Recto-perineal fistula - Do we need to fix it? Long-term outcomes of non-operative management

Surgical reconstruction has traditionally been considered the standard of care for imperforate anus with recto-perineal fistula. However, increasing recognition of the role of functional anatomy raises the possibility that selected patients may be managed without surgery.

We conducted a single-center retrospective cohort study of children with imperforate anus and perineal fistula managed either non-operatively or surgically. Patients were selected for non-operative management based on clinical assessment of fistula caliber, perineal body, and sphincter muscle coverage. Long-term bowel function was evaluated using a standardized ARM-Net-based questionnaire derived from the Rintala score. Clinical outcomes and need for delayed surgical intervention were recorded.

A total of 97 patients with recto-perineal fistula were included, of whom 62 (63.9%) were managed non-operatively. At a mean follow-up age of 7.0 ± 3.0 years, most non-operatively managed patients achieved normal bowel function (73.3%), with low rates of constipation and minimal need for bowel management. No patients required delayed surgical reconstruction. Compared to a contemporaneous surgical cohort (n = 35), non-operatively managed patients demonstrated superior functional outcomes; however, these findings reflected baseline differences in anatomical characteristics, including greater sphincter muscle coverage. On univariable analysis, favorable anatomical features and non-operative management were associated with normal bowel function.

In carefully selected patients with imperforate anus and recto-perineal fistula, non-operative management is associated with excellent long-term bowel function and may obviate the need for surgical reconstruction. These findings support a more individualized, anatomy-based approach to management.