PurposeThis randomized clinical trial was conducted to compare a fistulectomy and a fistulotomy with marsupialization in the management of a simple anal fistula.MethodsForty patients with simple anal fistula were randomized into two groups. Fistulous tracts were managed by using a fistulectomy (group A) while a fistulotomy with marsupialization was performed in group B. The primary outcome measure was wound healing time while secondary outcome measures were operating time, postoperative wound size, postoperative pain, wound infection, anal incontinence, recurrence and patient satisfaction.ResultsPostoperative wounds in group B healed earlier in comparison to group A wounds (4.85 ± 1.39 weeks vs. 6.75 ± 1.83 weeks, P = 0.035). No significant differences existed between the operating times (28.00 ± 6.35 minutes vs. 28.20 ± 6.57 minutes, P = 0.925) and visual analogue scale scores for postoperative pain on the first postoperative day (4.05 ± 1.47 vs. 4.50 ± 1.32, P = 0.221) for the two groups. Postoperative wounds were larger in group A than in group B (2.07 ± 0.1.90 cm2 vs. 1.23 ± 0.87 cm2), however this difference did not reach statistical significance (P = 0.192). Wound discharge was observed for a significantly longer duration in group A than in group B (4.10 ± 1.91 weeks vs. 2.75 ± 1.71 weeks, P = 0.035). There were no differences in social and sexual activities after surgery between the patients of the two groups. No patient developed anal incontinence or recurrence during the follow-up period of twelve weeks.ConclusionIn comparison to a fistulectomy, a fistulotomy with marsupialization results in faster healing and a shorter duration of wound discharge without increasing the operating time.

A 35-year-old man presented with persistent pain in right iliac fossa and nausea for one month. He did not have vomiting or urinary symptoms and had normal bowel habits. Physical examination revealed minimal tenderness in right iliac fossa. Microscopic urine analysis, complete blood count, and stool examination were within normal limits. Computed tomographic (CT) scan showed diffuse, eccentric wall thickening involving cecum and terminal ileum. There was a large laminated radioopaque shadow medial to the base of the cecum, leading to a linear streak of gas containing smaller radio-opaque shadows.There was a large multilocular fluid collection around the appendix extending towards the urinary bladder (Fig. 1). CT findings were suggestive of multiple appendicoliths with multilocular collection around appendix. He underwent diagnostic laparoscopy which demonstrated an appendicular lump (6 cm×6 cm). At laparotomy, an appendiceal mass formed of omentum, bowel loops and previously perforated retrocecal appendix were found. The base of appendix was sloughed off exposing the giant appendicolith measuring 2.1 cm (Fig. 2). The cecum was healthy. Histopathological examination showed acute appendicitis with peri-appendicitis.The appendicoliths are calcified deposits in the appendix and are usually <1 cm in size. Giant appendicoiths (>2 cm) are rarely reported in literature [1].