Simple fistula-in-ano: is it all simple? A systematic review

Abstract

Background Simple anal fistula is one of the most common causes of proctological surgery and fistulotomy is considered the gold standard. This procedure, however, may cause complications. The aim of this systematic review was to assess the surgical treatment of simple anal fistula with traditional and sphincter-sparing techniques. Methods A literature research was performed using PubMed, Cochrane, and Google Scholar to identify studies on the surgical treatment of simple anal fistulas. Observational studies and randomized clinical trials were included. We assessed the risk of bias of included studies using the Jadad scale for randomized controlled trials, and the MINORS Scale for the remaining studies. Results The search returned 456 records, and 66 studies were found to be eligible. The quality of the studies was generally low. A total of 4883 patients with a simple anal fistula underwent a sphincter-cutting procedure, mainly fistulotomy, with a weighted average healing rate of 93.7%, while any postoperative continence impairment was reported in 12.7% of patients. Sphincter-sparing techniques were adopted to treat 602 patients affected by simple anal fistula, reaching a weighted average success rate of 77.7%, with no study reporting a significant postoperative incontinence rate. The postoperative onset of fecal incontinence and the recurrence of the disease reduced patients’ quality of life and satisfaction. Conclusions Surgical treatment of simple anal fistulas with sphincter-cutting procedures provides excellent cure rates, even if postoperative fecal incontinence is not a negligible risk. A sphincter-sparing procedure could be useful in selected patients.

Anal Fistula of Crypto-Glandular Etiology: A Review of the Literature with a Step-by-Step Approach for Diagnosis and Surgical Management

“…This outcome of surgery should be explained to the patient and if is not ready to suffer minor continence problems for an interventional procedure with optimal results, alternative less invasive procedures should be performed. This category of simple fistulas seems to be a very common category of anal fistulas from Park's era with an approximate prevalence of 40-50% of cases reported, despite these simple fistulas are not so simple many times [37] . Therapy with cutting sphincter procedures (fistulotomy) or other sphincter sparing techniques provides excellent surgical results due to simplicity of the fistula.…”

Guidelines to diagnose and treat peri-levator high-5 anal fistulas: Supralevator, suprasphincteric, extrasphincteric, high outersphincteric, and high intrarectal fistulas

“…As the EAS plays a major role in continence, muscle-dividing procedures like fistulotomy or cutting setons are strictly contraindicated in these fistulas. In fact, fistulotomy with primary sphincter reconstruction or fistulectomy with primary sphincter reconstruction are also best avoided in these patients[ 1 , 12 - 14 ]. Therefore, the choice of procedures becomes limited.…”

Long term efficacy of Video‐Assisted Anal Fistula Treatment (VAAFT) for complex fistula‐in‐ano: a single‐centre Australian experience

“…In lay open, incidence of flatus/liquid incontinence occur in 20–25% of cases 11 . Even in simple fistulae, there is evidence that fistulotomy leads to reduced continence over long periods 12 The problem therefore is the realization of a method of treatment that is both highly apt at curing FIA while maintaining the long‐term integrity of the anal sphincter complex.…”