الفهرس 
Anatomy of AnorectumOnly 14 pages are availabe for public view
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Abstract
Anal fistula is an anorectal condition with over 90% of cases being cryptoglandular in origin and occurring after anorectal abscesses. The most feared complications associated with treatment of anal fistulas are fecal incontinence due to anal sphincter damage, and recurrence of the fistula. According to the Parks classification, fistulas are divided into four main groups; intersphincteric, transsphincteric, suprasphincteric, and extrasphincteric.
Generally speaking, even the simplest fistulas pose a limited risk for continence disorders. The reported overall incontinence rates vary up to 40% depending on the type of fistula and the surgical treatment applied. Even without anal sphincter damage, most cases experience minor anal incontinence in the early postoperative period.
Fistula in ano (FIA) is a chronic condition of ano-rectal sepsis characterized by cyclical pain and chronic purulent discharge. It usually starts with abscess re-accumulation and then continues as repeated episodes of intermittent spontaneous decompression. This condition does not heal spontaneously because of the persistent closed sepsis within the fistula tract constantly entering through its internal opening. Considering the complexity of underlying disease and the recurrence of the condition, the management of fistula is challenging and not satisfactory in many cases as it is rightly said that most of the reputations of great surgeons are lost in the management of fistula in ano than in any surgery.
In spite of all the advances and the developments in the management of fistula in ano, no single method is applicable to all the peri-anal fistulas due to differences in the complexity and the chronicity of the condition and also the healing rate, incontinence and recurrences associated with the individual procedures.
Anal fistulotomy can be considered the best AF treatment option, providing a perfect surgical field view, allowing direct access to the source of chronic inflammation (i.e., the intersphincteric space) and demonstrating high healing rates. Controversy exists concerning the risk of continence impairment associated with the approach. Several researchers consider the risk as acceptable, but many others the risk as to high.
Three decades ago, Parkash et al. proposed immediate sphincter reconstruction after fistulotomy, to reduce both the risk of postoperative fecal incontinence and to healing time. Despite proved efficacy also in complex AF cases, fistulotomy/fistulectomy and primary sphincteroplasty (FIPS) is still regarded with scepticism.
The main aim of this study was to Compare between fistula tract LASER closure FiLaCTM versus fistulotomy with primary sphincter reconstruction in management of high trans-sphincteric perianal fistula regarding surgical outcomes within short term follow up period of 6 months.
This prospective comparative study was conducted in General Surgery Department of Ain Shams University hospital. This study was conducted on 40 patients high trans-sphincteric perianal fistula. Patients divided into two groups: group A: subjects treated by FiLaC. group B: subjects treated by fistulotomy with primary sphincter reconstruction at the same session.
Age in group (A) was ranged between 21-65 years with mean ±S.D. 39.35±11.970 years while in group (B) was ranged between 18-63 years with mean ±S.D. 35.55±13.300 years. There were no statistically significant differences between groups.
Gender in group (A) show that 15(75%) were male and 5(25%) were female while in group (B) 14(70%) were male and 6(30%) were female. There were no statistically significant differences between groups
Comorbidity in group (A) show that 6(30%) had DM and 5(25%) had HTN while in group (B) 4(20%) had DM and 5(25%) had HTN. There were no statistically significant differences between groups.
Previous abscess in group (A) show that 16(80%) had previous abscess while in group (B) 17(85%) had previous abscess. There were no statistically significant differences between groups.
Fistula duration in group (A) was ranged between 6-36 months with mean ±S.D. 12.14±8.319 months while in group (B) was ranged between 6-24 months with mean± S.D. 13.60±6.367 months. There were no statistically significant differences between groups.
Operative time in group (A) was ranged between 20-44 min with mean ±S.D. 29.25±7.129 min while in group (B) was ranged between 25-48 min with mean ±S.D. 35.80±7.016 min. There were statistically significant differences between groups
Early post-operative complications in group (A) show that 1 patient (5.0%) had infection and no one had bleeding, while in group (B) 2 patients (10%) had bleeding and 2 patients (10%) had infection ,regarding VAS score there were statistically significant differences between groups with high score in group (B) when compared with group (A).
Follow-up after 1 months show no statistically significant differences between groups according to healing, Wexner score and VAS score. However, the mean Wexner and VAS scores were higher in group (B).
Follow-up after 3 months showed statistically high significant differences between groups as regard to VAS score with high score in group (B) when compared to group (A) where P<0.001 [however, at 3 months of post-operative period VAS score of any patient in both groups didn’t exceed the score of (1)], recurrence rate in group (A) was higher than group (B) but this was not statistically significant, Wexner score in group (B) was higher than group (A) which scored (0) for all patients.
Follow-up after 6 months show no statistically significant differences between groups as regard recurrence rate and Wexner score. However, recurrence rates were higher in group (A) and Wexner scores were higher in group (B).
There was negative statistically significant correlation between recurrence or delayed healing and each of DM and fistula duration.
Based on our findings, we recommend for further studies on larger sample size and on large geographical scale to emphasize our conclusion.