Effect of Fistulotomy With or Without Seton on Anal Pressures and Continence: Use of Anal Manometry and the Wexner Scoring System

Tarun Jacob, K John (2008) Effect of Fistulotomy With or Without Seton on Anal Pressures and Continence: Use of Anal Manometry and the Wexner Scoring System. Masters thesis, Christian Medical College, Vellore.

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Abstract

INTRODUCTION: Fistula in ano is a common general surgical problem. There are a number of possible operative options available to the surgeon. Though a patient may not often report incontinence, it is a real and possible complication of all operative procedures described. A practical, cost effective method of assessing incontinence is with incontinence scores. There are a number of such scores published. The anal manometer may prove to be a valuable adjunct in the pre operative assessment and post operative follow up of a patient with anorectal fistula. There is paucity of Indian data on anal manometry in fistula in ano and this remains an area for further investigation. AIMS AND OBJECTIVES: 1. To determine the percentage of patients who suffer from impaired continence after anal fistula operations. 2. Determine the predisposing factors that increase the risk of sphincter damage and incontinence. 3. To identify a) those patients who are likely to sustain sphincter damage as well as b) those patients who will be successfully cured from disease without suffering sphincter damage. PATIENTS AND METHODS: Patients: Consecutive patients that presented to the general surgery department with fistula in ano were recruited for the study. The protocol and research methodology was cleared by the institutional research committee, before the study was begun. The aims and purpose of the study were explained to the patient and informed consent was obtained before enrolment. The informed consent document is presented at the end of this dissertation in APPENDIX 5. Patients were recruited from August 2005 – Feb 2008 (A period of approximately 30 months). There were a total of 224 patients that were recruited for the study. The follow up rate was 25%, with 57 patients completing both preoperative and post operative assessments. Inclusion Criteria: • All patients presenting to the Christian Medical College with a fistula in ano. This included patients referred from the peripheral clinics of the hospital. • Any patient in whom the presence of a fistula had been confirmed by a consultant in General surgery. • Any patient with recurrent disease or those with a seton in situ were included in the study. • Patients with non crypto-glandular origin such as Crohn’s disease and tuberculosis were still included in the study, but identified and classified as such. Patients who were unable to attend follow up due to distance and travel concerns were not included into the study though their anal pressures and incontinence scores were documented in a separate departmental protocol. The data on such patients are not included in this dissertation for analysis or discussion. Exclusion Criteria: • All patients with a coexisting anal fissure were excluded from the study in view of discomfort caused by anal manometry. • Those unable to attend follow up 3 months after the start of the study were excluded. • Elderly patients over the age of 65 were excluded from the study as it was felt that they may have atrophic sphincters and this may confuse the data. • Women whose parity was 4 or more were excluded from the study because of possible sphincter and pelvic floor weakness. • Patients with diagnosed or demonstrable sphincter injuries from trauma, previous fistula surgery and obstetric injury were excluded from the study. • Neurological disorders involving the innervation of the sphincters or pelvic floor were excluded. CONCLUSIONS: • Aim: To determine the percentage of patients who suffer from impaired continence after anal fistula operations. 1. Incontinence is not uncommon after fistulotomy for fistula in ano. The rates of incontinence based on Wexner scores indicate that up to 50% of patients suffer from some degree of incontinence. Only 12 % of these patients are socially troubled by incontinence. Aim: Determine the predisposing factors that increase the risk of sphincter damage and incontinence. 2. Anal manometry values alone are unable to predict patients who will complain of fecal incontinence. 3. The study aimed to look at certain risk factors for incontinence. The parameters of type of fistula and previous operation were not significant risk factors. There were inadequate women in the study population to make a comment on sex as a predictor of incontinence. These may be addressed in a larger study along with other predictors. Aim: To identify a) those patients who are likely to sustain sphincter damage as well as b) those patients who will be successfully cured from disease without suffering sphincter damage. 4. Anal manometry and Wexner scores can be used to evaluate patients preparing for conventional fistula surgery, and have a role to play in quantification of incontinence. Anal manometry readings show changes in resting pressures that are possibly compensated by the puborectalis sling to maintain continence. The Wexner scores also show a significant drop after operation. 5. Changes in Wexner scores from before and after anal fistula surgery indicate a significant change, irrespective of whether the fistula is low or high trans sphincteric in nature. 6. The percentage of patients who were successfully cured from the disease without sustaining sphincter damage was not determinable as no statistically significant drop was measured in sphincter pressures pre operatively or after operation. 7. There is a suggestion of increased sphincter pressures post operatively high in the anal HPZ (about 40mm). The pressure changes, at this point are statistically significant between preoperative and postoperative values. This may be due to puborectalis muscle compensation, and this requires further investigation.

Item Type: Thesis (Masters)
Uncontrolled Keywords: Fistulotomy With or Without Seton ; Anal Pressures and Continence ; Anal Manometry ; Wexner Scoring System.
Subjects: MEDICAL > General Surgery
Depositing User: Devi S
Date Deposited: 04 May 2018 03:18
Last Modified: 04 May 2018 03:18
URI: http://repository-tnmgrmu.ac.in/id/eprint/7425

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