Gastroenterology

Surgery for anal fistula Treatment

LIFT procedure

An anal fistula is an abnormal connection between the anal canal and the skin near the anus. It has an entrance in the anal canal (internal opening) and an exit on the skin near the anus (external opening). The fistula itself is a tunnel or tube connecting the internal and external openings which crosses the anal sphincter muscles. Most anal fistulas follow an anal abscess. The pus can drain away onto your skin on its own or by an operation. A fistula happens when the track, made by the pus on the way to the surface of your skin, stays open.

                                 

What is an anal fistula?

An abnormal connection between the lining on the inside of your anal canal (back passage) and the skin near your anus is called An Anal Fistula.

Most of the anal fistulas are caused by an abscess (a collection of pus) which has developed in your anal canal. The pus can drain away onto the skin on its own or by a Surgery. A fistula occurs when the track, made by the pus on the way to the surface of the skin, stays open.

Surgery is usually essential to treat an anal fistula as very few heal by themselves.

The best option for you will depend on:

  • The position of your fistula
  • Whether it is a single channel or branches off in different directions.

Sometimes it is needed to have an initial examination of the area under general anesthetic (where you're asleep) to help determine the best treatment.

Your surgeon will tell you about the options available and which one they feel is the most suitable for you.

Usually, surgery for an anal fistula is carried out under general anesthetic. In many cases, it's not required to stay in the hospital overnight afterward.

The main objective of surgery is to heal the fistula while avoiding damage to the sphincter muscles, the ring of muscles that open and close the anus, which could potentially result in loss of bowel control bowel incontinence.

The main options are described below:

Fistulotomy

Fistulotomy is the most common type of surgery for anal fistulas. This procedure involves cutting along the whole length of the fistula to open it up so it heals as a flat scar.Page Image

A fistulotomy is the most effective treatment for many types of anal fistulas, although it's usually only suitable for fistulas that don't pass through much of the sphincter muscles, as the risk of incontinence is lowest in this type of cases.

If your doctor has to cut a small portion of anal sphincter muscle during the surgery, they will make every attempt to reduce the risk of incontinence.

If the risk of incontinence is considered too high, one of the procedures below may be recommended instead.

Seton techniques

If your fistula passes through a significant portion of the anal sphincter muscle, your doctor may initially recommend inserting a seton.

A seton is a piece of surgical thread that is left in the fistula for some weeks to keep it open. This allows it to drain and helps it heal while reducing the need to cut the sphincter muscles.

Loose setons allow fistulas to drain, but they don't cure them. Tighter setons may be used to cut through the fistula slowly to cure a fistula. This may require several techniques that your surgeon can discuss with you.

Alternatively, they may suggest carrying out several fistulotomy procedures, carefully opening up a tiny section of the fistula each time or one of the treatments described below. 

Advancement flap procedure

Your surgeon may suggest you an advancement flap procedure if your fistula passes through the anal sphincter muscles and having a fistulotomy carries a high risk of causing incontinence.

This procedure involves cutting or scraping out the fistula and covering the hole where it entered the bowel with a flap of tissue taken from inside the rectum, which is the final part of the bowel.

The Success rate of advancement flap procedure is lower than a fistulotomy but avoids the need to cut the anal sphincter muscles.

Bioprosthetic plug

Another procedure in cases where a fistulotomy carries a high risk of incontinence is the insertion of a bioprosthetic plug.

A Bioprosthetic plug is a cone-shaped plug made from animal tissue that is used to block the internal opening of the fistula.

Some studies on this have suggested that this may be an effective treatment for anal fistulas, but more evidence is needed to be certain.

The National Institute for Health and Care Excellence (NICE) currently recommends carrying out the technique as part of medical research.

LIFT procedure

The ligation of the intersphincteric fistula tract (LIFT) procedure is the latest treatment for anal fistulas.

It's designed as a treatment for a type of fistulas that pass through the anal sphincter muscles, where a fistulotomy would be too risky.

During the procedure, a cut (incision) is made in the skin above the fistula and the sphincter muscles are moved apart. The fistula is then sealed at both of the ends and cut open so it lies flat.

This technique has had some promising results so far, but it's only been around for a few years, so more research is needed to determine how well it works in the short and long term.

Fibrin glue

Treatment with fibrin glue is currently the only option which doesn’t include surgery for anal fistulas.

It involves your surgeon injecting special glue into your fistula while you've given a general anesthetic. The glue helps seal the fistula and also helps it heal.

Generally, it’s less effective than fistulotomy for simple fistulas and the results may not be long-lasting, but it may be a useful option for fistulas that pass through the anal sphincter muscles because they do not need to be cut.

What are the Risks involved in anal fistula surgery?

Like any type of medical treatment, treatment for anal fistulas also carries a number of risks.

The main risks in anal fistula surgery are:

  • Infection – Anal fistula surgery may require a course of antibiotics; severe cases may need to be treated in hospital
  • Recurrence of the fistula – Sometimes, the fistula can recur despite surgery
  • Bowel incontinence – This is a potential risk with most types of anal fistula treatment, although severe incontinence is rare and all possible efforts will be made to prevent it

The level of risk will depend on things like what is the location of your fistula and the specific procedure you have. Speak to your doctor about the potential risks of the procedure they recommend.

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