title: Fistulotomy and sphincter reconstruction in the treatment of complex fistula-in-ano: long-term clinical and manometric results.
abstract: OBJECTIVE
  To evaluate the long-term clinical and manometric results of fistulotomy and sphincter reconstruction for the treatment of complex fistula-in-ano.
  
  
  BACKGROUND
  Complex fistula-in-ano is difficult to treat due to the occurrence of postoperative anal incontinence and the high rate of recurrence.
  
  
  METHODS
  Seventy patients who were diagnosed with complex fistula-in-ano and underwent fistulotomy and sphincter reconstruction between October 2000 and October 2006 were analyzed in the present study. Preoperative assessment included physical examination, anorectal manometry, and anal endosonography. Appointments were scheduled every 6 months during the first and second year of treatment and every 2 years thereafter. Recurrence and incontinence were evaluated during each visit. Continence was assessed according to the Wexner continence grading scale. Anal manometry was performed 3 and 12 months after treatment and every 2 years thereafter. Anal endosonography was conducted 6 months after treatment.
  
  
  RESULTS
  Fistulas were classified as medium-high trans-sphincteric in 64 patients (91.42%) and were recurrent in 22 patients (32%). Before surgery, 22 patients (32%) reported fecal incontinence, which improved after surgery in 15 cases (70%), from 6.75 to 1.88 (P < 0.005) on the Wexner Scale. Eight preoperative continent patients (16.6%) reported postoperative incontinence (Wexner Score < 3), and 6 patients (8.5%) had recurrent incontinence. Among these patients, 2 developed recurrent incontinence 6 months after treatment, 2 developed recurrent incontinence 1 year after treatment, 1 developed recurrent incontinence 2 years after treatment, and 1 developed incontinence 5 years after treatment.
  
  
  CONCLUSIONS
  Fistulotomy with sphincter reconstruction is an effective technique for the treatment of complex fistula-in-ano. Continence and anal manometry results were improved in incontinent patients and were not jeopardized in continent ones. Fistulotomy with sphincter reconstruction is an especially suitable technique for incontinent patients with recurrent fistulas.
authors.affiliation: Coloproctology Unit, Department of Surgery, University Hospital of Elche, Elche, Spain. arroyocir@hotmail.com
authors.forename: Antonio
authors.initials: A
authors.lastname: Arroyo
authors.forename: Juan
authors.initials: J
authors.lastname: Pérez-Legaz
authors.forename: Pedro
authors.initials: P
authors.lastname: Moya
authors.forename: Laura
authors.initials: L
authors.lastname: Armañanzas
authors.forename: Javier
authors.initials: J
authors.lastname: Lacueva
authors.forename: Francisco
authors.initials: F
authors.lastname: Pérez-Vicente
authors.forename: Fernando
authors.initials: F
authors.lastname: Candela
authors.forename: Rafael
authors.initials: R
authors.lastname: Calpena
mesh_terms: D000328:Adult; D000368:Aged; D001003:Anal Canal / Q000000981:diagnostic imaging / Q000601:surgery*; D019160:Endosonography; D005260:Female; D006801:Humans; D007902:Length of Stay; D008297:Male; D008365:Manometry; D008875:Middle Aged; D011312:Pressure; D011446:Prospective Studies; D012003:Rectal Fistula / Q000000981:diagnostic imaging / Q000601:surgery*; D012008:Recurrence; D016896:Treatment Outcome