Rawal Medical Journal An official publication of Pakistan Medical Association Rawalpindi Islamabad branch Established 1975 Volume 36 Number

4 October - December 2011 Original Article

Fistulotomy versus fistulectomy in the treatment of low fistula in ano Yasmeen Bhatti, Saira Fatima, Ghulam Shabir Shaikh, Shahida Shaikh Department of Surgery, Chandka Medical College & Hospital, Larkana, Pakistan

ABSTRACT Objectives To evaluate the outcome of the fistulotomy and fistulectomy for the treatment of Low type Fistula in ano. Patients and Methods This analytical study was carried out at Surgical Unit II of Chandka Medical College Teaching Hospital, Larkana, from January 1, 2010 to December 31, 2010. The study included 50 patients of low type Fistula in ano admitted during study period. Out of these, 25 patients were operated by fistulotomy (Group A) and 25 by fistulectomy (Group B). Pain and bleeding were noted.

All the patients were followed up weekly till complete wound healing was observed, then monthly up to six months post operatively.2 Results Three patients of group A (12%) complained of pain postoperatively on first post operative day, while complaint of postoperative pain was noted in 7 patients of group B (28%). Postoperative bleeding was seen in 1 patients (04%) in group A, whereas it was seen in 3 patients (12%) of group B. None complained of incontinence either to flatus or feces; nor was recurrence seen in either group. The post operative hospital stay period in group A ranged between 1 to 4 days, with a median period of 1.5 days, and that in group B was 1 to 6 days, with median period of 2.5 days. The average healing time in patients in Group A was 24 days (range 18- 30 days); while that in patients in Group B was 35 days (range 28- 42 days). Conclusions Fistulotomy resulted in lesser pain, bleeding, lower hospital stay and early wound healing and better patient compliance. (Rawal Med J 2011;36:284-286 ). Key words Fistula in ano, fistulotomy, fistulectomy. INTRODUCTION A fistula in ano is a track, lined by granulation tissue that connects deeply in the anal canal or rectum and superficially on the skin around the anus. It usually results from an anorectal abscess which bursts spontaneously or after

inadequate surgery.1 Acute infection of the anal crypt leads to an anorectal abscess and an anal fistula represents the chronic form of this infection.2 Peri 3 fistula may be associated with a number of disease processes.3 These can be below or above the anorectal ring. Low level fistulae open in to the anal canal below the anorectal ring; high level fistulae open in to the anal canal at or above the anorectal ring. Two- thirds are posterior, one-third anterior. The commonest symptom is a watery or purulent discharge or recurrent episodes of pain.4 The mainstay of treatment is eradication of sepsis with preservation of anorectal function. A simple fistula is treated by fistulotomy (opening the fistulous tract), curettage or cautry of the track and healing by the secondary intention. Fistulectomy (complete excision of the fistulous track) is not indicated because the magnitude of tissue loss associated with the procedure increases the risk of compromise to sphincter function.2 Fistulotomy is preferred over fistulectomy.5 Low anal fistulae have been mainly treated by fistulotomy with good results.6 These can be laid open with minimal loss of sphincter muscle but as far as the high variety is concerned, it is safer to place a seton or stage the procedure.7 The purpose of this study was to evaluate the efficacy of fistulotomy and fistulectomy in treatment of low anal fistulae. PATIENTS AND METHODS

This study was conducted at Surgical Unit-II Chandka Medical College Teaching Hospital Larkana from January 1, 2010 to December 31, 2010. Fifty patients of Low fistula in ano selected with purposive sampling were included in the study. Those with perianal abscess, pilonidal sinus and those associated 4 with Crohns disease, ulcerative colitis, tuberculosis and rectal carcinoma rectum were excluded. Efficacy of the procedure meant an early recovery and and decreased postoperative complications like post operative anal incontinence and recurrence. All the patients were followed weekly until complete wound healing was observed and then monthly up to six months post operatively. Statistical analysis of data was done using SPSS software. RESULTS Most patients belonged to age group 21-40 years (Table 1). There were 46 (96%) male and 4 (8%) female. Table 1. Age distribution. Age Number Percentage 10- 20 years 5 10% 21- 30 years 15 30% 31- 40 years 18 36% 41- 50 years 7 14% 51 & above 5 10% The commonest symptom was the purulent/watery discharge from the external opening of the fistula in 40 patients (80%). The pain was present in 17 cases (34%); and swelling near anus was present in 16 (32%) patients. Out of 50

patients, 25 patients were operated by Fistulotomy and 25 underwent Fistulectomy. 5 Table 2. Post operative complications. Complication Fistulotomy Fistulectomy Postop pain 3 patients---12% 7 patients---28% Postop bleeding 1 patients---04% 3 patients---12% Incontinence 0 0 Recurrece 0 0 There was more postoperative pain and bleeding in Fistulectomy group. None developed incontinence to either flatus or feces nor the recurrence (Table 2). Table 3. Postoperative hospital stay. Procedure Range of period Median period Fistulotomy 1- 4 days 1. 5 days Fistulectomy 1- 6 days 2. 5 days Mean hospital stay was higher in fistulectomy group (Table 3). Table 4. Healing time. Procedure Range of healing time Average healing time Fistulotomy 18- 30 days 24 days Fistulectomy 28- 42 days 35 days The average healing time was longer in Fistulectomy group (p=0.006) (Table 4). DISCUSSION Over the last 30 years, many authors have presented new techniques and case

series to minimize recurrence rates and incontinence. The patient satisfaction 6 after surgical treatment for anal fistula depends on factors like period of hospitalization, postoperative pain and bleeding, return to routine activity, wound care, wound healing time, interference with the anal continence and the recurrence of the disease. The commonest symptom in our study was mucopurulent/watery discharge which is supported by previous reports.4 A shorter hospital stay and less postoperative bleeding after Fistulotomy were seen. Thus, fistulotomy has been preferred over Fistulectomy.5,6 Low fistulae can be laid open with minimal loss of sphincter muscle but as far as the high variety is concerned, it is safer to place a seton or stage the procedure. 7 For the low and simple fistulas, fistulotomy is easy to perform but meticulous assessment must be emphasized on the amount of external sphincter involvement. 8,9 Removal of complete track and adjacent tissue in fistulectomy results in larger wound, thus there is more risk of postoperative bleeding and pain with longer healing time. 10 Excision of lesser amount of tissue in fistulotomy results to earlier healing time as compared to fistulectomy.11 Another study from Mexico reported that the average of the lesion in the sphincter, mechanism

was larger in the fistulectomy versus fistulotomy.12 CONCLUSION Our study showed that fistulotomy resulted in lesser pain, bleeding, shorter hospital stay and early wound healing in the treatment of low type fistula in ano. 7 Correspondence: Dr. Ghulam Shabir Shaikh Mobile: 03003413035 Email: sghlamshabir@ymail.com shabir_lrk@yahoomail.com Received: April 28, 2011 Accepted: August 28, 2011 REFERENCES 1. Williams NS. The anus and anal canal. In: Russell RCG, Williams NS, Bulstrode CJK, editors. Bailey & Loves Short practice of surgery. 24th ed. London: Edward Arnold;2004;p1242-71. 2. Kodner IJ, Fry RD, Fleshman JW, Birnbaum EH. Colon rectum and anus. In: Schwartz SI, Shires GT, Spencer FC, editors. Principles of surgery. 6th ed. New York: Mc Gaw-Hill;1994;p192-1306. 3. Steele RJC, Campbell K. Disorders of the anal canal. In: Cuscheri A, Steele RJC, Moosa AR, editors. Essential surgical practice. 4th ed. London: Arnold; 2005;p447-65. 4. Browse NL, Black J, Burnand KG, Thomas WEG. An Introduction to the symptoms and signs of surgical disease. 4 rd ed. London: Arnold,

1997;p425-43. 5. Al-Fallouji MAR, editor. Postgraduate Surgery. 2nd ed. Oxford: Butterworth Heinemann;1998;p282-4. 6. Khan MR, Shah HA, Alam M. Treatment of perianal fistula analysis of 42 cases. Ann KE Med Coll 2001;7:44-6.8 7. Qureshi H, Kamal M, Shah MHA. Management of fistula in ano. J Coll Physicians Surg Pak 2002;12:361-3. 8. Garcia-Aguilar J, Davey CS, Le CT, Lowry AC, Rothenberger DA. Patient satisfaction after surgical treatment for fistula in ano. Dis Colon Rectum 2000;43:1206-12. 9. Malouf AJ, Buchanan GN, Carapeti EA, Rao S, Guy RJ, Westcott E, et al. A prospective audit of fistula in ano at St. Marks hospital. Colorectal Dis 2002;4:13-19. 10. Anwar I, Niaz Z, Muneeb A, Cheema M, Moeen A. Fistulotomy a better treatment modality than fistulectomy for low fistula in ano. Ann King Edward Med Uni 2003;9:171- 2. 11. Isbister WH. Fistula in ano. Aust NZ J Surg 1999; 69:94-96. 12. Belmonte MC, Ruiz GH, Montes VJL. Fistulotomy vs Fistulectomy, Ultrasonographic evaluation of lesion of the anal sphincter function. Rev. Gastroenterol Mex 1999;64:167-70.