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Anal fistula

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Anal canal Anal glands Patient UK

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This article includes a list of references, but its sources remain unclear because it has insufficient inline
citations. Please help to improve this article by introducing more precise citations. (April 2010)

Anal fistula

Different types of anal fistula (right side of image)

Classification and external resources
General surgery
Specialty
K60.3
ICD-10
565.1
ICD-9-CM
med/2710
eMedicine
Anal fistula
Patient UK
Anal fistula, or fistula-in-ano, is a chronic abnormal communication between the epithelialised surface of the
anal canal and (usually) the perianal skin.
Anal fistulae originate from the anal glands, which are located between the internal and external anal
sphincter and drain into the anal canal. If the outlet of these glands becomes blocked, an abscess can form
which can eventually point to the skin surface. The tract formed by this process is the fistula.

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Abscesses can recur if the fistula seals over, allowing the accumulation of pus. It then points to the surface
again, and the process repeats.
Anal fistulas per se do not generally harm, but can be very painful, and can be irritating because of the
pus-drain (it is also possible for formed stools to be passed through the fistula); additionally, recurrent
abscesses may lead to significant short term morbidity from pain, and create a nidus for systemic spread of
infection.
Surgery is considered essential in the decompression of acute abscesses; repair of the fistula itself is
considered an elective procedure which many patients elect to undertake due to the discomfort and
inconvenience associated with a draining tract.

Signs and symptoms

Anal fistulae can present with many different symptoms:
Pain
Discharge either bloody or purulent
Pruritus ani itching
Systemic symptoms if abscess becomes infected
Heavy pain

Diagnosis
Diagnosis is by examination, either in an outpatient setting or under anaesthesia (referred to as EUA
Examination Under Anaesthesia). The examination can be an anoscopy.
Possible findings:
The opening of the fistula onto the skin may be seen
The area may be painful on examination
There may be redness
An area of induration may be felt thickening due to chronic infection
A discharge may be seen
It may be possible to explore the fistula using a fistula probe (a narrow instrument) and in this way it
may be possible to find both openings of the fistula
Pilonidal cysts/sinuses are another condition in which infected perianal "holes" or openings may appear

Diagnosis
Probing
Fistulogram
Proctoscopy & sigmoidoscopy

Types
Low level fistulae:
Subcutaneous

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Submucous
Low anal
High level fistulae:
High anal
Pelvi-rectal
Park's classification:
Intersphincteric
Transphincteric
Suprasphincteric
Extrasphincteric

Treatment
There are several stages to treating an anal fistula:
Definitive treatment of a fistula aims to stop it recurring. Treatment depends on where the fistula lies, and
which parts of the internal and external anal sphincters it crosses.
There are several options:
Doing nothing a drainage seton can be left in place long-term to prevent problems. This is the safest
option although it does not definitively cure the fistula.

Anal fistula after surgical treatment

Lay-open of fistula-in-ano this option involves an operation to cut the fistula open. Once the fistula
has been laid open it will be packed on a daily basis for a short period of time to ensure that the wound
heals from the inside out. This option leaves behind a scar, and depending on the position of the fistula
in relation to the sphincter muscle, can cause problems with incontinence. This option is not suitable for
fistulas that cross the entire internal and external anal sphincter.
Cutting seton if the fistula is in a high position and it passes through a significant portion of the
sphincter muscle, a cutting seton (from the Latin seta, "bristle") may be used. This involves inserting a
thin tube through the fistula tract and tying the ends together outside of the body. The seton is tightened
over time, gradually cutting through the sphincter muscle and healing as it goes. This option minimizes
scarring but can cause incontinence in a small number of cases, mainly of flatus. Once the fistula tract

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is in a low enough position it may be laid open to speed up the process, or the seton can remain in place
until the fistula is completely cured. This was the traditional modality used by physicians in Ancient
Egypt and formally codified by Hippocrates,[1] who used horsehair and linen.
Seton stitch a length of suture material looped through the fistula which keeps it open and allows
pus to drain out. In this situation, the seton is referred to as a draining seton. The stitch is placed close
to the ano-rectal ring which encourages healing and makes further surgery easy.
Fistulotomy till anorectal ring
Colostomy to allow healing
Fibrin glue injection is a method explored in recent years, with variable success. It involves injecting
the fistula with a biodegradable glue which should, in theory, close the fistula from the inside out, and
let it heal naturally. This method is perhaps best tried before all others since, if successful, it avoids the
risk of incontinence, and creates minimal stress for the patient.
Fistula plug involves plugging the fistula with a device made from small intestinal submucosa. The
fistula plug is positioned from the inside of the anus with suture. According to some sources, the
success rate with this method is as high as 80%. As opposed to the staged operations, which may
require multiple hospitalizations, the fistula plug procedure requires hospitalization for only about 24
hours. Currently, there are two different anal fistula plugs cleared by the FDA for treating ano-rectal
fistulas in the United States. This treatment option does not carry any risk of bowel incontinence. In the
systematic review published by Dr Pankaj Garg, the success rate of the fistula plug is 65-75%.[2]
Endorectal advancement flap is a procedure in which the internal opening of the fistula is identified
and a flap of mucosal tissue is cut around the opening. The flap is lifted to expose the fistula, which is
then cleaned and the internal opening is sewn shut. After cutting the end of the flap on which the
internal opening was, the flap is pulled down over the sewn internal opening and sutured in place. The
external opening is cleaned and sutured. Success rates are variable and high recurrence rates are
directly related to previous attempts to correct the fistula.
LIFT Technique is a novel modified approach through the intersphincteric plane for the treatment of
fistula-in-ano, known as LIFT (ligation of intersphincteric fistula tract) procedure. LIFT procedure is
based on secure closure of the internal opening and removal of infected cryptoglandular tissue through
the intersphincteric approach. Essential steps of the procedure include, incision at the intersphincteric
groove, identification of the intersphincteric tract, ligation of intersphincteric tract close to the internal
opening and removal of intersphincteric tract, scraping out all granulation tissue in the rest of the
fistulous tract, and suturing of the defect at the external sphincter muscle.[3] The procedure was
developed by Thai colorectal surgeon, Arun Rojanasakul, The first reports of preliminary healing result
from the procedure were 94% in 2007.[4] Additional ligation of the intersphincteric fistula tract did not
improve the outcome after endorectal advancement flap.[5]
Fistula clip closure (OTSC Proctology) is the latest surgical development, which involves the closure
of the internal fistula opening with a superelastic clip made of nitinol (OTSC). During surgery, the
fistula tract is debrided with a special fistula brush and the clip is transanally applied with the aid of a
preloaded clip applicator. The surgical principle of this technique relies on the dynamic compression
and permanent closure of the internal fistula opening by the superelastic clip. Consequently, the fistula
tract dries out and heals instead of being kept open by continuous feeding with stool and fecal
organisms. This minimally-invasive sphincter-preserving technique has been developed and clinically
implemented by the German surgeon Ruediger Prosst.[6][7] First clinical data of the clip closure
technique demonstrate a success rate of 90% for previously untreated fistulae[8] and a success rate of
70% for recurrent fistulae.[9]

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Japan: A man with an anal fistula. From the Yamai no Soshi, late 12th century.
PERFACT Procedure is another latest addition to the armamentarium to treat complex and highly
complex fistula-in-ano. Invented by Dr Pankaj Garg, it is a minimally cutting procedure as both the anal
sphincters (internal and external sphincters) are not cut/damaged at all. Therefore the risk of
incontinence is minimal. PERFACT procedure (proximal superficial cauterization, emptying regularly
fistula tracts and curettage of tracts) entails two steps: superficial cauterization of mucosa at and around
the internal opening and keeping all the tracts clean. The principle is to permanently close the internal
opening by granulation tissue. This is achieved by superficial electrocauterization at and around the
internal opening and subsequently allowing the wound to heal by secondary intention. Early results of
this procedure are quite encouraging for complex fistula-in-ano (86.4% in highly complex anal fistulas).
The procedure is effective even in fistula associated with abscess, supralevator fistula-in-ano and fistula
where the internal opening is non-localizable. [10]

Infection
Some people will have active infection when they present with a fistula, and this requires clearing up before
definitive treatment can be decided.
Antibiotics can be used as with other infections, but the best way of healing infection is to prevent the buildup
of pus in the fistula, which leads to abscess formation. This can be done with a seton.

References
1. ^ Hippocrates, "On Fistulae", translation by Francis Adams, Internet Classics Archive, Massachusetts
Institute of Technology.
2. ^ Garg P, Song J, Bhatia A, Kalia H, Menon GR (October 2010). "The efficacy of anal fistula plug in
fistula-in-ano: a systematic review". Colorectal Dis 12 (10): 96570.
doi:10.1111/j.1463-1318.2009.01933.x. PMID 19438881.
3. ^ Rojanasakul A (September 2009). "LIFT procedure: a simplified technique for fistula-in-ano". Tech
Coloproctol 13 (3): 23740. doi:10.1007/s10151-009-0522-2. PMID 19636496.
4. ^ Rojanasakul A, Pattanaarun J, Sahakitrungruang C, Tantiphlachiva K (March 2007). "Total anal
sphincter saving technique for fistula-in-ano; the ligation of intersphincteric fistula tract". J Med
Assoc Thai 90 (3): 5816. PMID 17427539.
5. ^ van Onkelen, RS; Gosselink, MP; Schouten, WR (February 2012). "Is it possible to improve the

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outcome of transanal advancement flap repair for high transsphincteric fistulas by additional
ligation of the intersphincteric fistula tract?". Diseases of the colon and rectum 55 (2): 1636.
doi:10.1097/DCR.0b013e31823c0f74. PMID 22228159.
6. ^ Prosst RL, Herold A, Joos AK, Bussen D, Wehrmann M, Gottwald T, Schurr MO (September 2012).
"The anal fistula claw: the OTSC clip for anal fistula closure". Colorectal Dis 14 (9): 11127.
doi:10.1111/j.1463-1318.2011.02902.x. PMID 22122680.
7. ^ Prosst RL, Ehni W (July 2012). "The OTSC Proctology clip system for anorectal fistula closure: the
'anal fistula claw': case report". Minim Invasive Ther Allied Technol 21 (4): 30712.
doi:10.3109/13645706.2012.692690. PMID 22657572.
8. ^ Prosst RL, Ehni W, Joos AK (September 2013). "The OTSC Proctology clip system for anal fistula
closure: first prospective clinical data". Minim Invasive Ther Allied Technol 22 (5): 2559.
doi:10.3109/13645706.2013.826675. PMID 23971828.
9. ^ Mennigen R, Lauktter M, Senninger N, Rijcken E (April 2015). "The OTSC() proctology clip
system for the closure of refractory anal fistulas". Tech Coloproctol 19 (4): 2416.
doi:10.1007/s10151-015-1284-7. PMID 25715788.
10. ^ Garg P, Garg M (7 April 2015). "PERFACT procedure: a new concept to treat highly complex anal
fistula". World J Gastro 21 (13): 40209. doi:10.3748/wjg.v21.i13.4020. PMID 25852290.
Wikimedia Commons has media related to Anal fistula.
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Diseases of the digestive system (primarily K20K93, 530579)

Categories
Categories:
Colorectal surgery
Diseases of intestines
Fistulas
Related topics
General surgery General surgery is a surgical specialty that focuses on abdominal contents including
esophagus, stomach, small bowel, colon, liver, pancreas, gallbladder and bile ducts, and often the thyroid
gland (depending on local reference patterns). Epithelium Epithelium (epi- + thele + -ium) is one of the four
basic types of animal tissue. The other three types are connective tissue, muscle tissue and nervous tissue.
Internal anal sphincter The internal anal sphincter, IAS, (or sphincter ani internus) is a muscular ring that
surrounds about 2.54.0 cm of the anal canal; its inferior border is in contact with, but quite separate from,
the external anal sphincter. It is about 5 mm thick, and is formed by an aggregation of the involuntary circular
fibers of the rectum.
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Cover photo is available under CC BY-SA 3.0 License. Credit: Thomas H. (see original file).

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Anal fistula
Introduction
Signs and symptoms
Diagnosis
Diagnosis
1. Types
Treatment
1. Infection
References
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