From the Guidelines
The treatment of anal fistulas should start with the insertion of a seton, followed by medical treatment, preferably anti-TNF, and surgical closure should be considered in the absence of proctitis. This approach is based on the most recent guidelines from the Journal of Crohn's and Colitis, published in 2024 1. The primary goal of treatment is to control sepsis, create a patent tract, and ultimately achieve closure of the fistula.
Treatment Approach
- Insertion of a seton to control sepsis and create a patent tract
- Medical treatment with anti-TNF therapy to reduce inflammation and promote healing
- Surgical closure, such as fistulotomy, advancement flap procedures, LIFT, or fibrin glue/plug insertion, should be considered in the absence of proctitis
- For complex perianal fistulae, alternative approaches such as AF, LIFT, or stem cells may be offered
Pre-Surgical Management
- Antibiotics, such as metronidazole or ciprofloxacin, may be prescribed for 7-10 days to control infection, as recommended by a global consensus on the classification, diagnosis, and multidisciplinary treatment of perianal fistulising Crohn's disease 1
- Sitz baths and pain management with acetaminophen or NSAIDs can help relieve discomfort
Post-Surgical Management
- Patients should maintain good hygiene and follow post-operative instructions carefully
- Recovery typically takes 2-6 weeks depending on the procedure
- Regular follow-up with a healthcare provider is necessary to monitor healing and prevent recurrence.
From the Research
Treatment Options for Anal Fistula
- The ideal surgical treatment for anal fistula should aim to eradicate sepsis and promote healing of the tract, whilst preserving the sphincters and the mechanism of continence 2.
- Conventional surgical options such as laying open of the fistula tract seem to be relatively safe and well accepted in clinical practice for simple and most distal fistulae 2.
- For complex fistulae, sphincter-preserving procedures have been introduced to minimize injury to the anal sphincters and preserve optimal function 2, 3, 4.
- The ligation of intersphincteric fistula tract procedure appears to be safe and effective and may be routinely considered for complex anal fistula 2.
- The anal fistula plug, derived from porcine small intestinal submucosa, is safe but modestly effective in long-term follow-up, with success rates varying from 24%-88% 2, 3.
Comparison of Treatment Outcomes
- A retrospective study compared the outcomes of anal fistula plug, fibrin glue, advancement flap closure, and seton drain insertion, and found that the fistula plug and advancement flap closure resulted in similar fistula healing rates, which were superior to seton placement and fibrin glue 3.
- The study found that the postoperative healing rates at the 12-week follow-up for the fistula plug, fibrin glue, flap advancement, and seton drain groups were 59.3%, 39.1%, 60.4%, and 32.6%, respectively (P < .0001) 3.
Evolution of Treatment
- The treatment of fistula-in-ano has evolved over time, with a shift from traditional cutting procedures such as fistulotomy to non-cutting procedures such as sphincter-sparing techniques 5.
- A retrospective review of 2,267 fistula operations found that the percentage of cutting and non-cutting procedures significantly differed over time, with cutting procedures decreasing and non-cutting procedures increasing proportionally 5.
- The use of new technologies such as fibrin sealant, dermal or endorectal flap, and fistula plug has increased over time, with these procedures being used in 33.4% of cases between 1975 and 2009 5.