Evaluation of One Stage Lay Open Operation with Primary Sphincter Repair versus Staged Rerouting Operation in Case of High Transsphincteric Perianal Fistula

Abstract

Introduction: Perianal fistula is a chronic anorectal infection that predominantly affects patients in their activeyears of life. Some cases of specific anal fistula, such as Crohn’s fistula, could be treated medically; however, surgeryis the only curative treatment for cryptogenic anal fistula. Operations for anal fistula can be divided into sphincterpreservingand sphincter-sacrificing techniques. The former is known to be associated with more recurrence andless incontinence, whereas the latter is associated with less recurrence and significant postoperative incontinence.Incontinence associated with sphincter-sacrificing operations is related to the amount of sphincter divided, and inhigh arching transsphincteric fistula, the continence mechanism may be seriously affected after fistulotomy.Aim of work: To compare the outcome of one stage lay open operation with primary sphincter repair versus stagedrerouting operation for high trans-sphincteric perianal fistula to detect their effect on recurrence and continence.Patients and methods: 60 consecutive patients with high transsphincteric perianal fistula were enrolled into thestudy by prospective method, after ethical committee approval. All the patients signed an informed written consent.Fistulae were assessed clinically and by MRI when the clinical diagnosis was unclear. Preoperative continencestatus was assessed using the Wexner incontinence score. Preoperative incontinence did not exclude patients fromthe study, but its degree was reported to be compared with postoperative continence status. All operations weredone by expert consultants anorectal surgeons in the Colorectal Surgery Unit, El Demerdash Hospital, Ain ShamsUniversity and Dar El Shifa Hospital in a period of 6 months starting from January 2023 till June 2023.Results: 2 patients (6.7%) developed mild Incontinence, also 2 (6.7%) patients had recurrence among reroutinggroup, while in sphincterotomy with sphincteroplasty 3 patients (10%) had mild incontinence and 3 (10%) patientshad recurrence.Conclusion: Both procedures appear to be valid options in the treatment of a high transsphincteric fistula-in-anowith no preference between them, with a low failure rate and acceptable risk of incontinence. Both procedures arechallenging, so they should be done by an expert specialized surgeon.