Fistula-in-Ano
Current Therapy 2015
Michael J. Snyder, MD, FACS
The University of Texas
Health Science Center, Houston
Anorectal Abscess
Signs and Symptoms
• Pain
Throbbing and continuous
• Swelling with erythema of skin
• Fever
• May be apparent only on rectal exam
(bi-digital)
Anorectal Abscess
Classification
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Perianal
Ischiorectal
Intersphincteric
Supralevator
Abscess Classification
Anal Fistulas
• Hippocrates (460 B.C.)
Describes use of seton
• Frederick Salmon
“Benevolent Dispensary for the Relief of the
Poor Afflicted with Fistulas, Piles and other
diseases of the Rectum and Lower Intestine”
Later known as St Mark’s Hospital, London
• Lockhart Mummery
“Perhaps more surgical reputations have been
damaged by unsuccessful treatment of fistula
than by excision of the rectum or
gastroenterostomy”
Goals of Fistula Surgery
• Cure of the fistula
• Maintenance of continence
Anorectal Abscess/Fistula
• Anal glands in crypts
• Glands extend through internal
sphincter
• Intersphincteric abscess
• Extension along fascial planes
Modes of Fistula Development
Rectal Abscess
Management
• Drain under local anesthesia if
superficial
Drain close to anus
Don’t probe!
Don’t wait for fluctuance
Little if any role for antibiotics
• Refer if deep or recurrent
• Abscess associated with fistula in
>60% of cases
Probing of Fistula or
Abscess
Supralevator Abscess
Fistula-in-Ano
Classification
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Intersphincteric
Trans-sphincteric
Suprasphincteric
Extrasphincteric
Parks, Gordon, & Hardcastle, 1976
Issues in Management of
Fistula-in-Ano
• Primary vs delayed fistulotomy
• Fistulotomy vs fistulectomy
• Role of antibiotics
Systemic sepsis
Immunosuppressed
With advancement flaps
Intersphincteric Fistula
Transsphincteric Fistulae
Suprasphincteric Fistulae
Suprasphincteric Fistula
• Does it occur without iatrogenic
assistance?
• Fucini (1991)
No fistula went above the puborectalis
unless they recurred after prior surgery
Fucini C. Int J Colorectal Dis, 1991, 6:12-16
Extrasphincteric Fistulae
Anal Fistula
Operative Approach
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Inspection and palpation of the tract
Digital examination and anoscopy
Adequate lighting and exposure
Magnification (loupes)
Meticulous hemostasis
 Local with epinephrine
 Cautery
• Gentle probing
• Follow granulation tissue
• Use of methylene blue or hydrogen peroxide
Results of Surgery for
Fistula-in-ano
Alteration of Continence after
Fistulotomy
• Definition important
Leakage of gas
Minor soiling
Leakage of liquid stool
Leakage of solid stool
• Less common after secondary fistulotomy
due to scar formation (internal
sphincterotomy does not separate)
Colorectal Disease, 9:18-50, 2007
The Treatment of Anal Fistula
ACPGBI Position Statement
Fistulotomy
• “Division of the external sphincter should
always be undertaken with caution, taking
account of the sex of the patient, the
position of the fistula, previous surgery,
and associated diseases.”
• Division of >30-50% of external sphincter
probably results in significant functional
impairment.
Colorectal Disease, 9:18-50, 2007
Evaluation Prior to Fistulotomy
• Location (avoid anterior fistulotomy
in women)
• Level (internal openings above
dentate line)
• Resting and squeeze tone prior to
surgery (manometry?)
• Inflammatory bowel disease?
Toyonaga et al, Int J Colorectal Dis 2007; 22:1071-75
Complex Fistulae
• Definition: fistula in which
fistulotomy is likely to result in
significant impairment of continence
• Examples
Rectovaginal fistula
Suprasphincteric fistula
Extrasphincteric fistula
High transsphincteric fistula
Inflammatory bowel disease
Complex Fistulae
Management Options
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Fistulotomy
Parks’ fistulectomy
Seton techniques
Closure of internal opening
Layered closure
Endorectal advancement flap
Island flap anoplasty
• Fibrin glue
• Fistula plugs
• LIFT procedure
Complex Fistula-in-Ano
This image cannot currently be displayed.
Evaluation
• Fistulogram
• CT or MR scan with contrast in
fistula
• GI X-rays
• Endorectal ultrasound with H2O2 in
tract
Fistulography
• 27 patients
• Effect on Management
• none
14
• altered tx 13
– unexpected
findings (7)
– altered
surgery (6)
• Most useful in pts w/
IBD and recurrent
fistulas
Weisman et al Dis Colon
Rectum 1991:34:181-4.
Use of MRI to Identify Fistula
• Advantage-non-invasive multi-planar
capabilities, high inherent soft tissue
contrast, radiation sparing
• Ability to contrast pus and
granulation tissue
• Drawback epithelialized tracts may
not be visualized
•Endocoil or phased array
•Bartram Radiol Clin N Am
2003;41:443-457.
•Halligan Clin Radiol 1998;53:85-95.
MRI for Anal Fistula
Anal Fistula
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Anal ultrasonography
Safe, quick, well tolerated
Fistula tracts hypoechoic
defects
Hydrogen peroxide
enhanced- 21 pts –PE, us
and hydrogen peroxide
enhanced
Tract classified correctly in
20 and overall
concordance with surgery
was 95%
• Poen DCR
1998;41:1147-52
Ultrasound for Fistula
Parks’ Fistulectomy
Seton as Marker or Drain
Seton
Long-term Drainage
Cutting Seton
Staged Division of Tract
Seton Results
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Staged fistulotomy
116 patients
23 month mean followup
Major incontinence 5% (pad)
Recurrence 3%
Safe and effective for high or
complex fistulae
Pearl et al, DC&R, 36: 573-7, 1993
Flap Advancement for
Fistula
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Trapezoidal flap, wider at base
Deep flap incorporates circular muscle
Debride tract and remove epithelium
Leave external tract open for drainage
Closure of muscle defect with suture
Cover with flap
Non-opposed suture lines
• Suitable for RV fistula and complex
anorectal
Endoanal Advancement
Flap
Flap Advancement
Results
• Aguilar (DC&R 28:496-8,1985)
179 patients (mostly simple fistulae)
98.5% healing
10% minor symptoms, mostly soiling
• Mizrahi (DC&R 45:1616-21, 2002)
106 patients (complex fistulae)
60% healing
Worst results with Crohn’s 43% healing)
Cutaneous (Island)
Advancement Flap
Cutaneous (Island)
Advancement Flap
Results
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Abcarian (96)
Robertson (98)
Zimmerman (01)
Hossack (05)
Aycinena (11)
8/11
11/14
12/26
15/16
85/100
Fibrin Glue Repair of Fistula
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Debride tract (Nu-Gauze)
Autologous fibrinogen + bovine thrombin
Commercial fibrinogen + human thrombin
Dual lumen applicator
? Closure of internal opening with suture
Best for long tracts
Personal success about 50%
Can re-treat, burns no bridges
Fibrin Glue Results
• Cintron (DC&R 43:944-9, 2000)
79 patients
54-64% healed
• Loungnarath (DC&R 47:432-6, 2004)
42 patients (complex)
31% durable healing
Most failures within 3 months
Fistula Plug (Cook)
Gore Fistula Plug
Fistula Plug Results
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Armstrong (06)
Ellis (07)
van Kropen (07)
Schwander (08)
Lawes (08)
Thekkinkattil (08)
Christofordis (08)
Ky (08)
GA
AL
Netherlands
Germany
Mayo
Leeds
U Minn
Mt Sinai
83%
88%
41%
45%
24%
44%
43%
57%
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Technique is critical
Not indicated for routine intersphincteric fistulas
Initial seton to allow sepsis to resolve
Expected success rate is 50-60%
Colorectal Disease 2007; 10:17–20
LIFT Procedure
LIFT Procedure
94% healing
J Med Assoc Thai Vol. 90 No. 3 2007
LIFT Procedure
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Rojanasakul (Thailand)
Alfred (Singapore)
Ellis (BioLift)
Kumar et al
ASCRS, 2008
90% healing
77% healing
94% healing
68% healing
Factors Associated With
Recurrence of Fistula
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Complex fistula
Horseshoe extension
Failure to identify internal opening
Lateral location of internal opening
Previous fistula surgery
Crohn’s Disease
Surgeon performing operation
Aguillar et al. Dis Colon Rectum 1996; 39:723
Horseshoe Abscess
Horseshoe Abscess/Fistula
• Deep post-anal space
• Un-roof post-anal space
• Counter-drainage of lateral
extensions
Hanley, 1965
Horseshoe Abscess/Fistula
Rectovaginal Fistula
Etiology
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Trauma (episiotomy)
Infection (cryptoglandular)
Inflammatory bowel disease
Radiation
Neoplasm
Rectovaginal Fistula
Surgical Options
• Fistula division and sphincter repair
• Trans vaginal
Direct layered repair
Martius procedure (bulbocavernosus flap)
• Trans anal
Layered closure
Endorectal advancement flap
• Perineal approach
Separate rectum from vagina
Divide fistula
Close rectal wall
Interpose sphincter muscle (sphincteroplasty)
Conclusions
• There is still a role for fistulotomy (not
fistulectomy)
• Need better reporting of what we mean by
“alteration of continence”
• Continence disturbances reported with all
techniques
• Use draining seton to allow resolution of sepsis
• Tailor the operation to the patient
• Consider alternative approaches for complex
fistulae
• Critical to be familiar with multiple approaches
successfully manage complex fistulae