Published online Apr 7, 2015. doi: 10.3748/wjg.v21.i13.4020
Peer-review started: September 13, 2014
First decision: October 14, 2014
Revised: October 22, 2014
Accepted: November 7, 2014
Article in press: November 11, 2014
Published online: April 7, 2015
Processing time: 206 Days and 16.2 Hours
AIM: To check the efficacy of the PERFACT procedure in highly complex fistula-in-ano.
METHODS: The PERFACT procedure (proximal superficial cauterization, emptying regularly fistula tracts and curettage of tracts) entails two steps: superficial cauterization of mucosa at and around the internal opening and keeping all the tracts clean. The principle is to permanently close the internal opening by granulation tissue. This is achieved by superficial electrocauterization at and around the internal opening and subsequently allowing the wound to heal by secondary intention. Along with this, all the tracts are curetted and it is ensured that they remain empty and clean in the postoperative period until they heal completely. The latter step also facilitates the closure of the internal opening by preventing collected fluid in the tracts from entering the internal opening and thus not letting it close. Objective incontinence scoring was done preoperatively and 3 mo after the operation.
RESULTS: Fifty-one patients with complex fistula-in-ano were prospectively enrolled. The median follow-up was 9 mo (5-14 mo). The mean age was 42.7 ± 11.3 years. Male:female ratio was 43:8. Fistula was recurrent in 76.5% (39/51), horseshoe in 50.1% (26/51), had multiple tracts in 52.9% (27/51), had an associated abscess in 41.2% (21/51), was anterior in 33.3% (17/51), the internal opening was not found in 15.7% (8/51) and 9.8% (5/51) of fistulas had a supralevator extension. Seven patients were excluded (5 lost to follow up, 2 with tuberculosis leading to/associated with fistula-in-ano). The success rate was 79.5% (35/44) and the recurrence rate was 20.5% (9/44). Out of these recurrences, three underwent reoperation (2 PERFACT procedure, 1 fistulotomy) and all three were successful. Thus, the overall success rate was 86.4%. The only complication was a non-healing tract in 9.1% (4/44) of patients. There was no significant change in objective incontinence scores three months after the operation. The pain was minimal, with all patients resuming their normal activities within 72 h of the operation.
CONCLUSION: The PERFACT procedure is a new effective method for complex fistula-in-ano, effective even in fistula associated with abscess, supralevator fistula-in-ano and where the internal opening is non-localizable.
Core tip: The PERFACT procedure is a simple, economical and novel method to cure complex fistula-in-ano. It is associated with little pain, low morbidity and minimal risk of incontinence as both the anal sphincters are completely preserved. It is quite effective in complex fistula cases where other methods do not have a high success rate, like in horseshoe fistula, fistula with multiple tracts, recurrent fistula and fistula with supralevator extension. The PERFACT procedure is also quite successful in cases where the internal opening cannot be localized and in patients presenting with perianal/ischiorectal abscess where it can be done as a definitive procedure at the initial presentation.