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212
V. Vilchez and A. L. Lightner
Division of the anoderm overlying the stula is
required. Then, the seton is serially tightened in
clinic and slowly cuts through the involved tissue
layers, leaving an intact scar once all tissues have
been cut at the seton fall out. The duration for the
seton to fall out and mature scar to develop
depends on the amount of tissue to be divided.
There is a large variability in the incontinence
rate observed with this technique ranging up to
60% on follow-up and surveillance after the procedure [13, 14]. A cutting seton may be used
selectively in the management of complex cryptoglandular anal stula if other options have been
exhausted. While this treatment was considered
more readily in the past, it has largely been abandoned in routine clinical practice due to its high
rates of incontinence [6]. However, it still holds a
place in selected circumstances, which involve
dividing more muscle than the surgeon is comfortable dividing for a stulotomy, but other more
advanced treatments are not feasible.
Fistula Plugs/Fibrin Glue
Anal stula plugs and brin glue are relatively
ineffective treatments for stula-in-ano [6].
A bioprosthetic anal stula plug, an acellular
collagen matrix used to close the internal stula
opening, provides a scaffold for native tissue
ingrowth to obliterate a stula tract. Although
early data demonstrated 70%–100% clinical
healing with the plug, more recently published
outcomes have been less encouraging with healing rates of 50% or less [15–17]. Plug failure is
reported to be more common in patients with
Crohn’s disease, anovaginal stula, or recurrent
stula and in active smokers.
Fibrin glue injection for treating anal stulas
has decreased in popularity because of disappointing contemporary data. In a 2019 randomized controlled double-blind trial, only 10 of 24
patients (41%) in the brin glue treatment arm
had complete stula healing [18]. In a retrospective review of 462 patients who underwent
sphincter-preserving surgery for cryptoglandular
anal stula between 2005 and 2015, the use of an
anal stula plug (healing rate of 24%) and brin
glue (healing rate of 18%) decreased signicantly
over the interval and the overall stula healing
rate increased signicantly from 32% to 64%
[19]. This decreased success has been attributed
to multiple variables, including inadequate tract
debridement, excessive tract debridement, an
inadequately secured plug, and the presence or
lack of a preoperative seton. The sphincterpreserving nature, even coupled with a remote
chance of success, has allowed for the continued
selective use of these approaches [6].
Ligation ofIntersphincteric Fistula
Tract (LIFT)
LIFT was developed as a sphincter-preserving
technique in 2007 by Rojanasakul etal. [20] and
entails dissection of the intersphincteric space
until the mature stula is encountered and subsequently divided and double ligated. The internal
and external openings are debrided and left open
to drain. In the initial description, the authors
reported a 94.4% healing rate with a 0% rate of
incontinence [20] (Fig.20.5).
Overall, the rates of success range from 61%
to 94% with rare instances of change in continence. Recurrence is associated with a shorter
stula tract. When the LIFT procedure fails, it
may result in drainage via the intersphincteric
incision as a persistent intersphincteric stula,
which can be subsequently managed by stulotomy [21, 22]. A draining seton may be used
before the LIFT procedure to allow for brosis of
the tract that may facilitate the procedure, but this
has not been shown to affect the success rate of
the LIFT procedure.
Modications of the LIFT procedure, including excising the lateral aspect of the tract, incorporating a stula plug or biologic mesh
interposition, or using video-assisted techniques,
have been described and, in some studies, are
20 Perianal Abscess andFistula
Fig. 20.5 Schematic
representation of the
LIFT procedure. Fistula
tract is divided at points
B and C, and a suture is
placed at both points
213
B
C
A
associated with improved healing rates compared
to the standard LIFT. However, the evidence
evaluating these techniques is limited to small
studies, and such modications to the standard
LIFT technique are typically not recommended
[23–25].
Endorectal Advancement Flap (ERAF)
The technique of an endorectal advancement ap
(ERAF) entails debridement or excision of the
stula tract and mobilization of a wide-based
mucosal/submucosal rectal ap, followed by
coverage of the internal opening after removal of
the overlying tissues and suture closure of the
internal opening. (Fig.20.6). Given its reproducible success rate of 60–100%, ERAF is recommended as a treatment option for complex anal
stulas [6, 26–28].
Successful aps require adequate blood supply (wide-based submucosal plexus) and lack
of tension (adequate mobilization/length).
Recurrence has been associated with smoking,
Crohn’s disease, a prior horseshoe abscess, and
a high body mass index (BMI). Contraindications
to ERAF include undrained sepsis, persistent
secondary tracts, a stula with a diameter
greater than 3 cm, a malignancy or radiationrelated etiology, and an anorectal stricture [29].
Flap conguration does not make a signicant
difference in the recurrence rate. Repeat ERAF
is feasible and carries an acceptable success
rate; however, it is also associated with a higher
rate of recurrence than initial ERAF repair [30].
The technique does not divide the sphincter
muscle but the incorporation of the sphincter
bers into the ap to varying degrees can lead
to worsening continence in up to 35% of
patients [6]. It can be a balance between having
some of the bers of the sphincter incorporated
into the body of the ap (which provides the
ap with thickness) and the concern for
incontinence.
An alternative ap design has been described
using a dermal advancement ap instead of a
mucosal ap. These aps can be in a house, diamond, or V-Y advancement of the skin. Studies
evaluating this type of ap are heterogeneous,
but, overall, the procedure is safe and has low-tomoderate rates of incontinence of up to 20% and
moderate rates of success between 50 and 70%
[29].
214
ab
V. Vilchez and A. L. Lightner
c
d
Fig. 20.6 Schematic representation of the ERAF procedure. (a) Fistula tract. (b) Curettage of the stula tract. Dotted
line represents the outline of the intended tissue ap harvest. (c) Flap raised with appropriate dimensions. (d) Flap being
stretched into place after closure of the internal opening at the muscular level
Minimally Invasive Approaches
Most institutional experiences with VAAFT
have been preliminary. This technique involves
Minimally invasive techniques to treat anal stulas have been studied over the past two decades to
develop approaches with improved outcomes
compared to more conventional stula operations. Endoscopic or laser closure techniques
have reasonable short-term healing rates but
unknown long-term stula healing and recurrence rates [6]. These techniques, described in
small, single-institution series with limited follow- up and with various degrees of industry support, include video-assisted anal stula treatment
(VAAFT), stula-tract laser closure (FiLaC), and
endoscopic clipping using an over-the-scope clip
(OTSC) device.
stuloscopy through the external opening to
identify the internal opening, closure of the internal orice with sutures, clips, or a stapling device,
and selective debridement or closure of the stula
tract. Reported healing rates after VAAFT range
from 71% to 85% with no reported incontinence
at a follow-up of less than 12months [31–34].
FiLaC uses a radially emitting laser probe
that, when passed along the tract, traumatizes the
epithelium and, in this way, closes the stula
tract. In a recent meta-analysis, Elfeki etal. have
reviewed 7 case series and comparative studies
involving 454 patients who underwent FiLaC.At
a median follow-up of 24months, 65% of patients
20 Perianal Abscess andFistula
215
were healed, 4% experienced a complication, and
the mean rate of incontinence was 1% [35].
Closure of the internal opening of a stula
tract has also been described using an OTSC
device. This approach, frequently combined with
a stuloscopy, places a superelastic nitinol clip
over the internal stula opening with the aid of a
transanal applicator. Outcomes of this technique
have been reported in small, single-institution
reviews showing primary healing rates of 79%–
90% with limited follow-up [36]. Clip removal to
relieve pain has been required in a minority of
patients.
Anorectal Fistula Associated
withCrohn’s Disease
The management of stulizing anorectal Crohn’s
disease typically involves a multidisciplinary
approach to control infection and optimize the
medical management used to treat the underlying
Crohn’s disease [6]. The mainstay of medical
management of anorectal Crohn’s disease is biological therapy [37–39]. Randomized controlled
trials have shown initial stula healing rates of
38%–55% in patients treated with iniximab,
with long-term healing occurring in 39% of
patients [39]. In many instances, medical therapy
is combined, at least initially, with a draining
seton [37, 38].
The decision to perform denitive stula surgery in selected patients with anorectal Crohn’s
must be individualized and should take into consideration the severity of symptoms, the presence
of infection, the stula tract’s anatomy, the presence of a stricture, and the status of Crohn’s disease (especially the presence of proctitis).
Following stula surgery, patients with Crohn’s
disease may require additional interventions for
nonhealing wounds or recurrent stula more
often than patients with cryptoglandular stula
[6].
In patients who do not require drainage, antibiotic therapy alone has been shown to be effective in stulizing Crohn’s disease; treatment with
metronidazole and uoroquinolones has demonstrated improvement in symptoms (at least tem-
porarily) in more than 90% of patients [6, 40].
Despite medical and surgical management,
patients with Crohn’s disease with severe refractory anorectal stulizing disease may ultimately
require proctectomy and permanent fecal diversion [41–43].
Patients with Crohn’s disease who present
with an asymptomatic stula secondary to
Crohn’s disease or a cryptoglandular infection
without signs of local sepsis do not require surgical intervention as these tracts may remain quiescent for extended periods of time. Draining
setons are typically useful in the multimodality
therapy of stulizing anorectal Crohn’s disease
and may be used for long-term disease control
[6]. However, setons can be associated with persistent seepage, a chronic and bothersome symptom for patients, and recurrent sepsis can occur in
more than 20% of patients.
In a retrospective study of 32 consecutive
patients treated with iniximab for anorectal
Crohn’s disease, patients who also underwent
seton placement (n=9) had a lower stula recurrence rate (44% vs. 79%; p<0.001) at 3months
and longer time to recurrence (13.5 vs.
3.6months; p<0.001) [44]. A systematic review
and meta-analysis of 10 studies, including 4 randomized controlled trials, concluded that antitumor necrosis factor (anti-TNF) therapy in
combination with temporary seton placement
was likely benecial for stula healing [45].
Multimodal treatment with biological agents and
seton drainage has also been associated with
improved stula healing rates [46, 47]. The time
to continue with a seton in place and/or removal
has not been well-elucidated.
Fistulotomy may be safely performed in
appropriately selected patients with Crohn’s disease with an uncomplicated low stula in the
absence of proctitis. Healing rates after stulotomy range from 62% to 100%, and 6% to 12% of
patients report mild incontinence. However,
some studies report higher rates of postoperative
incontinence (up to 50%), especially in patients
with active proctitis, underscoring the importance of appropriate patient selection [6].
Fistula patients with Crohn’s disease may be
considered for denitive operative repair if the
216
V. Vilchez and A. L. Lightner
stula has a single dominant tract without associated sepsis, anal stenosis, proctitis, or interfering scarring from previous anorectal disease or
procedures. In patients without signs of sepsis
and with otherwise well-controlled disease, the
most commonly performed repairs are ERAF
and LIFT. A systematic review including 91
patients with Crohn’s disease who underwent
endorectal advancement ap reported overall stula healing in 64% of patients at a median follow-up of 29months. Incontinence was reported
in 9.4% of patients after ap procedures and was
associated with having had previous surgical
repairs [48].
The LIFT procedure was evaluated in a prospective study of 15 patients with Crohn’s disease with transsphincteric stulas. In this study,
10 patients (67%) remained healed 12 months
after surgery, no patients reported incontinence,
and quality of life was signicantly improved
postoperatively [49]. A subsequent retrospective
study of 23 consecutive patients with Crohn’s
disease with transsphincteric stulas who underwent LIFT found that 11 patients (48%) healed
after a median follow-up of 23months; in patients
who failed LIFT, the median time to failure was
9months [50].
In patients with severe anorectal stulizing
Crohn’s disease who do not respond adequately
to medical therapy, local surgical intervention or
long-term seton drainage fecal diversion with or
without proctectomy to control anorectal sepsis
and improve incontinence symptoms and overall
quality of life may be considered [6].
Mesenchymal Stem Cell (MSC) Therapy
The local administration of mesenchymal stem
cells (MSCs) appears safe and effective in
selected patients with refractory anorectal stulas
in the setting of Crohn’s disease [6]. Several
phase I, II, and III clinical trials recently conducted have consistently demonstrated the safety
and efcacy of the direct injection of MSCs in
the treatment of medically and surgically refractory stulizing anorectal Crohn’s disease [51–54].
There are multiple varied study protocols. Some
of the variations include using allogeneic or
autologous MSCs derived from the bone marrow
or adipose tissue. Other variations are on the
delivery of the product—with or without scaffolding at varying doses ranging from 20million
to 120million cells. Despite the heterogenicity of
all published studies, the only reported adverse
events have been anorectal pain and abscesses.
The efcacy of MSCs ranges from 50% to 83% at
follow-up intervals ranging from 6 months to
1 year with no reported rates of incontinence.
ADMIRE was a randomized controlled doubleblind phase III trial, including 212 patients
receiving either placebo or 120 million MSCs.
The reported results were equivalent rates of anorectal pain and abscess in the two arms of the
study (13% vs. 11% and 12% vs. 13%, respectively). In this trial, study patients had signicantly improved stula healing rates compared to
placebo control patients (50% vs. 34%; p=0.02)
at 6 and 12months of follow-up [52]. This led to
approval of the adipose-derived MSC product
Alosel in Europe for the treatment of perianal
stulizing Crohn’s disease [55]. Further clinical
trials investigating MSCs in the setting of Crohn’s
disease are underway including the completion
of ADMIRE II and clinical trials evaluating
MSCs in rectovaginal stula, pouch stula, and
pediatric patients.
Complex Advanced Fistula Therapy
Fistulas that develop in the setting of pelvic radiation and recurrent and complex rectovaginal stulas may be repaired with a muscle ap
interposition or proctectomy with a primary or
staged coloanal anastomosis.
In patients with severe, complex stulizing
disease secondary to Crohn’s disease for whom
proctectomy is considered, Marchesa et al.
described the advancement rectal sleeve procedure. This involves circumferential excision, lifting the anal canal mucosa from the dentate line to
the anorectal ring, mobilization of a full- thickness
rectal ap, and anastomosis of the rectal sleeve to
the dentate line [56].
20 Perianal Abscess andFistula
217
In the setting of proctectomy, a primary or
staged coloanal anastomosis may be used to
restore continuity of the bowel. The Turnbull–
Cutait technique is reserved for situations in
which there are multiple stulous tracts or an
internal opening close to the suture line.
Circumferential sutures are placed at the neodentate line. The proximal bowel is prolapsed out
of the anus and wrapped in gauze for 5–7days at
which point the patient returns to the operating
room for amputation of the prolapsed rectum and
suture xation to the neo-dentate line. Temporary
fecal diversion is recommended in the setting of
abdominal procedures and history of radiation
[57, 58]. Karakayali etal. reported outcomes on
10 patients with rectovaginal stula secondary to
pelvic radiation who underwent pull-through and
straight coloanal anastomosis with proximal
diversion, and all patients healed without a leak
and without signicant changes in reported continence and improved quality of life [59].
Conclusions
At least one-third of cryptoglandular abscesses
will progress to stulas. Anorectal abscess should
be treated with surgical drainage. Antibiotics are
reserved for special circumstances when cellulitis, sepsis, or immunosuppression is present.
Anal stulas should be evaluated with examination under anesthesia prior to determining subsequent management. With any surgical
management, control of sepsis and maintenance
of continence are imperative. It important the surgeon takes into consideration and guides the
decision-making process by the patient’s presenting symptoms, the underlying etiology of the
problem, the anatomy of the stula tract, the
quality of the surrounding tissues, and prior
attempts at stula repair. It is important to learn
and take into consideration the different techniques that can be used to treat anal stulas.
When one method fails or is not adequate for the
occasion, another approach should be considered. Patient expectations should be set at the initial visit, and failure rates as well as recurrence
and potential need of further interventions should
be discussed with the patients during the informed
consent process.
Perianal Crohn’s disease can be a source of
signicant morbidity for the affected patients.
Combined medical and surgical therapy is essential for optimal outcomes, especially in complex
disease. Sepsis control, adequate symptom control, continence preservation and function, and
optimizing quality of life should be the goals of
any attempt at treatment.
Conict of Interest ALL: CMO at Direct Biologics; consultant CMO at Boomerang Medical.
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Fecal Incontinence
AnnaR.Spivak
21
Fecal incontinence (FI) is dened as uncontrolled
passage of stool lasting for the duration of
3months in a patient who previously had control
[1]. Severity and frequency of FI can be debilitating and have a great impact on one’s quality of
life.
Fecal continence is one of the most important
early acquired social habits and depends on the
function of multiple variables such as sphincter
anatomy and function, rectal compliance, neurologic state, sensorimotor function, pelvic oor
muscle coordination, stool consistency, colonic
transit and motility, mental cognition, as well as
psychological state. Any alterations to the abovementioned anatomy, function, innervation, or
mentation can become a factor leading to fecal
incontinence.
Fecal incontinence has been well-documented
as a consequence of obstetrical trauma, pelvic
surgery, and pelvic radiation. Sideris et al.
reviewed 103 studies involving 16,110 women.
Obstetric anal sphincter injuries (OASIS) were
diagnosed on ultrasound in 26% of women and
19% experienced FI. [2] Obstetric-related occult
sphincter injury can occur and not be recognized
at the time of delivery. This is reported to occur in
21–35% of women after vaginal delivery.
A. R. Spivak (*)
Cleveland Clinic Foundation, Cleveland, OH, USA
e-mail: spivaka2@ccf.org
Therefore, occult anal sphincter injuries are not
uncommon and may result in FI later in life. [2]
FI has also been documented to occur after
pelvic surgery. Al-Mehaisen et al. followed 59
women for 10years after an abdominal hysterectomy and found an increased risk of mild-tomoderate FI postoperatively with the risk being
increased by simultaneous bilateral salpingooopherectomy. An increased risk of FI symptoms
was not identied in patients who underwent
vaginal hysterectomy [3].
Bowel function can be altered by pelvic surgery and can affect FI.Women who underwent
surgery for deep pelvic endometriosis and segmental resection were compared to those who
only underwent a shaving technique to excise
their endometriosis. Patients who underwent segmental resection had higher scores on a standardized questionnaire (low anterior resection
syndrome (LARS) score, which measures some
elements of FI), and this correlated with a lower
sexual quality of life. In the group that underwent
the shaving technique, one-third presented with
FI-type symptoms (when LARS scores were
measured), which was surprising as no bowel
was resected. [4] Another study looked at urinary
and fecal incontinence in patients with ovarian
cancer who were treated with debulking surgery
and hyperthermic intraperitoneal chemotherapy.
The results showed an increased rate of fecal and
urinary incontinence [5].
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2025
M. Hoffman et al. (eds.), Major Complications of Female Pelvic Surgery,
https://doi.org/10.1007/978-3-031-66772-5_21
221
222
A. R. Spivak
Problems with FI, loose stools, and defecation
urgency has been reported in patients after pelvic
radiotherapy. [6] Radiation can affect many areas
that maintain continence. These include damage
to the sphincter complex, leading to weakness
and reduced compliance of the rectal wall. The
reduced compliance is associated with heightened rectal sensitivity. All these changes can
result in altered continence. The dose of radiation
therapy to the pelvis has been found to affect FI
symptoms. In patients who required radiation
therapy to the pelvis for a gynecological malignancy, a mean dose of >50 Gy was associated
with the occurrence of FI symptoms. Twelve percent of patients reported having FI symptoms
post-treatment [7].
Surgery for a gynecological malignancy has
been associated with FI and defecation alteration.
Ribas et al. utilized a questionnaire to access
bowel function in patients who were treated for
endometrial (71.8%) and cervical cancers
(28.2%). Of the 109 patients who responded, FI
was reported in 10% of the endometrial group
and in 15% of the cervical cancer group. [8]
Dunberger et al. evaluated 616 gynecological
cancer survivors and compared them to 344 controls to assess FI.Loose stools leading to fecal
urgency and FI symptoms were 7.7 times higher
in cancer survivors than in the controls. [9]
Damage to the sphincter can occur during vulvar
cancer excision. Hoffman etal. reviewed patients
undergoing resection for carcinoma of the vulva
involving perianal tissue. They found that in most
cases, the external anal sphincter could be spared
when resecting the cancer. If the sphincter
required resection for adequate cancer removal,
the patient was then at a signicant risk of subsequent FI. [10] When extensive resection involving the sphincter is required, anal reconstruction
consisting of plication of both the external anal
sphincter and the puborectalis muscles leads to
signicant improvement in bowel function and FI
in the postoperative period. [11] Overall, fecal
incontinence can be a sequala of pelvic surgery
for benign condition, malignancy, pelvic radiation, and perineum.
Diagnosis andEvaluation ofFI
Diagnosis of FI involves a thorough history and
physical exam focusing on the time at the onset
of symptoms, duration of symptoms, character of
the stool, assessment of bowel habits and bowel
regiment, and review of new medications.
Delineation of the exact symptoms is crucial as
some patients report FI and really have diarrhea.
Relevant details of FI symptoms include frequency, severity, urgency, character of the stool,
continence to atus, usage of pads, nocturnal
accidents, and the presence of sensations to defecate prior to having an accident. A history of
chronic conditions that can affect continence,
such as diabetes, stroke, neurological conditions,
previous pelvic radiation, irritable bowel syndrome, and inammatory bowel disease, is
recorded.
Surgical history, including obstetrical history,
episiotomy and tears, usage of forceps during
delivery, a prolonged second stage of labor, history of pelvic and abdominal surgery, history of
radiation, anorectal procedures, sphincter repairs,
and prior hemorrhoidectomy and stula repair, is
reviewed.
The physical exam begins with evaluation of
the perianal skin to look for skin irritation, scars,
trauma, stulas, hemorrhoids, an open or patulous anus, full-thickness or mucosal rectal prolapse, and length of the perineal body. Sensations
can be assessed by stoking the perianal skin with
a Q-tip. This stimulation leads to contraction of
the anal sphincter and is called anocutaneous
reex. Seeing the reex signals an intact sacral
reex arch and pudendal nerve innervation of the
anal sphincter.
A digital rectal exam is performed in order to
determine anal sphincter tone while at rest and
then asking the patient to squeeze. It is important
to rule out a distal rectal mass, a stricture, or fecal
impaction. Other ndings to note during a digital
exam include the presence of a rectocele, rectal
intussusception, or tenderness, particularly of the
levator muscles. If rectal prolapse is suspected,
the patient is asked to bear down while sitting on