Subscribe to RSS
DOI: 10.1055/a-2049-9722
Current Therapy of Cryptoglandular Anal Fistula: Gold Standards and Alternative Methods
Article in several languages: deutsch | English![](https://www.thieme-connect.de/media/zblchir/202303/lookinside/thumbnails/10-1055-a-2049-9722_zbc-2023-02-1858_en-1.jpg)
Abstract
Cryptoglandular anal fistulas are one of the most common colorectal diseases and occur with an incidence of about 20/100,000. Anal fistulas are defined as an inflammatory junction between the anal canal and the perianal skin. They develop from an abscess or chronic infection of the anorectum. Surgical treatment of the disease is the method of choice. Even when treating an acute abscess, its cause should be sought at the same time. If there is a connection to the anal canal without affecting relevant parts of the sphincter muscles, primary fistulotomy should be performed. If larger parts of the sphincter muscle are involved, the insertion of a seton drain is usually useful. There are essentially two recommendations for the elective treatment of cryptoglandular anal fistulas. Distal fistulas should be excised, with the proviso that as little sphincter muscle as possible is sacrificed. In the case of highly proximally located and complex fistulas, sphincter-preserving surgical techniques should be used. In this case, the method of choice is the mucosal or advancement flap. Alternatively, clips, fibrin injections, fistula plugs, fistula ligatures, or laser-based procedures are described in the literature. In the case of intermediate fistulas, a fistulectomy with primary sphincter reconstruction can be useful. Every operation is carried out as a compromise between definitive healing of the fistula and a potential risk to the patient’s continence. It is often difficult to make a reliable prognosis about the continence function to be expected postoperatively. In addition to the fistula morphology, particular attention should be paid to whether previous proctological operations have already been performed, the gender of the patient, and whether there are pre-existing sphincter dysfunctions. Since the surgeon’s expertise plays a decisive role in the success of the treatment, the procedure should be carried out in a specialist proctological centre, especially in the case of complex fistulas or in the case of a condition after previous operations. In addition to the classic procedures, such as fistulectomy or the plastic fistula closure, this article examines alternative methods and their areas of application.
Publication History
Received: 16 February 2023
Accepted: 06 March 2023
Article published online:
02 June 2023
© 2023. Thieme. All rights reserved.
Georg Thieme Verlag KG
Rüdigerstraße 14, 70469 Stuttgart, Germany
-
Literature
- 1 Ommer A, Herold A, Berg A. et al. S3-Leitlinie: Kryptoglanduläre Analfisteln. Coloproctology 2017; 39: 16-66
- 2 Ommer A, Herold A, Berg E. et al. Cryptoglandular anal fistulas. Dtsch Arztebl Int 2011; 108: 707-713 DOI: 10.3238/arztebl.2011.0707. (PMID: 22114639)
- 3 Yamana T. Japanese Practice Guidelines for Anal Disorders II. Anal fistula. J Anus Rectum Colon 2018; 2: 103-109 DOI: 10.23922/jarc.2018-009. (PMID: 31559351)
- 4 Sugrue J, Nordenstam J, Abcarian H. et al. Pathogenesis and persistence of cryptoglandular anal fistula: a systematic review. Tech Coloproctol 2017; 21: 425-432 DOI: 10.1007/s10151-017-1645-5. (PMID: 28620877)
- 5 Amato A, Bottini C, De Nardi P. et al. Evaluation and management of perianal abscess and anal fistula: SICCR position statement. Tech Coloproctol 2020; 24: 127-143 DOI: 10.1007/s10151-019-02144-1. (PMID: 31974827)
- 6 Nottingham JM, Rentea RM. Anal Fistulotomy. 2022 Accessed March 09, 2023 at: https://www.ncbi.nlm.nih.gov/books/NBK555998/
- 7 Vogel JD, Johnson EK, Morris AM. et al. Clinical Practice Guideline for the Management of Anorectal Abscess, Fistula-in-Ano, and Rectovaginal Fistula. Dis Colon Rectum 2016; 59: 1117-1133 DOI: 10.1097/DCR.0000000000000733. (PMID: 27824697)
- 8 Herold A. Fistulektomie und primäre Sphinkterrekonstruktion. Coloproctology 2019; 41: 267-271
- 9 Seyfried S, Bussen D, Joos A. et al. Fistulectomy with primary sphincter reconstruction. Int J Colorectal Dis 2018; 33: 911-918 DOI: 10.1007/s00384-018-3042-6. (PMID: 29651553)
- 10 Sandborn WJ, Fazio VW, Feagan BG. et al. AGA technical review on perianal Crohn’s disease. Gastroenterology 2003; 125: 1508-1530 DOI: 10.1016/j.gastro.2003.08.025. (PMID: 14598268)
- 11 Tobisch A, Stelzner S, Hellmich G. et al. Total fistulectomy with simple closure of the internal opening in the management of complex cryptoglandular fistulas: long-term results and functional outcome. Dis Colon Rectum 2012; 55: 750-755 DOI: 10.1097/DCR.0b013e3182569b29. (PMID: 22706126)
- 12 Tyler KM, Aarons CB, Sentovich SM. Successful sphincter-sparing surgery for all anal fistulas. Dis Colon Rectum 2007; 50: 1535-1539 DOI: 10.1007/s10350-007-9002-9. (PMID: 17674105)
- 13 Hirschburger M, Schwandner T, Hecker A. et al. Fistulectomy with primary sphincter reconstruction in the treatment of high transsphincteric anal fistulas. Int J Colorectal Dis 2014; 29: 247-252 DOI: 10.1007/s00384-013-1788-4. (PMID: 24337835)
- 14 Arroyo A, Perez-Legaz J, Moya P. et al. Fistulotomy and sphincter reconstruction in the treatment of complex fistula-in-ano: long-term clinical and manometric results. Ann Surg 2012; 255: 935-939 DOI: 10.1097/SLA.0b013e31824e9112. (PMID: 22504192)
- 15 Perez F, Arroyo A, Serrano P. et al. Randomized clinical and manometric study of advancement flap versus fistulotomy with sphincter reconstruction in the management of complex fistula-in-ano. Am J Surg 2006; 192: 34-40 DOI: 10.1016/j.amjsurg.2006.01.028. (PMID: 16769272)
- 16 Glasgow SC, Lowry AC. Long-term outcomes of anal sphincter repair for fecal incontinence: a systematic review. Dis Colon Rectum 2012; 55: 482-490 DOI: 10.1097/DCR.0b013e3182468c22. (PMID: 22426274)
- 17 Garcia-Aguilar J, Belmonte C, Wong WD. et al. Anal fistula surgery. Factors associated with recurrence and incontinence. Dis Colon Rectum 1996; 39: 723-729 DOI: 10.1007/BF02054434. (PMID: 8674361)
- 18 De Hous N, Van den Broeck T, de Gheldere C. Fistulectomy and primary sphincteroplasty (FIPS) to prevent keyhole deformity in simple anal fistula: a single-center retrospective cohort study. Acta Chir Belg 2021; 121: 308-313 DOI: 10.1080/00015458.2020.1753151. (PMID: 32253992)
- 19 Blumetti J, Abcarian A, Quinteros F. et al. Evolution of treatment of fistula in ano. World J Surg 2012; 36: 1162-1167 DOI: 10.1007/s00268-012-1480-9. (PMID: 22362043)
- 20 Litta F, Parello A, De Simone V. et al. Fistulotomy and primary sphincteroplasty for anal fistula: long-term data on continence and patient satisfaction. Tech Coloproctol 2019; 23: 993-1001 DOI: 10.1007/s10151-019-02093-9. (PMID: 31538298)
- 21 Ommer A, Wenger FA, Rolfs T. et al. Continence disorders after anal surgery--a relevant problem?. Int J Colorectal Dis 2008; 23: 1023-1031 DOI: 10.1007/s00384-008-0524-y. (PMID: 18629515)
- 22 Balciscueta Z, Uribe N, Balciscueta I. et al. Rectal advancement flap for the treatment of complex cryptoglandular anal fistulas: a systematic review and meta-analysis. Int J Colorectal Dis 2017; 32: 599-609 DOI: 10.1007/s00384-017-2779-7. (PMID: 28247060)
- 23 Whiteford MH, Kilkenny 3rd J, Hyman N. et al. Practice parameters for the treatment of perianal abscess and fistula-in-ano (revised). Dis Colon Rectum 2005; 48: 1337-1342 DOI: 10.1007/s10350-005-0055-3. (PMID: 15933794)
- 24 Mei Z, Wang Q, Zhang Y. et al. Risk Factors for Recurrence after anal fistula surgery: A meta-analysis. Int J Surg 2019; 69: 153-164 DOI: 10.1016/j.ijsu.2019.08.003. (PMID: 31400504)
- 25 Ortiz H, Marzo J, Ciga MA. et al. Randomized clinical trial of anal fistula plug versus endorectal advancement flap for the treatment of high cryptoglandular fistula in ano. Br J Surg 2009; 96: 608-612 DOI: 10.1002/bjs.6613. (PMID: 19402190)
- 26 Perez F, Arroyo A, Serrano P. et al. Prospective clinical and manometric study of fistulotomy with primary sphincter reconstruction in the management of recurrent complex fistula-in-ano. Int J Colorectal Dis 2006; 21: 522-526 DOI: 10.1007/s00384-005-0045-x. (PMID: 16237531)
- 27 Roig JV, Garcia-Armengol J, Jordan JC. et al. Fistulectomy and sphincteric reconstruction for complex cryptoglandular fistulas. Colorectal Dis 2010; 12: e145-e152 DOI: 10.1111/j.1463-1318.2009.02002.x. (PMID: 19604292)
- 28 Ratto C, Litta F, Parello A. et al. Fistulotomy with end-to-end primary sphincteroplasty for anal fistula: results from a prospective study. Dis Colon Rectum 2013; 56: 226-233 DOI: 10.1097/DCR.0b013e31827aab72. (PMID: 23303152)
- 29 Roig, Garcia-Armengol, Jordán et al.. Immediate reconstruction of the anal sphincter after fistulectomy in the management of complex anal fistulas. Colorectal Dis 1999; 1: 137-140 DOI: 10.1046/j.1463-1318.1999.00021.x. (PMID: 23577759)
- 30 Farag AFA, Elbarmelgi MY, Mostafa M. et al. One stage fistulectomy for high anal fistula with reconstruction of anal sphincter without fecal diversion. Asian J Surg 2019; 42: 792-796 DOI: 10.1016/j.asjsur.2018.12.005. (PMID: 30738718)
- 31 Ritchie RD, Sackier JM, Hodde JP. Incontinence rates after cutting seton treatment for anal fistula. Colorectal Dis 2009; 11: 564-571 DOI: 10.1111/j.1463-1318.2008.01713.x. (PMID: 19175623)
- 32 Prosst RL, Joos AK. Short-term outcomes of a novel endoscopic clipping device for closure of the internal opening in 100 anorectal fistulas. Tech Coloproctol 2016; 20: 753-758 DOI: 10.1007/s10151-016-1537-0. (PMID: 27669711)
- 33 Rojanasakul A, Pattanaarun J, Sahakitrungruang C. et al. Total anal sphincter saving technique for fistula-in-ano; the ligation of intersphincteric fistula tract. J Med Assoc Thai 2007; 90: 581-586 (PMID: 17427539)
- 34 Emile SH, Khan SM, Adejumo A. et al. Ligation of intersphincteric fistula tract (LIFT) in treatment of anal fistula: An updated systematic review, meta-analysis, and meta-regression of the predictors of failure. Surgery 2020; 167: 484-492 DOI: 10.1016/j.surg.2019.09.012. (PMID: 31648932)
- 35 Hong KD, Kang S, Kalaskar S. et al. Ligation of intersphincteric fistula tract (LIFT) to treat anal fistula: systematic review and meta-analysis. Tech Coloproctol 2014; 18: 685-691 DOI: 10.1007/s10151-014-1183-3. (PMID: 24957361)
- 36 Garg P, Singh P. Video-Assisted Anal Fistula Treatment (VAAFT) in Cryptoglandular fistula-in-ano: A systematic review and proportional meta-analysis. Int J Surg 2017; 46: 85-91 DOI: 10.1016/j.ijsu.2017.08.582. (PMID: 28882770)
- 37 Meinero P, Mori L. Video-assisted anal fistula treatment (VAAFT): a novel sphincter-saving procedure for treating complex anal fistulas. Tech Coloproctol 2011; 15: 417-422 DOI: 10.1007/s10151-011-0769-2. (PMID: 22002535)
- 38 Emile SH, Elfeki H, Shalaby M. et al. A Systematic review and meta-analysis of the efficacy and safety of video-assisted anal fistula treatment (VAAFT). Surg Endosc 2018; 32: 2084-2093 DOI: 10.1007/s00464-017-5905-2. (PMID: 29052068)
- 39 Brabender DE, Moran KL, Brady M. et al. Assessing the effectiveness of laser fistulectomy for anal fistula: a retrospective cohort study. Tech Coloproctol 2020; 24: 1071-1075 DOI: 10.1007/s10151-020-02281-y. (PMID: 32770423)
- 40 Cintron JR, Park JJ, Orsay CP. et al. Repair of fistulas-in-ano using autologous fibrin tissue adhesive. Dis Colon Rectum 1999; 42: 607-613 DOI: 10.1007/BF02234135. (PMID: 10344682)
- 41 Cadeddu F, Salis F, Lisi G. et al. Complex anal fistula remains a challenge for colorectal surgeon. Int J Colorectal Dis 2015; 30: 595-603 DOI: 10.1007/s00384-014-2104-7. (PMID: 25566951)
- 42 Zimmerman DD, Briel JW, Gosselink MP. et al. Anocutaneous advancement flap repair of transsphincteric fistulas. Dis Colon Rectum 2001; 44: 1474-1480 DOI: 10.1007/BF02234601. (PMID: 11598477)