Pediatric Fistula-in-Ano Treatment & Management

Updated: May 01, 2018
  • Author: Jayant Deodhar, MD; Chief Editor: Harsh Grewal, MD, FACS, FAAP  more...
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Treatment

Approach Considerations

Surgery is required if pain is severe, if medical treatment fails, or if the fistula-in-ano recurs. About 95% of patients are completely cured, and 5% have a recurrence. Subsequent application of a kshara sutra is painless in 85% patients.

Associated severe medical conditions may contraindicate surgical procedures or anesthesia.

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Medical Therapy

Medical therapy includes antibiotics and analgesics. In addition, treatment of the cause (eg, malignancy, Crohn disease or ulcerative colitis) is necessary. If underlying tuberculosis is detected, antitubercular treatment using rifampin, isoniazid, and ethambutol should be administered for 6 months.

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Surgical Therapy

Asymptomatic fistulae require no treatment. Submucosal, intersphincteric, or low transsphincteric fistulae may be adequately treated by means of fistulectomy or fistulotomy. [12] Treatment varies according to the patient's sex and according to the type of fistula.

Fistulectomy

With the patient under anesthesia, the fistula tract is dissected from all sides by means of sharp dissection with scissors or diathermy from the external opening to the internal opening. The cavity left behind is allowed to heal by secondary intention.

Fistulotomy

With the patient under anesthesia, the fistula tract is probed. The probe is passed from the external opening and taken out from the internal opening. The whole fistula tract is then laid open over the probe. As with fistulectomy, the wound is allowed to heal by secondary intention. [13]

Radiowave fistulotomy

Radiowave fistulotomy offers benefits such as less postoperative pain, faster wound healing, and an early return to normal activity. [14] However, recurrence rates and continence problems are similar to those following conventional techniques.

Treatment of high anal fistula

A supralevator (pelvirectal) fistula may be secondary to local disease. If a traumatic fistula perforates the rectal ampulla, colostomy is usually needed.

Treatment of transsphincteric fistula

A transsphincteric fistula usually starts as an intersphincteric tract with a secondary tract in the ischiorectal fossa extending up to the levator axis. Treatment is directed toward the lower part of the tract, as healing of the upper tract may occur. If this does not take place, colostomy is required. A study by van Onkelen et al found that low transsphincteric fistulae could be treated successfully by ligation of the intersphincteric fistula tract without affecting fecal continence. [15]

Treatment of intersphincteric high anal fistula

This primarily starts as an abscess of the anal gland and extends upward and downward between the internal and external sphincters. Patients may have an opening into rectum above the anorectal ring. Treatment consists of laying open the tract by dividing only a small segment of the internal sphincter.

Use of seton, including medicated seton (kshara sutra)

A seton is a surgical thread often used to treat this condition. The seton can be silk, cotton, or any other suture material. It may be coated with medications.

A kshara sutra is a medicated thread often used in India to treat fistula-in-ano. [16, 17, 18, 19] To prepare this medicated type of seton, equal amounts of milk from the Euphorbianerifolia plant and powder of dry rhizomes from the Carcuma longa plant are thoroughly mixed. Cotton surgical threads (No. 20) are immersed in the mixture for 1-2 hours and then dried in hot air. This procedure is repeated often, sometimes as many as seven times.

Medicated setons are not commonly used in the rest of the world. Medications used in the kshara sutra are anti-infective and anti-inflammatory.

With the patient under anesthesia, the fistulous tract is probed to determine its extent and direction. A silver malleable probe is passed into fistula tract, and a suitable length of seton (kshara sutra) is cut and threaded over the eye of the probe. The kshara sutra is moderately tightened and is tied outside the anal verge over a piece of gauze.

A new piece of kshara sutra is replaced and tied every 6 days, using the railroad technique, until the last seton cuts through the fistula tract. The thread is shortened during each change, and the tract shortens. The wound heals by secondary intention.

The fistulous tract is cut as a result of the pressure the kshara sutra exerts on the anorectal tissue. The presence of the kshara sutra does not allow the cavity to close and facilitates continuous drainage of pus. Cutting and healing of the tract occurs simultaneously, and no pus pocket is retained. The chemicals applied to the thread are anti-inflammatory agents and have antibacterial properties. In addition, the alkaline pH of the kshara sutra prevents rectal pathogens from invading the cavity.

Video-assisted anal fistula treatment

Video-assisted anal fistula treatment (VAAFT), initially described in 2011 for use in adults with anal fistula, is being studied in children. [20] Pini Prato et al cited preliminary results indicating that VAAFT is feasible and safe in the pediatric population, as well as versatile. [21]  They found that older children and adolescents appeared to benefit most from the video-assisted approach.

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Complications

Complications of fistula-in-ano include the following:

  • Recurrence
  • Delayed or impaired healing
  • Anal disease
  • Mucosal prolapse (which is not uncommon after fistula surgery)
  • Incontinence [22]
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Long-Term Monitoring

Follow-up care involves antibiotic treatment, surgical dressing, and use of laxatives. A high-fiber diet is recommended.

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