Fistulotomy or fistulectomy and primary sphincteroplasty for anal fistula (FIPS): a systematic review

Abstract

There is still no clear consensus about surgical treatment of anal fistulas. Fistulotomy or fistulectomy and primary sphincter reconstruction is still regarded with skepticism. The aim of this systematic review was to evaluate the evidence in the literature supporting the use of this technique in the treatment of complex anal fistulas. MEDLINE, EMBASE and Cochrane Library databases were searched for the period between 1985 and 2015. The studies selected were peer-reviewed articles, with no limitations concerning the study cohort size, length of the follow-up or language. Technical notes, commentaries, letters and meeting abstracts were excluded. The major endpoints were the technique adopted, clinical efficacy, changes at anorectal manometry and assessment of quality of life after the procedure. Fourteen reports (666 patients) satisfied the inclusion criteria. The quality of the studies was low. Some differences about the surgical technique emerged; however, after a weighted average duration of follow-up of 28.9 months, the overall success rate was 93.2 %, with a low morbidity rate. The overall postoperative worsening continence rate was 12.4 % (mainly post-defecation soiling). In almost all cases, the anorectal manometry parameters remained unchanged. The quality of life, when evaluated, improved significantly. Fistulotomy or fistulectomy and primary sphincteroplasty could be a therapeutic option for complex anal fistula. Success rates were very high and the risk of postoperative fecal incontinence was lower than after simple fistulotomy. Well-designed trials are needed to support the inclusion of this technique in a treatment algorithm for the management of complex anal fistulas.

Post-surgical fecal incontinence

“…A systematic review has shown that significantly larger IAS and EAS defects were detected by endoanal ultrasound in 40 patients randomized to fistulectomy compared with fistulotomy [18]. This observation may explain why several surgeons included primary sphincteroplasty with fistulectomy for complex fistula in order to minimize the sphincteric lacuna [19]. Nevertheless, fecal incontinence can appear (12.4%).…”

Longterm outcome of anal fistula – A retrospective study

“…In 1999 Belmonte Montes et al compared the two techniques in a randomized controlled trial, showing that in fistulectomy there is a higher risk for sphincter lesions compared to fistulotomy 3 . However, Ratto et al stated in their review, comparing fistulotomy alone with fistulectomy and primary sphincteroplasty, lower incontinence rate for the more demanding procedure 4 . The fistulotomy operating time is slightly shorter compared to fistulectomy, but statistically significant 5 .…”

A comparative study of laying open of wound vs primary closure in low fistula in ano

“…In the surgical management of fistula-in-ano, the two standard procedures used are -a fistulotomy and a fistulectomy. 2,3 Fistulotomy involves laying open of fistulous tract wherein the fistulous tunnel is laid open, which allows the fistula to heal from below upwards. 4 Fistulectomy, on the other hand aims at complete removal of the fistulous tract which is supposed to eliminate the risk of missing secondary tracts.…”

“…4 Fistulectomy, on the other hand aims at complete removal of the fistulous tract which is supposed to eliminate the risk of missing secondary tracts. 3 Aim of the study is to study the outcome of primary wound closure over non closure of wound after fistulectomy in low anal Fistulas.…”