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60
P. Sheikh and P. Bajaj
5.6.4.4 Anal Fistula Plug
Champagne BJ et al. in 2006 published results of
treating fi stula using a biological plug derived
from the submucosa of porcine small intestine
(Surgisis from Cook Surgical) (Fig. 5.19 ). Its
components are collagen which provide strength,
proteoglycan (regulates growth factor activity),
elastin (provides elasticity), glycosaminoglycans
like heparin (promotes angiogenesis), and hyaluronic acid (prevents scarring and adhesions).
Adjacent cells are attracted. Capillary growth
delivers nutrients and allows more cells to enter.
Surgical site gets saturated by host cells replacing plug. An impressive success rate of 85 % in
46 patients followed up for a median period of
1 year has been reported (Champagne et al.
2006 ). Unfortunately, the same success rate
could not be replicated by most surgeons. It is
indicated for Crohn’s fi stula, patients with poor
sphincter function, and those unfi t for surgery.
The fi stula plug is inserted into the primary
opening of fi stula and is secured in place with
one or two stitches. A systematic review of cases
that used anal fi stula plug from 1995 to 2011 was
published in 2012 (O’ Riordan et al. 2012 ). This
revealed an overall healing rate for non-Crohn’s
fi stula to be around 54 %. One of the common
causes of failure was the extrusion of the plug in
almost 8.4 % of the cases. The healing rates in
Crohn’s fi stula were higher in most studies
reaching to almost 85 % (Schwandner et al.
2008 ). The Gore Bio-A® Fistula Plug is another
bioprosthetic plug which is used with similar
results ranging from 57.5 to 72.7 % (Ommer
et al. 2012 ; Ratto et al. 2012 ).
The main advantages of the bioprosthetic plug
are its safety, the incidence of incontinence is
very low, has low septic complications, and can
be repeated. However, using a plug increases the
cost of the surgery; the results may be inferior as
compared to the other standard procedures. It is
recommended for Crohn’s fi stula, patients with
poor sphincter function, and those unfi t for
surgery.
a
c
2
1
Mucosa
Submucosa
Internal Sphincter
External Sphincter
Side View
Fig. 5.19 Anal fi stula plug. ( a ) Surgisis® AFP™ anal fi stula plug. ( b ) Gore Bio-A® Fistula Plug. ( c ) Shows how to
suture the fi stula plug
Needle
b
3
5 Perianal Sepsis and Fistula
61
5.6.4.5 Ligation of Intersphincteric Fistula Tract (LIFT)
In 2007, Dr. Arun Rojanasakul fi rst published an
article on a total sphincter-saving procedure
which he termed as LIFT (ligation of intersphincteric fi stula tract). The procedure is quite simple
and consists of ligation of the fi stula tract in the
ab
intersphincteric space with curettage of the
remaining tract (Fig. 5.20 ). Rojanasakul’s initial
success rate was 94.4 % (Arun Rojanasakul et al.
2007 ). Subsequent studies have revealed a heal-
ing rate ranging from 68 to 83 % with an average
healing time from 6 to 7 weeks. The sample size
of these studies has been mostly small. Recently,
d
c
e
Fig. 5.20 LIFT technique. ( a , b ) Approach to intersphincteric space. ( c ). Fistula tract dissected and identifi ed. ( d )
Fistula tract ligated with Vicryl suture. ( e , f ) Fistula tract divided
f
62
P. Sheikh and P. Bajaj
two large series have been reported with a longer
follow-up. The series from Singapore reported 93
cases with a mean follow-up of 23 weeks. At the
end of 1 year, 78 % of their patients were cured
(Tan et al. 2011 ). A very important observation,
which was made in this study, was that the median
time to recurrence was 22 weeks. Thus, studies
with longer follow-up are needed to validate the
success or failure of a particular procedure. The
second large series of 93 cases has been reported
from Minnesota with a median follow-up of
19 months (Wallin et al. 2012 ). The results, how-
ever, were not very encouraging (40 % after the
fi rst LIFT procedure). The success rate improved
to 57 % after subsequent surgery. Rojanasakul
has stressed the need to follow the proper steps in
the LIFT technique as described by him,
water- tight ligation of the intersphincteric tract
being the most important step to ensure success
of the procedure. The marked difference in the
success rates in the two series also raises the
issue of surgical competence, which needs to be
considered.
Modifi cations of the LIFT technique have been
described to increase its success rate. One of the
causes of failure of the LIFT technique has been
attributed to inadequate clearance of all unhealthy
granulation tissue/sepsis in the distal tract. A
recent study of 41 cases compared the LIFT technique with LIFT along with the additional step of
coring fi stulectomy, which was done from the
external opening till the anal sphincter (Siripong
Sirikurnpiboon et al.
2013 ). No signifi cant differ-
ence in success rate was noted (85 % vs. 81 %).
Another study of 41 patients to determine whether
adding an advancement fl ap to the LIFT technique would help to increase the success rate
revealed an overall healing rate of 71 % (Van
Onkelen et al. 2012 ). Both the above series were
small and revealed no signifi cant incontinence.
Reinforcing the LIFT with a bioprosthetic graft
has been used to signifi cantly improve the success
rate of LIFT (75– 94 %) (Ellis 2010 and Ellis et al.
2010 ). This has been reported from a single center
and not much data is otherwise available. Another
small study of 13 patients published recently
showed a primary healing of 68.8 % with the BioLIFT procedure (Tan and Lee 2013 ). LIFT, due to
its simplicity and safety, is becoming the popular
technique for transsphincteric fi stula worldwide.
It gives less postoperative pain and heals wound
faster with early return to normal work. However,
it should be done in selected patients. Further
reports are awaited to confi rm the long-term
results and feasibility of the technique in various
types of fi stula.
5.6.4.6 Video-Assisted Anal Fistula Treatment (VAAFT)
In 2006, Dr. P. Meinero described the videoassisted anal fi stula treatment (VAAFT) technique
for fi stula-in-ano. This technique basically consists of an initial diagnostic phase which is performed by an 18-cm long rigid fi stuloscope with
an 8° angled eyepiece, which is passed through
the external opening (Fig. 5.21 ). Glycine–manni-
tol solution is used to open the fi stula tract. The
fi stuloscope is advanced till the internal opening.
a
b
Fig. 5.21 VAAFT. ( a ) Instrumentation for VAAFT. ( b )
Fistuloscope passed through the external opening—
illumination seen at the internal opening
5 Perianal Sepsis and Fistula
63
In the operative phase, a unipolar electrode is used
to cauterize the lining of the fi stula tract, and an
endobrush is used to extract the necrotic material.
A semicircular or linear stapler is then used to seal
off the internal opening. Alternately, a cutaneous
or mucosal fl ap can be used. At the end of the
surgery, synthetic cyanoacrylate is injected to
reinforce the staple/suture line. He published his
results in 2012 (Meinero and Mori 2012 ). The
procedure was performed in 136 patients over a
period of 5 years. In a mean follow-up of
13 months, primary healing was achieved in 72
(73.5 %) patients at the end of 3 months. At the
end of 1 year, 87.1 % of fi stulas had healed. In his
series, only six patients had a suprasphincteric fi stula. It is not very clear as to how many of those
six recurred. The main advantage of this technique is sphincter preservation, thereby very low
incidence of incontinence, and the postoperative
pain is minimum. However, no mention is made
about how to manage tracts which are longer than
18 cm, tracts which have no external openings,
and tracts which are acutely curved. Adding
another procedure, like advancement fl ap to
VAAFT, may improve the results (Schwandner
2013 ). Since this is a relatively new procedure, it
would be advisable to look out for some more evidence before one can give a verdict.
5.6.4.7 Autologous Adipose-Derived Stem Cell
Autologous adipose-derived stem cells (20 million) derived from liposuction have been used to
treat fi stula-in-ano. They can be used in combination with fi brin glue. The results at 1 year vary
from 50 to 71 % (Garcia-Olmo et al.
2009 ;
Herreros et al. 2012 ). The results may be superior
as compared to the use of fi brin glue alone. There
were no signifi cant side effects with minimal
morbidity after this procedure. However, the low
success rates and the as yet experimental nature
of this procedure still prelude it from being
recommended as a standard treatment for
fi stula-in-ano.
5.6.4.8 Fistulectomy and Fistulotomy
Fistulectomy is recommended for low anal fi stulas, as the success rate is high with this procedure
and with minimal risk of incontinence. The success rates can be as high as 93 to 100 % in experienced hands (Tozer et al.
2013 ; Cariati 2013 ).
The incontinence is usually minor and ranges
from 11.5 to 20 %. It is also indicated in epithelialized tracts and tracts surrounded by dense
fi brous tissue. A tract is cannulated and excised
in toto leaving the wound to heal by secondary
intention or closed primarily (Figs. 5.22a–d ).
Alternatively, a coring technique may be used in
which circular incision is made around the external opening which is held in Allis forceps. The
wound is deepened and tract is cored out up to
internal opening (Fig. 5.23 ). The internal defect
is closed by approximating the mucosa and
internal sphincter or by advancement fl aps if the
mucosal defect cannot be closed by approximation. The defect in the internal and external
sphincter can be closed with 2/0 Vicryl. The technique gives excellent results with rapid healing
and acceptable rates of incontinence and recurrence if properly executed. There is less wound
discharge and soiling, minimal fi brosis, and minimal anal deformity. However, tuberculosis and
Crohn’s should be ruled out before undertaking
this procedure and repair of inner defect by
mucosal fl ap.
For low transsphincteric or intersphincteric
fi stula and those of recent origin, the fi stulous
tract can be laid open as fi stulotomy (Fig. 5.24 )
with all unhealthy granulation tissue curetted
out. The external wound can either be left open
to heal by secondary intention or closed primarily or partially to reduce the defect and healing
time.
All side tracks should be looked for, laid open,
and curetted out. Counter-incisions may be
needed for complex fi stulas with long and multiple external tracts (Fig.
5.25 ). The internal open-
ing along with adjacent part of internal sphincter
and anal gland should be excised.
Division of external and internal sphincters
can be undertaken safely up to dentate line in
young healthy individuals, but one should be
careful in elderly frail patients with low sphincter
tone. In such patients, either a seton or some
other conservative technique is used to reduce the
chances of developing incontinence.
64
a
b
P. Sheikh and P. Bajaj
d
c
Fig. 5.22 Fistulectomy. ( a ) Fistula being excised. ( b ) Wound with shelving edges after fi stulectomy. ( c ) Healing
healthy wound 2 wks after fi stulectomy. ( d ) Primary closure after fi stulectomy
5.6.4.9 Fistulectomy with Primary Sphincter Reconstruction
Cutting seton has a high success rate, but one
has to deal with the higher rate of incontinence
that goes with it. The reason for the incontinence is that even though the seton cuts slowly,
thus enabling the sphincter ends not to retract
much, it still does cut the anal sphincter. If one
were to cut the sphincter and suture it primarily,
the success rates would be still high, while
reducing the incontinence rates. Based on this
principle, two recent papers showed a success
rate as high as 95.8 % with an insignifi cant
change in the continence scores (Ratto et al.
2013 ). Continence and anal manometry results
were improved in incontinent patients and were
not jeopardized in continent ones (Arroyo et al.
2012 ). Fistulotomy with sphincter reconstruc-
5 Perianal Sepsis and Fistula
65
Fig. 5.23 Coring technique for fi stulectomy
Fig. 5.25 Complex fi stula with long and multiple tracts
Fig. 5.24 After fi stulotomy, underlying granulations to
be curetted
tion is an especially suitable technique for
incontinent patients with recurrent fi stulas. The
primary sphincter repair enhances wound healing and reduces the hospital stay. The author
also follows this procedure for transsphincteric
fi stula with similar satisfying results.
5.6.5 Intersphincteric Fistula-in-Ano
Most of the procedures described above are useful for transsphincteric fi stulas. Low intersphincteric fi stulas typically may have an external
opening close to the anal verge and can be easily
treated by a simple fi stulotomy. High intersphincteric fi stulas are the most diffi cult to diagnose
Fig. 5.26 Supralevator tract extending to the preperitoneal space. The drains are positioned in the preperitoneal
space
because they do not have any external fi ndings.
They also have the highest recurrence rate and
take the longest to heal. Their symptoms are similar to those of fi ssure-in-ano, and it is not uncommon to fi nd these patients being treated both
medically and surgically for fi ssure-in-ano. One
should suspect an intersphincteric tract especially
when the patient has additional symptoms of discharge per rectum, soiling of undergarments, and
pain over the sacrococcygeal area. These fi stulas
can extend superiorly to the supralevator space
and still further to the preperitoneal and retroperitoneal spaces. The later two circumstances
may be misdiagnosed as peritonitis, and the
patient may be subjected to a laparotomy (Sheikh
P and Baazka A 2014 ) (Fig. 5.26 ).
66
P. Sheikh and P. Bajaj
Treatment for high intersphincteric fi stulas
has not been mentioned much in the literature. A
simple approach is to excise the internal opening
along with the underlying indurated affected anal
gland and to curette the rest of the tract. In a tract
which extends to the preperitoneal space, an
additional extraperitoneal abdominal approach
will be needed to curette this part of the tract.
These cases will have to be closely followed up
and wound irrigated with saline till they heal
completely. Sometimes, they may require additional curettage of the wounds under anesthesia
to get rid of the hypergranulation tissue that usually occurs in these cases. A short high intersphincteric fi stula can also be cored out
completely by an intersphincteric dissection and
the wound can then be primarily closed. This
does require some technical expertise, but can
shorten the postoperative period and make it very
easy to manage.
5.6.6 Anal Fistula in Special
Conditions
It is important to subject all excised tissue during
surgery to histological examination. This will
enable the surgeon to diagnose and treat other
uncommon causes of anal fi stula like tuberculosis, Crohn’s disease, and malignancy.
Anal fi stula due to Crohn’s disease is not as
common in the east as it is in the west. One
should suspect Crohn’s fi stula when the patient
has corresponding abdominal complaints. There
may be multiple draining sinuses and scarring in
the perianal area (Fig.
may have a preexisting intestinal disease. The
diagnosis is confi rmed on histology of the fi stula
tact. The main treatment in Crohn’s fi stula unlike
a cryptoglandular fi stula is medical rather than
surgery. Surgery is carried out as a supportive
procedure. Usually, a long-term seton is the safest option. This reduces perianal drainage and
pain without damaging the sphincter and minimizes the risk of future abscesses arising from
the fi stula track (Faucheron et al. 1996 ).
Fistulotomy for low fi stulas can be attempted.
Success rates will still be lower than in patients
5.27 ). Many of the patients
Fig. 5.27 Crohn’s fi stula
without Crohn’s disease (Schwartz et al.
2001 ).
There may be some role of anal fi stula plugs in
these fi stulas. Infl iximab is a murine chimeric
monoclonal antibody against tumor necrosis
factor-α. It is the only medical treatment proven
to lead to a reduction in the number of perianal
fi stulas in patients with Crohn’s disease (Present
et al. 1999 ). However, in practice, recurrence
after cessation is common.
Tuberculosis causes anal fi stula in 4–5 % of
the cases in the east. A preoperative chest x-ray is
necessary to rule out pulmonary tuberculosis
which is a commoner form of tuberculosis. It is
very diffi cult to clinically diagnose tuberculosis
fi stula preoperatively. The classical description
of the presence of multiple openings is more
often not true. Once histology reveals tuberculosis, it has to be treated as extrapulmonary tuberculosis, and the complete treatment may extend
from 9–12 months. These patients heal very rapidly once they are started on antituberculosis
treatment.
Malignancy arising from an anal fi stula tract is
rare. It is more common to see an anorectal
malignancy being diagnosed as an anal fi stula.
One can have a long-standing fi stula where
malignancy can develop in one part of the tract.
In the author’s experience, most of these fi stulas
are mucinous adenocarcinoma and should be
treated accordingly.
Anal fi stula in HIV patients needs to be particularly investigated for tuberculosis. The surgical management of these patients essentially
remains the same as non-HIV patients, except
5 Perianal Sepsis and Fistula
67
that one should ensure a good immunologic
status of the patient before surgery. They should
preferably be managed by some conservative
method.
Conclusion
A clear understanding of the anorectal anatomy, along with the knowledge of etiopathogenesis of anal fi stula, is of paramount for any
surgeon who treats it. In the last decade, new
surgeries have been added to the existing list
of procedures for anal fi stula. This has only
added to the number of procedures available
and may confuse the surgeon further with the
choice of operations available. Advancement
fl aps are useful in closing big mucosal defects.
Seton placements have been widely used in
the past and are still being used either as draining setons or as cutting setons in patients
where incontinence is threatened. Newer technique like LIFT, due to its simplicity and conservative nature, is proving to be increasingly
popular especially for low transsphincteric
fi stula. The anal fi stula plug has low success
rate except for Crohn’s disease. VAAFT and
autologous adipose-derived stem cells are new
techniques with not much data available to
opine about their success. Fibrin glue has
moderate success rate with simple low fi stula,
but poor results with high or complex anal fi stula. It should be used in patients unfi t for surgery and those with low sphincter tone like
fi stula plug. Cutting seton and fi stulotomy
have high success rate, but one has to take
steps to avoid or reduce rate of incontinence.
Primary suturing after fi stulectomy for transsphincteric fi stula appears to take care of this
incontinence and is something to look out for
in the future. Recurrence after draining an
anorectal abscess can be decreased, if fi stulotomy is done primarily by experienced surgeons in selected patients. Most of the studies
available are small in size, and there are no
randomized trials available to compare the
success of various procedures against equivalent types of fi stula. At present, there is no evidence to recommend or condemn any single
procedure. Similar views were echoed in the
Cochrane database systematic review which
was published in 2010 . There is certainly no
ideal surgery as yet for anal fi stula. The sur-
geon has to decide about the type of procedure
based on his experience, patient factors, and
the nature of fi stula he or she is dealing with.
There is certainly a lot of scope for more stud-
ies in this area, but the diversity and the com-
plex nature of the disease probably prevent
one to undertake such a study.
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