[Management of complications of fissure and fistula surgery].

BACKGROUND: Fistula-in-ano and anal fissures are common proctological diseases. In most cases of anal fissures conservative treatment provides good clinical results, whereas for fistula-in-ano operative treatment is the only option.

OBJECTIVE: The most important and for the patient most stressful long-term complication is postoperative incontinence, especially as the deliberate severance of the anal sphincter musculature is part of the treatment for many patients. In this article the causes and treatment options are discussed.

RESULTS: The therapy of choice for patients with persisting symptoms caused by an anal fissure is fissurectomy. Incontinence disorders develop due to severance of parts of the internal sphincter or resection of the anoderm. In patients with anal fistulas the occurrence of incontinence disorders depends on the anatomical relationship of the fistula to the sphincter, the surgical procedure and also on pre-existing damage, e.g. from childbirth or other sphincter trauma and scar formation, notably in patients with multiple surgical interventions. Severance of the sphincter muscles in proximal transsphincteric and suprasphincteric fistulas in particular bears a high risk of postoperative incontinence. Data from the literature regarding postoperative fecal incontinence vary enormously due to different follow-up intervals and also variable definitions of the term fecal incontinence.

CONCLUSION: Options for the treatment of postoperative fecal incontinence are limited. Treatment of postoperative incontinence should first be conservative. Surgical repair of damaged sphincter muscles is often of limited success and sacral nerve stimulation might be an option in selected patients. Especially in patients with fissure-in-ano the indications for surgery should be strictly adhered to. For fistula-in-ano the least invasive and most sphincter-preserving procedure should be selected.