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58
3 Anal Abscesses and Fistulae
Fig. 3.2 Surgical wound marsupialization after fistulotomy
(from Pescatori, 2011)
Fig. 3.1 Lay-open of a low posterior intersphinteric fistula. The
patient was placed in the lithotomy position. Mild intraoperative bleeding was observed, coming from a submucosal venous
plexus. A few days after surgery, severe rectal bleeding required urgent tamponade with gauze soaked in coagulant. Surgical
wound marsupialization at the end of operation might have prevented the complication
that particular patient I thought that this was
unnecessary, as the fistulotomy wound was rather
small and prevalently external. In retrospect, I
should have marsupialized the wound.
If we look at the literature, it is clear that I have
been rather lucky, as a bleeding rate of 20% after
fistulotomy and after seton, and of 10% following
fistulectomy and rectal flap advancement have
been reported (Ho and Ho, 2005).
To prevent or at least minimize the risk of postoperative bleeding, it is better:
1. Not to rely upon the gauze filling the residual
cavities, also because excessive compression,
which is likely to cause postoperative pain,
should be avoided; instead, a careful hemosta-
sis should be carried out, if necessary using
Surgicel or Tabbotamp.
2. To marsupialize even small wounds, especially if
they are associated with internal piles, which
might bleed afterwards; marsupialization signifi-
cantly decreases the wound size (Fig. 3.2), thus
shortening the convalescence, and reduces the risk
of bleeding without increasing postoperative pain
(Pescatori et al., 2006; Malik and Nelson, 2008).
3. To carefully inspect the surgical wound once
the patient has returned to the ward; if the
gauze has become bloodied, it is advisable to
take it out and to control any active bleeding.
3.3 Iatrogenic Fistula
This condition may be caused by excessive intraoperative probing. In patients with a trans-sphincteric fistula, once a probe has been inserted through the
external orifice, we should bear in mind that, after a
few centimeters, the tract direction is likely to
change: rather than proceed cranially, towards the
anorectum, it will cross the external sphincter. By
continuing to push the probe upwards, a false tract is
created, i.e., an extra-sphincteric iatrogenic fistula,
across the levator ani muscle to the supralevator
space, which thereafter will communicate with the
external orifice at the level of the perianal skin.
3.4 Persisting or Early Recurrent Local
Sepsis
After the operation, when seeing the patient in the
ward, there is nothing worse than hearing: “Doctor,
listen, I feel a painful induration here, close to the
anus,” or “Look, there is some pus coming out here in
the groin…” or “….here on the tip of the coccyx, I
feel discomfort, is there anything wrong?”. Upon
examination, we may unfortunately find residual sep-
3.4 Persisting or Early Recurrent Local Sepsis
sis, an undiscovered abscess, or a neglected tract. This
happened to me twice early in my career, in a female
patient with Crohn’s disease who had septic extension
to the inguinal region and in a male patient who had a
concomitant anal fistula and pilonidal sinus. Since
then, I routinely prepare a wide operative field in
patients in whom sepsis extends far from the perianal
region, in order to be able to evaluate the extent by
adequate inspection, palpation, and probing. It should
be noted that an inguinal sepsis is likely to be neglected if the patient is examined only in the Sims position.
What happens if there is either residual abscess
or a fistula tract? How did I manage the two abovementioned patients? The small groin abscess of the
patient with Crohn’s disease (who was maintained
on antibiotics) was successfully curetted in the
office after ten days, at the first postoperative visit.
The male with the pilonidal sinus was successfully
managed with a simple lay-open, carried out in the
office after a week under local anesthesia.
Horse-shoe fistulae, by definition, have retroanal and/or retro-rectal, deep and/or superficial
extensions. Therefore, the posterior spaces need to
be adequately drained, with a retro-anal incision if
necessary; otherwise, a closed space will be at risk
of persistent or recurrent sepsis due to the growth of
anaerobic germs. Two lateral incisions might not be
sufficient to achieve adequate drainage. Khoeler et
al. (2004) reported that satisfactory results can be
obtained by means of two incisions, provided that
the posterior spaces are adequately drained with silicon setons or drains and the internal orifice is
either sutured or covered with a rectal advancement
flap. In case residual sepsis persists, due to insufficient surgical drainage and/or inadequate dressing,
the patient needs to be re-operated on, as shown in
Figs. 3.3 and 3.4. When fibrin glue is used or stem
cells are injected, an early sepsis may occur, as
reported by Garcia-Olmo et al. (2009) in 12 of their
49 patients. However, according to these authors, in
only half of the cases was the abscess due to the
procedure itself, namely to the fibrin glue, the use of
which is declining compared with other methods.
An early anal abscess requiring drainage
occurred postoperatively in three out of eight
patients following a combined operation consisting
of placement of a plug and rectal mucosal flap
advancement (Mitalas et al., 2010). Due to this complication, the authors had to interrupt a pilot study.
59
Fig. 3.3 Fistulectomy and a rectal advancement flap were per-
formed in a woman with an anal fistula caused by a suppurative Bartholin’s cyst. Postoperatively, the surgical wound did not
heal due to persisting sepsis. Antibiotic therapy was preferred
to re-operation, but the sinus created a trans-sphincteric fistula
that required a new operation. The patient is in the Sims position and a probe has been inserted into the tract
Fig. 3.4 a Patient in the lithotomy position. The high anterior
fistula was located above the external sphincter. The patient
was 50 years old and had previously undergone two anal operations. The second, a fistulotomy, was followed by anal incontinence. The decision was made to perform a re-do flap, that is,
to make a new rectal flap after curettage of the septic tissue of
the fistula
60
3 Anal Abscesses and Fistulae
Fig. 3.4 b The probe is inserted in the fistula, which included
the entire external sphincter
Fig. 3.4 d Re-do of a mucosal rectal advancement flap
Fig. 3.4 c The fistula tract is removed
Fig. 3.4 e Anterior levatorplasty to create another diaphragm
between the anal canal and perineum with vital tissue not previously used. The lateral left branch of the puborectalis muscle
is shown
3.5 Suture Dehiscence and
Non-healing Wounds
The following patients are at greater risk of suture
dehiscence and/or a non-healing wound: a) those
with diabetes, obesity, Crohn’s disease, or
immunosuppression (HIV and AIDS); b) those
with anal hypertonicity and an endoanal wound; c)
those who do not appropriately care for the wound
or carry out adequate perineal hygiene by means of
hip baths; and d) those who are highly sensitive to
3.5 Suture Dehiscence and Non-healing Wounds
61
Fig. 3.4 f Both puborectalis branches are sutured one to the
other during anterior levatorplasty
Fig. 3.4 h Complication 10 days postoperatively, when the
patient, after a week of peripheral parenteral nutrition and
Loperamide, had the first bowel movement. The small dehiscence of the rectal flap was treated by positioning a draining
seton, to prevent sepsis. This seton was eventually converted to
a cutting one
pain, as they will not tolerate a proper dressing and
an effective postoperative curettage of the wound,
Fig. 3.4 g Aspect of the operating field at the end of the opera-
tion
due to excessive gluteal contraction. In these
cases, in which painful maneuvers are necessary,
the patients should be sedated. Curettage of the
wound should be performed during an office visit
by the surgeon, using a Volkmann spoon. It might
be also suggested to the patient to clean the wound
at home with a toothbrush or gauze. If subclinical
chronic sepsis occurs, it is likely to affect wound
healing, in which case re-intervention might be
indicated: the chronic ulcer with its hardened margins excised and the defect covered with an
advancement anoplasty (Fig. 3.5). If the residual
wound is wide, a VAC (vacuum-assisted closure)
procedure may be successfully used as it favors
rapid healing by means of negative pressure, as
reported by the group of Professor Ronan
O’Connell in 2010. Further details on the use of
the VAC system in coloproctology were provided
in an interesting review published by Bemelman in
2009. More rarely, the wound becomes chronic and
fibrotic and leads to perianal retraction, preventing
anal closure and causing incontinence. In this case,
anal-perineoplasty might be needed, as reported in
12 patients who underwent re-operation on our
unit (Bernardi and Pescatori, 2001). A full-thickness skin graft was successfully used by Binda and
Trizi (2007).
62
3 Anal Abscesses and Fistulae
Fig. 3.5 a Non-healing endoanal wound that developed into a
chronic ulcer in a heavy smoker, who underwent re-operation
due to the recurrence of an intersphincteric posterior anal fistula. Preoperative transanal ultrasound showed a small posterior
chronic abscess below the surgical wound. The patient was placed in the lithotomy position in the operating theatre for a surgical revision
Fig. 3.5 c Curettage of the small chronic abscess
Fig. 3.5 b A probe was inserted in the ulcer but a fistula orifice
was not found
Fig. 3.5 d Endoanal surgical wound after curettage and trim-
mings of the fibrotic ulcer margins
The presence of parasites in the stool or the
persistence of a foreign body might also prevent
wound healing, as happened in two patients on our
unit. One was an elderly woman whose wound did
not heal for years after a fistula operation performed elsewhere. Following a course of perianal
electrostimulated acupuncture, a procedure which
enhances tissue trophism, a retained surgical gauze
was surprisingly expelled through the underskin
below the wound, which then healed. The other
patient was a young female who had undergone
fistulectomy and a rectal advancement flap procedure. The flap suture healed properly in due time,
but the perianal wound was still open and became
3.5 Suture Dehiscence and Non-healing Wounds
63
Fig. 3.5 e The whitish fibers of the internal sphincter can be
seen at the base of the wound
Fig. 3.5 g In the posterior anal canal, there is fibrosis and ische-
mia, both of which delay healing. The decision was made to
perform an anoplasty, with a cutaneous flap to cover the wound
Fig. 3.5 f A 0.5-cm section of the internal sphincter, in its
middle portion, was performed to carry out a lay-open
Fig. 3.5 h The anoplasty has been completed and a well-vascu-
larized cutaneous flap sutured to the anal canal
infected after a month, until we found that she had
an oxyuriasis and gave her proper treatment. The
wound fully healed in a couple of weeks. Since
then, we routinely carry out a parasitological exam
prior to performing anal fistula surgery.
Careful local disinfection together with the use
of cicatrizing agents, both local and systemic, also
promotes healing of the wound. Van Koperen et al.
(2010) stressed the importance of excising the
granulomatous tissue, i.e., the pathological epithelium, at the posterior aspect of the fistula when
performing a lay-open. This maneuver encourages
wound healing. The completeness of diseased tissue excision may be appreciated by palpating the
deep part of the surgical wound, which should be
soft. If it is hard, the residual fibrotic tissue is like-
64
Fig. 3.5 i At the end of the operation, the anus was closed. The
patient received nil by mouth and was kept constipated with
Loperamide, receiving intravenous fluids and antibiotic therapy
for 5 days. The patient is continent and without recurrence after
six months
ly to prevent healing and necessitates removal
using either a Volkmann spoon or scissors.
A “technological” alternative to conventional
curettage consists of destruction of the diseased
tissue by means of a laser probe (Biolitec), carried
out by introducing the probe in the fistula tract
through the external orifice. This approach was
used by Wilhelm (2011), who reported no postoperative complications in a series of 11 patients
apart from one case of soiling.
A brief mention is needed on the management
of suture dehiscence, i.e., the breakdown of a rectal advancement flap—usually constructed to
cover the endoanal defect—following the excision
of a trans-sphincteric or high intersphincteric fistula. The risk of dehiscence is greater in the presence
of proctitis or pus, in patients with Crohn’s diease,
and in heavy smokers (Zimmerman et al., 2003). If
fibrin glue is used, the shorter the tract, the greater
the risk of dehiscence. The association of a rectal
flap with the use of fibrin glue is unlikely to ensure
better healing and increases the risk of suture
breakdown, as reported by Van Koperen et al.
(2008) and Alexander et al. (2008). A soft rubber
tube with a proximal rigid end, aimed at keeping
the tube in place above the anorectal ring, i.e., the
Kosorok device, may also be used to successfully
protect the endoanal suture of a rectal flap
(Pescatori, 1997) (Fig. 3.6).
3 Anal Abscesses and Fistulae
Fig. 3.6 Kosorok tube to preserve endoanal surgical wounds
from fecal contamination
3.6 The Prevention of Postoperative Anal Incontinence
In patients who clearly require treatment for an anal
fistula, even prior to the examination it may become
apparent that he/she is at risk of postoperative incontinence, simply based on an inquiry about bowel
habits and on the obstetric and clinical history.
Patients of advanced age, a short woman who has had
more than one vaginal delivery with heavy babies,
patients with associated inflammatory bowel disease
or irritable bowel syndrome with frequent diarrhea,
patients with a history of anal surgery and hysterectomy, or, of course, those with episodes of fecal incontinence need special care to preserve the integrity of
the anal sphincter, the length of the anal canal, and its
sensitive epithelium. With the patient in the Sims
position, merely by looking at the perineum and the
anus we may be able to predict the risk of incontinence. Perineal descent, gaping or deformed anus,
perianal scars, and mucosal prolapse protruding
through the anus are all signs of a weak sphincter and
short anal canal. Using a few simple maneuvers—
such as asking the patient to squeeze while the perianal skin is gently touched with a needle and the
reflex contraction of the external sphincter, i.e., the
anal reflex, is evaluated—gross signs of pudendal
neuropathy potentially can be determined. Based on
3.6 The Prevention of Postoperative Anal Incontinence
this finding, and if the patient is constipated, a
reduced rectal sensation can be suspected. This can be
measured by simply inflating a latex balloon in the
rectum to assess the onset of feeling (around 20 ml of
air), the urge to pass stool (60 ml), and the maximal
urgency (120). If these responses are altered, they
may predict postoperative incontinence, even in male
patients with intact anal sphincters (Pescatori et al.,
2004). Patients should be questioned repeatedly, as
almost none is happy to admit fecal incontinence. If
the patient is simply asked: ”Do you lose stool?” the
answer is likely to be: “No, I don’t.” But if we ask: “In
cases in which you have had diarrhea but there was no
toilet nearby, did the stool ever leak?” the answer is
likely to be: “Yes, it did, sometimes.” Therefore, it is
important to spend some time talking with the patient,
alone, without relatives in the room.
If a patient has indeed had episodes of incontinence, we need to know why, i.e., the altered component of the continence mechanism must be identified. It may be anatomical, e.g., localized sphincter injury related to previous fistula surgery, or simply a functional disorder, such as deficient innervation causing a weak squeeze or a lack of rectal sensitivity. Regardless, the patient should undergo further examination by anal-vaginal or dynamic perineal ultrasound (US), defecography, anal manometry and manovolumetry, or, in some cases, magnetic
resonance imaging, which may well evidence
obstetric injuries and asymmetries of the upper
pelvic floor muscles. In selected cases in which voluntary contraction is found to be of short duration
and the anal reflex is deficient, it may be useful to
measure PNTML (pudendal nerve terminal motor
latency) to confirm the suspicion of pudendal neuropathy. If this alteration is present, pelvic floor
rehabilitation, especially aimed at improving rectal
sensation by means of transanal electrostimulation,
might be indicated prior to (or after) fistula surgery
in order to minimize the risk of postoperative incontinence. A fibrotic internal sphincter, poor voluntary
contraction, and perineal scars are negative predictors of outcome following biofeedback training in
these incontinent patients (Terra et al., 2006).
Ellis (2010), interviewing 78 patients who were
candidates for fistula surgery, determined that for the
majority of them the main goal was, rather than cure
and the avoidance of anal sepsis recurrence, not to
become incontinent after the operation. This marked-
65
Fig. 3.7 Trans-sphincteric anal fistula. A lay-open is likely to
cause fecal incontinence, because the three portions of the
external sphincter (subcutaneous, superficial, and deep) were
below the fistula. Patient in the lithotomy position
ly increased the number of operations carried out by
colorectal surgeons that were aimed at preserving
anal continence, i.e., sphincter-sparing procedures. In
fact, these procedures accounted for 50% of anal continence procedures in the 1990s but more recently
increased to 80%, according to a report by Abcarian’s
group in Chicago (Blumetti et al., 2010). Never theless, a recent paper from St. Marks Hospital
(Atkin et al., 2011) concluded that, when dealing
with high fistulae, the lay-open is still the best option,
as the British authors did not report a significant
incontinence rate using this more aggressive policy,
which is more radical but is associated with a very
low number of recurrences.
My personal policy is to carry out a sphincter saving procedure in all high trans-sphincteric fistulae
(Fig. 3.7).
De Stefano, a colorectal surgeon from Orbassa no, recounted a story told at a Congress by Bruno
Roche, in which a patient with a recurrent anal fistula preferred to permanently keep a seton rather
than undergo a lay-open of the fistula tract, which
might have rendered him incontinent.
As far as the risk of incontinence, it was noted
above that bowel habit, clinical history, rectal sensation, and the integrity of the anal sphincters are
important factors. But what is even more important
is the type of fistula to be managed, as this strongly influences the choice of the operation:
66
3 Anal Abscesses and Fistulae
• Lay-open (fistulotomy) or fistulectomy, descri bed by many authors.
• Fistulectomy alone, with seton (Hanley and
many other investigators) or with internal sphincteromy (Parks).
• The Mann and Clifton re-routing procedure
(Mann and Clifton, 1985), with the technical
variation reported by Zbar and Pescatori (2004).
• Rectal advancement flap (Aguilar et al., 1999).
• Cutaneous flap (Nelson et al., 2000).
• Primary suture of the internal orifice
(Athanasiadis et al., 2004).
• Fibrin glue (Buchanan et al., 2003) or Permacol,
i.e., porcine collagen (Hammond et al., 2011)
injection.
• Plug insertion (Christoforidis et al., 2009; Lenisa
et al., 2010).
• The not novel but revisited LIFT (ligation of the
intersphincteric fistula tract) procedure originally proposed by Phillips (Rojanasakul, 2009;
Bleier et al., 2010).
• The novel bio-lift (Ellis, 2010).
• Stem cells injection (Garcia-Olmo et al., 2009).
• Video-assisted ablation of the fistula tract
(VAAFT), the “triumph” of modern technology
(Meinero and Mori, 2011).
Of the above mentioned techniques, all but one
(fistulotomy) are aimed at sparing the anatomy and
function of the anal sphincter and decreasing the
risk of postoperative incontinence, especially in
case of high and trans-sphincteric tracts.
Interestingly, St. Mark’s Hospital’s policy is still
fistulotomy-oriented, even in case of high fistulae.
At our unit, 40% of the cases are still treated with
a lay-open, compared with 50% in Chicago
(Abcarian, in Blumetti et al., 2010) and 80% at St.
Mark’s Hospital (Phillips, in Atkin et al., 2011).
As far as the risk of postoperative incontinence
is concerned, according to personal experience and
as reported in the literature, the surgeon’s policy
should be based on the following principles: First,
a low posterior intersphinteric fistula in a young
continent male who does not suffer from diarrhea
and has never had anal surgery may be laid-open
with minimal risk of complications. Second, a high
anterior trans-sphincteric fistula of an elderly multiparous (vaginal) female with diarrhea, weak
sphincters, and perineal descent, rectal hyposensation, and previous anal surgery cannot be laid-open
as there is a risk of postoperative incontinence.
Instead, the patient will need a fistulectomy with a
sphincter-saving technique, possibly without
seton, as anteriorly the external sphincter is thin
and there is no puborectalis muscle (Fig. 3.8).
Therefore, in the operating theatre, prior to “cutting” we need to carefully inspect, palpate, gently
probe, and visualize (by injecting methylene blue,
peroxide water, or milk).
However, it also should be noted that between
the two above-described possibilities there is a
wide range of intermediate conditions, which renders our subspecialty more difficult but also more
appealing and allows us to better appreciate why a
patient with anal fistula and abscess should be
dealt with by an experienced colorectal surgeon, as
stated at the beginning of this chapter.
In the following, we consider the various
options, i.e., the dos and don’ts when dealing with
different anatomical and physiological patterns,
while always bearing in mind the final goals: to
prevent or minimize postoperative incontinence
and to achieve permanent eradication of the sepsis.
If the tract is either high or anterior, it is better not
to perform a fistulotomy. If it is trans-sphincteric
and the sphincters are weak, it is likewise better to
avoid a lay-open. In these two cases, fistulectomy
is the preferred option.
Following fistulectomy, what is the best way to
preserve anal function? It does not involve a seton,
which is expected to cause some degree of muscle
fibrosis and likely to leave an anal deformity,
which might favor soiling. Instead, a plug, fibrin
glue, and rectal mucosal flap advancement (less
costly) are advantageous strategies, as they do not
affect the sphincters and keep most of the sensitive
epithelium intact.
The literature findings are as follows: fibrin
glue was reported to cause local sepsis, pruritus,
and pain in 47% of the patients in one series
(Zmora et al., 2005), whereas in other reports there
were no significant postoperative complication
when fibrin glue was mixed with Permacol
(Hammond et al., 2011).
O’Connor et al. (2006) did not observe any
adverse events in their patients treated by the
insertion of a Surgisis plug, made of porcine
lyophilized intestinal submucosa, into the curetted
fistula tract. Among these patients, 80% were
3.6 The Prevention of Postoperative Anal Incontinence
67
Fig. 3.8 a In a male patient, a posterior low intersphincteric
fistula (P) can be usually laid-open without continence problems. The puborectalis muscle is in the posterior aspect. After
fistulotomy, curettage is performed with a Volkman’s spoon to
prevent residual sepsis
cured, with no case of new-onset anal incontinence, as no sphincter division was carried out. It
should be said, however, that O’Connor is a consultant of the company manufacturing the plug, as
noted by the author at the end of the article.
American authors are requested by law to disclose
any potential conflict of interest. In a prospective
study, European (Italian and Spanish) authors,
with no conflicts of interest, reported just three
complications (pain and edema) out of 60 patients
surgically treated with a plug; there was no case of
anal incontinence (Lenisa et al., 2010). Similar
findings, i.e., the absence of incontinence, were
reported in 49 patients operated upon at the
University of Minnesota by Christoforidis et al.
(2008). Unfortunately, incidental protrusion of the
plug occurred in 14 patients. The same complication occurred in 22% of the 43 patients who also
had the plug procedure, carried out by
Thekkinkattil et al. (2009). However, recurrence
rates of 80% with the plug vs. 13% using a rectal
advancement flap (Ortiz et al., 2009) and 69%
(including persisting fistulae) with fibrin glue
Loungarath et al. (2004) have been reported.
Therefore, due to the high complication and failure
rates, neither the plug nor the glue has become
Fig. 3.8 b In a female, a laid-open high anterior trans-sphincte-
ric (or intersphincteric) fistula would almost always be follow ed by incontinence. Fistulectomy is more often preferred.
Anteriorly, there is no puborectalis muscle
popular. By contrast, a trial comparing seton with
fibrin glue showed superiority of the seton in terms
of recurrence (Altomare et al., 2011).
Three prospective studies, by Shukla et al.
(1991), Ho et al. (2001), and Zbar et al. (2003),
reported a low incontinence rate (5, 8, and 5%,
respectively) with respect to flatus and liquid stool
following fistulectomy and seton. Similarly, the
rate of incontinence in our patients after the same
procedure was 5% (Pescatori et al., 1995). Overall,
no case of incontinence to solid stool was reported
in about 700 patients in the above quoted studies.
Ritchie et al. (2009) reviewed 37 studies in which
a cutting seton was used and reported a higher
incontinence rate (12%), but many series were retrospective and also included patients with Crohn’s
diseases, who are more prone to continence problems due to the liquid stool. In 63 patients treated
for complex fistulae with a Silastic or Penrose
seton, Abarca et al. (2010) reported recurrence in
just 6% and incontinence, mostly to flatus, in 10%.
Finally, Sung et al. (2010) had no case of postoperative incontinence among their patients who
received a seton following fistulectomy performed
for trans-sphincteric tracts, and none of the
patients of Thornton et al. (2005) who were treat-