Anal fistula treatments

The type of surgery required for the treatment of a simple anal fistula usually depends on the level at which the fistula crosses the circular back passage muscle (sphincter) that controls bowel motions. To lessen the risk of you developing incontinence a number of operations over a few months may be required. All operations are performed under a general or regional (spinal) anaesthetic as day procedures. Symptoms usually get worse without an operation. The most appropriate option for you will be discussed with you at the clinic at an individualised basis.

Fistulotomy (laying open the fistula)

This procedure involves cutting across the fistula to open it and allow it to heal from inside out. It provides the best chances of healing. It can only take place though if the fistula tunnel passes through a small portion of the sphincter (low fistula) which will then be cut open. The reason for this is that if a larger portion of the sphincter is involved (high fistula) and it is cut open then the risk involuntary passing wind or stool through the back passage (incontinence) increases. The majority of patients will have a low fistula and will be suitable for this procedure

Insertion of seton

In cases of a high fistula a seton (stitch or plastic ribbon) is tied around the fistula tract. This allows for the drainage of any residual infection and for the fistula tunnel wall to thicken up in preparation for potential future procedures. Some patients may choose to live with a permanent seton if they consider that the risks of any future operation for their continence is too high. The seton can then be checked from time to time and changed as required. Further surgical operations may be required if you have persistent significant symptoms from the seton or the fistula. These operations attempt to close the internal opening of the fistula inside the back passage and preserve the back passage muscle.

Insertion of fistula plug/paste

This is a treatment option for high fistulas once the seton has been in place for a few weeks and there are no signs of residual infection. It involves the insertion and stitching in place of a specialised plug into the fistula tunnel to plug the tunnel closed or the use of a special paste to close the tunnel. This procedure has a 50 to 60% success rate and as it does not involve any cutting of the sphincter muscle it has a very low risk of causing incontinence.

Anal advancement flap

This is a treatment option for high fistulas once the seton has been in place for a few weeks and there are no signs of residual infection. An enema may be given to you on the day to clear your bowel. The operation lasts for approximately 60 minutes. It involves the creation of a flap of healthy skin or lining of the bowel with a rich blood supply which is moved and sutured over the internal opening of the fistula tunnel. Specific risk to this procedure involves the wound opening up and a wound developing. It is thus important to avoid sitting on the wound for 2 weeks until you are seen in clinic. If you are worried about the wound opening please let my office know. The success rate is approximately 70%.

LIFT (ligation of intersphincteric tract) procedure

This is a treatment option for high fistulas once the seton has been in place for a few weeks and there are no signs of residual infection. The operation lasts for approximately 60 minutes. It involves identifying the fistula tunnel between the two layers of sphincter muscle and stitching it closed. Success rate is approximately 70%.

Recovery

After the procedure you will wake up in a hospital room. All of the above procedures are normally performed as day case operations but sometimes patients may need to spend a night in hospital. You are typically expected to go home once you are eating and drinking, are able to manage the pain and walk unaided and have passed some urine. You will be prescribed some pain killers to go home with and you will need to use laxatives for at least 4 weeks after the procedure and try and keep your motions soft.  It normally takes about 2 to 4 weeks to fully recover from the above procedures and return back to work and a few days from the insertion of seton, but it varies from person to person and depends on their general health and the nature of their work.

Procedure risks

All of the above procedures carry a similar risk to complications as other procedures. These include complications common to all surgical procedures such as infection, bleeding, blood clots, heart problems, pneumonia, urinary retention, anaesthetic risks.

Specific complications to the above procedures include a small risk of temporary difficulty in passing urine and a small risk of involuntary passing wind or stool.