Diagnosis and surgical tactics in recurrent extrasphincteric fistulas of the rectum

Aim. To increase the effectiveness of surgical treatment in patients with recurrent forms of extrasphincteric rectal fistula.
Material and Methods. Clinical data of 108 patients with recurrent extrasphincteric rectal fistulas were analysed. The patients were divided into two groups. The first, the main group, included 58 (53.7%) patients who underwent improved and developed surgical procedures. The second, control group, included 50 (46.3%) patients who were treated with traditional, well-known methods.
In 6 (5.6%) cases grade I complexity of extrasphincteric recurrent rectal fistula was observed, in 23 (21.3%) cases grade II, in 62 (57.4%) cases grade III and in 17 (15.7%) cases grade IV complexity of fistula was observed.
Results. In 13 (26.0%) cases, patients in the control group underwent surgery using the ligature method, and in 37 (74.0%) patients various known plastic surgery methods were used to close the internal hole. In patients with recurrent complex horseshoe-shaped extrasphincteric fistulas from the main group, a three-stage surgical procedure was performed, developed and improved in our clinic (n=18) to prevent disease recurrence and reduce the incidence of postoperative complications. In 21 (36.2%) patients, the method we developed for surgical correction of recurrent rectal fistulas of grade III-IV complexity with an extrasphincteric course was used.
Conclusion. The developed and improved methods of surgical correction of recurrent extrasphincteric fistulas of the rectum allow radical excision of scar-inflammatory altered parafistula tissue, especially in fistulas of III-IV degree of complexity. These methods help to minimise both early and late postoperative complications, in particular they reduce the frequency of disease recurrence.

1. Groshilin V.S. Effektivnost modifitsirovannoy metodiki fistuloskopii pri slozhnykh i retsidivnykh rektalnykh svishchakh [Effectiveness of modified fistuloscopy technique in complicated and recurrent rectal fistulas]. Ulyanovskiy mediko-biologicheskiy zhurnal – Ulyanovsk medical and biological journal, 2018, No. 2, pp. 53-62.

2. Katorkin S.E. Sovremennye sfinkterosokhranyayushchie metody lecheniya chres– i ekstrasfinkternykh pararektalnykh svishchey [Modern sphincter-preserving methods of treatment of per- and extrasphincteric pararectal fistulas]. Novosti khirurgii – News of surgery, 2018, Vol. 26, No. 2, pp. 204-214.

3. Kostarev I.V. Kliniko-manometricheskie izmeneniya funktsionalnogo sostoyaniya zapiratelnogo apparata pryamoy kishki u patsientov, perenesshikh issechenie trans- ili ekstrasfinkternogo svishcha s ushivaniem sfinktera [Clinical and manometric changes in the functional state of the rectal closure apparatus in patients undergoing excision of trans- or extrasphincteric fistula with sphincter suturing]. Koloproktologiya – Coloproctology, 2018, No. 4 (66), pp. 31-38.

4. Kostarev I.V. Klinicheskie rezultaty odnotsentrovogo prospektivnogo issledovaniya po otsenke effektivnosti khirurgicheskogo lecheniya trans- i ekstrasfinkternykh svishchey pryamoy kishki s primeneniem bioplasticheskogo kollagenovogo materiala [Clinical results of a single-center prospective study to evaluate the efficacy of surgical treatment of trans- and extrasphincteric rectal fistulas using bioplastic collagen material]. Annaly khirurgii – Annals of surgery, 2018, Vol. 23, No. 2, pp. 99-107.

5. Krasnova V.N. Sravnitelnye rezultaty primeneniya ligirovaniya svishchevogo khoda v mezhsfinkternom prostranstve v lechenii chressfinkternykh i ekstrasfinkternykh pararektalnykh svishchey [Comparative results of intersphincteric fistula ligation in the treatment of transsphincteric and extrasphincteric pararectal fistulae]. Vrach–aspirant - Postgraduate doctor, 2017, Vol. 80, No. 1, pp. 179-189.

6. Kuzminov A.M. Funktsionalnoe sostoyanie zapiratelnogo apparata pryamoy kishki pri lechenii ekstrasfinkternykh svishchey pryamoy kishki metodom segmentarnoy proktoplastiki [Functional state of the rectal locking apparatus during treatment of extrasphincteric rectal fistulae by segmental proctoplasty]. Aktualnye voprosy koloproktologii - Topical issues of coloproctology, 2017, No. 2, pp. 60-63.

7. Mukhabbatov D.K. Metabolicheskiy sindrom u bolnykh so svishchami pryamoy kishki [Metabolic syndrome in patients with rectal fistulas]. Rossiyskiy mediko-biologicheskiy vestnik imeni akademika I.P. Pavlova – Russian Medical and Biological Bulletin named after academician I.P. Pavlov, 2018, Vol. 26, No. 1, pp. 86-95.

8. Khitaryan A.G. Obosnovanie tekhnologii FiLaC pri lechenii ekstrasfinkternykh svishchey pryamoy kishki [The rationale of FiLaC technology in the treatment of extrasphincteric rectal fistulae]. Koloproktologiya – Coloproctology, 2019, Vol. 18, No. 2 (68), pp. 75-81.

9. De Hous N. Fistulectomy and primary sphincteroplasty (FIPS) to prevent keyhole deformity in simple anal fistula: a single-center retrospective cohort study. Acta Chirurgica Belgica, 2021, Vol. 121, No. 5, pp. 308-313.

10. Omar W. Drainage Seton Versus External Anal Sphincter–Sparing Seton After Rerouting of the Fistula Tract in the Treatment of Complex Anal Fistula: A Randomized Controlled Trial. Diseases of the Colon & Rectum, 2019, Vol. 62, No. 8, pp. 980-987.

11. Vander Mijnsbrugge G.J.H. Perianal fistulas and the lift procedure: results, predictive factors for success, and long-term results with subsequent treatment. Techniques in coloproctology, 2019, Vol. 23, No. 7, pp. 639-647.