Fistula Repair and Management

Educational Objectives

The goal of this program is to improve the management of anal fistula. After hearing and assimilating this program, the clinician will be better able to:

1. Compare the risks and benefits of various surgical procedures for anal fistula and deep postanal space infections.

Summary

Parks classification of anal fistula (AF): intersphincteric — easier to manage; transphincteric — depends on the level of involvement of the external anal sphincter (EAS); suprasphincteric — the tract goes cephalad through the levators; extrasphincteric — sphincters are not involved

Prognosis of AF: in 50% of patients presenting with perianal abscess, resolution occurs with incision and drainage; in those (the other 50%) who develop AF, 50% of patients heal spontaneously (6-8 wk); the longer a fistula persists, the less likely it is to spontaneously resolve

Goals for fistula management: elimination of sepsis (fistulotomy may be necessary); closure or opening of the fistula tract (helps minimize recurrence); improve quality of life (preserve fecal continence and sphincter function); set realistic expectations

Management of AF: in 2022,the American Society of Colon and Rectal Surgeons published guidelines for the management of AF; the presence of an external opening or a fluctuant area warrants examination under anesthesia; assess sphincter function and baseline sphincter control; digital rectal examination and pelvic floor assessment (eg, squeeze, relax, push) help assess baseline tone and guide intraoperative decisions; computed tomography (sensitivity, 75%) can be helpful for identifying areas of undrained sepsis; magnetic resonance imaging is more sensitive and is helpful for identifying horseshoe fistulas, undrained collections, and blind tracts; endoanal ultrasonography is not routinely used; simple AF — intersphincteric or low transphincteric (<33% of EAS) AF; the fistula is cut open, and continence is maintained (≈90% resolution rate); marsupialization of the edges improves the speed of healing and reduces the risk for reformation

Antibiotic therapy: postoperative antibiotic therapy is indicated in patients with cellulitis, signs of systemic infection, and immunosuppression

Seton placement: helps preserve sphincter length, prevents recurrent abscesses by allowing for adequate drainage, and helps with fibrosis of the tract; indicated in high transphincteric, suprasphincteric, anterior (in women), and Crohn fistulas; the tail approach enables the patient to apply tension

Deep postanal space infection (DPSI): control of sepsis is important for a mature tract; imaging can help identify DPSI; abscess in the DPS can travel bilaterally into the ischiorectal space, leading to horseshoe abscess; entering the DPS through the anococcygeal ligament enables control of the sepsis; Hanley or modified Hanley procedure involves counter incisions bilaterally to drain peripheral abscesses (using Penrose drains) and seton placement in the posterior midline (to convert it into a complex posterior midline fistula)

Sphincter-preserving fistula treatment: cutting setons forces the fistula to close spontaneously; mucosal advancement flaps (MAF) and ligation of the intersphincteric fistula tract (LIFT) are popular; cutting seton — use of silk suture or silicone rubber (eg, Silastic) vessel loops allows for slow transection of the EAS with proximal fibrosis (gradual fistulotomy); helps prevent separation of the sphincter complex and allows conversion to a low transphincteric fistula; the anoderm is incised to reach the muscle complex; LIFT — healing rate is ≈76%; seton placement (for a mature tract) upon initial presentation is followed by the LIFT procedure; involves incision in the intersphincteric groove and suture ligation of both ends of fistula with division of the tract; factors for failure include horseshoe anatomy, undrained sepsis, Crohn disease, and subsequent attempts

Readings

Gaertner WB, Burgess PL, Davids JS, et al. The American Society of Colon and Rectal Surgeons clinical practice guidelines for the management of anorectal abscess, fistula-in-ano, and rectovaginal fistula. Dis Colon Rectum. 2022;65(8):964-985. doi:10.1097/DCR.0000000000002473; Litta F, Parello A, Ferri L, et al. Simple fistula-in-ano: is it all simple? A systematic review. Tech Coloproctol. 2021;25(4):385-399. doi:10.1007/s10151-020-02385-5; Sancho-Muriel J, Garcia-Granero A, Fletcher-Sanfeliu D, et al. Surgical anatomy of the deep postanal space and the re-modified Hanley procedure - a video vignette. Colorectal Dis. 2018;20(7):645-646. doi:10.1111/codi.14217.

Disclosures

For this program, members of the faculty and planning committee reported nothing relevant to disclose.

Acknowledgements

Dr. Kanters was recorded at the 5th Annual Updates in General Surgery, held January 20–23, 2023, in Vail, CO, and presented by the Cleveland Clinic Foundation. For more information about upcoming CME activities from this presenter, please visit www.clevelandclinicmeded.com. Audio Digest thanks the speakers and presenters for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 0.50 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 0.50 CE contact hours.

Lecture ID:

GS702102

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.

More Details - Certification & Accreditation