Published online Jul 16, 2022. doi: 10.12998/wjcc.v10.i20.6845
Peer-review started: January 14, 2022
First decision: May 10, 2022
Revised: May 12, 2022
Accepted: June 13, 2022
Article in press: June 13, 2022
Published online: July 16, 2022
The transanal opening of intersphincteric space (TROPIS) procedure, performed to treat complex anal fistulas, preserves the external anal sphincter (EAS) but involves partial incision of the internal anal sphincter (IAS).
To ascertain the incidence of incontinence after the division of the IAS as is done in TROPIS and to evaluate whether regular Kegel exercises (KE) in the postoperative period can prevent incontinence due to IAS division.
Patients operated on for high complex fistulas and having no preoperative continence problem (score = 0) were included in the study. All patients were operated on by the TROPIS procedure and were recommended KE (pelvic contraction exercises) 50 times/day. KE were commenced on the 10th posto
Of 102 anal fistula patients operated on between July 2018 and July 2020 were included in this study. There were 90 males, the mean age was 42.3 ± 12.8, and the median follow-up was 30 mo (18-42 mo). Three patients were lost to follow-up. There were 65 recurrent fistulas, 92 had multiple tracts, 42 had associated abscess, 46 had horseshoe fistula and 34 were supralevator fistulas. All were magnetic resonance imaging-documented high fistulas (> 1/3 EAS involved). Overall incontinence occurred in 31% patients (Pre-KE group) with urge and gas incontinence accounting for the majority of cases (28.3%). The mean incontinence scores in the Pre-KE group were 1.19 ± 1.96 (in 31 patients, solid = 0, liquid = 7, gas = 8, urge = 24) and in the Post-KE group were 0.26 ± 0.77 (in 13 patients, solid = 0, liquid = 2, gas = 3, urge = 10) (P = 0.00001, t-test).
Division of the IAS led to incontinence, mainly urge incontinence, and also to a mild degree of gas and liquid incontinence. However, regular KE led to a significant reduction in incontinence (both in the number of affected patients and the severity of scores in these patients).
Core Tip: This is the first study in which the incidence of fecal incontinence, especially urge incontinence, has been studied after an anal fistula procedure that involves division of only the internal anal sphincter and sparing of the external anal sphincter. Overall incontinence occurred in 31% of patients in the postoperative period. Urge and gas incontinence accounted for the majority of incontinence cases (28.3%). The benefits of Kegel exercises (KE) in reversing fecal incontinence have been highlighted for the first time. KE initiated early in the postoperative period reversed incontinence in a significant majority of patients. Even in patients with residual incontinence, the severity of incontinence became significantly reduced.