The fistula tract was dissected from all sides by sharp dissection with scissors or diathermy from the external opening to the internal opening (Fig. 6).
Postoperative pain control, antibiotics (appropriate broad-spectrum antibiotics, effective against gram-negative enteric bacilli, gram-positives, and anaerobes), and surgical dressing were used. Parents were counseled that a drop of blood in the diaper or dressing is not unusual but persistent bleeding is a problem and requires medical attention. Patients were discharged home on the first postoperative day. Babies were given a brief warm bath after every bowel movement to ensure local hygiene. The wound was cleaned and lightly packed with gauze soaked in povidone iodine 10% or native honey to allow gradual filling of the cavity by granulation tissue; thus, the wound was allowed to heal by secondary intention.
Patients were followed up weekly until the wound had healed completely and monthly thereafter until 4 months had passed without any evidence of recurrence.
Randomization was carried out using closed envelopes before surgery at the time of admission in hospital. Demographic information of the patients, symptoms, and localization of the lesion were recorded and analyzed. Operative time, healing time, and complication rate all were recorded and compared. Statistical analysis of data was carried out using SPSS (Chicago, Illinois, USA) and data were summarized and expressed with percentages, means±SD, and the level of statistical significance was set at P equal to 0.05.
Thirty-six infants with low FIA were included and were subjected to either fistulotomy or fistulectomy. The most commonly affected site was in the 3 O’clock direction with 15 (41.7%) lesions, followed by the 9 O’clock direction in 12 (33.3%) patients. Twenty-three of these 29 patients had received previous surgical drainage for PAA (nine patients in our hospitals and 14 elsewhere); the remaining six patients had received nonoperative management. Demographic and other baseline characteristics are presented in (Table 1).
The mean values for operative time were 13.9±1.76 min for group A (range 12–18 min) and 15.9±0.94 min for group B (range 15–18 min).
The overall complication rate for group A was documented in one patient (5.6%) and it was reported in two patients (11.1%) in group B. There was one wound infection in a patient in group A that was treated conservatively. One patient experienced granuloma in group B. Recurrence was observed in one patient (5.6%) in group B who was 20 months old and had a previous history of nonoperatively treated PAA. This patient underwent fistulotomy 4 months later and was completely cured after the second operation. Intraoperative and postoperative bleeding was negligible and usually controlled by diathermy or compression. Histopathological examination of tissue obtained was performed in two cases and indicated no specific inflammatory cells and no evidence of specific granuloma.
The mean values of healing time were 21±3.01 days for group A (range 17–28 days) and 26.6±1.42 days for group B (range 25–30 days).
The statistical analysis showed that there was a statistically significant difference (P=0.00) between the two groups in both the operative time and the healing time (Table 2).
Although there was a numerical difference between the two groups as regards the complication rate, it was statistically insignificant (P=0.5) (Table 3).
In 2011, Carmona et al. 1 documented in his case series a male predominance in 94.1% of cases. Other studies reported incidences of male predominance varying from 75 to 100% 2,5,10,14–16, which is in agreement with our results.
The disease was presented before the age of 1 year in 87.1% of infants 17. Chang et al. reported in 2010 that the mean age of the presented infants was 6±4.5 months 14.
The usual presentation involves intermittent relapse of inflammation with purulent discharge, perianal pruritis, and granuloma 2.
Lesion localization and characteristics vary in the literature; lesions were right sided in 62.5% and left sided in 22.5% of cases 18 and all patients with FIA had been treated previously for PAA 19. In a case series of 17 patients, lesions were located on the right side in 31.25%, on the left side in 18.75%, and were preceded by PAA in 25% of cases 1. This is almost consistent with our results.
In our study, the mean operative time was shorter for group A and this may be attributed to the simpler technique and less time taken to control bleeding, especially using needle diathermy. Our results are in agreement with those of many studies in the literature.
Postoperative complications such as wound infection, recurrence, and other complications were reported in the literature with variable incidence. Wound infection and granuloma were reported at a rate of 2.8% for each 20. Oh et al. (2001) reported that none of the patients who underwent fistulotomy had recurrent fistula during an average follow-up of 25.4 months 2. However, in 2010, Jun 10 reported a recurrence rate of 4.5% in surgically treated FIA, whereas other authors reported a recurrence rate up to 13% 9.
However, many reviews have reported no recurrence of FIA after either fistulotomy or fistulectomy 1,14,19. Novotny et al. 13 reported that recurrence is more likely in older children and in children who had previous episodes of PAA or if pus was noted at the time of surgery. Our results are in agreement with those of many authors.
The average healing time after fistulotomy was found to be shorter than that after fistulectomy in the general population 21. In our study, the shorter healing time in group A may be attributed to less tissue loss than that in group B.
Although FIA in infants can be treated either by fistulotomy or by fistulectomy, its treatment remains controversial and fistulotomy is still considered the standard surgical treatment. Fistulotomy is simple and results in shorter operative time, lesser recurrence rate, and earlier wound healing as compared with fistulectomy.
Conflicts of interest
There are no conflicts of interest.
1. Carmona J, Osterman A, Lugo Vicente H.Fistula-in-ano in children: a case series.Bol Asoc Med P R2011;103:14–17.
2. Oh J-T, Han A, Han SJ, Choi SH, Hwang EH.Fistula-in-ano in infants: is nonoperative management effective?J Pediatr Surg2001;36:1367–1369.
3. Shafer AD, McGlone TP, Flanagan RA.Abnormal crypts of Morgagni: the cause of perianal abscess and fistula-in-ano.J Pediatr Surg1987;22:203–204.
4. Gupta PJ.Anal fistulotomy using radiowaves – long-term outcome.Acta Chir Iugosl2008;55:115–118.
5. Christison-Lagay ER, Hall JF, Wales PW, Bailey K, Terluk A, Goldstein AM, et al..Nonoperative management of perianal abscess in infants is associated with decreased risk for fistula formation.Pediatrics2007;120:e548–e552.
6. Macdonald A, Wilson-Storey D, Munro F.Treatment of perianal abscess and fistula-in-ano in children.Br J Surg2003;90:220–221.
7. Piazza DJ, Radhakrishnan J.Perianal abscess and fistula-in-ano in children.Dis Colon Rectum1990;33:1014–1016.
8. Longo WE, Touloukian RJ, Seashore JN.Fistula in ano in infants and children: implications and management.Pediatrics1991;87I737–739.
9. Festen C, Van Harten H.Perianal abscess and fistula-in-ano in infants.J Pediatr Surg1998;33:711–713.
10. Jun SY.Fistula-in-ano in children less than 2 years of age.J Korean Assoc Pediatr Surg2010;16:170–176.
11. Rosen NG, Gibbs DL, Soffer SZ, Hong A, Sher M, Peña A.The nonoperative management of fistula-in-ano.J Pediatr Surg2000;35:938–939.
12. Al-Salem AH, Laing W, Talwalker V.Fistula-in-ano in infancy and childhood.J Pediatr Surg1994;29:436–438.
13. Novotny NM, Mann MJS, Rescorla FJ.Fistula in ano in infants: who recurs?Pediatr Surg Int2008;24:1197–1199.
14. Chang HK, Ryu JG, Oh J-T.Clinical characteristics and treatment of perianal abscess and fistula-in-ano in infants.J Pediatr Surg2010;45:1832–1836.
15. Afşarlar ÇE, Karaman A, TanIr G, Karaman I, YIlmaz E, Erdoğan D, et al..Perianal abscess and fistula-in-ano in children: clinical characteristic, management and outcome.Pediatr Surg Int2011;27:1063–1068.
16. Ezer SS, Oguzkurt P, Ince E, Hiçsönmez A.Perianal abscess and fistula-in-ano in children: aetiology, management and outcome.J Paediatr Child Health2010;46:92–95.
17. Meyer T, Weininger M, Höcht B.Perianal abscess and anal fistula in infancy and childhood: a congenital etiology?Chirurg2006;77:1027–1032.
18. Al-Salem AH, Qaisaruddin S, Qureshi SS.Perianal abscess and fistula in ano in infancy and childhood: a clinicopathological study.Pediatr Pathol Lab Med1996;16:755–764.
19. Serour F, Somekh E, Gorenstein A.Perianal abscess and fistula-in-ano in infants: a different entity?Dis Colon Rectum2005;48:359–364.
20. Poenaru D, Yazbeck S.Anal fistula in infants: etiology, features, management.J Pediatr Surg1993;28:1194–1195.
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21. Bhatti Y, Fatima S, Shaikh GS, Shaikh S.Fistulotomy versus fistulectomy in the treatment of low fistula in ano.Rawal Med J2011;36:284–286.