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14 Contemporary Management of Fistula in Ano 347
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plug is inserted through the internal opening and rests in the tract disconnecting the
tract from the gut. The disc of the plug is then secured to the internal opening with
absorbable sutures [56]. Tracts greater than 4 cm in length have been associated
with better outcomes. Tracts with a high internal opening are not suitable as access
to the internal opening will be limited [57]. The FIAT trial compared surgeon’s
preference to the use of fistula plug and found no significant difference in rates
of fistula healing. Fistula plug was associated with a higher rate of complications
including pain [58]. Randomised controlled trials comparing RAF with fistula plug
found that the RAF had a high rate of fistula healing at 48% compared to fistula
plug at 29% at a median 12 months follow up [59]. Tract preparation and patient
selection are important. Plug failure does not preclude the use of other sphincter
preserving procedures.
Other procedures
A number of sphincter preserving procedures have been trialled over the past
decade without much evidence of success. Over the scope clip (OTSC) involves the
use of a super elastic alloy (Nitinol) to occlude the internal opening of the fistula
tract. The rate of fistula healing is variable and ranges between 47 and 90%. Clip
migration and clip removal due to post operative pain are reported complications
[60–62].
Fibrin glue has been used in the treatment of simple anal fistula with variable
outcomes reported in case studies. A randomised controlled trial comparing fibrin
glue to mucosal advancement flap found a low rate of fistula healing in the fibrin
glue group (40%) compared to mucosal advancement flap (80%) [63].
Platelet rich plasma (PRP) is a relatively new adjunct for the management of
anal fistula. PRP has been used in conjunction with LIFT and mucosal advancement flap. The patient’s own plasma is centrifuged to retrieve PRP which is
infiltrated into the fistula tract to promote fistula healing. A recent meta-analysis of
randomised studies did not find any significant difference in rates of fistula healing
with addition of PRP [64]. The studies were limited by the inclusion of fistula of
various aetiology, short follow up and small patient cohort.
The ESCP [32] cryptoglandular fistula guideline includes two decision aids for
managing new or complex fistulas with sphincter preserving procedures (Figs. 14.4
and 14.5).
Limitations
The main limitation of managing anal fistula is the lack of high quality, robust evidence. As discussed above, heterogenous definitions of anal fistula introduce bias
and uncertainty in the evidence. Preoperative MRI to assess fistula complexity
should be encouraged to introduce objectivity in clinical assessment. The impact
of anal fistula on QoL has recently been identified by patients and clinicians as
an important outcome for measurement in the Anal Fistula Core Outcome Set
study (AFCOS) [65]. Despite this, QoL is measured in only 14% of studies reporting outcomes in the management of anal fistula. Outcomes commonly measured
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Fig.14.4 Proposed algorithm for managing a patient with a new fistula
in interventional studies of anal fistula include fistula healing (clinical or radiological) in 77% of studies, incontinence in 63% and recurrence in 40% [66].
Management of anal fistula should include a holistic approach with the primary
aim of improving quality of life. The current literature of interventional studies
lacks standardised outcome reporting. This can be mitigated by including core
outcome measures and an assessment of quality of life which will improve the
14 Contemporary Management of Fistula in Ano 349
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Fig.14.5 Proposed algorithm for treating a fistula with sphincter preserving procedures
quality of evidence base for management of anal fistula. Standardised outcome
measures (AFCOS) and inclusion of quality of life assessment (e.g. AF-QoL) will
also ensure that outcomes are relevant to patients and comparable across the literature. Long term follow up should be included in all studies. Follow up with clinical
and radiological assessment will provide additional credibility to outcomes.
14.6 Conclusion
The vast array of sphincter preserving procedures demonstrates the lack of a single reliable modality for use in the management of complex anal fistula. Complex
anal fistulas are heterogenous in morphology, so it is unlikely that any one modality will be suitable for all clinical presentations. Patient factors such as burden of
fistula symptomatology, continence, bowel function and individual circumstances
will also influence the available options for intervention. These features should
be assessed for all anal fistulas including those that are deemed to be ‘simple’
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on examination. Patients should be offered individualised care as acceptability of
minor incontinence will vary. MRI should be used with a low threshold where
there is suspicion of complexity. Extensions, collections, and inconspicuous internal openings should be identified and treated (rationalisation) prior to treating the
primary tract as this is more likely to ensure success. Setons remain an honourable
option for some patients. Lay open works but may carry risks unacceptable to the
patient. Sphincter preserving procedures do not work often enough but provide
some hope to patients for whom lay open and permanent setons are unsuitable.
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