Abstract
Background and aim
Anal fistulae (AF) are considered a challenge for colorectal surgeons, as they recur if not properly operated. Being a septic disease, they are correlated with immunodeficiency and surgery may be followed by anal incontinence (AI). The aim of this paper is to suggest a state-of-the-art treatment of AF.
Methods
Pathogenesis, classification, diagnostic tools, intraoperative assessment, and surgeries proposed for AF have been reviewed, together with the results following conventional surgery and innovations aimed at sphincters’ preservation.
Results
Stress causes immunodepression and favors anal sepsis, and heavy smoking facilitates AF recurrences. Evacuation fistulography, MRI, and transanal ultrasound may help the diagnosis. Fistulotomy allows high cure rate, up to 96.4%, but may cause up to 64% of AI in transsphincteric AF. Fistulectomy with rectal advancement flap is effective in 80% of these cases and avoids AI. Other options are either suturing of AF internal orifice or positioning a cutting seton. Ligation of intersphincteric fistula track (LIFT) is a costless alternative carrying a success of 57–99% with 0–23% AI. Costly innovations, i.e., autologous stem cells, porcine derma sheet (Permacol), video-assisted fistula excision (VAAFT), porcine matrix (PLUG), and laser closure (FiLaC), minimize AI, but may carry AF recurrence. Their grades of recommendation range between 2B and 2C in the Guidelines of the Italian Society of Colorectal Surgery.
Conclusion
Postoperative incontinence in transsphincteric AF may be minimized by both costless and costly sphincter-saving procedures, the latter carrying higher recurrence rate. The success of surgery may be increased by a different lifestyle.
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References
Pescatori M (2014) Chapter 1, page 2. The art of surgical proctology. Pertinax Publishing
Parks AG (1963) Etiology and surgical treatment of fistula-in-ano. Dis Colon Rectum 6:17–22
Schouten W R (2008) Abscess, fistula in coloproctology, European Manual of Medicine, Herold A, Lehur P-A, Matzel KE, O’Connell PR. eds Springer
Cioli VM, Gagliardi G, Pescatori M (2015) Psychological stress in patients with anal fistulae. Int J Colorect Dis 30:1123–1129
Zimmerman DE, Mitalas L, Schouten WR (2013) Reoperation in recurrent complex anal fistula. In: Reconstructive Surgery of the Rectum, Anus and Perineum. AP Zbar, RD Madoff, SD Wexner eds. Springer
Parks AG, Gordon PH, Hardcastle JD (1976) A classification of fistula in ano. Br J Surg 63:1–2
Marks C (1996) Classification, in Anal Fistula. Surgical evaluation and management. RKS Phillips and PJ Lunniss eds, Chapman and Hall
Nicholls RJ (1996) Clinical assessment. Anal fistulae. Surgical evaluation and management. RKS Phillips and PJ Lunnis eds, Chapman and Hall
Scalej M, Bongers H, Aicher H et al (1992) Value of MR-tomography in perianal Crohn’s diseases - a prospective study. Gastroenterology 102:A691
Lunnis PJ, Sultan AH (1996) Magnetic resonance and anal endosonography. Anal fistulae. Surgical evaluation and management. RKS Phillips and PJ Lunnis eds, Chapman and Hall
Ramanujan PS, Prasad ML, Abcarian H, Tan A (1984) Perianal abscess and fistula: a study of 1023 patients. Dis Colon Rectum 27:593–597
Hanley PH (1965) Conservative surgical correction of horseshoe abscess fistula. Dis Colon Rectum 8:364–365
Kuijpers JHC (1982) Diagnosis and treatment of fistula-in-ano. Neth J Surg 34:147–152
Mc Elwain JW, Mac Lean D, Alexander MR et al (1975) Anorectal problems. Experience with primary fistulotomy for anorectal abscess. Report on 1000 cases. Dis Colon Rectum 18:646–649
Blumetti J, Quinteros F, Abcarian H et al (2010) The evolution of treatment of fistula-in-ano. Dis Colon Rectum 53:570
van Tets WF, Kuijpers HC (1994) Continence disorders after anal fistulotomy. Dis Colon Rectum 37:1194–1197
Garcia-Aguilar J, Belmonte C, Wong WD, Goldberg SM, Madoff RD (1996) Anal fistula surgery. Factors associated with recurrence and incontinence. Dis Colon Rectum 39:723–729
Mylonakis E, Katsios C, Godevenos D, Nousias B, Kappas AM (2001) Quality of life of patients after surgical treatment of anal fistula; the role of anal manometry. Colorectal Dis 3:417–421
Cavanaugh M, Hyman N, Osler T (2002) Fecal incontinence severity index after fistulotomy: a predictor of quality of life. Dis Colon Rectum 45:349–353
Westerterp M, Volkers NA, Poolman RW, van Tets WF (2003) Anal fistulotomy between Skylla and Charybdis. Colorectal Dis 5:549–551
Atkin GK, Martins J, Tozer P, Ranchod P, Phillips RK (2011) For many high anal fistulas, lay open is still a good option. Tech Coloproctol 15:143–150
Eleouet M, Spiroudhis L, Guillon N et al (2010) Chronic posterior tibial nerve transcutaneous electrical nerve stuulation (TENS) to treat fecal incontinence. Int Colorectal Dis 25:1127–1132
Altomare DF, La Torre F, Rinaldi M et al (2008) Carbon-coated microbeads anal injection in outpatient treatment of minor fecal incontinence. Dis Colon Rectum 51:423–435
Bernardi C, Pescatori M (2001) Reconstructive perineoplasty in the management of no healing wound after anorectal surgery. Tech Coloproctol 5:27–32
Chaudary BN, Chadwick M, Roe AM (2010) Selecting patients with fecal incontinence for anal sphincter surgery: the influence of irritable bowel syndrome. Colorectal Dis 12:750–753
Nordenstam JF, Altman DH, Mellgren AF, Rothenberger DA, Zetterström JP (2010) Impaired rectal sensation at anal manometry is associated with anal incontinence one year after primary sphincter repair in primiparous women. Dis Colon Rectum 53:1409–1414
Devesa JM, Hervàs PL, Vicente R et al (2011) Anal encirclement with a simple prosthetic ring for faecal incontinence. Tech Coloproctol 15:17–22
Jordan J, Roig JV, Armengol G et al (2010) Risk factor for recurrence and incontinence after anal fistula surgery. Colorect Dis 12:224–260
Ratto C, Litta F, Donisi L, Parello A (2015) Fistulotomy or fistulectomy and primary sphincteroplasty for anal fistula (FIPS): a systematic review. Tech Coloproctol 19:391–400
Shafik AA, El Sibai O, Shafik IA (2014) Combined partial fistulectomy and electro-cauterization of the intersphincteric tract as a sphincter-sparing treatment of complex anal fistula: clinical and functional outcome. Tech Coloproctol 18:1105–1111
Lunniss PJ, Thomson JPS (1996) In Anal fistula. Surgical evaluation and management. Phillips RK and Lunnis PJ eds, Chapman and Hall
Misra MC, Kapur BML (1988) A new non-operative approach to fistula in ano. Br J Surg:751093–751094
Pino D, Nelson RL, Pearl RK et al (1996) Island flap anoplasty for treatment of trans-sphincteric fistula-in-ano. Dis Colon Rectum 39:224–226
Lewis P, Bartolo DCC (1990) Treatment of trans-sphincteric fistulae by full-thickness anorectal advancement flaps. Br J Surg 81:1382–1385
Lunnis PJ, Phillips RKS (1996) The intersphincteric approach. In: Anal Fistula. Surgical evaluation and management, pages 115-121. Chapman and Hall
Rojanasakul A (2009) LIFT procedure: a simplified technique for fistula-in-ano. Tech Coloproctol 13:237–240
Rojakanasul A, Pattanarun J, Sahakitrungruang C, Tantiphlachiva K (2007) Total anal sphincter saving technique for fistula-in-ano: the ligation of intersphincteric fistula tract. J Med Assoc Thai 90:581–586
Bleier JI, Moloo H, Goldberg SM (2010) Ligation of the intersphincteric fistula tract, an effective new technique for complex fistulae. Dis Colon Rectum 53:43–46
Garcia-Olmo D, Herreros D, Pasqual I et al (2009) Expanded adipose-derived stem cells for the treatment of complex perianal fistula: a phase 2 clinical trial. Dis Colon Rectum 52:79–86
Shanwani A, Nor AM, Amri N (2010) Ligation of the intersphincteric fistula tract (LIFT): a sphincter-saving technique for fistula-in-ano. Dis Colon Rectum 53:39–42
Aboulian A, Kaji AH, Kumar RR (2011) Early result of ligation of the intersphincteric fistula tract for fistula-in-ano. Dis Colon Rectum 54:289–292
Cirocchi R, Trastulli S, Morelli U, Desiderio J, Boselli C, Parisi A, Noya G (2013) The treatment of anal fistulas with biologic derived products: is innovation better than conventional surgical treatment? Tech Coloproctol 17:259–273
Zmora O, Neufeld D, Ziv Y, Tulchinsky H, Scott D, Khaikin M, Stepansky A, Rabau M, Koller M (2005) Prospective multicenter evaluation of highly concentrated fibrin glue in the treatment of complex cryptogenic perianal fistulas. Dis Colon Rectum 48:2167–2172
Champagne BJ, O’Connor LM, Ferguson M et al (2006) Efficacy of anal fistula plug in closure of cryptoglandular fistulae long-term follow-up. Dis Colon Rectum 49:1817–1821
Johnson EK, Gaw JU, Armstrong DN (2006) Efficacy of anal fistula plug vs.fibrin glue in closure of anorectal fistulae. Dis Colon Rectum 49:371–376
Lawes DA, Efron JE, Abbas M et al (2008) Early experience with the bioabsorbable anal fistula plug. World J Surg 32:1157–1159
Chung W, Kazemi P, Ko D, Sun C, Brown CJ, Raval M, Phang T (2009) Anal fistula plug and fibrin glue vs. conventional treatment in repair of complex anal fistulae. Am J Surg 197:604–608
Christoforidis D, Pieh MC, Madoff RD et al (2000) Treatment of trans-sphincteric anal fistulae by endorectal advanced flap or collagen fistula plug: a comparative study. Dis Colon Rectum 52:18–22
Schiano di Visconte M, Braini A, Moras L, Brusciano L, Docimo L, Bellio G (2019) Permacol collagen paste injection for treatment of complex cryptoglandular anal fistulas. An observational cohort study with 2 years of follow-up. Surg Innov 26:168–179
Meinero PC, Mori L (2011) Videoassisted anal fistula treatment (VAAFT): a novel sphincter-saving produre for treating complex anal fistulae. Tech Coloproctol 15:417–422
Meinero PC, Mori L, Gasloli G (2014) VAAFT, a new concept for the treatment of anal fistula. Dis Colon Rectum 57:2003–2009
Giamundo P, Esercizio L, Geraci M, Tibaldi L, Valente M (2015) Fistula tract laser closure: long-term results and new operative strategies. Tech Coloproctol 19:449–453
Wilhelm A, Fiebig A, Krawczac M (2017) Five years of experience with the FiLaC laser for fistula-in-ano management: long term follow-up from a single Institution. Tech Coloproctol 21:269–276
Amato A, Bottini C, De Nardi P et al (2020) Evaluation and management of perianal abscess and anal fistula: SICCR position statement. Tech Coloproctol 24:127–143
Miliacca C, Gagliardi G, Pescatori M (2010) The ‘draw-the-family test’ in the preoperative assessment of patients with anorectal diseases and psychological distress: a prospective controlled study. Colorectal Dis 12:792–798
Zimmerman DD, Delemarre JB, Gosselink MP, Hop WC, Briel JW, Schouten WR (2003) Smoking affects the outcome of transanal mucosal advancement flap repair of trans-sphincteric fistulas. Br J Surg 90:351–354
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Pescatori, M. Surgery for anal fistulae: state of the art. Int J Colorectal Dis 36, 2071–2079 (2021). https://doi.org/10.1007/s00384-021-03917-7
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DOI: https://doi.org/10.1007/s00384-021-03917-7