Fistula in ano disease: a comprehensive guide: part 2

In the second article of a two-part series, Mr Daniel Baird, renowned colorectal surgeon discusses the various management methods for fistula in ano, including one of the specialised treatments he offers, video assisted anal fistula treatment (VAAFT).

How can fistula in ano be managed?

The management of a fistula in ano involves addressing the infection and promoting drainage. The following methods are used to address the condition:

‘Status Quo’ Management: This involves discovering a method for patients to coexist with a fistula while minimising its impact on their quality of life. Certain fistulas are handled over an extended period using conservative strategies. The approach entails acknowledging the persistent presence of the fistula and implementing measures to facilitate drainage, preventing the recurrence of abscesses that significantly compromise a patient's quality of life.

‘Curative Attempt’ management: A patient may wish to aim for a cure of the fistula, and the approach taken will be determined by various factors that I will evaluate during the assessment process.

What do I need to consider when choosing a treatment option?

Damage to the anal sphincter muscle can reduce partially or completely the patient’s ability to control the anus, which can lead to flatus incontinence (accidentally passing wind) or faecal incontinence (accidents with stool involving soiling). If the fistula involves the muscle, treatment options must be tailored to account for this.

A male anal sphincter is around 3 times larger than a female sphincter. Carrying a pregnancy and childbirth can damage an anal sphincter. As a result, the operative options in a female, especially if she plans to have children in the future, may be more limited.

Fistula in ano disease is a recurrent disease, which can be very disheartening for a patient, is a treatment that fails at achieving cure.

Medical / non-operative management

Antibiotics may be prescribed to treat or prevent infection associated with the fistula. In some cases antibiotics are given with an abscess, but are unlikely to be curative in larger abscess, surgery will be required.

For patients with Crohn’s disease, biological medications can work to manage inflammation and reduce the risk of recurrent fistulas, while warm sitz baths or other local hygiene measures may be recommended to ease discomfort and promote drainage.

Lifestyle modifications can include increasing exercise, weight management (if overweight), stopping smoking (if a smoker) and a high-fibre diet with plenty of fresh fruit and vegetables are all likely to help.

What surgical interventions are available for anal fistula?

The management plan for a fistula in ano is highly individualised, and the choice of intervention depends on factors such as the type, location, and complexity of the fistula, as well as the patient's overall health. Early diagnosis and appropriate management are crucial for preventing complications and promoting optimal outcomes.

Drainage of infection: As a first priority, if a fluid collection or an abscess is present, this will need to be drained with an operation commonly with a general anaesthetic. Wounds will be left open, in some cases packing is required.

Seton placement: A seton (like a piece of thin string) is placed through the fistula to allow gradual drainage and prevent the closure of the hole on the outside (the external opening). In my practice, I only use loose, low-profile setons and feel the incontinence rates, and the discomfort of cutting setons prohibits the use of them.

The purpose of the seton is to facilitate drainage, serving as a fundamental component of a 'Status Quo' management approach. Individuals leading busy lives often discover that its presence brings about minimal discomfort, typically reducing abscess occurrences to zero. Anticipated is a small daily discharge volume (nonetheless, not causing any unpleasant odour), enabling patients to maintain a complete and normal quality of life.

Seton management is also used as a bridge into the sphincter sparing, curative attempt, treatments.

Fistulotomy / lay open: A surgical procedure involving the cutting open of or complete division of the fistula tract. This has a favourable cure rate (70-90%). The potential risk of continence arises when the fistula tract encompasses a portion of the sphincter. If the entire sphincter is involved, this surgical approach is not a viable option due to the irreversible damage it would inflict on continence, making it unsuitable as a treatment choice.

VAAFT: Video Assisted Anal Fistula Treatment (VAFFT) is a technique that allows me to view the tract directly. The tract can be treated with a thermal treatment aiming to cure the patient. The cure rate is 50-70%, and there is minimal risk of damaging a patient’s continence. Video Assisted Anal Fistula Treatment (VAFFT) is not widely available, allowing me to offer a unique treatment aspect to my patients.

LIFT Procedure: Ligation of the inter sphincteric fistula tract (LIFT). This procedure involves dividing the fistula tract at a deeper level and is used for intershpincteric fistulas. It has a cure rate of 50-70% in appropriate fistulas and poses minimal risk to continence.

Fistula plug: This is used in certain fistula tracts that are longer than 5cm in length and has a cure rate of 50-70%, with minimal risk to the sphincters.

If you are suffering from fistula in ano and would like to book a consultation with Mr Baird, do not hesitate to do so by visiting his Top Doctors profile today.