From the Guidelines
Anal fistula repair can be performed in stages through multiple operations, with the goal of balancing fistula elimination and preserving continence. This approach is particularly necessary for complex fistulas, such as high transsphincteric, suprasphincteric, or extrasphincteric fistulas, where a single-stage repair might risk incontinence by damaging the sphincter muscles 1. The first stage typically involves placing a seton (a surgical thread or drain) through the fistula tract to promote drainage and reduce inflammation, as recommended by the WSES-AAST guidelines 1. Some key points to consider in the management of anal fistulas include:
- The use of a loose draining seton in patients with anorectal abscess and an obvious fistula involving any sphincter muscle 1
- The performance of fistulotomy at the time of abscess drainage only in cases of low fistula not involving sphincter muscle (i.e., subcutaneous fistula) 1
- The importance of maintaining good perianal hygiene and possibly using sitz baths 2-3 times daily between surgeries 1
- The potential need for antibiotics if infection develops 1
- The consideration of subsequent operations, such as advancement flap procedures, LIFT (ligation of intersphincteric fistula tract) procedures, or fibrin glue injections, to gradually close the fistula while preserving sphincter function 1. Overall, the staged approach to anal fistula repair allows surgeons to prioritize the preservation of continence while eliminating the fistula, which is critical for maintaining quality of life and minimizing morbidity and mortality.
From the Research
Anal Fistula Treatment
- Anal fistulas can be treated in stages, with the goal of eradicating sepsis and promoting healing of the tract while preserving the sphincters and the mechanism of continence 2.
- The treatment plan for complex anal fistulas may involve staged operations over a period of many months, usually with the fashioning of a protective stoma at the primary operation 2.
Staged Operations
- Staged operations for anal fistulas may include a combination of surgical techniques, such as fistulotomy, seton placement, and rectal advancement flap surgery 3, 4, 5.
- The choice of surgical technique depends on the complexity of the fistula, the patient's overall health, and the surgeon's expertise 3, 6.
Sphincter-Saving Techniques
- Sphincter-saving techniques, such as ligation of the intersphincteric fistulous tract (LIFT) and rectal advancement flaps, are recommended for complex anal fistulas to minimize the risk of incontinence 3, 6, 5.
- These techniques have been shown to have high healing rates and low recurrence rates, with minimal impact on anal continence 3, 6, 5.
Treatment Outcomes
- The outcomes of anal fistula treatment can vary depending on the surgical technique used, the complexity of the fistula, and the patient's overall health 2, 3, 4, 5.
- Recurrence rates, incontinence rates, and wound infection rates can be minimized with the use of sphincter-saving techniques and staged operations 2, 3, 4, 5.