Modified fistulotomy with internal orifice distalization for optimized perianal fistula management: Pressure zone transition.

Background: Both the etiology and treatment of perianal fistulas present challenges, and there is no standard surgical approach.

Aim: To present the results of a modified fistulotomy technique that was implemented in a tertiary coloproctology reference center.

Methods: Seventy-two patients who underwent surgical intervention for perianal fistula between August 2019 and January 2023 were treated using a modified fistulotomy technique. In this approach, the fistula tract was excised from the external opening up to the external sphincter fibers. The internal orifice was widened, and the septic focus within the inter sphincteric space was curetted. Partial internal sphincterotomy was performed up to the inter sphincteric plane. The anoderm from the internal orifice to the inter sphincteric space was closed with absorbable suture material, and a loose seton was placed at the level of the external sphincter.

Results: The 72 patients who underwent modified fistulotomy were 77.8% male and 22.2% female, with a mean age of 42.2 ± 11.5 years. The median follow-up period was 19 months. Preoperatively, 93.1% of patients had high trans sphincteric fistulas, and 6.9% were females with anterior low trans sphincteric fistulas. In all cases, setons were placed during surgery using vascular tape. A total of 12.5% of patients experienced incontinence, involving gas (6.9%) or soiling (5.6%). There were no reports of solid or liquid incontinences. Complete healing was achieved in 83.3% of the patients, with a recurrence rate of 4.2% and a non-healing rate of 12.5%.

Conclusion: Our preliminary analysis suggests that this modified fistulotomy technique that targets distalization of the internal orifice is a promising alternative management strategy for perianal fistulas.