administración en tiempos de crisis

Patient Satisfaction After Surgical Treatment for Fistula-In-Ant Julio Garcfa-Aguilar, M.D., Ph.D.,*J- Cynthia S. Davey, M.S.,~* J" Chap T. Le, Ph.D.,tg Ann C. Lowry, M.D.,* David A. Rothenberger, M.D.*-~ From the *Division of Colon and Rectal Surgery, ~University of Minnesota Cancer Center, and ~Division of Biostatistics, University of Minnesota, Minneapolis, Minnesota PURPOSE: The surgical treatment of fistula-in-ant frequently results in recurrence of the fistula or postoperative anal incontinence. Despite these problems, most patients are satisfied with the results of their surgery. To clarify this apparent discrepancy, we attempted to identify factors that affect patient's lifestyles and may contribute to their satisfaction. METHODS: A questionnaire was mailed to 624 patients surgically treated for cryptoglandular fistula-in-ant at the University of Minnesota during a five-year period. Three hundred seventy-five patients returned their questionnaires. Patients who were followed up for a minimum of one year were included in this retrospective study. Associations between postoperative complications and patient satisfaction were identified by chi-squared tests and multiple logistic regression. Attributable fractions for patient dissatisfaction were calculated using study population dissatisfaction rates. RESULTS: Patient satisfaction was strongly associated with fistula recurrence, difficulty holding gas, soiling of undergarment, and accidental bowel movements. Effects of incontinence on patient quality of life were also significantly associated with patient satisfaction as was the number of lifestyle activities affected by incontinence. Patients with fistula recurrence reported a higher dissatisfaction rate (61 percent) than did patients with anal incontinence (24 percent), but the attributable fraction of dissatisfaction for incontinence (84 percent) was greater than that for fistula recurrence (33 percent). Patient satisfaction was not significantly associated with age, gender, history of previous fistula surgery, type of fistula, surgical procedure, time since surgery, or operating surgeon. CONCLUSION: Patient satisfaction after surgical treatment for fistula-in-a_no is associated with recurrence of the fistula, the development of anal incontinence, and with the effects of anal incontinence on patient lifestyle. In our series of patients treated mainly with laying open of the fistula tract, patients with fistula recurrence had a higher dissatisfaction rate than did patients with anal incontinence. However, because anal incontinence was more prevalent than fistula recurrence, a higher fraction of dissatisfaction was attributable to anal incontinence. [Key words: Fistula-in-ant; Recurrence; Incontinence; Quality of life; Lifestyle; Satisfaction] Garcia-Aguilar J, Davey CS, Le CT, Lowry AC, Rothenberger DA. Patient satisfaction after surgical treatment for fistulain-ant. Dis Colon Rectum 2000;43:1206-1212. eports of the surgical m a n a g e m e n t o f fistula-ina n t focus almost exclusively o n clinical outcomes, mainly recurrence of the fistula and the de-

R

Presented at the meeting of the Association of Coloproctology of Great Britain and Ireland, Brighton, United Kingdom, July 10 to 12, 2O00. No reprints are available.

v e l o p m e n t of postoperative anal incontinence. 1 Reported rates o f recurrence range from 0 to 32 percent a n d postoperative anal incontinence from 0 to 63 percent, d e p e n d i n g o n the complexity o f the fistula, the type of treatment, and the methods, completeness, and length of follow-up. 2-5 Despite these significant rates o f postoperative problems, few studies have e x a m i n e d the impact of fistula surgery on patients' p e r c e p t i o n o f health and well-being. In our o w n series of 375 patients treated for chronic fistula of cryptoglandular origin, 8 percent of the patients experienced recurrence of the fistula a n d 46 percent reported s o m e degree of incontinence persisting for m o r e than a year after the operation. 5 Surprisingly, only 12 percent o f the patients w e r e dissatisfied with the results of their surgery. A similar discrepancy b e t w e e n clinical o u t c o m e s and patient satisfaction h a d b e e n f o u n d previously after ttae surgical treatm e n t of fistula-in-ant 6 a n d anal fissure. 7 To identify factors that m a y contribute to patient satisfaction after surgical treatment o f fistula-in-ant, w e used data from our series of patients to c o m p a r e patient satisfaction rates across the patient profile, characteristics o f the fistula, types of treatment, and clinical outcomes. To gain further insight into the long-term experience of patients treated for fistula-ina n t , w e explored the relationship b e t w e e n patient satisfaction a n d the effects of persistent anal incontin e n c e o n lifestyle activities.

PATIENTS

AND

METHODS

To obtain follow-up information regarding their postoperative experience, w e mailed questionnaires to 624 patients w h o w e r e surgically treated for fistulai n - a n t at the University of Minnesota and affiliated hospitals during a five-year period by 12 Board certified colorectal surgeons. Patients eligible for this study w e r e identified b y retrospective review o f patient charts a n d operative report.5 O n l y patients with chronic fistula of cryptoglandular origin w e r e se-

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PATIENT SATISFACTIONAFTERFISTULASURGERY

lected. Patients were excluded if they had superficial fistula associated with fissure, inflammatory bowel disease, hematologic malignancy, preoperative incontinence, or if they underwent primary fistulotomy at the time of abscess drainage. Clinical results of this series of patients have been published previously. 5

The type, grade, and duration of the incontinence were assessed with a scoring system that has been used routinely in our clinical practice> The questionnaire also requested information about the necessity of wearing a pad and lifestyle alteration caused by the incontinence (Fig. 1). Anal incontinence was defined

1. Did the operation heal the fistula?

~._yes __no

2, How long did it take for the fistula wound to heal?

weeks

3, Have you developed any new abscess or fistula?

__ ves___no

4. Have you required any further operation for abscess or fistula?

_._yes_.no

5. Have you had A B C __

difficulty distinguishing between gas and stool? Never For a short perind of time after my operation Ever since my operation

6. Have you had any problem holding gas? A Never B For a short period of time after my operation C __ Ever since my operation 7. Have you had A B __ C __

problem with soiling of your underwear? Never For a short period of time aftar my operation Ever since my operation

8. Have you had A B __ C __

accidental bowel movements? Never For a short period of time after my operation Ever since my operation,

9. Are you satisfied with the results of the operatian? Very satisfied Satisfied Dissatisfied -Very dissatisfied If you answered "C" in any of questions 5 to 8 above, please complete the following questions 10. How often do you have problems holding gas? Never Rarely (Less than once a month) Sometimes (More than once a month) Frequently (More than once a week) 11. How often do yon have staining of your underwear? Never Rarely (Less than once a month) __ Sometimes (More than once a month) Frequently (More than once a week 12. How often do you have accidental bowel movements? Never __ Rarely (Less than once a month) Sometimes (More than once a month) Frequently (More than once a week) 13. Do you have to wear a pad? Never __ Only at night Sometimes (Dayxime) __ All the time (Daytime) 14. Does this problem affect your life style? (Mark the best answer for each eolunm) Physical Activities

Social Activities

Sexual Activities

Not at all To some extent Greatly I5.

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Other comments:

Figure 1. Questionnaire for fistula recurrence, postoperative anal incontinence, and quality of life.

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as any reported difficulty holding gas, soiling of the undergarmeht, or accidental bowel movements that persisted since surgery. Of the 624 patients mailed the questionnaire, 375 (60 percent) responded. Of these, the 300 patients who were followed up longer than one year (time elapsed between surgery and survey completion) were included in the study population. A subset of this group, the 139 patients who reported persistent incontinence, comprised the study population for the analysis of the association between patient satisfaction and the effects of persistent incontinence on lifestyle. Associations between patient satisfaction and patient profile, type of surgical treatment, and clinical outcomes were identified by chi-squared tests and stepwise multiple logistic regression analysis. The attributable fraction (AF), a measure of potential impact, was used to estimate the proportion of dissatisfaction attributable to either fistula recurrence or anal incontinence. 9 AF was calculated using the following formula: dissatisfaction rate in study population - dissatisfaction rate in patients without complication AF-

dissatisfaction rate in study population

where complication refers to either recurrence or incontinence.

RESULTS Patient demographics, type of fistulas, and surgical procedures are presented in Table 1. Average fop low-up time was 33 (range, 12-59) months. The fistula recurred in 23 patients (8 percent). Anal incontinence, including soiling of undergarment, accidental bowel movements, or difficulty holding gas persisting for more than one year was reported by 139 patients (46 percent). Overall, 88 percent of the study population were either very satisfied (53 percent) or satisfied (35 percent) with the results of their surgery. Few patients were dissatisfied (11 percent) or very dissatisfied (1 percent) with their outcomes. Fistula recurrence and all forms of anal incontinence were significantly associated with patient satisfaction in univariate analysis (Table 1). Patients with recurrence of the fistula reported the highest rate of dissatisfaction (61 percent) with the results of their surgery. Fistula recurrence, staining of the undergarment, and

Dis Colon Rectum, September 2000

accidental bowel movements retained a significant association with patient satisfaction with stepwise multiple logistic regression analysis (P < 0.001, P < 0.001, and P = 0.008, respectively). Difficulty holding gas was not significantly associated with satisfaction after adjusting for other factors. Patient satisfaction was not significantly associated with patient age, gender, type of fistula, history of previous fistula surgery, type of surgical procedure, time elapsed between the operation and the survey, or the surgeon performing the procedure by either chi-squared test (Table 1) or multiple logistic regression analysis. Dissatisfaction rates among patients in this study population increased linearly with the number of incontinence problems experienced (Fig, 2). Only 1.9 percent of patients without incontinence were dissatisfied whereas 50 percent of those with all three incontinence problems (i.e., difficulty holding gas, soiling undergarment, and accidental bowel movements) were dissatisfied. Incontinence problems that occurred more frequently than once per week resulted in increased dissatisfaction rates for each number of problems experienced, indicating that the frequency of incontinence episodes was inversely related to patient satisfaction (Fig. 2). All but one patient who experienced all three incontinence problems more often than once a week were dissatisfied with the results of the procedure. The attributable fractions for recurrence ((0.120.08)/0.12 = 0.33) and incontinence ((0.12-0.019)/ 0,12 = 0.84) indicate that 33 percent and 84 percent of patient dissatisfaction was attributable to fistula recurrence and anal incontinence, respectively. Because 14 patients experienced both fistula recurrence and incontinence, the sum of the population attributable risk percents is greater than 100 percent. An estimate of the proportion of dissatisfaction attributable to either recurrence or incontinence was also calculated. Only 1 patient of the 152 patients without recurrence or postoperative incontinence reported dissatisfaction with the surgery. The resulting population attributable fraction for patients with either recurrence or incontinence ((0.12-0.0065)/0.12 = 0.945) of 94.5 percent indicates that patient dissatisfaction for this study population was attributable almost entirely to one or both of these undesirable outcomes. Of the subset of 139 patients who experienced any degree of postoperative anal incontinence, 65 patients (47 percent) indicated that one or more of their physical (30 percent), social (40 percent), or sexual activities (28 percent) were affected to some extent or

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PATIENT SATISFACTIONAFTER FISTULASURGERY Table 1. Patient Satisfaction After Fistula Surgery Number

Entire group Gender Females Males Age (yr) 65 Previous fistula surgery No Yes Type of fistula Intersphincteric Transsphincteric Suprasphincteric Extrasphincteric Unclassified Surgical procedure Fistulotomy Seton Surgeon No. 1 2 3 4 5 6 7 8 9 10 11 12 Time since surgery (months) 12-24 25-36 36-48 >48 Fistula recurrence No Yes Difficulty holding gas No Yes Soiling of underwear No Yes Accidental bowel movements No Yes * Chi-squared test of independence.

Satisfied (%)

300

263 (88)

80 220

66 (82) 197 (90)

265 35

234 (88) 29 (83)

274 26

243 (89) 20 (77)

143 88 4 6 59

129 76 4 4 50

238 62

210 (88) 53 (85)

P Value* 0.101

0.36

0.08

0.35

(90) (86) (100) (66) (85) 0.56

0.25 32 23 31 29 3 49 14 13 (12 (92) 24 14 47 21

27 23 27 28 3 42 11

91 74 78 57

82 65 66 50

(84) (100) (87) (97) (100) (86) (79)

19 (79) 14 (100) 41 (87) 16 (76) 0.76

(90) (88) (85) (88)