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Chapter7
FistulotomyandFistulectomy
ShotaTakanoandMaryliseBoutros

INDICATIONS/CONTRAINDICATIONS

Patientswhopresentwitharecurrentperianalabscess,oraconstantlyor intermittentlydrainingopeningintheperianalregion,shouldbe consideredforoperativetreatmenttocuretheanalfistula.
Thegoalofthesurgeryistoeradicatethefistulawithanoperationthat resultsinthelowestrecurrencerate,withtheleastimpactoncontinence, overtheshortesttimeinterval.Todecideonthebestoperativeplanfora patient,itisessentialtoconsiderthreefactors:(1)theetiologyofthe fistula,(2)therelationshipbetweenthefistulatractandthesphincter muscles,and(3)thepatient’spremorbidsphincterfunction.
Theetiologyofthefistulacanbedeterminedbyathoroughhistoryand physicalexamination,andimaging,whenrequired,asdiscussedinthe nextsession.Themajorityoffistulasareofcryptoglandularorigin, whereastrauma,Crohn’sdisease,previousfissure,andtuberculosis constitutelesscommoncausesforanalfistula.
Therelationshipofthefistulawiththesphinctermuscleswasdescribed byParksetal.inaclearclassificationschemethatiswidelyacceptedand used(Table7-1).Anintersphinctericfistulahasatrajectoryonlyinthe intersphinctericplaneanddoesnotpenetratetheexternalsphincter(Fig.
7-1).Althoughthereareseveralsubtypesdescribed,themostcommonis
ahighblindtract,whichisacephaladextensionintheintersphincteric plane.Atranssphinctericfistulapenetratestheexternalsphincterbelow thelevelofthepuborectalismuscle,exitingintovaryinglevelswithinthe ischiorectalfossa(Fig.7-2).Suprasphinctericandextrasphincteric fistulasarefarlesscommon.Theformernamedescribesafistulatract thatloopsoverthepuborectalis,thendownwardsthroughthelevator plateintotheischiorectalfossa,andfinallydrainsthroughtheskin(Fig.
7-3).Thelattertypehasatrajectoryoutsidetheexternalsphincter
complex,andmayresultfromatranssphinctericfistulawithahighblind
tractthatpenetratesthroughthelevatorplate(Fig.7-4A),ormayhavean etiologyotherthancryptoglandulardiseasesuchastraumaorCrohn’s disease(Fig.7-4B).Submucosalfistulasarelikelytheresultofatractthat liesjustbeneaththesubmucosawithoutinvolvingthesphinctercomplex atall.Therelationshipofthepatient’sfistulawiththeirsphinctermuscles canbespeculatedbasedonthephysicalexaminationperformedinthe clinicoronpreoperativeimaging;however,thefistulatrajectoryis confirmedduringtheoperationbeforethefinaldefinitiveoperativeplan ischosen.Furthermore,analfistulascanbecategorizedassimpleor complex.Thedefinitionofacomplexfistulaisnotstandardized,butmost surgeonsagreethatanyfistulaisconsideredtobecomplexif:itishigh transsphincteric(morethanhalfofthesphinctercomplexinvolvedbythe fistula);suprasphincteric;extrasphincteric;hashighblindtracts;orwhen afistulotomywouldresultinincontinence.However,inretrospect,many “simple”fistulasarecomplexduetotheirrecalcitrantnaturediscovered bytheirpersistenceand/orrecurrenceaftermultipleattemptedrepairs.
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TABLE7-1 ClassificationofFistula-in-Ano
Submucosalfistula
INTERSPHINCTERIC
Simplelowtract
Highblindtract
Hightractwithrectalopening
Rectalopeningwithoutaperinealopening
Extrarectalextension
Secondarytopelvicdisease
TRANSSPHINCTERIC
Uncomplicated
Highblindtract
SUPRASPHINCTERIC
Uncomplicated
Horseshoeextension
EXTRASPHINCTERIC
Secondarytoanalfistula
Traumarelated
Pelvicinflammation
Inflammatoryboweldiseaseorotheranaldisease
FIGURE7-1Intersphinctericfistulawithasimplelow
tract. (AdaptedfromGordonPH,NivatvongsS.Anorectalabscesses
andfistula-in-ano.In:PrinciplesandPracticeofSurgeryfor theColon,Rectum,andAnus.CRCPress,2007:191–234,with permission.)
FIGURE7-2Uncomplicatedtranssphinctericfistula.
(AdaptedfromGordonPH,NivatvongsS.Anorectalabscesses andfistula-in-ano.In:PrinciplesandPracticeofSurgeryfor theColon,Rectum,andAnus.CRCPress,2007:191–234,with permission.)
FIGURE7-3Suprasphinctericfistula.
(AdaptedfromGordonPH,NivatvongsS.Anorectalabscesses andfistula-in-ano.In:PrinciplesandPracticeofSurgeryfor theColon,Rectum,andAnus.CRCPress,2007:191–234,with permission.)
FIGURE7-4A.Extrasphinctericfistulasecondaryto
cryptoglandulardisease.B.Extrasphinctericfistulasecondary totraumaorpelvicdisease.
(AdaptedfromGordonPH,NivatvongsS.Anorectalabscesses andfistula-in-ano.In:PrinciplesandPracticeofSurgeryfor theColon,Rectum,andAnus.CRCPress,2007:191–234,with permission.)
Thepatient’spremorbidsphincterfunctionisofutmostimportancein choosingtheappropriatetreatmentplan.Thisstatusisascertainedbya thoroughhistory,includinginformationregardingstoolconsistency, urgency,leakage,incontinencetosolidorliquidstool,orgas.Avalidated incontinencescoreshouldbeobtainedanddocumented.Furthermore, thepatient’ssphinctertoneisassessedduringthephysicalexamination, asdescribedinthenextsection.
Fistulaoperationscanbebroadlycategorizedas:(1)cuttingprocedures ornonsphinctersparing,or(2)sphincter-sparingprocedures.Ingeneral, non–sphincter-sparingoperationshavemuchbettersuccessrateswithin ashorterintervaloftimecomparedwiththoseofsphincter-sparing procedures(tobediscussedinotherchapters).However,non–sphincter­sparingoperationsrequiredivisionordestructionofsomedegreeof sphinctermuscles,makingitcriticaltochoosethemostsuitablepatient andfistulafortheseoperations.
Fistulotomyinvolvesdivisionoftheentirefistulatractonits longitudinalaxis,alongwithanymuscleortissuessuperficialtothetract. Fistulotomyisconsideredthegoldstandardfistulatreatmentandthe mostwidelyperformedprocedureforsimpleanalfistulas. Intersphinctericandlow-transsphincteric(involvinglessthanone-third ofthesphinctercomplex)fistulasarethemostcommonindicationsfor fistulotomy.Intheauthors’practice,femalepatientswhohavelow­transsphinctericfistulas,especiallyintheanteriorlocationwherethe sphinctercomplexistheshortest,aremanagedbysphincter-sparing approachesratherthanfistulotomy.Mid-andhigh-transphincteric fistulasandsuprasphinctericfistulasarebestmanagedbyasphincter­sparingapproachtoavoiddivisionordestructionofanysphincter muscle.However,astheseapproacheshaveahigherfailurerate, recurrenceofthesecomplexfistulascanbemanagedbycarefulstagedor partialfistulotomy.
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Fistulectomyinvolvestheremovaloftheentirefistulatractincluding thesurroundingtissues.Althoughthistechniquehasnotgained widespreaduse,itisaninterestingtoolinthearmamentariumofthe surgeonasitallowstheremovalofthefistulatractwithoutprobing,while
fullydefiningtherelationshipofthetractwiththesphincters.Becauseof thelargerwoundscreatedbytheremovalofthetractwithits surroundingtissues,thisoperationisindicatedforlow-transsphincteric fistulas,whereashigh-transsphinctericandsuprasphinctericfistulasare bettermanagedbysphincter-sparingapproaches.
SpecialConsiderations
Crohn’sDisease
FistulasinCrohn’sdiseasearealsoconsideredcomplex.Fistulasin Crohn’sdiseasetendtodeviatefromnormalanatomicclassifications.The tractsareusuallyfibroticwithapossibleskinirritation.Patientswith Crohn’sdiseaseoftenhavehighrectalopenings,butmayalsohavelow fistulas.ThekeytothetreatmentoffistulasinCrohn’sdiseaseistofirst evaluatethesymptoms,thencontrolsystemicinflammationwithmedical therapy.FistulotomyandfistulectomyarerarelyusedinCrohn’sdisease. Thesepatientsareatriskofhavingfuturefistulas;thus,when inflammationistreatedwithasurgicalapproach,anoncutting, sphincter-sparingapproachisadvisable.Aloosedrainingsetonmaybe insertedtocontrolsepsisandkeepthetractopenuntilafurtherdefinitive operationisperformed.
PREOPERATIVEPLANNING
ClinicalAssessment
Assessmentbeginswithathoroughhistorytoinquireaboutsymptomsof recurrentanalabscessesoradrainingopeningintheperianalregion. Etiologyisexploredbyaskingaboutgastrointestinalandextraintestinal manifestationsofCrohn’sdiseaseandafamilyhistoryofinflammatory boweldisease,priorhistoryoftuberculosis,previousfissures,surgery, andtrauma.Forfemalepatients,itisimportanttoobtainanobstetric historyincludingprolongedlabor,tears,andepisiotomies.Information regardingthepatient’spremorbidsphincterfunctioncanbeascertained byinquiringaboutstoolconsistency,urgency,leakage,andincontinence ofsolidorliquidstool,inadditiontogasincontinence.Again,avalidated incontinencescoringsystemshouldbeusedtoobtainanddocumentthe incontinencescore.
Physicalexaminationintheclinicsettingconsistsofinspection, palpation,digitalrectalexamination(DRE),anoscopy/sigmoidoscopy, andpossiblyprobing,whiletheremainderoftheexaminationcanbe completedintheoperatingroomunderanesthesia.
InspectionandPalpation
Inspectionoftheperianalregionshouldidentifytheexternalopening, whichusuallyappearsasasmallelevationofgranulatedtissuewith purulentserosanguinousdischargeoncompression.Sometimes,the openingisascarredorpuckeredregionatthesiteofapreviousdrainage procedureoritmaybesosubtlethatitcanonlybedetectedwhen palpationaroundtheanusexpressesafewdropsofpus(Fig.7-5).Careful inspectionoftheanalmarginmayalsogivesomehintsregardingthe locationoftheinternalopening;therelationshipbetweenthefistulatract andthesphincters;andthepresenceofanysecondarytracts.
FIGURE7-5Externalopeningofafistula(notethelong
distancebetweentheexternalandtheinternalopenings, hintingtothecomplexityofthissuprasphinctericfistulaina patientwithCrohn’sdisease).
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Goodsall’sruleusesthelocationoftheexternalopeningtopredictthe locationoftheinternalopening.Thisrulestatesthatiftheexternal openingisposteriortothecoronalplane,thefistulaprobablyoriginates fromtheposteriormidline.However,iftheopeningisanteriortothis plane,thetractlikelyrunsradiallytothenearestanalcrypt(Fig.7-6).In aretrospectivereviewof213patients,Goodsall’sruleaccurately predictedthecourseof90%offistulaswithaposteriorexternalopening, butonly49%oftheanteriorones.Thetrajectoryofthefistulatractcanbe suspectedbythedistanceoftheexternalopeningfromtheanalmargin. Thefartherthedistanceoftheexternalopeningfromtheanalmargin,the greateristheprobabilityofanunderlyinghighfistula.Thus,anexternal openingthatisfarfromtheanalmarginislikelysecondarytoa transsphinctericfistula,whereasanexternalopeningthatisneartheanal marginislikelyduetoanintersphinctericfistula.Goodsall’srulealso predictsthatananteriorexternalopeninggreaterthan3cmfromthe analvergehasahighlikelihoodoforiginatingintheposteriormidline andistheanteriorextensionofa“halfhorseshoefistula.”Widelyplaced bilateralanteriorexternalopeningsareconsistentwitha“horseshoe” fistulaoriginatingintheposteriormidline.Furthermore,thegreaterthe numberofexternalopenings,themorecomplexthefistulaislikelytobe
—aseachsecondaryopeningisduetoasecondarytractfromtheprimary fistulatract.Also,morethanoneexternalopeningindicatesthatthis fistulahassecondaryorside-branches,whichmustalsobemanaged. Finally,ifthetractispalpablefromtheexternalopeningtotheanal verge,itissafetoregardthefistulaasasimpletype(Fig.7-7).Palpation oftheexternalopeningisalsoimportanttoensurethatitisnotacutely induratedsecondarytoarecurrentabscessthatwouldrequireimmediate drainage.
FIGURE7-6Goodsall’srule.
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