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R. Shi and J. Gu
cure rate of the anal stula, and reducing postoperative complications and sequelae. In order to
improve the accuracy of diagnosis, we must pay
attention to the following aspects.
6.2.2.1 Make Good Use ofVarious
Inspection Means
andTechniques
At present, all kinds of methods used in the diagnosis of anal stula have their respective advantages and limitations. It is helpful for the accurate
diagnosis of anal stula to use a comprehensive
application of digital rectal examination, transanal ultrasonography, and rectal and pelvic oor
magnetic resonance imaging. From the threedimensional location and morphology of the anal
stula, we can have a comprehensive and accurate understanding of the internal orice, direction, shape, and relationship with the sphincter of
anal stula. With the improvement in the examination technology of anal stula such as MRI, it
seems that the accurate location of complex anal
stula, from its shape and course, can be on the
whole achieved at present. However, not all clinicians can understand the information reected by
the MRI images or accurately understand the
morphological structure of anal stula and its
relationship with the sphincter, etc. Therefore,
colorectal and anal surgeons should learn and
master anal MRI lm reading in order to help further improve their expertise in diagnosis and
treatment.
6.2.2.2 Colonoscopy Before Anal
Fistula Operation Should
BeDone asMuch asPossible
At present, the incidence of Crohn's disease and
ulcerative colitis tends to increase, and the concept of colonoscopy before complex anal stula
to exclude perianal Crohn's disease has become
more widely supported. It has been reported that
more than 10% of complex anal stula is actually
a perianal stula change of inammatory bowel
disease, which means that preoperative colonoscopy can help about one-tenth of complex anal
stula patients avoid inappropriate surgery and
get more suitable treatment. Although the current
guidelines for the treatment of anal stula
(including Crohn's disease and anal stula) do
not include colonoscopy as recommended, we
recommend that preoperative colonoscopy be
performed for all patients with anal stula, especially for those with high complex anal stula.
Colonoscopy before an operation on anal stula
can exclude perianal Crohn's disease, intestinal
malignant tumors, intestinal tuberculosis, and so
on. It does not increase the additional risk of
diagnosis and treatment.
6.2.2.3 Preoperative Evaluation
ofAnal Function Is Helpful
toFormulate Individualized
Treatment Plans
Preoperative decline of anal defecation control
function is a risk factor for postoperative anal
incontinence. Anorectal nger examination and
other examinations can be used to understand
the situation of anorectal defect, the integrity of
the anorectal ring, and the diastolic and contractile function of the anorectal muscles; an appropriate scoring scale can be used to evaluate the
preoperative anorectal function; MR examination and anorectal color Doppler ultrasound are
used to determine whether there are any minor
injuries to the anal sphincter; and anorectal
manometry is used to assess the contraction and
sensory function of anal muscles. Then, according to the different conditions of each patient,
doctors should develop targeted surgical methods for improving the one-time cure rate of anal
stula, better protection of patients’ anal function, and even prevention of doctor–patient
disputes.
Anorectal manometry is one of the most commonly used methods for preoperative evaluation
of anal function. Although there are many reports
in the literature and the examination is considered to be of great signicance, the data obtained
by the examination are not stable, so there is no
accepted standard value. Because of the inuence of translocation, examiner, and even
patient's cooperation and other inherent defects,
the examination results may not truly reect the
most realistic functional state of a patient’s anus
before operation. Therefore, the author believes
that anorectal manometry can only be used as a
6 Classication andDiagnosis ofAnal Fistula
97
reference in the evaluation of anal function. In
the preoperative functional evaluation of anal
stula, the patient's complaint, anal function
score, anorectal digital examination, and MRI
examination are arguably more useful than anorectal manometry. We should learn to use all
kinds of possible means of examination and
functional evaluation in order to formulate a
treatment plan more comprehensively and
pertinently.
6.2.2.4 Preoperative Pathological
Examination andDiagnosis If
Necessary
Pathological examination is necessary for those
patients who are clinically highly suspected of
carcinogenesis, tuberculosis, and Crohn's disease
complicated with anal stula, seemingly simple
cases that not cured after multiple operations,
delayed wound healing, or difculties in wound
healing. In principle, specimens should be taken
for pathological examination in all kinds of anal
stula operations.
6.3.2 Perianal Folliculitis
andFuruncle
In perianal folliculitis and furuncle, small red,
swollen, and painful nodules are found locally,
which then gradually swell and protrude.
Several days later, the central tissue of the nodule becomes soft and necrotic, and yellow-white
pus will appear. The range of redness, swelling,
and pain will also be enlarged. The pus drops
off, and pus is discharged. The inammation
gradually disappears and recovers. Occasionally,
the infection of boils spreads, causing lymphangitis and lymphadenitis. If multiple boils occur
simultaneously or repeatedly, they are called
furunculosis.
Perianal folliculitis or furuncle lesions are
small, shallow, and limited, not connected with
the anal canal. It is easy to know the limitations
and supercial features of perianal folliculitis or
furuncle when making sliding palpation, and
therefore it is easy to differentiate from anal
stula.
6.3 Dierential Diagnosis
oftheThird Anal Fistula
There are other diseases around the anus and
sacrococcygeal region, such as ulceration and
secretion, which are easily confused with anal
stula, and these need to be differentiated.
6.3.1 Hidradenitis Suppurativa
Hidradenitis suppurativa is a chronic suppurative
disease of the skin and subcutaneous tissue. The
lesions are often widespread, diffuse, or aky,
with many ulcers, pus, or particular odor. The
skin in the lesion area is often blackened by pigmentation. Hidradenitis suppurativa is more
supercial, generally only in the skin and subcutaneous tissue, mostly not connected with the
anal canal. But sometimes it can communicate
with the anal canal and rectum to form complex
anal stula or multiple anal stulas, which needs
attention.
6.3.3 Perianal Sinus Tract
Anal trauma or infection can form a sinus tract
because it is not connected with the anus, and
generally after a dressing change can be cured. If
there is foreign body in the sinus tract, it is difcult to heal though drainage is smooth, so clinical
attention must be paid to it. History is an important basis for differential diagnosis. Combined
with the clinical features that are not connected
with the anal canal, it is generally easy to differentiate from anal stula.
6.3.4 Sacrococcygeal Cyst
Sacrococcygeal cyst is a congenital disease that
is generally believed to be caused by abnormal
embryonic development. Epidermal cysts and
dermoid cysts are common, located in the anterior and posterior sacral space. Cysts can be
monocystic, bicystic, or polycystic, as large as
eggs, as small as yolk, and with gelatinous
98
R. Shi and J. Gu
mucus in the cavity. The age of onset is mostly
about 20–30 years old. There is no infection,
often asymptomatic, or a slight sacrococcygeal
pain. If the cyst grows in size or secondary infection occurs, fever, local swelling, pain, and other
symptoms can occur. After ulceration or incision
and drainage, a stula might be formed, but there
is no internal orice. The main points of differentiation are the following: cysts often have
sacrococcygeal swelling and pain; most of the
stulas are located in or near the middle hip
suture, far from the anal margin and near the tip
of the coccyx; epithelial tissue extends into the
stula; and the stula is depressed, which is not
easy to close. If the cyst is large, the presacral
swelling can be found in digital rectal examination, and the cystic mass can be touched. The
surface is smooth, and the boundary is clear. CT
or MRI examination will show sacrococcygeal
cystic lesions, often with obvious cystic wall and
outer membrane.
6.3.5 Perineal Urethral Fistula
This kind of stula is the urethral bulb connected
with the skin. The oricium stulae are often
located in the perineal urogenital triangle. When
urinating, there is urine owing out of the external orice. Most of them are congenital anomalies, but some are also caused by trauma, tumors,
and so on. The diagnosis and differential diagnosis can only be made by a local specialist examination combined with CT and MRI.
6.3.6 Sacrococcygeal Osteomyelitis
Sacral osteomyelitis can cause an abscess
between the sacrum and the rectum. The abscess
is perforated near the coccyx to form a stula.
The stula is usually on both sides of the coccyx
tip and is even with the tip of the coccyx.
Sometimes there are two symmetrical stulas
with equal distances. The probe can penetrate
several centimeters. The stula is parallel to the
rectum. It is located in the anterior sacral fossa.
There is no stiffening tissue between the stula
and the anal canal, and it is not connected to the
rectum. Pelvic oor MRI is an important basis
for differential diagnosis.
6.3.7 Sacroiliac Bone Tuberculosis
Sacral, iliac, hip, and pubic tuberculosis can
form abscesses, pus in the buttocks or perineum,
or inguinal perforation. The formation of stula
needs to be identied with anal stula. The
onset of bone tuberculosis is slow, mostly without acute inammation. After the break, the
purulent uid ows away, the wound is not
closed for a long time, the wound mouth is
depressed, and the oricium stulae are far from
the anus, which is not connected with the rectum. Bone tuberculosis is often manifested as
low fever, night sweat, poor appetite, and other
tuberculosis. CT or X-ray examination of the
sacrococcygeal bone can detect bone tuberculosis manifestations such as sacrococcygeal bone
destruction.
6.3.8 Rupture ofAnterior Sacral
Space Teratoma
Presacral space teratoma is a congenital disease
associated with abnormal embryonic development. Most of them occur in the young and
middle- aged period and have no obvious symptoms in the initial stage. If the tumor enlarges and
compresses the rectum, symptoms such as anal
distension or difculty in defecation may occur.
Anal nger examination can often touch the
sacral anterior cystic mass sensation but generally cannot nd the internal orice. Presacral
space teratoma can sometimes burst from the
back of the anus when it is secondary to infection. Imaging examination is an important means
in differential diagnosis. It is often found that
there are teeth and bones in the tumors during
imaging examination or surgery. Hair, teeth, and
6 Classication andDiagnosis ofAnal Fistula
99
other tissues are often seen in cysts removed during surgery.
6.3.9 Carcinoma ofAnal Canal
andRectum
Anal stula can also occur after canceration of
anal or low rectal cancer. It can be found that there
are hard masses in the anus and rectum with more
xed basement and less abscess. Sometimes it can
be seen that the surface of the tumors has cauliower-like changes, with pus, blood, mucus, and
other secretions. Although it is easy to differentiate according to clinical features, denite diagnosis still depends on pathological examination.
Suggested Reading
1. Masahiro Takano. Compilation by Shi Renjie. The
essence of treatment of anorectal diseases. Beijing:
Chemical Press Biomedical Branch, 2009, 107–166.
2. Cao Jixun. Chinese Hemorrhoidology. Chengdu:
Sichuan Science and Technology Press, 2015, 37–64.
3. Huang Naijian. Chinese anorectal pathology. Jinan:
Shandong Science and Technology Publishing House,
1996, 731–734.
4. Wang F, Gong XC, Alimas et al. A collection of studies on the causes, classication and
diagnostic methods of anal stula. Xinjiang
Medicine,2007,37(5):271–274.
5. Qian Qun. Diagnosis of anal stula. Journal of Clinical
Surgery, 2011, 19(4): 224–225.
6. Xu Mengting, Chen Fujun. Diagnostic status of anal
stula. Journal of Modern Traditional Chinese and
Western Medicine,2009,18(8):936–938
The Therapeutic Principle
ofFistula-in-Ano
RenjieShi andLihuaZheng
7
Abstract
The purpose of anal stula treatment is to
relieve the pain caused by anal stula and
improve the life quality of patients. Besides
the cure rate, the protection of anal function
should be taken into account in anal stula
surgery to the maximum extent possible. The
basic requirement of curing anal stula is a
thorough treatment of the internal opening and
the primary lesions in the sphincter. The
sphincter involved in the surgery should be
protected as much as possible, and the minimum requirement is to avoid direct incision of
the deep external anal sphincter and levator
ani muscle. Excision and drainage of the
external opening are sufcient. It is important
to ensure that the drainage of each wound is
kept open so that the healing of the stula is
not inuenced. The treatment should be individualized according to the type of stula and
the patient’s physical condition. The surgical
method should protect the anal sphincter as
much as possible. Drainage or nonsurgical
treatment could be used for those who are dif-
R. Shi (*)
Department of Anorectal Surgery, Afliated Hospital
of Nanjing University of Traditional Chinese
Medicine, Nanjing, Jiangsu, China
L. Zheng
Department of Proctology, China-Japan Friendship
Hospital, Beijing, China
cult to cure and for whom surgery can easily
lead to anal incontinence.
Keywords
Anal stula · Treatment · Principle
Operation · Seton therapy · Anal sphincter
Primary lesion · Drainage · Crohn’s disease
with anal stula
It is impossible to accomplish autotherapy once
stula-in-ano or anal stula has appeared. Put
frankly, stula-in-ano must undergo surgery. In
the treatment of stula-in-ano, some principles
must be followed, and with reasonable techniques, an ideal clinical curative effect can be
achieved. The basic principles of stula-in-ano
surgery are as follows.
7.1 Both Healing Fistula-in-Ano
andProtecting Anal
Function Are Equally
Important
The purpose of stula-in-ano surgery is to relieve
the pain caused by an anal stula and improve the
patient’s quality of life. Surgery is the necessary
means for the treatment of stula-in-ano; however, in healing anal stula, surgery is bound to
© 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_7
101
102
R. Shi and L. Zheng
cause some damage due to its disruptions. How
to protect anal function to a maximum is always
a problem in the operation of anal stula. The socalled equal importance of curing anal stula and
protecting anal function is to cure anal stula
while at the same time maximally protect anal
function by taking necessary measures in the
operation.
It is the most basic and important principle
that must be strictly grasped in anal stula surgery: paying equal attention to curing the anal
stula and protecting anal function. Otherwise,
even if the anal stula is cured, if anal function is
seriously damaged or there is even fecal incontinence, the quality of life of patients is greatly
reduced after the procedure. In this case, the benets of anal stula surgery are offset, and the
postoperative pain might even be greater than
before surgery, so it will not be worth it.
Anal stula surgery has many serious complications and sequelae of anal incontinence such as
anal incontinence, anal stenosis, anal malformation, etc. In order to avoid the occurrence of these
complications and sequelae and to maximize the
protection of the anus function, doctors need to
choose the appropriate surgical methods and
measures. They should maximally protect the
internal and external anal sphincters and anorectal tissue during surgery so as to minimize and
avoid incontinence and anal malformation and
improve patients’ quality of life after surgery.
There has been a long-standing debate on the
damage and retention of the anal sphincter in the
domestic and foreign anorectal communities.
Modern research shows that important factors
affecting the function of anal continence include
anal external sphincter integrity, integrity of internal sphincter reex, anal local epithelial electrophysiological sensation, anal canal coloboma, etc.
We need to point out that anal sphincter preservation is not a complete procedure that does not
destroy the sphincter at all. It also causes some
damage to anal sphincter but will try to protect the
anal sphincter in terms of ideas and measures.
For high complexity anal stula, Crohn’s disease accompanied with anal stula, anal stula
that recurs after multiple operations and whose
cause of recurrence is unknown, when there is no
cure or a low cure rate, or when anal function
cannot be effectively protected, the operation
may not be performed both temporarily or even
permanently so as to avoid failure. For those difcult miscellaneous cases, drained by widening
the wound, drained with medicated strip, traditional Chinese medicine for oral or external use,
etc. can be used to reduce the scope of inammation and the probability of repeated infection,
protect the anal control function, reduce local
symptoms, and improve the quality of life of
patients. This “survival with stula” method is
also a reasonable choice or method in the treatment of stula-in-ano. This practice is widely
recognized at home and abroad, widely used in
the treatment of anal stula caused by Crohn’s
disease and anal stula that is highly complexed.
7.2 The Treatment
oftheInternal or Primary
Opening andthePrimary
Lesion Should BeClean
andThorough
Most anal stulas are caused by infection of anal
glands; therefore, for the vast majority of anal stulas, the thorough treatment of the internal opening and the primary intersphincteric abscess is
the most basic and necessary condition for the
healing of the anal stula. Otherwise, it will easily relapse. Most recidivation of anal stula correlates with inappropriate or halfway treatment
of the internal opening or primary abscess.
Accurately nding the internal opening is the
premise of handling the internal opening.
Treatment for the internal orice is usually incision, or excision, or ligation.
The primary abscess is the initial lesion caused
by an infection of the anal gland. It includes the
anal duct and intersphincteric anal abscess. The
primary abscess is a submucosal induration of
the internal opening during digital examination.
During the operation, it is a tubal wall or an
abscess wall that turns hard between the sphincters. These necrotic tissues cannot be left behind
and need to be completely removed during
surgery.
7 The Therapeutic Principle ofFistula-in-Ano
103
7.3 Protect theAnal Sphincter
asMuch asPossible
Because the anal stula passes through the internal and external anal sphincters or the tract passes
within the intersphincteric space, when dealing
with the stula, the anal sphincter will be damaged more or less a bit. Therefore, the anal
sphincter must be protected as much as possible
during the operation of anal stula.
Protecting the anal sphincter as much as possible includes measures such as not letting the
anal sphincter divide during surgery, or dividing
it as little as possible. This requires certain principles to be followed and certain measures to be
adopted during the surgery.
In an anal stula surgery, the range of sphincters allowed to be cut is 1–2 pots in the lower
half of the internal sphincter, 1–3 places in the
subcutaneous parts of the external sphincter, 1–2
places in the supercial part of the external
sphincter, and 1 place in the posterior deep part
of external sphincter. According to this principle,
it generally does not cause severe anal
incontinence.
In anal surgery, the scope in which the sphincter cannot be incised is all of the internal sphincter, more than three places in the supercial part
of the external sphincter, the deep part of external
sphincter (except behind the anus), and all the
levator ani muscles.
When cutting the internal sphincter deep or
incising the internal sphincter in two or three
places at the same time, the continuous occlusion
of the internal sphincter will be lost; thus, the
anus cannot remain completely closed. Although
the external sphincter has a compensatory function, but because the external sphincter is prone
to fatigue, it is worn out, and it tends to cause
loose stools and gas leakage. This is the main
cause of anus dampness, discharge, and underwear dirt after an anal stula operation.
Cutting the external sphincter has less effect
on anal function than it has on the levator ani
muscle. But cutting too deeply or multiple inci-
sions can also cause anal incontinence. In addition, a lateral incision of the sphincter can easily
cause anal deformation.
The levator ani muscle is located in the deepest part of the anus and has the function of continuously and powerfully closing the anus from
the back. As long as the levator ani muscle is
retained, the basic constriction function of the
anus can be preserved, and at the very least, function of control over solid feces can be maintained.
Therefore, in general, cutting the levator ani muscle will cause anal incontinence except for very
rare cases such as where the anorectal ring is
already stiff. So in principle, unless the anorectal
ring is already stiff, the levator ani muscle cannot
be divided in one go.
At present, some scholars have different
views on whether the levator ani muscle can be
incised in one go. Hill reports three cases of
incisions of all anal sphincter muscles including
the levator ani muscle where after the operation,
solid stools can still be controlled. The three
patients he reported on had all their sphincters
cut off, but there were no diarrhea or soft stools,
and they had bowel movement once a day only.
On the other hand, in patients with only mild to
moderate incision of the sphincter, there are also
cases of severe anal incontinence. The investigation found that these patients have nonanal
local factors such as psychological factors,
functional or organic intestinal diseases, etc.
Therefore, it is necessary to know the psychological and defecation situations of patients
before operating on anal stula, as well as the
functional or organic lesions of the large intestine anus.
On the other hand, the integrity of anal function is related not only to the anal sphincter but
also to the soft tissue of the anus. When the anal
soft group defect caused by anal stula surgery
is too large, the anus cannot be completely
closed. Therefore, attention should be paid to
protecting the soft tissue of the perianal rectum
as much as possible during the anal stula
operations.
104
R. Shi and L. Zheng
7.4 The External Opening
andWound Should
BeProperly Managed
inFistulas
Fistulas and external openings of the anal stulas
need to be properly treated in order to ensure the
smooth healing of the raw surface. If the intraoperative treatment is not in place, it is difcult for
anal stulas to heal smoothly. Clinically, even if
the treatment of the primary lesion is correct,
inadequate intraoperative treatment of the stula,
having an external opening or raw surface, can all
lead to recurrence or partial recurrence of the
anal stula.
The septic tissue in the stula must be
scratched and scraped clean, and hard and thick
tube walls must be completely or properly ectomized. Fistulas supercial to and below the external sphincter are usually incised or excised.
However, care should be taken when opening
anterior and lateral stulas, especially in female
patients and patients with particularly weak anterior sphincters. It is generally recommended to
adopt the cutting seton method. A stula in the
intersphincter and which tracts upward above the
depth of the external setonsphincter can be
treated by cutting seton or drain seton or catheter
drainage.
Drainage of the wound should be adequate
and appropriate. The anal stula wound in most
cases treated with the method of open drainage,
but because the wound surface in the anus is
often contaminated by stool, mucus, exudation,
etc., and also constricted by the sphincter, sometimes the wounds are difcult to heal. In order to
drain the wound, it is necessary to extend the
wound outwardly to the anus, a form that allows
dirt on the surface of the wound to easily ow
out. The size of the drainage wound depends on
the size and depth of the lesion and the route of
the lesion in the anus. Generally, the deeper and
longer the stula is, the larger and longer the
drainage wound must be.
If the supercial stula along the perianal circumference is longer, in order to ensure the
smooth drainage of the lumen, it is necessary to
make a cut at intervals of 2–3cm in the middle of
the stula. Loose drainage should be undertaken
between two adjacent incisions.
At present, pocket stitching is often used in
the treatment of anal stulas, and the edge of the
wound is often clipped. All of these methods are
not only benecial to the wound drainage, but
also in deating the raw surface, which may
speed up the duration of healing.
Usually, regardless of the number of external
openings, in principle, all of them should be ectomized to form an open raw surface so as to facilitate drainage.
7.5 The Selection
andIndividualization
ofTreatment Program
forFistula-in-Ano
There is no technique available for treating all stulas; therefore, the anal stula treatment plan
must be determined according to the etiology,
anatomy, severity of the disease, whether there
are any complications, and the surgeon’s treatment experience. The pros and cons between
sphincter cutoff range, cure rate, and anal function impairment should be traded off so as to
develop a reasonable treatment plan. Meanwhile,
for specic cases of anal stula, the situation of
anal stula patients, combined with their physical
state, mental state, etc., should also be taken into
account. In order to develop targeted treatment
plans, the choice of specic case treatment plans
should both follow general principles and also
meet the individual’s particular circumstances.
7.5.1 Simple Anal Fistulas
7.5.1.1 Anal Fistulotomy
The cure rate of anal stulotomy can reach
92–97% among particular patients. Recurrence is
often associated with the following reasons:
complicated anal stulas, unclear position of the
internal opening, and Crohn’s disease.
At present, there is no consensus on how many
anal sphincters can be cut without signicantly
affecting anal function. The rate of anal inconti-
7 The Therapeutic Principle ofFistula-in-Ano
105
nence after anal stulotomy is 0–73%. The large
differences in incontinence rates are related to the
denition of anal incontinence, the time of follow- up, and the degree of sphincter injury.
Preoperative anal incontinence, recurrent anal
stula, complex anal stula, previous history of
anal stula surgery, and even female anterior anal
stula are all risk factors for incontinence after
surgery, so care must be taken when performing
anal stulotomy in such cases.
When performing anal stulotomy, pocket
stitching can reduce postoperative bleeding and
shorten the duration of healing (4 weeks). The
healing rates of anal stulectomy and anal stulotomy are similar; however, wound healing time
of the former is longer because the wound is
larger and the rate of incontinence is higher.
7.5.1.2 First-Stage Incision
andDrainage withAnal
Fistulotomy
When the anal stula is associated with a perianal
abscess, patients with clear internal openings can
perform rst-stage incision and drainage and anal
stulotomy. That way, they can avoid two surgeries. A meta-analysis of 405 patients enrolled in
ve studies indicated that the recurrence rate can
be signicantly reduced by abscising the sphincter muscle (anal stulotomy or anal stulectomy)
during incision and drainage.
However, there is still controversy over performing anal stulotomy while incising and
draining the perianal abscess. Some people think
that this one-stage operation increases the rate of
anal incontinence. Also, although some patients
can be cured by incision and drainage and may
not need to undergo another operation, there
might still be recurrence after the operation for
others. Therefore, physicians should weigh the
pros and cons of reduced recurrence rates against
increased rates of anal incontinence before making a decision.
7.5.1.3 Fistula Debridement
andFibrin Glue Injection
Fibrin glue injection for anal stula has the
advantages of a simple method and good repeatability and avoids sphincter injury. Fibrin glue
injection therapy is more suitable for the highrisk population prone to anal incontinence.
However, the recurrence rate after brin injection
is very high, and there are more failures.
Retrospective and prospective studies have
shown that the healing rate of simple anal stula
treated with brin glue is 40–78%. Some control
studies show that the healing rate of brin glue in
treating simple low anal stula is 50% (3/6), but
the cure rate of anal stulotomy is 100% (7/7).
The incidence of anal incontinence was lower in
both groups. It is suggested that brin glue injection therapy for simple anal stula has no obvious advantages.
7.5.2 Complicated Anal Fistulas
7.5.2.1 Fistula Debridement
andFibrin Glue Injection
In a randomized controlled study published by
Lindsey etal., 29 patients with complicated anal
stula were randomized to receive a mucosal
advancement ap transfer or brin glue injection
after seton and drainage. The healing rate of the
brin glue group was higher (69% (9/13) vs. 13%
(2/16), P=0.003), and the rates of anal incontinence were similar in both groups (0/13 vs. 2/16).
In nonrandomized controlled studies, the healing
rate of brin glue in the treatment of complex
anal stula was 10–67%. Although the healing
rate of brin glue in the treatment of complex
anal stula is relatively low, it can be considered
as the initial treatment due to fewer
complications.
7.5.2.2 Anal Fistula Plug
An anal stula plug made of biological materials
can suture internal openings and ll in the stula.
Some studies report that the healing rate of anal
stula plug in treating low anal stula can reach
70–100%; however, its efcacy in complex anal
stula is poor. Early literature reported that the
healing rate of anal stula plug in the treatment
of stula in Crohn’s disease was up to 80%.
Patients in the same group that included all types
of complicated anal stula had an average cure
rate of 83% after 12 months of follow-up.
106
R. Shi and L. Zheng
However, most of the research reports failed to
repeat the above results, and the cure rate of most
of the studies on the treatment of anal stula with
anal stula plug is less than 50%. The reduced
cure rate may be related to the longer follow-up
time. Due to fewer complications, good repeatability, and the lack of other ideal treatment
methods, the stula plug can be considered a
good treatment for complicated anal stula.
7.5.2.3 Rectal Mucosa
AdvancementFlap
Rectal mucosa advancement ap is a technique
that can protect the sphincter muscle. Its specic
operations include stulous tract scraping and the
normal proximal mucosal ap freeing (including
anorectal mucosa, submucosa, and muscle layer)
to cover the sutured stula internal opening. The
postoperative recurrence rate of this surgery is
13–56%. Combining brin glue failed to improve
the cure rate. The associated factors for treatment
failure were radiotherapy, Crohn’s disease, active
proctitis, rectovaginal stula, malignancy, and
the number of previous repair operations.
Although the operation does not cut the anal
sphincter, the rate of mild and moderate anal
incontinence was still 7–38%. Postoperative anal
pressure measurement indicated that both resting
pressure and systolic pressure were reduced.
7.5.2.4 Seton andFistulotomy
inStages
The goal of seton is to pass through the stula,
transforming the inammatory process into a foreign body reaction that causes brosis around the
sphincter. Seton is divided into cutting seton,
slack seton, and virtual and real combination
seton. The cutting seton is gradually tightened,
and the stula is cut down gradually within several weeks, thus resulting in part scar and healing. Loose seton acts as a drainage and reduces
recurrence, which can be retained for a long
duration or removed in the next treatment. The
virtual and real combination seton is the combination of the cutting and slack seton: cutting
seton in the rst week, gradually cut a part of the
high stula; in the second to third week, the loose
seton will play the role of drainage, and the
stitches will be removed in 20 days and until the
wound has healed. There are only four randomized controlled studies, but the results vary.
Seton for complicated anal stula is usually
performed in stages. Seton to control infection in
the rst stage, a few weeks later, secondary procedures (such as mucous advancement ap, brin
glue injection, and anal plug tamping) will be
performed. This can avoid cutting the sphincter.
Due to the different techniques of the second
phase operation, the cure rate of the threaded
treatment is 62–100%. The rate of anal incontinence treated by staging and cutting seton is
0–54%. When anal incontinence occurs, the control of gas function is signicantly worse than
that of liquid or solid feces.
7.5.2.5 Ligation ofIntersphincteric
Fistula (LIFT)
LIFT is an operative procedure that ligates and
cuts the stula between the anal canal sphincters.
The classic description includes drain seton for
more than 8 weeks to promote brosis of the stula; intersphincter incisions will be performed to
separate the stulas, ligate both ends, and remove;
close the internal opening as much as possible
and expand the external opening to facilitate
drainage.
The technique does not theoretically cut the
sphincter and does not impair anal sphincter
function. Reported in the literature, the mean
follow-up time was 3.8 months, and the cure rate
was 57–94%. The recurrence rate was 6–18%.
There is still some controversy about
LIFT. Although it is recommended in foreign
guides, the recurrence rate of this operation is
higher, and there are certain requirements for
indications.
7.5.3 Treatment ofAnal Fistula
inCrohn’s Disease
The incidence of perianal disease in Crohn’s disease ranges from 40 to 80%. Drug treatment of
anal stula in Crohn’s disease is the rst choice.
Surgical treatment is used to control infection
and is occasionally chosen as a treatment.