Causes of recurrences of anal fistulae

Małgorzata Kołodziejczak¹, Iwona Sudoł-Szopińska²

Summary
The paper discusses the problem of anal fistula recurrence after surgery. The recurrence rate after surgical treatment of anal fistulae ranges from 0 to 26.5%, according to literature data. Most recurrences develop within a year following surgery. In most cases of recurrence, the fistulae are of type 3 and 4 according to Park´s classification (i.e. high suprasphincteric and extrasphincteric fistulae), fistulae in Crohn´s disease, and also fistulae in patients with decreased immunity and diabetes mellitus. The prophylaxis of fistula recurrence includes three stages: 1) preoperative diagnostics, 2) appropriately conducted surgery, and 3) correct postoperative management of the patient. In the preoperative diagnostics of fistula, transrectal ultrasonography, which is presently regarded as "gold standard”, should be used for assessment of both anatomical location of the fistula and sphincter muscles, and also, in individual cases, classic fistulography and the most recent imaging techniques, i.e. magnetic resonance imaging (MRI) and tri-dimentional (3D) endosonography, should be applied. The latter are used in the diagnosis of ramified fistulae of complex shape, e.g. in Crohn´s disease. Leaving of the main canal, failure to find the internal opening, which in most cases is the cause of fistula, or failure to excise all ramifications, are basic errors in surgical technique leading to disease recurrence. Other causes of fistula recurrence include too tight suturing of the surgical wound, insufficient drainage and consequent development of a new inflammatory canal as well as incorrect diagnosis of the cause of fistula, e.g. failure to remove a foreign body or to diagnose Crohn´s disease. Incorrect postoperative management, a factor that is frequently omitted in the literature, is also discussed in detail in the paper.

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