Treatment Approaches for the Effective Management of Anal Fistula in the Modern Era
DOI:
https://doi.org/10.37285/ijpsn.2023.16.6.6Abstract
A complication of incision drainage or abscess ulceration around the anus and rectum is anal fistula which manifests as the creation of irregular channels linking the rectum and anal canal with the skin circumambient to the anus. It mostly affects the male population having a yearly frequency of two cases per ten thousand individuals. Histologically in anal fistula chronic inflammatory cells and fibrous tissues are surrounded by epithelialization of variable degree, which are categorized as squamous, columnar, or transitional zone epithelium. Anal fistula influences the psychological condition of the patients, which leads to depression or anxiety symptoms, in addition to severely impacting their standards of living. In general, anal fistula cannot be treated without medical intervention and the most efficient treatment for anal fistula is surgery. The optimal treatment in the modern era includes the elimination of the infected lesion, adequate drainage, and fistula closure while minimizing injury to the anal sphincter which includes treatment with fibrin glue, fistula plug, LIFT, etc.
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Keywords:
Anal fistula, Treatment, sphincter-sparing, sphincter sparing, Ligation of Inter sphincteric, Fistula TractPublished
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References
Eisenhammer S. The internal anal sphincter and the anorectal abscess. Surgery, gynecology & obstetrics. 1956 Oct;103(4):501-6.
Parks AG, Gordon PH, Hardcastle JD. A classification of fistula-in-ano. The British journal of surgery, 1976 Jan;63(1):1-12. doi: 10.1002/bjs.1800630102.
Sneider EB, Maykel JA. Anal abscess and fistula. Gastroenterology clinics of North America. 2013 Dec;42(4):773-84. doi: 10.1016/j.gtc.2013.08.003
Zanotti C, Martinez-Puente C, Pascual I, Pascual M, Herreros D, García-Olmo D. An assessment of the incidence of fistula-in-ano in four countries of the European Union. International journal of colorectal disease. 2007 Dec;22(12):1459-62. doi: 10.1007/s00384-007- 0334-7
Sainio P. Fistula-in-ano in a defined population. Incidence and epidemiological aspects. Annales chirurgiae et gynaecologiae. 1984;73(4):219-24.
Hämäläinen KP, Sainio AP. Incidence of fistulas after drainage of acute anorectal abscesses. Diseases of the colon and rectum. 1998 Nov;41(11):1357-61; discussion 1361-2. doi: 10.1007/BF02237048.
Parks AG, Gordon PH, Hardcastle JD. A classification of fistula-in-ano. The British journal of surgery. 1976 Jan;63(1):1-12. doi: 10.1002/bjs.1800630102.
Fazio VW. Complex anal fistulae. Gastroenterology clinics of North America. 1987 Mar;16(1):93-114.
Lunniss PJ, Sheffield JP, Talbot IC, Thomson JP, Phillips RK. Persistence of idiopathic anal fistula may be related to epithelialization. The British journal of surgery. 1995 Jan;82(1):32-3. doi: 10.1002/bjs.1800820112.
van Koperen PJ, ten Kate FJ, Bemelman WA, Slors JF. Histological identification of epithelium in perianal fistulae: a prospective study. Colorectal disease: the official journal of the Association of Coloproctology of Great Britain and Ireland. 2010 Sep;12(9):891-5. doi: 10.1111/j.1463-1318.2009.01880. x.
Mitalas LE, van Onkelen RS, Monkhorst K, Zimmerman DD, Gosselink MP, Schouten WR. Identification of epithelialization in high transsphincteric fistulas. Techniques in coloproctology. 2012 Apr;16(2):113-7. doi: 10.1007/s10151-011-0803-4.
Jimenez M, Mandava N. Anorectal Fistula. In: StatPearls. Treasure Island (FL): StatPearls Publishing; 2023 Feb. PMID: 32809492.
Sileri P, Cadeddu F, D'Ugo S, Franceschilli L, Del Vecchio Blanco G, De Luca E, Calabrese E, Capperucci SM, Fiaschetti V, Milito G, Gaspari AL. Surgery for fistula-in-ano in a specialist colorectal unit: a critical appraisal. BMC gastroenterology. 2011 Nov 9; 11:120. doi: 10.1186/1471-230X-11-120.
Vasilevsky CA, Gordon PH. The incidence of recurrent abscesses or fistula-in-ano following anorectal suppuration. Diseases of the colon and rectum. 1984 Feb;27(2):126-30. doi: 10.1007/BF02553995.
Hall JF, Bordeianou L, Hyman N, Read T, Bartus C, Schoetz D, Marcello PW. Outcomes after operations for anal fistula: results of a prospective, multicenter, regional study. Diseases of the colon and rectum. 2014 Nov;57(11):1304-8. doi: 10.1097/DCR.0000000000000216.
Atkin GK, Martins J, Tozer P, Ranchod P, Phillips RK. For many high anal fistulas, lay open is still a good option. Techniques in coloproctology. 2011 Jun;15(2):143-50. doi: 10.1007/s10151-011-0676-6.
Tozer P, Sala S, Cianci V, Kalmar K, Atkin GK, Rahbour G, Ranchod P, Hart A, Phillips RK. Fistulotomy in the tertiary setting can achieve high rates of fistula cure with an acceptable risk of deterioration in continence. Journal of gastrointestinal surgery : official journal of the Society for Surgery of the Alimentary Tract. 2013 Nov;17(11):1960-5. doi: 10.1007/s11605-013- 2198-1
Nottingham JM, Rentea RM. Anal Fistulotomy. 2023 Aug 8. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan–. PMID: 32310458.
Arroyo A, Pérez-Legaz J, Moya P, Armañanzas L, Lacueva J, Pérez-Vicente F, Candela F, Calpena R. Fistulotomy and sphincter reconstruction in the treatment of complex fistula-in-ano: long-term clinical and manometric results. Annals of surgery. 2012 May;255(5):935-9. doi: 10.1097/SLA.0b013e31824e9112.
Singer M, Cintron J. New techniques in the treatment of common perianal diseases: stapled hemorrhoidopexy, botulinum toxin, and fibrin sealant. The Surgical clinics of North America. 2006 Aug;86(4):937-67. doi: 10.1016/j.suc.2006.06.009.
Loungnarath R, Dietz DW, Mutch MG, Birnbaum EH, Kodner IJ, Fleshman JW. Fibrin glue treatment of complex anal fistulas has low success rate. Diseases of the colon and rectum. 2004 Apr;47(4):432-6. doi: 10.1007/s10350-003-0076-8.
Singer M, Cintron J, Nelson R, Orsay C, Bastawrous A, Pearl R, Sone J, Abcarian H. Treatment of fistulas-in-ano with fibrin sealant in combination with intra-adhesive antibiotics and/or surgical closure of the internal fistula opening. Diseases of the colon and rectum. 2005 Apr;48(4):799-808. doi: 10.1007/s10350-004-0898-z.
Zmora O, Neufeld D, Ziv Y, Tulchinsky H, Scott D, Khaikin M, Stepansky A, Rabau M, Koller M. Prospective, multicenter evaluation of highly concentrated fibrin glue in the treatment of complex cryptogenic perianal fistulas. Diseases of the colon and rectum. 2005 Dec;48(12):2167-72. doi: 10.1007/s10350-005-0199-1.
Witte ME, Klaase JM, Gerritsen JJ, Kummer EW. Fibrin glue treatment for simple and complex anal fistulas Hepato-gastroenterology. 2007 Jun;54(76):1071-3.
Buchanan GN, Bartram CI, Phillips RK, Gould SW, Halligan S, Rockall TA, Sibbons P, Cohen RG. Efficacy of fibrin sealant in the management of complex anal fistula: a prospective trial. Diseases of the colon and rectum. 2003 Sep;46(9):1167-74. doi: 10.1007/s10350-004-6708-9.
Lawes DA, Efron JE, Abbas M, Heppell J, Young-Fadok TM. Early experience with the bioabsorbable anal fistula plug. World journal of surgery. 2008 Jun;32(6):1157-9. doi: 10.1007/s00268-008-9504-1.
Ratto C, Litta F, Parello A, Donisi L, Zaccone G, De Simone V. Gore Bio-A® Fistula Plug: a new sphincter-sparing procedure for complex anal fistula. Colorectal disease: the official journal of the Association of Coloproctology of Great Britain and Ireland. 2012 May;14(5):e264-9. doi: 10.1111/j.1463-1318.2012.02964. x.
Rojanasakul A, Pattanaarun J, Sahakitrungruang C, Tantiphlachiva K. Total anal sphincter saving technique for fistula-in-ano; the ligation of intersphincteric fistula tract. Journal of the Medical Association of Thailand = Chotmaihet thangphaet. 2007 Mar;90(3):581-6.
van Onkelen RS, Gosselink MP, Schouten WR. Ligation of the intersphincteric fistula tract in low transsphincteric fistulae: a new technique to avoid fistulotomy. Colorectal disease: the official journal of the Association of Coloproctology of Great Britain and Ireland. 2013 May;15(5):587-91. doi: 10.1111/codi.12030.
Wallin UG, Mellgren AF, Madoff RD, Goldberg SM. Does ligation of the intersphincteric fistula tract raise the bar in fistula surgery? Diseases of the colon and rectum. 2012 Nov;55(11):1173-8. doi: 10.1097/DCR.0b013e318266edf3.
Hong KD, Kang S, Kalaskar S, Wexner SD. Ligation of intersphincteric fistula tract (LIFT) to treat anal fistula: systematic review and meta-analysis. Techniques in coloproctology. 2014 Aug;18(8):685-91.
Liu WY, Aboulian A, Kaji AH, Kumar RR. Long-term results of ligation of intersphincteric fistula tract (LIFT) for fistula-in-ano. Diseases of the colon and rectum. 2013 Mar;56(3):343-7. doi: 10.1097/DCR.0b013e318278164c.
Schouten WR, Zimmerman DD, Briel JW. Transanal advancement flap repair of transsphincteric fistulas. Diseases of the colon and rectum. 1999 Nov;42(11):1419-22; discussion 1422-3. doi: 10.1007/BF02235039.
Ortíz H, Marzo J. Endorectal flap advancement repair and fistulectomy for high trans-sphincteric and suprasphincteric fistulas. The British journal of surgery. 2000 Dec;87(12):1680-3. doi: 10.1046/j.1365-2168.2000.01582.x.
Sonoda T, Hull T, Piedmonte MR, Fazio VW. Outcomes of primary repair of anorectal and rectovaginal fistulas using the endorectal advancement flap. Diseases of the colon and rectum. 2002 Dec;45(12):1622-8. doi: 10.1007/s10350-004-7249-y.
Yassin NA, Hammond TM, Lunniss PJ, Phillips RK. Ligation of the intersphincteric fistula tract in the management of anal fistula. A systematic review. Colorectal disease: the official journal of the Association of Coloproctology of Great Britain and Ireland. 2013 May;15(5):527-35. doi: 10.1111/codi.12224.
Alasari S, Kim NK. Overview of anal fistula and systematic review of ligation of the intersphincteric fistula tract (LIFT). Techniques in coloproctology. 2014 Jan;18(1):13-22. doi: 10.1007/s10151-013-1050-7.
Ellis CN. Outcomes with the use of bioprosthetic grafts to reinforce the ligation of the intersphincteric fistula tract (BioLIFT procedure) for the management of complex anal fistulas. Diseases of the colon and rectum. 2010 Oct;53(10):1361-4. doi: 10.1007/DCR.0b013e3181ec4470.
van Onkelen RS, Gosselink MP, Schouten WR. Is it possible to improve the outcome of transanal advancement flap repair for high transsphincteric fistulas by additional ligation of the intersphincteric fistula tract? Diseases of the colon and rectum. 2012 Feb;55(2):163-6. doi: 10.1097/DCR.0b013e31823c0f74.
Han JG, Yi BQ, Wang ZJ, Zheng Y, Cui JJ, Yu XQ, Zhao BC, Yang XQ. Ligation of the intersphincteric fistula tract plus a bioprosthetic anal fistula plug (LIFT-Plug): a new technique for fistula-in-ano. Colorectal disease: the official journal of the Association of Coloproctology of Great Britain and Ireland. 2013 May;15(5):582-6. doi: 10.1111/codi.12062.
Parkash S, Lakshmiratan V, Gajendran V. Fistula-in-ano: treatment by fistulectomy, primary closure and reconstitution. The Australian and New Zealand journal of surgery. 1985 Feb;55(1):23-7. doi: 10.1111/j.1445-2197. 1985.tb00849. x.
De Hous N, Van den Broeck T, de Gheldere C. Fistulectomy and primary sphincteroplasty (FIPS) to prevent keyhole deformity in simple anal fistula: a single-center retrospective cohort study. Acta chirurgica Belgica. 2021 Oct;121(5):308-313. doi: 10.1080/00015458.2020.1753151.
Seyfried S, Bussen D, Joos A, Galata C, Weiss C, Herold A. Fistulectomy with primary sphincter reconstruction. International journal of colorectal disease. 2018 Jul;33(7):911-918. doi: 10.1007/s00384-018-3042-6.
Litta F, Parello A, De Simone V, Grossi U, Orefice R, Ratto C. Fistulotomy and primary sphincteroplasty for anal fistula: long-term data on continence and patient satisfaction. Techniques in coloproctology. 2019 Oct;23(10):993-1001. doi: 10.1007/s10151-019-02093-9.
Johnson EK, Gaw JU, Armstrong DN. Efficacy of anal fistula plug vs. fibrin glue in closure of anorectal fistulas. Diseases of the colon and rectum. 2006 Mar;49(3):371-6. doi: 10.1007/s10350-005-0288-1.
Champagne BJ, O'Connor LM, Ferguson M, Orangio GR, Schertzer ME, Armstrong DN. Efficacy of anal fistula plug in closure of cryptoglandular fistulas: long-term follow-up. Diseases of the colon and rectum. 2006 Dec;49(12):1817-21. doi: 10.1007/s10350-006-0755-3.
Steele SR, Kumar R, Feingold DL, Rafferty JL, Buie WD; Standards Practice Task Force of the American Society of Colon and Rectal Surgeons. Practice parameters for the management of perianal abscess and fistula-in-ano. Diseases of the colon and rectum. 2011 Dec;54(12):1465-74. doi: 10.1097/DCR.0b013e31823122b3.
Lewis R, Lunniss PJ, Hammond TM. Novel biological strategies in the management of anal fistula. Colorectal disease: the official journal of the Association of Coloproctology of Great Britain and Ireland. 2012 Dec;14(12):1445-55. doi: 10.1111/j.1463-1318.2012.03192. x.
Ortiz H, Marzo J, Ciga MA, Oteiza F, Armendáriz P, de Miguel M. Randomized clinical trial of anal fistula plugs versus endorectal advancement flap for the treatment of high cryptoglandular fistula in ano. The British journal of surgery. 2009 Jun;96(6):608-12. doi: 10.1002/bjs.6613.
Ellis CN, Rostas JW, Greiner FG. Long-term outcomes with the use of bioprosthetic plugs for the management of complex anal fistulas. Diseases of the colon and rectum. 2010 May;53(5):798-802. doi: 10.1007/DCR.0b013e3181d43b7d.
Adamina M, Ross T, Guenin MO, Warschkow R, Rodger C, Cohen Z, Burnstein M. Anal fistula plug: a prospective evaluation of success, continence and quality of life in the treatment of complex fistulae. Colorectal disease: the official journal of the Association of Coloproctology of Great Britain and Ireland 2014 Jul;16(7):547-54. doi: 10.1111/codi.12594.
Ky AJ, Sylla P, Steinhagen R, Steinhagen E, Khaitov S, Ly EK. Collagen fistula plug for the treatment of anal fistulas. Diseases of the colon and rectum. 2008 Jun;51(6):838-43. doi: 10.1007/s10350-007-9191-2.
Soltani A, Kaiser AM. Endorectal advancement flap for cryptoglandular or Crohn's fistula-in-ano. Diseases of the colon and rectum. 2010 Apr;53(4):486-95. doi: 10.1007/DCR.0b013e3181ce8b01.
van Onkelen RS, Gosselink MP, Schouten WR. Is it possible to improve the outcome of transanal advancement flap repair for high transsphincteric fistulas by additional ligation of the intersphincteric fistula tract? Diseases of the colon and rectum. 2012 Feb;55(2):163-6. doi: 10.1097/DCR.0b013e31823c0f74.
Schouten WR, Zimmerman DD, Briel JW. Transanal advancement flap repair of transsphincteric fistulas. Diseases of the colon and rectum. 1999 Nov;42(11):1419-22; discussion 1422-3. doi: 10.1007/BF02235039.
Ortíz H, Marzo J. Endorectal flap advancement repair and fistulectomy for high trans-sphincteric and suprasphincteric fistulas. The British journal of surgery. 2000 Dec;87(12):1680-3. doi: 10.1046/j.1365-2168.2000.01582. x.
Sonoda T, Hull T, Piedmonte MR, Fazio VW. Outcomes of primary repair of anorectal and rectovaginal fistulas using the endorectal advancement flap. Diseases of the colon and rectum. 2002 Dec;45(12):1622-8. doi: 10.1007/s10350-004-7249-y.
Zimmerman DD, Delemarre JB, Gosselink MP, Hop WC, Briel JW, Schouten WR. Smoking affects the outcome of transanal mucosal advancement flap repair of trans-sphincteric fistulas. British journal of surgery. 2003 Mar;90(3):351-4. doi: 10.1002/bjs.4044.
van Koperen PJ, Wind J, Bemelman WA, Bakx R, Reitsma JB, Slors JF. Long-term functional outcome and risk factors for recurrence after surgical treatment for low and high perianal fistulas of cryptoglandular origin. Diseases of the colon and rectum. 2008 Oct;51(10):1475-81. doi: 10.1007/s10350-008-9354-9.
Mitalas LE, Gosselink MP, Zimmerman DD, Schouten WR. Repeat transanal advancement flap repair: impact on the overall healing rate of high transsphincteric fistulas and on fecal continence. Diseases of the colon and rectum. 2007 Oct;50(10):1508-11. doi: 10.1007/s10350-007- 9015-4.
van Koperen PJ, Wind J, Bemelman WA, Slors JF. Fibrin glue and transanal rectal advancement flap for high transsphincteric perianal fistulas; is there any advantage? International journal of colorectal disease. 2008 Jul;23(7):697-701. doi: 10.1007/s00384-008-0460-x.
Ellis CN, Clark S. Fibrin glue as an adjunct to flap repair of anal fistulas: a randomized, controlled study. . Diseases of the colon and rectum. 2006 Nov;49(11):1736-40. doi: 10.1007/s10350-006-0718-8
Makowiec F, Jehle EC, Becker HD, Starlinger M. Clinical course after transanal advancement flap repair of perianal fistula in patients with Crohn's disease. The British journal of surgery. 1995 May;82(5):603-6. doi: 10.1002/bjs.1800820509.
Mizrahi N, Wexner SD, Zmora O, Da Silva G, Efron J, Weiss EG, Vernava AM 3rd, Nogueras JJ. Endorectal advancement flap: are there predictors of failure? Diseases of the colon and rectum. 2002 Dec;45(12):1616-21. doi: 10.1097/01.DCR.0000037654. 01119.CD
