One Stage Fistulotomy and Fistulectomy

Fistulotomy involves the deroofing or the laying open of a fistulous tract along a probe. Fistulectomy means excision of all the fistulous tract, granulation, and dense fibrous tissue, creating larger wounds and a greater separation of the ends of the sphincter, which results in a longer healing time and increased risk of incontinence. Fistulectomy and fistulotomy are easy to perform in cases of perineal, intersphinc-teric and low trans-sphincteric fistulae. If the fistu-lous tract crosses the external sphincter, a lay-open technique or fistulotomy results in some sphincter damage, depending on the amount of sphincter which is divided [64, 65].

After excision or incision of a fistulous tract, the wound can be left open for healing by second intention. In some cases, a partial suture at the level of the pectineal line and anoderm may achieve haemostasis, speed up healing time and prevent an anal key-hole deformity. The outer part of the excision is left open to ensure drainage. The wide inter-study variability in success rates of surgery probably depends on the non-homogeneity of the sample of patients treated, but might also depend on the type of fistula treated. Makowiec et al. [66] found the healing rates after surgical treatment of low perianal, transsphincteric and high perianal fistulae to be 64, 40 and 33%, respectively. Moreover, absence of active rectal Crohn's disease decreased the recurrence rate and increased the probability of complete healing. Due to the high incontinence rate and keyhole deformity generated by these procedures, we prefer to use the advancing flap technique in cases of Crohn's perineal fistulae, unless the fistulous tract is quite distal.

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