Surgery for Fistula-in-Ano in a Specialist Colorectal Unit: a Critical Appraisal
Pierpaolo Sileri*1, Livia Biancone2, Vito M. Stolfi1, Giovanna Del Vecchio Blanco2, Valeria Fiaschetti4, Carmen Petruzziello2, Sara Onali2, Emma Calabrese2, Giampiero Palmieri3, Francesco Pallone2, Achille Gaspari1
1Surgery, University of Rome Tor Vergata, Rome, Italy; 2Gastroenterology, University of Rome Tor Vergata, Rome, Italy; 3Pathology, University of Rome Tor Vergata, Rome, Italy; 4Radiology, University of Rome Tor Vergata, Rome, Italy
Background: The balance of the occasional conflicting outcomes of cure and continence after fistula-in-ano management is challenging. We reviewed the outcome of surgical management of fistula related or not to Inflammatory Bowel Disease (IBD) in a specialist colorectal unit.Methods: From 02/02 to 10/08, 113 consecutive patients underwent 140 procedures. Data on fistula morphology, underlying disease, surgical procedure, healing period, morbidity of surgery and fistula recurrence were prospectively collected and analyzed according to aetiology: Cryptoglandular (C) and associated to IBD (IBD). Results: demographics, fistula type and treatment results are shown in table 1. As expected, single tract fistulae were more common in C compared to IBD (86% vs 28%, p=0.001). Primary fistulotomy (52%) was the most common procedure. Staged fistulotomy was performed in 35% of cases, more commonly in IBD group. Advancement flap was performed in 5% of patients. Additional procedures were fistulectomy (4%) and fibrin glue injection (5%). Three patients required fecal diversion. Median number of procedures/patient was higher in IBD compared to C (2 vs 1; p 0.04). Inpatient length of stay was longer for IBD (3.7 days vs 1.3, p 0.002). Imaging accuracy for fistula was 93% for MRI and 94% for ultrasound. Of the IBD patients, 33% were also treated with anti-TNFα. One patient was found to have squamous carcinoma along the fistula tract. Conclusions: The majority of idiopatic fistulae were treated by primary fistulotomy or staged fistulotomy with low recurrence rate and no permanent incontinence. Conversely, IBD fistulae required additional imaging, complex and further procedures as well as multidisciplinary approach.
Table I: patients's demographics, fistula type and treatment results.
| CRYPTOGLANDULAR | IBD | p | |
| NUMBER | 83 | 30 | |
| AGE | 43+/-14 | 43+/-16 | 0.43 |
| FISTULA CLASSIFICATION | |||
| inter-sphincteric | 65.9% | 30.3% | 0.0001 |
| trans-sphincteric | 26.3% | 56.0% | 0.0002 |
| extra-sphincteric | 6.6% | 6.0% | 0.976 |
| supra-sphincteric | 1.1% | 7.6% | 0.083 |
| N° of TRACTS (1/>2) | 86%/14% | 28%/72% | 0.0001 |
| PREOPERATIVE IMAGING | 23.6% | 73.3% | <0.0001 |
| CONCOMITANT ABSCESS DRAINAGE | 32.5% | 86.6% | <0.0001 |
| PRINCIPAL SURGERY | |||
| single stage fistulotomy | 68.6% | 25.9% | <0.0001 |
| staged fistulotomy | 27.9% | 46.2% | 0.028 |
| advancement flap | 1.2% | 9.2% | 0.031 |
| MEAN FOLLOW-UP(months) | 25+/-16 | 13+/-11 | 0.0001 |
| RECURRENCE RATE | 6% | 30% | 0.001 |
| INCONTINENCE | 0% | 10% | 0.017 |
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