Discussion
incontinence, colorectal surgeons, inter-sphincteric fistula, primary sphincter repair, trans-sphincteric fistulae, fistula, perianal fistula
POSTOPERATIVE WOUND INFECTION, RECURRENCE, INCONTINENCE, COMPLICATIONS
Anal fistula presents a chronic problem for patients and colorectal surgeons alike. Surgical treatment may result in impairment of continence and long-term risk of recurrence. Treatment options vary according to their location and complexity. The ideal approach should result in low recurrence rates and minimal impact on continence [The present study is a prospective study comparing between ligation of the inter-sphincteric fistula tract by lateral approach (modified LIFT) and Fistulotomy and primary sphincteroplasty in the management of high trans-sphincteric fistulae, first technique was first introduced by Chen et al. as a modification for LIFT technique [The mean age of group (I) is 46.65 with a standard deviation of 6.6. While, in group (II) the mean age is 45.85 with standard deviation 6.07 (p = 0.576). From the included 80 patients 55(68.7%) were males and 25 (31.25%) were females (p = 0.469), in addition we found no difference between both groups as regard co-morbidities. These data could eliminate presence of any additional co-factor that could deviate our results as regard to the efficacy and complications of both techniques.Wound healing was faster in group (I) managed by modified LIFT than in group (II) managed by fistulotomy and primary sphincter reconstruction. The mean time of wound healing in group (I) is 4.67 weeks with ± 0.916 standard deviation ranging from 3 to 7 weeks and the mean in group (II) is 6.05weeks with ± 0.95 standard deviation ranging from 5 to 8 weeks with high statistical significance as Postoperative wound infection occurred in 2(5%) Patients in group (I) and 7(17.5%) patients in group (II) with no statistical significance (As regardpain though the difference between both groups is statistically insignificant(After a one year of follow-up, we noticed a lessrecurrence in group (II) than in group (I). in our opinion this difference sounds logic. The technique of fistulotomy with primary sphincter repair eradicate the pathological tract from the external to the internal opening while with modified LIFT the internal opening still present. Group (I) technique was first introduced by Chen et al. [The literature has shown a wide range of recurrence rates following Fistulotomy and primary sphincteroplasty depending on the type and level of complexity of the fistula. According to recurrence rate, Ratto et al. a study included 203 patients with perianal fistula with the recurrence rates 7% in a mean time of follow-up 56 months [There were no cases ofincontinence in group I as during the procedure, which is a great advantage in this technique, the operator did not cut the anal sphincter but dissected and cored through the external anal sphincter muscles toward the internal opening and stopped any further dissection when exposed the outer fibers of the internal anal sphincter [However, in group II, there were 6(15%) cases of incontinence to gases (Wexner score of 1–3/20) which is a significant difference between the two techniques, A great variability exists within the literature This variability is dependent on the form and degree of complexity of the fistula treatment. Ratto et al. reported That the overall postoperative worsening continence rate was 12.4% (mainly post-defecation soiling) in patients who underwent Fistulotomy or fistulectomy and primary sphincter reconstruction for the treatment of complex anal fistulas [The limitations of this study include the sample size. In addition to, we have nearly no papers comparing both techniques in management of high trans-sphincteric fistula-in-ano. Therefore, further work is still warranted to confirm the long-term outcome of these two techniques.