الفهرس 
Anatomy of the anal canalOnly 14 pages are availabe for public view
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Abstract
A
nal fistula is a common disease that has long challenged surgeons’ skills Perianal fistula, if not treated properly will result in one of two terrible complications, recurrence or incontinence. Despite many preoperative investigations that can help to identify the correct anatomy of the fistula, one might face difficult or unexpected intraoperative findings that require wise decisions. Appropriate decisions in such circumstances have a significant impact on the outcome of surgery and the patient’s quality of life (Abou-Zeid., 2011).
The risk of postoperative incontinence was shown to be greater for females than for males. It is commonly believed that women are more prone than men to incontinence after surgical treatment for the fistula because of the smaller sphincter mechanism that may also be impaired by vaginal childbirth (Takayuki et al., 2007).
The ideal surgical treatment for anal fistula should eradicate sepsis and promote healing of the tract, whilst preserving the sphincters and the mechanism of continence. For the simple and most distal fistulae, conventional surgical treatment such as lay-open of the fistula tract as a complete transection of the tissue between the fistula tract and anoderm is very effective with a success rate of up to 100%. Although reported incontinence rates following fistula surgery is very variable and is influenced by many factors, incontinence rate after laying open of intersphincteric and distal fistulae seems to be under 10% (Limura and Giordano, 2015).
Perianal (fistula is defined as an opening between perianal skin and the cavity of the anal canal or rectum (Lioyd-Jhoes and Giles., 1995).
The incidence of perianal fistula ranges from 1.1to 2.2per 10, 000people per year. Fistula most commonly affect people in their third, fourth or fifth decades, peak incidence has been reported at a lower age in Nigerians and in black Americans, whether bowel habits may be influential is unclear, some believe that diarrhea may allow easier access of bacteria to anal glands, others believe that hard stools are implicated by their abrasive passage through the anal canal, also there is male predominance as male to female ratio between 2:1to 4:1 (Garcia-Aguilar et al., 2000).
Although fistula in ano may be found In association with a variety of specific conditions, the majority is classified as non-specific, It seems likely that all fistulas arise from a pyogenic abscess, which has been allowed to develop to the patient of spontaneously discharging or one, which has been inadequately drained surgically. The point of debate thereafter is to explain why the condition has persisted (Lioyd-Jhoes and Giles., 1995).
The eight primary criteria for determining success or failure of fistula surgery are the following: recurrence, time needed for wound healing, time of operation, pain score in VAS, hospital stay, postoperative complications, time to return work and incontinence.
The present study is a retrospective clinical trial study including twenty five (25) patients who presented with simple perianal fistula to surgical outpatient clinic at Ain Shams University Hospitals in Egypt.
The patients were divided in to two groups:
A. group A: patients who underwent fistulectomy.
B. group B: patients who underwent fistulotomy with marsupialization.
Surgical modalities:
• In the fistulectomy, a keyhole skin incision was made over the fistulous tract and encircled the external opening. The incision was depened through the subcutaneous tissue, and the tract was removed from surrounding tissue.
• In the fistulotomy with marsupialization, the fistula tract was laid open over the probe placed in the tract. After the fistula tract had been laid open, the tract was curretted and examined for secondary extensions. Wound edges were sutured with the edge of fistula tract by using interrupted 3-0 chromic catgut sutures to marsupialization.
The operative time in our study was significantly shorter in group B, with a mean of 20.22±8.46 min, compared with group A, with a mean of 30.7±11.94 min. This is because in fistulectomy we cored out the fistula tract completely after probing and it took time for dissection of the fistula tract and for the identification of structures. In addition, after removal of the fistula tract, closure of the internal opening was performed, which took more time, whereas in fistulotomy we only layed open the tract after probing from the external opening to the internal opening of the fistula; this technique saves time leading to less operative time.
In this study, there was a significant decrease in the time needed to return to normal activity and need for analgesics in group B, with a mean of 10.84±3.45days, compared with group A, with a mean of 15.54±3.77days.
In group A, the pain lasts longer postoperatively because of more dissection around the fistula tract and after coring there is raw area left, whereas in group B laying out the tract with no dissection leaves less raw area leading to less pain postoperatively.The operative pain (VAS score) in our study was significantly shorter in group B, with a mean of 6.15±2.07 min (at 6 hours), compared with group A, with a mean of 8.2±2.4 min.
In this study, the postoperative wound infection occurs in one (8.33%) patient in group B and in three (23.07%) patients in group A, with no statistical significance. Wound infection occurs because of bad hygiene of the patients and causes delayed wound healing; this infection was treated early by antibiotics and regular dressing, and there was good response.
In our study, change in the continence status occurred in zero patient scoring in both groups. No patients suffered from complete incontinence to stool from both groups in our study, and the three patients with partial incontinence to flatus scored by Lickert three point scale and were assured; this condition was temporary, as the incontinence disappeared after 8 weeks and the patients regained complete continence after that. There is no statistically significant difference between the two groups, and assessment also continued during the follow up period. No incontinence occurred in any patient in our study.
In our study, wound healing (complete epithelialization and absence of discharge) was significantly faster in group B, with a mean of 4.35 weeks, which is less than group A, with a mean of 5.94 weeks.
Recurrence after six months follow up was not significant (p value=0.587) in our study but in group B one paient of total 12 patients underwent recurrence, compared with group A, with two patients of 13 patients. This is because in fistulectomy we cored out the fistula tract completely after probing and it took time for dissection of the fistula tract and for the identification of structures.
The postoperative stay in our study was significantly shorter in group B, with a mean of 1.7±0.59 days, compared with group A, with a mean of2.4±0.8 day.
The time needed to return to normal activity was significantly shorter in group B, with a mean of 10.84±3.45days, compared with group A, with a mean of 15.54±3.77 days.
The post operative bleeding in our study was not significant (p value is 0.076) but in group B no patients had a bleeding, compared with group A, with three patients dad a bleeding.
The postoperative urinary retention in our study was not significant (p value is 0.748) but in group B three patients had a urinary retention, compared with group A, with four patients had a urinary retention.