|Year : 2016 | Volume
| Issue : 3 | Page : 564-569
Fistulectomy versus fistulotomy in the management of simple perianal fistula
Olfat I Elsebai, Alaa A Elsesy, Mohammed S Ammar, Ahmed M Khatan
Department of General Surgery, Faculty of Medicine, Menoufia University, Menoufia, Egypt
|Date of Submission||19-Apr-2015|
|Date of Acceptance||29-Jul-2015|
|Date of Web Publication||23-Jan-2017|
Ahmed M Khatan
11 El-Safa w El Marwa Street, Damanhour, El-Behera, 32511
Source of Support: None, Conflict of Interest: None
The objective of this research was to study the functional and clinical outcomes of fistulectomy versus fistulotomy in the treatment of simple perianal fistula.
Anal fistula has been known as a common surgical ailment for over two and a half millennia. Current management remains dependent on surgeon preference between options such as fistulotomy and fistulectomy.
Patients and methods
This is a prospective clinical study that included 30 patients suffering from simple perianal fistula; patients were divided into two groups each containing 15 patients: group A was managed by fistulectomy and group B was managed by fistulotomy. Both groups were evaluated according to the operative time, postoperative pain, time of wound healing, postoperative complication, incontinence, and recurrence.
There was a significant decrease in the operative time in group B compared with group A (P < 0.05), there was a significant decrease in postoperative pain in group B compared with group A (P < 0.05), and there was a significant decrease in the time needed for wound healing in group B compared with group A (P < 0.05). There was no significant difference in postoperative complications, incontinence, and recurrence between the two groups (P > 0.05).
Fistulotomy is a simple and effective method for the treatment of simple perianal fistula, as it has shorter operating time with less postoperative pain and less time needed for wound healing compared with fistulectomy, with the same incidence of postoperative complications, incontinence, and recurrence as fistulectomy.
Keywords: fistulectomy, fistulotomy, perianal fistula
|How to cite this article:|
Elsebai OI, Elsesy AA, Ammar MS, Khatan AM. Fistulectomy versus fistulotomy in the management of simple perianal fistula. Menoufia Med J 2016;29:564-9
|How to cite this URL:|
Elsebai OI, Elsesy AA, Ammar MS, Khatan AM. Fistulectomy versus fistulotomy in the management of simple perianal fistula. Menoufia Med J [serial online] 2016 [cited 2019 Mar 25];29:564-9. Available from: http://www.mmj.eg.net/text.asp?2016/29/3/564/198710
| Introduction|| |
The anal fistula is a common chronic abnormal communication usually lined by some degree of granulation tissue, which runs outward from the anorectal lumen (internal opening) to the external opening in the skin of the perineum or the buttock  . The vast majority of anal fistula are secondary to infection of the anal gland, which is present as perianal abscess that may spontaneously burst or is inadequately drained  . Other causes of perianal fistula include inflammatory bowel disease, trauma, fungal or mycobacterial infection, and neoplasm  ; it may also occur after internal sphincterotomy  .
The most comprehensive and practical classification that is widely used is that devised by Sir Alan Parks, who classified perianal fistula according to its location to anal sphincter muscle into four main groups: intersphincteric, trans-sphincteric, suprasphincteric, or extrasphincteric. These groups can be further subdivided according to the presence and course of any extensions or secondary tracks  .
The goal of surgical treatment of perianal fistula is permanent eradication of the suppurative process without compromising anal continence. There are several surgical options for the treatment of perianal fistula, and the best choice is determined by the anatomy of the fistula: fistulotomy with opening and unroofing of the fibrous portion of the tract, fistulectomy with excession of the tract  , or seton may be used as a drain placed through a fistula to maintain drainage and/or induce fibrosis  . There are a number of sphincter-sparing methods for the treatment of perianal fistula such as fibrin glue injection, anal fistula plug, endorectal muscular or mucosal advancement flap, core-out fistulectomy, radiofrequency ablation, ligation of the intersphincteric fistula tract, and, finally, video-assisted anal fistula treatment  .
In fistulotomy, the tract must be layed open from its termination (external opening) to its source (internal opening); it is the surest way of getting rid of the fistula. It is applied manly to the intersphincteric fistula and trans-sphincteric fistula involving less than 30% of the external sphincter  . Fistulectomy involves coring out of the fistula by either sharp dissection or diathermy cautery. It allows better definition of fistula anatomy than fistulotomy, especially the level at which the tract crosses the sphincters and the presence of secondary extensions  .
Two major complications may result: recurrence and incontinence. Major causes of recurrence include preoperative causes such as specific fistulas or poor identification of fistulous tract and openings, operative causes such as poor technical aspects of surgery, and postoperative causes such as poor postoperative wound healing  .
The aim of this work was to study the functional and clinical outcomes of fistulectomy versus fistulotomy in the treatment of simple perianal fistula.
| Patients and methods|| |
This is a prospective clinical study that included 30 patients diagnosed to have a simple perianal fistula, with age ranging from 18 to 59 years and from both sexes, attending the Department of Surgery in Menoufia University Hospital and Damanhour Medical National Institute during the period from April 2013 to April 2014. The patients presented with discharge, pain, pruritis ani, and anal swelling. The patients were divided randomly (by lottery method) into two groups, each including 15 patients.
Group A: This group included 15 patients who underwent treatment with fistulectomy.
Group B: This group included 15 patients who underwent treatment with fistulotomy.
Inclusion criteria were patients with intersphincteric anal fistula and patients with trans-sphincteric anal fistula crossing less than and equal to 30% of the external anal sphincter.
Exclusion criteria were patients with trans-sphincteric fistula traversing more than 30% of the external anal sphincter, patients with suprasphincteric and extrasphincteric fistula, fistula on top of Crohn's disease, tuberculosis or malignancy, complex or recurrent fistula, traumatic fistula, fistula associated with fecal incontinence, patients younger than 18 years, and pregnancy.
Full medical history and clinical data were obtained from each patient, with special emphasis on the presenting symptoms; digital rectal examination was performed to establish a diagnosis, and continence status of the patients of the study was assessed using the Wexner incontinence score system (WIS)  ([Table 1]).
Preoperative investigations included routine preoperative evaluation, and MRI when necessary.
The study was approved by the Ethical Committee of Department of Surgery of Menoufia University. The techniques were explained to the patients who accepted it with written consents.
All patients were admitted to the hospital at least 1 day before surgery, the anal region was shaved on the morning of the operation, and the rectum was evacuated with the aid of a disposable enema.
Under spinal anesthesia, the patient was positioned in lithotomy position, inspection and identification of the site of external opening was performed, and proctoscopy was applied for detection of internal opening and the fistula tract. Hydrogen peroxide was injected in the external opening to identify the presence and site of internal opening. A probe is passed in the external opening to define the direction of the fistula tract (thick granulation tissue) to the internal opening and to classify the fistula according to Park's classification. Coring out the primary track reduces the risk of missing secondary tracks, which were seen as transected granulation tissue, which may be followed by the same technique. Once the track had been cored out from the external toward the internal opening, either with scissors or with cautery dissection, simple anatomical closure of the cored-out tunnel with mucosal closure of the defect with interrupted absorbable sutures was performed. The wound outside the sphincters was lightly packed.
Fistulotomy was performed under spinal anesthesia, after positioning and probing of the fistula tract as in fistulectomy. Probing not only provides the identification of the course of the fistula tracts but also facilitates fistulotomy over the probe. Probing should be gentle; otherwise, it results in the creation of a false route, which further complicates the operative procedure. By use of diathermy, the perianal skin and anal epithelium were divided. The internal sphincter, if it was encountered, was identified and partially divided. If a high blind track was encountered, it should be loosely curetted and adequately drained through the fistulotomy incision. The fistula track can be safely opened, any bleeding from the edges should be secured by cautery and a gauze dressing was applied.
The operative time was recorded for each case in both operations.
Postoperative care included antibiotic treatment (at the time of induction of anesthesia and for 3 days postoperatively), analgesia (systematic analgesia as nonsteroidal anti-inflammatory drugs was used: diclofenac sodium is used usually), and observation for urine retention and postoperative bleeding. Intake of liquid food was resumed in the evening after the operation and for 2 days, and then normal diet was continued. Patient discharge to home was authorized from day 1 after surgery. The patients of both groups were evaluated weekly for 10 weeks and then once a month for 8 months at the outpatient clinic, and the following criteria were assessed: Time of postoperative pain relief, time of hospital stay, postoperative time needed for healing, continence status by WIS, and recurrence. The main criteria of recurrence are persistence of discharge and early postoperative complications such as urine retention, bleeding, abscess formation, wound infection, and early incontinence.
All the results of the study were subjected to statistical analysis by using IBM SPSS software package, version 20.0 (SPSS Inc, Chicago, U.S.A). Qualitative data were described using number and percentage. Quantitative data were described using range (minimum and maximum) mean and SD and median. Comparison between different groups regarding categorical variables was tested using χ2 -test and comparison between populations was performed using Mann-Whitney test. Significance of the obtained results was judged at the 5% level.
| Results|| |
The study was conducted on 30 patients, 23 male and seven female, with a mean age of 35.3 ± 8.53 years in group A and 37.4 ± 10.97 years in group B. There was history of abscess drainage in ten patients in group A and in nine patients in group B ([Table 2]).
|Table 2 Comparison between the two studied groups according to the history of abscess drainage |
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Discharge was the main complaint, and it was present in all patients in the study; pain was present in 20 (66.7%) patients in the study. Swelling was present in 20 (66.7%) patients in the study, and pruritis ani was present in only seven (23.3%) patients in the study ([Table 3]). There was a statistically significant difference in the mean operative time, as it was 19.39 min in group B and 40.67 min (P < 0.001) in group A ([Table 4]). Postoperative hospital stay was the same in all patients as it was on 1 day. It was found that postoperative pain perception and need for analgesics was less in group B, with a mean of 1.53 days, in comparison with group A, with a mean of 3.53 days. In addition, there was a statistical significance (P < 0.001) ([Table 5]). Incontinence was assessed for all patients by WIS preoperatively, and the score of all them was 0/20, indicating perfect continence; reassessment was done in the follow-up period, and only one (6.7%) patient in group A suffered from postoperative partial incontinence to flatus, with a score of 4/20 by WIS, whereas two (13.3%) patients in group B had partial incontinence to flatus, with a score of 4/20 by WIS; this condition was temporary and resolved within 2 months. There was no statistical significance. None of the patients in both groups suffered from postoperative complete incontinence to stool. No recurrence occurred in any patient from both groups in the follow-up period. Postoperative urine retention occurred in two patients in group A and in one patient in group B, with no statistical significance. Postoperative wound infection occurred in one patient in group A and in two patients in group B, with no statistical significance. No cases in both groups suffered from other minor complications such as bleeding or abscess formation ([Table 6]). Wound healing was faster in group B than in group A, as the mean time in group B was 4.07 weeks, which is less than that in group A, with a mean of 6.47 weeks. In addition, there was a statistical significance (P < 0.001) ([Table 7]).
|Table 3 Comparison between the two studied groups according to main complaints |
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|Table 4 Comparison between the two studied groups according to time of operation (min) |
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|Table 5 Comparison between the two studied groups according to postoperative pain (days) and hospital stay (days) |
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|Table 6 Comparison between the two studied groups according to postoperative complications |
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|Table 7 Comparison between the two studied groups according to the time of complete wound healing (weeks) |
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| Discussion|| |
Few studies attempted to standardize fistula classification by either surgical assessment or the use of preoperative radiological imaging, and many failed to provide precise criteria of fistula healing. All this makes it difficult to tease out individual factors that may account for the diversity in the healing rates  .
The three primary criteria for determining success or failure of fistula surgery are the following: recurrence, delayed healing, and incontinence  .
Our study was conducted on 30 patients suffering from simple perianal fistula, 23 male and seven female; patients were divided into two groups: group A was treated by fistulectomy and group B was treated by fistulotomy, and the mean age in group A was 35.3 ± 8.53 years and in group B it was 37.4 ± 10.97 years.
The operative time in our study was significantly shorter in group B, with a mean of 19.39 min, compared with group A, with a mean of 40.67 min. This is because in fistulectomy we cored out the fistula tract completely after probing and it took time for dissection of the fistula tract and for the identification of structures. In addition, after removal of the fistula tract, closure of the internal opening was performed, which took more time, whereas in fistulotomy we only layed open the tract after probing from the external opening to the internal opening of the fistula; this technique saves time leading to less operative time. According to Zuhair Bashir  , the mean operative time for fistulotomy was 17.3 min and for fistulectomy it was 33 min.
In this study, there was a significant decrease in the postoperative pain perception and need for analgesics in group B, with a mean of 1.53 days, compared with group A, with a mean of 3.53 days; diclofenac sodium ampoule is used twice daily, and we assess how many days the patient needed analgesic. In group A, the pain lasts longer postoperatively because of more dissection around the fistula tract and after coring there is raw area left, whereas in group B laying out the tract with no dissection leaves less raw area leading to less pain postoperatively.
In this study, the postoperative wound infection occurs in one (6.7%) patient in group A and in two (13.3%) patients in group B, with no statistical significance. Wound infection occurs because of bad hygiene of the patients and causes delayed wound healing; this infection was treated early by antibiotics and regular dressing, and there was good response. According to Zuhair Bashir  , wound infection occurred in one (2.27%) patient out of 44 patients managed by fistulectomy and in one (3.12%) patient out of 32 patients managed by fistulotomy, and it was not statistically significant. In our study, postoperative urine retention occurred in two (13.3%) patients in group A and in one (6.7%) patient in group B, with no statistical significance. In our study, none of the patients in both groups suffered from bleeding in the early postoperative period, and this was because of good hemostasis and because of the use of diathermy during operations.
In our study, change in the continence status occurred in one (6.7%) patient scoring 4/20 by WIS in group A and in two (13.3%) patients scoring 4/20 by WIS in group B. No patients suffered from complete incontinence to stool from both groups in our study, and the three patients with partial incontinence to flatus scored 4/20 by Wexner and were assured; this condition was temporary, as the incontinence disappeared after 5-8 weeks and the patients regained complete continence after that. There is no statistically significant difference between the two groups, and assessment also continued during the follow-up period. No complete incontinence occurred in any patient in our study. These results are in accordance with a study of Kronborg  , in which postoperative incontinence for flatus occurred in one (3.85%) patient out of 26 patients managed by fistulotomy, whereas it occurred in three (14.29%) out of 21 patients managed by fistulectomy, with no statistically significant difference between both groups. In addition, according to Belmonte et al.  , in his study on 45 patients, partial incontinence occurs in one (4.16%) out of 24 patients managed by fistulotomy and in three (14.28%) out of 21 patients managed by fistulectomy. According to Zuhair Bashir  , in his study partial (minor) incontinence developed in two (6.25%) out of 32 patients managed by fistulotomy and in five (11.36%) out of 44 patients managed by fistulectomy, with no statistically significant difference.
In our study, no recurrence occurred in any patient from both groups, as we assessed recurrence by persistence of discharge, which, if present in the follow-up period (for 8 months), indicates recurrence. In our study, the discharge stops in all patients and no recurrence occurred. According to Kronborg  , recurrence occurred in three (12.5%) out of 24 patients treated by fistulotomy and in two (9.52%) out of 21 patients treated by fistulectomy, with no statistically significant difference between both groups. According to Qureshi et al.  , recurrence occurred in two (4.44%) out of 45 patients managed by fistulotomy and no recurrence occurred in patients managed by fistulectomy, with no statistically significant differences. According to Zuhair Bashir  , recurrence occurred in two (6.25%) out of 32 patients managed by fistulotomy and in three (6.81%) out of 44 patients managed by fistulectomy, with no statistically significant difference.
In our study, wound healing (complete epithelialization and absence of discharge) was significantly faster in group B, with a mean of 4.07 weeks (28.49 days), which is less than group A, with a mean of 6.47 weeks (45.29 days). This is in agreement with the study by Kronborg  , which was conducted on 47 patients; the mean healing time for the fistulotomy group was 34 days (range: 7-85 days) and it was shorter than the mean healing time for the fistulectomy group, which was 41 days (range: 26-116 days). In addition, this is also in agreement with the study by Zuhair Bashir  conducted on 76 patients, in which the mean healing time for the fistulotomy group was 26.38 days (range: 21-36 days) and was shorter than the time for healing in the fistulectomy group, with a mean of 38.64 days (range: 32-46 days). According to Nazeer et al.  , in a study conducted on 150 patients, the mean healing time for the fistulotomy group was 28 days, which is shorter than the fistulectomy group, with a mean healing time of 40 days.
| Conclusion|| |
Fistulotomy is a simple, easy, and effective method for the treatment of simple perianal fistula, as it has shorter operating time with less postoperative pain and less time needed for wound healing than fistulectomy with the same incidence of postoperative complications, recurrence, and incontinence as fistulectomy.
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Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]