FistulaInAno

Drainageofananorectalabscessresultsincureforabout50%ofpatients.The
remaining50%developapersistentfistulainano.Thefistulausuallyoriginatesin
theinfectedcrypt(internalopening)andtrackstotheexternalopening,usually
thesiteofpriordrainage.Thecourseofthefistulacanoftenbepredictedbythe
anatomyofthepreviousabscess.
Whilethemajorityoffistulasarecryptoglandularinorigin,trauma,Crohns
disease,malignancy,radiation,orunusualinfections(tuberculosis,actinomycosis,
andchlamydia)mayalsoproducefistulas.Acomplex,recurrent,ornonhealing
fistulashouldraisethesuspicionofoneofthesediagnoses.
Diagnosis.Patientspresentwithpersistentdrainagefromtheinternaland/or
externalopenings.Aninduratedtractisoftenpalpable.Althoughtheexternal
openingisofteneasilyidentifiable,identificationoftheinternalopeningmaybe
morechallenging.Goodsallsrulecanbeusedasaguideindeterminingtheloca
tionoftheinternalopening(Fig.2939).Ingeneral,fistulaswithanexternal
openinganteriorlyconnecttotheinternalopeningbyashort,radialtract.Fistulas
withanexternalopeningposteriorlytrackinacurvilinearfashiontothe
posteriormidline.However,exceptionstothisruleoftenoccurifananterior
externalopeningisgreaterthan3cmfromtheanalmargin.Suchfistulasusually
tracktotheposteriormidline.
Fistulasarecategorizedbasedontheirrelationshiptotheanalsphinctercomplex,
andtreatmentoptionsarebasedontheseclassifications.Anintersphincteric
fistulatracksthroughthedistalinternalsphincterandintersphinctericspacetoan
externalopeningneartheanalverge(Fig.2940A).Atranssphinctericfistula
oftenresultsfromanischiorectalabscessandextendsthroughboththeinternal
andexternalsphincters(Fig.2940B).Asuprasphinctericfistulaoriginatesinthe
intersphinctericplaneandtracksupandaroundtheentireexternalsphincter(Fig.
2940C).Anextrasphinctericfistulaoriginatesintherectalwallandtracksaround
bothsphincterstoexitlaterally,usuallyintheischiorectalfossa(Fig.2940D).
Treatment.Thegoaloftreatmentoffistulainanoiseradicationofsepsis
withoutsacrificingcontinence.Becausefistulous
tracksencirclevariableamountsofthesphinctercomplex,surgicaltreatmentis
dictatedbythelocationoftheinternalandexternalopeningsandthecourseofthe
fistula.Theexternalopeningisusuallyvisibleasaredelevationofgranulation
tissuewithorwithoutconcurrentdrainage.Theinternalopeningmaybemore
difficulttoidentify.Injectionofhydrogenperoxideordilutemethylenebluemay

behelpful.Caremustbetakentoavoidcreatinganartificialinternalopening(thus
often
convertingasimplefistulaintoacomplexfistula).Simpleintersphinctericfistulas
canoftenbetreatedbyfistulotomy(openingthefistuloustract),curettage,and
healingbysecondaryintention(seeFig.2940A).Horseshoefistulasusually
haveaninternalopeningintheposteriormidlineandextendanteriorlyand
laterallytooneorbothischiorectalspacesbywayofthedeeppostanalspace.
Treatmentofatranssphinctericfistuladependsonitslocationinthesphincter
complex.
Fistulasthatincludelessthan30%ofthesphinctermusclescanoftenbetreatedby
sphincterotomywithoutsignificantriskofmajorincontinence(seeFig.2940B).
Hightranssphinctericfistulas,whichencircleagreateramountofmuscle,are
moresafelytreatedbyinitialplacementofaseton(seebelow).Similarly,
suprasphinctericfistulasareusuallytreatedwithsetonplacement(seeFig.29
40C).Extrasphinctericfistulasarerare,andtreatmentdependsonboththe
anatomyofthefistulaanditsetiology.Ingeneral,theportionofthefistulaoutside
thesphinctershouldbeopenedanddrained.Aprimarytractatthelevelofthe
dentatelinemayalsobeopenedifpresent.Complexfistulaswithmultipletracts
mayrequirenumerousprocedurestocontrolsepsisandfacilitatehealing.Liberal
useofdrainsandsetonsishelpful.Failuretohealmayultimatelyrequirefecal
diversion(seeFig.2940D).Complexand/ornonhealingfistulasmayresultfrom
Crohnsdisease,malignancy,radiationproctitis,orunusualinfection.Proctoscopy
shouldbeperformedinallcasesofcomplexand/ornonhealingfistulastoassess
thehealthoftherectalmucosa.Biopsiesofthefistulatractshouldbetakentorule
outmalignancy.
Asetonisadrainplacedthroughafistulatomaintaindrainageand/orinduce
fibrosis.Cuttingsetonsconsistofasutureorarubberbandthatisplacedthrough
thefistulaandintermittentlytightenedintheoffice.Tighteningthesetonresultsin
fibrosisandgradualdivisionofthesphincter,thuseliminatingthefistulawhile
maintainingcontinuityofthesphincter.Anoncuttingsetonisasoftplasticdrain
(oftenavesselloop)placedinthefistulatomaintaindrainage.Thefistulatract
maysubsequentlybelaidopenwithlessriskofincontinencebecausescarring
preventsretractionofthesphincter.Alternatively,thesetonmaybeleftinplace
forchronicdrainage.Higherfistulasmaybetreatedbyanendorectal
advancementflap(seebelow).Fibringlueandavarietyofcollagenbasedplugs
alsohavebeenusedtotreatpersistentfistulaswithvariableresults.Amorerecent
technique,ligationoftheintersphinctericfistulatract(LIFT),alsoshowspromise.
Inthisprocedure,thefistulaisidentifiedintheintersphinctericplane(usuallyby

placementofalacrimalprobe),divided,andthetwoendsligated.Earlyreports
haveshownsuccesswiththistechnique,butlongtermoutcomeisnotyetknown.