Clinical study on etiopathogenesis and management of Fistula-in-Ano at a tertiary care hospital

 

Rajesh C¹, Bharani Rajkumar K^2*

 

Abstract              Background: Fistula-in-ano is a chronic abnormal communication, usually lined to some extent by granulation tissue, which run outward from anorectal lumen to an external opening on the skin of perineum or buttock. The purpose of present study was to study the etiological factors, clinical presentations of fistula in ano, various methods of management of fistula in ano and its outcome at our tertiary care hospital. Material and Methods: Present study was a prospective observational study conducted in patients more than 18 years, with first episode fistula in ano or with recurrence after previous surgery, underwent surgical treatment at our hospital. Results: In present study, total 82 patients of fistula in ano were studied. Male patients (88%) were far more than female (12%), male to female ratio was 7.2:1 . Most common age group was 31-40 years (48%) followed by 41-50 years (28%) age group. Pain (93%) was most common presenting symptoms followed by discharge (87%), past history of perianal abscess (84%) and swelling (26%). No. of external openings were 1,2 and more than 2 in 74%, 17% and 9% patients respectively. Most common location of external openings was posterior (83%). Lower level fistulas (91%) were more common than higher level fistula (9%). Perianal sepsis (60%), prolonged sitting on the toilet for defecation (57%), excessive intake of spicy/greasy food (39%), history of smoking and alcohol intake (29%) and history of anorectal surgery (9%) were common high-risk factors noted in study patients. Other factors were fissure-in-ano (5%), history of perineal trauma (4%), Crohn’s disease (1%) and tuberculosis (1%). In present study most common surgical management was fistulotomy (45%) followed by fistulectomy (40%), LIFT (10%) and use of seton (5%). Post-operative recurrence (7%), post-operative pain (6%) and post-operative anal incontinence (5%) were common complications noted in patients. Other complications were bleeding (4%), pain + discharge (4%), discharge (2%) and wound Infection (2%). No serious morbidity or any mortality was noted in present study. Conclusion: Most of the fistulas had single external opening, located posteriorly and were low level fistulas. Fistulectomy was the most common procedure performed with less complications.

Keywords: Fistula-in-Ano, perianal abscess, low level fistulas.

 

INTRODUCTION

Fistula-in-ano is a chronic abnormal communication, usually lined to some extent by granulation tissue, which run outward from anorectal lumen (the internal opening) to an external opening on the skin of perineum or buttock (or rarely, in women, to the vagina).¹ Anal Fistula is a common surgical condition which presents as an abnormal communication between the anorectum and perianal skin. Most commonly these fistulae develop following an anal abscesses secondary to infection of an anal gland and most common cause of seropurulent discharge in perianal region.² Tuberculosis, lymphogranuloma inguinale, inflammatory bowel disease like Crohn’s or ulcerating proctocolitis can also lead to development of anal fistula. Fistulae have been reported following external injury or probing an abscess or low anal fistula.³ The chief complaint of anorectal fistula is intermittent or constant drainage or discharge. There is usually a history of previous pain, swelling and recurrent abscess that ruptured spontaneously or was surgically drained A chronic anal fistula presents with periodic exacerbation and pus discharging openings around the anus The purpose of present study was to study the etiological factors, clinical presentations of fistula in ano, various methods of management of fistula in ano and its outcome at our tertiary care hospital.

 

MATERIAL AND METHODS

Present study was a prospective observational study conducted in the Department of General Surgery, Melmaruvattur Adhiparasakthi Institute of Medical Science & Research between August 2019 to July 2020. Study was approved by institutional ethics committee.

Inclusion criterion: Patients more than 18 years, with first episode fistula in ano or with recurrence after previous surgery, underwent surgical treatment at our hospital, willing to participate and follow up.

Exclusion criterion

Patients with malignancy. Patients not willing to participate in the study. A written consent was taken from patients for participation and follow up. After obtaining detailed history (for complaints, age, sex and co-morbidities like diabetes, obesity, COPD, etc.), complete physical examination was done and appropriate investigations were conducted. Chest X-ray and blood parameters were done as necessary. Trans-rectal ultrasonography was performed in all patients. Magnetic Resonance Imaging fistulography was performed in selected patients. After complete evaluation, surgical technique was decided. Patients requiring surgical intervention were operated under strict aseptic precautions while practicing meticulous technique. All the resected specimens were sent for histopathological analysis. Post operatively patients were followed for 3 months.

Data was collected in Microsoft excel sheet and analysis was done using descriptive statistics.

 

RESULTS

In present study, total 82 patients of fistula in ano were studied. Male patients (88%) were far more than female (12%), male to female ratio was 7.2:1 . Most common age group was 31-40 years (48%) followed by 41-50 years (28%) age group. Pain (93%) was most common presenting symptoms followed by discharge (87%), past history of perianal abscess (84%) and swelling (26%). No. of external openings were 1,2 and more than 2 in 74%, 17% and 9% patients respectively. Most common location of external openings was posterior (83%). Lower-level fistulas (91%) were more common than higher level fistula (9%).

DISCUSSION

Fistula in ano is one of the most common diseases with significant morbidity and complications, especially recurrence and fecal incontinence. Adequate surgical management requires appropriate imaging to delineate anatomy and relationship of tracts to the sphincter complex. Ashok S⁴ studied 50 patients and noted that common age of incidence of fistula in ano was 31 to 40 years. It was common in males from lower socio economic strata. Pain was seen in more than 90% subjects. Posteriorly situated, single opening, lower level fistula was common finding Hareesh GSR⁵ studied 75 patients of fistula in ano, 82.70% patients presented with discharge in perianal region. Posterior fistulas are seen in 93.30% and anterior in 6.70% patients. 94.70% patients have low level fistula, 84% patients had simple fistula and 16% had complex fistula. 49.30% patients were treated with fistulectomy. 36.0% have undergone fistulotomy. 8.0% had LIFT and 6.7% had SETON. Recurrence is seen in 6.70% of patients.70.70% patients have stayed 4-6 days. Similar findings were noted in present study. Qureshi IP et al.,⁶ studied 44 cases of fistula in ano, 56.81% of patients were in the age group of 31-60 years followed by 34.09% of patients were in the age group of 11-30 years. Only 9.09% of patients were in the age group above 60 years. About major clinical features were noted perianal discharge, pain, swelling and peri anal irritation were 75%, 65.91%, 43.18% and 11.36% respectively. Pancholi M⁷ studied 30 patients, maximum number of patients were from age group of 30 to 60 years. There were 27 (90%) male patients, with a ratio of male to female is 9:1. Most common symptom was discharge in all patients, pain or perineal discomfort in 20 (66.6%) of patients. The commonest sign is presence of external opening in all cases and internal opening in 21 (70%) of patients. 20 patients (66.66%) underwent fistulectomy, while 06 patients (20%) underwent fistulotomy and seton was tried in 04 patients (13.33%). Independent risk factors for fistula-in-ano: body mass index of >25.0 kg/m2, high daily salt intake, history of diabetes, hyperlipidemia, dermatosis, anorectal surgery, history of smoking and alcohol intake, sedentary lifestyle, excessive intake of spicy/greasy food, very infrequent participation in sports and prolonged sitting on the toilet for defecation.⁸ Similar findings were noted in present study. Transrectal ultrasound scan is a very valuable tool which gives an accurate road map of the fistulous tract/tracts, internal opening and external opening which is of paramount importance in successful management of fistula-in-ano. Transrectal ultrasound scan is a reliable, noninvasive, less expensive, investigative procedure which serves as a beacon for the surgeon intraoperatively to ensure complete cure and prevent recurrences.⁹ Surgery for fistula in ano is considered essential for decompression of acute abscesses and to prevent spread of infection. The surgical management of anal fistula should be to resolve sepsis, promote healing of the tract and preserving the sphincters for continence. Advancement flaps, setons and fistulectomy are widely used for treatment. Drainage of anal abscess with fistulotomy can be safely performed in cases of subcutaneous, intersphincteral, or low transsphincteral fistulae with a minimal recurrence rate. Newer conservative surgeries like ligation of intersphincteric fistula tract (LIFT) and video-assisted anal fistula treatment (VAAFT) have mixed success rates. A recent meta-analysis¹⁰ showed recurrence rates after surgery for anal fistula ranging from 2.5% to 57.1%, most important risk factors for recurrence were high transphincteric fistula, non-detected internal opening, treating the fistula only with seton drain, the presence of a horseshoe-formed abscess, more than one fistula tracts and prior anal surgery. There are multiple techniques available for the repair of complex anal fistulas. The best technique is not known, and the available evidence suffers from a lack of high-quality data, with very few large randomized studies. The technique of choice will depend on appropriate delineation of the anatomy, surgeon preference, and familiarity with the different techniques.¹¹

 

 

 

CONCLUSION

Fistula-in-ano is an abnormal communication between the anal canal or rectum and the perianal skin, which causes a chronic inflammatory response. Most of the fistulas had single external opening, located posteriorly and were low level fistulas. Fistulectomy was the most common procedure performed with less complications.

 

REFERENCES

1. Williams N, O’Connell PR. Baily and Love Short Practices of Surg. 26th ed. Boca Raton, FL: CRC Press; 2013. p. 1259-60.
2. Merchea A, Larson DW. Sabiston text book of surgery. In: Townsend C, Beauchamp RD, Evers BM, Mattox K, eds. chapter 52, 20th ed, Elsevier; 2016: 1394.
3. Babu AK, Naik MB, Babu MR, Madhulikia M; seton - as a gold standard treatment for high fistula in ano. Journal of Evidence Based Medicine And Healthcare. 2015; 2(11): 1687-1693
4. Ashok Shelake, Dwarka Dhanwe. A comprehensive evaluation of fistula in ano in Maharashtra population. MedPulse International Journal of Surgery. October 2018; 8(1): 30-32.
5. Hareesh GSR, Nenavath SPN. A prospective clinical study of fistula in ano: comparing different treatment modalities in a tertiary care hospital. Int Surg J 2019;6:2411-6.
6. Qureshi IP, Sahani IS, Qureshi S, Modi V. Clinical study of fistula in ano in patients attending surgical OPDs of a tertiary care teaching hospital, Central India. Int Surg J 2018;5:3680-4.
7. Pancholi M, Sonvane SR. An observational study on etiopathogenesis and management in Fistula-in-Ano. Int Surg J 2020;7:4011-6.
8. Wang D, Yang G, Qiu J, Song Y, Wang L, Gao J, Wang C. Risk factors for anal fistula: a case-control study. Tech Coloproctol. 2014;18(7):635-9.
9. Krishna BRS, Kantu R. Role of Transrectal Ultrasound Scan in Patients with Fistula-in-ano: A Clinical Study. Int J Sci Stud 2016;4(8):1-8.
10. Mei, Z. et al. Risk Factors for Recurrence after anal fistula surgery: A meta-analysis. International. Journal of Surgery 2019, 69, 153–164.
11. Bubbers EJ, Cologne KG. Management of Complex Anal Fistulas. Clinics in Colon and Rectal Surg. 2016;29(1):43-9.

 

 

 

 

 

Policy for Articles with Open Access
Authors who publish with MedPulse International Journal of Anesthesiology (Print ISSN:2579-0900) (Online ISSN: 2636-4654) agree to the following terms:
Authors retain copyright and grant the journal right of first publication with the work simultaneously licensed under a Creative Commons Attribution License that allows others to share the work with an acknowledgement of the work's authorship and initial publication in this journal.
Authors are permitted and encouraged to post links to their work online (e.g., in institutional repositories or on their website) prior to and during the submission process, as it can lead to productive exchanges, as well as earlier and greater citation of published work.