Evaluation of One Stage Lay Open Operation with Primary Sphincter Repair versus Staged Rerouting Operation in Case of High Transsphincteric Perianal Fistula

Introduction: Perianal fistula is a chronic anorectal infection that predominantly affects patients in their active
years of life. Some cases of specific anal fistula, such as Crohn’s fistula, could be treated medically; however, surgery
is the only curative treatment for cryptogenic anal fistula. Operations for anal fistula can be divided into sphincterpreserving
and sphincter-sacrificing techniques. The former is known to be associated with more recurrence and
less incontinence, whereas the latter is associated with less recurrence and significant postoperative incontinence.
Incontinence associated with sphincter-sacrificing operations is related to the amount of sphincter divided, and in
high arching transsphincteric fistula, the continence mechanism may be seriously affected after fistulotomy.
Aim of work: To compare the outcome of one stage lay open operation with primary sphincter repair versus staged
rerouting operation for high trans-sphincteric perianal fistula to detect their effect on recurrence and continence.
Patients and methods: 60 consecutive patients with high transsphincteric perianal fistula were enrolled into the
study by prospective method, after ethical committee approval. All the patients signed an informed written consent.
Fistulae were assessed clinically and by MRI when the clinical diagnosis was unclear. Preoperative continence
status was assessed using the Wexner incontinence score. Preoperative incontinence did not exclude patients from
the study, but its degree was reported to be compared with postoperative continence status. All operations were
done by expert consultants anorectal surgeons in the Colorectal Surgery Unit, El Demerdash Hospital, Ain Shams
University and Dar El Shifa Hospital in a period of 6 months starting from January 2023 till June 2023.
Results: 2 patients (6.7%) developed mild Incontinence, also 2 (6.7%) patients had recurrence among rerouting
group, while in sphincterotomy with sphincteroplasty 3 patients (10%) had mild incontinence and 3 (10%) patients
had recurrence.
Conclusion: Both procedures appear to be valid options in the treatment of a high transsphincteric fistula-in-ano
with no preference between them, with a low failure rate and acceptable risk of incontinence. Both procedures are
challenging, so they should be done by an expert specialized surgeon.