Department of General Surgery, Hadassah Medical Organization and Faculty of Medicine, Hebrew University of Jerusalem, POB 12000, Jerusalem, 91120, Israel.
Tech Coloproctol. 2021 Dec;25(12):1311-1318. doi: 10.1007/s10151-021-02525-5. Epub 2021 Oct 1.
Fistula-in-ano due to cryptoglandular disease is a common condition. While a simple anal fistula can be treated successfully by a fistulotomy, the risk of potential damage to the anal sphincters and subsequent poor functional outcomes persist in a large portion of patients with complex fistulae. Several sphincter-preserving treatment procedures have been described for complex fistulae over the past 3 decades, with variable results and complication rates, and no procedure is proven to be superior to the others. We developed external sphincter-sparing anal fistulotomy (ESSAF), a reproducible simple modification of the ligation of intersphincteric fistula tract (LIFT) technique for the treatment of complex fistula-in-ano.. The aim of the present study was to describe the technique and our outcomes.
This was a retrospective review of all patients who underwent ESSAF for a complex anal fistula at our institution from January 2014 to December 2019. The primary outcome measure of this study was the primary fistula healing rate. Secondary outcome measures included fecal and/or gas incontinence and postoperative complications. During the ESSAF procedure, the mucosa and skin overlying the fistula tract are incised to allow complete exposure of the sphincter complex. Then the internal sphincter muscle fibers overlying the tract are divided and the tract is meticulously curetted and debrided. Next, the internal opening of the tract traversing the external sphincter muscle is suture-ligated with absorbable sutures. Then, a minimal amount of mucosa is advanced and the incision is partially closed with absorbable sutures, while its external portion is left open for drainage.
Fifty-nine patients [43 males, median age was 50 years (range 36-63 years)] underwent ESSAF for complex anal fistula during the study period. Mean follow-up was 12 ± 14.7 months. Of the 59 patients, 42 (71.2%) experienced fistula closure, with a median healing time of 8 weeks (IQR 4-16 weeks). None of the patients developed significant anal incontinence following the procedure. One patient (1.7%) suffered from soiling and another patient (1.7%) developed postoperative bleeding. There were no infectious complications. Of the 17 patients (28.8%) who failed to heal successfully, 9 (15.2%) did not heal primarily and 8 (16%) experienced recurrence after complete healing. Thirteen (76%) of these patients underwent reoperation with complete recovery after ESSAF (n = 4), fistulotomy (n = 8) or endorectal advancement flap (ERAF) (n = 1). Overall ESSAF initiated recovery in 93.2% of the patients.
ESSAF is a feasible, safe, reproducible and effective sphincter-sparing procedure for the treatment of complex anal fistulae.
肛门直肠瘘（肛瘘）是一种常见的疾病，通常是由于肛隐窝的腺体感染所致。单纯性肛瘘可以通过瘘管切开术成功治疗，但对于复杂性肛瘘患者，仍然存在潜在的肛门括约肌损伤和随后功能不良的风险。过去 30 年来，已经描述了几种保留括约肌的治疗方法来治疗复杂性肛瘘，这些方法的结果和并发症发生率各不相同，没有一种方法被证明优于其他方法。我们开发了一种保留肛门外括约肌的肛瘘切开术（ESSAF），这是一种可重复的改良结扎直肠肛管间瘘管（LIFT）技术，用于治疗复杂性肛瘘。本研究的目的是描述该技术及其结果。
这是一项对 2014 年 1 月至 2019 年 12 月在我院接受 ESSAF 治疗的复杂性肛瘘患者的回顾性研究。本研究的主要结局指标是初次瘘管愈合率。次要结局指标包括粪便和/或气体失禁以及术后并发症。在 ESSAF 手术中，切开瘘管上方的黏膜和皮肤，以充分暴露括约肌复合体。然后，切开并切除瘘管上方的内括约肌肌纤维。接下来，用可吸收缝线缝合穿过外括约肌的瘘管内口。然后，推进少量黏膜，用可吸收缝线部分关闭切口，而外部部分保持开放以引流。
在研究期间，59 例[43 例男性，中位年龄 50 岁（范围 36-63 岁）]患者接受了 ESSAF 治疗复杂性肛瘘。平均随访时间为 12±14.7 个月。59 例患者中，42 例（71.2%）的瘘管闭合，中位愈合时间为 8 周（IQR 4-16 周）。术后无患者发生明显的肛门失禁。1 例（1.7%）患者出现污粪，另 1 例（1.7%）患者出现术后出血。无感染性并发症。17 例（28.8%）患者未成功愈合，其中 9 例（15.2%）未初次愈合，8 例（16%）在完全愈合后复发。这些患者中有 13 例（76%）接受了再次手术，再次手术后，所有患者均通过 ESSAF（n=4）、瘘管切开术（n=8）或直肠内推进皮瓣（n=1）完全恢复。总体而言，ESSAF 使 93.2%的患者得到了恢复。
ESSAF 是一种可行、安全、可重复和有效的保留括约肌的手术方法，适用于治疗复杂性肛瘘。
