Sphincter-preserving techniques for anal fistuals in Japan

Abstract

After the articles by Eisenhammer, Parks, Hanley, and Goligher and the classification system established by Sumikoshi, surgeons in Japan became very active in creating and modifying new sphincter-preserving surgical procedures for low intersphincteric and ischiorectal fistulas. This article reviews the literature, summarizes each procedure, identifies the transitions, and discusses recurrence rates, cures, and subsequent variations. Japanese surgeons favor sphincter-preserving techniques for low intersphincteric fistulas that involve partial or complete coring out of fistula tracts. Common sphincter-preserving procedures for ischiorectal fistulas involve coring-out techniques and muscle-filling procedures. The recurrence rates of sphincter-preserving procedures for low intersphincteric fistulas are between 5 and 6 percent, whereas the recurrence rates for the sphincter-preserving techniques used on ischiorectal fistulas are in the 7 to 10 percent range.

Long-Term Results and Quality-of-Life Outcomes in Patients With Transsphincteric Fistulas After Muscle-Filling Procedure

“…It also reduces the recurrence rate. 6,7 Even though the technique requires cutting the external and internal sphincters appropriately to make a pedicle muscle flap, proponents of the muscle-filling procedure believe the damage to the sphincter is far less than in other procedures, and the damage to the internal sphincter is virtually negligible, whereas opponents argue that the technique could produce unnecessary damage to the external sphincter. We think that because the dead space left by excision of the primary abscess is quite deep, it requires a wider wound for appropriate drainage, which would sacrifice more of the external sphincter.…”

“…The muscle-filling technique in the management of transsphincteric fistulas is based on the assumption that it takes advantage of the muscle flap that is killed to create the drainage, allows the wound to be smaller, and shortens healing time. 6,7 Although transsphincteric fistulas may be cured by laying open the entire fistula tracks, a surgical procedure that excises the primary abscess only is preferable, to avoid subsequent damage to sphincters and the creation of anal deformity. However, because primary abscess of the transsphincteric fistula is located in the deep postanal space (Courtney's space), when an appropriate drainage is created, the wound after excision itself can be severe.…”

A New Concept for the Surgical Anatomy of Posterior Deep Complex Fistulas

“…In Japan, Hanley or Parks_ theory on the extension course of an ischiorectal or pelvirectal fistula is commonly accepted. [6][7][8] Radical posterior complex fistula operations generally are performed by modified Hanley_s method, 3,4 i.e., a probe is inserted from the posterior anal crypt to the primary lesion, which is thereby exposed. [6][7][8] Our operation differs from the conventional method in that we first reach the primary lesion and expose it under direct vision.…”

“…Although several posterior complex fistula extension forms have been reported, interpretations of their anatomic significance vary widely. [1][2][3][4][5][6][7][8] Because it is essential to expose the duct from the primary opening to the primary lesion (primary duct), as well as the primary lesion, to treat the posterior complex fistula, we initially open the primary lesion under direct vision as a routine surgical procedure. Then, we focus on the secondary ducts and the primary duct.…”

Complex perirectal sepsis: clinical classification and imaging

“…For operative purposes, fistulae should be defined in their coronal, lateral and horizontal (axial or clock-face) planes with designation of the site of horseshoe extension as in the intersphincteric, ischiorectal or supralevator plane. Most of the traditional systems of categorization have been effectively too complex for general use and have made several presumptions regarding the aetiopathogenesis of anal fistula and its relationship to abscesses [12]. The principal system of use has been a variant of that originally proposed by Milligan and Morgan [13] which adopted the views of Goodsall and Miles where the fistula was defined by its relationship to the muscular anorectal ring [11].…”