title: Prospective clinical and manometric study of fistulotomy with primary sphincter reconstruction in the management of recurrent complex fistula-in-ano.
abstract: OBJECTIVE
  The aim of this study was to assess the results of fistulotomy with sphincter reconstruction in the management of recurrent complex fistula-in-ano in terms of recurrence and continence.
  
  
  METHODS
  Prospective study of 16 patients undergoing fistulotomy with sphincter reconstruction for recurrent complex fistula-in-ano was done. Preoperative and postoperative evaluation included physical examination, anal ultrasonography and anal manometry, with a 40-month follow-up. The Wexner Continence Grading Scale (0-20) was used to assess faecal continence.
  
  
  RESULTS
  Fistulas were classified as high transsphincteric in 13 patients (81.3%), suprasphincteric in 2 (12.5%) and extrasphincteric in 1 patient (6.2%). Four patients (25%) had recurred twice or more. Eight patients (50%) complained of varying degrees of prior faecal incontinence. Their mean score decreased from 8.5 to 1.875 after surgery, and all the patients improved except for one whose score remained the same. On anal manometry, the differences between continent and incontinent patients before surgery [maximum resting pressure (MRP) 86.3 vs 57.6 mmHg, maximum squeeze pressure (MSP) 196.5 vs 138.6 mmHg] decreased after surgery (MRP 81.9 vs 63.7 mmHg, MSP 179.8 vs 159.3 mmHg). In fully continent patients, both the clinical score and manometric values were quite similar after surgery. Two fully continent patients (25%) developed occasional flatus incontinence and soiling, scoring two and three points, respectively. One patient recurred (6.25%) 6 months after surgery.
  
  
  CONCLUSIONS
  Fistulotomy with sphincter reconstruction seems to be an effective resource in the management of recurrent complex fistula-in-ano. It improves both anal continence and manometric values in incontinent patients without compromising them in fully continent ones.
authors.affiliation: Coloproctology Unit, Department of Surgery, University Hospital of Elche, Camí de L'Almazara s/n, 03203 Elche, Alicante, Spain. faperez@vodafone.es
authors.forename: Francisco
authors.initials: F
authors.lastname: Perez
authors.forename: Antonio
authors.initials: A
authors.lastname: Arroyo
authors.forename: Pilar
authors.initials: P
authors.lastname: Serrano
authors.forename: Fernando
authors.initials: F
authors.lastname: Candela
authors.forename: Maria-Teresa
authors.initials: MT
authors.lastname: Perez
authors.forename: Rafael
authors.initials: R
authors.lastname: Calpena
mesh_terms: D000328:Adult; D000368:Aged; D001003:Anal Canal / Q000503:physiopathology* / Q000601:surgery; D013505:Digestive System Surgical Procedures / Q000379:methods*; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D008365:Manometry; D008875:Middle Aged; D011312:Pressure; D011446:Prospective Studies; D019651:Plastic Surgery Procedures / Q000379:methods*; D012003:Rectal Fistula / Q000503:physiopathology / Q000601:surgery*; D012008:Recurrence; D016896:Treatment Outcome