High perianal fistula: a narrative review of common management techniques
DOI:
https://doi.org/10.18203/2349-2902.isj20223281Keywords:
Perianal fistula, Surgery, Seton, ERAF, LIFT, Fistula plug, Laser ablationAbstract
Perianal fistula is a common and problematic condition that results in perianal pain, recurrent infection, anal discharge and overall reduced quality of life. Low perianal fistula, those that involve the lower third of the external anal sphincter, are relatively easily managed with the use of a fistulotomy. However, high perianal fistula, ones that involve the upper two thirds of the external anal sphincter are extremely difficult to treat. There is no consensus on best management of these type of fistula with little high-quality evidence to guide management. We perform a narrative review of recent literature on common surgical techniques and provide an opinion of the utility of each to guide management.
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Deeba S, Aziz O, Sains SP, Darzi A. Fistula-in-ano: advances in treatment. Am J Surg. 2008;196:95-9.
Zanotti C, Martinez-Puente C, Pascual I, Pascual M, Herreros D, Garcia-Olmo D. An assessment of the incidence of fistula- in-ano in four countries of the European Union. Int J Colorectal Dis. 2007;22(12):1459-62.
Parks AG. Pathogenesis and treatment of fistula-in-ano. BMJ. 1961;1:463-60.
Owen HA, Buchanan GN, Schizas A, Cohen R, Williams AB. Quality of life with anal fistula. Ann R Coll Surg Engl. 2016;98(5):334-8.
Williams J, Farrands P, Williams A. The treatment of anal fistula: ACPGBI position statement. Colorectal Dis. 2007;9(4):18-50.
Parks AG, Gordon PH, Hardcastle JD. A classification of fistula-in-ano. Br J Surg. 1976;63(1):1-12.
Bottini AC, De Nardi P, Giamundo P, Lauretta A, Realis Luc A, Piloni V. Evaluation and management of perianal abscess and anal fistula: SICCR position statement. Techniques in Coloproctol. 2020;24(2):127-43.
Rojanasakul A, Pattana-arun J, Sahakitrungruang C, Tantiphlachiva K. Total anal sphincter saving technique for fistula-in-ano: the ligation of intersphincteric fistula tract. J Med Asso Thai. 2007;90:581-6.
Rojanasakul. LIFT procedure: a simplified technique for fistula-in-ano. Techniques in Coloproctol. 2009;13(3):237-40.
Hong KS, Kalaskar S, Wexner SD. Ligation of intersphincteric fistula tract (LIFT) to treat anal fistula: systematic review and meta-analysis. Techn Coloproctol. 2014;18(8):685-91.
Chen SGD, Zhu P, Zhou ZL, Chen YG, Yang BL. Effective and long-term outcome following ligation of the intersphincteric fistula tract (LIFT) for transsphincteric fistula. Int J Colorectal Dis. 2017;32(4):583-5.
Malakorn ST, Khomvilai S, Chowchankit I, Gunarasa S, Kanjanasilp P, Thiptanakij C. Ligation of Intersphincteric Fistula Tract for Fistula in Ano: Lessons Learned From a Decade of Experience. Dis Colon Rectum. 2017;60(10):1065-70.
Göttgens WDK, Stijns J, Zimmerman D. Ligation of the Intersphincteric Fistula Tract for High Transsphincteric Fistula Yields Moderate Results at Best: Is the Tide Turning? Dis Colon Rectum. 2019;62(10):1231-7.
Wen K, Gu, YF, Sun XL, Wang XP, Yan S, He ZQ. Long-term outcomes of ligation of intersphincteric fistula tract for complex fistula-in-ano: modified operative procedure experience. ABCD Arq Bras Cir Dig. 2018;31(4):e1404.
Osterkamp J, Gocht-Jensen P, Hougaard K, Nordentoft T. Long-term outcomes in patients after ligation of the intersphincteric fistula tract. Dan Med J. 2019;66(4):A5537.
Noble G. New operation for complete laceration of the per- ineum designed for thepurpose of eliminating infection from the rectum. Trans Am Gynecol Soc. 1902;27:357-63.
Golub RW, Wise WE Jr, Kerner BA, Khanduja KS, Aguilar PS. Endorectal mucosal advancement flap: the preferred method for complex cryptoglandular fistula-in-ano. J Gastrointest Surg. 1997;1:487-91.
Aguilar PS, Plasencia G, Hardy TG Jr, Hartmann RF, Stewart WRC. Mucosal advancement in the treatment of anal fistula. Dis Colon Rectum. 1985;28:496-8.
Balciscueta Z, Uribe N, Balciscueta I, Andreu-Ballester JC, García-Granero E. Rectal advancement flap for the treatment of complex cryptoglandular anal fistulas: a systematic review and meta-analysis. Int J Colorectal Dis. 2017;32(5):599-609.
Dubsky PC, Stift A, Friedl J, Teleky B, Herbst F. Endorectal advancement flaps in the treatment of high anal fistula of cryptoglandular origin: full-thickness vs. mucosal-rectum flaps. Dis Colon Rectum. 2008;51(6):852-7.
Chaveli Diaz C, Esquiroz Lizaur I, Marzo Virto J, Oteiza Martínez F, Gonzalez Álvarez G, de Miguel Velasco M et al. Fistulectomy and endorectal advancement flap repair for cryptoglandular anal fistula: recurrence and functional outcome over 10 years of follow-up. Int J Colorectal Dis. 2021;36(4):841-6.
Ghahramani L, Bananzadeh AM, Izadpanah A, Hosseini SV. Late results of endorectal flap in management of high type perianal fistula. Middle East J Dig Dis. 2012;4(3):163-7.
Ortiz H, Marzo M, De Miguel M, Ciga MA, Oteiza F, Armendariz P. Length of follow-up after fistulotomy and fistulectomy associated with endorectal advancement flap repair for fistula in ano. Br J Surg. 2008;95(4):484-7.
Stremitzer S, Riss S, Swoboda P, Dauser B, Dubsky P, Bîrsan T et al. Repeat endorectal advancement flap after flap breakdown and recurrence of fistula-in-ano - is it an option?. Colorectal Dis. 2012;14(11):1389-93.
Mizrahi N, Wexner SD, Zmora O. Endorectal advancement flap: are there predictors of failure? Dis Colon Rectum. 2002;45:1616-21.
On Fistulae. The Internet Classics Archive. Available at: http://classics.mit.edu/Hippocrates/fistulae.mb.txt. Accessed on 25, August 2022.
Kelly HHM, McDermott FD, Nason GJ, Freeman C, Martin ST, Winter DC. The role of loose seton in the management of anal fistula: a multicenter study of 200 patients. Techniques in Coloproctol. 2014;18(10):915-9.
O’Keefe DJ, Heine JA. Draining Setons as Definitive Management of Fistula-in-Ano. Dis Colon Rectum. 2018;61(4):499-503.
Fung C, Ross NP, Yule SR, Aly EH. (2013). Operative strategy for fistula-in-ano without division of the anal sphincter. Ann Royal College Surgeons Eng. 2013;95(7):461-7.
Koliada EM, Bickel A. The Use of the Loose Seton Technique as a Definitive Treatment for Recurrent and Persistent High Trans-Sphincteric Anal Fistulas: A Long-Term Outcome. J Gastrointest Surg. 2009;13(6):1116-9.
Ritchie RD, Sackier JM, Hodde JP. Incontinence rates after cutting seton treatment for anal fistula. Colorectal Dis. 2009;11:564-71.
Soliman F, Sturgeon G, Hargest R. Revisiting an ancient treatment for transphincteric fistula-in-ano 'There is nothing new under the sun' Ecclesiastes 1v9. J R Soc Med. 2015;108(12):482-9.
Shirah BH, Shirah HA. The Impact of the Outcome of Treating a High Anal Fistula by Using a Cutting Seton and Staged Fistulotomy on Saudi Arabian Patients. Ann Coloproctol. 2018;34(5):234-40.
Akici M, Ersen O. The effect of suture selection in complex anal fistulas on the success of cutting seton placement and patient comfort. Pak J Med Sci. 2020;36(4):816-20.
Raslan SM, Aladwani M, Alsanea N. Evaluation of the cutting seton as a method of treatment for perianal fistula. Ann Saudi Med. 2016;36(3):210-5.
Patton V, Chen CM, Lubowski D. Long-term results of the cutting seton for high anal fistula. ANZ J Surg. 2015;85(10):720-7.
Rosen DR, Kaiser AM. Definitive seton management for transsphincteric fistula-in-ano: harm or charm? Colorectal Dis. 2016;18(5):488-95.
Keogh KM, Smart NJ. The proposed use of radiofrequency ablation for the treatment of fistula-in-ano. Med Hypotheses. 2016;86:39-42.
Virk JS, Kumar G, Al-Okati. Radiofrequency ablation in snoring surgery: local tissueeffects and safety measures. Eur Arch Otorhinolaryngol. 2014;271(12):3313-8.
Marref I, Spindler L, Aubert M, Lemarchand N, Fathallah N, Pommaret E et al. The optimal indication for FiLaC® is high trans-sphincteric fistula-in-ano: a prospective cohort of 69 consecutive patients. Tech Coloproctol. 2019;23(9):893-7.
Wilhelm A. A new technique for sphincter-preserving anal fistula repair using a novel radial emitting laser probe. Tech Coloproctol. 2011;15:445-9.
Giamundo P, Geraci M, Tibaldi L, Valente M. Closure of fistula-in-ano with laser--FiLaC™: an effective novel sphincter-saving procedure for complex disease. Colorectal Dis. 2014;16(2):110-5.
Oztürk E, Gülcü B. Laser ablation of fistula tract: a sphincter-preserving method for treating fistula-in-ano. Dis Colon Rectum. 2014;57(3):360-4.
Terzi MC, Agalar C, Habip S, Canda AE, Arslan NC, Obuz F. Closing Perianal Fistulas Using a Laser: Long-Term Results in 103 Patients. Dis Colon Rectum. 2018;61(5):599-603.
Isik O, Gulcu B, Ozturk E. Long-term Outcomes of Laser Ablation of Fistula Tract for Fistula-in-Ano: A Considerable Option in Sphincter Preservation. Dis Colon Rectum. 2020;63(6):831-6.
Wilhelm A, Fiebig A, Krawczak M. Five years of experience with the FiLaC™ laser for fistula-in-ano management: long-term follow-up from a single institution. Tech Coloproctol. 2017;21(4):269-76.
Elfeki H, Shalaby M, Emile SH, Sakr A, Mikael M, Lundby L. A systematic review and meta-analysis of the safety and efficacy of fistula laser closure. Tech Coloproctol. 2020;24(4):265-74.
Robb BWVS, Nussbaum MN, Sklow B. Early experience using porcine small intestinal submucosa to repair fistulas-in-ano. Dis Colon Rectum. 2004;47:565-660.
Lupinacci RM, Vallet C, Parc Y, Chafai N, Tiret E. Treatment of fistula-in-ano with the Surgisis(®) AFP(TM) anal fistula plug. Gastroenterol Clin Biol. 2010;34(10):549-53.
Jayne DG, Scholefield J, Tolan D, Gray R, Edlin R, Hulme CT et al. Anal fistula plug versus surgeon's preference for surgery for trans-sphincteric anal fistula: the FIAT RCT. Heal Technol Assess. 2019;23(21):1-76.
Adamina M, Ross T, Guenin MO, Warschkow R, Rodger C, Cohen Z et al. Anal fistula plug: a prospective evaluation of success, continence and quality of life in the treatment of complex fistulae. Colorectal Dis. 2014;16(7):547-54.
Bondi J, Avdagic J, Karlbom U, Hallböök O, Kalman D, Sˇ altyte ̇ Benth J et al. Randomized clinical trial comparing collagen plug and advancement flap for trans-sphincteric anal fistula. Br J Surg. 2017;104:1160-6.
Tan KK, Kaur G, Byrne CM, Young CJ, Wright C, Solomon MJ. Long-term outcome of the anal fistula plug for anal fistula of cryptoglandular origin. Colorectal Dis. 2013;15(12):1510-4.
Blom J, Husberg-Sellberg B, Lindelius A, Gustafsson UM, Carlens S, Oppelstrup H et al. Results of collagen plug occlusion of anal fistula: a multicentre study of 126 patients. Colorectal Dis. 2014;16(8).
Aho Fält U, Zawadzki A, Starck M, Bohe M, Johnson LB. Long-term outcome of the Surgisis® (Biodesign®) anal fistula plug for complex cryptoglandular and Crohn's fistulas. Colorectal Dis. 2021;23(1):178-85.
McGee MF, Champagne BJ, Stulberg JJ, Reynolds H, Marderstein E, Delaney CP. Tract length predicts successful closure with anal fistula plug in cryptoglandular fistulas. Dis Colon Rectum. 2010;53(8):1116-20.
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