This document discusses classifications and treatments for anal fistulas. It describes that anal fistulas are tracts connecting the perianal skin to the anal canal or rectum, and are usually cryptoglandular or associated with conditions like tuberculosis or IBD. Fistulas are classified based on their level and complexity. Treatment goals are to control sepsis, eradicate the tract, and minimize incontinence and recurrence. Common treatments include fistulectomy, fistulotomy, setons, plugs, and advanced procedures like LIFT, VAAFT, and FiLaC, which aim to close the tract while preserving sphincter function. The document analyzes success and incontinence rates of different options.

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..