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361© Springer International Publishing Switzerland 2017
N. Hyman, K. Umanskiy (eds.), Difficult Decisions in Colorectal Surgery,
Difficult Decisions in Surgery: An Evidence-Based Approach,
DOI 10.1007/978-3-319-40223-9_32
Chapter 32
Optimal Management of the Transsphincteric
Anal Fistula
Richard T. Birkett and Jason F. Hall
Introduction
Management of transsphincteric fistulas can pose a difficult challenge for surgeons.
The goal is to cure the fistula while retaining functional capacity of the sphincter
complex. The Parks system is the classic classification system, which divides fistu-
las into five types: intersphincteric, transsphincteric (high and low), suprasphinc-
teric, and extrasphincteric (Fig. 32.1), based on the course of the track in relation to
the anal sphincter complex [2]. Goals of management include eradicating sepsis,
promoting healing of the fistula tract, maintaining continence through preservation
of the sphincter complex, and preventing future recurrence. Simple submucosal,
intersphincteric, and low transsphincteric fistulas can be managed effectively with
conventional fistulotomy and represents the gold standard comparator owing to low
incontinence and recurrence rates [3]. However, transsphincteric fistulas cross
through the internal and external sphincter, predisposing patients to higher rates of
incontinence following fistulotomy. Therefore, a number of alternative approaches
have been developed to tackle these complex fistulas although no consensus algo-
rithm for management exists.
In this chapter, the data regarding sphincter-saving approaches to complex trans-
sphincteric fistulas is reviewed. We discuss the following techniques in our
review:fistulotomy, seton placement, fibrin glue, plug, endorectaladvancement flap
(ERAF) and ligation of the intersphincteric fistula tract procedure (LIFT). Our rec-
ommendations are based on data presented in Table 32.1, comparing fistulotomy,
R.T. Birkett, MD
Lahey Hospital and Medical Center, Burlington, MA, USA
e-mail: jason.f.hall@lahey.org
J.F. Hall, MD, MPH, FACS (
*)
Department of Surgery, Boston Medical Center, Boston, MA, USA
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plug, ERAF and LIFT. In addition, we comment on the experience at our institution
and our personal approach to this problem (Table 32.2).
Search Strategy
We performed a literature search in the MEDLINE database (using PUBMED)
under the search titles “transsphincteric fistula” or “fistula-in-ano”. We initially
focused on prospective trials randomized studies. Further mining was performed
using the reference lists of published systematic reviews. Given the lack of random-
ized trials involving all treatment interventions, especially the LIFT procedure, we
did include multicenter prospective observation studies and multicenter center ret-
rospective review studies. Although discussed in text, we excluded meta-analyses,
single-surgeon reviews, single-surgeon observational studies and those published in
foreign languages.
Results
Fistulotomy
Fistulotomies are performed by unroofing the track between the internal and exter-
nal openings (Fig. 32.2). Reported recurrence rates are low. A zero recurrence rate
was reported by a single surgeon case series of 38 patients over 5 years [17]. A more
recent multicenter retrospective review of 537 patients undergoing fistulotomy for
low perianal fistula reports a primary healing rate of 83.6 %, 81.7 % for transsphinc-
teric, and a secondary healing rate of 90.3 % after treatment for recurrence [4].
Fig. 32.1 Parks
classification (A)
superficial fistula (B)
intersphincteric fistula (C)
transsphincteric fistula (D)
suprasphinteric fistula (E)
extrasphincteric fistula
(From Simpson et al. [1])
R.T. Birkett and J.F. Hall
363
Table 32.1 Summary of evidence
Author (year) Population Procedure N Median follow-up Success
Function
change post-op Between groups
Gottgens [4] (2015) Low transsphincteric Fistulotomy 164 38.9 months (6–74.8) 134 (81.7 %)
Abramowitz [5]
(2015)
Low transsphincteric Fistulotomy 93 12 months =
High transsphincteric Seton + staged
fistulotomy
59 −
Schwander [6]
(2009)
Transsphincteric after seton Plug 66 12 months 37 (62 %) =
Stamos [7] (2015) Complex transsphincteric Plug 55 12 months 49 % +
Perez [8] (2006)* High transsphincteric &
suprasphincteric
Fistulotomy 28 38 months (24–52) 26 (92.8 %) = =
ERAF 27 25 (92.5 %) =
Ortiz [9] (2009)* High transsphincteric Plug 15 12 months 3 (20 %)
ERAF 16 14 (87.5 %)
Van Koperen [10]
(2011)*
High transsphincteric Plug 31 11 months (5–27) 9 (29 %) = =
ERAF 29 14 (48 %) =
Hall [11] (2014) Low tanssphincteric LIFT 17 3 months 14 (82 %) +
High transsphincteric 19 15 (79 %) +
Sileri [12] (2014) Complex fistulas LIFT 26 20 months (16–24) 19 (73 %) =
Han [13] (2015)* Transsphincteric LIFT 118 6 months 99 (83.9 %) = =
LIFT-Plug 117 110 (95 %) =
Madbouly [14]
(2014)*
High transsphincteric ERAF 35 12 months 23 (65.7 %) = =
LIFT 35 26 (74.3 %) =
Mushaya [15]
(2012)*
Transsphincteric or complex ERAF 14 19.2 months
(1.7–32.2)
13 (92.9 %) = =
LIFT 25 23 (92 %) =
*Randomized study; + improvement incontinence score; − worsening incontinence score; = no statistic difference in incontinence score
32 Optimal Management of the Transsphincteric Anal Fistula
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364
Incontinence rates following fistulotomy depends on both the amount of muscle
divided at the time of operation as well as any preexisting sphincter damage.
Although Gottgens et al. reported a major incontinence rate of 28 %, the risk of
incontinence in simple fistulas is very low. Abramowitz et al. described only a
1-point increase in Wexner score postoperatively after 1 year in patients undergoing
fistulotomy for low fistula with a reported score ≤5 in 69 %. However, the median
Wexner score worsened by 3 points for patients with high transsphincteric fistulas,
which was statistically significant [5].
Fig. 32.2 Fistulotomy
(Fischer et al. [16])
Table 32.2 Comparison of available approaches for management of transphincteric fistulas
Pt population Intervention Comparator Outcomes studied
Patients with transsphincteric
fistulas
Fistulotomy Sphincter saving
approach
Cure, continence
R.T. Birkett and J.F. Hall
365
Setons
Setons are the oldest recorded surgical approach to fistula management, first
described by the Indian Surgeon Shushruta 1200 BC. A seton serves to drain sepsis,
enables preservation of the sphincter mechanism and can prepare the patient for a
two-stage procedure. A draining seton prevents the internal and external orifices of
the fistulas from closing, allowing infection to dissipate. Cutting setons enable slow
division of a fistula tract by pressure necrosis of the intervening tissue. Because the
division is slow, it is postulated that this leads to greater fibrosis without a signifi-
cant gap in the sphincter complex.
Short-term healing rates with draining setons have been reported to be between
44 and 83 % [18]. These durability of these results must be questioned as draining
setons do little to alter the underlying anatomy and physiology of a fistula tract.
While they may reduce symptoms, it is doubtful that they lead to eradication of the
fistula tract in any circumstance. A recent retrospective analysis of 121 patients with
transsphincteric fistulas reported a 98 % healing rate with cutting setons.
Preoperatively, 23 (19 %) of the patients reported incontinence to feces or gas. At
follow-up, only 14 (11.6 %) reported seepage of stool or loss of flatus control, 0 and
none experienced major continence issues. Of the initial 23 patients that reported
continence disturbances preoperatively, symptoms had resolved in 17 patients after
surgery (73.9 %). New onset incontinence did occur in eight patients, but all denied
change in lifestyle or the need to wear a pad [19].
Although cutting setons have been reported to be effective, their use has been
limited due to concerns about subsequent fecal incontinence. A large review of
multiple studies on cutting setons including over 500 patients reported an average
incontinence rate of 32 % across all types of fistulas and 20.5 % when used for trans-
sphincteric fistulas. However, the definitions and grading of incontinence were
missing in over a third of the studies [20]. A UK position statement described simi-
lar results with incontinence rates ranging up to 62 % including major incontinence
in 10 % reported in seven studies reviewed [21]. Additionally, one must account for
the need of interval tightening and associated discomfort caused by cutting setons.
Advancement Flaps
ERAF is an alternative option to avoid division of the sphincter complex. A semi-
circular flap or U-shaped flap of mucosa, submucosa and a few muscle fibers is
raised from the level of the dentate line over a distance of 4–5 cm proximally. The
flap is then lifted to expose the fistula tract, which is cored out and the associated
muscle defect is sutured closed. The flap is then advanced down to the dentate line
and anchored with absorbable sutures.
A recent meta-analysis of 35 studies reported an 80.7 % success rate and 13.2 %
incontinence rates for cryptoglandular fistulas, although the quality of the reports
32 Optimal Management of the Transsphincteric Anal Fistula
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were low [22]. A study on long-term outcomes of advancement flaps in high trans-
sphincteric, suprasphincteric and extrasphincteric fistulas reports a meager success
rate of 37 % with a mean follow-up of 72 months [23]. Although this study accumu-
lated a reasonable sample size, it is a single-center observational study and the fis-
tula etiology was Crohn’s disease in more than a quarter of the patients. Perez et al.,
conducted a randomized, prospective trial randomizing 55 patients with high
transsphincteric fistulas and suprasphincteric fistulas to ERAF or fistulotomy with
sphincter reconstruction and found no difference in recurrence or incontinence
rates. The success rates in both groups remarkably exceeded 92 % and there was no
change in continence scores between groups [8]. Additional studies comparing
ERAF to LIFT will be discussed later in the chapter. The best reported outcomes
have been associated with a full-thickness flap in conjunction with fistulectomy,
without fibrin glue or preliminary draining seton [24].
Biologic Products
Fibrin glue is another sphincter-sparing option for complex fistulas, however, suc-
cess rates generally appear to be poor. The glue is a combination of fibrinogen,
thrombin and factor XIII which cross-links with collagen in the tissue, sealing the
tract and stimulates the growth of fibroblasts and pluripotent endothelial cells pro-
moting collagen deposition and wound healing.
One study looking at long-term results of fibrin glue over an average of 22 months
after seton drainage, reported an initial closure rate of 60 % which increased to 69 %
with retreatment [25]. In contrast, Buchanan et al. found successful healing in only 3
of 22 patients (14 %) with complex fistulas with fibrin glue after tract curettage [26].
An alternative to fibrin glue is a synthetic anal fistula plug. The plug rolled into
a conical configuration, then secured into the primary opening of the fistula tract to
promote healing. Schwander et al. followed 66 patients in a multicenter study over
12 months with transsphincteric fistulas treated with seton placement followed by
anal fistula plug 8 weeks later and reported a 62 % success rate [6]. A more recent
multicenter study of cryptoglandular transsphincteric anal fistulas included 55
patients from 11 centers and reported a 12-month healing rate of 49 %; all had sig-
nificantly improved Wexner scores by 6 months. There were 8 total and 5 partial
plug extrusions [7].
Ortiz et al. compared ERAF with anal fistula plugs. The study was cut short sec-
ondary to high recurrence rates in the plug arm whereas only 2 of 116 patients
treated with ERAF had recurrence [9]. These results were confirmed in another
double-blinded multicenter trial which found a recurrence rate of 71 % using fistula
plug vs 52 % with ERAF, although this was not a significant difference given the
number of patients completing the study. Interestingly, there were no differences in
post-operative pain or incontinence scores [10]. The plug procedure has been aban-
doned by many owing to poor results.
R.T. Birkett and J.F. Hall
367
LIFT Procedure
The LIFT procedure was first described by Rojanasakul et al. in 2007 [27]. The
procedure involves dissection in the intersphincteric plane to define and encircle the
fistula tract. The fistula is then ligated without division of the sphincter complex.
The mean success rate at 10 months was 76.5 %, with a 5.5 % post-operative com-
plication rate in one review [28]. Another recent review analyzed 26 studies which
included one randomized controlled trial and 25 cohort/case series. Seven technical
variations of the ligation of the intersphincteric fistula tract procedure were identi-
fied and classified according to the surgical technique. Primary healing rates ranged
from 47 to 95 %. In 12 of these studies, the classic LIFT procedure was used, and
healing rates ranged between 61 and 94.4 %. Several technical modifications have
been described, including LIFT combined with excision of the intersphincteric
tract, coring out of the fistula tract, intraoperative seton, advancement flap, plug and
adjunctive use of a bioprosthetic graft; a similar range of success was observed [29].
Early results from a multicenter study in China suggest a higher primary healing
rate with placement of a bioprosthetic plug in the tract extending to the external open-
ing. Han et al. randomized over 100 patients to either a LIFT or LIFT-plug arm. Initial
results include an 83.9 % success rate after LIFT and 95 % combined with the plug.
No difference was found in continence scores; longer follow-up is necessary [13].
A prospective multicenter study of high volume New England centers reported
results of operative options for surgical management of anal fistulas. These authors
were particularly interested in short term outcomes of the LIFT procedure. They
found that of the 43 LIFT procedures, 88 % of were performed for transsphincteric
fistulas. Hospital site was the only variable associated with healing. Hospitals that
performed more LIFT procedures had higher healing rates. At 3 months, 79 % of
high transsphincteric fistulas had healed versus 82 % for low fistulas, with no statis-
tical difference. Patients that had a seton placed preoperatively before LIFT proce-
dure did not appear to have higher healing when compared to patients treated with
LIFT alone. Mean continence scores improved in all groups [11]. Sileri et al. found
similar results with respect to the success rate after LIFT. This multicenter prospec-
tive study reported an 73 % healing rate in 26 patients followed over 20 months,
with no change in function.
Two randomized studies compared LIFT to ERAF in managing complex trans-
sphincteric fistulas. Mabdouly et al. found a cure rate of 74.3 % with LIFT versus
65.7 % after ERAF at 1 year. No change in Wexner score was reported, however,
mean healing time was shorter (22.6 days) after LIFT than ERAF (32 days) and
patients reported less immediate postoperative pain in the LIFT group [14]. An
earlier, smaller study found a comparable success rates of over 92 % in both groups,
and similar secondary outcomes to other studies. They found that the LIFT group
had faster healing times, less postoperative pain and higher patient satisfaction
scores in comparison to patients undergoing ERAF.
15
32 Optimal Management of the Transsphincteric Anal Fistula
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Conclusion and Personal View
Low transsphincteric fistulas can usually be managed readily with fistulotomy.
These patients usually go on to prompt healing with low rates of long term fecal
incontinence. More complex fistulas are often very challenging as one must balance
the desire for healing with the risk of fecal incontinence. Management should be
individualized and tailored to the patient’s current bowel habits and sphincter
function.
The initial approach for all patients should be control of sepsis and precise evalu-
ation of the anatomy. Examination in the clinic setting or under anesthesia are both
effective tools for defining the anatomy of the fistula tract. Occasionally, imaging
might be required to delineate the anatomy of a fistula. We often find that placement
of a seton helps to clearly delineate the anatomy of the fistula tract as well as reduce
local sepsis. Once these objectives have been accomplished, then a rational choice
can be made regarding the most appropriate definitive strategy for addressing the
fistula.
For high transphincteric fistulas where the fistula traverses more than a third of
the external sphincter, we favor a sphincter-saving approach over fistulotomy. Also,
patients with low transsphincteric fistulas and higher baseline fecal incontinence
scores are typically better served with a sphincter-sparing procedure.
Level 1 data comparing advancement flap to the LIFT procedure are limited.
Both randomized trials comparing ERAF to LIFT reported largely equivalent results
and involve only short follow-up. Smaller case-series examining each technique are
limited by selection bias.
Our approach is to offer ERAF or LIFT to patients with high transsphincteric
fistulas or in those with poor sphincter function. Some important technical details
merit consideration when making a decision about which technique to use. We have
found that identification of the fistula in the intersphincteric groove can be difficult
in patients with posterior fistulas. This makes ligation of the fistula track difficult
and often leads to technical failure of a LIFT procedure. Thus, we offer most patients
with posterior fistulas ERAF. Most other patients can be offered LIFT as we have
demonstrated that it can be performed safely with good short term healing rates. In
the evaluation and treatment of patients with complex fistulas, there is no substitute
for the patient’s understanding of the anatomic complexity and technical consider-
ations that are associated with each approach.
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