Prospective Study
Copyright ©The Author(s) 2016. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastrointest Surg. Apr 27, 2016; 8(4): 326-334
Published online Apr 27, 2016. doi: 10.4240/wjgs.v8.i4.326
PERFACT procedure to treat supralevator fistula-in-ano: A novel single stage sphincter sparing procedure
Pankaj Garg
Pankaj Garg, Colorectal Surgery Division, Indus Super Specialty Hospital, Mohali, Punjab 160055, India
Pankaj Garg, Garg Fistula Research Institute, Panchkula, Haryana 134113, India
Author contributions: Garg P conceived the idea, designed the study, did the acquisition and analysis of data, drafted, revised and submitted the manuscript.
Institutional review board statement: The study was reviewed and approved by the Indus Hospital Ethical Committee.
Clinical trial registration statement: Not applicable.
Informed consent statement: All study participants, or their legal guardian, provided informed written consent prior to study enrollment.
Conflict-of-interest statement: The author has not received any fees for serving as a speaker or in a position (such as consultant and/or an advisory board member) which could have a conflict of interest with this study. The author has not received research funding from any organization or individual. The author is not an employee of an organization and does not own stocks and/or shares in an organization which has a potential conflict of interest with the study.
Data sharing statement: Technical appendix, statistical code and dataset are available from the corresponding author at drgargpankaj@yahoo.com. Consent was obtained but the presented data are anonymized and the risk of identification is low.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Correspondence to: Dr. Pankaj Garg, MBBS, MS, FIAGES, Chief Colorectal Surgeon, Garg Fistula Research Institute, 1042, Sector-15, Panchkula, Haryana 134113, India. drgargpankaj@yahoo.com
Telephone: +91-950-1011000 Fax: +91-172-2594556
Received: September 30, 2015
Peer-review started: October 1, 2015
First decision: November 13, 2015
Revised: November 22, 2015
Accepted: January 21, 2016
Article in press: January 22, 2016
Published online: April 27, 2016
Processing time: 202 Days and 20.8 Hours
Abstract

AIM: To prospectively perform the PERFACT procedure in supralevator anal fistula/abscess.

METHODS: Magnetic resonance imaging was done preoperatively in all the patients. Proximal cauterization around the internal opening, emptying regularly of fistula tracts and curettage of tracts (PERFACT) was done in all patients with supralevator fistula or abscess. All types of anal fistula and/or abscess with supralevator extension, whether intersphincteric or transsphincteric, were included in the study. The internal opening along with the adjacent mucosa was electrocauterized. The resulting wound was left open to heal by secondary intention so as to heal (close) the internal opening by granulation tissue. The supralevator tract/abscess was drained and thoroughly curetted. It was regularly cleaned and kept empty in the postoperative period. The primary outcome parameter was complete fistula healing. The secondary outcome parameters were return to work and change in incontinence scores (Vaizey objective scoring system) assessed preoperatively and at 3 mo after surgery.

RESULTS: Seventeen patients were prospectively enrolled and followed for a median of 13 mo (range 5-21 mo). Mean age was 41.1 ± 13.4 years, M:F - 15:2. Fourteen (82.4%) had a recurrent fistula, 8 (47.1%) had an associated abscess, 14 (82.4%) had multiple tracts and 5 (29.4%) had horseshoe fistulae. Infralevator part of fistula was intersphincteric in 4 and transsphincteric in 13 patients. Two patients were excluded. Eleven out of fifteen (73.3%) were cured and 26.7% (4/15) had a recurrence. Two patients with recurrence were reoperated on with the same procedure and one was cured. Thus, the overall healing rate was 80% (12/15). All the patients could resume normal work within 48 h of surgery. There was no deterioration in incontinence scores (Vaizey objective scoring system). This is the largest series of supralevator fistula-in-ano (SLF) published to date.

CONCLUSION: PERFACT procedure is an effective single step sphincter saving procedure to treat SLF with minimal risk of incontinence.

Keywords: Anal fistula; Complex; Simple; Horseshoe; Abscess; Supralevator; Tracts

Core tip: Supralevator fistula-in-ano (SLF) and abscess are quite difficult to treat. There is no good treatment available for this dreaded disease as the risk of incontinence is quite high when operating on such fistula. PERFACT (proximal cauterization around the internal opening, emptying regularly of fistula tracts and curettage of tracts) was done in seventeen patients with SLF. The overall healing rate was 80% (12/15). All patients could resume normal work within 48 h of surgery and there was no deterioration in incontinence scores. This is the largest series of treatment of SLF published to date.