eMedicine Specialties > General Surgery > Colorectal

Fistula-in-Ano: Follow-up

Author: Dennis F Zagrodnik II, MD, FACS, Consulting Staff, Premier Surgical of Wisconsin, SC
Contributor Information and Disclosures

Updated: Jul 16, 2009

Outcome and Prognosis

Following standard fistulotomy, the reported rate of recurrence is 0-18% and the rate of any stool incontinence is 3-7%.

Following seton use, the reported rate of recurrence is 0-17% and the rate of any incontinence of stool is 0-17%.

Following mucosal advancement flap, the reported rate of recurrence is 1-17% and the rate of any incontinence of stool is 6-8%.18

Future and Controversies

Future Recent advances in biotechnology have led to the development of many new tissue-adhesives and biomaterials formed as fistula plugs. By their less-invasive nature, these therapies lead to decreased postoperative morbidity and risk of incontinence, but long-term data are lacking for eradication of disease, especially in complex fistulas, which carry high recurrence rates.19 Reported series exist of fibrin glue treatment of fistula-in-ano, with 1-year follow-up showing recurrence rates approaching 40-80%.20,21,22 The Surgisis fistula plug has also had mixed long-term results in direct clinical trials.23,24 Early success rates have been reported for newer materials, such as acellular dermal matrix and the bioabsorbable Gore Bio-A fistula plug, in low fistulas and good animal model data.25 Evidence regarding long-term success with plug techniques for complex disease awaits randomized trials.

Controversies

Crohn's disease of the perineum with multiple and often complex fistulae requires careful surgical treatment. Acute perianal abscess requires incision and drainage. Definitive repair of fistulae in these patients requires that the intra-abdominal disease be under control with medical therapy. If controlled, routine therapy, as outlined in Treatment, is warranted. Recurrent fistulous disease to the rectum and perineum with persistent anorectal sepsis is an indication for panproctocolectomy. Studies have identified a role for medical therapy with infliximab, the monoclonal antibody to tumor necrosis factor, with 50-60% response rates for perianal fistulae.17,26

 


More on Fistula-in-Ano

Overview: Fistula-in-Ano
Workup: Fistula-in-Ano
Treatment: Fistula-in-Ano
Follow-up: Fistula-in-Ano
Multimedia: Fistula-in-Ano
References
Further Reading
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References

  1. Belliveau P. Anal fistula. In: Current Therapy in Colon and Rectal Surgery. Philadelphia: BC Decker; 1990:22-7.

  2. Cosman BC. All's Well That Ends Well: Shakespeare's treatment of anal fistula. Dis Colon Rectum. Jul 1998;41(7):914-24. [Medline].

  3. Sainio P. Fistula-in-ano in a defined population. Incidence and epidemiological aspects. Ann Chir Gynaecol. 1984;73(4):219-24. [Medline].

  4. Hancock BD. ABC of colorectal diseases. Anal fissures and fistulas. BMJ. Apr 4 1992;304(6831):904-7. [Medline].

  5. Hamalainen KP, Sainio AP. Incidence of fistulas after drainage of acute anorectal abscesses. Dis Colon Rectum. Nov 1998;41(11):1357-61; discussion 1361-2. [Medline].

  6. Rosen L. Anorectal abscess-fistulae. Surg Clin North Am. Dec 1994;74(6):1293-308. [Medline].

  7. Ross ST. Fistula in ano. Surg Clin North Am. Dec 1988;68(6):1417-26. [Medline].

  8. Parks AG, Gordon PH, Hardcastle JD. A classification of fistula-in-ano. Br J Surg. Jan 1976;63(1):1-12. [Medline].

  9. Sun MR, Smith MP, Kane RA. Current techniques in imaging of fistula in ano: three-dimensional endoanal ultrasound and magnetic resonance imaging. Semin Ultrasound CT MR. Dec 2008;29(6):454-71. [Medline].

  10. Weisman RI, Orsay CP, Pearl RK, Abcarian H. The role of fistulography in fistula-in-ano. Report of five cases. Dis Colon Rectum. Feb 1991;34(2):181-4. [Medline].

  11. Beckingham IJ, Spencer JA, Ward J, Dyke GW, Adams C, Ambrose NS. Prospective evaluation of dynamic contrast enhanced magnetic resonance imaging in the evaluation of fistula in ano. Br J Surg. Oct 1996;83(10):1396-8. [Medline].

  12. Buchanan GN, Halligan S, Williams AB, Cohen CR, Tarroni D, Phillips RK, et al. Magnetic resonance imaging for primary fistula in ano. Br J Surg. Jul 2003;90(7):877-81. [Medline].

  13. American Society of Colon and Rectal Surgeons. Practice parameters for treatment of fistula-in-ano--supporting documentation. The Standards Practice Task Force. Dis Colon Rectum. Dec 1996;39(12):1363-72. [Medline].

  14. Ho YH, Tan M, Leong AF, Seow-Choen F. Marsupialization of fistulotomy wounds improves healing: a randomized controlled trial. Br J Surg. Jan 1998;85(1):105-7. [Medline].

  15. Sangwan YP, Rosen L, Riether RD, Stasik JJ, Sheets JA, Khubchandani IT. Is simple fistula-in-ano simple?. Dis Colon Rectum. Sep 1994;37(9):885-9. [Medline].

  16. McCourtney JS, Finlay IG. Setons in the surgical management of fistula in ano. Br J Surg. Apr 1995;82(4):448-52. [Medline].

  17. Seow-Choen F, Nicholls RJ. Anal fistula. Br J Surg. Mar 1992;79(3):197-205. [Medline].

  18. Abbas MA, Lemus-Rangel R, Hamadani A. Long-term outcome of endorectal advancement flap for complex anorectal fistulae. Am Surg. Oct 2008;74(10):921-4. [Medline].

  19. Chung W, Kazemi P, Ko D, Sun C, Brown CJ, Raval M, et al. Anal fistula plug and fibrin glue versus conventional treatment in repair of complex anal fistulas. Am J Surg. May 2009;197(5):604-8. [Medline].

  20. Johnson EK, Gaw JU, Armstrong DN. Efficacy of anal fistula plug vs. fibrin glue in closure of anorectal fistulas. Dis Colon Rectum. Mar 2006;49(3):371-6. [Medline].

  21. Buchanan GN, Bartram CI, Phillips RK. Efficacy of fibrin sealant in the management of complex anal fistula: a prospective trial. Dis Colon Rectum. Sep 2003;46(9):1167-74. [Medline].

  22. Loungnarath R, Dietz DW, Mutch MG, Birnbaum EH, Kodner IJ, Fleshman JW. Fibrin glue treatment of complex anal fistulas has low success rate. Dis Colon Rectum. Apr 2004;47(4):432-6. [Medline].

  23. Champagne BJ, O'Connor LM, Ferguson M, Orangio GR, Schertzer ME, Armstrong DN. Efficacy of anal fistula plug in closure of cryptoglandular fistulas: long-term follow-up. Dis Colon Rectum. Dec 2006;49(12):1817-21. [Medline].

  24. Safar B, Jobanputra S, Sands D, Weiss EG, Nogueras JJ, Wexner SD. Anal fistula plug: initial experience and outcomes. Dis Colon Rectum. Feb 2009;52(2):248-52. [Medline].

  25. Han JG, Xu HM, Song WL, Jin ML, Gao JS, Wang ZJ, et al. Histologic analysis of acellular dermal matrix in the treatment of anal fistula in an animal model. J Am Coll Surg. Jun 2009;208(6):1099-106. [Medline].

  26. Present DH, Rutgeerts P, Targan S, Hanauer SB, Mayer L, van Hogezand RA, et al. Infliximab for the treatment of fistulas in patients with Crohn's disease. N Engl J Med. May 6 1999;340(18):1398-405. [Medline].

  27. Ratto C, Gentile E, Merico M, Spinazzola C, Mangini G, Sofo L, et al. How can the assessment of fistula-in ano be improved?. Dis Colon Rectum. Oct 2000;43(10):1375-82. [Medline].

  28. Topstad DR, Panaccione R, Heine JA, Johnson DR, MacLean AR, Buie WD. Combined seton placement, infliximab infusion, and maintenance immunosuppressives improve healing rate in fistulizing anorectal Crohn's disease: a single center experience. Dis Colon Rectum. May 2003;46(5):577-83. [Medline].

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Keywords

fistula-in-ano, fistula, anus, anorectal fistula, hemorrhoidectomy, sphincterotomy, perianal fistula, anorectal abscess, Crohn disease, Crohn's disease, anal fissures, actinomycoses, anorectal sepsis, intersphincteric fistula, transsphincteric fistula, trans-sphincteric fistula, suprasphincteric fistula, supra-sphincteric fistula, extrasphincteric fistula, extra-sphincteric fistula, Goodsall rule, Parks classification

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Contributor Information and Disclosures

Author

Dennis F Zagrodnik II, MD, FACS, Consulting Staff, Premier Surgical of Wisconsin, SC
Dennis F Zagrodnik II, MD, FACS is a member of the following medical societies: American College of Chest Physicians, American College of Surgeons, American Medical Association, Phi Beta Kappa, Society of American Gastrointestinal and Endoscopic Surgeons, Southeastern Surgical Congress, and Wisconsin Medical Society
Disclosure: Nothing to disclose.

Medical Editor

Oscar Joe Hines, MD, Assistant Professor, Department of Surgery, University of California at Los Angeles School of Medicine
Oscar Joe Hines, MD is a member of the following medical societies: Alpha Omega Alpha, American Association of Endocrine Surgeons, American College of Surgeons, Association for Academic Surgery, Society for Surgery of the Alimentary Tract, and Society of American Gastrointestinal and Endoscopic Surgeons
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

David L Morris, MD, PhD, Professor, Department of Surgery, St George Hospital, University of New South Wales, Australia
Disclosure: RFA Medical None Director; MRC Biotec None Director

CME Editor

Paolo Zamboni, MD, Professor of Surgery, Chief of Day Surgery Unit, Chair of Vascular Diseases Center, University of Ferrara, Italy
Paolo Zamboni, MD is a member of the following medical societies: American Venous Forum and New York Academy of Sciences
Disclosure: Nothing to disclose.

Chief Editor

John Geibel, MD, DSc, MA, Vice Chairman, Professor, Department of Surgery, Section of Gastrointestinal Medicine and Department of Cellular and Molecular Physiology, Yale University School of Medicine; Director of Surgical Research, Department of Surgery, Yale-New Haven Hospital
John Geibel, MD, DSc, MA is a member of the following medical societies: American Gastroenterological Association, American Physiological Society, American Society of Nephrology, Association for Academic Surgery, International Society of Nephrology, New York Academy of Sciences, and Society for Surgery of the Alimentary Tract
Disclosure: AMGEN Royalty Other

 
 
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