ANORECTAL FISTULA

Assoc. Prof. Dr. Gülçin Ercan

Sultan 2. Abdulhamid Khan Educational and Research Hospital, İstanbul Provincial Directorate of Health, Department of General Surgery, İstanbul, Türkiye

ABSTRACT

Anorectal fistulas, also known as “fistula-in-ano,” are chronic conditions typically developing after an anal abscess has ruptured or drained. These fistulas form epithelialized tracts, creating an abnormal connection between the anal canal and the surrounding perianal or perirectal skin. Symptoms can range from mild discomfort to severe complications like pain, abscess formation, and systemic infections. Surgical treatment pri- marily focuses on removing the fistula tract, controlling infection, and preventing recurrence while preserving anal sphincter function.

Anorectal fistulas are relatively rare, with an incidence of about 1 to 10,000 people, commonly affecting males in their 40s. Risk factors include obesity, diabetes, smoking, and prior anorectal surgeries. Up to 25% of anorectal fistula cases in the Western world are associated with Crohn’s disease, underscoring the importance of identifying underlying causes.

Most anorectal fistulas are cryptoglandular in origin, resulting from infected anal crypt glands. However, they may also arise from Crohn’s disease, infections, obstetric injuries, or malignancies. Fistulas are classified de- pending on their anatomical relationship to the anal sphincter muscles using the Parks, Gordon, and Hardcastle classification system. This classification helps determine the complexity of the fistula and the surgical approach required.

Imaging techniques such as MRI, endoanal ultrasound, and fistulography play a crucial role in defining the fistula’s anatomy and extent. MRI is considered the gold standard for evaluating anorectal fistulas, but other imaging modalities may also be useful depending on availability and the complexity of the case.

Management strategies include fistulotomy, seton placement, fibrin glue application, and endorectal advancement flaps. The primary goals of treatment are to control infection, achieve definitive closure of the fistula, and maintain continence. Surgical approach is often tailored based on the complexity of the fistula, with sphincter-preserving techniques preferred for complex cases.

Keywords: Fistula; Anorectal diseases; Etiology; Classification; Physical examination; Disease management; General surgery

Referanslar

  1. Abcarian H. Anorectal infection: abscess-fistula. Clin Colon Rectal Surg. 2011 Mar;24(1):14-21. [Crossref]  [PubMed]  [PMC]
  2. Gosselink MP, van Onkelen RS, Schouten WR. The cryptoglandular theory revisited. Colorectal Dis. 2015 Dec;17(12):1041-3. [Crossref]  [PubMed]
  3. Williams JG, Farrands PA, Williams AB, Taylor BA, Lunniss PJ, Sagar PM, Varma JS, George BD. The treatment of anal fistula: ACPGBI position statement. Colorectal Dis. 2007 Oct;9 Suppl 4:18-50. [Crossref]  [PubMed]
  4. Gurer A, Ozlem N, Gokakin AK, Ozdogan M, Kulacoglu H, Aydin R. A novel material in seton treatment of fistula-in-ano. Am J Surg. 2007 Jun;193(6):794-6. [Crossref]  [PubMed]
  5. Zanotti C, Martinez-Puente C, Pascual I, Pascual M, Her- reros D, García-Olmo D. An assessment of the incidence of fistula-in-ano in four countries of the European Union. Int J Colorectal Dis. 2007 Dec;22(12):1459-62. Epub 2007 Jun 7. [Crossref]  [PubMed]
  6. Ramanujam PS, Prasad ML, Abcarian H, Tan AB. Perianal abscesses and fistulas. A study of 1023 patients. Dis Colon Rectum. 1984 Sep;27(9):593-7. [Crossref]  [PubMed]
  7. Wang D, Yang G, Qiu J, Song Y, Wang L, Gao J, Wang C. Risk factors for anal fistula: a case-control study. Tech Coloproctol. 2014 Jul;18(7):635-9. Epub 2014 Jan 23. [Crossref]  [PubMed]
  8. Zheng LH, Zhang AZ, Shi YY, Li X, Jia LS, Zhi CC, Yu QX, Zhang W, Liu YJ, Wang L, Xiao D, Wang C. Impact of Smoking on Anal Abscess and Anal Fistula Diseases. Chin Med J (Engl). 2018 May 5;131(9):1034-1037. [Crossref]  [PubMed]  [PMC]
  9. Hamadani A, Haigh PI, Liu IL, Abbas MA. Who is at risk for developing chronic anal fistula or recurrent anal sepsis after initial perianal abscess? Dis Colon Rectum. 2009 Feb;52(2):217-21. [Crossref]  [PubMed]
  10. Park SH, Aniwan S, Scott Harmsen W, Tremaine WJ, Lightner AL, Faubion WA, Loftus EV. Update on the Natural Course of Fistulizing Perianal Crohn's Disease in a Population-Based Cohort. Inflamm Bowel Dis. 2019 May 4;25(6):1054-1060. [Crossref]  [PubMed]  [PMC]
  11. Panés J, Rimola J. Perianal fistulizing Crohn's disease: pathogenesis, diagnosis and therapy. Nat Rev Gastroenterol Hepatol. 2017 Nov;14(11):652-664. Epub 2017 Aug 9. [Crossref]  [PubMed]
  12. Tozer PJ, Lung P, Lobo AJ, Sebastian S, Brown SR, Hart AL, Fearnhead N; of ENiGMA Collaboration. Review article: pathogenesis of Crohn's perianal fistula-understanding factors impacting on success and failure of treatment strategies. Aliment Pharmacol Ther. 2018 Aug;48(3):260-269. Epub 2018 Jun 19. [Crossref]  [PubMed]
  13. Gupta PJ. Ano-perianal tuberculosis--solving a clinical dilemma. Afr Health Sci. 2005 Dec;5(4):345-7. [PubMed]
  14. Coremans G, Margaritis V, Van Poppel HP, Christiaens MR, Gruwez J, Geboes K, Wyndaele J, Vanbeckevoort D, Janssens J. Actinomycosis, a rare and unsuspected cause of anal fistulous abscess: report of three cases and review of the literature. Dis Colon Rectum. 2005 Mar;48(3):575-81. [Crossref]  [PubMed]
  15. Kotsafti A, Scarpa M, Angriman I, Castagliuolo I, Caruso A. Fistula-Related Cancer in Crohn's Disease: A Systematic Review. Cancers (Basel). 2021 Mar 22;13(6):1445. [Crossref]  [PubMed]  [PMC]
  16. Moureau-Zabotto L, Vendrely V, Abramowitz L, Borg C, Francois E, Goere D, Huguet F, Peiffert D, Siproudhis L, Ducreux M, Bouché O. Anal cancer: French Intergroup Clinical Practice Guidelines for diagnosis, treatment and follow-up (SNFGE, FFCD, GERCOR, UNICANCER, SFCD, SFED, SFRO, SNFCP). Dig Liver [Crossref]  [PubMed]
  17. Kurer MA, Davey C, Khan S, Chintapatla S. Colorectal foreign bodies: a systematic review. Colorectal Dis. 2010 Sep;12(9):851-61. Epub 2009 Nov 5. [Crossref]  [PubMed]
  18. Parks AG, Gordon PH, Hardcastle JD. A classification of fistula-in-ano. Br J Surg. 1976 Jan;63(1):1-12. [Crossref]  [PubMed]
  19. Johnson EK, Bernier G. Cryptoglandular Abscess and Fistula. In: Steele SR, Hull TL, Hyman N, Maykel JA, Read TE, Whitlow CB eds. The ASCRS Textbook of Colon and Rectal Surgery. 4th ed. Cham, Switzerland: Springer, 2022. p. 249-264. [Crossref]  [PMC]
  20. 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. [Crossref]  [PubMed]
  21. Pomerri F, Dodi G, Pintacuda G, Amadio L, Muzzio PC. Anal endosonography and fistulography for fistula-in-ano. Radiol Med. 2010 Aug;115(5):771-83. English, Italian. Epub 2010 Feb 22. [Crossref]  [PubMed]
  22. Soker G, Gulek B, Yilmaz C, Kaya O, Arslan M, Dilek O, Gorur M, Kuscu F, İrkorucu O. The comparison of CT fistulography and MR imaging of perianal fistulae with surgical findings: a case-control study. Abdom Radiol (NY). 2016 Aug;41(8):1474-83. [Crossref]  [PubMed]
  23. Halligan S. Magnetic Resonance Imaging of Fistula-In-Ano. Magn Reson Imaging Clin N Am. 2020 Feb;28(1):141-151. [Crossref]  [PubMed]
  24. Konan A, Onur MR, Özmen MN. The contribution of pre-operative MRI to the surgical management of anal fistulas. Diagn Interv Radiol. 2018 Nov;24(6):321-327. [Crossref]  [PubMed]  [PMC]
  25. deSouza NM, Gilderdale DJ, Coutts GA, Puni R, Steiner RE. MRI of fistula-in-ano: a comparison of endoanal coil with external phased array coil techniques. J Comput Assist Tomogr. 1998 May-Jun;22(3):357-63. [Crossref]  [PubMed]
  26. Brillantino A, Iacobellis F, Reginelli A, Monaco L, Sodano B, Tufano G, Tufano A, Maglio M, De Palma M, Di Martino N, Renzi A, Grassi R. Preoperative assessment of simple and complex anorectal fistulas: Tridimensional endoanal ultrasound? Magnetic resonance? Both? Radiol Med. 2019 May;124(5):339-349. Epub 2019 Jan 3. [Crossref]  [PubMed]
  27. 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. [Crossref]  [PubMed]
  28. Kim Y, Park YJ. Three-dimensional endoanal ultrasonographic assessment of an anal fistula with and without H(2)O(2) enhancement. World J Gastroenterol. 2009 Oct 14;15(38):4810-5. [Crossref]  [PubMed]  [PMC]
  29. Davis BR, Kasten KR. Anorectal abscess and fistula. In: Steele SR, Hull TL, Read TE, Saclarides TJ, Senagore AJ, Whitlow CB, eds. The ASCRS textbook of colon and rectal surgery. 3rd ed. Cham: Springer International Publishing; 2016. [Crossref]
  30. Whiteford MH, Kilkenny J 3rd, Hyman N, Buie WD, Cohen J, Orsay C, Dunn G, Perry WB, Ellis CN, Rakinic J, Gregorcyk S, Shellito P, Nelson R, Tjandra JJ, Newstead G; Standards Practice Task Force; American Society of Colon and Rectal Surgeons. Practice parameters for the treatment of perianal abscess and fistula-in-ano (revised). Dis Colon Rectum. 2005 Jul;48(7):1337-42. [Crossref]  [PubMed]
  31. Garcia-Aguilar J, Belmonte C, Wong WD, Goldberg SM, Madoff RD. Anal fistula surgery. Factors associated with recurrence and incontinence. Dis Colon Rectum. 1996 Jul;39(7):723-9. [Crossref]  [PubMed]
  32. Pescatori M, Ayabaca SM, Cafaro D, Iannello A, Magrini S. Marsupialization of fistulotomy and fistulectomy wounds improves healing and decreases bleeding: a randomized controlled trial. Colorectal Dis. 2006 Jan;8(1):11-4. [Crossref]  [PubMed]
  33. Browder LK, Sweet S, Kaiser AM. Modified Hanley procedure for management of complex horseshoe fistulae. Tech Coloproctol. 2009 Dec;13(4):301-6. Epub 2009 Oct 8. [Crossref]  [PubMed]
  34. Martellucci J, Vuolo ML. The Seton in Anal Fistula Management. In: Rotto C, Parello A, Litta F, De Simone V, Campenni P eds. Anal Fistula and Abscess. 1st ed. Cham: Springer International Publishing; 2022. [Crossref]
  35. Izadpanah, A., Rezazadehkermani, M., Hosseiniasl, S. M., Farghadin, A., Ghahramani, L., Bananzadeh, A., Roshanravan, R., & Izadpanah, A. (2016). Pulling Seton: Combination of mechanisms. Advanced biomedical research, 5, 68. [Crossref]  [PubMed]  [PMC]
  36. 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. Dis Colon Rectum. 2005 Apr;48(4):799-808. [Crossref]  [PubMed]
  37. Cintron JR, Park JJ, Orsay CP, Pearl RK, Nelson RL, Sone JH, Song R, Abcarian H. Repair of fistulas-in-ano using fibrin adhesive: long-term follow-up. Dis Colon Rectum. 2000 Jul;43(7):944-9; discussion 949-50. [Crossref]  [PubMed]
  38. Vogel JD, Johnson EK, Morris AM, Paquette IM, Saclarides TJ, Feingold DL, Steele SR. Clinical Practice Guideline for the Management of Anorectal Abscess, Fistula-in-Ano, and Rectovaginal Fistula. Dis Colon Rectum. 2016 Dec;59(12):1117- 1133. [Crossref]  [PubMed]
  39. Johnson EK, Gaw JU, Armstrong DN. Efficacy of anal fistula plug vs. fibrin glue in closure of anorectal fistulas. Dis Colon Rectum. 2006 Mar;49(3):371-6. [Crossref]  [PubMed]
  40. Limura E, Giordano P. Modern management of anal fistula. World J Gastroenterol. 2015 Jan 7;21(1):12-20. [Crossref]  [PubMed]  [PMC]
  41. 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 Oct;114(4):682-9; discussion 689-90. [PubMed]
  42. Lee CL, Lu J, Lim TZ, Koh FH, Lieske B, Cheong WK, Tan KK. Long-term outcome following advancement flaps for high anal fistulas in an Asian population: a single institution's experience. Int J Colorectal Dis. 2015 Mar;30(3):409-12. Epub 2015 Jan 11. [Crossref]  [PubMed]
  43. Balciscueta Z, Uribe N, Balciscueta I, Andreu-Ballester JC, García-Granero E. Rectal advancement flap for the treatment of complex cryptoglandular anal fistulas: a systematic review and meta-analysis. Int J Colorectal Dis. 2017 May;32(5):599- 609. Epub 2017 Feb 28. [Crossref]  [PubMed]
  44. Boenicke L, Karsten E, Zirngibl H, Ambe P. Advancement Flap for Treatment of Complex Cryptoglandular Anal Fistula: Prediction of Therapy Success or Failure Using Anamnestic and Clinical Parameters. World J Surg. 2017 Sep;41(9):2395- 2400. [Crossref]  [PubMed]
  45. Yellinek S, Krizzuk D, Moreno Djadou T, Lavy D, Wexner SD. Endorectal advancement flap for complex anal fistula: does flap configuration matter? Colorectal Dis. 2019 May;21(5):581-587. [Crossref]  [PubMed]
  46. Rojanasakul A, Pattanaarun J, Sahakitrungruang C, Tanti- phlachiva K. Total anal sphincter saving technique for fistula-in-ano; the ligation of intersphincteric fistula tract. J Med Assoc Thai. 2007 Mar;90(3):581-6. [PubMed]
  47. Malakorn S, Sammour T, Khomvilai S, Chowchankit I, Gunarasa S, Kanjanasilp P, Thiptanakij C, Rojanasakul A. Ligation of Intersphincteric Fistula Tract for Fistula in Ano: Lessons Learned From a Decade of Experience. Dis Colon Rectum. 2017 Oct;60(10):1065-1070. [Crossref]  [PubMed]
  48. Lau YC, Brown KGM, Cheong J, Byrne C, Lee PJ. LIFT and BioLIFT: a 10-Year Single-Centre Experience of Treat-ing Complex Fistula-In-Ano With Ligation of Intersphincteric Fistula Tract Procedure With or Without Bio-prosthetic Reinforcement (BioLIFT). J Gastrointest Surg.2020 Mar;24(3):671-676. Epub 2019 Jun 25. [Crossref]  [PubMed]
  49. Han JG, Wang ZJ, Zheng Y, Chen CW, Wang XQ, Che XM, Song WL, Cui JJ. Ligation of Intersphincteric Fistula Tract vs Ligation of the Intersphincteric Fistula Tract Plus a Bioprosthetic Anal Fistula Plug Procedure in Patients With Transsphincteric Anal Fistula: Early Results of a Multicenter Prospective Randomized Trial. Ann Surg. 2016 Dec;264(6):917-922. [Crossref]  [PubMed]
  50. Sirikurnpiboon, S., Awapittaya, B., & Jivapaisarnpong, P. (2013). Ligation of intersphincteric fistula tract and its modification: Results from treatment of complex fistula. World journal of gastrointestinal surgery, 5(4), 123-128. [Crossref]  [PubMed]  [PMC]