Intersphincteric Exploration With Ligation of Intersphincteric Fistula Tract or Attempted Closure of Internal Opening for Acute Anorectal Abscesses

Abstract

BACKGROUND: Acute anorectal abscesses of cryptoglandular origin are commonly managed by incision and drainage, which results in fistula development in up to 73% of cases, requiring subsequent definitive fistula surgery. However, given that fistula tracts may already be present at the initial presentation, primary closure of the tract as secondary prevention of fistula formation, using ligation of intersphincteric fistula tract, may be useful. OBJECTIVE: This study aims to examine the feasibility and outcomes of performing intersphincteric exploration with ligation of intersphincteric fistula tract or attempted closure of internal opening for acute anorectal abscesses. DESIGN: This is a retrospective study of patients with acute anorectal cryptoglandular abscesses who underwent surgery between January 2014 and December 2016. SETTINGS: The patients were treated at a tertiary referral center in Thailand. PATIENTS: Eighty-six patients with acute anorectal abscesses without previous surgery were included. INTERVENTIONS: Intersphincteric dissection was performed. Further surgical intervention was dependent on the intersphincteric findings. MAIN OUTCOME MEASURE: The main outcome measure was the 90-day healed rate. RESULTS: Of the 86 patients, 3 had low intersphincteric abscesses, 26 had low transsphincteric abscesses, 25 had anterior high transsphincteric abscesses, 27 had posterior high transsphincteric abscesses, and 5 had high intersphincteric abscesses. Ligation of intersphincteric fistula tract was successfully performed in 66 patients with an identifiable intersphincteric tract. Intersphincteric exploration with attempted closure of the internal opening was performed in the remaining 20 patients. The success rates were 86% and 70%. Unidentified internal opening and intersphincteric pathology were risk factors for nonhealing. No patients reported fecal incontinence postoperatively. LIMITATIONS: The limitation of this study is its retrospective nature and that all operations were performed by a single surgeon; therefore, the results may vary according to the individual surgeon’s expertise. CONCLUSIONS: Fistula tract formation was found in most cases of acute anorectal abscesses. Definitive surgery using this strategy provides promising results. See Video Abstract at http://links.lww.com/DCR/B451. EXPLORACIÓN INTERESFINTÉRICA CON LIGADURA DEL TRAYECTO EN LA FÍSTULA INTERESFINTÉRICA O INTENTO DE CIERRE DEL ORIFICIO INTERNO EN ABSCESOS ANORRECTALES AGUDOS ANTECEDENTES: Los abscesos anorrectales agudos de origen criptoglandular, comúnmente se manejan mediante incisión y drenaje, lo que resulta en el desarrollo de una fístula hasta en un 73% de los casos, requiriendo posteriormente cirugía definitiva de la fístula. Sin embargo, dado que los trayectos de la fístula ya pueden estar inicialmente presentes, puede ser útil el cierre primario del trayecto, como prevención secundaria en la formación de la fístula, mediante la ligadura del trayecto de la fístula interesfintérica. OBJETIVO: El estudio tiene como objetivo, examinar la viabilidad y los resultados en realizar exploración interesfintérica, con ligadura del trayecto de fístula interesfintérica o intento de cierre del orificio interno para abscesos anorrectales agudos. DISEÑO: Se trata de un estudio retrospectivo de pacientes con abscesos criptoglandulares anorrectales agudos, que fueron operados entre enero de 2014 y diciembre de 2016. AJUSTES: Los pacientes fueron tratados en un centro de referencia terciario en Tailandia. PACIENTES: Se incluyeron 86 pacientes con abscesos anorrectales agudos, sin cirugía previa. INTERVENCIONES: Se realizó disección interesfintérica. La intervención quirúrgica adicional dependió de los hallazgos interesfintéricos. PRINCIPALES MEDIDAS DE RESULTADO: La principal medida de resultado, fue la tasa de cicatrización a 90 días. RESULTADOS: De los 86 pacientes, hubo 3 abscesos interesfintéricos bajos, 26 abscesos transesfintéricos bajos, 25 abscesos transesfintéricos anteriores altos, 27 abscesos transesfintéricos posteriores altos y 5 abscesos interesfintéricos altos. La ligadura del tracto de la fístula interesfintérica, con tracto interesfintérico identificable, se realizó con éxito en 66 pacientes. Se realizó exploración interesfintérica, con intento de cierre del orificio interno en los 20 pacientes restantes. Las tasas de éxito fueron 86% y 70% respectivamente. Orificio interno no identificado y patología interesfintérica, fueron factores de riesgo para la falta de cicatrización. Ningún paciente reportó incontinencia fecal posoperatoria. LIMITACIONES: La limitación de este estudio, es su naturaleza retrospectiva y que todas las operaciones fueron realizadas por un solo cirujano, por lo tanto, los resultados pueden variar según la experiencia de cada cirujano. CONCLUSIONES: En la mayoría de los casos de abscesos anorrectales agudos, se encontró formación de trayectos fistulosos. La cirugía definitiva con esta estrategia, proporciona resultados prometedores. Consulte Video Resumen en http://links.lww.com/DCR/B451.

Understanding New Ideas in Cryptoglandular Fistula-in-Ano

“…In line with sphincter preservation as an important principle, a recent prospective study showed promising results utilizing sphincter preserving techniques for drainage and definitive treatment of fistulous anorectal abscess [29]. 86 patients with anorectal abscesses were operated by a single surgeon with intention of definitive single stage surgery and preservation of sphincter muscles.…”

“…There were no cases of post-op incontinence. The remaining 17% non-healing group went on to elective surgery for definitive surgery of chronic fistula [29].…”

“…It is well known that in patients with anorectal abscesses undergoing simple drainage, 2/3 will progress to chronic fistula [27]. Definitive treatment of fistula may reduce the incidence of chronic fistula to an estimated below 30% based on recent evidence [28,29]. With emerging sphincter preserving approaches, guided by our understanding of patterns of infection spread and imaging modalities, we are better equipped to approach acute fistulous abscesses with intention of single stage surgery.…”

“…Surgeons generally try to avoid sphincter cutting techniques. Ligation of Intersphincteric Tract (LIFT) procedure avoids sphincter cutting, using a small incision to explore the intersphincteric space to ligate and excise the intersphincteric tract [4] or to drain intersphincteric abscess [29]. Additional procedure in combination with LIFT such as closure of internal opening, excision of external tract and bioprosthetic mesh have been reported to improve outcomes [32].…”

“…In the author's view, LIFT procedure is best combined with additional curettage, drainage or excision of external fistula tracts/abscess. Recently, the original author reported slight modification where LIFT incision was loosely approximated and tube drain inserted to reduce intersphincteric space infection and promote secondary healing [29]. A recent meta-analysis and systematic review reported overall pooled success rate of 76.5% and incontinence rate of 1.4% [21].…”