Anal Fistula (Fistula in ano)

Definition:

An anal fistula is a small tunnel that develops between the end of the bowel and the skin near the anus (where poo leaves the body).

Why anal fistula occurs?

They're usually the result of an infection near the anus causing a collection of pus (anal abscess) in the nearby tissue. When the pus drains away, it can leave a small channel behind.

Symptoms of Anal Fistula

Anal fistulas can cause discharge like pus or blood mixed fluid and creates unpleasant symptoms, such as discomfort and skin irritation, and will not usually get better on their own without surgery.

Surgery is recommended in most cases.

Symptoms of an anal fistula can include:

• skin irritation around the anus

• a constant, throbbing pain that may be worse when you sit down, move around, poo or cough

• smelly discharge from near your anus

• passing pus or blood when you poo

• swelling and redness around your anus and a high temperature (fever) if you also have an abscess

• difficulty controlling bowel movements (bowel incontinence) in some cases

The end of the fistula might be visible as a hole in the skin near your anus, although this may be difficult for you to see yourself.

When to get medical advice

See a Colorectal Surgeon if you have persistent symptoms of an anal fistula. You will be asked about your symptoms and whether you have any bowel conditions. Colorectal Surgeon may examine your anus to check for signs of a fistula. If he/she thinks you might have a fistula, further tests may be requested for the most suitable treatment.

These may include:

• a further physical and rectal examination

• a proctoscopy, where a special telescope with a light on the end is used to look inside your anus

• an ultrasound scan, MRI scan or CT scan

• Most of the general surgeon give a fistulogram (X ray). We don’t suggest Fistulogram because it is unnecessary and usually misleading.

Causes of anal fistulas

Most anal fistulas develop after an anal abscess. You can get one if the abscess does not heal properly after the pus has drained away.

Less common causes of anal fistulas include:

• Crohn's disease – a long-term condition in which the digestive system becomes inflamed

• infection with tuberculosis (TB)

• hidradenitis suppurativa – a long-term skin condition that causes abscesses and scarring

• a complication of surgery near the anus

Treatments for an anal fistula

Anal fistulas almost always require surgery as they do not heal if left untreated. There are several different procedures. The best option for you will depend on the position of your fistula and whether it's a single channel or branches off in different directions.

The surgeon will talk to you about the options available and which one they feel is the most suitable for you. Surgery for an anal fistula is usually carried out under regional anaesthetic. In many cases, it's not necessary to stay in hospital overnight afterwards.

The aim 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 outlined here.

Fistulotomy

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

A fistulotomy is the most effective treatment for many anal fistulas, although it's usually only suitable for fistulas that do not pass through much of the sphincter muscles, as the risk of incontinence is lowest in these cases. If the surgeon has to cut a small portion of anal sphincter muscle during the procedure, they'll make every attempt to reduce the risk of incontinence.

In cases where the risk of incontinence is considered too high, another procedure may be recommended instead.

Seton techniques

If your fistula passes through a significant portion of anal sphincter muscle, the surgeon may initially recommend inserting a seton. A seton is a piece of surgical thread that's left in the fistula for several weeks to keep it open. This allows it to drain and helps it heal, while avoiding the need to cut the sphincter muscles.

Loose setons allow fistulas to drain, but do not cure them. To cure a fistula, tighter setons may be used to cut through the fistula slowly. This may require several procedures that the surgeon can discuss with you.

Or they may suggest carrying out several fistulotomy procedures, carefully opening up a small section of the fistula each time, or a different treatment.

Advancement flap procedure

An advancement flap procedure may be considered if your fistula passes through the anal sphincter muscles and having a fistulotomy carries a high risk of causing incontinence.

This 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.

This has a lower success rate than a fistulotomy, but avoids the need to cut the anal sphincter muscles.

LIFT procedure

The ligation of the intersphincteric fistula tract (LIFT) procedure is a treatment for fistulas that pass through the anal sphincter muscles, where a fistulotomy would be too risky.

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

This procedure 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.

Endoscopic ablation

In this procedure, an endoscope (a tube with a camera on the end) is put in the fistula. An electrode is then passed through the endoscope and used to seal the fistula. Endoscopic ablation works well and there are no serious concerns about its safety.

Laser surgery

Radially emitting laser fibre treatment involves using a small laser beam to seal the fistula. There are uncertainties around how well it works, but there are no major safety concerns.

Fibrin glue

Treatment with fibrin glue is currently the only non-surgical option for anal fistulas. It involves the surgeon injecting a glue into the fistula while you're under a general anaesthetic.

The glue helps seal the fistula and encourages it to heal.

It's generally 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.

Bioprosthetic plug

Another option is the insertion of a bioprosthetic plug. This is a cone-shaped plug made from animal tissue that's used to block the internal opening of the fistula. This procedure works well for blocking an anal fistula and there are no serious concerns about its safety. Risks of anal fistula surgery Like any type of treatment, treatment for anal fistulas carries a number of risks.

The main risks are:

• recurrence of the fistula – the fistula can sometimes recur despite surgery

• bowel incontinence – this is a potential risk with most types of anal fistula treatment, although severe incontinence is rare and every effort will be made to prevent it

• infection – this may require a course of antibiotics; severe cases may need to be treated in hospital

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

Which doctor is best for anal fistula?

A colorectal surgeon is best for anal fistula diagnosis, surgery and total care.

Who is a Colorectal Surgeon?

A colorectal surgeon should have a MS degree on Colorectal Surgery &/or is the faculty of Bangabandhu Sheikh Mujib Medical University (BSMMU). He/she has huge knowledge, expertise and experience on this field enough to do both medical and surgical treatment. There are very few colorectal surgeons in Bangladesh. We can offer you the best treatment in this field. We treat piles (haemorrhoid), colon cancer, rectum cancer, Anal cancer, anal fistula, anal abscess, anal fissure, rectal prolapse, incontinence, constipation, chronic dysentery, abdominal pain, IBS, ulcerative colitis, Crohn's disease, tuberculosis, polyps, vomiting, abdominal gas, per rectal bleeding, anal pain, pilonidal sinus, obstructed defecation(ODS), rectocele, rectal intussusception, pelvic floor descend, rectovaginal fistula. We do colonoscopy, LASER Surgery, Laparoscopic surgery, rubber band/ring ligation, injection sclerotherapy, Longo, STARR, rectopexy, fistula surgery, Colon/rectal/anal cancer treatment, APR, Anterior resection, colectomy etc with excellence and hospitality.

কলোরেক্টাল সার্জন হচ্ছেন পায়ুপথ, মলাশয়, বৃহদান্ত্র ও ক্ষুদ্রান্ত্র এর সকল রোগের চিকিতসা ও অপারেশনে বিষেশজ্ঞ। তিনি কলোরেক্টাল সার্জারী বিষয়ের উপর এমএস ডিগ্রী করেছেন কিংবা বঙ্গবন্ধু শেখ মুজিব মেডিকেল বিশ্ববিদ্যালয়ের কলোরেক্টাল সার্জারী বিষয়ের শিক্ষক হিসাবে কর্মরত আছেন অথবা কর্মরত ছিলেন। একজন কলোরেক্টাল সার্জন এসব রোগ সম্পর্কে দীর্ঘদিন পড়ালেখা ও গবেষণা করেছেন তাই তিনি এসব বিষয়ে ডিটেইল জানেন এবং তাদের ভুল করার সম্ভাবনা কম। আমরা যেসব রোগের সর্বোত্তম চিকিৎসা নিশ্চিত করিঃ পাইলস, কোলন ক্যান্সার, রেক্টাম/মলাশয় ক্যান্সার, পলিপ, এনাল/মলদারের ক্যান্সার, ফিস্টুলা, ফোঁড়া, এনাল ফিসার, রেক্টাল প্রোলাপ্স (হালিশ), কোষ্ঠকাঠিন্য, মলত্যাগে বাধাগ্রস্ততা, ডায়রিয়া, আমাশয়, পেটে ব্যাথা, আইবিএস, আলসারিটিভ কোলাইটিস, ক্রনস ডিসিস, পেটের ও মলদারের যক্ষা, বমি, পেট ফাঁপা, পেট ফোলা, বদ হজম, পেটে গ্যাস, মলদারে রক্ত যাওয়া, মলদারে ব্যাথা, পাইলোনিডাল সাইনাস ইত্যাদি। আমরা বিনা অপারেশনে পাইলসের চিকিৎসা, লেজার চিকিৎসা, কলোনস্কপি, রাবার ব্যান্ড/রিং লাইগেশন, ইঞ্জেকশন স্কেরোথেরাপি, লঙ্গো, STARR, ফিস্টুলা সার্জারী, ল্যাপারোস্কপিক রেক্টোপেক্সি, মলদার রেখেই কোলন ও রেক্টাম ক্যান্সার অপারেশন ইত্যাদি সেবা আন্তরিকভাবে দক্ষতার সাথে দিয়ে আসছি।

Take home message:

Anal fistula are divided into simple and complex types. Complex fistula surgery in a non Colorectal or less skilled Surgeon may lead into fecal incontinence (loss of power to control stool or flatus) or recurrence of the disease (failed surgery). Take the professional service from the specialist in a good centre and get rid of this nasty disease.

Read More:

1.https://fascrs.org/patients/diseases-and-conditions/a-z/abscess-and-fistula-expanded-information

2.https://www.nhs.uk/conditions/anal-fistula/#:~:text=An%20anal%20fistula%20is%20a,leave%20a%20small%20channel%20behind.

3.https://my.clevelandclinic.org/health/diseases/14466-anal-fistula

4.https://www.webmd.com/digestive-disorders/anal-fistula-overview

5.https://www.mayoclinic.org/diseases-conditions/anal-fistula/symptoms-causes/syc-20352871

Appointment

For treatment and care of Anal Fistula by Colorectal Surgeon Dr Tariq Akhtar Khan please call 01736-369536 and take an appointment.