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demonstratedthattherewerenostatisticallysignificantdifferencesinthe overallrecurrenceorincontinencerates,neitherwasthereadifferencein healingtimes.Thus,inexperiencedhands,fistulectomycanbeperformed withexcellentsuccessandminimalmorbidityforlowfistulas.

CONCLUSIONS

Treatmentoffistulasrequiresanimportantbalanceofdecreasingriskof recurrencewithpreservationofcontinence.Thus,thechoiceoftreatment dependsontheamountofsphincterinvolvedinthefistulatract,with cuttingproceduresmorelikelyusedforintersphinctericandlow­transsphinctericfistulaandnoncuttingtechniquesforallotherfistulas. Patientpreferencealsoinfluencestheprocedurechoicewithpatientswho wishtouseaconservativeapproachandalikelylongertimetocure optingforsphincter-preserving,noncuttingprocedures,andpatientswho wishtoexpeditehealingchoosingacuttingtechnique.Ultimately, surgeonsshouldrelyontheirclinicaljudgment,experience,andcomfort withthemanydescribedfistulaoperationstobestguidethedecision­makingprocess.
RECOMMENDEDREFERENCESAND READINGS
AkagiK,TsujinakaH,HmasakaK.Setonmethodforlowintersphinchtericfistula.JColoproctol
2010;63:488–93. BuchananGN,HalliganS,BartramCI,WilliamsAB,TarroniD,CohenCR.Clinicalexamination,
endosonography,andMRimaginginpreoperativeassessmentoffistulainano:comparison
withoutcome-basedreferencestandard.Radiology2004;233(3):674–81. CiroccoWC,ReillyJC.ChallengingthepredictiveaccuracyofGoodsall’sruleforanalfistulas.Dis
ColonRectum1992;35:537–42. DavisBR,KastenKR.Anorectalabscessandfistula.In:TheASCRSManualofColonandRectal
Surgery.NewYork,NY:Springer,2009:215–44. DeMarcoC,Abou-KhalilM,Morin,N,etal.Shouldwebequicktodismissnon-sphincter-sparing
surgeryforfistula-in-ano?Ananalysisoflong-termoutcomes.Seattle,WA:AmericanSociety
ofColonandRectalSurgery,2017. GordonPH.Anorectalabscessesandfistula-in-ano.In:GordonPH,NivatvongsS,eds.Principles
andPracticeofSurgeryfortheColon,Rectum,andAnus.BocaRaton,FL:CRCPress,
2007:191–234. JorgeJM,WexnerSD.Etiologyandmanagementoffecalincontinence.DisColonRectum
1993;36:77–97. KimY,ParkYJ.Three-dimensionalendoanalultrasonographicassessmentofananalfistulawith
andwithoutH2O2enhancement.WorldJGastroenterol2009;15(38):4810–5. KronbergO.Tolayopenorexciseafistula-in-ano:arandomizedtrial.BrJSurg1985;72:970. ParksAG,GordonPH,HardcastleJD.Aclassificationoffistula-in-ano.BrJSurg1976;63(1):1–
12.
Ritchie,RD,SackierJM,HoddeJP.Incontinenceratesaftercuttingsetontreatmentforanal
fistula.ColorectalDis2009;111(6):564–71. SiddiquiMR,AshrafianH,TozerP,etal.Adiagnosticaccuracymeta-analysisofendoanal
ultrasoundandMRIforperianalfistulaassessment.DisColonRectum2012;55(5):576–85. TanKK,KohDC,TsangCB.Managingdeeppostanalspacesepsisviaanintersphincteric
approach:ourearlyexperience.AnnColoproctol2013;29(2):55–9. XuY,LiangS,TangW.Meta-analysisofrandomizedclinicaltrialscomparingfistulectomyversus
fistulotomyforlowanalfistula.SpringerPlus2016;5:1722.
Chapter8
AnalFistulaPlug
BruceW.RobbandMarcA.Singer

INDICATIONS/CONTRAINDICATIONS

Treatmentofanalfistulacanbeafrustratingproblemforboththepatient andthesurgeon.Whereassimplefistulasaregenerallyveryeffectively treatedwithfistulotomy,thetreatmentofcomplexfistulahasprovento bemoredifficult.Fistulotomyorcuttingsetonisaneffectivetreatment forfistulaclosure,butmaycausefecalincontinence.Thesearchfor effectivetreatmentsthatdonotcompromisecontinencehasledtotheuse offibringlue,theligationoftheintersphinctericfistulatract,endorectal advancementflaps,andtheuseofabsorbablematerialsasanalfistula plugs.Theinitialuseofanalfistulaplugswasconceivedanddescribedby BradSklow,inspiredbyacasereportbySchultzandcoworkersinthe JournaloftheAmericanCollegeofSurgeons,whichdescribedtheuseof atightlyrolledsheetofporcinesmallintestinesubmucosaplacedinan enterocutaneousfistulatractasaplug.Thistechniquewasmodifiedfor analfistula.Subsequently,aspecificallydesignedplugwasfashionedby CookMedical,Inc.(Bloomington,IN;SurgisisAnalFistulaPlug). Conceptuallysimple,analfistulaplugsprovideamatrixonwhichtissue growthmayoccur,leadingtofistulaclosurewithnotheoreticalriskto continence.
Indications
abscess
Contraindications
Currently,thereisonecommerciallyavailablefistulaplugapprovedby theFDA:CookBiodesignAnalFistulaPlug(CookMedicalInc.).
PREOPERATIVEPLANNING
Patientsshouldhaveundergoneprevioussurgicaldrainageofthe perirectalabscessandhavehadadrainingsetonplaced6–12weeksin advanceoffistulaplugplacement.Aplugmaybeprimarilyplacedin thosepatientswhohavenoevidenceofinfectionandhaveawell-formed fistulatract.Asinglepreoperativedoseofabroad-spectrumantibioticis recommended.Noconsensusaboutbowelpreparationexists,withsome authorsadvocatingcompletemechanicalpreparationsandotherssimply administeringanenemaonthemorningoftheprocedure.Itshouldbe stressedthatthereshouldbenoactiveinfectionpresentatthetimeofthe surgeryandthepatientshaveawell-formedtract.

SURGERY

Theanalfistulaplughasbeenwidelyadoptedforcomplexanalfistula surgerybecauseofitsfavorablesafetyprofilewithregardtocontinence andpurportedtechnicalease.Therehavebeenwidevariationsin publishedoutcomeswiththoseauthorswhoaremostsuccessful, attributingthedifferencestopatientselectionandtechnicaldetails.In 2007,agroupofsurgeonsexperiencedintheusageoftheSurgisisAnal FistulaPlugmetandissuedasetofrecommendationsforitsmost effectiveuse.
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Positioning
Patientpositioningandanesthesiacanbeperformedaccordingtothe surgeon’spreferenceforanorectalprocedures.Positioningisgenerally easilyaccomplishedwithpatientssedatedinthepronejackknifeposition witheitherapudendalnerveblockoraspinalanesthetic.However,many publishedseriesusegeneralanesthesiaandthelithotomyposition.
Technique
Thepreviouslyplaceddrainingsetonisnoted(Fig.8-1).Theperineum andtheanalcanalareinspectedagaintoconfirmthatallinternaland externalopeningshavebeenidentified.Athoroughinspectionshould alsoverifythatthereisnoactiveinfectionpriortopreparingthefistula plug.A2-0sutureissecuredtotheseton.Thesetonisthencutand pulledoutofthefistulasothatthesuturenowcrossesthefistula,leaving theneedleonthe“internalopening”sideofthefistula(Fig.8-2).The fistulatractisthenirrigatedwithdilutehydrogenperoxideusingan angiocatheterorgentlydebridedwithacytobrushorsmallcurettes(Figs.
8-3and8-4).Finally,thetractisirrigatedwithsaline.Theplugsare
rehydratedbyfullysubmerginginsterilesalinefornotmorethan2 minutes.Placementofasurgicalinstrumentsuchasahemostatoverthe pluginabowlofsalinewillkeepthematerialsubmerged.Thesuture placedearlierissecuredtotheplugmaterialonthe“externalopening” sideoftheplug.Thesutureisthenusedtodrawtheplugmaterial throughthefistulatract.Theplugisthensecuredattheinternalopening withanabsorbable2-0coatedpolyglycolicacidsuture,anchoringittothe sphinctercomplexandcoveringtheplug.Twosuturesplacedatright
anglestooneanotherarerecommended.Thesesuturesareplaced throughthesphinctermuscleandthenseparatelythroughtheplugsoas to“bury”theplug.Ifnecessary,theplugistrimmedatthistime.Some surgeonschoosetocreatesmallmucosalflapstobettercovertheplugat theinternalopening.
FIGURE8-1Thepreviouslyplacedsetoniscut.Careful
inspectionshowsnoinflammationorinfection.
FIGURE8-2Thesuturematerialispassedthroughthe
fistulatract.
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FIGURE8-3Thetractisirrigatedwithhydrogenperoxide.
FIGURE8-4Thetractisgentlydebridedwithasoftbrush.
TheGoreBio-A(R)FistulaPlugwasdesignedtobesizedtothefistula tractwithremovablelimbsattachedtoacentraldisk.Placementis similartothatoftheSurgisis(R)AnalFistulaPlug,inthatthesetonis usedtobringasuturethroughthetract,whichisthensecuredtothe
“sized”plugthathasbeenpreviouslywetted.Thesutureshouldbeplaced approximately3mmfromtheendsoftheplugsoastohaveenough strengthtopulltheplugintothetract,butnottofoldovertoomuchand makeitdifficulttopullintothetract(Figs.8-5and8-6).Theplugis securedwitha2-0coatedpolyglycolicacidsutureonaURneedleusing theattacheddiskwithaminimumofthreesuturestothesurrounding tissues.Thediskcanbeburiedinamucosalpocketorsimplysutured securelytothesurroundingtissueperthesurgeon’spreference.The excessmaterialistrimmedattheskin.Inboththecases,theexternal openingiseitherleftopenorlooselyclosedwithoutfixingtheplugatthe externalopening(Fig.8-7).
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FIGURE8-5The“sized”plugispassedfromtheinternal
totheexternalopening.
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