Highlight
– Fistulotomy with primary sphincteroplasty achieves a 91.9% primary healing rate and 96.9% final success rate in complex anal fistulas.
– Recurrence occurred in 8.1% of cases, with a low persistent recurrence rate of 3.1% after retreatment.
– No major fecal incontinence was observed; minor incontinence affected less than 5% of patients.
– Risk factors for recurrence include female gender, diabetes, smoking, higher BMI, and longer operative time.
Study Background
Complex anal fistulas represent a challenging subset of anorectal disease due to their intricate anatomy, high likelihood of recurrence, and potential for compromising continence. Surgical management aims to eradicate the fistulous tract while preserving the anal sphincter complex to prevent fecal incontinence. Conventional fistulotomy, though effective for simple fistulas, carries considerable risk when applied to complex fistulas due to extensive sphincter division. Primary sphincteroplasty performed concurrently has emerged as a strategy to reconstruct disrupted sphincter fibers, potentially reducing postoperative incontinence.
Despite promising clinical rationale, widespread adoption of fistulotomy combined with primary sphincteroplasty has been limited by concerns surrounding functional outcomes, particularly fecal incontinence. Therefore, robust evidence on both long-term healing rates and continence preservation is needed to guide surgical decision-making.
Study Design
This investigation was a retrospective cohort study conducted at the University Hospital of Mersin, Turkey, including 382 patients with complex cryptoglandular anal fistulas treated between January 2013 and January 2023. All procedures were performed by three expert colorectal surgeons using a standardized surgical technique comprising fistulotomy and immediate primary sphincteroplasty.
The primary endpoints were fistula healing, recurrence rates, and continence status assessed by the Wexner incontinence score. Follow-up was on average 52.5 months, allowing meaningful analysis of long-term clinical and functional outcomes. Multivariate analyses were conducted to identify independent predictors of fistula recurrence.
Key Findings
The patient cohort was predominantly male (72.5%) with a mean age of 42.1 years and a broad representation of metabolic risk factors. The primary success rate, defined as complete fistula healing without recurrence after initial surgery, was 91.9% (351/382). Recurrence was observed in 31 patients (8.1%), most of whom underwent successful redo surgery with the same technique, resulting in a final persistent recurrence rate of 3.1%. Thus, overall treatment efficacy reached 96.9%.
Regarding functional outcomes, no patients reported major fecal incontinence, a significant concern with extensive sphincter division surgeries. Minor incontinence was documented in only 4.9% of patients, highlighting the sphincterrepair technique’s protective effect. Continence outcomes were monitored via the Wexner score, a validated scale quantifying incontinence severity.
Multivariate regression identified female sex, diabetes mellitus, active smoking, body mass index (BMI) above 28 kg/m2, and operative time exceeding 60 minutes as independent risk factors associated with recurrence. These findings underscore the influence of systemic and procedural variables on fistula healing.
Expert Commentary
The high success rates and low complication profile reported align with emerging evidence supporting the combined approach of fistulotomy with primary sphincteroplasty in managing complex anal fistulas. By repairing the sphincter immediately during initial surgery, this technique may mitigate the risk of postoperative incontinence traditionally associated with fistulotomy alone.
However, the study’s retrospective, single-center design warrants cautious interpretation. The excellent outcomes likely reflect the surgeons’ high expertise and consistent technique. Generalizability may be limited in centers with less experience or variability in surgical approaches.
Additionally, risk factors for recurrence, such as diabetes and smoking, highlight modifiable targets for optimizing patient outcomes through comprehensive preoperative counseling and medical management.
Current guidelines, such as those from the American Society of Colon and Rectal Surgeons, emphasize individualized treatment balancing cure and continence. This study offers supportive evidence to consider fistulotomy with primary sphincteroplasty as a viable option for complex cases when performed by skilled surgical teams.
Conclusion
Fistulotomy with primary sphincteroplasty demonstrates excellent long-term efficacy in treating complex cryptoglandular anal fistulas, achieving durable healing rates above 90% with minimal impact on continence. This single-stage surgical approach effectively addresses the dual challenge of fistula eradication and sphincter preservation.
While favorable functional outcomes reduce concerns about postoperative fecal incontinence, careful patient selection and surgeon experience remain crucial. Future prospective, multicenter studies will be valuable to confirm these findings and further refine patient stratification and perioperative management to optimize results.
Funding and Clinical Trials
No information on funding sources or clinical trial registrations was provided in the original report.
References
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2. Temtanakitpaisan T, Sahakitrungruang C, Tantiphlachiva K. Primary sphincteroplasty for complex anal fistula: A systematic review and meta-analysis. Dis Colon Rectum. 2020;63(5):626-634.
3. Garcia-Aguilar J, Belmonte C, Wong WD, et al. Anal fistula surgery and considerations for preserving continence. Ann Surg. 1996;224(2):229-235.
4. American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Management of Anal Fistula. Dis Colon Rectum. 2016;59(12):1117-1133.
