Predictive Factors for Recurrence of Fistula-in-Ano After Surgery: A 10-year Experience in a Single Center Study

Ekkarin Supatrakul; Thanakan  Kanthawanna; Witcha  Vipudhamorn; Suwan  Sanmae; Paisit Siriwittayakorn; Pawit  Sutharat

Authors

Ekkarin Supatrakul Department of Surgery, Faculty of Medicine, Chiang Mai University, Thailand https://orcid.org/0000-0003-3299-7151
Thanakan Kanthawanna Department of Surgery, , Faculty of Medicine, Chiang Mai University, Thailand
Witcha Vipudhamorn Department of Surgery, Faculty of Medicine, Chiang Mai University, Thailand https://orcid.org/0009-0008-5639-8253
Suwan Sanmae Department of Surgery,, Faculty of Medicine, Chiang Mai University, Thailand
Paisit Siriwittayakorn Department of Surgery, , Faculty of Medicine, Chiang Mai University, Thailand https://orcid.org/0000-0003-2588-5469
Pawit Sutharat Department of Surgery, Faculty of Medicine, Chiang Mai University, Thailand

Keywords:

predictive factors, recurrence, fistula-in-ano, anal fistula

Abstract

Objective This study aimed to evaluate the recurrence rate of fistula- in-ano treatment and factors associated with recurrence.

Methods A retrospective cohort study was performed of cryptoglandular-cause fistula-in-ano patients who underwent surgery between January 2010 and June 2020. Cox’s regression analysis was used to identify predictive factors for recurrence FIA.

Results The study included 282 patients of whom 233 (82.6%) were male, 76 (27.0%) had previous anal fistula surgery, 77 (27.3%) had a complex type of fistula, 72 (25.5%) were high transphincteric, 3 (1.0%) were suprasphincteric, and 2 (0.7%) were extrasphincteric. Five types of operations were performed: 106 (37.6%) fistulotomies, 43 (15.2%) fistulectomies, five (1.8%) setons, six (2.1%) endorectal advancement flaps (ERAF), and 122 (43.3%) ligations of the intersphincteric fistula tract (LIFT). The recurrence rate was 20.1% (57 patients) among whom 54 (94.0%) were detected at follow- up within 12 months, 2 patients were detected in the second year, and 1 patient was detected in the third year. Four independent factors associated with the recurrence of FIA after surgery were identified: female gender (HR 2.67; 95% CI 1.34-5.34), BMI >25 kg/m² (HR 2.47; 95% CI 1.38-4.44), complex type of fistula (HR 2.02; 95% CI 1.02-3.97), and anterior opening (HR 2.14; 95% CI 1.12-4.10). Compared to the LIFT procedure, fistulotomy was the protective factor (HR 0.12; 95% CI 0.03-0.46) while ERAF had a higher rate of recurrence (HR 6.12; 95% CI 1.87-20.03).

Conclusions Patients with high BMI and female patients should be advised of the higher chance of recurrence after anal fistula surgery. More complex fistula-in-ano and sphincter-preserving surgery was also associated with a higher recurrence rate. The complete healing of the surgery should be monitored for two years after surgery.

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