Open fistulectomy with sphincter fixation for anal fistula

doi:10.4236/ojgas.2013.34037

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Open Journal of Gastroenterology, 2013, 3, 223-226 OJGas

doi:10.4236/ojgas.2013.34037 Published Online August 2013 (http://www.scirp.org/journal/ojgas/)

Open fistulectomy with sphincter fixation for anal fistula

Tatsuya Abe1*, Masao Kunimoto1, Yoshikazu Hachiro1, Yoshiaki Ebisawa1, Houhei Hishiyama1,

Seishu Abe2

1Department of Proctology, Kunimoto Hospital, Asahikawa, Japan

2Department of Plastic Surgery, Kunimoto Hospital, Asahikawa, Japan

Email: *[email protected]

Received 1 June 2013; revised 1 July 2013; accepted 20 July 2013

which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

ABSTRACT

Purpose: This study aimed to report clinical data and

recurrence rates in patients with anterolateral low

fistulas who underwent open fistulectomy with sphinc-

ter fixation. Methods: The study group consisted of

133 consecutive patients with anterolateral, low in-

tersphincteric, or low trans-sphincteric fistulas who

had undergone open fistulectomy with sphincter fixa-

tion between January 2006 and December 2010. This

procedure involves complete removal of the fistula

tract by incision of anal sphincters, followed by fixa-

tion of the sphincter muscles. Results: Success was

achieved in 127 (95.5%) patients with a median fol-

low-up time of 12 months. Anal fistula recurred in 4

cases (3%). Non-healing fistula with persistent anal

discharge developed in 2 patients. Maximal resting

pressure, but not maximal squeeze pressure, was sig-

nificantly decreased after surgery. Five patients (4%)

developed temporary anal incontinence after surgery.

Conclusions: Open fistulectomy with sphincter fixa-

tion was effective for the management of patients

with anterolateral low fistula in this study. The high

success rate suggests that this procedure is a reason-

able option in this gro up of patients.

Keywords: Anal Fistula; Fistulectomy; Sphincter

Fixation; Fecal Incontinence

1. INTRODUCTION

Anal fistula is a devastating problem that most com-

monly occurs in healthy subjects, with cryptoglandular

infection being the most widely accepted etiological fac-

tor [1]. On the basis of their anatomical course relative to

the sphincter complex, cryptoglandular fistulas are cate-

gorized as intersphincteric, trans-sphincteric, suprasphinc-

teric, and extrasphincteric types [2]. The most common

type is intersphincteric, followed by transsphincteric [2,

3]. Anal fistulas can also be classified as simple or com-

plex. The major type is simple, which includes low in-

tersphincteric and low trans-sphincteric fistulas that cross

<30% of the external sphincter [4].

Most fistulas have been conventionally treated by fis-

tulotomy or fistulectomy, which have both proven to be

effective [5]. However, these techniques, even for simple

fistulas, result in some form of incontinence in approxi-

mately 12% - 39% of patients [3,5,6]. In most patients,

the internal opening of the fistula is located along the

posterior midline [7]. Fistulas located laterally are sig-

nificantly associated with recurrence, and those located

along the anterior midline are associated with inconti-

nence [3,8]. Anterolateral localization results in greater

postoperative anal deformity when fistulotomy or fis-

tulectomy is used to excise the fistula [9]. Therefore,

more attention is needed for the management of anter-

olateral fistulas.

Open fistulectomy with sphincter fixation (OFSF) is

another option for the management of anterolateral fistu-

las. The procedure is based on the premise that removal

of the chronic epithelialized tract will allow healing by

secondary intention of healthier tissue, and sphincter

fixation may result in less deformity and prevention of

incontinence compared with leaving the sphincters di-

vided. However, this is a more extensive procedure, and

there is lack of support for it in the literature. Th e aim of

this study was to evaluate clinical data and recurrence

rates in patients with anterolateral fistulas who under-

went OFSF.

2. PATIENTS AND METHODS

The study group consisted of 133 consecutive patients

with anterolate ral, low intersphincteric, or low transphinc-

teric fistulas who had undergone OFSF between January

2006 and December 2010 at our institution. The median

*Corresponding a uthor.

Published Online August 2013 in SciRes. http://www.scirp.org/journal/ojgas

T. Abe et al. / Open Journal of Gastroenterology 3 (2013) 223-226

224

age of these 133 patients (122 males) was 42 years

(range, 16 - 87 years). All patients presented with chronic

fistula of the cryptoglandular origin. All had a history of

previous perineal suppuration drained surgically or spon-

taneously. Fistula tracks and internal opening were clini-

cally and endosonographically evaluated and were found

in the anterior quadrant in 89 (67%) and in the left or

right lateral quadrant in 44 (33%) patients.

OFSF was performed under caudal epidural anesthesia

in the prone jackknife position with the buttocks taped

widely apart. A suppository rather than an enema was

used to empty the rectum before surgery. The external

opening along with the fistula tract was circumscribed

and dissected using an electric cautery or Metzenbaum

scissors. Dissection was performed as deep into the

sphincter as possible. The internal opening was excised

using a Parks retracter to efface the anal canal. All tissues

between the internal and ex tern al open ing s were cut op en

by sphincterotomy, and all of the fistula tract was re-

moved. Both edges of the incised internal and external

anal sphincter (IAS and EAS, respectively) muscles were

slightly mobilized to ensure fixation without tension.

Next, interrupted 3-0 poliglecaprone was used to suture

the muscles to the base of the defect area after fistulec-

tomy (Figure 1). A simple layer of interrupted 3-0 poli-

glecapronesutures was used to marsupialize the proximal

edge of the anoderm to prevent postoperative bleeding.

Distal anoderm and perianal skin were left open to fa-

cilitate drainage. Postoperatively, the patients were ad-

ministered prophylactic oral antibiotics (cefaclor 750

mg/day) and oral analgesia (loxoprofen 180 mg/day) for

3 days, and the re were n o di etary restricti o ns.

A 5 mm diameter, 1-channel, solid-state catheter with

a microtipped transducer anorectalmanometry (ARM)

system (P-31; Star Medical Co., Tokyo, Japan) was used

to perform ARM before and 3 months after surgery. All

patients were examined in the left lateral position with

the hips flexed to 90˚. The maximal resting pressure

(MRP) and maximal squeeze pressure (MSP) were ana-

lyzed. Manometric data were expressed as means ± stan-

Figure 1. Detail of open fistulectomy with sphincter fixation.

(A) IO = internal opening, EO = external opening, IAS = inter-

nal anal sphincter, EAS = external anal sphincter; (B) Sphincter

division and total fistulectomy; (C) Both edges of the incised

IAS and EAS were sutured to the base of the defect area after

fistulectomy.

dard deviations. Wilcoxon signed-rank test was used to

test statistical significance. Statistical significance was

set at p < 0.05.

This study was a retrospective review of existing

clinical data prospectively collected on a hospital anal

physiology unit computer database. The study was ap-

proved by the research and ethics committee of Kuni-

moto Hospital, and all patients gave written informed

consent.

3. RESULTS

The median operative time was 21 min (range, 10 - 42

min). There were no postoperative deaths. Postoperative

bleeding occurred in 2 patients (1.5%) and required

stitching of the bleeding area, which was sited at the

edge of the wound. No significant dehiscence of the

sphincter fixation occurred. Of the 133 patients, 127

(95.5%) healed completely and did not require any fur-

ther surgical treatment, with a median follow-up of 12

months (range, 2 - 62 months). Anal fistula recurred in 4

cases (3%). Recurrence in these patients was observed at

3, 6, 8, and 12 months. Non-healing fistula with persis-

tent anal discharge developed in 2 patients (1.5%); 1 of

them with persistent symptoms had an identifiable fistula

tract connecting the anal canal to skin, and the external

opening failed to close, with infected granulation in the

other pati e nt.

Seventy two (54%) of the 133 patients underwent

ARM before and after surgery. MRP was significantly

decreased after surgery, but not MSP (Table 1). Clini-

cally, 5 patients (4%) developed temporary anal inconti-

nence after surgery. Solid stool incontinence was not

present, but liquid stool incontinence and flatus were

observed in 2 and 3 males, respectively; all had recov-

ered in <6 months.

4. DISCUSSION

The overall rate of fistula persistence or recurrence was

4.5% and temporary minor incontinence was 4%, which

showed the effectiveness of OFSF in the management of

anterolateral low fistulas in these patients. The manage-

ment of anal fistulas includes 3 main goals: to cure the

fistula, to prevent or minimize recurrence, and to retain

continence. Since OFSF allows recognition of the full

length of an anal fistula via direct visualization enabled

Table 1. Changes in maximal resting and squeeze pressure (n =

72).

Preoperative Postoperative p value

MRP (mmHg)77.6 ± 18.0 65.8 ± 18.1 <0.05

MSP (mmHg)239 ± 86.8 249 ± 99.4 0.41

MRP = maximal resting pressure; M SP = maximal squeeze pressure.

T. Abe et al. / Open Journal of Gastroenterology 3 (2013) 223-226 225

by sphincter division, removal can certainly be a primary

focus, which eliminates the risk of missing secondary

tracts and allows healing by secondary intention of

healthier tissue. Moreover, divided sphincters are fixed

to prevent reduction in anal resting tone. We have also

used this technique successfully to manage complex fis-

tulas, but the present study was limited to a more com-

mon group, simple fistulas.

Both fistulotomy and fistulectomy have long been ac-

cepted as the gold standard for simple fistulas. Although

fistulotomy has been associated with success rates of

92% - 97%, the procedure will result in some form of

incontinence even for simple fistulas in approximately

12% - 39% of patients [3,5,6].

Both fistulotomy and fistulectomy leaves the unepi-

thelialized wound opened, which may cause undesired

pain and complications, such as bleeding and suppura-

tion. Marsupializatio n of the unepithelialized wound was

introduced to provide the benefit of shortened healing

times and improved continence by minimizing anal de-

formity [10]. The addition of marsupialization also has

been associated with less postoperative pain and bleeding

[11]. However, this procedure leaves the sphincters di-

vided, and Pescatori et al. [11] did not observe any supe-

riority of marsupialization with respect to incontinence

rates.

Fistulectomy and immediate sphincter repair for low

fistulas, described by Parkash et al. [12], aim to eradicate

infection and to anatomically reconstruct the muscular

defect. However, very few studies have been published

on this technique. Dehiscence of sphincteroplasty is the

most fearful complication of this technique and is re-

sponsible for its infrequent use [13]. Roig et al. [14]

treated 75 patients in whom most of the fistulas were

complex (69%) by fistulectomy and end-to-end recon-

struction of the disrupted EAS. Five recurrences in total

have been described (6.7%), and the postoperative in-

continence rate was 21%. Perez et al. [13] included 16

patients with recurrent complex fistulas in whom fistu-

lotomy was performed with overlapping repair of the

disrupted EAS. Two (25%) of 8 fully continent patients

developed incontinence for watery stools and flatus,

which gave a recurrence rate of 6.3% (1 patient). By

overlapping the muscle, the area in contact is increased

and rupture of the sutures may be more unlikely. How-

ever, when the width of overlap is too long, the anal ca-

nal may narrow and drainage worsen.

The strengths of sphincter fixation, our original me-

thod, are as follows: 1) since both edges of the sphincters

are sutured separately, the tension on the sutures can be

reduced by half relative to that on end-to-end sutures; 2)

extensive dissection of sphincter muscles is not needed

to achieve overlap; 3) the anal canal does not become

narrow as can occur with overlap. The edges of the di-

vided sphincter muscles will separate rapidly when they

are not at all repaired. Even if they are fixed in the origi-

nal position, continence will be fully maintainable. In

fact, it was found that sphincter fixation was better pre-

served for MSP 3 months after surgery. Although MRP

was significantly reduced, the extent was only 15%. Cli-

nically, 5 patients (4%) developed temporary inconti-

nence for liquids and gas, and all of them had recovered

in <6 months.

5. CONCLUSION

The true advantages of the OFSF procedure may not be

clear until larger prosp ective rando mized studies are co n-

ducted. However, considering the current reported data,

we believe that OFSF can achieve complete removal of

fistulas safely and easily with minimal risk of post-

operative incontinence and low recurrence rates.

REFERENCES

[1] Parks, A.G. (1961) Pathogenesis and treatment of fis-

tula-in-ano. British Medical Journal, 1, 463-469.

doi:10.1136/bmj.1.5224.463

[2] Parks, A.G., Gordon, P.H. and Hardcastle, J.D. (1976) A

classification of fistula-in ano. British Journal of Surgery,

63, 1-12. doi:10.1002/bjs.1800630102

[3] Garcia-Aguilar, J., Belmonte, C., Wong, W.D., et al.

(1996) Anal fistula surgery. Factors associated with re-

currence and incontinence. Disease of the Colon and

Rectum, 39, 723-729. doi:10.1007/BF02054434

[4] Parks, A.G. and Stitz, R.W. (1976) The treatment of high

fistula-in-ano. Disease of the Colon and Rectum, 19, 487-

499. doi:10.1007/BF02590941

[5] Davies, M., Harris, D. and Lohana, P. (2008) The sur-

gical management of fistula-in-ano in a specialist colo-

rectal unit. International Journal of Colorectal Disease,

23, 833-838. doi:10.1007/s00384-008-0444-x

[6] Roig, J.V., Jordan, J., Garcia-Armengol, J., et al. (2009)

Change in anorectal morphologic and functional parame-

ters after fistula-in-ano surgery. Disease of the Colon and

Rectum, 52, 1462-1469.

doi:10.1007/DCR.0b013e3181a80e24

[7] Atkin, G.K., Martins, J., Tozer, P., et al. (2011) For many

high anal fistulas, lay open is still a good option. Tech-

niques in Coloproctology, 15, 143-150.

doi:10.1007/s10151-011-0676-6

[8] Steele, S.R., Kumar, R., Feingold, D.L., et al. (2011)

Practice parameters for the management of perianal ab-

scess and fistula-in-ano. Disease of the Colon and Rectum,

54, 1465-1474. doi:10.1097/DCR.0b013e31823122b3

[9] Iwadare, J. (2000) Sphincter-preserving techniques for

anal fistulas in Japan. Disease of the Colon and Rectum,

43, S69-S77. doi:10.1007/BF02237229

[10] Ho, Y.H., Tan, M., Leong, A.F.P.K., et al. (1998) Marsu-

pialization of fistulotomy wounds improves healing: A

randomized controlled trial. British Journal of Surgery,

T. Abe et al. / Open Journal of Gastroenterology 3 (2013) 223-226

226

OJGas

85, 105-107. doi:10.1046/j.1365-2168.1998.00529.x

[11] Pescatori, M., Ayabaca, S.M., Cafaro, D., et al. (2005)

Marsupialization of fistulotomy and fistulectomy wounds

improves healing and decreases bleeding: A randomized

controlled trial. Colorectal Disease, 8, 11-14.

doi:10 .1111/j.1463-1318.2005.00835.x

[12] Parkash, S., Lakshmiratan, V. and Gajendran, V. (1985)

Fistula-in-ano: Treatment by fistulectomy, primary clo-

sure and reconstruction. Australian and New Zealand

Journal of Surgery, 55, 23-27.

doi:10 .1111/j.1445-2197.1985.tb00849.x

[13] Perez, F., Arroyo, A., Serrano, P., et al. (2006) Prospec-

tive clinical and manometric study of fistulotomy with

primary sphincter reconstruction in the management of

recurrent complex fistula-in-ano. International Journal of

Colorectal Disease, 21, 522-526.

doi:10.1007/s00384-005-0045-x

[14] Roig, J.V., Garcia-Armengol, J., Jordan, J.C., et al. (2009)

Fistulectomy and sphincteric reconstruction for complex

cryptgrandular fistulas. Colorectal Disease, 12, e145-

e152.