PERFACT procedure: A new minimally invasive simple concept to treat highly complex anal fistula

Pankaj Garg, Dr1, Pratiksha Singh, Dr1, Devika Singh2, Mohinder K Garg, Prof3. 1Garg Fistula Research Institute, Panchkula, India, 2Boston University, Boston, 3BPS Government Medical College for women, Khanpur kalan, Haryana, India

Introduction: To check the efficacy of PERFACT (Proximal superficial cauterization around the internal opening, emptying regularly of fistula tracts and curettage of tracts):  procedure to treat highly complex fistula-in-ano

Methods: PERFACT procedure entails two steps- superficial cauterization of mucosa at and around the internal opening & keeping all the tracts clean. The internal opening along with the adjacent mucosa was electrocauterized. The resulting wound was left open so as to heal/close the internal opening by granulation tissue(secondary intention). Objective incontinence scoring was done preoperatively & postoperatively.

Results: After getting approval from ethics committee of the hospital, this procedure – PERFACT (Proximal superficial cauterization around internal opening, emptying regularly of fistula tracts in post operative period and curettage of tracts) – was performed in 122 patients.  All were complex fistula – intersphincteric with multiple extensions (Park’s type-1, James type-2) in 5, transpshincteric (Park’s type-2, James type-3 &4) in 104 and supralevator fistula (Park’s type-3, James type-5) in 13 patients. There were multiple tracts in 65.5% (80/122), recurrent fistula in 58.1% (71/122), horseshoe tracts in 49 (40.1%), abscess in 43 (35.2%), supralevator in 13 (10.7%) and anterior fistulae in 10 (8.2%) female patients. M/F was 102/20 and average age was 42.6 ±11.8 years. The median follow up was 12 months (5-22 months). Sixteen patients were excluded (lost to follow-up/ non-adherence to protocol). The healing rate after the first operation was 70.8% (75/106). Twelve out of 31 non-healed patients were operated again. Eight out of these got alright.  So the overall healing rate was 78.3% (83/106). All patients were discharged from the hospital within 24 hours of admission. There was no significant change in incontinence scores.

Conclusions: Perfact procedure is a minimally invasive and  novel method to cure complex fistula-in-ano. It is simple and economical It is associated with little pain, least morbidity and minimal risk of incontinence as both the anal sphincters are completely preserved. It is quite effective in complex fistula cases (overall success rate of  upto 78.3%) where other methods do not have a high success rate like horseshoe fistula, fistula with multiple tracts, recurrent fistula and fistula with supralevator extension. Perfact procedure is also quite successful in cases where internal opening cannot be localized and  presenting with perianal/ischiorectal abscess where it can be done as a definitive procedure on initial presentation.

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