Anal Fistulotomy Technique

Updated: Jul 22, 2016
  • Author: Vassiliki Liana Tsikitis, MD, MCR, FACS, FASCRS; Chief Editor: Kurt E Roberts, MD  more...
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Technique

Approach Considerations

Treatment of fistula-in-ano is challenging. To improve healing rates, understanding of the anatomy and delineation of the tracts of the fistula with any potential extensions is paramount.

Fistulas may be classified according to their type (ie, intersphincteric, transsphincteric, suprasphincteric, or extrasphincteric) and to whether they are simple or complex (see Overview, Technical Considerations). No single technique is appropriate for the treatment of all anal fistulae, and treatment must be directed by the etiology and anatomy of the fistula, degree of symptoms, patient comorbidities, and surgeon experience.

Future directions

The potential treatment of fistula-in-ano with adipose-derived stem cells has been explored by a few international groups. In a pilot trial, expanded adipose-derived stem cells (eADSCs) were obtained from subcutaneous fat by liposuction, a process that yields more stem cells than bone marrow aspirates. [8]  The technique comprises the following steps:

  • Identification of the fistula tract and internal opening
  • Curettage of the fistula tract and suture closure of the internal opening
  • Injection of the suspension of stem cells into the walls and tract of the fistula
  • Sealing of the tract with fibrin glue

The proposed rationale for this approach was that the biologic properties of eADSCs would suppress inflammation and enhance wound healing. Initial results were promising, with 71% of recipients reporting closure of the fistula; however, healing rates were notably lower at 1 year and 3 years after the procedure. [9, 10] Although injection of eADSCs is a generally safe treatment that does not pose a significant risk of incontinence or any other adverse effects, it does not seem to yield better healing results than does the application of any other biomaterial products.

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Anal Fistulotomy

The first surgical step is to classify the fistula type by identifying the primary and secondary openings. Examination under anesthesia may be all that is needed to identify the internal opening. A probe can then be gently passed through to the external opening to define the tract. This maneuver almost always requires that the patient be anesthetized.

Care must be taken in passing a probe from an external opening to internal; this step can result in iatrogenic injury and creation of a false tract. Goodsall’s rule can help in guiding this maneuver. Diluted methylene blue, hydrogen peroxide, or both can be injected into the external opening to facilitate identification of the internal opening at the dentate line.

Once the anatomy is defined as either simple or complex, the techniques discussed below may be employed. In general, complex fistulae are treated with more conservative approaches because fistulotomy is associated with a high incidence of postoperative incontinence.

Surgery for simple fistula-in-ano

Simple fistula is defined by American Society of Colon and Rectal Surgeons (ASCRS) as having the following characteristics [3] :

  • Includes a single, nonrecurrent tract that crosses less than 30% of the external sphincter
  • Is not an anterior fistula in women
  • Occurs in patients without impaired continence, a history of Crohn disease, or previous pelvic irradiation

These fistulae include intersphincteric and low transsphincteric fistulae and are typically treated by means of primary fistulotomy (also known as the "lay open technique").

A probe is inserted into the tract, followed by division of the overlying tissue. Division of the internal sphincter alone does not usually compromise fecal continence. The base of the wound is then curetted and left open to heal by secondary intention. Marsupialization is sometimes performed and may improve the rate of wound healing. [1]  Healing is assisted by frequent sitz baths and fiber therapy.

Surgery for complex fistula-in-ano

Complex anal fistulae may include high transphincteric fistulae, suprasphincteric fistulae, extrasphincteric fistulae, and fistulae with various associated comorbid conditions.

A number of treatment options may be considered. Seton placement is commonly employed. Continence-preserving approaches include the following:

  • Fibrin glue
  • Anal fistula plug
  • Endoanal or endorectal advancement flaps
  • Ligation of intersphincteric fistula tract (LIFT) procedure

These continence-preserving procedures are associated with relatively high recurrence rates (30-50% overall). [11]

Seton placement or staged fistulotomy

A seton, which can be a nonabsorbable suture, a rubber band, or a Silastic vessel loop, is passed through the fistula tract and secured to itself externally. The use of cutting setons, in which the seton is progressively tightened in the office until it eventually cuts through the fistula tract (see the image below), can also be considered.

In the treatment of complex fistulae, setons are usually placed loosely to allow drainage and control sepsis, and seton placement is then followed by a secondary procedure (eg, endoanal advancement flap, fibrin glue, or plug) to avoid division of the sphincter muscle.

Postoperative continence changes range from 0% to 54% in patients treated with two-stage procedures or cutting setons, and incontinence to flatus is more common than stool incontinence. [12, 13, 14]

Fibrin glue

Fibrin glue is easy to use, avoids sphincter division, can be repeated with low risk, and does not preclude the use of other methods of treatment.

The procedure starts with identification of the internal and external openings of the fistula tract. The tract is cleaned and debrided with a curette or gauze. A commercially available preloaded syringe is introduced into the tract, and fibrin glue is slowly injected until it is seen exuding from the internal opening. Time is usually given to allow the reaction to stabilize the clot.

Although early results were promising, recurrence was found to be common. In a randomized controlled trial by Lindsey et al, fibrin glue was associated with higher healing rates (69% vs 13%) than conventional treatment (fistulotomy or loose seton with or without subsequent advancement flap) for complex fistulae. [15]  In nonrandomized studies using fibrin glue for complex disease, overall healing rates ranged from 10% to 67%. [16, 17, 18, 19]  Despite fibrin glue's relatively low success rate in complex disease, its low morbidity makes it worth considering for initial therapy.

Anal fistula plug

The bioprosthetic anal fistula plug, manufactured from porcine small intestine, is used to close the primary internal opening and serves as a matrix for the obliteration of the fistula tract (see the image below).

Fistula plug technique. Fistula plug technique.

After identification of the internal and external openings of the fistula, the tract is cleaned and debrided with a curette or gauze. The conical plug is pulled, starting from the internal opening with the narrow end first, into the tract until the internal opening is blocked. It is then sutured into place. The external opening is not completely sealed, so as to allow continued drainage of the fistula.

This technique has inherent appeal in that it is simple to perform and avoids sphincter division. It seems to work best with long tracts without active sepsis. Success rates in the limited studies vary but are usually lower than 50%. [20, 21]

Endoanal or endorectal advancement flaps

The goal of advancement flap procedures for anal fistulae is to obliterate the internal opening and leave the tract and external opening to drain and heal secondarily while avoiding sphincter division.

The first step is identification of the openings, followed by curettage of the tract. Any fibrous tissue around the internal opening is excised. The incision is begun distal to the internal opening. A segment of proximal healthy anorectal mucosa, submucosa, and some muscle is mobilized to allow tension-free coverage of the internal opening. The base of the flap should be twice the tip of the flap to maintain the blood supply. The distal tip harboring the fistula opening is then excised. (See the image below.) Recurrence rates range from 13% to 56%. [3]

Anorectal advancement flap. A) Transsphincteric fi Anorectal advancement flap. A) Transsphincteric fistula-in-ano. B) Enlargement of external opening and curettage of granulation tissue. C) Mobilization of flap and closure of internal opening. D) Suturing of flap covering internal opening.

Ligation of intersphincteric fistula tract procedure

The LIFT procedure is a relatively new sphincter-sparing approach that involves ligation and division of the fistula tract in the intersphincteric space.

A seton is usually placed weeks before the operation to allow fibrosis of the tract. The procedure begins with a curvilinear incision in the intersphincteric groove. The fistula tract is identified and dissected out. The fistula tract next to the internal opening is ligated with absorbable suture. The lateral tract is curetted and then suture-ligated externally to the first ligation site. The tract is divided. Tract division is confirmed by injection or probing. The external opening can be widened for drainage if needed.

Success rates have ranged from 40% to 90% in patients with complex fistulae, and studies with longer follow-up have shown late failures or recurrences. [22, 23]  The LIFT procedure appears to be a safe and effective option for complex fistulae. The 2011 ASCRS Practice Parameters stated that at the time of writing, the data were too preliminary to allow this procedure to be placed in the treatment algorithm. [3]

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Complications

Results of fistula surgery can vary considerably, depending on the chronicity and the complexity of the fistula and on the experience of the surgeon.

Patients with high transsphincteric fistulae and females with anterior fistulae present complex problems to the surgeon, in that postoperative incontinence rates after fistulotomy can be significant. [24]  As a general rule, the internal sphincter and about 30% of the external sphincter can be sacrificed in the posterior quadrant, as long as the puborectalis is not compromised. Not all patients, however, have the same quality of sphincter function; results may therefore vary.

Preoperative anorectal physiology tests, such as endoanal ultrasonography and anorectal manometry, can delineate the anatomy of the sphincteric complex and may predict the functional outcome of fistula surgery. [25]

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