The direct closure of the internal fistula opening without advancement flap for transsphincteric fistulas-in-ano.

PURPOSE: The recommended closure techniques for transsphincteric fistulas demonstrate divergent results for postoperative continence and recurrence rates. An incontinence rate of 35 percent and a recurrence rate of up to 54 percent has been reported after transanal advancement techniques. The authors hypothesize that a direct closure of the internal fistula opening without tissue mobilization is easier to facilitate and generally leads to better clinical and functional results.
METHODS: A prospective, observational study between 1995 and 1999 was undertaken in 90 patients with transsphincteric fistulas. A direct closure of the internal fistula opening without a flap was performed in all patients. A three-layer, nonstaggered closure of mucosa, submucosa, internal, and external anal sphincters was performed. The follow-up time periods ranged from one-half to six (median, 2.6) years and included assessment of fistula recurrence and continence using patients' histories, physical examinations, proctoscopy, and continence scores. Statistical analysis was performed using Student's t-test or chi-squared test.
RESULTS: Data from 90 patients with a total of 106 operations were analyzed (65 males and 41 females; average age 46 (range, 22-78) years). Sixty-six patients had previous anorectal abscess surgery, and 41 had a previous fistula operation. The mean number of previous fistula operations was 1.7. All patients were continent before surgery. Mean elapsed operative time period was 37 +/- 11 minutes, and the mean anal retraction time was 20 +/- 7 minutes. Suture line dehiscence was the main postoperative complication. It was found to occur between the fourth and tenth postoperative days in 15 patients (14 percent). In 12 of 15 patients (80 percent), the fistula persisted and operative treatment was necessary. In three patients (20 percent), spontaneous closure took place. A recurrent fistula after wound healing was observed in seven patients (6.6 percent). The risk of developing a suture line dehiscence leading to a persistent fistula or a recurrent fistula was 22.5 percent. Ninety-four percent of the patients were continent (continence score 0), 6 percent had a minimal disorder of continence (score 4). A continence level for all patients was determined by the international classification of continence disorders.
CONCLUSIONS: Direct closure for the treatment of transsphincteric fistulas is a safe and effective approach and achieves a good functional outcome; a small risk of suture line dehiscence, which may lead to a recurrent or persistent fistula, remains.