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Fistula-in-ano: When to Cut, Tie, Plug, or Sew

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Journal of Gastrointestinal Surgery Aims and scope

Abstract

Introduction

Management of fistula-in-ano requires understanding of both perianal and rectal anatomy, as well as the surgical approaches available to ensure the highest possible postoperative continence and wound healing. Further, high rates of recurrence with medical management commonly bring these patients under the care of the colorectal surgeon after variable periods of failed conservative management. Novel techniques provide surgeons with tools to treat increasingly complex fistulas with a focus on maintaining sphincteric functionality and limiting recurrence.

Method

This manuscript presents our practice, including perioperative decision making regarding surgical approach, in managing patients with fistula-in-ano.

Conclusion

Familiarity with these techniques prepares the general surgeon and colorectal surgeon to improve wound healing and functional outcomes in these patients, especially with complex disease involving the external and internal anal sphincters.

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References

  1. Saino, P. “Fistula-in-ano in a defined population: incidence and epidemiological aspects.” Ann. Chir. Gynaecol., 73 (1984), pp. 219–224.

    Google Scholar 

  2. Malik AI, Nelson RL, Tou S. Incision and drainage of perirectal abscess with or without treatment of anal fistula. Cochrane Database Syst Rev. 2010 Jul 7;(7):CD006827

  3. Welton, ML, Shelton AA, Chang GJ, Varma MG. Chapter 51: Colon, Rectum, and Anus. Surgery: Basic Science and Clinical Evidence. 2nd Ed. 2008. 1076–7.

  4. Parks AG, Gordon PH, Hardcastle JD. “A classification of fistula-in-ano” Br. J. Surg., 63 (1976), pp. 1–12.

    Article  PubMed  CAS  Google Scholar 

  5. Gonzalez-Ruiz C, Kaiser AM, Vukasin P, Beart RW Jr, Ortega AE “Intraoperative physical diagnosis in the management of anal fistula.” Am Surg. 2006 Jan;72(1):11–5.

    PubMed  Google Scholar 

  6. Rosa G, Lolli P, Piccinelli D, Mazzola F, Bonomo S. “Fistula in ano: anatomoclinical aspects, surgical therapy and results in 844 patients.” Tech Coloproctol. 2006 Oct;10(3):215–21. Epub 2006 Sep 20.

  7. Parks AG, Stitz RW. The treatment of high fistula-in-ano. Dis Colon Rectum. 1976;19:487–499.

    Article  PubMed  CAS  Google Scholar 

  8. Kodner IJ, Mazor A, Shemesh EI, Fry RD, Fleshman JW, Birnbaum EH. Endorectal advancement flap repair of rectovaginal and other complicated anorectal fistulas. Surgery. 1993;114:682–689; discussion 689–690.

    PubMed  CAS  Google Scholar 

  9. 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? Dis Colon Rectum. 2002;45:1616–1621.

    Article  PubMed  Google Scholar 

  10. West RL, Zimmerman DD, Dwarkasing S, Hussain SM, Hop WC, Schouten WR, Kuipers EJ, Felt-Bersma RJ. “Prospective comparison of hydrogen peroxide-enhanced three-dimensional endoanal ultrasonography and endoanal magnetic resonance imaging of perianal fistulas.” Dis Colon Rectum. 2003 Oct;46(10):1407–15.

    Article  PubMed  CAS  Google Scholar 

  11. Mullen R, Deveraj S, Suttie SA, Matthews AG, Yalamarthi S. “MR imaging of fistula in ano: indications and contribution to surgical assessment.” Acta Chir Belg. 2011 Nov-Dec;111(6):393–7.

    PubMed  CAS  Google Scholar 

  12. Halligan S, Buchanan G. “MR imaging of fistula-in-ano.” Eur J Radiol. 2003 Aug;47(2):98–107.

    Article  PubMed  Google Scholar 

  13. Hori M, Oto A, Orrin S, Suzuki K, Baron RL. “Diffusion-weighted MRI: a new tool for the diagnosis of fistula in ano.” J Magn Reson Imaging. 2009 Nov;30(5):1021–6.

    Article  PubMed  Google Scholar 

  14. Morris J, Spencer J, Ambrose S. MR Imaging Classification of Perianal Fistulas and Its Implications for Patient Management. Radiographics 2000;20:623–635

    PubMed  CAS  Google Scholar 

  15. Nunoo-Mensah JW et al. “Fistula-in-ano: do antibiotics make a difference?” Int J Colorectal Dis. 2006 Jul; 21(5) 441–3.

    Article  PubMed  Google Scholar 

  16. Keighley MRB, Williams NS. Surgery of the anus, rectum and colon. 1993; London: Saunders.

  17. Fucini, C, Giani, I. “Why do we have to review our experience in managing cases with idiopathic fistula-in-ano regularly?” World J Gastroenterol. 2011 July 28; 17(28): 3297–9.

    Article  PubMed  Google Scholar 

  18. Whiteford MH, Kilkenny J 3rd, Hyman N, Buie WD, Cohen J, Orsay C, Dunn G, Perry WB, Ellis CN, Rakinic J, Grego- rcyk S, Shellito P, Nelson R, Tjandra JJ, Newstead G. Prac- tice parameters for the treatment of perianal abscess and fistula-in-ano (revised). Dis Colon Rectum 2005; 48: 1337–1342

    Article  PubMed  Google Scholar 

  19. Garcia-Aguilar J et al. Anal Fistula Surgery: Factors Associated with recurrence and incontinence. Dis Colon Rectum 1996. 39(7) 723–9.

    Article  PubMed  CAS  Google Scholar 

  20. Rojanasakul A, Pattana-arun J, Sahakitrungruang C, Tantiphlachiva K (2007) “Total anal sphincter saving technique for fistula-in-ano: the ligation of intersphincteric fistula tract.” J med Asso Thai 90: 581–6.

    Google Scholar 

  21. Ooi K., Skinner I., et al. “Managing fistula-in-ano with ligation of the intersphincteric fistula tract procedure: the Western Hospital experience.” Colorectal Dis. 2012; 14(5): 599–603.

    Article  PubMed  CAS  Google Scholar 

  22. Hjortup A., Moesgaard F, Kjaergard J. “Fibrin adhesive in the treatment of perianal fistuals.” Dis Colon Rectum. 1991; 34:752–4.

    Article  Google Scholar 

  23. Singer M, Cintron J, Nelson R, et al. “Treatment of fistulas-in-ano with fibrin sealant in combination with intra-adhesive antibiotics and/or surgical closure of the internal fistula opening.” Dis Colon Rectum 2005; 48: 799–808.

    Article  PubMed  Google Scholar 

  24. Johnson EK, Gaw JU, Armstrong DN (2012) “Efficacy of Anal Fistual Plug vs. Fibrin Glue in closure of anorectal fistulas.” Dis Colon Rectum. 2006; 49:371–6.

    Article  PubMed  Google Scholar 

  25. Cameron JL, Sandone C (2012) Atlas of Gastrointestinal Surgery, 2nd ed., Vol. 2. BC Decker, Hamilton

    Google Scholar 

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Author information

Authors and Affiliations

  1. Department of Surgery, Johns Hopkins Medical Institutions, 600 North Wolfe Street, Blalock 618, Baltimore, MD, 21287, USA

    Robert Beaulieu & Susan Gearhart

  2. Department of Radiology, Johns Hopkins Medical Institutions, Baltimore, MD, USA

    David Bonekamp

  3. Department of Art as Applied to Medicine, Johns Hopkins Medical Institutions, Baltimore, MD, USA

    Corinne Sandone

Authors
  1. Robert Beaulieu
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  2. David Bonekamp
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  3. Corinne Sandone
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  4. Susan Gearhart
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Correspondence to Susan Gearhart.

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Beaulieu, R., Bonekamp, D., Sandone, C. et al. Fistula-in-ano: When to Cut, Tie, Plug, or Sew. J Gastrointest Surg 17, 1143–1152 (2013). https://doi.org/10.1007/s11605-012-2126-9

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  • DOI: https://doi.org/10.1007/s11605-012-2126-9

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