Cutting of sphincter in fistulectomy with primary closure in complex fistula-in-ano: is it feasible?

Introduction: Treatment of complex fistulas such as inter- or transsphincteric, recurrent, and high fistulae have high rate of recurrence or incontinence. Fistulectomy with primary sphincter reconstruction might represent an effective and safe alternative to reduce rate of recurrence and incontinence. The aim of this study is to assess incontinence and recurrence after fistulectomy with primary sphincter reconstruction for management of complex fistulas. Material and Methods: There were 60 patients with complex fistulae involving the sphincter, with 56 male and 4 female, mean age 40.6 years, operated by fistulectomy and primary sphincter repair over a period of 7 years. Patients were followed up for 6months for any complications, recurrence, and incontinence. Results: The majority of patients (50, 83.3%) had complete wound healing in 2 weeks, while 4 (6.6%) patients had hematoma and superficial wound dehiscence, which were managed conservatively and healed in 4 weeks. There was one recurrence. All patients had good continence postoperatively, except for mild fecal incontinence (FI, score 3), seen in 6 (10%) patients. However, all these patients regained continence within 6 weeks. Conclusions: Primary reconstruction of anal sphincter with fistulectomy is a safe option for complex fistula-in-ano. (AU)

Management of complex fistula-in-ano by interception of fistula track with application of ksharasutra (IFTAK): a novel technique

Objective: Despite all the technological advances, successful management of complex fistula-in-ano is still a challenge due to recurrence and incontinence. The present study evaluates the outcomes of a novel technique, Interception of Fistula Track with Application of Ksharasutra (IFTAK) in terms of success rate and degree of incontinence. Methods: In the present prospective study, 300 patients with complex fistula-inano were treated by the IFTAK technique, whose surgical steps include: incision at the anterior or posterior midline perianal area, identification and interception of the fistulous track at the level of the external sphincter, rerouting the track (and extensions) at the site of interception, and application of a ksharasutra (medicated seton) in the proximal track (from the site of interception to the internal opening) that is laid open gradually, with the resulting wound healing with minimum scarring. The distal track is allowed to heal spontaneously. Results: There were 227 transsphincteric and 73 intersphincteric varieties of fistula with supralevator extension in 23 cases, of which 130 were recurrent fistulas, 29 had horseshoe track, while 25 had blind fistula with no cutaneous opening. The mean duration of the ksharasutra application was 8.11 ± 3.86 weeks with an overall success rate of 93.33% at the 1-year follow-up. A total of 3.67% of the cases reported with a mild impairment of continence on the Wexner incontinence scoring system. Pre- and postoperative anal manometry evaluation showed minimal reduction in median basal and squeeze pressures. Conclusion: The IFTAK technique is a minimally invasive, daycare surgical procedure for the management of complex fistula-in-ano with low recurrence and minimal sphincter damage. (AU)

Long-term outcomes of ligation of intersphincteric fistula tract for complex fistula-in-ano: modified operative procedure experience / Resultados em longo prazo da ligadura da fístula interesfincteriana no complexo das fístulas perianais: modificação técnica de procedimento cirúrgico

ABSTRACT Background: It is important but difficult to treat complex fistula-in-ano due to the high recurrent rate and following incontinence. Ligation of the intersphincteric fistula tract (LIFT), a novel surgical procedure with the advantage of avoiding anal incontinence, has a variable success rate of 57-94.4 %. Aim: To evaluate the long-term outcomes of modified LIFT operative procedure - ligation of intersphincteric fistula tract - to treat complex fistula-in-ano. Methods: Retrospective analysis of 62 cases of complex fistula-in-ano. The group was treated with the modified approach of LIFT (curved incision was made in the anal canal skin; purse-string suture was performed around the fistula; the residual fistulas were removed in a tunnel-based way) and had a follow-up time of more than one year. Patient´s preoperative general condition, postoperative efficacy and their anal function were compared. Results: The median age of the participants was 34, and 43 (69.4%) cases were male. Forty-one (66.1%) cases were of high transsphincteric fistula, four (6.5%) cases of high intrasphincter fistula, and 17 (27.4%) cases of anterior anal fistula in female. The median follow-up duration was 24.5 (range, 12-51) months. The success rate in the end of follow-up was 83.9% (52/62). The anorectal pressure and Cleveland Clinic Florida Fecal Incontinence (CCF-FI) evaluated three months before and after the operation did not find apparent changes. Conclusions: Compared with LIFT, the modified LIFT remarkably reduces postoperative failure and the recurrence rate of complex fistula with acceptable long-term outcomes.

RESUMO Racional: É importante, mas difícil de se tratar fístula anal complexa devido à alta taxa de recorrência e de incontinência pós-operatória. A ligadura do trajeto da fístula interesfincteriana (LIFT) - um novo procedimento cirúrgico com a vantagem de evitar a incontinência anal - tem taxa de sucesso variável entre 57-94,4%. Objetivo: Avaliar os resultados em longo prazo do procedimento cirúrgico LIFT modificado - ligadura do trato interesfincteriano com fístula - para tratar fístula complexa anal. Métodos: Análise retrospectiva de 62 casos de fístula complexa no ânus tratados com abordagem modificada de LIFT (incisão curva na pele do canal anal; sutura em bolsa realizada em torno da fístula; as fístulas residuais removidas em um túnel) e teve tempo de acompanhamento de mais de um ano. A condição geral pré-operatória dos pacientes, a eficácia pós-operatória e a função anal foram comparadas. Resultados: A mediana de idade dos participantes foi de 34 anos, e 43 (69,4%) dos casos eram de homens. Quarenta e um (66,1%) casos eram de fístula transesfincteriana alta, quatro (6,5%) de fístula intra-esfincteriana alta e 17 (27,4%) de fístula anal anterior em mulheres. A mediana da duração do acompanhamento foi de 24,5 meses (12-51). A taxa de sucesso no final do acompanhamento foi de 83,9% (52/62). A pressão anorretal e a Incontinência Fecal da Cleveland Clinic Florida (CCF-FI) avaliadas três meses antes e após a operação não encontraram alterações aparentes. Conclusões: Comparado com o LIFT, o LIFT modificado reduz notavelmente a falha pós-operatória e a taxa de recorrência de fístula complexa com resultados aceitáveis em longo prazo.