Management of Fistula in Ano

1. Dr Paritosh Kumar Singh.

2. Introduction:
 It is a tract lined by granulation tissue which connects
perianal skin superficially to anal canal; anorectum or
rectum deeply.
 Etiology:
1. Cryptoglandular(90%)
2. Non cryptoglandular: Tuberculosis, Carcinoma,
Crohn’s disease, Ulcerative colitis ,Lymphogranuloma
venereum, Hydradenitis suppurativa, Traumatic.

3. Classifications:
 Standard classification:
 Subcutaneous commonest •
 Low anal—common •
 Submucous •
 High anal •
 Pelvi-rectal.

4.  Parks classification:

5. Classifications:
 It can be.
 Low level fistulas—these open into the anal canal below
the internal ring.
 High level fistulas—these open into the anal canal at or
above the internal ring
 It can be:
 Simple fistula without extensions.
 Complex fistula with extensions.
 It can be:
 Single external opening.
 Multiple external openings which are often seen in
tuberculosis,ulcerative colitis, Crohn’s disease, LGV,
hidradenitis suppurativa, actinomycosis

6. Goodsall’s Rule:
 Fistulas with an external opening in relation to the anterior
half of the anus is of direct type.
 Fistulas with external openings in relation to posterior half
of the anus, has a curved track may be of horse-shoe type,
opens in the midline posteriorly and may present with
multiple external opening all connected to a single internal
opening.

7. Investigations:
 Fistulogram
 MRI/MRI fistulogram.
 Endoanal ultrasonography
 Colonoscopy when IBD is suspected.
 DRE.
 EUA.
 Routine blood investigations.

9. Treatment:
 Goal:
 Control of sepsis.
 Eradicate the tract.
 Minimizing the risk of fecal incontinence, and
recurrence

10. Fistulectomy:
 Usually recommended for low anal fistula, as the
success rate is high with this procedure, and with
minimal incontinence.
 Success rate 93% to 100%..
 Incontinence rate 11.5 to 20%.

11. Fistulotomy:
 After passing the probe through the entire fistulous
tract, incision is made over the probe to cut and lay
open the fistulous tract.
 It allows to granulate and heal from the floor/surface.
 Success rate 93%
 Risk of incontinence for intersphincteric and trans-
sphincteric fistulae is 37% & 54% respectively and
higher rate for suprasphincteric and extrasphincteric.

13. SETON:
 Used either for the purpose of cutting sphincter in a
phased manner or to mature the tract for another
definitive surgery.
 It is recommended to reduce postoperative fecal
incontinence after surgery.
 Recurrence rate in whom internal sphincter is
preserved is 5% and in those sphincter is not preserved
is 3%.
 Overall fecal incontinence rate in internal sphincter
preserving is 5.6% and in those of sphincter not
preserving is 25.2%.

15. Advanced Treatment options for
complex fistula
Ligation of tract Filling the tract Obliteration of
tract.
Glue
Plug
Advancement
flap
LIFT FiLaC
VAAFT

16. Anal fistula plug.
 Made up of synthetic polymer, that provide a scaffold
to promote tract healing using sphincter preserving
approach.
 It is positioned from inside the anus with sutures and
conforms to the tract. A mucosal flap can be raise and
used to cover internal opening.
 Success rate is 55% for both cryptoglandular and
Crohn's fistulae.
 Complications: Plug dislodgement, infection, or
failure with formation of a persistent tract.

17. Glue.
 Made up of fibrinogen, thrombin, and other clotting
factors.
 It is injected into a prepared anal fistula tract to seal it.
 Healing rate is 50-60%.
 Results are better in case of simple fistulae.
 Advantage: simple to use, sphincter sparing, should
not effect the later treatment options in the event of its
failure.
 Disadvantage is it high failure rate.
 Modification: adding stem cells.

18. Anorectal advancement flap:
• Done for high or complex anal fistulae.
• It involves debridement of the fistula tract, utilization
of a well-vascularized rectal mucosa or anodermal flap
to cover the internal opening of the tract with or
without closure of the tract.
• The success rate at one year to be 60%.
• Repeating the procedure multiple times can further
increase the success rate to as much as 90%

19. Ligation of Intersphincteric Fistula
Tract ( LIFT ).
 Principle: disconnection of the fistula tract from the
anal canal with eradication of the tract in the
intersphincteric space.
 Proc: Involves a radial incision at the intersphincteric
groove, with dissection continued cranially in the
intersphinteric plane to isolate the fistula tract as it
crosses from the internal to the external sphincter.
 The tract is ligated ( watertight ligation) with
absorbable sutures at the lateral border of the internal
anal sphincter and the external component is treated
by curettage or fistulotomy.

20.  Drawbacks: This surgery require large tissue dissection
so, in case of previous operated patient it will be
difficult to identify the tract.
 This surgery is best suited for patient with simple high
trans-sphincteric fistulae of cryptoglandular etiology.
 Success rate 40 – 95% ( Short term outcomes 71-76%).
 Modifications:
 placement of biological graft to reinforce the ligation
and closure of the fistula tract( success rate 92%).
 Use of anal plug to close the external tract in addition to
the LIFT procedure. ( success rate 95%, complete
healing time 4 weeks).
 Partial fistulotomy may also be done ( success rate 85%)

21. Video assisted anal fistula
treatment ( VAAFT).
 It uses 5mm fistuloscope with 8 degree angled eye
piece, Gylycine-mannitol is used to open the fistula
tract.
 Unipolar electrode is used to cauterize the lining of
the fistula tract and endobrush is used to extract the
necrotic materials.
 Closure of the internal opening by stapler, suture or
advancement flap.
 Primary healing rate of 74% at 3 months and 87% at
the end of 1 year.

22. Fistula Laser Closure ( FiLaC ):
 It uses radial emitting laser probe, drawn through a
prepared tract, which destroys the epithelial lining
with minimal thermal spread or extra-luminal tissue
damage.
 The internal opening is closed by advancement flap.
 Data suggest that 71% closure rate at median 20
months follow up with no deterioration in continence.

23. Discussion:
 Fistula plugs and glue have a high failure rate with fistula
healing occurring in only ½ of the patients but the risk of
sphincter damage is low.
 The LIFT procedure appears to be a attractive treatment
option for cryptoglandular trans-sphincteric fistulae with
around 3/4th of patients having successful healing but the
results may not be favorable in case of complex or recurrent
fistulae.
 Endoluminal obliteration of the fistula tract using Laser (
FiLaC) or diathermy is a novel approach in the treatment of
fistulae with encouraging results in Pilot data, further
studies are required before these interventions are adopted
into routine clinical practice.

24. Thank you..