A commentary on “Risk factors for postoperative recurrence of anal fistula identified by an international, evidence-based Delphi consultation survey of surgical specialists” (Int J Surg 2021; 92:106038)

Abstract

Dear Editor, Treatment of complex anorectal fistula is very controversial. The main objective of anal fistula surgery is to cure the suppurative process without altering anal incontinence. The optimal surgical procedure should aim to drain local infection and promote fistula occlusion without affecting sphincteric function and anal continence [1]. However, recurrence of anal fistula after surgery remains a challenge to surgeons. Therefore, surgeons should understand why recurrences occur and how to prevent recurrences from happening. Mei et al. conducted an international evidence-based Delphi surgical expert consultation survey in which 60 specialists from 13 countries in four continents participated in two Delphi processes [2]. Based on the predetermined anal fistula recurrence risk factors, the patient-related, fistula-related, and surgery-related factors which were significantly associated with post-operative anal fistula recurrence were identified. Surgeons can then make use of these factors to give preoperative recommendations for patients who are at high risks of postoperative relapse. This study is important because it is very comprehensive and uses high standards of statistical methods. Based on our decades of clinical experience, we would like to elaborate on our understanding of the risk factors for postoperative anal fistula recurrence. First, detailed rectal examination is required before surgery, which can help to determine the tension of the anal sphincter, determine the internal opening of the fistula, and to rule out proctitis. If surgery is performed in the presence of proctitis, the risk of recurrence is high [3]. The internal opening represents the extent and type of fistula pathology. Therefore, effective preoperative and intraoperative identification of internal openings is critical for successful treatment and prevention of recurrence. Second, failure to supplement clinical examination with appropriate medical imagings increases the risk of recurrence [4]. Finding the internal openings without proper medical imagings can be difficult even for experienced surgeons. Attempts to identify internal fistula openings intraoperatively may not be successful because these openings can be blocked by inflammation of perianal crypts. In addition, attempts to use probes can lead to formation of false passages, or even iatrogenic fistulas. Third, recurrence can also arise when surgeons abandon the basic principles of rectal surgery and emphasize on cosmetic effects. In actual fact, following the principles of proctology can result in quite satisfactory cosmetic results after healing, regardless of the size of the incision. Therefore, cosmetic effects should not be the major consideration in preventing surgeons from correctly removing or draining fistulas. Finally, factors which are known to be related to postoperative care of fistula patients have received limited attention by surgeons. Lack of effective postoperative care also increases the risks of recurrence. Once operated, it takes at least six weeks for the anal canal to properly heal. During this time, a thorough medical examination should be performed at least once a week to rule out potential complications. Wounds after anal surgery should be rinsed daily with daily changes of dressings to avoid complications and recurrence. Complex fistulas secondary to Crohn’s disease or a complex high fistula will require a longer healing time. Assessment and care for such fistulas should be more frequent and rigorous. “ProvenaSnce and peer review. Commentary, internally reviewed” Conflicts of interest None. Sources of funding Postgraduate Research & Practice Innovation Program of Jiangsu Province (SJCX21_0729). Ethical Approval Not Applicable. Research registration unique identifying number (UIN) Not applicable. Author contribution The author read and approved the final version of the letter to the Editor. Guarantor Yunfei Gu.