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4 Unconventional Insights in the Pathogenesis and Etiology of Fistulas in... 53
Fig. 10 (a) Transversal and (b) sagittal. Endo-anal ultrasound obtained after H2O2instillation in
the external fistula opening at 7 o’clock and 1.5 cm from the anal verge obtaining an image showing
a transsphincteric fistula track. The hyperreflection of the H
at the border of the external anal sphincter at 7 o’clock on the transverse transection and extends
proximally to the internal fistula opening crossing the anal sphincters located at 6 o’clock and
1.5 cm from the anal verge
shows the fistula track which starts
2O2
Fig. 11 (a and b). Intraoperative images with a Czerny retractor inserted showing the internal
opening of the fistula at 6 o’clock at the dentate line with no hypergranulation and the external
opening 7 o’clock and 1.5 cm from the anal verge with a drop of pus
4 Discussion and Conclusions
Throughout the years several new techniques based on different theories have been
introduced for treating perianal fistulas. However, about the etiology and pathogenesis of the anorectal suppurative disease, most, if not all, remains unsolved,
despite 60 years of treatment and research. An important role, as suggested by
54 C. B. H. Molenaar et al.
Table 3 Features of
phenotype 3
Fig. 12 A typical aspect of a
hidradenitis suppurativa with
several fistula openings and
areas with hyperpigmentation
of the skin. It has been
discovered that hidradenitis
isn’t an infection of the
apocrine sweat glands but an
inflammation of the hair
follicles inside the duct of the
gland. Patients with
hidradenitis appear to have a
higher incidence of perianal
fistulas
No previous history of an abscess
External opening with epithelialization
Long subcutaneous track
Parks, for infection of the anorectal ducts and glands by the gut-microbiome, has
never been proved.
In clinicalpractice we cannot deny the fact that among our patients, the presentation
and underlying process in developing a perianal fistula is diverse. Identifying different
types of perianal fistulas based on their clinical presentation might be the lead to
answer our questions on how to improve the results of their treatment. We suggest the
underlying etiology in the different phenotypes may have a different pathogenesis.
Although the presented clinical phenotyping has not been published or scientifi-
cally approved, experienced proctologists will probably recognize the various clinical
presentations. We propose to take a different approach and take into account that a
different clinical appearance could have a different etiology. Therefore, it is necessary
to have a more individually applied treatment which is suitable for that specific
perianal fistula. We think that the low rate of positive results could be accounted to
the fact that the treatment of all these different fistulas is considered as one size fits all.
It is time for new concepts, new approaches. To consider, for example, the theory
based on the pathogenesis of hidradenitis suppurativa with epithelial remnants
causing continuous activation of the inflammatory response around the fistula or
4 Unconventional Insights in the Pathogenesis and Etiology of Fistulas in... 55
Fig. 13 (a–c) Endo-anal ultrasound after instillation of H2O2in the external fistula opening at
1o’clock showing clearly a track traversing from left to right and the suggestion of an internal
fistula opening at 12 o’clock (a). The extension of the abscess pocket at 1 o’clock is visible in
images b and c
track or exhausting microbiological and immunological research methods with
employing the newest PCR methods like in other chronic inflammatory processes
(e.g., in TLO research: tertiary lymphoid organs) could possibly reveal the causative
mechanism.
Furthermore the local anatomy of the anal transitional zone is the same
(squamous-columnar junction on the fusion of the embryological hindgut and
proctodeum) as other fusion zones (Z-line on the esophagus-gastric junction and
SCJ on the ecto-endocervical junction) and therefore already a predilection zone of
problems like chronic inflammation, hyperplasia, metaplasia, dysplasia, and the
development of malignancies.
Prospective clinical and basic research should be performed to connect the new
clinical phenotypes with new histopathological concepts about pathogenesis. Also
the use of complex algorithms in data analysis with artificial intelligence, including
56 C. B. H. Molenaar et al.
Fig. 14 Endo-anal
ultrasound in rendering mode
showing the 3D appearance of
the proximal extension of the
abscess pocket at 1 o’clock
Fig. 15 An intraoperative
image with the wound after
drainage of the abscess lateral
to the right labium majora is
shown on the left upper side
and a small drainage wound at
1o’clock. In the anoderm at
12 o’clock is an internal fistula
opening visible. Instillation of
in the wound at
H
2O2
1o’clock shows a connection
with the wound at 11 o’clock.
wasn’t coming out of
H
2O2
the internal fistula opening
because the track was too
narrow
various patient parameters, previous history, characteristics of the fistula, and
inflammatory parameters, will provide us the links for improvement of the treat ment
results for our patients in the future.
4 Unconventional Insights in the Pathogenesis and Etiology of Fistulas in... 57
Table 4 Features of phenotype 4
Epithelialized external fistula opening
Sometimes a complex of subcutaneous tracks with fistula openings in the perianal skin
Areas of hyperpigmentation of the skin
Internal opening of the fistula in the anoderm
Fig. 16 A female patient
presenting with a Bartholinlike infection
Fig. 17 (a and b). Endo-anal ultrasound with H2O2instillation in the fistula track 3 months after
drainage shows a typical perianal fistula located anteriorly
Table 5 Features of phenotype 5
Previous abscess without anaerobic infection
Sometimes history of drainage of a Bartholin cyst or episiotomy infection
Abscess predominantly located in the anterior half of the anus
External opening of the fistula with little hypergranulation tissue
58 C. B. H. Molenaar et al.
5 Cross-References
▶ Anorectal Anatomy Related to Anal Fistula and Abscess
▶ Anorectal Physio logy Related to Anal Fistula and Abscess
▶ Classification of Anal Fistula and Abscess
▶ Epidemiology of Anal Fistula and Abscess
▶ From Abscess to Fistula
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From Abscess to Fistula
Is This the Rule?
Martijn P. Gosselink and Heeva Baharlou
Contents
1 Anorectal Abscess ... . . . ....... . . . ..... . . . . . ...... . . . . ...... . . . . ...... . . . . ...... . . . . ...... . . . . 62
References .................... ................................ ................................ .... 66
Abstract
Anorectal abscess and perianal fistulas are considered two phases of the same
disease. It is still unclear why some patients completely heal after incision and
drainage of the anorectal abscess and others go on to develop a perianal fistula.
This chapter evaluates the incidence and risk factors for the development of
cryptoglandular perianal fistulas.
Keywords
5
Anorectal abscess · Perianale fistula · Cryproglandular disease · Anal immune
system
M. P. Gosselink (*)
Department of Surgery, Dr. Horacio E. Oduber Hospital, Oranjestad, Aruba
H. Baharlou
Centre for Virus Research, The Westmead Institute for Medical Research, Westmead, NSW,
Australia
The University of Sydney, School of Medical Sciences, Faculty of Medicine and Health Sydney,
Sydney, Australia
e-mail: heeva.baharlou@sydney.edu.au
© Springer Nature Switzerland AG 2022
C. Ratto et al. (eds.), Anal Fistula and Abscess, Coloproctology,
https://doi.org/10.1007/978-3-030-76670-2_6
61
62 M. P. Gosselink and H. Baharlou
1 Anorectal Abscess
Several studies have been conducted to identify the factors that contribute to the
development of an anorectal abscess. It has been suggested that in 90% of cases, the
abscess originates from an infection arising in the glandular tissue at the bottom of
the anal crypts (Parks 1961; Waggener 1969; Eisenhammer 1978; Lai et al. 1983).
The anal crypts are the grooves between the approximately ten anal columns of
Morgagni, and are a consistent finding after week 9 of gestation (Fritsch et al. 2010).
Glandular tissue can be found in approximately half of these crypts, especially in the
posterior half of the anus (Fritsch et al. 2007). These anal glands have a tubular, ductlike structure, lined by stratified columnar epithelium, similar to the epithelium in the
anal transitional zone (Muranaka et al. 2018). The epithelial lining of the anal gland
is interspersed with mucus-secreting cells. Most of the gland tissue is located in the
submucosa with branches entering the internal sphincter, and in one half, the
branches cross the internal anal sphincter completely to end in the external longitudinal layer in the intersphincteric plane (Lee and Kim 2018).
According to the cryptoglandular theory, occlusion of the opening of the crypt,
caused by a faecaloid, trauma, or nearby anodermal irritation (e.g., anal fissure) may
result in draining difficulties of the mucus (Parks 1961). The following mucus stasis
may result in dysbiosis causing alterations in both the local immune response and the
epithelial permeability of the crypt. These changes may underlie the formation of an
anorectal abscess. The accumulating pus will seek the path of least resistance. If the
gland tissue is located in the submucosa and the internal sphincter is intact, the pus
will drain internally via the crypt into the anal canal, probably even without the
patient being aware. However, when branches of the crypt cross the internal sphincter into the external longitudinal layer, an intersphincteric abscess may emerge.
Usually, this abscess egresses downwards to emerge at the lower border of the
anal canal as a perianal abscess (Read and Abcarian 1979; McElwain et al. 1975).
Another common route is laterally through the external sphincter muscle, via the
corrugator cutis ani muscles, to enter the ischiorectal space and give rise to a
transsphincteric ischiorectal fossa abscess. A less common route of spread is superiorly up the intersphincteric groove, becoming a supralevatoric abscess. In 1954
Dr. Stephen Eisenhammer first coined the term “acute fistulous abscess” to describe
the close relationship of the anorectal abscess to the anal canal (Eisenhammer 1954).
Usually, the treatment of an acute anorectal abscess has been simple radial incision
and drainage. This procedure will immediately relieve the pain; however, it may not be
sufficient. This is because in many patientsthe abscess might recur, or the drainagesite
might persist beyond 6 weeks, which is then called a perianal fistula. Table 1 shows the
incidence of recurrent abscess or persistent fistula subsequent to the initial simple
incision and drainage in 12 studies. The incidence varied considerably across studies
and was between 28 and 66% of patients.The large variation may be due to differences
in follow-up, operation technique, usage of adjuvant antibiotic treatment, and differences in patient population. These numbers indicate that a substantial portion of
patients will have no further problems after incision and drainage of the abscess;
however, in almost half of the patients further surgery is necessary.
5 From Abscess to Fistula 63
Table 1 Incision and drainage of cryptoglandular anorectal abscess
Recurrence
Author Year
Scoma et al. (1974) 1974 232 24 66
Lai et al. (1983) 1983 260 5 41
Vasilevsky et al.
(1984)
Schouten et al.
(1991)
Ho et al. (1997) 1997 28 16 28
Li et al. (1997) 1997 32 25 56
Hämäläinen et al.
(1998)
Knoefel et al. (2000) 2000 65 40 34
Oliver et al. (2003) 2003 100 12 29
Sözener et al. (2011) 2011 183 12 30
Hasan (2016) 2016 68 18 55
Ghahramani et al.
(2017)
Number of
patients
1984 103 20 48
1991 34 43 38
1998 146 99 47
2017 306 3 30
Follow-up duration
(months)
(%)
abscess or
fistula
During the initial surgical procedure, external pressure on the abscess, with a
speculum in the anal canal, may demonstrate pus discharging from the crypt into the
anal canal and thereby demonstrate the internal opening of the acute anorectal
fistulous abscess. By this method, in more than one-third of cases an internal opening
can be identified (Parks 1961; Lee and Kim 2018; Ramanujam et al. 1984). In the
other cases the anal crypt ca n be obstructed by a faecolith, which is the reason for
anorectal abscess development in the first place, accordi ng to the cryptoglandular
pathogenesis theory. It is also possible that the crypt may be obliterated by the
inflamed edematous surrounding tissue.
Some surgeons recommend immediate fistulotomy or sphincterotomy in the acute
abscess stage in order to eradicate the internal cryptal origin, thereby eliminating the
development of what they believe is an inevitable recurrent abscess or persistent fistula
(Eisenhammer 1954). If an internal opening is demonstrated in the initial procedure, a
curved probe could be carefully placed in the internal opening, and if the probe is
immediately visible in the abscess cavity, a low transsphincteric or intersphincteric
fistula can be easily laid open (Waggener 1969). If there is a high transsphincteric
fistulous abscess, a primary partial internal sphincterotomy could be performed to
eradicate the intersphincteric part of the abscess (Schouten and van Vroonhoven
1991). Even if there is no internal opening visible and the abscess is near the anal
groove, a primary partial internal sphincterotomy could be performed to affect a
saucerization of the anorectal abscess (Read and Abcarian 1979). Table 2 shows
excellent results after these combined procedures with recurrence rates ranging between
0 and 10%. However, in most of these studies it remains unclear how many patients