doi:10.1111/j.1463-1318.2007.01227.x

Original article

Surgery for fistula-in-ano: an audit of practise of colorectal and general surgeons1 N. Nwaejike and R. Gilliland Department of Surgery, Altnagelvin Hospital, Londonderry, UK Received 16 December 2006; accepted 3 January 2007

Abstract Objective Some conditions, previously managed by general surgeons, may be treated more successfully by colorectal specialists. This argument is well established for rectal cancer but does it also apply to benign conditions? This study compares the treatment strategies and outcomes for fistulae-in-ano by general and colorectal surgeons in a district general hospital. Method Patients who had surgery for fistula-in-ano from January 1992–October 2003 were identified from theatre records. Case notes were reviewed for data on type of fistula, aetiology, surgery performed and recurrence. All patients were sent a questionnaire requesting details of recurrence and incontinence. The severity of incontinence was assessed using the Faecal Incontinence Quality of Life Scale (FIQOLS) and the Faecal Incontinence Severity Index (FISI). Results Eighty four patients (male ¼ 53) were identified. Colorectal surgeons performed surgery in 34 and general surgeons in 50 patients. These groups were comparable with terms of age, gender, aetiology (colorectal: IBD ¼ 5, cryptoglandular ¼ 21: general IBD ¼ 14, cryptoglandular ¼ 24; P ¼ 0.28; Chi-squared test), and type of fistulae (colorectal: inter-sphincteric ¼ 20, trans-sphincteric ¼ 13: general inter-sphincteric ¼ 30, trans-sphincteric ¼ 18: P ¼ 1.0; Fisher’s exact test). Colorectal surgeons carried out fewer fistulotomies (47.1% vs

Introduction Anal fistulae can arise as a result of the development of sepsis in the anal glands. These glands are situated at the Correspondence to: Mr R Gilliland, Altnagelvin Hospital, Glenshane Road, Londonderry BT47 6SB, UK. E-mail: [email protected] 1 Association of Coloproctology of Great Britain and Ireland, 2004 Annual Meeting, Monday, 28th June - Thursday, 1st July. Venue: International Convention Centre, Birmingham. Northern Ireland Surgical Trainees Prize Day 2004, Friday 12 November, Venue: Stormont Hotel, Belfast.

84.0%; P < 0.001; Fisher’s exact test), more staged fistulotomies with Setons (44.1% vs 10.0%: P < 0.001; Fisher’s exact test), and had fewer recurrences (9.7% vs 30.0%: P < 0.05; Fisher’s exact test) when compared with general surgeons. Five patients with recurrence from the general surgery group were subsequently referred to the colorectal surgeons; four patients had further surgery (fistulotomy ¼ 2; staged fistulotomy ¼ 2) with no recurrence to date; one patient required proctectomy. Forty seven (64.4%) patients answered the questionnaire. There was no difference between patients operated on by colorectal or general surgeons with regards the frequency (43.5% vs 62.5%: P ¼ 0.25; Fisher’s exact test) or severity [FISI 26 (21–38); median (inter-quartile range) vs 26 (17–38); median (inter-quartile range: P ¼ 0.85; Mann– Whitney test) of faecal incontinence. There was no difference between the groups with regards any of the four scales that comprised the FIQOLS. Conclusions The number of included patients is far too low to draw any conclusions but there were some interesting trends. For similar patient samples, colorectal surgeons seem to adopt a more conservative approach and have fewer recurrences than general surgeons. These differences are not reflected in the frequency or severity of postoperative incontinence. Keywords Fistula-in-ano, surgery, anorectal sepsis

base of the anal crypts within the anal canal. They are distributed circumferentially around the anus and about one to two thirds of them will penetrate the internal sphincter to terminate in the inter-sphincteric space. Thus sepsis arising within the anal glands can spread into the inter-sphincteric space causing an inter-sphincteric abscess. From here the sepsis can spread within the ano-rectal planes horizontally, vertically or circumferentially to form abscesses and possibly fistulae. Hence the vast majority of fistulae are crypto glandular in origin and multiple series have shown that the

Ó 2007 The Association of Coloproctology of Great Britain and Ireland. Colorectal Disease, 9, 749–753

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Fistula surgery in a DGH

N. Nwaejike & R. Gilliland

formation of a fistula tract following anorectal abscess occurs in 7–40% of cases [1]. A proportion is secondary to inflammatory bowel disease (particularly Crohns disease), anal fissures, carcinoma, radiation therapy, actinomycoses, tuberculosis and chlamydial infections. The prevalence rate is 8.6 cases per 100 000. The prevalence in men is 12.3 cases per 100 000. In women, it is 5.6 cases per 100 000. The male-to-female ratio is 1.8:1. The mean age of patients is 38.3 years [2,3,4]. Several classification methods are available but the Parks classification is the most frequently used. The Parks classification system defines four types of fistula-in-ano that result from cryptoglandular infections; intersphincteric (70% of fistulae), trans-sphincteric (25% of fistulae), suprasphincteric (5% of fistulae) and extrasphincteric (1% of fistulae) [2,3]. Whilst some complex fistulae require the use of imaging modalities such as contrast fistulography [14], endoanal ultrasound [10] or magnetic resonance imaging [12,13] to be correctly classified, 85% can be correctly diagnosed by careful examination under anaesthetic and the judicious use of probes. The main complications of fistula-in-ano are recurrence and incontinence and surgical treatment aims to remove the fistula without compromising anal continence. The surgical treatment of fistulae can be divided into two broad categories; sphincter sparing and nonsphincter sparing surgery. Sphincter sparing treatment involves the injection of fibrin glue or the use of endorectal advancement flaps. More commonly, a nonsphincter sparing approach is adopted with either laying open of the fistula by means of fistulotomy or the insertion of Seton sutures either for cure or as part of a staged fistulotomy procedure. Nonsphincter spring surgery is therefore associated with a higher rate of incontinence as there is interference with the anal sphincter. There is some evidence to suggest that certain conditions formally managed by general surgeons may be more successfully treated by colorectal specialists [5,6]. This argument is well established for rectal cancer [5] but may extend to benign anal conditions also. Dorrance et al. 2000 examined the effect of the surgeon’s specialty on patient outcome after potentially curative colorectal cancer surgery. This showed that surgeons with an interest in colorectal cancer achieve lower local and overall recurrence rates compared with other sub specialties. No such study has been done for fistula-in-ano surgery. The aim of this study was to compare the treatment strategies for fistulae-in-ano by general and colorectal surgeons in a district general hospital and to assess the outcome of surgery in terms of recurrence and incontinence.

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Method Ethical approval was obtained from the local Hospital Ethics Committee prior to commencement of the study. Patients who had surgery for fistula-in-ano from January 1992 to October 2003 were identified from theatre records. Case notes were retrieved and reviewed; data including patient demographics were recorded on a proforma. The aetiology and type (according to Park’s classification) of each fistula was noted along with surgical details including the grade of the operating surgeon and the surgical procedure performed. All patients were then sent a questionnaire requesting details of symptoms from surgery, further surgery for recurrence, and incontinence following the initial operation. Recurrence was assessed from notes made about patients after examination in subsequent out-patient clinics, and cross checked with replies in the questionnaires in case they had treatment in a different hospital. Follow-up was calculated as the time from first operation to the date the questionnaires were sent out. Patients who admitted to faecal incontinence as a complication of their surgery were asked to complete two additional questionnaires, a Faecal Incontinence Quality Of Life Scale (FIQOLS) and a Faecal Incontinence Severity Index (FISI). The FIQOLS is comprised of 29 items which form four scales assessing lifestyle (10 items), coping ad behaviour (nine items), depression and self perception (seven items) and embarrassment (three items). The FISI is based on the patient’s perception of symptom severity with a higher score indicating worse severity of symptoms. Both questionnaires are standard validated tools for the assessment of faecal incontinence developed and approved by the American Society of Colon and Rectal Surgeons. Patients were divided into two groups depending on whether they had been operated on under the care of a general or colorectal surgeon. All data were stored on spreadsheet (Microsoft excel 2002). Statistical analysis was performed using Chi-squared and Fisher’s exact tests for categorized data; Mann– Whitney test was used for evaluating numerical data; P < 0.05 was considered significant.

Results A total of 84 (male 53; female 31) patients were operated on during the period of the study. There were 34 patients by colorectal surgeons and 50 by general surgeons. Demographic data is shown in Table 1. There was no difference between the groups in terms of age (Table 1), gender (Table 1), aetiology (colorectal: IBD ¼ 5,

Ó 2007 The Association of Coloproctology of Great Britain and Ireland. Colorectal Disease, 9, 749–753

Fistula surgery in a DGH

N. Nwaejike & R. Gilliland

Table 1 Distribution of patients treated by coloproctologist and general surgeon.

Male/female Median age (years) Median follow-up (years)

20/14 41 2

General 33/17 43 8

P NS NS