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 Table of Contents  
ORIGINAL ARTICLE
Year : 2022  |  Volume : 7  |  Issue : 1  |  Page : 4-6

A large study on lifestyle factors increasing probability of fistula and factors responsible for recurrent fistula


1 Department of Proctology, Rana Hospital, Fatehgarh Sahib, Punjab, India
2 Department of Gynaecology, Rana Hospital, Fatehgarh Sahib, Punjab, India
3 Department of Surgery, Rana Hospital, Fatehgarh Sahib, Punjab, India

Date of Submission20-May-2022
Date of Acceptance03-Jun-2022
Date of Web Publication30-Jun-2022

Correspondence Address:
Dr. Hitender Suri
Department of Proctology, Rana Hospital, Fatehgarh Sahib, Punjab
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijmo.ijmo_10_22

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  Abstract 


Background: Fistula-in-ano (FIA) commonly affects males more than females. Some differences in the characteristics of FIA between both genders have been recognized, yet the impact of these differences on the outcomes of surgery for FIA is still unclear. The present study conducted a gender-specific analysis aiming to assess the characteristics and the outcomes of surgery of FIA in each gender. Methodology: The records of patients with FIA were retrospectively reviewed and the following variables were extracted: patients' demographics, type of FIA, the position of the external opening, the operation performed, the incidence of recurrence, and complications, particularly fecal incontinence (FI). Gender-based analysis of the characters and outcomes of surgery for FIA was performed. Results: When a detailed case study was done, most patients having abscess with fistula were either on long-term medication (prolonged use of antibiotics) or immunocompromised. Out of 11.4% of cases of recurrent fistula, 34% were diabetics and 2.4% were HIV reactive, 18.76% were tubercular. Conclusion: The majority of FIA in males were posterior and high trans-sphincteric, whereas most FIA in females were low and anteriorly based. Despite the different characteristics of FIA; no statistically significant differences in the rates of fistula recurrence and FI between males and females could be recorded.

Keywords: Fistula, immunocompromised, lifestyle factors, recurrent fistula


How to cite this article:
Suri H, Suri D, Bansal K, Suri S, Ghodke V. A large study on lifestyle factors increasing probability of fistula and factors responsible for recurrent fistula. Int J Med Oral Res 2022;7:4-6

How to cite this URL:
Suri H, Suri D, Bansal K, Suri S, Ghodke V. A large study on lifestyle factors increasing probability of fistula and factors responsible for recurrent fistula. Int J Med Oral Res [serial online] 2022 [cited 2022 Dec 4];7:4-6. Available from: http://www.ijmorweb.com/text.asp?2022/7/1/4/349239




  Introduction Top


Anal fistula is a hollow tract lined with granulation tissue that connects an internal opening in the anal canal with the perineal skin. The vast majority of fistula-in-ano (FIA) is secondary to anorectal abscess which is known as the cryptoglandular hypothesis where the infection starts in the anal glands and then progresses through the anal sphincters to cause an anorectal abscess. However, some FIA are secondary to a specific etiology such as trauma, inflammatory bowel diseases (IBDs), anal fissure, malignancy, and radiotherapy.[1],[2] Primary cryptoglandular FIA usually affects young- and middle-aged males, with a mean age of around 38 years.[3] The documented male-to-female ratio of FIA is 1.8:[1],[3] The male predilection of FIA is not only noticed in adults but also in the pediatric population where males represent more than 97% of infants with nonspecific FIA.[4],[5] Male and female are not only different with regard to the incidence of FIA, yet they also tend to differ in the characteristics of the disease and the outcomes of management.[6],[7] For example, the anterior location of FIA in females is considered a high-risk condition, rendering these fistulas a more complex entity that predisposes to higher risks of recurrence and fecal incontinence (FI).[8],[9],[10],[11],[12] Patient's gender seems to affect the outcome of fistula surgery. Lifestyle factors such as traumatic conditions, IBDs, malignancy, radiation therapy, sexually transmitted diseases such as HIV, tuberculosis, or other specific etiologies, diabetes, tuberculosis, dietary habits, such as vegetarian nonvegetarian, overweight, sedentary lifestyle, alcoholism, and tobacco usage (smokers) have an influence on FIA. This study aimed to conduct a gender-specific analysis of FIA in a large cohort of patients to highlight the differences between males and females with regard to the characteristics of FIA and lifestyle factors increasing the probability of fistula and factors responsible for recurrent fistula.


  Methodology Top


This is study on 1843 patients in 4 years, lifestyle factors increasing the probability of fistula and factors responsible for recurrent fistula. This is one of the largest studies conducted for 4 years in 1843 patients who were admitted to the colorectal surgery unit of Rana hospital. Ethical approval of the study was obtained from the institutional review board of Rana hospital. All procedures performed in the study were conducted in accordance with the ethics standards given in 1964 Declaration of Helsinki, as revised in 2013. The study proposal was submitted for approval and clearance was obtained from the ethical committee of our institution. A written informed consent was obtained from each participant. Adult patients (above 18 years) with anal fistula were considered eligible to be included in the study. Patients with incomplete records missing some of the vital data were also excluded from the study. Data were collected and were arranged in an Excel spreadsheet and analyzed using SPSSTM version 21 IBM, Chicago, Illinois, USA. Continuous variables were expressed as mean and standard deviation or median and normal range. Categorical variables were expressed as %age and ratio. Student's t-test was used to analyze the continuous variables, whereas Fisher's exact test or Chi-square test was used for categorical data. P < 0.05 was considered statistically significant.


  Results Top


During a survey conducted on 1843 no of FIA patients, 87% (1606) patients were suffering from transsphincteric fistula. Twelve percent (217) patients were suffering from intersphincteric fistula, 0.6%[11] of patients were suffering from extrasphincteric fistula and 0.5%[9] patients were suffering from suprasphincteric fistula. 1.85%, as shown in [Figure 1]. Thirty-four patients were suffering from tuberculosis diagnosed by reverse transcription-polymerase chain reaction (RT-PCR) test. About 38% (700) patients were vegetarian 61% (1124) patients were nonvegetarian. About 57% of patients were overweight and 66% of patients were following a sedentary lifestyle, sitting more than 80% of their working time. About 80.4% (1482) patients were male and 19.60% (361) patients were female. Forty-seven percent of patients were alcoholics and 20% (368) were chronic smokers. This is one of the largest studies conducted for 4 years in 1843 patients, conclusions drawn. Maximum patients suffering from fistula are having transsphincteric fistula (87%). FIA in males is more common as compared to females. FIA is more common in overweight patients. Our results also show that FIA is more common in patients on a nonvegetarian diet (61%). Low anal fistula is more common (64%) as compared to high anal fistula. This survey concluded that extrasphincteric and suprasphincteric fistula are very rare. Supra sphincteric and extra sphincteric fistula are also called human-made fistula. Forty-seven percent of patients were alcoholics (more than 60 ml/day) and 20% were smokers (more than two cigarettes per day). In alcoholics and smokers, we observed delayed healing; the average healing period is 6–8 weeks. However, in alcoholics and smokers, it was 8–12 weeks. About 89.6% fistula were virgin fistula. This study concludes that recurrence in fistula is not as common as said. Out of 181 cases of recurrent fistula, 18.78% of cases were tubercular. This is a significant number, so all cases of recurrent fistula should be ruled out for tuberculosis by RT-PCR test and biopsy. About 3.2% of all fistula had perianal abscess, 1.03% had an ischioanal abscess, and 1.79% had an ischiorectal abscess. Hence, abscess with the fistula is not very common. When a detailed case study was done, most patients having abscess with fistula were either on long-term medication (prolonged use of antibiotics) or immunocompromised. Out of 11.4% cases of recurrent fistula, 34% were diabetics and 2.4% were HIV reactive, 18.76% were tubercular.
Figure 1: Distribution of FIA. FIA: Fistula-in-ano

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  Discussion Top


FIA represents one of the most common anorectal disorders in surgical practice. Reviewing the current literature, all efforts have been directed toward improving the outcome of management of FIA by the application of new diagnostic tools and the introduction of novel treatment modalities. However, very few reports[3],[6],[7] have discussed the differences in the incidence, characters, and management outcomes of FIA between males and females. The male predominance of anal fistula is obvious in the literature, we found the male-to-female ratio to be 6.6:1, within the range (1.8:1–9:1) reported in the previous studies.[3],[4] A few theories were proposed to explain this male predominance including the role of androgens and the strong tone of the external anal sphincter in males.[7] Lunniss et al. recommended further investigations to ascertain the possibility of conversion of estradiol to androgen locally in the anal glands or a possible increased sensitivity of the anal glands to the circulating androgens in females with FIA. The reason for this high prevalence of anterior-based fistulas in females is not clear, perhaps the anatomic differences between both genders can shed some light on this issue.[10],[11],[12] The external anal sphincter is relatively deficient anteriorly in females due to less defined transverse perinii and longitudinal muscles, in addition to the obstetric trauma sustained during vaginal delivery which can add further weakness to the anterior sphincter complex. Although according to Goodsall's rule,[10] anterior FIA are expected to have a short straight tract leading directly to the anal canal; anterior fistulas in female patients have been recognized as a complex type of FIA that may predispose to higher rates of recurrence and FI.[8] On the other hand, around two-thirds of the patients had posterior anal fistula, the incidence of posterior FIA in males was more than three-folds that in females. Since posterior FIA can have more complex tracks than that of anterior FIA, 18 this explains the higher incidence of high transsphincteric fistula in males that we observed. On analysis of the procedures performed for the treatment of FIA in both genders, the results were quite concordant with the previously stated characteristics of anal fistula. The overall recurrence rate in our series was around 7.5%. Anocutaneous flap had the highest recurrence rate (44%) in concordance with Zimmerman et al. who reported a success rate of only 46% after the use of anocutaneous flap for transsphincteric FIA. This high failure rate can be due to the early disruption of the flap which occurred in 55% of the patients.[1],[5] On the other hand, ligation of the inter-sphincteric fistula tract (LIFT) achieved a recurrence rate of 18% which copes with the mean success rate (76.4%) of LIFT reported by Hong et al. in a recent meta-analysis. However, the limited number of patients treated with LIFT in our series may prevent drawing any meaningful conclusions about its clinical efficacy. Fistulotomy and fistulectomy achieved comparably low recurrence rates in line with a recent meta-analysis that concluded no significant differences in healing and recurrence rates between the two procedures. Recurrence after drainage seton occurred in 10.7% of patients, slightly higher than other series by Lim et al. which can be attributed to the larger number of patients with previous fistula surgery.[9],[12]


  Conclusion Top


Despite the difference in some of the characteristics of FIA among both genders; there were no significant differences between males and females with regard to the recurrence of anal fistula and the occurrence of FI postoperatively. Maximum patients suffering from fistula are having transsphincteric fistula. FIA in males is more common as compared to females. FIA is more common in overweight patients. Our results also show that FIA is more common in patients on a nonvegetarian diet. Low anal fistula is more common as compared to high anal fistula. This survey concluded that extra sphincteric and supra sphincteric fistula are very rare. In alcoholics and smokers, we observed delayed healing. This study concludes that recurrence in fistula is not as common as said.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Hancock BD. ABC of colorectal diseases. Anal fissures and fistulas. BMJ 1992;304:904-7.  Back to cited text no. 1
    
2.
Sainio P. Fistula-in-ano in a defined population. Incidence and epidemiological aspects. Ann Chir Gynaecol 1984;73:219-24.  Back to cited text no. 2
    
3.
Lunniss PJ, Jenkins PJ, Besser GM, Perry LA, Phillips RK. Gender differences in incidence of idiopathic fistula-in-ano are not explained by circulating sex hormones. Int J Colorectal Dis 1995;10:25-8.  Back to cited text no. 3
    
4.
Hyman N, O'Brien S, Osler T. Outcomes after fistulotomy: Results of a prospective, multicenter regional study. Dis Colon Rectum 2009;52:2022-7.  Back to cited text no. 4
    
5.
Mizrahi N, Wexner SD, Zmora O, Da Silva G, Efron J, Weiss EG, et al. Endorectal advancement flap: Are there predictors of failure? Dis Colon Rectum 2002;45:1616-21.  Back to cited text no. 5
    
6.
Ellis CN, Clark S. Effect of tobacco smoking on advancement flap repair of complex anal fistulas. Dis Colon Rectum 2007;50:459-63.  Back to cited text no. 6
    
7.
Garcia-Aguilar J, Belmonte C, Wong WD, Goldberg SM, Madoff RD. Anal fistula surgery. Factors associated with recurrence and incontinence. Dis Colon Rectum 1996;39:723-9.  Back to cited text no. 7
    
8.
Rojanasakul A. LIFT procedure: A simplified technique for fistula-in-ano. Tech Coloproctol 2009;13:237-40.  Back to cited text no. 8
    
9.
Bartram CI. Anal sphincter disorders. Gastrointest Endosc 1996;43:S32-4.  Back to cited text no. 9
    
10.
Zimmerman DD, Briel JW, Gosselink MP, Schouten WR. Anocutaneous advancement flap repair of transsphincteric fistulas. Dis Colon Rectum 2001;44:1474-80.  Back to cited text no. 10
    
11.
Xu Y, Liang S, Tang W. Meta-analysis of randomized clinical trials comparing fistulectomy versus fistulotomy for low anal fistula. Springerplus 2016;5:1722.  Back to cited text no. 11
    
12.
Lim CH, Shin HK, Kang WH, Park CH, Hong SM, Jeong SK, et al. The use of a staged drainage Seton for the treatment of anal fistulae or fistulous abscesses. J Korean Soc Coloproctol 2012;28:309-14.  Back to cited text no. 12
    


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