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- •Preface
- •Acknowledgements
- •Contents
- •Contributors
- •Suggested Reading
- •2.1 Anorectal Genesis
- •2.2.1 Anal Canal
- •2.2.2 Rectum
- •2.3 The Anal Gland
- •2.4 Anal Muscles
- •2.4.1 Internal Anal Sphincter
- •2.4.2 External Anal Sphincter
- •2.4.2.1 Subcutaneous Sphincter
- •2.4.2.3 Deep External Sphincter
- •2.4.3 The Levator Ani Muscle
- •2.4.3.1 Puborectal Muscle
- •2.4.3.2 Pubococcygeus Muscle
- •2.4.3.3 The Iliac Coccygeus Muscle
- •2.4.5 Anorectal Ring
- •2.5.1 Perianal Subcutaneous Space
- •2.5.2 Ischiorectal Space
- •2.5.3 Posterior Anal Space
- •2.5.4 Sphincter Muscle Space
- •2.5.5 The Submucosal Space
- •2.5.6 The Pelvic-Rectal Space
- •2.5.7 The Posterior Rectal Space
- •2.6.1 Arteries
- •2.6.1.1 Superior Rectal Artery
- •2.6.1.2 Inferior Rectal Artery
- •2.6.1.3 Anal Artery
- •2.6.1.4 The Middle Sacral Artery
- •2.6.2 Veins
- •2.6.2.2 External Hemorrhoid Venous Plexus
- •2.8 Anorectal Innervation
- •2.8.1.2 Parasympathetic Nerves
- •Suggested Reading
- •3.2.1.1 Anal Gland Infection Theory
- •3.2.1.2 Central Gap Infection Theory
- •Suggested Reading
- •4.1 Symptoms
- •4.1.2 Pain
- •4.1.4 Dysdefecation
- •4.1.5 Systemic Symptoms
- •4.2 Signs
- •Suggested Reading
- •5.1.1 Common Positions
- •5.1.1.1 Lateral Position
- •5.1.1.2 Knee-Chest Position
- •5.1.1.3 Lithotomy Position
- •5.1.2 Inspection Methods
- •5.1.2.1 Visual Examination
- •Secretions
- •5.1.2.2 Palpation
- •External Anal Palpation
- •Anal Internal Palpation
- •Bimanual Examination
- •5.1.2.3 Probe Examination
- •5.1.2.4 Anoscope Examination
- •Leaf Anoscope
- •5.1.2.6 Methylene Blue Staining Examination
- •Dye Injection
- •5.2.1 Ultrasonic Examination
- •5.2.1.1 Equipment
- •5.2.1.2 Examination Methods
- •Transanal ultrasonography
- •Endoscopic Ultrasonography
- •Intersphincteric Abscess, Intersphincteric Fistula (II Type)
- •Ischioanal Abscess, Ischioanal Fistula (Type III)
- •Pelvirectal Abscess, Pelvirectal Fistula (Type IV)
- •5.2.2.1 Examination Methods
- •5.2.2.2 Diagnostic Value
- •The Internal Opening
- •5.2.3 CT Examination
- •5.2.3.1 Examination Methods
- •5.2.3.2 Diagnostic Value
- •5.2.4 Fistula Angiography
- •5.2.4.1 Examination Methods
- •5.2.4.2 Diagnostic Value
- •5.2.5 Anal Fistula Endoscopy
- •5.2.5.1 Inspection Methods
- •5.2.5.2 Diagnostic Value
- •5.2.6 Pathological Examination
- •5.2.7 Bacterial Culture
- •5.3.5.2 Temperature Sense Detection
- •5.3.5.3 Rectal Volume Sensory Function
- •Rectal Sensation Threshold
- •Rectal Initial Intentional Capacity
- •Rectal Maximum Tolerance Capacity
- •5.3.6.1 Rating Scale
- •5.2.8 General X-Ray Examination
- •5.2.9 Colonoscopy
- •5.2.9.2 Operating Methods
- •5.2.9.3 Diagnostic Value
- •5.3.1 Anorectal Manometry
- •5.3.1.1 Equipment
- •5.3.1.2 Detection Indicators
- •Stress Indicators
- •Rectal Compliance
- •5.3.4 Pelvic Floor EMG Examination
- •5.3.4.1 Inspection Methods
- •5.3.4.2 Testing Indicators
- •Simulated EMG Activity During Defecation
- •5.3.5 Anorectal Sensory Function Examination
- •5.3.5.1 Observation Indicators
- •Mucosal Electrical Sensitivity Test
- •5.3.6.2 Total Score Evaluation Scale
- •Suggested Reading
- •Low Simple Anal Fistula
- •Low Complex Anal Fistula
- •High Simple Anal Fistula
- •High Complex Anal Fistula
- •6.1.2.2 Parks 4 Class Method (1976)
- •Intersphincter Fistula (Low Anal Fistula)
- •Transsphincter Anal Fistula (Low or High Anal Fistula)
- •Superior Sphincter Anal Fistula (High Anal Fistula)
- •6.1.2.4 Other Taxonomies
- •6.3.1 Hidradenitis Suppurativa
- •6.3.3 Perianal Sinus Tract
- •6.3.4 Sacrococcygeal Cyst
- •6.3.5 Perineal Urethral Fistula
- •6.3.6 Sacrococcygeal Osteomyelitis
- •6.3.7 Sacroiliac Bone Tuberculosis
- •Suggested Reading
- •7.5.1 Simple Anal Fistulas
- •7.5.1.1 Anal Fistulotomy
- •7.5.2 Complicated Anal Fistulas
- •7.5.2.2 Anal Fistula Plug
- •Suggested Reading
- •8.1.5 Wound Management Skills
- •8.2.1.1 Anal Fistula Incision (Excision)
- •8.2.1.5 Hanley Method
- •8.2.1.6 Goligher-UI Method
- •8.2.2 Anal Fistula Thread-Drawing
- •8.2.2.1 The Origins
- •Foreign Body Irritation
- •Marking Function
- •Tunnel Thread-Hanging Surgery
- •Traditional Medicine Thread Hanging
- •Drainage Tube Therapy
- •8.2.3 Anal Fistula Sphincter Retention Surgery
- •8.2.3.2 The Main Method of Anal Fistula Retention Sphincter Surgery
- •Fistula Removal
- •Fistula Removal (Parks’s Method)
- •Improved Fistula Removal
- •Anatomical Radical Surgery (Takano)
- •Coring-Out Method (Takao Moriya)
- •Subcutaneous Primary Lesion Resection (Sumie Method)
- •Ischiorectal Fossa Fistula Retention Sphincter Surgery
- •Pelvirectal Fossa Fistula Retention Sphincter Surgery
- •Anal Fistula Muscle Flap Filling Surgery
- •Internal Sphincterotomy (Eisenhammer Method)
- •Detachment Therapy (Insert Medicine Therapy)
- •Detachment Nail Detachment Therapy
- •Fibrin Glue Sealing
- •Biological Patch Filling
- •Endorectal Advancement Flap
- •Perianal Skin Advancement Flap Repair
- •Minimally Invasive Video-Assisted Anal Fistula Treatment
- •Fistula Peeling
- •Low-Temperature Plasma Knife Fistula Ablation
- •Laser Fistula Ablation
- •Wound Stitching Method
- •Fistula Resection or Retention
- •Suggested Reading
- •9.1 Indications
- •9.2 Methods
- •9.2.1 Internal Treatment
- •9.2.1.3 Fuzheng Tuodu Method
- •9.2.2 External Treatment
- •9.2.2.1 External Application Method
- •Encirclement Medicine
- •Ointment
- •Dusting Power Medicine
- •9.2.2.2 Drainage Method
- •Wound Cavity Flushing Method
- •9.2.2.5 Cotton Pad Drainage Treatment
- •9.2.2.6 Dressing Change Method
- •Suggested Reading
- •10.1 Crohn’s Disease Anal Fistula
- •10.1.2 Diagnosis
- •10.1.2.1 Clinical Manifestations
- •10.1.2.2 Examination
- •10.1.2.5 CD Anal Fistula Canceration
- •10.1.3 Treatment
- •10.1.3.1 Drug Therapy
- •Antibiotics
- •Immunosuppressants
- •Antitumor Necrosis Factor
- •Adalimumab
- •Cetuzumab
- •Anti-adhesion Molecule Antibody
- •10.1.3.2 Surgical Treatment
- •Fistulotomy
- •Reconstructive Mucosal Flap/Flap Repair
- •Other Treatments
- •Stem Cell Therapy
- •Gracilis Muscle Transplantation
- •10.2 Infant Anal Fistula
- •Anal Crypt
- •Incidence Rate
- •General Characteristics
- •10.2.2.1 Immune Dysfunction Theory
- •10.2.2.2 Sex Hormone Theory
- •10.2.2.4 Diaper Dermatitis Pathology
- •10.2.2.5 Residual Epithelium
- •10.2.2.6 Fecal Compression
- •10.2.3.2 Surgical Methods
- •Anal Fistula Incision
- •Dragline Therapy
- •10.3 Rectal Vaginal Fistula
- •10.3.1 Cause
- •10.3.2 Categories
- •10.3.3 Diagnosis
- •10.3.4 Treatment
- •10.3.4.1 Commonly Used Surgery
- •Rectal Mucosal Flap Replacement Repair
- •Autologous Tissue Flap Transfer Tamponade Repair
- •Transvaginal Repair
- •Transperitoneal Repair
- •Kraske Posterior Approach
- •By Perineal Incisional Repair (Musset)
- •Transanal Endoscopic Minimally Invasive (TEM) Surgery
- •Synthetic Materials Repair Spells
- •10.3.4.2 Preoperative Management
- •10.3.4.3 Others
- •10.4 Tuberculous Anal Fistula
- •10.4.1 Cause
- •10.4.2 Clinical Manifestations
- •10.4.4 Treatment
- •10.4.4.1 Anti-tuberculosis Treatment
- •Medication Plan
- •10.4.4.2 Surgical Therapy
- •10.4.4.3 Topical Treatment
- •10.5 AIDS Associated with Anal Fistula
- •10.5.1 Diagnosis
- •10.5.2 Treatment
- •Suggested Reading
- •Crohn’s Disease Anal Fistula
- •Infant Anal Fistula
- •Rectal Vaginal Fistula
- •Tuberculous Anal Fistula
- •AIDS Associated with Anal Fistula
- •11.3 “Minimally Invasive” and “Invasive” Anal Fistula Surgery
- •Suggested Reading

Diagnosis and
Treatment of
Anal Fistula
Renjie Shi
Lihua Zheng
Editors

Diagnosis and Treatment of Anal Fistula

Renjie Shi • Lihua Zheng
Editors
Diagnosis and Treatment
of Anal Fistula

Editors
Renjie Shi
Department of Anorectal Surgery
Afliated Hospital of Nanjing
University of Traditional
Chinese Medicine
Nanjing, Jiangsu, China
Lihua Zheng
Department of Proctology
China-Japan Friendship Hospital
Beijing, China
ISBN 978-981-16-5803-7 ISBN 978-981-16-5804-4 (eBook)
https://doi.org/10.1007/978-981-16-5804-4
© Chemical Industry Press 2021
Jointly published with Chemical Industry Press
The print edition is not for sale in China (Mainland). Customers from China (Mainland) please
order the print book from: Chemical Industry Press.
This work is subject to copyright. All rights are reserved by the Publishers, whether the whole or
part of the material is concerned, specically the rights of reprinting, reuse of illustrations,
recitation, broadcasting, reproduction on microlms or in any other physical way, and
transmission or information storage and retrieval, electronic adaptation, computer software, or
by similar or dissimilar methodology now known or hereafter developed.
The use of general descriptive names, registered names, trademarks, service marks, etc. in this
publication does not imply, even in the absence of a specic statement, that such names are
exempt from the relevant protective laws and regulations and therefore free for general use.
The publishers, the authors, and the editors are safe to assume that the advice and information in
this book are believed to be true and accurate at the date of publication. Neither the publishers
nor the authors or the editors give a warranty, express or implied, with respect to the material
contained herein or for any errors or omissions that may have been made. The publishers remain
neutral with regard to jurisdictional claims in published maps and institutional afliations.
This Springer imprint is published by the registered company Springer Nature Singapore Pte Ltd.
The registered company address is: 152 Beach Road, #21-01/04 Gateway East, Singapore
189721, Singapore

Preface
This book deals with the diagnosis and treatment of anal stula, a difcult
anorectal disease. This book is an elaboration and discussion on the history of
anal stula, anatomy and physiology related to anal stula, etiology and
pathology of anal stula, examination, diagnosis, treatment principles, surgical procedures and their evaluation, conservative treatments, academic disputes, and other aspects. The research and progress of the diagnosis and
treatment of anal stula at home and abroad are comprehensively and deeply
expounded on. It contains the author’s long-term research accumulation and
clinical experience. This book provides an overview of both the history and
current situation of the disease, pays close attention to new research trends,
combines closely with clinical practice, is comprehensive in content and rich
in information, and has excellent practicability. It is suitable for all researchers, graduate students, and clinical medical personnel engaged in anorectal
specialty to learn from and reference.
Nanjing, China RenjieShi
Beijing, China LihuaZheng
v

Acknowledgements
I would like to thank Joanna song (Oxon) and Junfang song for their help in
language edit. I also would like to thank my family for their support, especially my daughter Yunyang Shi, for her help in language edit.
vii

Contents
1 History of Cognition and Treatment of Anal Fistula . . . . . . . . . . 1
Renjie Shi and Feng Jiang
2 Anatomy and Physiology of Anal Fistula . . . . . . . . . . . . . . . . . . . 11
Renjie Shi, Dong Yang, and Min Zhang
3 The Etiology of Anal Fistula. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
Renjie Shi, Feng Jiang, and XiaYong Yang
4 Clinical Manifestations of Anal Fistula . . . . . . . . . . . . . . . . . . . . . 43
Renjie Shi and Hongsheng Mao
5 Common Methods of Examination for Anal Fistula . . . . . . . . . . 47
Renjie Shi and Lihua Liu
6 Classification and Diagnosis of Anal Fistula. . . . . . . . . . . . . . . . . 89
Renjie Shi and JinHui Gu
7 The Therapeutic Principle of Fistula-in-Ano . . . . . . . . . . . . . . . . 101
Renjie Shi and Lihua Zheng
8 Surgical Treatment of Anal Fistula . . . . . . . . . . . . . . . . . . . . . . . . 109
Renjie Shi and Lihua Zheng
9 Nonoperative Treatment of Anal Fistula . . . . . . . . . . . . . . . . . . . . 173
Renjie Shi and YiXin Zhang
10 Diagnosis and Treatment of Special Anal Fistula . . . . . . . . . . . . . 181
Renjie Shi and Fang Liu
11 Controversial Problems in the Diagnosis and Treatment
of Anal Fistula . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 223
Renjie Shi and Yu He
ix

Contributors
JinhuiGu Suzhou Hospital of Traditional Chinese Medicine, Afliated to
Nanjing University of Chinese Medicine, Suzhou, Jiangsu, China
YuHe People’s Hospital of Suzhow New District Hospital, Suzhou, Jiangsu,
China
FengJiang Afliated Hospital of Nanjing University of Traditional Chinese
Medicine, Nanjing, Jiangsu, China
Fang Liu Sixth Afliated Hospital, Sun Yat-sen University, Guangzhou,
Guangdong, China
LihuaLiu Nanjing Jiangbei Hospital, Nanjing, Jiangsu, China
HongshengMao Jingjiang People’s Hospital, Jingjiang, Jiangsu, China
RenjieShi Department of Anorectal Surgery, Afliated Hospital of Nanjing
University of Traditional Chinese Medicine, Nanjing, Jiangsu, China
DongYang Afliated Lianyungang Hospital of Xuzhou Medical University,
Lianyungang, Jiangsu, China
XiayongYang Taizhou Hospital of Traditional Chinese Medicine, Taizhou,
Jiangsu, China
MinZhang People’s Hospital of Deyang, Deyang, Sichuan, China
Yixin Zhang Afliated Hospital of Xuzhou Medical University, Xuzhou,
Jiangsu, China
LihuaZheng Department of Proctology, China-Japan Friendship Hospital,
Beijing, China
xi

History ofCognition
andTreatment ofAnal Fistula
RenjieShi andFengJiang
1
Abstract
The names of anal stula and perianal abscess
have been recorded in Chinese literature more
than 2000 years ago. For the treatment of anal
stula, historical documents of anal stulectomy and internal medication could be found.
In the Sui Dynasty, it was believed that the
cause of anal stula was related to the body as
a whole. The treatment method of inserting
medicine into stulas to corrode stulas was
proposed in the Song Dynasty. In the Yuan
Dynasty, the seton therapy of anal stula
based on gravity and medicated thread was
developed. Since then, this therapy has been
continuously improved and optimized in terms
of materials and methods and is still widely
used in clinical practice at present. Modern
medicine has recognized the etiology, examination methods, and treatment principles of
anal stula since the time of Hippocrates more
than 2000 years ago. However, the role of the
anal gland in the pathogenesis and treatment
of anal stula was not recognized until 1958,
R. Shi (*)
Department of Anorectal Surgery, Afliated Hospital
of Nanjing University of Traditional Chinese
Medicine, Nanjing, Jiangsu, China
F. Jiang
Afliated Hospital of Nanjing University of
Traditional Chinese Medicine,
Nanjing, Jiangsu, China
and it has been possible to cure anal stula
since then. Currently, the treatment of anal stula is developing in the direction of protecting anal function and improving the cure rate.
Keywords
Anal stula · Chinese medicine · History
Name of the disease · Pathogen · Pathology
Treatment · Seton therapy
1.1 The Knowledge
andTreatment History
ofAnal Fistula inChinese
Medicine
In the ancient Chinese literature, “abscess,” “stula,” or other terms were rst put forward in the
“Shan Hai Jing,” which was written in the
Western Zhou Dynasty. For example, an extract
in “Shan Hai Jing • Zhongshan Jing” details,
“there were many Teng Fish in He River which
can be eaten to get carbuncle and treat stula.”
Next, hemorrhoids were classied into four
categories: male piles, female piles, pulse piles,
and blood piles in the “Prescriptions of Fifty-Two
Diseases,” which was written in the Western Han
Dynasty (206 BC–AD 8). The symptoms of male
piles were the anus having snail-like, rat-nipple
like prolapses. The prolapses were small tumors
on the surface of which there were often erosions,
© Chemical Industry Press 2021
R. Shi, L. Zheng (eds.), Diagnosis and Treatment of Anal Fistula,
https://doi.org/10.1007/978-981-16-5804-4_1
1

2
R. Shi and F. Jiang
ulcers, and mouthwashes. The symptoms of
female piles were half-inch of hemorrhoids in the
anus shaped like a horn. Hemorrhoids that prolapsed and bled during defecation or female pile
had several orices, and many white mites came
out of the orice. Oral medicine, fumigation
treatment, and surgical treatment for male piles
and abscess were also written in this book. The
treatment methods for male piles and abscess
were mainly external, such as smoking, dressing,
and ironing. For example, when treating male
piles, “Quickly burn the base of the hemorrhoids
to make it necrotic, and use ointment made from
rice and ashes to apply to the wound. The patients
who had male piles with multiple orices should
eat the fat from the cooked sheep meat and three
buckets of rice. If Male piles are located on the
external edge of the anus, about the size of the
nucleus of jujube, sometimes itchy, sometimes
painful, if it can be cut, it should be cut. If not,
mix turtle's brain and bile worms into an application or iron the hemorrhoids with small cobblestones after burning with vinegar. When treating
Male piles without stula, cook a bucket of dates,
a bucket of ointment, make four buckets of medicine solution and pour it into a tub for a sitz bath,
so that pinworms can run out by themselves.”
The book recorded that “Male piles are located
outside the anus, the size of larger ones like a
jujube and the size of smaller ones like a nucleus
of jujube. When treating these kinds of male
piles, it is effective to use a small cupping to pull
the nucleus out for two measures of rice cooking
time, pull out the cupping, ligature the nucleus
with a thin wire, and then use a knife to peel off
it. There will be a small block of blood clots in
the nucleus, and the operation is completed after
peeling it off.” This is similar to the incision and
drainage of the perianal abscess.
Under the section for female piles, there was a
record: for patients with deep rectal rectum, kill a
dog, take the dog’s bladder, put it on a bamboo
tube, insert it into the anus and inate it, pull the
lesion out of the anus, and slowly cut the lesion
with a knife under direct vision. After the operation, the powder of Scutellaria baicalensis was
applied to the patient for recovery. This is likely
to be an incision treatment of the anal stula.
The earliest record of abscess was found in the
“Huang Di Nei Jing,” “Ling Shu • Yong Ju”:
abscess occurs on the buttocks that are red and
swollen, named pilonidal disease. “The patients
need to be treated immediately, if not, the patient
will die in 30 days.” Pilonidal disease may be the
earliest name in Chinese medicine for an anorectal abscess. The earliest record of a stula is
found in the article “Su Wen • Sheng Qi Tong
Tian Lun”: the coldness is deep in the veins and
stays in the muscles and the movement of blood
and Qi is not smooth, resulting in stagnation. As
time progresses, it becomes a scab.
The term of “hemorrhoid and stula” was
seen in the “Shen Nong’s Herbal” rstly. It documented the main cause of the diseases carbuncle
sore and hemorrhoid stula. Hemorrhoid stula
refers to hemorrhoids, stula, and other anorectal
diseases. A total of 365 kinds of effective drugs
were collected in this book before the Han
Dynasty, and there were more than 50 types of
involuntary diseases involving anorectal diseases,
21 types can be used to cure hemorrhoids such as
astragalus, acacia, clam, hedgehog skin, beehives, and so on, and 14 kinds of them can cure
stulas such as oysters and scorpions. There are
astragalus, realgar, and other four types that can
be used to cure hemorrhoids and stulas together.
Gong Qingxuan in the Southern and Northern
Dynasties wrote “Liu Juan-zi’s Gui-Yi-fang”
(AD 499), which is the earliest existing surgical
monograph in China. In this book, the dialectical
treatment of perianal abscesses, such as “Yun Ju”
and “Chi Shi,” is discussed in detail.
The etiology, pathogenesis, and syndrome differentiation and treatment of hemorrhoid stula
were recorded in “Zhu Bing Yuan Hou Lun” (AD
610), which was written by Chao Yuanfang in the
Sui Dynasty. In the “Zhi Bing Zhu Hou,” he proposed seven categories: male piles, female piles,
pulse piles, intestinal piles, blood piles, Qi piles,
and alcohol piles. The etiology and pathogenesis
of these were also expressed vividly in the book.
The male pile is a description of the symptoms of
anal stula, which are rat-like, nipple-like scorpions that grow next to the anus and always have
outows of pus and blood. In the section of
“Earthworm stula”: “earthworm stula … Its
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