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12.9 Preoperative Evaluation andImaging inAnal Fistula
191
12.8.1 Simple Fistula
A stula is simple when the tract is intersphincteric or low trans-sphincteric [17]. A stulotomy
is the best surgical option since it affects only 30
percent of the external sphincter.
12.8.2 Complex Fistula
Any stula that is not simple is referred to as a
complex stula. Following are the complex
stulas:
• Any stula that involves over 30% of the
external sphincter [17]
• Fistulas with multiple openings
• All recurrent stulas
• Anterior stulas in females
• Fistulas with pre-existing incontinence
• Inammatory bowel and Crohn’s-related stula
• Fistula secondary to radiation [17]
12.9 Preoperative Evaluation
andImaging inAnal Fistula
The objectives of preoperative imaging are:
stula classication. A surgeon must know the
type of stula he is dealing with and its path.
Various imaging modalities available are:
• Fistulography
• Computerized Tomography
• Anal Endosonography
• MRI (Magnetic Resonance Imaging)
X-ray Fistulography and Computerized
Tomography (CT) are not used because of the
suboptimal visualization of stulas with a contrast medium. X-ray Fistulography has the disadvantage of missing the secondary tract, difculty
in determining the course or location of the
abscess with the sphincter complex, and difculty determining the level of internal opening
due to lack of accurate markers [18]. A CT scan
is insufcient for a thorough study of comparative stulous anatomy. Unless there is air or contrast within, CT attenuation of the pelvic oor
musculature and sphincter muscles is indistinguishable from the stula [18].
The stula tract site and direction are referred
to as the “anal clock”.
At 12 o’clock in lithotomy position, it is anterior,
and at 6 o’clock, it is posterior or a natal cleft [1].
1. To evaluate the stula tract’s relation to the
sphincters.
2. To nd secondary stulous tracts and
abscesses.
A detailed digital rectal examination might
help locate the tract in case of a simple anal stula. According to practicing parameters, a complex stula or a recurrent stula must be examined
using radio-diagnostic procedures [18]. Imaging
helps to identify the openings and formulates the
12.9.1 Anal Endosonography
The rectal wall, intersphincteric, and transsphincteric stulas and their association with
anal sphincters may be seen by anal endosonography [18]. Endosonography, on the other hand,
is inconvenient for assessing extrasphincteric and
suprasphincteric tracts or secondary extensions
due to the limited eld view. Secondly, they are
operator-dependent, and the artifacts can sometimes be misinterpreted as tracts [18].
192
12 Clinical Evaluation andClassication ofAnal Fistula
12.9.2 Magnetic Resonance Imaging
(Fig.12.14a–c)
a
EAS
IAS
b
c
12.9.2.1 Indications
• Noncryptoglandular abdominopelvic source
• Suspected supralevator abscess
• Persistent discharge post incision and
drainage
• Multiple space abscess
• Horseshoe presentation
• Inability to perform physical examination of
an abscess
12.9.2.2 Advantages
• Because of its multiplanar imaging and a great
extent of soft-tissue distinction, it helps evaluate stula tracts and their specic course and
underlying anatomy to plan a surgical procedure [19].
• It may be done with or without the use of a
contrast medium.
• Complex and recurrent stulas can be correctly identied up to 90% and 70%, respectively, using MRI [20].
• The capacity to detect hidden abscesses and
secondary extensions to prevent recurrence
after surgery [19].
• The potential to examine the anal sphincter
complex from any surgically relevant perspective [19].
• The ability to anticipate the risk of postoperative incontinence by dening the anatomic
relationship of the stula [19].
Fig. 12.14 Magnetic resonance induction (MRI). (a)
Normal external and internal anal sphincters as seen in
MRI. (b) Intersphincteric stula with sagittal section. (c)
With a 6 o’clock position axial section opening-transsphincteric stula
Sphincter complex, ischiorectal fossa, and
the levator plate may be seen clearly in unenhanced T1 MRI scans. Pathologic processes
like stulas, uid collections, and secondary
tracts are exhibited clearly on T2 [1]. Fistula
tracts, abscesses, and inammation present as
low- to intermediate- intensity signal areas that
are difcult to differentiate from normal
tissues.
12.10 Dierential Diagnosis
193
The coronal and axial planes of anatomic MRI
were related to the classication given by Park
and the radiologists at St. James’s Hospital [19,
20].
12.9.2.3 Classication ofSt James’s
University Hospital
As per the Magnetic Resonance induction results
and axial landmarks, the stulas have been
graded as follows [1, 21]:
• Grade I: Simple intersphincteric linear
tract.
• Grade II: Abscess with an intersphincteric
tract.
• Grade III: Trans-sphincteric tract.
• Grade IV: Abscess associated with trans-
sphincteric tract.
• Grade V: Supralevator extensions.
12.9.2.4 Ecacy Results
Detection of stulas using MRI has a specicity
of 100% and a sensitivity of 97% [20]. One
should always get an MRI done for patients presenting with complex stulas, which provides a
precise, noninvasive, and rapid presurgical
assessment.
Accurate diagnosis and thorough identication of the internal as well as the external openings make the surgeon’s task easy, assisting him
in mapping and planning the technique.
12.9.2.5 Can MRI BeDeceptive?
“It is not the machine that matters; it is the man
behind the machine which matters.”
Sometimes reporting of MRI may be wrongly
predictive, which does not correlate clinically, a
limitation that I experienced in my practice. In three
of my cases, the MRI suggested pilonidal sinus.
Clinically the signs of pilonidal sinus were missing,
and the internal opening was easily palpable. The
age of the patients were more than 50years. I could
easily diagnose them to be cases of stula-in-ano.
During the surgical exploration, the tracts were
present as described in the MRI, but the diagnosis
mentioned in the MRI was inaccurate.
Similarly, Mahmoud e. Agha et al. reported
false-positive diagnosis in ve of their patients
[21]. Therefore, clinical correlation is necessary.
12.10 Dierential Diagnosis
Refer Table12.1.
Table 12.1 Differential stula diagnosis [22]
Infected Bartholin’s cyst
Subcutaneous abscess
Infected anal ssure
Hidradenitis suppurativa
Rectorectal vestigial cyst with stula formation
Foreign body affected in the rectal wall
Crohn’s disorder
Infected pilonidal cyst
Infections (actinomycosis, tuberculosis, gonococcal
infection, lymphogranuloma venereum)
Progressive septic granulomatosis
Anal colloid adenocarcinoma
Diverge pathologies (prostatic abscess, osteomyelitis,
etc.)
Lymphoma
194
12 Clinical Evaluation andClassication ofAnal Fistula
12.11 Evaluating Incontinence
Wexner’s score includes the frequency of soiling
and allows for examining the three components
of fecal incontinence (liquid, solid, and atus)
[23]. The difculty in controlling the transit of
the solid part of the stool is referred to as fecal
incontinence. Anal incontinence, on the other
hand, is the failure to manage the atus and the
liquid part of the stool [23]. The primary reason
for fecal incontinence may be rectal or sphincter
dysfunctions or neurological disorders [24].
12.11.1 Wexner’s Score
It is essential to know the Wexner’s score before
stula surgery (Table12.2).
• Never—0
• Rarely—<1/month
• Usually—<1/day⩾1 per week
• Sometimes—⩾1 per month; < 1 per week
• Always—⩾1 per day
• 20—Complete incontinence
• Total score: 0—Perfect
Table 12.2 Wexner score
Frequency
Incontinence
type Always Usually Sometimes Never Rarely
Liquid 4 3 2 1 0
Solid 4 3 2 1 0
Lifestyle
alteration
Wears pad 4 3 2 1 0
Gas 4 3 2 1 0
4 3 2 1 0
Take-Home Message
Effective stula management requires proper
clinical evaluation, including a thorough history
and a careful clinical assessment. The purpose
of clinical assessment remains twofold: rst, to
identify the openings and the tract, and second,
to assess the type of stula. Proper classication
is mandatory before taking the patient for stula
surgery. The amount of sphincter left behind is
always more crucial than the amount that will be
divided [25]. Imaging is essential when a patient
has an intersphincteric abscess, uctuant or suppurative drainage, multiple space abscesses, a
poorly drained or nonresolving infection, or
complex stulas. As crucial as anatomy is,
understanding pathogenesis is signicant in the
detailed mapping of anal stulas. Without
proper anatomical markers, it is hard to do stula surgery, which may lead to recurrence or
incontinence.
References
1. Morris J, Spencer JA, Ambrose NS. MR imaging classication of perianal stulas and its implications for patient management. Radiographics.
2000;20(3):623–35.
2. Jimenez M, Mandava N. Anorectal stula. In: Stat
Pearls. Treasure Island, FL: Stat Pearls Publishing;
2021.
3. Lunniss PJ. Aspects of stula-in-ano. London:
University of London, University College London;
1994.
4. Sigmon DF, Emmanuel B, Tuma F.Perianal Abscess.
In: Stat Pearls. Treasure Island, FL: Stat Pearls
Publishing; 2021.
5. Murad-Regadas SM, Dealcanfreitas ID, Oliveira
MTCCD, Pessoa Morano D, Regadas FSP, Rodrigues
LV, Regadas Filho FSP.Anatomical characteristics of
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7. Cuiñas K, Williams JP.TU-196 Goodsall’s rule—past
its sell-by date? Gut. 2015;64:A149.
8. Cirocco WC, Reilly JC. Challenging the predictive accuracy of Goodsall’s rule for anal stulas.
Dis Colon Rectum. 1992;35(6):537–42. https://doi.
org/10.1007/BF02050532.
9. Kartzer GL, Dockerty MB.Histopathology of the anal
ducts. Surg Gynecol Obstet. 1947;84:333–8.
10. Parks AG, Gordon PH, Hardcastle JD.A classication
of stula-in-ano. Br J Surg. 1976;63(1):1–12. https://
doi.org/10.1002/bjs.1800630102.
11. Parks AG. Pathogenesis and treatment of stula-inano. Br Med J. 1961;1(5224):463.
12. Abcarian H.Classication and management strategies.
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https://doi.org/10.1007/978- 1- 4614- 9014- 2_5.
13. Eisenhammer S.The nal evaluation and classication
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abscess and stula. Dis Colon Rectum. 1978;21(4):237–
54. https://doi.org/10.1007/BF02586698.
14. Shawki S, Wexner SD. Idiopathic stula-in-ano.
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doi.org/10.3748/wjg.v17.i28.3277.
15. Goligher JC, Ellis M, Pissidis AG.A critique of anal
glandular infection in the etiology and treatment
of idiopathic anorectal abscesses and stulas. Br J
Surg. 1967;54(12):977–83. https://doi.org/10.1002/
bjs.1800541202.
16. Frenkel J. Fistula-in-ano: a new classication system for perirectal stulas. Dis Colon Rectum.
2002;45(4):A25–8.
17. Steele SR, Kumar R, Feingold DL, Rafferty JL,
Buie WD, Standards Practice Task Force of the
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19. de Miguel CJ, del Salto LG, Rivas PF, del Hoyo
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M. Preoperative MRI of perianal stula: is it really
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article/776150- differential.
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Fistulotomy: Still aGold Standard!
13
“Too aggressive stulotomy results in incontinence, too timid stulotomy renders stula
to persist.”
Herand Abcarian
Key Concepts
• Fistula surgery aims to cure the stula with
minimal complications and recurrence.
• Fistulotomy is still a gold standard for simple
stula tracts.
• Fistulotomy means laying open the tract.
• A stulectomy is a surgical intervention that
removes the entire stulous tract.
• Fistulotomy combined with primary sphincter
repair can be used in selected patients with
good results.
13.1 Introduction
The expertise and preference of the surgeon are
deciding elements in stula management. The
options available are stulotomy, stulectomy, or
seton placement. Minimally invasive procedures
have become popular recently, including stula
plugs, brin glue, LIFT, VAAFT, stem cells, and
lasers.
Mention of the stula disease and its manage-
ment can be noticed in the work of Hippocrates,
dated 400BC, in which he described stulotomy
and the use of horsehair wrapped in lint threads as
a cutting seton [1]. The basis of the “lay open technique” was laid by John of Aderene in his descriptions of stula treatment in the fteenth century [2].
An anorectal fistula can be simple or complex, and fistulotomy may be performed safely
for “simple” tracts, including low transsphincteric or intersphincteric fistulas [3].
However, for “simple” fistulas, a fistulotomy
may cause anal incontinence in about 12% of
cases [3].
13.2 Fistulotomy
The fistula tract is opened between the distal
external anal sphincter (EAS) and the lower
half of the internal anal sphincter (IAS). Only
the superficial and subcutaneous portions of
the external anal sphincter are divided. As a
rule, the deep segment of the external anal
sphincter forming an anorectal ring with
puborectalis is never divided. Marsupialization
of the edges of the fistulotomy can also be
done to decrease the size of the wound and
maintain hemostasis.
13.2.1 Principle
Fistulotomy is a surgical technique in which a stula is cut open and allowed to heal by secondary
intention.
© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2022
K. Gupta, Lasers in Proctology, https://doi.org/10.1007/978-981-19-5825-0_13
197
198
13 Fistulotomy: Still aGold Standard!
The aim and objectives are to manage the
internal opening of the stula tracts. There are
two ways to tackle it:
• Park’s Technique: The internal opening is
removed by excising the mucosa, submu-
cosa, surrounding tissue, and bers of the
internal anal sphincter reaching the deep
intersphincteric area. An oval incision is
given starting 5mm above the internal open-
ing and carried downwards up to the anal
verge [4].
• Eisenhammer’s Technique: The alternative
is to open the tract, curette, and scoop the
primary infected source in the intersphincteric
space [5].
Table 13.1 Intersphincteric stula management—at a glance
Sphincter involvement and amount
Type of intersphincteric stula
A1—Simple intersphincteric
stula
A2—Intersphincteric stula with
high blind tract
A3—Intersphincteric stula with
an opening in the lower rectum
A4—High intersphincteric stula
without perineal opening
A5—High intersphincteric stula
with pelvic extension
A6—Intersphincteric stula
extending from pelvic disease
of sphincter to be cut Outcome and alternatives
Only the lower half of IAS No risk of incontinence
The whole IAS can be divided to
lay open the tract
The whole IAS can be divided to
lay open the tract
The tract can be laid open by
dividing IAS
Such stulas should be drained
into the rectum
A suprasphincteric stula may occur
if the ischiorectal fossa is drained
Manage pelvic disease The stula will heal after eradicating the
13.2.2 Indications
• Simple anal stulas involving up to 50% of
the external anal sphincter
• A low-lying stula with an abscess (Primary
stulotomy)
13.2.3 Contraindications
• Complex stulas
Based on Park’s classication, a stepwise sur-
gical approach to different types of stulas has
been discussed. The alternative approach using
laser is shown in Tables13.1, 13.2 and 13.3.
No risk of incontinence
A hybrid procedure is a better approach
No risk of incontinence
A hybrid procedure is a better approach
No risk of incontinence
Transanal opening of intersphincteric
space with stulotomy at 6 o’clock is done
A hybrid procedure is a better approach
No risk of incontinence
Transanal opening of intersphincteric
space with stulotomy at 6 o’clock is done
A hybrid procedure is a better approach
pelvic disease
Table 13.2 Trans-sphincteric stula management—at a glance
Type of trans- sphincteric
stula
B1—Uncomplicated The supercial and subcutaneous parts of
B2—Trans- sphincteric
stula with a high blind
tract
Table 13.3 Suprasphincteric stula
Type of stula
Suprasphincteric stula Avoid sphincter cutting procedures The laser procedure or seton is a
Sphincter involvement and amount of
sphincter cut Outcome and alternatives
Little disturbance in continence
EAS and the lower part of IAS are divided
Fistulotomy up to the supercial part of
EAS.The upper extension will heal on its
own. Always prefer a transanal approach
Sphincter involvement and amount of
sphincter cut Outcome and alternatives
Primary sphincter repair can be
carried out
The laser procedure is a better option
better option
Conjoined longitudinal muscl
tract from inter
Conjoined longitudinal muscle
13.3 Management ofIntersphincteric Fistula
199
13.3 Management
ofIntersphincteric Fistula
The surgical approach depends on the type of
“intersphincteric tract.”
a
e
External anal sphincter
13.3.1 Simple Intersphincteric Fistula (A1)
When stulotomy is performed, just the lowermost internal anal sphincter is cut (Fig.13.1a, b).
Therefore continence is preserved.
Internal opening
Dentate line
Internal anal sphincter
Inter - sphincteric tract
b
Fistulotomy for Inter - sphincteric
Fig. 13.1 (a) Simple intersphincteric stula. (b) Simple intersphincteric stula showing stulotomy
nal to external opeing
External anal sphincter
Excision of internal opeing
Dentate line
Internal anal sphincter
200
Excision of internal opening
Curetting of upward extensio
High blind inter - sphincteri
13 Fistulotomy: Still aGold Standard!
13.3.2 Intersphincteric Fistula
The entire internal sphincter may be divided with
minimal compromise to continence (Fig.13.2a, b).
withHigh Blind Tract (A2)
a
c
extension
Inter - sphincteric tract
As the upward extension is secondary to the primary source of infection, it will heal once the primary source is dealt with.
Internal opening
Dentate line
Internal anal sphincter
b
Opening of inter - sphincteric
External anal sphincter
Anorectal ring
n
tract upto anorectal ring
Dentate line
Internal anal sphincter
External anal sphincter
Fig. 13.2 (a) Intersphincteric stula with high blind tract. (b) Fistulotomy including the opening of intersphincteric space
High extension opening
Opening of inter - sphincteric
Excision of internal opening
13.3 Management ofIntersphincteric Fistula
201
13.3.3 Intersphincteric Fistula
As in the A2 type, the tract is intersphincteric,
and the entire internal sphincter can be divided
with minimal risk of incontinence (Fig.13.3a, b).
withanOpening intheLower
Rectum (A3)
a
into the rectum
Inter - sphincteric tract
13.3.4 High Intersphincteric Fistula
Without anExternal
Opening(A4)
The primary source of infection lies below the
internal opening in the deep intersphincteric space.
A transanal approach is considered for the manage-
Internal opening
Dentate line
External anal sphincter
b
Curetting of the tract
tract upto anorectal ring
External anal sphincter
Internal anal sphincter
Anorectal ring
Dentate line
Internal anal sphincter
Fig. 13.3 (a) Intersphincteric stula with upward extension opening in the lower rectum. (b) Fistulotomy with excision
of internal opening and opening of intersphincteric space up to anorectal ring