DISCUSSION

More than 85% of perianal suppuration in infants occurs in the first year of life with an obvious male predominance as more than 90% of the affected infants are male. The etiology of FIA in infants is mostly attributed to a congenital developmental defect in anal crypts. However, FIA in infants can be secondary to a number of conditions including crypto glandular infection, IBD, tuberculosis, and immune-suppression [1]. Regarding infants, who have more delicate tissues and whose FIA are likely to heal spontaneously [6]; there are some controversies and dilemmas about what constitutes optimal management. These controversial issues include: type of treatment whether conservative or surgical, type and timing of surgical treatment and need for antibiotics [7]. There are number of studies that concern the incidence, presentation and management and recurrence rate of anal fistula in infants is quite small. No definite guidelines regarding the optimal treatment of FIA in the pediatric population exist. The present study comprised infants with FIA, with around 90 % of them aging below 1 year, in line with other authors [8] who stated that 87-96 % of pediatric anal fistulae occur in infants below 1 year of age. More than 97% of infants with anal fistula were males, which were concordant with the data previously published about the male predominance of anal fistula in the pediatric population [9,10]. This male predominance is mostly attributed to excess androgen or androgen sensitive anal glands in males [11]. Emile et al. [1] collect and analyze the results of individual studies in an attempt to understand the magnitude of the problem and the outcome of various treatments in this particular age group. Treatment of anal fistula varied in the included studies: Around 20% of patients were managed on a conservative basis and this non-surgical treatment succeeded in 73% of patients who achieved complete resolution of fistula with no recorded cases of complications or recurrence [1].

Several recent reports have recommended conservative management in infants [4,12].Watanabe et al. [12] reported successful results of conservative treatment in 82% of infants with FIA. The authors recommended avoiding surgical treatment of FIA in infants as they are likely to resolve spontaneously. Similarly, in a study conducted by Rosen et al. [4] all infants with anal fistula achieved complete healing after non-surgical treatment. According to them, the non-operative treatment of FIA in infants appears to be safe and effective. Rosen et al. [4] found that none of the 14 male infants who developed FIA following PA treatment required surgery, and the lesions healed in those patients after non-operative therapy [4].

Serour et al. [7] claimed that non-operative treatment was preferred for patients with FIA for 1 or 3 months, and fistulectomy was performed in persisting FIA. It is recommended that once the fistula is developed, surgical treatment should be done if conservative management failed.

Oh et al. [5] reported a 100% failure rate of conservative treatment stating that not all infants with FIA could be treated non-surgically. This 100% failure rate of conservative management in this particular study can be attributed to the fact that all the infants included were referred to the authors’ institution after failure of conservative treatment received elsewhere against the recommendations of the surgeon. Since the authors did not apply and follow the conservative treatment of these infants by themselves, the 100% failure rate can be attributed to poor application of non-surgical management and/or non-compliance of the parents with the treatment plan. However, many reports support the operative treatment of FIA [13,14]. These studies have suggested that the surgical treatment of PA and FIA is easy and have a very low complication rate. Oh et al. [5] postulated that non-operative management of FIA could not guarantee a successful cure for all patients. They also claimed that although there were advantages of non-operative treatment as avoidance of general anesthesia and surgical intervention, many parents experienced anxiety during the conservative treatment [5]. The surgical management of FIA either by fistulotomy or by fistulectomy is the most accepted treatment for that disorder but results in a high recurrence rate (up to 68%) [4,5,15]. In our study we have supported using conservative treatment in FIA management and surgical intervention is restricted only to cases with failed conservative management.

Conservative treatment of anal fistula in infants basically consists of local wound care with frequent sitz baths and adequate hygiene. Systemic antibiotics can be used if the infant shows signs of systemic infection such as fever and irritability. New methods for non-surgical management of FIA in infants have been advised by Kubota et al. [16]. The excellent results reported by the authors indicate that this method is an effective new treatment strategy for management of peri-anal abscesses and FIA in infants.

On the other hand, drawbacks of conservative treatment include longer duration of treatment, prolonged antibiotic use, exposing infants to more pain, increasing the anxiety level of the parents and possibility of relapse [13].

Shortcomings of surgical treatment included the need for general anesthesia and development of postoperative complications which were, however, encountered in less than 3% of infants, mostly after fistulectomy. The majority of these complications were minor, short-term consequences of surgery.

All patients with a fistula were treated with operative treatment in Ezer et al. [2] series. After surgical treatment, FIA recurred in five patients (15.1%), all of which underwent a second operation that resulted in cure.

SUMMARY AND CONCLUSION

The search of the literature shows that there are some controversies in the treatment of FIA, a common and troublesome condition in children and there is still not a consensus in patient selection for operative and non-operative treatment, particularly in infancy. In spite of these controversies, the results of our study give enough clues that conservative management by laying the fistula open ended up with good outcome and low recurrence rate in the treatment of FIA in children. However, further prospective randomized studies are needed to outline the advantages and disadvantages of operative and non-operative treatment approaches.