Francesco Litta1, Salvatore Bracchitta2, Gabriele Naldini3, Massimiliano Mistrangelo4, Nicola Tricomi5, Marco La Torre6, Donato Francesco Altomare7, Marta Mozzon8, Alessandro Testa9, Daniele Zigiotto10, Giuseppe Sica11, Roberta Tutino12, Giorgio Lisi13, Fabio Marino14, Gaetano Luglio15, Roberto Vergari16, Giovanni Terrosu17, Francesco Cantarella18, Nicola Foti19, Antonio Giuliani20, Rossana Moroni21, Carlo Ratto22. 1. Proctology Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy. Electronic address: francescolitta83@yahoo.it. 2. UCP Clinica del Mediterraneo, Ragusa, Italy. 3. Proctology and Pelvic Floor Clinical Centre, University Hospital of Pisa, Italy. 4. Surgical Science Department, University of Turin, Città della Salute e della Scienza Hospital, Turin, Italy. 5. UCP Casa di Cura Candela, Palermo, Italy. 6. Coloproctology Unit, Salvator Mundi International Hospital, UPMC (University of Pittsburgh Medical College), Rome, Italy. 7. Surgical Unit, Department of Emergency and Organ Transplantation, University of Bari, Bari, Italy. 8. Chirurgia Generale, Azienda Ospedaliero Universitaria Friuli Centrale, Udine, Italy. 9. Chirurgia Generale, Ospedale San Pietro FBF, Rome, Italy. 10. Proctological and Perineal Surgical Unit, Ospedale Civile Maggiore, University of Verona, Verona, Italy. 11. Department of Surgical Science, University Hospital Tor Vergata, Rome, Italy. 12. Department of Surgical, Oncological and Stomatological Disciplines (Di. Chir. On. S.), University of Palermo, Italy. 13. General Surgery, Sant'Eugenio Hospital, Rome, Italy. 14. Unit of Surgery, National Institute of Gastroenterology "Saverio de Bellis", Research Hospital, Castellana Grotte, Bari, Italy. 15. Department of Public Health, School of Medicine Federico II of Naples, Naples, Italy. 16. Clinica Chirurgica, Azienda Ospedaliero Universitaria Ospedali Riuniti di Ancona, Italy. 17. Department of Medicine, University of Udine, Italy. 18. Unit of Proctology, Ospedali Privati Forlì, Italy. 19. UOC Chirurgia Generale e Week Surgery, Ospedale "Andosilla" di Civita Castellana (VT), Italy. 20. U.O.C. Chirurgia Generale Universitaria, San Salvatore Hospital. Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, Italy. 21. Direzione Scientifica, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy. 22. Proctology Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy; Catholic University of Rome, Italy.
Abstract
BACKGROUND: Surgical treatment of anal fistulas is still a challenge. The aims of this study were to evaluate the adoption and healing rates for the different surgical techniques used in Italy over the past 15 years. METHODS: This was a multicenter retrospective observational study of patients affected by simple and complex anal fistulas of cryptoglandular origin who were surgically treated in the period 2003-2017. Surgical techniques were grouped as sphincter-cutting or sphincter-sparing and as technology-assisted or techno-free. All patients included in the study were followed for at least 12 months. RESULTS: A total of 9,536 patients (5,520 simple; 4,016 complex fistulas) entered the study. For simple fistulas, fistulotomy was the most frequently used procedure, although its adoption significantly decreased over the years (P < .0005), with an increase in sphincter-sparing approaches; the overall healing rate in simple fistulas was 81.1%, with a significant difference between sphincter-cutting (91.9%) and sphincter-sparing (65.1%) techniques (P = .001). For complex fistulas, the adoption of sphincter-cutting approaches decreased, while sphincter-sparing techniques were mildly preferred (P < .0005). Moreover, there was a significant trend toward the use of technology-assisted procedures. The overall healing rate for complex fistulas was 69.0%, with a measurable difference between sphincter-cutting (81.1%) and sphincter-sparing (61.4%; P = .001) techniques and between techno-free and technology-assisted techniques (72.5% and 55.0%, respectively; P = .001). CONCLUSION: Surgical treatment of anal fistulas has changed, with a trend toward the use of sphincter-sparing techniques. The overall cure rate has remained stable, even if the most innovative procedures have achieved a lower success rate.
BACKGROUND: Surgical treatment of anal fistulas is still a challenge. The aims of this study were to evaluate the adoption and healing rates for the different surgical techniques used in Italy over the past 15 years. METHODS: This was a multicenter retrospective observational study of patients affected by simple and complex anal fistulas of cryptoglandular origin who were surgically treated in the period 2003-2017. Surgical techniques were grouped as sphincter-cutting or sphincter-sparing and as technology-assisted or techno-free. All patients included in the study were followed for at least 12 months. RESULTS: A total of 9,536 patients (5,520 simple; 4,016 complex fistulas) entered the study. For simple fistulas, fistulotomy was the most frequently used procedure, although its adoption significantly decreased over the years (P < .0005), with an increase in sphincter-sparing approaches; the overall healing rate in simple fistulas was 81.1%, with a significant difference between sphincter-cutting (91.9%) and sphincter-sparing (65.1%) techniques (P = .001). For complex fistulas, the adoption of sphincter-cutting approaches decreased, while sphincter-sparing techniques were mildly preferred (P < .0005). Moreover, there was a significant trend toward the use of technology-assisted procedures. The overall healing rate for complex fistulas was 69.0%, with a measurable difference between sphincter-cutting (81.1%) and sphincter-sparing (61.4%; P = .001) techniques and between techno-free and technology-assisted techniques (72.5% and 55.0%, respectively; P = .001). CONCLUSION: Surgical treatment of anal fistulas has changed, with a trend toward the use of sphincter-sparing techniques. The overall cure rate has remained stable, even if the most innovative procedures have achieved a lower success rate.