmodernanestheticprocedures,

shortoperationtimeand alowcomplicationrates. Careful

patientselectionremainsthekeytoasuccessfuloutcome.

InColoproctology, thehigh incidenceofanorectal

disor-ders and the economicimpact ofvarious typesofsurgical

treatmenthavemotivatedattemptstodiscoverpossibilities

ofoutpatientmanagement.While30–50%ofallsurgeriescan

besafelydoneinoutpatientsectors,thisratereaches90%in

thecaseofanorectaloperations.4_Among_all_the_surgical

spe-cialties, anorectalsurgeryhasbenefitedthe mostfrom the

useoflocalanesthesiaandambulatorysurgery.Many

stud-iesagreethattheoutpatientenvironmentissafeforanorectal

surgery.5

Despite thesocial,economicand medicaladvantagesof

ambulatory proctologic surgery, the majority of surgeons

are reluctant to put this into practice for several reasons

suchasdifficultyinassuringadequate paincontrol,fearof

postoperativecomplications,andthelackofpatient’s

dissem-ination knowledge about safety and feasibilityof daycare

surgeries.6

Several studies have been conducted to analyze the

feasibility of day case surgeries in proctology. Different

procedures have been tested such as haemorrhoidectomy,

sphincterotomy,anorectalpolypexcisionandpilonidalsinus

surgery.

In regards to fistula-in-ano surgeries, its feasibility has

beenproveninseveralstudies.InthestudybyCarditelloetal.7

172 fistulas-in-anohavebeenoperatedoninanoutpatient

setting.Thirty-fourpercentofpatientswerehospitalizedfor

24h,whiletheremainingwashospitalizedfor7–10h.No

con-siderable complicationshave beendocumented apart from

postoperativepain.

InapaperwrittenbyGuptaetal.,themeanhospitalstay

was7.3h(range4–21h)whiletheoverallcomplicationratewas

2.5%, whichincludedbleeding, urinaryretention,infection,

continenceproblemsandrecurrence.8

Conclusion

Transsphincteric and complex anal fistulas can be treated

safelyandeffectivelyinanoutpatientsettingwithless

com-plicationandwithhighpatientsatisfactioninthepopulation

westudied.Itwasproventobecosteffectiveandimproved

thehospitalcapacity.

Conflicts

of

interest

Theauthorsdeclarenoconflictsofinterest.

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2.JorgeJM,WexnerSD.Etiologyandmanagementoffecal incontinence.ColonRectum.1993;36:77–97.

3.MassonJL.OutpatienthemorrhoidectomyusingtheCO2laser.

JChir.1990;127:227–9.

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5.BergantinoA.Thesurgicaltherapyofhaemorrhoidal pathologyperformedinone-daysurgery.MinervaChir. 1999;54:485–90.

6.KolbertG,KirschJ.Outpatientsurgeryinproctology.WienMed Wochenschr.2004;154:73–5.

7.CarditelloA,MeduriF,CardilloP,MuleV,LaRoccaT,CaminitiF. Proctologicday-surgery:resultsof2000surgicalinterventions. ChirItal.2001;53:219–24.