Skip to main content

Advertisement

SpringerLink
Log in

Fistulotomy and primary sphincteroplasty for anal fistula: long-term data on continence and patient satisfaction

  • Original Article
  • Published:
Techniques in Coloproctology Aims and scope Submit manuscript

Abstract

Background

The aim of this study was to evaluate the safety and long-term efficacy of fistulotomy and primary sphincteroplasty (FIPS). Secondary endpoints were its impact on postoperative continence status and patients’ satisfaction.

Methods

A retrospective study was conducted on patients with cryptoglandular anal fistula (AF) who had FIPS between June 2006 and May 2017. Patients were evaluated with standardized telephone interviews and clinical/instrumental assessment. Main outcome measures included fistula healing rate, continence status, and patient satisfaction. Incontinence was defined as an inability to hold either gas, liquid, or solid stools, as well as postdefecation soiling, and was measured by the Cleveland Clinic fecal incontinence score. Patient satisfaction was evaluated by an 11-point numeric rating scale.

Results

There were 203 patients (139 males; mean age: 48.7 years) who had FIPS. The overall healing rate was 93% (188 patients) with a mean follow-up period of 56 ± 31 months. Half of the total cohort (51%) had a complex fistula. Preoperatively, 8 (4%) patients complained of postdefecation soiling and 2 (1%) of gas incontinence. Postoperatively, 26 (13%) patients had continence impairment (de novo n = 24), mainly consisting of postdefecation soiling (10%). In univariate analysis, patients with recurrent (RR 6.153 95% CI 2.097–18.048; p = 0.002) or complex (RR 3.005 95% CI 1.203–7.506; p = 0.012) AF and those with secondary tracts (RR 8.190 95% CI 2.188–30.654; p = 0.004) or previous set on drainage (RR 5.286 95% CI 2.235–12.503; p = 0.0001) were at higher risk of incontinence. In multivariate analysis, no significant predictors were found, although fistula complexity approached statistical significance (RR 5.464 95% CI 0.944–31.623; p = 0.050). The mean patient satisfaction numeric rating scale was 9.3 ± 1.6. Lower satisfaction rates were found in patients with transphincteric (p = 0.011) or complex (p = 0.0001) AF, with secondary tracts (p = 0.041) or previous seton drainage (p = 0.008), and in those with postoperative continence impairment (p = 0.0001). Postoperative onset of incontinence was the only significant factor in multivariate analysis (p = 0.0001).

Conclusions

FIPS should be considered a valid therapeutic option for selected AF. However, the risk of postoperative minor fecal incontinence exists, and should be discussed during preoperative patient counselling.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2

Similar content being viewed by others

References

  1. Shawki S, Wexner SD (2011) Idiopathic fistula-in-ano. World J Gastroenterol 17:3277–3285

    Article  PubMed  PubMed Central  Google Scholar 

  2. Limura E, Giordano P (2015) Modern management of anal fistula. World J Gastroenterol 21:12–20

    Article  PubMed  PubMed Central  Google Scholar 

  3. Sugrue J, Mantilla N, Abcarian A, Kochar K, Marecik S, Chaudhry V et al (2017) Sphincter-sparing anal fistula repair: are we getting better? Dis Colon Rectum 60:1071–1077

    Article  PubMed  Google Scholar 

  4. Wallin UG, Mellgren AF, Madoff RD, Goldberg SM (2012) Does ligation of the intersphincteric fistula tract raise the bar in fistula surgery? Dis Colon Rectum 55:1173–1178

    Article  PubMed  Google Scholar 

  5. Oldfield F, Gilbert T, Skaife P (2016) Is modern management of fistula-in-ano acceptable? Br J Hosp Med (Lond). 77:388–393

    Article  Google Scholar 

  6. Tozer PJ, Lung P, Lobo AJ, Sebastian S, Brown SR, Hart AL, Fearnhead N (2018) ENiGMA Collaboration. Review article: pathogenesis of Crohn’s perianal fistula-understanding factors impacting on success and failure of treatment strategies. Aliment Pharmacol Ther 48:260–269

    Article  CAS  PubMed  Google Scholar 

  7. Garg P (2018) Is fistulotomy still the gold standard in present era and is it highly underutilized?: an audit of 675 operated cases. Int J Surg. 56:26–30

    Article  PubMed  Google Scholar 

  8. Tozer P, Sala S, Cianci V, Kalmar K, Atkin GK, Rahbour G et al (2013) Fistulotomy in the tertiary setting can achieve high rates of fistula cure with an acceptable risk of deterioration in continence. J Gastrointest Surg. 17:1960–1965

    Article  CAS  PubMed  Google Scholar 

  9. Göttgens KW, Janssen PT, Heemskerk J, van Dielen FM, Konsten JL, Lettinga T et al (2015) Long-term outcome of low perianal fistulas treated by fistulotomy: a multicenter study. Int J Colorectal Dis 30:213–219

    Article  PubMed  Google Scholar 

  10. Visscher AP, Schuur D, Roos R, Van der Mijnsbrugge GJ, Meijerink WJ, Felt-Bersma RJ (2015) Long-term follow-up after surgery for simple and complex cryptoglandular fistulas: fecal incontinence and impact on quality of life. Dis Colon Rectum 58:533–539

    Article  CAS  PubMed  Google Scholar 

  11. Parkash S, Lakshmiratan V, Gajendran V (1985) Fistula-in-ano: treatment by fistulectomy, primary closure and reconstitution. Aust N Z J Surg 55:23–27

    Article  CAS  PubMed  Google Scholar 

  12. 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

    Article  CAS  PubMed  Google Scholar 

  13. Jorge JM, Wexner SD (1993) Etiology and management of fecal incontinence. Dis Colon Rectum 36:77–97

    Article  CAS  PubMed  Google Scholar 

  14. Ratto C, Litta F, Parello A, Zaccone G, Donisi L, De Simone V (2013) Fistulotomy with end-to-end primary sphincteroplasty for anal fistula: results from a prospective study. Dis Colon Rectum 56:226–233

    Article  PubMed  Google Scholar 

  15. Ommer A, Wenger FA, Rolfs T, Walz MK (2008) Continence disorders after anal surgery–a relevant problem? Int J Colorectal Dis 23:1023–1031

    Article  CAS  PubMed  Google Scholar 

  16. Seyfried S, Bussen D, Joos A, Galata C, Weiss C, Herold A (2018) Fistulectomy with primary sphincter reconstruction. Int J Colorectal Dis 33:911–918

    Article  PubMed  Google Scholar 

  17. van der Hagen SJ, Baeten CG, Soeters PB, van Gemert WG (2006) Long-term outcome following mucosal advancement flap for high perianal fistulas and fistulotomy for low perianal fistulas: recurrent perianal fistulas: failure of treatment or recurrent patient disease? Int J Colorectal Dis 21:784–790

    Article  PubMed  Google Scholar 

  18. Lauretta A, Falco N, Stocco E, Bellomo R, Infantino A (2018) Anal Fistula Laser Closure: the length of fistula is the Achilles’ heel. Tech Coloproctol 22:933–939

    Article  CAS  PubMed  Google Scholar 

  19. Romaniszyn M, Walega P (2017) Video-assisted anal fistula treatment: pros and cons of this minimally invasive method for treatment of perianal fistulas. Gastroenterol Res Pract. 2017:9518310

    Article  PubMed  PubMed Central  Google Scholar 

  20. Dudding TC, Vaizey CJ, Kamm MA (2008) Obstetric anal sphincter injury: incidence, risk factors, and management. Ann Surg 247:224–237

    Article  PubMed  Google Scholar 

  21. Cook TA, Keane DP, Mortensen NJ (1999) Is there a role for the colorectal team in the management of acute severe third-degree vaginal tears? Colorectal Dis 1:263–266

    Article  CAS  PubMed  Google Scholar 

  22. Gilliland R, Altomare DF, Moreira H Jr, Oliveira L, Gilliland JE, Wexner SD (1998) Pudendal neuropathy is predictive of failure following anterior overlapping sphincteroplasty. Dis Colon Rectum 41:1516–1522

    Article  CAS  PubMed  Google Scholar 

  23. Perez F, Arroyo A, Serrano P, Sánchez A, Candela F, Perez MT 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

    Article  PubMed  Google Scholar 

  24. Abramowitz L, Soudan D, Souffran M, Bouchard D, Castinel A, Suduca JM et al (2016) Groupe de Recherche en Proctologie de la Société Nationale Française de Colo-Proctologie and the Club de Réflexion des Cabinets et Groupe d’Hépato-Gastroentérologie. The outcome of fistulotomy for anal fistula at 1 year: a prospective multicentre French study. Colorectal Dis 18:279–285

    Article  CAS  PubMed  Google Scholar 

  25. Jordán J, Roig JV, García-Armengol J, García-Granero E, Solana A, Lledó S (2010) Risk factors for recurrence and incontinence after anal fistula surgery. Colorectal Dis 12:254–260

    Article  PubMed  Google Scholar 

Download references

Acknowledgements

We thank Dr. Franziska Michaela Lohmeyer for English language editing of this manuscript.

Author information

Authors and Affiliations

  1. Proctology Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Largo A. Gemelli, 8, 00168, Rome, Italy

    F. Litta, A. Parello, V. De Simone, U. Grossi, R. Orefice & C. Ratto

  2. Università Cattolica del Sacro Cuore, Rome, Italy

    C. Ratto

Authors
  1. F. Litta
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. A. Parello
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. V. De Simone
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. U. Grossi
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. R. Orefice
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. C. Ratto
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

FL and CR contributed substantially to the conception and design of the study. FL, AP, VDS, UG, and RO provided data collection and contributed to literature review. FL conducted statistical analysis and wrote the manuscript. All authors contributed in the processes discussing findings, drawing conclusions, as well as the completion of the manuscript. All authors read and approved the final manuscript.

Corresponding author

Correspondence to F. Litta.

Ethics declarations

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical approval

The study was conducted in accordance with the Declaration of Helsinki. It received approval form our local Ethics Committee.

Informed consent

All patients signed a written consent.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

This manuscript was a poster presentation at the “International Conference Anal Fistula”, Rome, Italy, July, 2–3 2018.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Litta, F., Parello, A., De Simone, V. et al. Fistulotomy and primary sphincteroplasty for anal fistula: long-term data on continence and patient satisfaction. Tech Coloproctol 23, 993–1001 (2019). https://doi.org/10.1007/s10151-019-02093-9

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s10151-019-02093-9

Keywords

Search

Navigation