title: Fistulotomy in the tertiary setting can achieve high rates of fistula cure with an acceptable risk of deterioration in continence.
abstract: BACKGROUND
  Surgery is the mainstay of treatment of anal fistulas. Low fistulas are often laid open, but higher fistulas present a more difficult problem. Patient choice centres on a compromise between risk of recurrence and risk of impairment of continence. We aimed to determine the efficacy and safety of fistulotomy at a tertiary referral centre, in particular the additional risk of impairment of continence following fistulotomy of the often recurrent, multiply-operated patients seen.
  
  
  METHODS
  Patients undergoing surgery under the senior author (RKSP) for an anal fistula during the study period (2005-2006) were identified, and a thorough review of the patients' clinical records was undertaken. Demographic, fistula anatomy, treatment and follow-up data were obtained.
  
  
  RESULTS
  Eighty-four patients underwent either fistulotomy (50), insertion of permanent loose (drainage) seton (28) or EUA with or without drainage of abscess. Mean length of follow up was 11 months (SD 14.22). In the fistulotomy group, we found an overall success rate of 93 %. Secondary extensions were associated with failure to achieve cure (P = 0.008). Nine patients (20 %) suffered deterioration in continence after surgery. A longer time to referral was associated with impaired final continence. In the group referred from a surgeon in secondary care, 91 % of patients were cured, and continence impairment (mostly minor) rose from 32 % at referral to 40 % after surgery.
  
  
  CONCLUSIONS
  We have shown that it is safe and reasonable to offer fistulotomy to appropriate patients despite previous surgery and within the tertiary setting. By so doing, a very high rate of healing can be achieved in patients who have previously failed. The additional risk of impairment of continence is around one in five, and in the majority will represent only minor incontinence.
authors.affiliation: Imperial College London, London, UK.
authors.forename: P
authors.initials: P
authors.lastname: Tozer
authors.forename: S
authors.initials: S
authors.lastname: Sala
authors.forename: V
authors.initials: V
authors.lastname: Cianci
authors.forename: K
authors.initials: K
authors.lastname: Kalmar
authors.forename: G K
authors.initials: GK
authors.lastname: Atkin
authors.forename: G
authors.initials: G
authors.lastname: Rahbour
authors.forename: P
authors.initials: P
authors.lastname: Ranchod
authors.forename: A
authors.initials: A
authors.lastname: Hart
authors.forename: R K S
authors.initials: RK
authors.lastname: Phillips
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D005242:Fecal Incontinence / Q000209:etiology*; D005260:Female; D006801:Humans; D015212:Inflammatory Bowel Diseases / Q000150:complications; D008297:Male; D008875:Middle Aged; D011183:Postoperative Complications; D012003:Rectal Fistula / Q000473:pathology / Q000601:surgery*; D012008:Recurrence; D012017:Referral and Consultation; D018570:Risk Assessment; D062606:Tertiary Care Centers; D013997:Time Factors; D055815:Young Adult