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Stuart Hamm. Steve Morse. Instrumental Steve Morse Band. Michael Angelo Batio. Hard Rock Mr. Neil Zaza. The site of the IFO was identified as a sub-epithelial breach connected to an internal sphincter defect, or as a root-like budding which is in contact with, or is positioned inside the internal anal sphincter. This was according to the Cho criteria for identifying the IFO of an anal fistula tract [ 10 ].

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The height of the IFO was measured starting from the anal verge. Low transsphincteric were classified as simple fistulas. Postoperative FI was evaluated by means of a paper questionnaire in December and by face-to-face contact or telephone in The patients arrived on the day of surgery. No bowel preparation or antibiotics were given prior to the surgery. The LIFT procedure was performed under general anesthesia. Essential steps of the procedure include incision at the intersphincteric groove, identification of the intersphincteric portion of the tract, thorough cleaning of the tract, ligation of intersphincteric tract close to the internal opening, removal of intersphincteric portion of the tract, core out of the external tract and the external opening, and suturing of the defect at the intersphincteric site of the external sphincter muscle, and the external opening was left open for discharge.

The classic approach had to be modified if the tract could not be dissected safely a very thick tract, too much fibrosis around the tract, proximal curving of the tract, and immediate branching of the tract at the intersphincteric site.

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The intersphincteric tract was then cut rather than dissected, and after removal of the intersphincteric portion of the tract, the tract was sutured. The suture was placed at the level of the internal sphincter muscle. To verify that the fistula tract was closed, hydrogen peroxide was introduced into the IFO during the operation.

The patients were discharged the same day of surgery. Paracetamol and ibuprofen were prescribed for pain management. The next consultations were at 4-weekly intervals until recurrence or complete healing had occurred. The initial follow-up period with extensive questionnaires was from the first perianal fistula-related surgery up to December The second follow-up was in September to evaluate recurrence and complaints only.

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The electronic patient files were reviewed and the checked for recurrences. In December , questionnaires regarding the current fistula-related perianal symptoms, complaints of fecal incontinence, and the impact of current fistula-related complaints on QOL Procto-PROM were sent out to all the participants.


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Current fistula-related complaints were defined as perianal pain, tenderness, or fistula-related pus secretion. If a patient did not return the first set questionnaires, they were sent a second set. A patient-reported outcome measurement or PROM is a validated questionnaire used in a clinical trial or a clinical setting, where the responses are collected directly from the patient.

Evidence shows that the systematic use of information from PROMs leads to better communication and decision-making between doctors and patients and improves patient satisfaction with care [ 11 , 12 , 13 ]. The validated Procto-PROM questions were divided in five categories: daily life, stool related, social life, coping, relationships, and intimacy. The maximum score per category is 10 points with a total score of 50 points. The higher the score, the more impact the symptoms have per category. Univariate analysis was performed on factors possibly associated with recurrence.

There were three diabetic patients using oral medication. Three patients smoked. None had an enterostomy. The first operations took longer due to the learning curve. There was no postoperative bleeding or infection. The patients with mid and high transsphincteric fistulas all had secondary tracts or an extension higher than the internal opening. Three patients refused to fill in the questionnaire and ten patients could not be contacted. Preoperatively, eight patients had existing FI, seven had a history of fistula-related surgery, and one had a previous seton and abscess drainage only.

Three women and one man were incontinent for solid stool Parks 4 , two men and one woman for liquid stool Parks 3 , and one man for flatus Parks 2. Three men had soiling due to a keyhole deformation. Postoperatively, their Parks score was unaltered and no additional symptoms of soiling were reported.

There was a negative effect of a CF simple 5. Flow sheet of Patients and follow-up of the questionnaires in and telephone call long-term follow-up in There were no statistically significant differences between the two groups concerning, age, previous fistula treatment, the complexity of fistula tract s , the surgical technique of suture versus ligation, the clockwise orientation of the IFO, and the duration of the placement of a seton.

A higher IFO had a higher chance of recurrence Of the patients who were lost to follow-up, one had a persisting asymptomatic fistula and one had an active fistula without complaints who moved abroad. Their last follow-up was in Two patients treated additionally with a fistulotomy developed minor soiling.

The importance of downgrading is that the remaining fistula tract is easier to treat. In general, a fistulotomy can be performed with little risk of FI.

Other centers have had the same experience [ 14 ]. There was a trend towards a higher healing rate and less subsequent procedures between the downgraded and unaltered fistulas. Our results seem disappointing compared to the results in the literature, where the success rates are generally higher. First, the definition of complex and simple fistulas and the number of included CF.

This is not always mentioned. The definition involves the height of the fistula and side branches. Finally, our fistulas had extensions or side branches above the IFO. Recurrences have been related to complexity of fistulas [ 24 , 27 , 28 ]. Third, the definition of success differs between different studies. The initial closure is often noted as success and not the corrected number after subsequent recurrences. Furthermore, whether cure occurred after subsequent treatments is not always clear.

Fourth, we had a high percentage of previously operated patients many of whom had undergone more than 1 procedure. Recurrence has been related to past fistula surgery [ 24 , 27 , 28 ]. Besides the previous surgery, several other factors have been associated with recurrence.

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Unexplored secondary tracts are a well-known cause [ 27 ]. There is some discussion about surgery being the golden standard to evaluate secondary tracts, but studies with anal ultrasound and MRI have demonstrated that tracts found with these modalities can be missed during surgery. EAUS is an easy to use bedside tool providing excellent visualization of the fistula tracts [ 29 ]. The length of the fistula [ 15 ], lateral localization of the IFO [ 28 ], diabetes, smoking, and obesity [ 15 , 18 , 22 , 27 ] have also been mentioned as possible causes of recurrence or failure.

The previous treatment with a seton is still a matter of debate. Epithelialization of the tract as a result of seton placement seems logical, but has not been demonstrated [ 30 ] and has been associated with failure [ 21 ]. Antibiotics were not used in our study. The role of concomitant infection is controversial. The use of antibiotics or core out [ 22 , 24 , 27 ] has been successful in some cases, but is not generally applied. Most studies do not mention the use of antibiotics and no clear evidence exists concerning recurrence.

The only predictor which we found for recurrence was the height of the IFO. We believe that the height of the IFO is crucial in the definition of the complexity of the fistula. The unexpected finding that men had more recurrences than women was possibly due to the higher IFO in men. Although persistence or recurrence is disappointing, subsequent surgery can often cure the fistula [ 14 , 15 ]. Other studies report similar experiences [ 19 , 21 , 23 ].

We used a PROM questionnaire, since this is now a routine procedure in our clinic before and after treatment. The FI QOL scale is also a good tool [ 31 ], but does not reflect the real disease burden with problems in fistula surgery. This retrospective study has some limitations.

Although our prospective database is very extended and precise, the questionnaires were not applied before surgery at that time.