Evidence - Fistulectomy with primary anal sphincter reconstruction

  1. Literature summary

    Fistula in ano is a condition characterized by pain and discharge of purulent secretions from an orifice in the anorectal region. There are two stages of the disease: The acute stage of abscess formation and the chronic stage of fistulization [1, 2].

    The most common cause of anal fistula is inflammation of the anal glands. This is why this type of fistula is also called a cryptoglandular fistula in ano. The second most common cause of anorectal fistula is chronic inflammatory bowel disease, particularly Crohn disease. Fistulas resulting from malignancies or surgical procedures in the lesser pelvis are less common. Fistulas in infancy are a separate entity and often can be traced to a congenital origin.[3, 4]

    Anal abscess and fistula in ano are seen primarily in younger adults between the ages of 30 and 50 years.[5] Men are affected more often than women. In Europe, the incidence of this condition is 1–2 cases per 10,000 population per year and varies depending on the population.[6]

    Cryptoglandular anal fistulas originate in the anal glands in the intersphincteric plane.[7, 8] The glands cluster posteriad and number higher in males than females.[9, 10] The excretory duct of these glands terminate in the anal canal at the level of the dentate line. Purulent inflammation in these glands may induce local necrosis surrounded by granulation tissue (abscess capsule). Depending on the virulence of the pathogens, the abscess spreads in the direction of least resistance and breaches the skin. The junction of the abscess with the body surface is lined with granulation tissue and is called a fistula.

    The acute inflammatory stage, with no discharge of secretion, is perceived as anal abscess, while the chronic course with putrid secretion in the presence of an external orifice is called anal fistula or fistula in ano.

    In chronic inflammatory disorders, on the other hand, the fistulas result from transmural inflammation, which sometimes involves the perianal and perirectal tissue planes and respects anatomic structures only to a limited extent.[11] It is not uncommon to find intersphincteric anal fistulas in conjunction with anal fissures.

    Microbiological testing has no bearing on the treatment of anal fistulas and usually reveals a mixed microflora.[12, 13] The literature does not describe any risk factors for abscess formation and thus for the development of an "ordinary" anal fistula (in contrast to IBD).

    The treatment of anal fistula is mainly surgical.

    Fistulectomy with primary anal sphincter repair

    Fistulectomy with primary sphincter repair (FPSR) is a safe and promising method, particularly for distal and intermediate transsphincteric fistula in ano, and may also be an option in proximal fistulas.[16, 21, 22]

    Suture dehiscence, a complication of high fistulas, is associated with an increased risk of postoperative disorders of fecal continence, which is why a clinical examination should be performed 2 to 4 weeks after the FPSR so that the repair can be revised promptly, if needed.[14] Specialized centers can have healing rates of 88% for FPSR, and up to 96% following revision.[15, 16]

    Varying rates of fecal continence impairment have been reported. A study from 2012 reported that preoperatively continent patients did not suffer any deterioration in fecal continence function after FPSR. Preoperatively incontinent patients even experienced improved continence performance.[17] A systematic review from 2015 (14 studies, 666 patients) compared the outcomes of fistulotomy with those of FPSR.[18] FPSR was followed by a higher incidence of mild and severe postoperative fecal incontinence (mild: 8.6% vs. 15.4%, severe 1.1% vs. 2.7%). In patients with unimpaired preoperative fecal continence, the rate of postoperative continence disorders was 12.4%. A randomized study did not find any differences between FPSR and advancement flap in terms of functional outcome and recurrence rate.[19]

    De Hous et al. describe that FPSR avoids unfavorable anal keyhole deformities in most cases and has a high healing rate of almost 96%.[20] FPSR offers low morbidity, good healing rate and good postoperative fecal continence outcome.[23–26]

    However, the data from the studies is not enough to provide a definitive answer to the question of which surgical procedure is best suited for the treatment of higher or complex anal fistulas. In particular, there is a lack of further randomized controlled trials. Even though FPSR is now an established procedure, it should be reserved for proctological centers, as the individual expertise of the surgeon is also key.[21]

  2. Ongoing trials on this topic

  3. References on this topic

    1. Ommer A, Herold A et al (2017) S3-Leitlinie Kryptoglanduläre Analfistel – 2. revidierte Fassung. Coloproctology 39:16–66

    2. Ommer A, Herold A et al (2017) German S3 guidelines: anal abscess and fistula (second revised version). Langenbecks Arch Surg 402:191–201

    3. Emile SH, Elfeki H et al (2016) A systematic review of the management of anal fistula in infants. Tech Coloproctol 20:735–744

    4. Meyer, T (2019) Perianale Abszesse und Fisteln im Säuglings- und Kleinkindalter. Monatsschr Kinderheilkd 167, 226–233

    5. Ommer A, Athanasiadis S et al (1999) Die chirurgische Behandlung des anorektalen Abszesses. Sinn und Unsinn der primären Fistelsuche. Coloproctology 21:161–169

    6. Zanotti C, Martinez-Puente C et al (2007) An assessment of the incidence of fistula-in-ano in four countries of the European Union. Int J Colorectal Dis 22:1459–1462

    7. Conole FD (1967) The significance of the anal gland in the pathogenesis of anorectal abszess and fistula. Am J Proctol 18:232–238

    8. Herman G, Desfosses L (1880) Sur la muqueuse de la region cloacale du rectum. C R Hebd Seances Acad Sci 90:1301–1302

    9. Lilius HG (1968) Fistula-in-ano, an investigation of human foetal anal ducts and intramuscular glands and a clinical study of 150 patients. Acta Chir Scand Suppl 383:7–88

    10. Seow-Choen F, Ho JM (1994) Histoanatomy of anal glands. Dis Colon Rectum 37:1215–1218

    11. Braithwaite GC, Lee MJ et al (2017) Prognostic factors affecting outcomes in fistulating perianal Crohn’s disease: a systematic review. Tech Coloproctol 21:501–519

    12. Seow-En I, Ngu J (2014) Routine operative swab cultures and postoperative antibiotic use for
    uncomplicated perianal abscesses are unnecessary. ANZ J Surg 87:356–359

    13. Tozer P, Rayment N et al (2015) What role do bacteria play in persisting fistula formation in idiopathic and Crohn’s anal fistula? Colorectal Dis. Mar;17(3):235-41

    14. Herold A (2019) Fistulektomie und primäre Sphinkterrekonstruktion. coloproctology 41:267–271

    15. Seyfried S, Bussen D, Joos A et al (2018) Fistulectomy with primary sphincter reconstruction. Int J Colorectal Dis 33(7):911–918

    16. Perez F, Arroyo A, Serrano P et al (2006) Prospective clinical and manometric study of fistulotomy with primary sphincter reconstruction in the management of recurrent complex fistula-in-ano. Int J Colorectal Dis 21(6):522–526

    17. Arroyo A, Perez-Legaz J, Moya P et al (2012) Fistulotomy and sphincter reconstruction in the treatment of complex fistula-in-ano: long-term clinical and manometric results. Ann Surg 255(5):935–939

    18. Ratto C, Litta F, Donisi L et al (2015) Fistulotomy or fistulectomy and primary sphincteroplasty for anal fistula (FIPS): a systematic review. Tech Coloproctol 19(7):391–400

    19. Perez F, Arroyo A, Serrano P et al (2006) Randomized clinical and manometric study of advancement flap versus fistulotomy with sphincter reconstruction in the management of complex fistula-in-ano. Am J Surg 192(1):34–40

    20. De Hous N, Van den Broeck T, de Gheldere C (2020) Fistulectomy and primary sphincteroplasty (FIPS) to prevent keyhole deformity in simple anal fistula: a single-center retrospective cohort study. Acta Chir Belg.

    21. Roig JV, Garcia-Armengol J, Jordan JC et al (2010) Fistulectomy and sphincteric reconstruction for complex cryptoglandular fistulas. Colorectal Dis 12(7):e145–e152

    22. Litta F, Parello A, De Simone V et al (2019) Fistulotomy and primary sphincteroplasty for anal fistula: long-term data on continence and patient satisfaction. Tech Coloproctol 23(10):993–1001

    23. Whiteford MH, Kilkenny J 3rd, Hyman N et al (2005) Practice parameters for the treatment of perianal abscess and fistula-in-ano (revised). Dis Colon Rectum 48(7):1337–1342

    24. Ratto C, Litta F, Parello A et al (2013) Fistulotomy with end-to-end primary sphincteroplasty for anal fistula: results from a prospective study. Dis Colon Rectum 56(2):226–233

    25. Roig GAJ et al (1999) Immediate reconstruction of the anal sphincter after fistulectomy in the management of complex anal fistulas. Colorectal Dis 1(3):137–140

    26. Farag AFA, Elbarmelgi MY, Mostafa M et al (2019) One stage fistulectomy for high anal fistula with reconstruction of anal sphincter without fecal diversion. Asian J Surg 42(8):792–796



García-Olmo D, Gómez-Barrera M, de la Portilla F. Surgical management of complex perianal fistula r

Activate now and continue learning straight away.

Single Access

Activation of this course for 3 days.

€4.99 inclusive VAT

Most popular offer

webop - Savings Flex

Combine our learning modules flexibly and save up to 50%.

from €3.29 / module

€39.50 / yearly payment

price overview

general and visceral surgery

Unlock all courses in this module.

€9.08 / month

€109.00 / yearly payment

  • literature search

    Literature search on the pages of pubmed.