Fistulotomy versus fistulectomy for simple fistula-in-ano: a systematic review and meta-analysis of randomized controlled trials.

backgroundPerianal fistulas are a common anorectal pathology. The sphincter-cutting techniques of fistulectomy and fistulotomy are associated with high cure rates for low or simple fistula-in-ano, with negligible risk of incontinence. However, the superiority of either technique has not previously been conclusively demonstrated. The aim of this systematic review is to compare the outcomes of the two surgical techniques for the management of simple fistula-in-ano.

methodsA search of MEDLINE, EMBASE and Cochrane Databases for randomized controlled trials (RCT) comparing fistulotomy to fistulectomy for simple fistula-in-ano was conducted. The primary outcome was healing time; secondary outcomes included operative time, length of hospital stay, post-operative pain score, post-operative complications and fistula recurrence.

resultsThirteen RCTs meet inclusion criteria, comprising a total of 685 fistulectomy and 688 fistulotomy patients. There was no significant difference between the techniques for healing time (P = 0.15), operative time (P = 0.13), length of stay (P = 0.05), wound infection (P = 0.97), flatus or faecal incontinence (P = 0.35 and P = 0.70, respectively) or recurrence (P = 0.19). Post-operative pain at 24 h, assessed using a visual analogue scale, was significantly lower in the fistulectomy group (MD-0.49, 95% CI: -0.90, -0.08; P = 0.02), and we found significantly fewer post-operative bleeding complications in the fistulotomy group (OR: 3.81, 95% CI: 1.23, 11.80; P = 0.02).

conclusionThis systematic review did not find conclusive evidence of the superiority of either fistulectomy or fistulotomy in terms of healing time. The two statistically significant findings were lower post-operative pain scores with fistulectomy and reduced post-operative bleeding with fistulotomy.