Advances: Management of Fistula in Ano - Recent

Management of fistula in ano -Recent
advances
Moderator : PROF.Dr.V.BALAKRISHNAN,
Head of the Department.
Presentor:Dr.S.SIVA SANKAR
● Anatomy of anal canal
● Ischiorectal abscess
● Fistula in ano
● Classification
● Evaluation
● Management
● Recent advances
Anal canal
The anal canal commences at the level where the rectum passes through the
pelvic diaphragm at the anorectal ring and ends at the anal verge and is
approximately 4cm in length.
The muscular junction between the rectum and anal canal can be felt with the
finger as a thickened ridge – the anorectal ‘bundle’ or ‘ring’.
The external anal sphincter
The external sphincter forms the bulk of the anal sphincter
complex.
The external sphincter is composed of striated voluntary
muscle supplied by the pudendal nerve
The superior part of the external sphincter fuses with the
puborectalis muscle, which is essential for maintaining the
anorectal angle, necessary for continence

The internal anal sphincter
The internal sphincter is the thickened (2–5 mm) distal
continuation of the circular muscle coat of the rectum.
The internal sphincter is composed of circular, non-striated
involuntary muscle supplied by autonomic nerves

The anal glands
Anal glands found in the submucosa and intersphincteric
space , and between 0 and 10 in number.
They drain via ducts into the anal sinuses
at the level of the dentate line

Anal glands
source of anal sepsis,
acute, presenting as perianal, ischiorectal or even pelvic

sepsis,
chronic, presenting as a cryptoglandular (non-specific) anal

fistula
Anorectal abscess
Fistula in ano
A fistula-in-ano, or anal fistula, is a chronic

abnormal communication, usually lined to some
degree by granulation tissue, which runs
outwards from the anorectal lumen (the internal
opening) to an external opening on the skin of the
perineum and gluteal region.
Fistula in ano can develop in approximately 40% of patients
during the acute phase of sepsis or even be discovered
within 6 months of initial therapy for anorectal sepsis.
Etiology
Nonspecific :
Cryptoglandular in origin.
Specific :
Crohn’s
Ulcerative colitis
TB
Actinomycosis
Carcinoma
Trauma
Radiation
Foreign body
Lymphoma
Pelvic inflammation
Park’s Classification:
Based on relationship of fistulous tract to the anal sphincters-
4 types.
● Intersphincteric Fistula
● Trans sphincteric Fistula
● Supra Sphincteric Fistula
● Extra Sphincteric Fistula

Low type- Internal opening below the anorectal ring.
High Type-Internal opening above the anorectal ring.
Importance – Low type fistula- fistulotomy without

damage to sphincter
High type fistula – Staged operation

GOODSALLS RULE
Goodsall's rule relates the external opening (in the perianal
skin) of an anal fistula to its internal opening (in the anal
canal).
It states that if the perianal skin opening is posterior to the

transverse anal line, the fistulous tract will open into the anal
canal in the midline posteriorly taking a curvilinear course.
A perianal skin opening anterior to the transverse anal line is

usually associated with a radial fistulous tract.
However, the predictive accuracy of Goodsall rule has been challenged, especially
with anterior external openings or when Crohn disease or carcinoma is present.

History
• previous history of anorectal suppuration
• intermittent or persistent purulent or
serosanguineous drainage from an external
opening in the perianal area.
• Pruritic symptoms may be present
Evaluation of Anal Fistula
● An accurate preoperative assessment of the anatomy of an anal fistula
is very important.
● Five essential points of a clinical examination of an anal fistula :
(1) location of the internal opening.
(2) location of the external opening.
(3) location of the primary track .
(4) location of any secondary track.
(5) determination of the presence or absence of underlying
Endoluminal USG:
Anal endosonography (ultrasound) may be the firstline
investigation for patients with an anal fistula that is suspected
to be complex.
Patients with recurrent fistula may benefit from anal

endosonography, but MRI will also be required
Fistulography:
Fistulography provides only very limited information
on fistula anatomy
Fistulography has been superseded by other imaging
modalities in the assessment of cryptogenic anorectal
sepsis.
Computed tomography
CT is inferior to MRI in the assessment of anal fistula, but
newer techniques can provide useful information in selected
patients
Thin-slice spiral CT may be helpful when MRI is either not

available or is contraindicated
MRI
Gold Standard
MRI is an accurate method of imaging anal fistula
MRI should be considered in any primary fistula deemed after

clinical or endosonographic assessment to be complex.
It should also be considered in patients with a recurrent anal

fistula.
TREATMENT
All modalities of treatment adhere by a few general principles:
1. Obliteration of the internal opening is key to the success of
treatment
2. There should be good local sepsis control
3. The part of the fistula tract that is outside the sphincter

should be opened and drained
4. If <30% of the sphincter muscle length is enveloped by the
fistula tract, it can be safely cut without fear of major
incontinence.
5. If >30% of the sphincter muscle length would be cut, then it
would be safer to use a seton.
6. Biopsies should be performed from the tract to rule out
malignancy.
Management : Fistula in Ano
● Fistulotomy
● Fistulectomy
● Setons- Loose & Tight Setons
● Fibrin glue
● Fibrin plug
● Advancement Flaps
NEWER MODALITIES OF TREATMENT
● Ligation of Intersphinteric Fistula tract ( LIFT )
● VAAFT: Video Assisted Anal Fistula Treatment.
● STEM CELL THERAPY -expanded adipose derived stem cells

● FISTULA LASER CLOSURE-( FiLaC ) radial emitting laser probe
● FISTULA CLIPS
Fistulotomy
Laid open the track
Indication : Intersphincteric & Low Transsphincteric

Fistula.
Marsupialization after fistulotomy is associated with a

significantly shorter healing time and a shorter duration of
wound discharge.
FISTULECTOMY: Excision of
whole Fistulous tract:
This technique involves coring out of the fistula, usually by
diathermy cautery;
allows better definition of fistula anatomy than fistulotomy,

especially the level at which the track crosses the sphincters
and the presence of secondary extensions.
Seton Management
A seton can be used in three main ways in the treatment of an anal fistula,.
The seton can be inserted and tied loosely over the sphincter to drain the track
and allow sepsis to settle before it is removed (loose seton).
The seton can be used to divide the sphincter muscle slowly to eradicate the
fistula (cutting seton)
seton can be used as a long-term drain to provide palliation of symptoms from the
fistula, where other techniques are deemed unsuitable.
Setons:Bristle material
Thread
Wire
Prolene
Infant feeding tube

Ideal seton
● Non-absorbable
● Non-Degradable
● Comfortable
-absorbable
Uses of Loose Setons
● A loose seton can be used to treat ‘high’ and complex
anal fistulas with low risk to diminishing anal control
● .Crohn’s Diseases & Problematic fistulae- To prevent
the incontinence.
● Prior steps of other techniques like
Fistulectomy, Advanced f lap & Cutting Seton
● Staged fistulotomy
● strategy to preserve the external sphincter in trans-
sphincteric fistula
Tight seton
A tight seton can be used to treat selected ‘high’ and
complex anal fistulas where other techniques are either
not suitable or have failed.
The patient should be counselled carefully as to the risk of

permanent incontinence.
Placed with intention to cut the enclosed muscles.

Fistulous tract is replaced by a thin line of fibrosis.
Anorectal Advancement Flaps
Advancement flap surgery is a well-established technique
with reliable outcomes in experienced hands.
The technique should be considered in patients in whom

fistulotomy would result in a compromise to continence.
An advancement flap may also be used to close an anorectal

or recto-urethral fistula.
Transanal advancement flap
Division of the external sphincter is avoided with less risk of
impairment of continence,
and defects of the contour of the anal canal, such as a

keyhole deformity, are avoided and healing is quicker than
after fistulotomy.
The success rate of transanal advancement flap is of the

order of 60%.
Studies found little impairment of continence following
advancement flap surgery.
. Meta-analysis suggests a greater likelihood of continence

impairment with full-thickness flaps (20%)than mucosal or
partial thickness flaps
Fibrin Glue
is a mixture of fibrinogen, thrombin and calcium ions.
act via two mechanisms.
The fibrinogen, thrombin and calcium ions react with factor

XIII to form a clot.
The proteins within the glue promote the proliferation of

fibroblasts and pleuripotent endothelial cells which then
replace the glue with fibrous tissue.
Available in 2 forms
an autologous preparation made from pooled human blood.
Commercial preparation.
procedure
1. Identify the external and internal openings of the tract
2. Currette the tract
3. The double barrelled syringe containing the two components of
the glue is inserted from external opening to the internal opening
4. Tract filled completely from internal to external opening until a
blob is seen outside
5. It is allowed to set for 30-60 seconds

Fistula plugs
Biological plugs are designed from lyophilized porcine small
intestinal submucosa
It acts as a strong scaffold for growth of fibroblasts and

promotes the ingrowth of native tissues.
1. The plug must be rehydrated first, usually in a 0.9% normal saline solution for 3
to 5 minutes, before insertion
2. It is inserted in the internal opening and then pulled through the tract and then
sutured securely in the internal opening
3. The external opening must be partially open at the end of the procedure that
allows drainage and prevents a closed-space infection
4. Most common cause for failure with plug is due to dislodgement of the plug.
Ligation of Intersphincteric tract (LIFT)
. In this procedure, the intersphincteric space is opened via a
small incision made in the intersphincteric groove and the
fistula tract is identified as it crosses from the internal to the
external sphincter.
It is clearly defined and ligated with a suture.
The technique disconnects the internal and external

openings, thus allowing for fibrosis of the tract without any
damage to the anal sphincter
The LIFT procedure is an option for treatment of
transsphincteric fistula.
LIFT is associated with less functional compromise than

some traditional treatments of transsphincteric fistulas,
although recurrence/persistence rates are probably similar.
Modifications to the LIFT procedure have been described.
The Bio-LIFT procedure involves placing a biograft (usually a

piece of collagen mesh) in the intersphincteric space
following ligation of the intersphincteric fistula track.
VAAFT: Video Assisted Anal Fistula Treatment.
VAAFT consistsof a diagnostic phase, followed by an

operative phase.
Diagnostic phase involves localizing the internal opening by

passing the fistuloscope through the tract via the external
opening.
Diagnostic phase
a fistuloscope and obturator are used to identify the internal

opening as well as any secondary tracks and/or abscesses.
The scope is inserted through the external opening and a
glycine-mannitol solution infused to enable opening of
the primary track and advancement under direct vision.

The therapeutic phase
Involves destruction and cleaning of the track using cautery

and irrigation.
principle - closure of the internal opening using circular/linear

stapler, OTSC or advancement/mucosal Flap.
Cyanoacrylate may be used to reinforce the closure
Track must be left open to allow secretions to drain.

Laser therapy.
Laser therapy was described as a treatment option for anal

fistula recently with a radial emitting laser probe , the
principle being to destroy epithelial cells lining the fistula
track.
At present, laser ablation of a fistula track is in its infancy,

with evidence supporting its use confined to a few case
series.
Stem cell therapy
. Autologous adipose-derived stem cells may represent a
novel treatment option for complex fistulas, although as yet
there is insufficient evidence to attest to its efficacy.
As a technique it may be used in isolation or in combination

with fibrin glue or advancement flaps. It has been used in
patients with Crohn’s disease.
Fistula clips
. The principle of this technique is to debride the primary track
and close the internal opening with a tightly applied metal
clip.
The most extensively investigated apparatus is the OTSC

proctology clip which employs a nitinol clip.
Migration and pain, requiring removal of the clip at the
request of patient, are significant risks that have been
reported in the few studies which have been reported.
similar to laser ablation, clipping the internal opening of a

fistula is at an early stage of evolution.
Anal fistula continues to perplex surgeons, and in the last
10 years, a number of new treatments have
been developed. Although many of these treatments
show promise, it is too early to state whether they are
superior to well-tried surgical treatments for anal fistula,
which should continue to be the ‘gold-standard’ against
which newer treatments are compared.

● Persistent anal gland infection is the commonest cause of
Fistula in Ano
● Goodsall’s rule is very useful in determining the site of
external & internal opening as well as about the fistulous
tract.
● Intersphincteric type of fistula in Ano is the commonest
type (45%)
● MRI is the gold standard for fistula imaging in complicated
fistula
● Fistulotomy and Fistulectomy are common procedure to
treat it.
● VAAFT is the recent advance in Fistula surgery
References;
● Sabiston Textbook of Surgery: The Biological Basis of Modern Surgical
Practice. Saunders.
● Bailey and Love's Short Practice of Surgery; 27th edition.
● Schwartz's Principles of Surgery, McGraw-Hill Education/Medical.
● Fischer JE, Daniel B, Jones MD , Fischer's Mastery of Surgery 1, 2.

journals
● Fistula in Ano - Recent Advances in Management.,J Gen Practice
ISSN:2329-9126 JGPR, an open access journal Volume 4 • Issue 1 •
1000218
● The treatment of anal fistula: second ACPGBI Position Statement – 2018
Colorectal Disease ª 2018 The Association of Coloproctology of Great Britain
and Ireland. 20 (Suppl. 3), 5–31
● Modern management of anal fistula. World J Gastroenterol 2015 January 7;
21(1): 12-20 ISSN 1007-9327 (print) ISSN 2219-2840 (online)
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Management of fistula in ano -Recent

The external sphincter is composed of striated voluntary

muscle supplied by the pudendal nerve

The superior part of the external sphincter fuses with the

puborectalis muscle, which is essential for maintaining the

anorectal angle, necessary for continence

The internal sphincter is composed of circular, non-striated

involuntary muscle supplied by autonomic nerves

space , and between 0 and 10 in number.

They drain via ducts into the anal sinuses

at the level of the dentate line

acute, presenting as perianal, ischiorectal or even pelvic

chronic, presenting as a cryptoglandular (non-specific) anal

A fistula-in-ano, or anal fistula, is a chronic

● Trans sphincteric Fistula

● Supra Sphincteric Fistula

● Extra Sphincteric Fistula

High Type-Internal opening above the anorectal ring.

Importance – Low type fistula- fistulotomy without

High type fistula – Staged operation

It states that if the perianal skin opening is posterior to the

A perianal skin opening anterior to the transverse anal line is

with anterior external openings or when Crohn disease or carcinoma is present.

Patients with recurrent fistula may benefit from anal

Fistulography has been superseded by other imaging

modalities in the assessment of cryptogenic anorectal

Thin-slice spiral CT may be helpful when MRI is either not

MRI should be considered in any primary fistula deemed after

It should also be considered in patients with a recurrent anal

1. Obliteration of the internal opening is key to the success of

2. There should be good local sepsis control

3. The part of the fistula tract that is outside the sphincter

5. If >30% of the sphincter muscle length would be cut, then it

would be safer to use a seton.

6. Biopsies should be performed from the tract to rule out

● VAAFT: Video Assisted Anal Fistula Treatment.

● STEM CELL THERAPY -expanded adipose derived stem cells

Indication : Intersphincteric & Low Transsphincteric

Marsupialization after fistulotomy is associated with a

allows better definition of fistula anatomy than fistulotomy,

Infant feeding tube

The patient should be counselled carefully as to the risk of

Placed with intention to cut the enclosed muscles.

The technique should be considered in patients in whom

An advancement flap may also be used to close an anorectal

and defects of the contour of the anal canal, such as a

The success rate of transanal advancement flap is of the

. Meta-analysis suggests a greater likelihood of continence

act via two mechanisms.

The fibrinogen, thrombin and calcium ions react with factor

The proteins within the glue promote the proliferation of

an autologous preparation made from pooled human blood.

2. Currette the tract

3. The double barrelled syringe containing the two components of

the glue is inserted from external opening to the internal opening

4. Tract filled completely from internal to external opening until a

blob is seen outside

5. It is allowed to set for 30-60 seconds

It acts as a strong scaffold for growth of fibroblasts and