Fistulotomy with Primary Sphincter Reconstruction in the Management of Complex Fistula-in-Ano: Prospective Study of Clinical and Manometric Results

BACKGROUND: Complex fistula-in-ano is a frequent source of concern for both patients and surgeons, because of its high rate of recurrence and postoperative anal incontinence. The objective of this study was to assess the results of fistulotomy with sphincter reconstruction in terms of recurrence and anal function. STUDY DESIGN: We conducted a prospective study of 35 patients undergoing fistulotomy with sphincter reconstruction for complex fistula-in-ano. Preoperative and postoperative evaluation included physical examination, anal ultrasonography, and anal manometry, with a 32-month followup. Fecal continence was assessed using the Wexner Continence Grading Scale (0 to 20). RESULTS: Fistulas were classified as high trans-sphincteric in 30 patients (85.7%), suprasphincteric in 4 patients (11.4%), and extrasphincteric in 1 patient (2.9%). Eleven patients (31.4%) reported varying degrees of earlier fecal incontinence. Their mean continence scores decreased from 7.2 to 2.0 (p=0.008) after operation, and all patients improved except for 2, whose scores remained unchanged. On anal manometry, there were significant differences between continent and incontinent patients before operation (maximum resting pressure: 89.2 versus 65.5 mmHg, p=0.013; maximum squeeze pressure: 203.6 versus 148 mmHg, p=0.008) that disappeared after operation (maximum resting pressure: 81.9 versus 70.6 mmHg, p=0.21; maximum squeeze pressure: 199.1 versus 154.8 mmHg, p=0.052). There were neither clinical nor manometric differences between pre- and postoperative values in fully continent patients, although 3 patients (12.5%) reported minor alterations of continence (Wexner<4). Two female patients had recurrences (5.7%), 3 and 6 months after operation, respectively. CONCLUSIONS: Fistulotomy with sphincter reconstruction is an effective resource in the management of complex fistula-in-ano. It improves both anal continence and manometric values in incontinent patients without compromising them in fully continent ones.