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18 Fistulectomy 303
Fig. 19 Wound edges
marsupialization with 2.0
Vicryl running suture
6 Fistulectomy with Sphincter Recons truction
In the last two decades, there has been an increasing interest in immediate reconstruction of the anal sphincter muscle in the setting of fistulectomy in order to
mitigate the risk of incontinence. Most of the available literature on this modification
of fistulectomy has focused on the functional outcome by the addition of the
sphincter repair. Seyfried and co lleagues reported their experience with fistulectomy
with immediate primary sphincter reconstruction in all patients who underwent the
procedure in a single coloproctology unit between 2003 and 2015 (Seyfried et al.
2018). During a mean follow-up of 11 months (range 7 to 200 months), primary
healing was noted in 374 out of 424 patients (88.2%) with a secondary healing rate
of 95.8% in patients who underwent revisional surgery. Hirschburger and colleagues
published their results with fistulectomy and primary sphincter reconstruction in the
treatment of high trans-sphincteric anal fistula (Hirschburger et al. 2014). Fifty
patients underwent the operation for fistula of cryptoglandular origin between
2005 and 2008. Of these, 22 patients (44%) had a previous proctologic operation
and 11 patients (22%) presented with recurrent fistula. Mean operative time was
28 minutes. During a mean follow-up of 22 months, the overall healing rate was
noted in 44 patients (88%). Five pati ents (10%) developed recurrence after healing
304 M. A. Abbas
Fig. 20 The final appearance
of an open marsupialized
wound to allow for proper
drainage and minimize
postoperative sepsis
and one patient (2%) never healed. Farag and colleagues from Egypt conducted a
prospective cohort study in patients with complex high perianal fistula (Farag et al.
2019). A one stage fistula excision with anal sphincter reconstruction without fecal
diversion was performed in 175 patients. After wound healing, the patients were
followed up for 1 year to assess for recurrence and function. Recurrence was noted in
eight patients at 3 months and six patients between 6 and 9 months. MRI imaging
was carried out to assess healing and two additional patients were noted to have an
occult fistula with a high abscess cavity. The overall recurrence rate was 9.1%
(16 out of 175 patients).
In the study report ed by Seyfried and colleagues, 148 out of 424 patients were
evaluated for incontinence with a questionnaire (Seyfried et al. 2018). Preoperatively, some minor degree of continence disturbance was noted in 9.6% of the
patients. Postoperatively 34 patients (23%) reported incontinence disorders as follow: incontinence to flatus in 23 patients (15.5%), incontinence to liquids in
10 patients (6.8%), and incontinence to solid stool in one patient (0.7%). In their
retrospective review of 50 patients with high fistula, Hirschburger and colleagues
noted a slight but significant increase in the postoperative clinical continence score
compared to baseline (Hirschburger et al. 2014). Three patients developed incontinence to flatus. In their study, Farag and colleagues evaluated the continence level of
their patients using the Cleveland Clinic Florida incontinence score (Farag et al.
2019). Four out of 175 patients (2.3%) developed continence disturbance: two
18 Fistulectomy 305
patients with gas incontinence and two patients with soiling. Lux and Athanasiadis
performed a prospective study to assess the functional results following fistulectomy
with primary muscle suture in high anal fistula (Lux and Athanasiadis 1991). Fortysix patients were evaluated: 26 patients with no prior operation and 20 patients with
previous operation. Five out of the 26 patients (19.2%) without prior operation
developed incontinence to liquid stool. No incontinence to solid stool was noted.
Roig and colleagues reported their preliminary experience in patients undergoing
sphincter repair in the setting of fistulectomy for complex anal fistulas (Roig et al.
1999). A total of 31 patients deemed at risk for postoperative incontinence
underwent the sphincter repair immediately foll owing fistulectomy. Of these
patients, 25 (80.6%) had high trans-sphincteric fistula, four (12.9%) had low transsphincteric fistula, and two (6.5%) were classified as supra-sphincteric fistula.
Postoperative infection and dehiscence of the muscle repair was noted in one patient
(3.2%) and fistula recurrence was noted in three patients (9.7%). During a median
follow-up of 24 months, out of 25 patients with full preoperative continence, five
patients (20%) presented with anal soiling and one patient (4%) with gas incontinence. The same group published a subsequent larger retrospective study to report
their experience with 146 patients (Roig et al. 2010). Seventy -five patients who
underwent immediate sphincter repair after fistulectomy were compared to
71 patients who underwent an endorectal advancement flap repair. The complex
fistulas were cryptoglandular in origin and included recurrent fistulas (28.7%), transsphincteric (67.1%), and supra-sphincteric (25.3%). Some degree of continence
disturbance was noted in 11 patients (15.5%) in the flap group compared to
15 patients (20%) who underwent fistulectomy with repair. During a mean followup of 14 months (range 12 to 60 months), persistent or recurrent fistula was noted in
18.3% of the flap group compared to 10.6% of the fistulectomy with primary
sphincter reconstruction. Postoperatively, continence disturbance was noted in
43.6% of the patients who underwent a flap compared to 21.3% of the patients
who underwent the fistulectomy with muscle repair. However, no changes were
observed with the Faecal Incontinence Quality of Life Scale (FIQLS).
7 Conclusions
Fistulectomy is an acceptable treatment option for some patients with anal fistula. As
outlined in this chapter, the proper evaluation and selection of the patient is very
important to ensure the appropriate choice of this technique for patients who would
benefit the most. I have offered in this chapter my personal approach to the patient
with anal fistula and I clearly note that this approach is derived from a personal
experience and evaluation of a scientific literat ure plagued by the heterogeneity of
incomplete data and lack of standardization. A customized approach is in order for
every patient and it is incumbent for surgeons treating anal fistula to be familiar with
the various operative techniques as “one size does not fit all” when it comes to
managing this condition. However, when patients are properly selected, fistulectomy
can yield a high healing rate. Furthermore, the technical conduct of the operation is
306 M. A. Abbas
of paramount importance to minimize any continence disturbance. The judicious
conduct of the coring-out technique with minimal resection of surrounding sphincter
muscle or the addition of immediate primary sphincter repair for patient undergoing
division and excision of the tract can hopefully min imize any continence
disturbance.
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Utility of Adding Sphincter Reconstruction to Fistulotomy/Fistulectomy
Alexander Herold
Contents
1 Introduction . ............... .................................................................. 310
2 General Classification ........................................ ............................... 310
3 Preoperative Preparation ... . . . . ....... . . . . ....... . . . . . ...... . . . . . ..... . . . . . . ....... . . . . ..... 311
4 Surgical Technique Step by Step ............................................................ 312
5 Results .............................. ....................................................... .. 318
6 Conclusion ................................................................................... 319
7 Cross-References .......................... ............................................. ..... 320
References ............................ ............................................... ............ 320
Abstract
Despite modern surgical techniques, anal fistulas are still a challenge in colorectal
surgery. In former years, the standard of care was complete fistulectomy with a
high rate of continence disorders. Over the past 20–30 years, sphincter-saving
procedures have gained wide acceptance. They represent the technique used in
these cases. Also, many patients stayed wi th a long-term seton as definite
treatment. The main problem of all surgical possibilities is a high recurrence
rate with 30–50% in flap procedures and 100% of persistence in seton treatments.
In recent years we started to do a direct repair (primary reconstruction) in distal
fistulas with excellent results and evolved our technique for proximal (high) anal
fistulas. Our results demonstrated that fistulectomy with primary sphincter recon-
struction is a safe and feasible procedure for both distal and intermediate trans-
sphincteric fistulas alike, showing higher rates of healing than other procedures.
Even in proximal (high) transsphincteric and suprasphincteric fistulas, the proce-
dure shows comparable healing rates compared to other procedures. Continence
disorders are of minor relevance and consequence for these patients.
19
A. Herold (*)
Deutsches End- und Dickdarm-Zentrum, Mannheim, Germany
e-mail: a.herold@enddarm-zentrum.de
© Springer Nature Switzerland AG 2022
C. Ratto et al. (eds.), Anal Fistula and Abscess, Coloproctology,
https://doi.org/10.1007/978-3-030-76670-2_21
309
310 A. Herold
Keywords
Anal fistula · Operation · Therapy · Fistulectomy · Anal sphincter · Primary
reconstruction · Continence · Dehiscence · Recurrence
1 Introduction
Even today, anal fistulas are bothersome for the patient and a challenge for colorectal
surgeons. The higher – meaning proximal – the course of the fistula’s tract runs, the
more sphincter muscle is engaged. With the amount of sphincter musc le, the
difficulty in treatment is increasing. In former years, the standard of care was a
complete fistulectomy or fistulotomy, causing continence disorders (Ommer et al.
2011). The more sphincter muscle is involved in a fistulectomy or fistulotomy, the
higher is the risk for incontinence. Although in former years and up to now the
responsible surgeon was cautious, the rate of incontinence ranges from 0 up to 45%.
To overcome these disturbances, cutting setons were used. Their results were
accompanied by a 46% rate of incontinence for gas, 70% of incontinence for liquids,
and 18% for solid stool. For transsphincteric fistulas, 31%, and, for suprasphincteric
tracts, 53% of overall continence disorders were reported (Ritchie et al. 2009).
Because of this, there was a shift towards sphincter sparing procedures. Over the
past 20–30 years, flap procedures ha ve gained wide acceptance and were used in
these cases. Their results for non-Crohn’s fistulas range from 50% to 90% depending
on the different types of fistulas. So, in the last years, several new options – mostly
technical developments – appeared on the market: several plug procedures, over the
scope clip proctology (OTSC), laser-fistula procedure, radiofrequency, videoassisted anal fistula treatment (VAAFT), and lastly ligation of the intersphincteric
fistula tract (LIFT). Overall, they all showed some success in distal fistulas. Especially in proximal (high) fistulas, the healing rates are still far below 100%.
Because they all can be summarized under “sphincter-sparing procedures,” their
major drawback was no more disturbance of continence. The main complication of
all of these surgical possibilities is still a high rate of recurring and persisting fistulas,
ranging from a recurrence of 30–50% in flap procedures and 100% in seton
placements (Ommer et al. 2011).
2 General Classification
Anal fistulas are mostly classified using the same system as abscesses according to
their anatomic relation to the anal sphincter. In nearly all – except extrasphincteric
fistulas – the origin is cryptoglandular, and therefore the internal opening lies at the
dentate line (Parks et al. 1976):
19 Utility of Adding Sphincter Reconstruction to Fistulotomy/Fistulectomy 311
• Submucosal (synonym: subanodermal): they run under the anoderm or the rectal
mucosa.
• Intersphincteric: they cross the internal sphincter and reach the skin mostly near
the anus.
• Transsphincteric: they cross the internal and external sphincter, protrude the
ischioanal fossa, and reach the external skin mostly a few cm from the anus.
Depending on their height, we should distinguish distal (low), intermediate (mid),
and proximal (high) positions. Some authors describe their location depending on
the affected third of the anal sphincter.
• Suprasphincteric: they cross the internal sphincter, run proximally in the
intersphincteric plane, run curved around the complete external sphincter, and
reached the skin.
• Extrasphincteric: they originate in the distal rectum, pass through the retrorectal
space and the pelvic floor from proximally, protrude the ischioanal fossa, and
reach the skin.
Surgeons often differentiate into simple and complex fistulas: some state that
complex is more than 1/3 of the sphincter affected, but others use 1/2 of the
sphincter. And on the other side, other authors define complex as Crohn’s fistulas,
rectovaginal, multiple tracts, and others. Therefore, very often it is not possible to
compare the results of different studies with each other. From our standpoint the
above classifications were useful in the past and for overall general use, but they are
no more sufficient for expert treatments and modern procedures and statistical
evaluation.
Direct repairs in distal fistulas, via the use of primary reconstruction, began more
than 10 years ago and produced excellent results (Herold et al. 2009). This success
allowed surgeons to expand such surgical techniques to incorporate intermediate and
proximal (high) anal fistulas as well.
3 Preoperative Preparation
Primarily, patients present with a primary abscess or a chronic inflammation of a
residual fistula tract. Therefore, it is necessary to reduce inflammation with wide
abscess excisions or partial fistulectomies and to place a seton for at least 12 weeks.
After complete resolution of the inflammation, patients were planned for
fistulectomy with primary sphincter reconstruction.
Before surgery all patients might receive a complete bowel lavage and preoperative single-shot antibiotics, because to date no results are available as to whether no
bowel cleaning might be equivalent or superior in accordance to other large bowel
surgeries. In our experience emptying the rectum with a laxative suppository or a
klysma is sufficient. The mode of cleaning the rectum and diet after surgery seems of
little or no negative influence. No special preparation is mandatory.
312 A. Herold
4 Surgical Technique Step by Step
First, the fistula situation and precise location are examined again to check its
operative suitability. This entails the tract being probed with a fine fistula probe.
Via palpation, the amount of involved muscle can be estimated. In the vast majority
of patients, the internal orifice lies at the dentate line. The length of the fistula differs
from case to case and depends on whether the course of the tract is straight or curved.
Comparable internal and external openings might involve different amounts of the
sphincter muscle. At this point of the procedure, it is decided to proceed with
fistulectomy and primary reconstruction or to change to any other surgical technique
(Fig. 1).
After placing an anal retractor (Parks retractor, Ferguson retractor, or any other),
the incision starts directly distally of the internal opening from the anoderm to the
anocutaneous line (Fig. 2).
Fig. 1 Proximal
transsphincteric fistula an
6o’clock with seton and
probe
Fig. 2 Segmental straight
incision starting at the internal
opening
19 Utility of Adding Sphincter Reconstruction to Fistulotomy/Fistulectomy 313
Fig. 3 Excision of the scar
and cavities lateral to the
sphincter muscle
Fig. 4 Incision of the
sphincter muscle distal to the
fistula
From there, the external opening is excised in an elliptical form including the
lateral scar. After the dissection of all of the subcutaneous tissue, the fistula tract is
gently excised as far to the outer border of the external sphincter as possible. Now, all
lateral fistula cavities and scar tissue are excised; till this point the external sphincter
muscle is not touched and affected. Through this the later lateral drainage is enabled.
This is the last stage of the operation, where it is still feasible to alter techniques, if
the planned operation seems unsuitable (Fig. 3).
The sphincter muscle is then incised vertically, starting distally until the fistula
tract is reached (Fig. 4). Practically, one starts from the distal external side. This lay
open allows an ideal view of the tract and all surrounding tissue. No other
technique allows better exposure. In many cases, not a single tract will be found,
but instead, residual cavities and holes, especially in the proximal portion of the
sphincter. This technique allows these to be visualized, so that excision can be