Long term results of surgical treatment of anal fistula in a case series of 483 patients

Background: Anal fistula is a common condition with a wide variety of clinical presentations, which make evaluation and treatment challenging and patient outcomes uncertain. This study describes lessons learned in the surgical treatment of 483 patients over a 20-period that led to a logical, pragmatic, effective approach to treating this condition. Materials and methods: This is a retrospective, observational study of consecutive patients managed by a single surgeon at a tertiary medical center from 1996 through 2018. Age and gender, comorbidities, location of internal and external openings, sphincter length, initial and subsequent surgical treatments, number of operations performed, and final outcomes were recorded. Patients with inflammatory bowel disease and obstetrical injury were analyzed separately. Results: Data for analysis were available on 483 patients; 44 had inflammatory bowel disease; 22 had prior obstetrical injury. Among the 419 patients with neither IBD nor birth injury, men predominated (66% vs 34%); 80% had prior abscesses. A variety of surgical procedures were done, tailored to the specific characteristics of the patient. Digital measurement of sphincter length was the most important element of pre-operative evaluation to determine whether a simple fistulotomy, a sphincter saving procedure, or a series of staged procedures was needed. 97% of patients with non-complex fistulas healed after relatively simple procedures. The 18% with complex fistulas and those with recurrent fistulas needed up to 4 operations before healing was achieved. Fistulas healed in about half the patients with IBD and in 80% or women with prior obstetrical injury. Conclusion: Measurement of sphincter length along with careful evaluation of anatomy and etiology enable a tailored, successful approach to treatment of anal fistula. Surgeons should be familiar with a variety of surgical approaches so that treatment can be designed based on the specific anatomic and physiologic characteristics of individual patients. (C) 2021 The Author(s). Published by Elsevier Ltd on behalf of Surgical Associates Ltd.