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C. Choi
also benet from a postoperative antibiotic course. If there is adequate drainage,
then clinical improvement should be seen within 24h, with decreased pain and
decreasing leukocytosis. Depending on the depth of the cavity, drains can reassessed in the outpatient setting about 7days later. Factors such as drainage volume
can help with decision of slow removal (requiring re-suturing the drain at the skin
after partial removal) versus complete removal. Sitz baths or wound irrigation is
encouraged. Bowel regimen including ber supplement is also important to
maintain.
References
1. Carmichael JC, Mills S.Anatomy and embryology of the colon, rectum, and anus. In: ASCRS
textbook of colon and rectal surgery. Cham: Springer; 2016.
2. Davis BR, Kasten KR.Anorectal abscess and stula. In: ASCRS textbook of colon and rectal
surgery. Cham: Springer; 2016.
3. Vasilevsky C-A. Anorectal abscess and stula. In: The ASCRS manual of colon and rectal
surgery. 2nd ed. Cham: Springer; 2014.
4. Kiran RP.Anorectal abscess. In: Current therapy in colon and rectal surgery. 3rd ed. Amsterdam:
Elsevier; 2017.
5. Bolshinsky V, Trunzo J.Anorectal abscess. In: Cleveland clinic illustrated tips and tricks in
colon and rectal surgery. Wolters Kluwer; 2021.
6. Gaertner WB, et al. The American Society of Colon and Rectal Surgeons Clinical Practice
Guidelines for the Management of Anorectal Abscess, Fistula-in-Ano, and Rectovaginal
Fistula. Diseases of Colon and Rectum. 2022.
Figures References
1. Reference from ASCRS Textbook edition 3: # 168. Vasilevsky CA.Anorectal abscess and s-
tula- in ano. In: Beck DE, editor. Handbook of colorectal surgery. St Louis: Quality Medical
Publishing; 1997. SAME FIGURE also in the ASCRS Manual of CRS.
2. Fig.1.7—ASCRS textbook of colon and rectal surgery, anatomy and embryology of the colon,
rectum, and anus—Joseph C.Carmichael, Steven Mills.
Anorectal Fistula Repair
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SowmyaSharma andJuliaT.Saraidaridis
1 Introduction
The treatment of anal stula has been a challenging problem for both surgeons and
patients for millennia. This is due to a combination of factors including the heterogeneity of the condition, the complexity of the anatomy, and the continued failure
of available methods to consistently cure the condition. Hippocrates described using
a horse-hair cutting seton in 400 and we are still beset by the same challenges he
faced [1].
Perianal sepsis begins with abscess formation, most commonly secondary to
cryptoglandular infection. The glands within the anal canal can become obstructed
resulting in stasis of glandular secretions and eventual abscess formation. In addition to cryptoglandular etiologies of anal stula, stulae can arise from Crohn’s
disease, radiation injury, malignancy, trauma, iatrogenesis, tuberculosis, and other
more rare infections. Following abscess formation, the abscess will either spontaneously drain or require surgical drainage. 30–50% of the time an abscess will result
in the development of an epithelialized tract connecting the abscess cavity to an
epithelialized surface (perianal skin), referred to as anal stula.
Classication of anal stulae is via Parks’ classication, which includes intersphincteric, trans-sphincteric, supra-sphincteric, and extra-sphincteric stulae.
Other important distinctions when considering stula repair is whether the stula is
low versus high dened as the amount of involvement of external anal sphincter.
High trans-sphincteric stulae are dened as those involving greater than 25–30%
of the external anal sphincter. Complex anal stulas include high trans-sphincteric
S. Sharma · J. T. Saraidaridis (*)
Division of Colon and Rectal Surgery, Lahey Hospital and Medical Center,
Burlington, MA, USA
e-mail: Sowmya.Sharma@lahey.org; Julia.T.Saraidaridis@Lahey.org
Switzerland AG 2024
H. Chen, B. Lindeman (eds.), Illustrative Handbook of General Surgery,
https://doi.org/10.1007/978-3-031-63878-7_31
369© The Author(s), under exclusive license to Springer Nature
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stulae, supra-sphincteric stulae, extra-sphincteric stulae, horseshoe stulae,
inammatory bowel disease (IBD) related stulous disease, stulae in the setting of
radiation, and malignant stulae [2].
The overarching goals of stula repair are twofold: rst to repair the stula and
second to preserve continence. The choice of procedure as to how to accomplish
these goals is dependent on the location and complexity of stula.
S. Sharma and J. T. Saraidaridis
2 Pre-operative Preparation
Prior to undergoing surgical repair of their anal stula, patients require a disease
specic history and physical. Questions should focus on the history of the stula,
bowel habits, presence of incontinence, previous anorectal surgery, obstetric history, colon cancer screening, personal history of IBD, and family history of IBD.It
is very important to have a good baseline understanding of the patient’s continence
status. Validated questionnaires like the Wexner score, FIQL, FISI, and Vaizey score
can be helpful in characterizing continence [3]. In addition, pre-operative acquisition of this data provides a baseline from which to track continence following stula repair.
Following a disease specic history, patient should undergo an anorectal physical exam in the ofce with the caveat that a robust examination will likely require
exam under anesthesia. A close visual examination of their perineum should be
performed assessing for external openings, previous scars, thinning of the perineal
body, and signs of perianal Crohn’s disease. Following visual examination, a digital
rectal exam should be performed to provide a rough estimate of sphincter strength.
Sphincter strength should be assessed at rest and during squeeze. If anoscopy is
available in the ofce, it should be performed, but this can also be deferred for
planned exam under anesthesia and seton placement.
Following a presumed diagnosis of stula, the rst step of treatment is to delineate the perianal anatomy with an exam under anesthesia (EUA). In most cases,
anal stula diagnosis is a clinical one without need for imaging; however, in certain cases, particularly when there is concern for complex or multiple stulae,
MRI can be obtained to aid with operative planning [4]. But for the vast majority
of stula, patients should be brought to the operating room for an initial EUA to
delineate anatomy and draining seton placement without any need of additional
imaging.
Bowel preparation for the operating room can be a single eet enema administered 1 h prior to procedure. In patient whom colon cancer screening is overdue or
there is concern for Crohn’s disease, a colonoscopy can be performed as part of the
EUA procedure with subsequent need for preoperative bowel preparation with
mechanical bowel prep.
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2.1 Procedures
2.1.1 Initial EUA/Seton Placement
Following identication of the clinical suspicion for stula, the patient is brought to
the operating room for EUA.Patients can be positioned in lithotomy or jacknife
prone depending on surgeon preference. EUA can be done under monitored anesthesia care (MAC) or general anesthesia depending on patient factors and anesthesia
provider preference. Pre-operative antibiotics are not indicated for prophylaxis, and
are usually given only in setting of active infection in diabetic or immunocompromised patients, or patients with concern for systemic infection. VTE prophylaxis is
not indicated unless the patient is in a high risk group.
All exams are initiated with a exible sigmoidoscopy or colonoscopy depending
on age and risk factors for malignancy and IBD.Flexible sigmoidoscopy allows
assessment of the rectum for proctitis to help exclude Crohn’s Disease.
The perineum is examined again fully to evaluate for external openings, previous
scars, thinning of the perineal body, and signs of perianal Crohn’s disease. Given the
location of the external opening, hypotheses regarding the location of the internal
opening can be made using Goodsall’s rule. Goodsall’s rule uses the location of the
external opening to predict the location of the internal opening. If an external opening is anterior to the line dividing the anus in the coronal plane, the internal opening
is radial to the nearest anal crypt. If it is posterior to the coronal plane, it curves to
the posterior midline. However, recent studies have shown that Goodsall’s rule
accurately predicted the course of stulas with a posterior opening, but only predicted 49% of the anterior ones. The same authors suggest that the midline is more
prevalent for both anterior and posterior stulae [5, 6].
Anoscopy is performed to evaluate for the internal opening. Special attention is
made to evaluate for hemorrhoidal tissue, ssure, and inammation. With the anoscope inserted, the external opening is gently probed to connect the external to the
internal opening. Sometimes, the tract is not easily delineated with probing. Care
must be taken not to force the probe so as to create a false tract. If the tract is not
easily apparent, these authors suggest instillation of half strength hydrogen peroxide into the external opening to elucidate the internal opening. Complicated tracts
may require a stepwise approach where the incision is extended only as far as the
probe can be safely passed; once the tract has been partially opened, the probe is
advanced accordingly as the direction of the tract becomes apparent. Once the probe
is in the stula tract, the stula can be characterized by the Parks classication
scheme: intersphincteric, transsphincteric, suprasphincteric, or extrasphincteric.
The relation of the stula to the sphincter muscle determines this classication.
Estimates as to how much involvement of the external anal sphincter assist in determining the complexity of the stula and the appropriateness for certain types of
repair. Typically patients who have <25% of the external anal sphincter encircled by
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S. Sharma and J. T. Saraidaridis
the stula are appropriate for simple stulotomy, whereas “high” trans-sphincteric
stulae are not candidates for that “repair.” Overall sphincter strength should be
determined as well. Patients with weak tone should have very little derangement to
the sphincter complex if possible.
Unless the patient is determined a candidate for simple stulotomy (<25% of
sphincter involved in a patient with good strength sphincter), a non-cutting or drainage seton should be placed (Fig.1). Drainage setons are performed by attaching a
silk tie to the probe and pulling it through the stula. The silk tie is then attached to
silastic band and the silastic band pulled through the stula. The two ends of the
silastic band are then connected using additional silk ties. The draining seton should
not be so tight as to become a cutting seton or so loose as to cause difculties with
catching on clothes or toilet paper. A draining seton can be left in place indenitely
for patients who are not candidates for more complex procedures or for those who
prefer the seton to the risk of incontinence with other procedures.
Following placement of a draining seton, it is the authors’ preference to wait
2–3months minimum before proceeding with a denitive stula repair procedure.
Fig. 1 Seton in place
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Denitive Fistula Repair Procedures
Prior to denitive stula repair, patients should be counselled regarding realistic
expectations of the likelihood of success of their operation. For most sphincter sparing operations, approximately 60–70% are successful and 5–10% of patients report
some decrement in their continence. Following informed consent, patients are readied for the operating room. It is unclear what bowel preparation is ideal for stula
repair. Options include enema versus full mechanical bowel preparation. Most surgeons do use preoperative antibiotics and VTE prophylaxis is preserved for those
with long surgeries or strong risk factors.
Patients can be positioned in lithotomy or jacknife prone depending on surgeon
preference. At the authors’ institution, stulotomy and stulectomy are often performed in lithotomy, whereas LIFT and advancement ap are performed in the
prone position.
2.1.2 Fistulotomy
Inter-sphincteric and low trans-sphincteric stulae are both candidates for primary
or secondary stulotomy. In this procedure, once the stula tract is identied with a
probe, the stula is laid open over the probe using cautery. The edges of the stula
tract can be marsupialized which decreases healing time (but does not decrease
recurrence risk) [7]. When appropriately used, over 90% success rates are seen with
this procedure, with low incontinence rates [8]. Recurrence or persistence of the
stula occurs when the edges heal back over the base of the wound. Occasionally, a
stula is not thought to be appropriate for stulotomy during initial identication,
but then is deemed appropriate on planned operation for denitive stula repair. In
that setting, a secondary stulotomy can be performed. It is thought that the outcomes from secondary stulotomy are slightly improved compared to primary stulotomy given the amount of brosis already present from the seton.
2.1.3 Cutting Seton
A cutting seton can be used for supercial trans-sphincteric stulas to perform a
gradual stulotomy. The overlying skin and subcutaneous tissue are laid open, and
a silk tie seton is placed in the stula tract as described above, and tied tightly
around the tract in the muscle. The slow erosion of the seton into the muscle allows
brosis and eventually healing of the tract. This technique requires routine ofce
visits with seton tightening until the process is complete.
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S. Sharma and J. T. Saraidaridis
2.1.4 Fistulectomy
Fistulectomy involves excision of the stula tract (from external opening to internal
opening). It does not require probing of the stula for successful repair, but does
have signicant tissue destruction. It is only effective for well-dened stula tracts.
The external opening should be cored out using an elliptical incision and the stula
tissue grasped. Dissection is then performed along the tract to remove the entire
tract from the body. Careful attention should be paid to minimizing damage to the
sphincter complex. Once the stula tract is removed, the internal opening is closed
with either simple stitches or an advancement ap.
2.1.5 Ligation ofInter-sphincteric Fistula Tract (LIFT)
LIFT is a sphincter sparing option for trans-sphincteric stulae that was developed
in 2007 [9]. The seton is removed and a probe placed into the stula tract (Fig.2).
A curvilinear incision is made above the intersphincteric plane (Fig.3). The intersphincteric plane is then dissected and developed isolating the stula taking care not
to enter into the stula tract (Fig.4). Once the stula tract is clearly identied, it is
Fig. 2 Fistula probe in
stula
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Fig. 3 Marking incision
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Fig. 4 Encircling stula
tract
encircled. Ties are placed on either side of the tract (on the side of the internal and
external sphincter muscles) (Fig.5). Each side is ligated (Fig.5). Suture ligations
can be used if the ties fall off. The external side can be tested with dilute hydrogen
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Fig. 5 Silk ties on either
side of tract
S. Sharma and J. T. Saraidaridis
peroxide to ensure the closure is water tight. The internal opening is curetted and the
internal opening is closed with a gure-of-eight stitch. The dissection cavity is
closed with interrupted vicryls and the skin is closed loosely with interrupted vicryl
suture (Fig. 6). Reported success of the LIFT ranges from 50% to 94% [9–11]
(Fig.7).
2.1.6 Endoanal Advancement Flap
The endoanal advancement ap was rst proposed by Noble in 1902 [12]. In this
procedure, the anus is held open using a Lone star device and a Park’s anal retractor.
A tongue shaped ap is lifted in the anal mucosa. The ap consists of mucosa, submucosa and part of internal anal sphincter. The inferior portion of the “U” of the ap
is 10mm distal to the internal opening. It is imperative to raise a ap with adequate
blood supply. Once the ap has been raised, the portion containing the internal
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Fig. 6 Tying silks
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opening is trimmed. The internal opening is then closed at the level of the muscle.
The closure is leak tested from the external opening with dilute hydrogen peroxide.
The ap is then sutured over the closure of the muscle. Advancement aps have
been shown to have high rates of success (60–70%); however, they do carry a small
risk of incontinence (10–20%) [13, 14].
2.1.7 Other Options
There are a plethora of other historical procedures used for denitive stula repair
including brin glue, stula plug, stulotomy and immediate reconstruction, and
Fistula-tract Laser Closure. Both brin glue and stula plug, while initially very
appealing given their sphincter preservation, have fallen out of favour given poor
success rates.
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