Open Journal of Gastroenterology, 2013, 3, 223-226 OJGas
doi:10.4236/ojgas.2013.34037 Published Online August 2013 (
Open fistulectomy with sphincter fixation for anal fistula
Tatsuya Abe1*, Masao Kunimoto1, Yoshikazu Hachiro1, Yoshiaki Ebisawa1, Houhei Hishiyama1,
Seishu Abe2
1Department of Proctology, Kunimoto Hospital, Asahikawa, Japan
2Department of Plastic Surgery, Kunimoto Hospital, Asahikawa, Japan
Email: *
Received 1 June 2013; revised 1 July 2013; accepted 20 July 2013
Copyright © 2013 Tatsuya Abe et al. This is an open access article distributed under the Creative Commons Attribution License,
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Purpose: This study aimed to report clinical data and
recurrence rates in patients with anterolateral low
fistulas who underwent open fistulectomy with sphinc-
ter fixation. Methods: The study group consisted of
133 consecutive patients with anterolateral, low in-
tersphincteric, or low trans-sphincteric fistulas who
had undergone open fistulectomy with sphincter fixa-
tion between January 2006 and December 2010. This
procedure involves complete removal of the fistula
tract by incision of anal sphincters, followed by fixa-
tion of the sphincter muscles. Results: Success was
achieved in 127 (95.5%) patients with a median fol-
low-up time of 12 months. Anal fistula recurred in 4
cases (3%). Non-healing fistula with persistent anal
discharge developed in 2 patients. Maximal resting
pressure, but not maximal squeeze pressure, was sig-
nificantly decreased after surgery. Five patients (4%)
developed temporary anal incontinence after surgery.
Conclusions: Open fistulectomy with sphincter fixa-
tion was effective for the management of patients
with anterolateral low fistula in this study. The high
success rate suggests that this procedure is a reason-
able option in this gro up of patients.
Keywords: Anal Fistula; Fistulectomy; Sphincter
Fixation; Fecal Incontinence
Anal fistula is a devastating problem that most com-
monly occurs in healthy subjects, with cryptoglandular
infection being the most widely accepted etiological fac-
tor [1]. On the basis of their anatomical course relative to
the sphincter complex, cryptoglandular fistulas are cate-
gorized as intersphincteric, trans-sphincteric, suprasphinc-
teric, and extrasphincteric types [2]. The most common
type is intersphincteric, followed by transsphincteric [2,
3]. Anal fistulas can also be classified as simple or com-
plex. The major type is simple, which includes low in-
tersphincteric and low trans-sphincteric fistulas that cross
<30% of the external sphincter [4].
Most fistulas have been conventionally treated by fis-
tulotomy or fistulectomy, which have both proven to be
effective [5]. However, these techniques, even for simple
fistulas, result in some form of incontinence in approxi-
mately 12% - 39% of patients [3,5,6]. In most patients,
the internal opening of the fistula is located along the
posterior midline [7]. Fistulas located laterally are sig-
nificantly associated with recurrence, and those located
along the anterior midline are associated with inconti-
nence [3,8]. Anterolateral localization results in greater
postoperative anal deformity when fistulotomy or fis-
tulectomy is used to excise the fistula [9]. Therefore,
more attention is needed for the management of anter-
olateral fistulas.
Open fistulectomy with sphincter fixation (OFSF) is
another option for the management of anterolateral fistu-
las. The procedure is based on the premise that removal
of the chronic epithelialized tract will allow healing by
secondary intention of healthier tissue, and sphincter
fixation may result in less deformity and prevention of
incontinence compared with leaving the sphincters di-
vided. However, this is a more extensive procedure, and
there is lack of support for it in the literature. Th e aim of
this study was to evaluate clinical data and recurrence
rates in patients with anterolateral fistulas who under-
went OFSF.
The study group consisted of 133 consecutive patients
with anterolate ral, low intersphincteric, or low transphinc-
teric fistulas who had undergone OFSF between January
2006 and December 2010 at our institution. The median
*Corresponding a uthor.
Published Online August 2013 in SciRes.
T. Abe et al. / Open Journal of Gastroenterology 3 (2013) 223-226
age of these 133 patients (122 males) was 42 years
(range, 16 - 87 years). All patients presented with chronic
fistula of the cryptoglandular origin. All had a history of
previous perineal suppuration drained surgically or spon-
taneously. Fistula tracks and internal opening were clini-
cally and endosonographically evaluated and were found
in the anterior quadrant in 89 (67%) and in the left or
right lateral quadrant in 44 (33%) patients.
OFSF was performed under caudal epidural anesthesia
in the prone jackknife position with the buttocks taped
widely apart. A suppository rather than an enema was
used to empty the rectum before surgery. The external
opening along with the fistula tract was circumscribed
and dissected using an electric cautery or Metzenbaum
scissors. Dissection was performed as deep into the
sphincter as possible. The internal opening was excised
using a Parks retracter to efface the anal canal. All tissues
between the internal and ex tern al open ing s were cut op en
by sphincterotomy, and all of the fistula tract was re-
moved. Both edges of the incised internal and external
anal sphincter (IAS and EAS, respectively) muscles were
slightly mobilized to ensure fixation without tension.
Next, interrupted 3-0 poliglecaprone was used to suture
the muscles to the base of the defect area after fistulec-
tomy (Figure 1). A simple layer of interrupted 3-0 poli-
glecapronesutures was used to marsupialize the proximal
edge of the anoderm to prevent postoperative bleeding.
Distal anoderm and perianal skin were left open to fa-
cilitate drainage. Postoperatively, the patients were ad-
ministered prophylactic oral antibiotics (cefaclor 750
mg/day) and oral analgesia (loxoprofen 180 mg/day) for
3 days, and the re were n o di etary restricti o ns.
A 5 mm diameter, 1-channel, solid-state catheter with
a microtipped transducer anorectalmanometry (ARM)
system (P-31; Star Medical Co., Tokyo, Japan) was used
to perform ARM before and 3 months after surgery. All
patients were examined in the left lateral position with
the hips flexed to 90˚. The maximal resting pressure
(MRP) and maximal squeeze pressure (MSP) were ana-
lyzed. Manometric data were expressed as means ± stan-
Figure 1. Detail of open fistulectomy with sphincter fixation.
(A) IO = internal opening, EO = external opening, IAS = inter-
nal anal sphincter, EAS = external anal sphincter; (B) Sphincter
division and total fistulectomy; (C) Both edges of the incised
IAS and EAS were sutured to the base of the defect area after
dard deviations. Wilcoxon signed-rank test was used to
test statistical significance. Statistical significance was
set at p < 0.05.
This study was a retrospective review of existing
clinical data prospectively collected on a hospital anal
physiology unit computer database. The study was ap-
proved by the research and ethics committee of Kuni-
moto Hospital, and all patients gave written informed
The median operative time was 21 min (range, 10 - 42
min). There were no postoperative deaths. Postoperative
bleeding occurred in 2 patients (1.5%) and required
stitching of the bleeding area, which was sited at the
edge of the wound. No significant dehiscence of the
sphincter fixation occurred. Of the 133 patients, 127
(95.5%) healed completely and did not require any fur-
ther surgical treatment, with a median follow-up of 12
months (range, 2 - 62 months). Anal fistula recurred in 4
cases (3%). Recurrence in these patients was observed at
3, 6, 8, and 12 months. Non-healing fistula with persis-
tent anal discharge developed in 2 patients (1.5%); 1 of
them with persistent symptoms had an identifiable fistula
tract connecting the anal canal to skin, and the external
opening failed to close, with infected granulation in the
other pati e nt.
Seventy two (54%) of the 133 patients underwent
ARM before and after surgery. MRP was significantly
decreased after surgery, but not MSP (Table 1). Clini-
cally, 5 patients (4%) developed temporary anal inconti-
nence after surgery. Solid stool incontinence was not
present, but liquid stool incontinence and flatus were
observed in 2 and 3 males, respectively; all had recov-
ered in <6 months.
The overall rate of fistula persistence or recurrence was
4.5% and temporary minor incontinence was 4%, which
showed the effectiveness of OFSF in the management of
anterolateral low fistulas in these patients. The manage-
ment of anal fistulas includes 3 main goals: to cure the
fistula, to prevent or minimize recurrence, and to retain
continence. Since OFSF allows recognition of the full
length of an anal fistula via direct visualization enabled
Table 1. Changes in maximal resting and squeeze pressure (n =
Preoperative Postoperative p value
MRP (mmHg)77.6 ± 18.0 65.8 ± 18.1 <0.05
MSP (mmHg)239 ± 86.8 249 ± 99.4 0.41
MRP = maximal resting pressure; M SP = maximal squeeze pressure.
Copyright © 2013 SciRes. OJGas
T. Abe et al. / Open Journal of Gastroenterology 3 (2013) 223-226 225
by sphincter division, removal can certainly be a primary
focus, which eliminates the risk of missing secondary
tracts and allows healing by secondary intention of
healthier tissue. Moreover, divided sphincters are fixed
to prevent reduction in anal resting tone. We have also
used this technique successfully to manage complex fis-
tulas, but the present study was limited to a more com-
mon group, simple fistulas.
Both fistulotomy and fistulectomy have long been ac-
cepted as the gold standard for simple fistulas. Although
fistulotomy has been associated with success rates of
92% - 97%, the procedure will result in some form of
incontinence even for simple fistulas in approximately
12% - 39% of patients [3,5,6].
Both fistulotomy and fistulectomy leaves the unepi-
thelialized wound opened, which may cause undesired
pain and complications, such as bleeding and suppura-
tion. Marsupializatio n of the unepithelialized wound was
introduced to provide the benefit of shortened healing
times and improved continence by minimizing anal de-
formity [10]. The addition of marsupialization also has
been associated with less postoperative pain and bleeding
[11]. However, this procedure leaves the sphincters di-
vided, and Pescatori et al. [11] did not observe any supe-
riority of marsupialization with respect to incontinence
Fistulectomy and immediate sphincter repair for low
fistulas, described by Parkash et al. [12], aim to eradicate
infection and to anatomically reconstruct the muscular
defect. However, very few studies have been published
on this technique. Dehiscence of sphincteroplasty is the
most fearful complication of this technique and is re-
sponsible for its infrequent use [13]. Roig et al. [14]
treated 75 patients in whom most of the fistulas were
complex (69%) by fistulectomy and end-to-end recon-
struction of the disrupted EAS. Five recurrences in total
have been described (6.7%), and the postoperative in-
continence rate was 21%. Perez et al. [13] included 16
patients with recurrent complex fistulas in whom fistu-
lotomy was performed with overlapping repair of the
disrupted EAS. Two (25%) of 8 fully continent patients
developed incontinence for watery stools and flatus,
which gave a recurrence rate of 6.3% (1 patient). By
overlapping the muscle, the area in contact is increased
and rupture of the sutures may be more unlikely. How-
ever, when the width of overlap is too long, the anal ca-
nal may narrow and drainage worsen.
The strengths of sphincter fixation, our original me-
thod, are as follows: 1) since both edges of the sphincters
are sutured separately, the tension on the sutures can be
reduced by half relative to that on end-to-end sutures; 2)
extensive dissection of sphincter muscles is not needed
to achieve overlap; 3) the anal canal does not become
narrow as can occur with overlap. The edges of the di-
vided sphincter muscles will separate rapidly when they
are not at all repaired. Even if they are fixed in the origi-
nal position, continence will be fully maintainable. In
fact, it was found that sphincter fixation was better pre-
served for MSP 3 months after surgery. Although MRP
was significantly reduced, the extent was only 15%. Cli-
nically, 5 patients (4%) developed temporary inconti-
nence for liquids and gas, and all of them had recovered
in <6 months.
The true advantages of the OFSF procedure may not be
clear until larger prosp ective rando mized studies are co n-
ducted. However, considering the current reported data,
we believe that OFSF can achieve complete removal of
fistulas safely and easily with minimal risk of post-
operative incontinence and low recurrence rates.
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