BREAKING THE PARADIGM: FISTULOTOMY AND PRIMARY END‐TO‐END SPHINCTEROPLASTY FOR CRYPTOGENIC ANAL FÍSTULA (F. I .P.S.). A SINGLE SURGEON EXPERIENCE

Objective: For decades, sphincter reconstruction after fistulectomy or fistulotomy was technically forbidden, alleging various motivations (inflamed tissue, fibrosis, residual infection, high wound dehiscence rates, high recurrence rate etc). We present here the results obtained in a 3 year retrospective study where fistulotomy and primary end-to-end sphincteroplasty with a modified technique were used to treat cryptogenic anal fístulas. Method: This is a retrospective study. All patients were operated by a single surgeon (UM), with the same technique, fistulotomy associated to a fine excision of fístula tract tissue and primary end-to-end sphincteroplasty (of IAS, EAS or both), and a small anal mucosal flap to close the internal fistulous opening. All patients had a diagnosis of intersphincteric or trans-sphincteric perianal fístulas (low or highno suprasphincteric fístulas were included in this study);all patients were submitted to a preoperative Pelvic MRI, anorectal manometry and colonoscopy. The Wexner Incontinence Score was calculated preoperatively and postoperatively for all patient. All were followed up as outpatients at 7 days, 1 month, 3 and 6 months after surgery. Results: 37 patients were studied, 30 males and 7 females, mean age 40,97 (19-67). 12 patients were diagnosed with intersphincteric fístulas, 25 with transphincteric (12 anterior and 25 posterior fístulas), with 16 complex fístulas and 11 single tract fístulas. 1 patient related preoperative mild incontinence (resolved after surgery). Postoperative complications included 6 patients with delayed cicatrisation,1 postoperative (PO4) bleeding, 2 perianal dermatitis, 1 partial mucosal dehiscence and 1 anal profile deformity (resulting in a mild temporary fecal incontinence). No recurrences were observed during follow up. Conclusion: Fistulotomy and primary end-to-end sphincteroplasty is a safe surgical strategy to treat anal fístulas with very low complication rate. More studies are needed to asses the long term efficacy of this technique, but the early results are promising.