EP490 - Trans-Sphincteric Incision and Suture (TISS) for the Treatment of Trans-Sphincteric Anal Fistulas (TSAFs): A Hospital-Based Cohort Study

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Purpose/Background: Treatment of trans-sphincteric anal fistulas (TSAFs) is challenging due to their proximity to the anal sphincter. Precise localization and management of the internal opening are crucial for success. Inadequate handling can lead to recurrence and increase treatment complexity, potentially causing postoperative incontinence. We introduce a novel approach, Trans-Sphincteric Incision and Suture (TISS), to enhance efficacy and reduce recurrence risk.

Methods/Interventions: (1)Following intravenous anesthesia and corroborative imaging, intra-anal exploration localized the internal fistula opening using the index finger. An arc-shaped incision was made along the intersphincteric groove, exposing the internal (IAS) and external (EAS) anal sphincters. The fistulous tract was ablated with an electrocautery device and dissected up to 0.5 to 1.0 cm proximal to the fistula’s origin.
(2)The IAS plays a critical role as a barrier between the intestinal lumen and the external environment. To protect this function and prevent infections caused by intestinal flora, we utilized a continuous suture technique with 3-0 absorbable sutures to close the internal opening on the IAS. This approach effectively preserves the integrity of the IAS, serving as a barrier to prevent bacteria from entering the body via the fistula, thereby reducing the risk of infection.[illustrated in Figure 1.]
(3)To address the fistula, a tunneling incision was made surrounding the external opening, allowing for the dissection and liberation of the fistula tract down to the intersphincteric level. The fistulous tract was then excised completely. To maintain the structural integrity and functionality of the anal sphincters, any defects in the EAS were closed using a continuous suture technique with 3-0 absorbable sutures. This method effectively seals the defect in the EAS, ensuring a robust barrier against potential bacterial ingress. [illustrated in Figure 2.]
(4)Postoperatively, maintain open drainage by packing the intersphincteric space with povidone-iodine gauze and perform dressing changes twice daily. If the internal opening has not healed by 4 weeks, initiate staged seton placement under local anesthesia using a size 7 glove segment. Secure the seton with no. 0 silk sutures and tighten it every two weeks.

Results/Outcomes: The study included 45 patients with intersphincteric anal fistulas, mostly male (85%), with an average age of 41.7 years (SD 13.42; range 18-70). Preoperative assessments showed mean VAS-PS of 4.48 (SD 1.39), CCF-IS of 0.25 (SD 0.55), and CAF-QoL of 6.46 (SD 2.12). Surgical duration averaged 25.65 minutes (SD 4.21), with mean blood loss of 10.65 mL (SD 3.03). At the 4-week follow-up, 68.9% achieved healing, while 31.1% required seton placement. Three-month follow-up showed mean VAS-PS of 0.44 (SD 0.68), CCF-IS of 0.11 (SD 0.32), and a cure rate of 97.8%, with a 2.2% complication rate (one case of postoperative bleeding) and no incontinence reports.

Conclusion/Discussion: The study shows that the TISS technique for treating TSAFs is effective and safe. TISS involves thorough debridement via the intersphincteric route, promoting drainage and secondary healing. By suturing the internal and external anal sphincters, TISS maintains their integrity, prevents fecal debris entry, and reduces complications. As a sphincter-preserving technique, TISS offers lower pain, faster healing, fewer complications, reduced wound secretions, and lower recurrence rates compared to traditional methods.