The outcome of surgery for complex anal fistula

Abstract

OBJECTIVE: The aim of this study was to examine the results of surgery for complex anal fistulas treated by a variety of techniques, in terms of fistula healing, recurrent anal sepsis and effect of surgery on anal continence. PATIENTS AND METHODS: This study included 63 patients with complex fistulas treated between November 1995 and September 1999. A variety of techniques were employed, including short-term loose seton drain (12), long-term loose seton drain (11), cutting seton (17), and rectal advancement flap (19). Outcome was assessed at clinic review and continence was further assessed by detailed questionnaire sent to the patients sometime after surgery. RESULTS: Healing occurred in 9 (75%) patients treated with a short-term, loose drainage seton; 16 (94%) patients treated with a cutting seton and 17 (89%) patients in the rectal advancement flap group. Incontinence reported at clinic review seemed to be more frequent in the advancement flap group. However, a detailed continence questionnaire revealed that 50% of patients reported episodes of incontinence to flatus or liquid after all techniques, which had not been detected at routine clinical review. Incontinence to solids was only reported by two of the patients who had been treated with a cutting seton. CONCLUSIONS: Complex fistulas may be successfully treated by a variety of techniques. Disturbed anal continence following surgery is common and worse than clinic assessment would suggest.

Quality of life with anal fistula

“…26,27 The rationale for this is to facilitate drainage and thus avoid recurrent septic episodes and abscess formation. Our data, however, suggest that, while a loose seton does not involve sphincter division, there was no difference in QOL between patients with and without a seton, and no significant difference in urgency.…”

Anal fistula plug vs mucosa advancement flap in complex fistula-in-ano: A meta-analysis

“…The main objective of surgery for an anal fistula is to eradicate the fistula tract while maintaining anal continence [25] .…”

Incontinence rates after cutting seton treatment for anal fistula

“…Christensen et al [35] 13 ⁄ 21 Durgan et al [38] 2 ⁄ 10 Dziki and Bartos [39] 4 ⁄ 21 4 ⁄ 4 4⁄ 7 Fasth et al [40] 0 ⁄ 5 0⁄ 2 García-Aguilar et al [42] 8 ⁄ 12 Graf [44] 15 ⁄ 29 Gurer et al [25] 0 ⁄ 4 0⁄ 12 0 ⁄ 1 Hämäläinen and Sainio [45] 18 ⁄ 30 2 ⁄ 2 2⁄ 3 Hamel et al [46] 0 ⁄ 12 Hasegawa et al [48] 11 ⁄ 22 2 ⁄ 3 2⁄ 3 Joy and Williams [51] 5 ⁄ 10 McCourtney and Finlay [53] 3 ⁄ 16 Mentes et al [54] 4 ⁄ 20 Qureshi et al [57] 2 ⁄ 4 Tahir [58] 5 ⁄ 9 Tocchi et al [60] 4 ⁄ 28 Vatansev et al [61] 5 ⁄ 32 Walfisch et al [62] 0 ⁄ 23 Williams et al [63] 8 ⁄ 13 Zbar et al [22] 3 Despite the difficulty in comparing the different reports, this study has identified some important points. First the global rate of incontinence was 12% when any kind of cutting seton was used.…”

“…13 ⁄ 21 Cox et al [36] 4 ⁄ 8 Culp [26] 3 ⁄ 20 Decanini-Terán et al [37] 0 ⁄ 42 Deshpande et al [30] 0 ⁄ 397 Durgan et al [38] 2 ⁄ 10 Dziki and Bartos [39] 12 ⁄ 32 † Fasth et al [40] 0 ⁄ 7 Flich Carbonell et al [41] 3 ⁄ 19 García-Aguilar et al [42] 8 ⁄ 12 Gonzalez-Ruiz et al [43] 0 ⁄ 31 Graf et al [44] 11 ⁄ 29 4 ⁄ 4 Gurer ‡ et al [25] 0 ⁄ 17 Hämäläinen and Sainio [45] 22 ⁄ 35 Hamel et al [46] 0 ⁄ 12 Hammond et al [47] 4 ⁄ 16 Hasegawa et al [48] 15 ⁄ 28 Held et al [49] 0 ⁄ 9 Ho et al [20] 3 ⁄ 46 † Isbister and Al Sanea ‡ [50] 17 ⁄ 47 † Joy and Williams [51] 5 ⁄ 10 Malouf et al [52] 1 ⁄ 3 McCourtney and Finlay [53] 3 ⁄ 16 Mentes et al [54] 4 ⁄ 20 Misra and Kapur [55] 0 ⁄ 53 Mohite et al [31] 0 ⁄ 114 Pescatori et al [56] 3 ⁄ 17 Qureshi et al [57] 2 ⁄ 4 Shukla et al [21] 8 ⁄ 155 Tahir § [58] 5 ⁄ 9 Theerapol et al [59] 0 ⁄ 41 Tocchi et al [60] 4 ⁄ 28 Vatansev et al [61] 5 ⁄ 32 Walfisch et al [62] 0 ⁄ 23 Williams et al [63] 8 ⁄ 13 Zbar et al [22] 3 ⁄ 34 Average rates (%) 15.9% 100% 10.5%…”