From the Guidelines
The initial treatment approach for a complex fistula in ano typically involves placement of a loose draining seton, as suggested by the most recent guidelines 1. This approach is based on the principle of managing the fistula in a staged manner to minimize the risk of incontinence and promote healing. The use of a seton allows for drainage and reduction of inflammation, making it an essential step before considering more definitive treatments. Some key points to consider in the management of complex fistulas include:
- Adequate drainage of any associated abscess, often requiring examination under anesthesia
- The potential use of antibiotics such as metronidazole or ciprofloxacin if there is active infection or significant surrounding cellulitis
- The importance of MRI imaging to fully delineate the anatomy of the fistula tract before definitive treatment
- The consideration of staged procedures to minimize the risk of recurrence and incontinence, as complex fistulas carry a high risk of these complications if treated aggressively in a single procedure 1. It's also worth noting that the management of complex fistulas may involve a multidisciplinary approach, including the use of medical therapies such as infliximab, as well as surgical options like advancement flaps and fistula plugs 1. However, the placement of a loose draining seton remains a crucial initial step in the management of these complex cases.
From the FDA Drug Label
RENFLEXIS is indicated for: Crohn's Disease: reducing the number of draining enterocutaneous and rectovaginal fistulas and maintaining fistula closure in adult patients with fistulizing disease. The safety and efficacy of infliximab were assessed in 2 randomized, double-blind, placebo-controlled studies in patients with fistulizing Crohn's disease with fistula(s) that were of at least 3 months duration.
The initial treatment approach for a complex fistula in ano involves the use of infliximab at a dose of 5 mg/kg at weeks 0,2, and 6, followed by maintenance therapy every 8 weeks 2. This treatment has been shown to reduce the number of draining fistulas and maintain fistula closure in adult patients with fistulizing Crohn's disease.
- Key points:
- Infliximab is indicated for reducing the number of draining enterocutaneous and rectovaginal fistulas and maintaining fistula closure in adult patients with fistulizing disease.
- The initial dose of infliximab is 5 mg/kg at weeks 0,2, and 6.
- Maintenance therapy is given every 8 weeks.
- Infliximab has been shown to be effective in reducing the number of draining fistulas and maintaining fistula closure in adult patients with fistulizing Crohn's disease 2.
From the Research
Initial Treatment Approach for Complex Fistula in Ano
The initial treatment approach for a complex fistula in ano involves a conservative and palliative approach to avoid damaging the anal sphincter and prevent fecal incontinence.
- Accurate identification of the type of fistula is crucial for prognosis and choice of treatment 3
- Treatment options for complex fistulas include:
- Incision and drainage of abscesses accompanying fistulas
- Prolonged non-cutting seton placement
- Conservative, sphincter-preserving, and definitive procedures such as mucosal advancement or dermal island flaps, the use of plugs or glue, video assisted anal fistula treatment, ligation of the intersphincteric track, and vacuum assisted closure 3, 4
- The use of a biological plug, such as Surgisis® AFP, has been shown to be effective in closing the fistula without surgery, with a success rate of 73.9% and no incidence of incontinence 5
- A modified plug repair with limited sphincter sparing fistulectomy has also been shown to be effective, with a healing rate of 90% and no complaints of continence problems 6
Considerations for Treatment
- The treatment approach should be tailored to the individual patient, taking into account the type and complexity of the fistula, as well as the patient's overall health and medical history 4
- Operative treatment should be offered to selected patients with fistula-in-ano in the presence of Crohn's disease, with careful consideration of the potential risks and benefits 7
- The goal of treatment is to achieve complete healing of the fistula while preserving anal sphincter function and preventing fecal incontinence.