TREATMENT OF COMPLEX ANAL FISTULAS - A TAILORED APPROACH

Most anal fistulas can be easily dealt with by simple fistulotomy. So called complex fistulas-in-ano need a differentiated, individually tai lored surgical approach in order to avoid recurrence and sphincter inc ompetence. Complex fistulas comprise either tracks with high trans-, s upra-, or extrasphincteric extension or fistulas that are complicated by multiple side branches, chronic inflammatory disease, previous oper ations etc. Prior to treatment a thorough preoperative dia. gnostic wo rk-up is warranted. A precise intraoperative evaluation is paramount t o allow radical excision of all inflamed tissue, often necessitating a nal sphincter division with subsequent reconstruction. The treatment p lan involves staged operations over a period of many months, usually w ith the (laparoscopic) fashioning of a protective stoma at the primary operation. Analysing our patients in the study period from 1/95 to 12 /96 our different surgical approaches and their results are presented and discussed. During this period 96 patients with a fistula-in-ano we re operated upon in the Department of Surgery at Wurzburg University H ospital, of which 11 (11.5 %) had complex disease. We encountered one early and one late recurrence as well as a parastomal hernia and a sto ma prolapse. Anal continence was re-assessed three months following re versal of colostomy. All patients (n = 7) who had perfect continence p reoperatively remained unchanged. Preoperatively, four patients were i ncontinent Tor gas and liquid stool. Two of these were fully continent , one remained unchanged at re-assessment. The fourth patient did not undergo stoma reversal as yet, because all examinations revealed an in competent sphincter. This patient is therefore fully incontinent. Succ essful treatment of complex anal fistulas needs an individual approach and planning over a lengthy period of time, requiring a high level of motivation on the parr of both patient and surgeon.