Non-cure, recurrence and faecal incontinence have often been a major challenge in patients after surgical treatment for anal fistula. To overcome these problems, we have developed a sphincter-preserving total fistulectomy procedure involving resection of the anoderm and skin with intersphincteric space closure (TFRAS). The purpose of the present study was to evaluate this TFRAS technique. TFRAS was performed in 618 patients. The method involved excision of the anoderm and skin, including the internal opening, total removal of the fistula tract while preserving the sphincter, closure of the resulting intersphincteric space and open wound. The Parks classification was used, and subcutaneous, supralevatoric, and unclassifiable fistulas not included in this classification were newly defined and evaluated. The postoperative cure rate was 97.7% and the recurrence rate was 0.7%. The non-cure rate was significantly higher for supralevatoric fistulas and the recurrence rate was significantly higher for unclassifiable fistulas. No cases of postoperative solid faecal incontinence were observed, and the faecal incontinence rate was 0.7%. The mean postoperative Cleveland Clinic Faecal Incontinence (CCFI) score was 0.9, and the highest value of 8 was observed in only one case. No significant differences were found between the classifications based on faecal incontinence rates and the CCFI score. There was no significant difference in CCFI score between patients who underwent TFRAS at only one site and those who did so at two or more sites. TFRAS is considered a useful technique for anal fistulas, offering a high cure rate, a low recurrence rate, and no severe postoperative faecal incontinence.

Fistulotomy is considered the most effective treatment for anal fistula; however, it carries a risk of incontinence. Sphincteroplasty in the setting of fistulotomy is not standard practice due to concerns regarding healing and potential infectious complications. We aimed to compare the outcomes of patients who underwent fistulotomy with primary sphincteroplasty to those who did not undergo repair.

This was a retrospective review of consecutive patients who underwent fistulotomy for cryptoglandular anal fistula. All operations were performed by one colorectal surgeon. Sphincteroplasty was performed for patients perceived to be at higher risk for continence disturbance. The main outcome measures were the healing rate and postoperative septic complications.

In total, 152 patients were analyzed. Group A (fistulotomy with sphincteroplasty) consisted of 45 patients and group B (fistulotomy alone) included 107 patients. Both groups were similar in age (P=0.16) and sex (P=0.20). Group A had higher proportions of multiple fistulas (26.7% vs. 6.5%, P<0.01) and complex fistulas (mid to high transsphincteric, 37.8% vs. 10.3%; P<0.01) than group B. The median follow-up time was 8 weeks. The overall healing rate was similar in both groups (93.3% vs. 90.6%, P=0.76). No significant difference between the 2 groups was noted in septic complications (6.7% vs. 3.7%, P=0.42).

Fistulotomy with primary sphincter repair demonstrated a comparable healing rate to fistulotomy alone, without an increased risk of postoperative septic complications. Further prospective randomized studies are needed to confirm these findings and to explore the functional outcomes of patients who undergo sphincteroplasty.

Cryptoglandular anal fistulas are one of the most common colorectal diseases and occur with an incidence of about 20/100,000. Anal fistulas are defined as an inflammatory junction between the anal canal and the perianal skin. They develop from an abscess or chronic infection of the anorectum. Surgical treatment of the disease is the method of choice. Even when treating an acute abscess, its cause should be sought at the same time. If there is a connection to the anal canal without affecting relevant parts of the sphincter muscles, primary fistulotomy should be performed. If larger parts of the sphincter muscle are involved, the insertion of a seton drain is usually useful. There are essentially two recommendations for the elective treatment of cryptoglandular anal fistulas. Distal fistulas should be excised, with the proviso that as little sphincter muscle as possible is sacrificed. In the case of highly proximally located and complex fistulas, sphincter-preserving surgical techniques should be used. In this case, the method of choice is the mucosal or advancement flap. Alternatively, clips, fibrin injections, fistula plugs, fistula ligatures, or laser-based procedures are described in the literature. In the case of intermediate fistulas, a fistulectomy with primary sphincter reconstruction can be useful. Every operation is carried out as a compromise between definitive healing of the fistula and a potential risk to the patient's continence. It is often difficult to make a reliable prognosis about the continence function to be expected postoperatively. In addition to the fistula morphology, particular attention should be paid to whether previous proctological operations have already been performed, the gender of the patient, and whether there are pre-existing sphincter dysfunctions. Since the surgeon's expertise plays a decisive role in the success of the treatment, the procedure should be carried out in a specialist proctological centre, especially in the case of complex fistulas or in the case of a condition after previous operations. In addition to the classic procedures, such as fistulectomy or the plastic fistula closure, this article examines alternative methods and their areas of application.

Complete tract excision for complex fistula-in-ano, where the sphincter, is divided is increasingly being followed by immediate sphincter repair. We concluded, by a prospective study conducted on 60 consecutive patients, that this procedure is feasible and safe, and polydioxanone and polyglactin 910 in repair result in a comparable outcome.

Treatment of complex fistula-in-ano is challenging and there is no consensus on the optimal treatment that can provide complete healing and preserve sphincter function. The aim of this study was to evaluate fistulotomy with external tract fistulectomy and primary sphincter reconstruction (FFSR) in the treatment of high trans-sphincteric fistula.

This is a prospective single-centre study including patients with a high trans-sphincteric fistula who underwent FFSR from June 2017 to June 2018. All patients were evaluated preoperatively by pelvic MRI and clinical examination. Other types of complex fistula were excluded. All patients were followed up for 1 year for recurrence and incontinence.

Forty patients underwent FFSR during the study period, 62.5% were men and the mean age was 37.45 (range 20-60) years. The mean time to achieve complete healing was 8.4 weeks, 35 (87.5%) patients achieved primary healing within 8 weeks and 5 (12.5%) patients required more time to achieve delayed healing. Four (10%) patients developed recurrence with a mean time for recurrence of 20 weeks. Only four (10%) patients developed incontinence; one to liquid stools and three patients only to gas.

Fistulotomy with external tract fistulectomy and primary sphincter reconstruction is a safe option in the treatment of high trans-sphincteric fistula in selected patients. This showed an acceptable recurrence rate when compared with other procedures with comparable sphincter function outcomes.

Treating complex perianal fistulas in Crohn's disease patients remains a challenge. Classical surgical treatments for Crohn's disease fistulas have been extrapolated from cryptoglandular fistulas treatment, which have different etiology, and this might interfere with its effectiveness, in addition, they increase fecal incontinence risk. Recently, new surgical techniques with support from biological approaches, like stem cells, have been developed to preserve the function of the sphincter. We have performed a systematic literature review to compare the results of these different techniques in the treatment of Crohn's or Cryptoglandular fistula.

PubMed, EMBASE, Database of Abstracts of Reviews of Effectiveness, Cochrane Central Register of Controlled Trials were searched systematically for relevant articles. We included randomized controlled trials and observational studies that referred to humans, were written in English, included adults 18+ years old, and were published during the 10-year period from 2/01/2010 to 2/29/2020. Evidence level was assigned as designated by the Scottish Intercollegiate Guidelines Network.

Of the 577 citations screened, a total of 79 were ultimately included in our review. In Crohn's disease patients, classical techniques such as primarily seton, Ligation of Intersphincteric Fistula Tracks, or lay open, healing rates were approximately 50-60%, while in cryptoglandular fistula were around, 70-80% for setons or flaps. In Crohn's disease patients, new surgical techniques using derivatives of adipose tissue reported healing rates exceeding 70%, stem cells-treated patients achieved higher combined remission versus controls (56.3% vs 38.6%, p = 0.010), mesenchymal cells reported a healing rate of 80% at week 12. In patients with cryptoglandular fistulas, a healing rate of 70% using derivatives of adipose tissue or platelets was achieved, and a healing rate of 80% was achieved using laser technology. Fecal incontinence was improved after the use of autologous platelet growth factors and Nitinol Clips.

New surgical techniques showed better healing rates in Crohn's disease patients than classical techniques, which have better results in cryptoglandular fistula than in Crohn's disease. Healing rates for complex cryptoglandular fistulas were similar between the classic and new techniques, being the new techniques less invasive; the incontinence rate improved with the current techniques.

Currently, there is no agreement on the best treatment for complex anal fistulas with the least recurrence and lowest complication rate. The aim of this study was to evaluate the long-term recurrence and incontinence after fistulectomy and primary sphincteroplasty (FIPS) in a group of patients with complex perianal fistula.

This prospective observational study was done at the colorectal ward of Taleghani Hospital of Tehran from January 2010 to December 2020. Patients with anal fistula who underwent FIPS were studied. After surgery, patients were evaluated regularly by a colorectal surgeon for fistula recurrence and incontinence. Recurrence was described as a new fistula tract formation after the initial cure and failure of healing in the operation site or any purulent discharge from the fistula tract and openings. In addition, the patient's continence was assessed based on the Wexner score.

There were 335 patients (66 men and 269 women, mean age 42.74 ± 12.44 years), 191 of them with low fistula and 144 with high fistula. Thirteen patients (3.90%) experienced recurrence (all had a low fistula). Thirty-nine patients (11.64%), 19 patients with high and 20 patients with low fistula, had a Wexner score ≥ 3 during the follow-up. Fifteen patients were lost to follow-up. Male patients (OR = 2.67, 95% CI 0.84, 8.45, p = 0.094, adjusted OR = 4.41, 95% CI 1.05, 18.48, p = 0.042), patients with low fistula (p = 0.001), and recurrent cases had a significantly higher rate of recurrence (OR = 10.38, 95% CI 3.24-33.20 p ≤ 0.001, adjusted OR = 23.36, 95% CI 4.35-125.39, p ≤ 0.001). A significant correlation between body mass index > 35 kg/m² and incontinence was found (OR = 4.40, 95% CI 1.35, 14.33, p = 0.014).

In the present study, an acceptable healing rate and a low percentage of complications following FIPS were seen in patients with complex anal fistula. Randomized clinical trials with appropriate follow-up duration and sample size comparing different surgical methods in these patients are needed to confirm these results.

This systematic review aimed to assess the outcomes of fistulotomy or fistulectomy and immediate sphincter repair (FISR) in relation to healing, incontinence and sphincter dehiscence both overall and in patients with high anal fistulae.

Medline, Embase and The Cochrane library were searched for studies of patients undergoing FISR for anal fistula. Data regarding healing, continence and sphincter dehiscence were extracted overall and for high anal fistulae. The DerSimonian-Laird random-effects method was used for pooled analysis, heterogeneity between studies was assessed based on the significance of between-study heterogeneity, and on the size of the I²  value. Risk of bias was assessed using the Cochrane risk of bias tool and the Newcastle-Ottawa scale.

We identified 21 studies evaluating 1700 patients. Pooled analysis of healing reached 93% (95% CI: 91%-95%, I²  = 51% p-value for heterogeneity = 0.004), with continence disturbance and worsening continence reaching 11% (95% CI: 6%-18%, I²  = 87% p < 0.001) and 8% (95% CI: 4%-13%, I²  = 74% p < 0.001), respectively. Subgroup analysis according to fistula height could only be conducted on limited data. Pooled healing in high anal fistulae was 89% (95% CI: 84%-94%, I²  = 76% p < 0.001), 16% suffered disturbance of continence (95% CI: 7%-27%, I²  = 89% p < 0.001), 8% worsening continence from baseline (95% CI: 2%-16%, I²  = 80% p < 0.001) and 2% suffered sphincter dehiscence (95% CI: 0%-10%, I²  = 89% p < 0.001).

The evidence suggests FISR is a safe, effective procedure. However, data are limited by inconsistencies in reporting of continence and definition of fistula height, particularly high anal fistulae. Significant heterogeneity means that outcomes in high fistulae remain uncertain.

Bowel movements after reconstructive anorectal surgery may negatively affect surgical outcome. This study was aimed to assess any differences between a standard diet (SD) and the enteral resorbable diet (ED) in terms of operative outcomes and patient tolerance after fistulectomy with primary sphincter reconstruction.

Adult patients undergoing elective fistulectomy with primary sphincter reconstruction for anorectal and rectovaginal fistulas were eligible for inclusion. Patients were intraoperatively randomised to receive either the ED and peristalsis-inhibiting medication (ED) or a SD. The primary endpoint was the healing rate. Secondary endpoints included continence scores, complications and quality of life. Sample size calculation resulted in the analysis of 60 patients to detect a difference in fistula recurrence of 30% with 70% power and a 5% significance level.

Sixty-six patients (24 women) were prospectively and randomly assigned to the ED (n = 34: 51%) or a SD (n = 32; 48%); mean age was 47 (18-74) years. The primary healing rate was 64 out of 66 patients (96%). No statistical difference in healing rate was seen between the groups. However, patient satisfaction was significantly higher in the SD group (P < 0.0001).

Fistulectomy with primary sphincter reconstruction is a safe method with low complication rates. Postoperative stool behaviour has no significant influence on the healing rate but has a significant negative impact on patient satisfaction. Therefore, maintaining a standard diet seems to be preferable following reconstructive anal surgery.

The trial was registered with the German Clinical Trials Register ( DRKS00020524 ).

Anal fistula is by definition the communication between the rectum or anal canal with the perineal region, which may be epithelialized and has cryptoglandular origin in 90% of cases. There are a large number of techniques for successfully treating trans-sphincteric fistulas of 20-50%, including primary sphincteroplasty, but it is not clear whether the material used would influence the outcome.

To analyze the efficacy of polydioxanone and polypropylene wire in primary post-fistulotomy sphincteroplasty in the treatment of trans-sphincteric fistulas in rats.

Thirty Wistar rats had transfixation of the anal sphincter with steel wire, which remained for 30 days for the development of the anal fistula. After this period, it was removed and four groups were formed: A (control) without treatment; B (fistulotomy) submitted to such procedure and curettage only; C (polidioxanone) in which sphincteroplasty was performed after fistulotomy with polydioxanone wire; D (polypropylene) submitted to the same treatment as group C, but with polypropylene wire. After 30 days, euthanasia and removal of the specimens were performed for qualitative histopathological analysis, measurement of the area between the muscular cables edges and evaluation of the degree of local fibrosis.

There was persistence of the anal fistula in all animals of group A. There were no significant differences between groups B, C and D regarding the distance of the muscular cables (p=0.078) and the degree of fibrosis caused by the different treatments (p=0.373).

There was no difference between polydioxanone and polypropylene wires in post-fistulotomy primary sphincteroplasty, and this technique was not superior to simple fistulotomy in relation to the distance of the muscular cables nor did it present differences in relation to the degree of local fibrosis.

Despite modern medical techniques, anatomically proximal (high) anal fistulas are still a challenge in colorectal surgery. In previous years, the standard of care was complete fistulectomy with a high rate of continence disorders. Over the past 20 to 30 years, sphincter-saving procedures have gained wide acceptance. They represent the technique used in these cases. Additionally, many patients received indefinite treatment, namely the placement of a seton to maintain surgical drainage. The main problem with all fistula surgical possibilities is the high recurrence rate of 30 to 50% in flap procedures and 100% persistence in seton treatments. In recent years, a direct repair (primary reconstruction) in distal fistulas was instigated and shows excellent results. It allowed our technique for proximal (high) anal fistulas to evolve.

All patients who underwent surgery at the University Medical Center Mannheim, Department of Colo-proctology (from 06/2003 to 11/2015), were retrospectively evaluated using a prospective database. Patients who underwent fistulectomy with primary sphincter reconstruction were all included.

The primary healing rate, after a mean follow-up of 11 months (7 to 200 months), was 88.2% (374 of 424). Taking into account revisionary surgeries with secondary sphincter repair, this rate reaches 95.8% (406 of 424). Factors such as gender and fistula location as related to the sphincter had significant influence on the study outcome, whereas variables such as the amount of reconstructed muscle (in mm), number of revisions, patient age, other anal operations, and concomitant medication did not. The incontinence of a subgroup of 148 patients was evaluated in detail by way of a questionnaire. Even at a preoperative baseline, 9.6% of those patients reported some minor degree of continence disorders. After the procedure, incontinence disorders were observed in 34 patients (23.0%), with 23 of these patients suffering from flatus incontinence (15.5%), 10 patients from liquid incontinence (6.8%), and 1 patient from solid fecal incontinence.

Fistulectomy with primary sphincter reconstruction is a feasible procedure resulting in a low recurrence rate. No other procedure has shown better results in transsphincteric fistulas. Continence disorders seem to be of minor relevance/consequence for these patients.

The purpose of this study was to assess primary healing, recurrence and continence after endoanal advancement flap repair (EAFR).

Seventy-seven patients with fistulas-in-ano of different etiologies received endoanal advancement flap repair between 1997 and 2009. This is a prospective, non-randomized, single-centre, single-surgeon study.

Follow-up data was available for 71 patients. 47.9 % had cryptoglandular fistulas. In 40.8 %, the fistulas were due to chronic inflammatory bowel disease. In 11.3 %, the fistula was a consequence of treatment for cancer. Primary healing was observed in 41 of the cases (57.7 %). The median time to recurrence was 27 months (mean 43.43 ± 48.11) and differed significantly across the patient groups: cryptoglandular origin 51 months (mean 57.09 ± 52.57), condition after cancer treatment 43 months (mean 31 ± 23.142), inflammatory bowel disease 11 months (mean 23.65 ± 32.47) (p < 0.01). Preoperatively, 31 (44.3 %) of the patients had impaired continence vs 30 (42.9 %) postoperatively. Overall, postoperative mean Cleveland Clinic incontinence score values improved significantly (preoperative 3.74 ± 4.558 vs postoperative 2.68 ± 4.752, p = 0.03).

Full-thickness endoanal advancement flap repair is a successful treatment option for a range of fistula etiologies. Overall, fistula aetiology proved to be prognostically more relevant than fistula location. Fistulas associated with chronic inflammatory bowel disease were found to have a significantly higher rate of recurrence and shorter time to recurrence at long-term follow-up. Repeat interventions do not negatively impact postoperative continence.