Skip to main content

Anal fistula surgery

Factors associated with recurrence and incontinence

Abstract

PURPOSE: This study was undertaken to assess results of surgery for fistula-in-ano and identify risk factors for fistula recurrence and impaired continence. METHODS: We reviewed the records of 624 patients who underwent surgery for fistula-in-ano between 1988 and 1992. Follow-up was by mailed questionnaire, with 375 patients (60 percent) responding. Mean follow-up was 29 months. Fistulas were intersphincteric in 180 patients, transsphincteric in 108, suprasphincteric in 6, extrasphincteric in 6, and unclassified in 75. Procedures included fistulotomy and marsupialization (n=300), seton placement (n=63), endorectal advancement flap (n=3), and other (n=9). Factors associated with recurrence and incontinence were analyzed by univariate and multivariate regression analysis. RESULTS: The fistula recurred in 31 patients (8 percent), and 45 percent complained of some degree of postoperative incontinence. Factors associated with recurrence included complex type of fistula, horseshoe extension, lack of identification or lateral location of the internal fistulous opening, previous fistula surgery, and the surgeon performing the procedure. Incontinence was associated with female sex, high anal fistula, type of surgery, and previous fistula surgery. CONCLUSIONS: Surgical treatment of fistula-in-ano is associated with a significant risk of recurrence and a high risk of impaired continence. Degree of risk varies with identifiable factors.

This is a preview of subscription content, access via your institution.

References

  1. 1.

    Parks AG, Gordon PH, Hardcastle JD. A classification of fistula-in-ano. Br J Surg 1976;63:1–12.

    Google Scholar 

  2. 2.

    Garcia-Aguilar J, Rothenberger DA. Anal and perianal infections. In: Howard RJ, Simmons RL, eds. Surgical Infectious Diseases. 3rd ed. Norwalk: Appleton & Lange, 1995.

    Google Scholar 

  3. 3.

    Goldberg SM, Garcia-Aguilar J. The cutting seton. In: Phillips R, Lunniss P, eds. Anal Fistula. London: Chapman & Hall (in press).

  4. 4.

    Stone JM, Goldberg SM. The endorectal advancement flap procedure. Int J Colorectal Dis 1990;5:232–5.

    Google Scholar 

  5. 5.

    Parks AG, Stitz RW. Symposium: fistula-in-ano. The treatment of high fistula-in-ano. Dis Colon Rectum 1976;19:487–99.

    Google Scholar 

  6. 6.

    van Tets WF, Kuijpers HC. Continence disorders after anal fistulotomy. Dis Colon Rectum 1994;37:1194–7.

    Google Scholar 

  7. 7.

    Khubchandani IT, Reed JF. Sequelae of internal sphincterotomy for chronic fissure in ano. Br J Surg 1989;76:431–4.

    Google Scholar 

  8. 8.

    Reznick RK, Bailey HR. Closure of the internal opening for treatment of complex fistula-in-ano. Dis Colon Rectum 1988;31:116–8.

    Google Scholar 

  9. 9.

    Mann CV, Clifton MA. Re-routing of the track for the treatment of high anal and anorectal fistulae. Br J Surg 1985;72:134–7.

    Google Scholar 

  10. 10.

    Oh C. Management of high recurrent anal fistula. Surgery 1983;93:330–2.

    Google Scholar 

  11. 11.

    Aguilar PS, Plasencia G, Hardy TG Jr, Hartmann RF, Stewart WR. Mucosal advancement in the treatment of anal fistula. Dis Colon Rectum 1985;28:496–8.

    Google Scholar 

  12. 12.

    Wedell J, Meier zu Eissen P, Banzhaf G, Kleine L. Sliding flap advancement for the treatment of high level fistulae. Br J Surg 1987;74:390–1.

    Google Scholar 

  13. 13.

    Shemesh EI, Kodner IJ, Fry RD, Neufeld DM. Endorectal sliding flap repair of complicated anterior anoperineal fistulas. Dis Colon Rectum 1988;31:22–4.

    Google Scholar 

  14. 14.

    Kodner IJ, Mazor A, Shemesh EI, Fry RD, Fleshman JW, Birnbaum EH. Endorectal advancement flap repair of rectovaginal and other complicated anorectal fistulas. Surgery 1993;114:682–90.

    Google Scholar 

  15. 15.

    Thomson JP, Ross AH. Can the external anal sphincter be preserved in the treatment of trans-sphincteric fistula-in-ano? Int J Colorectal Dis 1989;4:247–50.

    Google Scholar 

  16. 16.

    Kennedy HL, Zegarra JP. Fistulotomy without external sphincter division for high anal fistulae. Br J Surg 1990;77:898–901.

    Google Scholar 

  17. 17.

    Matos D, Lunniss PJ, Phillips RK. Total sphincter conservation in high fistula-in-ano: results of a new approach. Br J Surg 1993;80:802–4.

    Google Scholar 

  18. 18.

    Parkash S, Lakshmiratan V, Gajendran V. Fistula-in-ano: treatment by fistulectomy, primary closure and reconstitution. Aust N Z J Surg 1985;55:23–7.

    Google Scholar 

  19. 19.

    Kuypers HC. Use of the seton in the treatment of extrasphincteric anal fistula. Dis Colon Rectum 1984;27:109–10.

    Google Scholar 

  20. 20.

    Ramanujam PS, Prasad ML, Abcarian H. The role of seton in fistulotomy of the anus. Surg Gynecol Obstet 1983;157:419–22.

    Google Scholar 

  21. 21.

    Williams JG, MacLeod CA, Rothenberger DA, Goldberg SM. Seton treatment of high anal fistulae. Br J Surg 1991;78:1159–61.

    Google Scholar 

  22. 22.

    Pearl RK, Andrews JR, Orsay CP,et al. Role of the seton in the management of anorectal fistulas. Dis Colon Rectum 1993;36:573–9.

    Google Scholar 

  23. 23.

    Culp CE. Use of penrose drains to treat certain anal fistulas: a primary operative seton. Mayo Clin Proc 1984;59:613–7.

    Google Scholar 

  24. 24.

    Christensen A, Nilas L, Christiansen J. Treatment of transsphincteric anal fistulas by the seton technique. Dis Colon Rectum 1986;29:454–5.

    Google Scholar 

  25. 25.

    Ustynoski K, Rosen L, Stasik J, Riether R, Sheets J, Khubchandani IT. Horseshoe abscess fistula: seton treatment. Dis Colon Rectum 1990;33:602–5.

    Google Scholar 

  26. 26.

    Hanley PH. Rubber band seton in the management of abscess-anal fistula. Ann Surg 1978;187:435–7.

    Google Scholar 

  27. 27.

    Seow-Choen F, Phillips RK. Insights gained from the management of problematical anal fistulae at St. Mark's Hospital, 1984–88. Br J Surg 1991;78:539–41.

    Google Scholar 

  28. 28.

    Cirocco WC, Reilly JC. Challenging the predictive accuracy of Goodsall's rule for anal fistulas. Dis Colon Rectum 1992;35:537–42.

    Google Scholar 

  29. 29.

    Sultan AH, Kamm MA, Hudson CN, Thomas JM, Bartram CI. Anal-sphincter disruption during vaginal delivery. N Engl J Med 1993;329:1905–11.

    Google Scholar 

Download references

Author information

Affiliations

Authors

Additional information

Read at the meeting of The American Society of Colon and Rectal Surgeons, Orlando, Florida, May 8 to 13, 1994.

About this article

Cite this article

Garcia-Aguilar, J., Belmonte, C., Wong, W.D. et al. Anal fistula surgery. Dis Colon Rectum 39, 723–729 (1996). https://doi.org/10.1007/BF02054434

Download citation

Key words

  • Fistulo-in-ano
  • Fistulotomy
  • Anal fistula
  • Functional results
  • Recurrence
  • Incontinence
  • Seton