Anal fistula

Anal fistula
Different types of anal fistula (right side of image)
Classification and external resources
Specialty	General surgery
ICD-10	K60.3
ICD-9-CM	565.1
eMedicine	med/2710
Patient UK	Anal fistula

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.

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
• 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 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]

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): 965–70. 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): 237–40. 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): 581–6. PMID 17427539.
5. van Onkelen, RS; Gosselink, MP; Schouten, WR (February 2012). "Is it possible to improve the 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): 163–6. 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): 1112–7. 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): 307–12. 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): 255–9. doi:10.3109/13645706.2013.826675. PMID 23971828.
9. Mennigen R, Laukötter M, Senninger N, Rijcken E (April 2015). "The OTSC(®) proctology clip system for the closure of refractory anal fistulas". Tech Coloproctol 19 (4): 241–6. 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): 4020–9. doi:10.3748/wjg.v21.i13.4020. PMID 25852290.