From the Guidelines
The initial treatment for a complex fistula in ano should involve a staged approach beginning with seton placement, as recommended by the most recent guidelines 1. This approach is based on the latest evidence from the ECCO guidelines on therapeutics in Crohn's disease, which suggests that surgical fistula closure in combination with medical therapy results in improved long-term outcomes for patients with complex perianal fistulae 1. A seton, which is a loose suture or drain placed through the fistula tract, helps promote drainage and prevents abscess formation while reducing inflammation. This is often combined with antibiotics such as metronidazole (500mg three times daily for 7-10 days) or ciprofloxacin (500mg twice daily for 7-10 days) to control infection. The seton is usually left in place for several weeks to months to allow the tract to mature and inflammation to subside before definitive surgical treatment. Some key points to consider in the management of complex fistula in ano include:
- The use of seton placement as the initial treatment to promote drainage and reduce inflammation 1
- The combination of medical therapy with surgical fistula closure to improve long-term outcomes 1
- The importance of allowing the tract to mature and inflammation to subside before definitive surgical treatment
- The potential need for subsequent definitive procedures such as advancement flap repair, LIFT procedure (ligation of intersphincteric fistula tract), or fibrin glue injection after the initial seton placement phase. During this period, sitz baths (warm water soaks) for 10-15 minutes, 2-3 times daily, can help with symptom management, and pain control with acetaminophen or NSAIDs may be necessary 1. This initial approach allows for better tissue healing and reduces the risk of incontinence that might occur with immediate aggressive surgical intervention. It is also worth noting that the WSES-AAST guidelines suggest that in patients with anorectal abscess and an obvious fistula involving any sphincter muscle, a loose draining seton should be placed 1. However, the most recent and highest quality study 1 supports the use of seton placement as the initial treatment for complex fistula in ano, and this approach should be prioritized.
From the Research
Initial Treatment for Complex Fistula in Ano
The initial treatment for a complex fistula in ano is a crucial aspect of managing this condition. According to the available evidence, several surgical techniques can be employed, each with its own success rates and potential complications.
Sphincter-Saving Techniques
- Ligation of the intersphincteric fistula tract (LIFT) is a sphincter-saving technique that has shown promising results, with success rates ranging from 60-90% 2, 3, 4.
- Rectal advancement flaps are another sphincter-saving technique that can be used to treat complex anal fistulas, with reported success rates of 60-90% 2.
- Fistula laser closure (FiLac) and video-assisted anal fistula treatment (VAAFT) are novel sphincter-saving techniques that have shown success rates ranging from 65% to 90% 2.
- The use of a biological plug, such as Surgisis® AFP, has also been reported to be effective in treating complex anal fistulas, with a success rate of 73.9% 5.
Other Treatment Options
- Fibrin glue application is a conservative treatment option that can be used to treat complex anal fistulas, especially in patients with impaired immunity or those who are at high risk of surgical complications 6.
- Seton drainage is another treatment option that can be used to manage complex anal fistulas, especially in cases where there is significant inflammation or infection.
Factors Affecting Treatment Outcome
- The etiology and complexity of the fistula can affect the outcome of treatment 2.
- The patient's overall health and medical status can also impact the success of treatment, with patients who are immunosuppressed or have underlying medical conditions potentially requiring more conservative treatment approaches 6.