Anal fistula surgery

Anal fistula Microchapters
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Manpreet Kaur, MD [2]

Surgery

• Mainstay of treatment of anal fistula is surgical treatment.
• According to British Medical Journal, the principles for the management of anal fistula are described by the acronym SNAP, which stands for sepsis, nutrition, anatomy, and procedure.
  • Treatment of sepsis is the first step.
  • Nutrition is very important for the healing of fistula.
    • Patients should be healthy during the treatment of anal fistula.
    • In malnourished patients and patients with comorbidities, fistula heals slowly.
  • Anatomy of fistula should be tracked before starting the treatment. Failure to track the secondary fistula leads to failure of treatment.
  • Selection of the appropriate procedure is key to successful management.

• According to the American Society of Colon and Rectal Surgeons, the goal of treatment of anal fistula is to obliterate the internal fistulous opening and any associated epithelialized tracks with minimal sphincter division. Thus, it is important to identify the internal opening and the course of all tracts relative to the sphincter muscles.

Various methods of surgery are:

• Fistulotomy: It is used to treat simple anal fistula with normal anatomy and with no other complication.
• Seton: Used to treat complex fistula.

Sphincter-saving methods are:

• Fibrin glue: Fibrin glue is a combination of fibrinogen, thrombin, and calcium in a matrix.
  • Fibrin glue heals the fistula by first forming the clot within the track and then helping in the growth of collagen fibers and healthy tissue.
• Fistula plug: Fistula plug is made from porcine small intestinal mucosa.
  • It encourages host cells to grow and ultimately fill the fistula track.
  • It is resistant to infection.