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External sphincter-sparing anal fistulotomy (ESSAF): a simplified technique for the treatment of fistula-in-ano

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Abstract

Background

Fistula-in-ano due to cryptoglandular disease is a common condition. While a simple anal fistula can be treated successfully by a fistulotomy, the risk of potential damage to the anal sphincters and subsequent poor functional outcomes persist in a large portion of patients with complex fistulae. Several sphincter-preserving treatment procedures have been described for complex fistulae over the past 3 decades, with variable results and complication rates, and no procedure is proven to be superior to the others. We developed external sphincter-sparing anal fistulotomy (ESSAF), a reproducible simple modification of the ligation of intersphincteric fistula tract (LIFT) technique for the treatment of complex fistula-in-ano.. The aim of the present study was to describe the technique and our outcomes.

Methods

This was a retrospective review of all patients who underwent ESSAF for a complex anal fistula at our institution from January 2014 to December 2019. The primary outcome measure of this study was the primary fistula healing rate. Secondary outcome measures included fecal and/or gas incontinence and postoperative complications. During the ESSAF procedure, the mucosa and skin overlying the fistula tract are incised to allow complete exposure of the sphincter complex. Then the internal sphincter muscle fibers overlying the tract are divided and the tract is meticulously curetted and debrided. Next, the internal opening of the tract traversing the external sphincter muscle is suture-ligated with absorbable sutures. Then, a minimal amount of mucosa is advanced and the incision is partially closed with absorbable sutures, while its external portion is left open for drainage.

Results

Fifty-nine patients [43 males, median age was 50 years (range 36–63 years)] underwent ESSAF for complex anal fistula during the study period. Mean follow-up was 12 ± 14.7 months. Of the 59 patients, 42 (71.2%) experienced fistula closure, with a median healing time of 8 weeks (IQR 4–16 weeks). None of the patients developed significant anal incontinence following the procedure. One patient (1.7%) suffered from soiling and another patient (1.7%) developed postoperative bleeding. There were no infectious complications. Of the 17 patients (28.8%) who failed to heal successfully, 9 (15.2%) did not heal primarily and 8 (16%) experienced recurrence after complete healing. Thirteen (76%) of these patients underwent reoperation with complete recovery after ESSAF (n = 4), fistulotomy (n = 8) or endorectal advancement flap (ERAF) (n = 1). Overall ESSAF initiated recovery in 93.2% of the patients.

Conclusions

ESSAF is a feasible, safe, reproducible and effective sphincter-sparing procedure for the treatment of complex anal fistulae.

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Availability of data and material

The primary investigator is holding original data.

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Funding

This study was financed by an academic research fund at Hadassah Hebrew University Medical Center and was not supported by any other grant from any other source.

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Authors and Affiliations

  1. Department of General Surgery, Hadassah Medical Organization and Faculty of Medicine, Hebrew University of Jerusalem, POB 12000, Jerusalem, 91120, Israel

    S. Y. Parnasa, B. Helou, I. Mizrahi, R. Gefen, M. Abu-Gazala, A. J. Pikarsky & N. Shussman

Authors
  1. S. Y. Parnasa
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  2. B. Helou
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  3. I. Mizrahi
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  4. R. Gefen
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  5. M. Abu-Gazala
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  6. A. J. Pikarsky
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  7. N. Shussman
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Contributions

SYP: study design, data acquisition, data analysis, manuscript writing. BH: study design, data acquisition. IM: study design, data analysis, critically reviewing manuscript. RG: study design, data acquisition, critically reviewing manuscript. MAG: study design, data analysis, critically reviewing manuscript. AJP: study conception and design, data analysis, critically reviewing manuscript. NS: study conception and design, data acquisition, data analysis, manuscript writining and revising.

Corresponding author

Correspondence to N. Shussman.

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None of the authors has any relevant conflicts of interests.

Ethics approval

The study protocol was approved by the Hadassah Medical Organization Institutional Review Board (study approval number: 0445-20-HMO).

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Parnasa, S.Y., Helou, B., Mizrahi, I. et al. External sphincter-sparing anal fistulotomy (ESSAF): a simplified technique for the treatment of fistula-in-ano. Tech Coloproctol 25, 1311–1318 (2021). https://doi.org/10.1007/s10151-021-02525-5

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