Fistulainano

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 anal sphincter 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.
• 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 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 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.
• 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 – 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. Small intestinal submucosa stimulates the body to close the fistula from the inside out. 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%.^[1]
• 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 inter sphincteric 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.^[2] The procedure was developed by Thai colorectal surgeon, Arun Rojanasakul, Colorectal Division Department of Surgery, Chulalongkorn University in Bangkok, Thailand. The fist reports of preliminary healing result from the procedure were 94% in 2007 ^[3]