Fistula

What is Fistula

An anal fistula ( Bhagandar / Fistula in ano ) is a small channel that develops between the end of the bowel and the skin around the anus. It frequently is the result of a previous or current anal abscess. Fistula has a tract with two openings – Internal opening into the rectum or anal canal and External opening through the skin of the buttocks.

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Causes Of Fistula​

  • Anorectal abcess – Almost all anal fistulas are a result of a preceding anorectal abcess. An anorectal abcess begins as an infection of one of the anal glands. The infection soon forms a pool of pus – abcess. An anal fistula results when the abcess fails to heal completely with/without treatment.
  • Conditions that cause inflammation of the intestines like Crohn’s disease, Diverticulitis.
  • Malignancy in the anorectal region.
  • Infections – Tuberculosis, HIV, sexually transmitted diseases
  • Iatrogenic – As a complication of a previous surgery in the region.

Symptoms Of Fistula

  • Throbbing pain that worsens on sitting
  • Swelling, tenderness, itching or redness around the anus
  • Discharge of pus, blood and debris which is usually foul smelling
  • Pain associated with bowel movements
  • Fever
anatomy-of-Anal-canal

Diagnosis Of Fistula

Usually a brief history followed by clinical evaluation – including a digital rectal examination is enough to diagnose an anal fistula. At the same time Proctoscopy ( a minor inspection of the rectum using a small tube like scope ) is also done to check for any concomitant condition in the rectum.

An MRI Fistulogram may be needed for complicated fistulas in which the tract is difficult to delineate. Fistulography, an X-Ray of the fistula after injecting a contrast solution is not done any longer as it may lead to the formation of a false tract due to forceful injection of the dye.

About Fistula Treatment

Very few anal fistulas heal by themselves and the only effective cure for a persistent anal fistula is surgery.

Dr Porwal is a renowned fistula doctor in India and Dubai. Team of doctors and surgeons have successfully cured rare cases of fistula, like those extending from rectum to abdomen ( Recto-abdominal ), rectum to groin ( Recto-inguinal ), rectum to tailbone ( Recto-nidal ).

fistula-treatment-chart1-1

I. FISTULECTOMY

This is a surgical procedure in which the fistula tract is completely excised. Done under General anaesthesia, the fistula tract is removed and the groove that is formed is left behind to heal. This procedure carries with it the risk of damage to the sphincter muscle resulting in fecal incontinence and is usually reserved as a treatment option for Complex fistula.

At Healing Hands Clinic, Laser is used as an adjunct to Fistulectomy to minimize the risk of damage to the sphincter muscle. Thus, with the added advantage of Laser the chances of post-operative incontinence are negligible.

II. KSHARSUTRA

This is an ancient Ayurvedic technique in which a special thread is used to treat the fistula. This thread is coated with Ayurvedic preparations and is inserted into the fistula tract.

The local irritation caused by the alkaline thread causes chemical cauterisation leading to inflammation within the tract. As a result the tract begins to debride. An important action of the Ksharsutra is that it allows continuous drainage of pus and debris from the tract. As all the infected material is drained, healing begins in a clean environment.

Ksharsutra

Advantages of Ksharsutra

  • Non-invasive technique. Therefore no cuts and stitches.
  • No damage to the sphincter muscle
  • Fairly good success rate.

Potential drawbacks of Ksharsutra

  • Multiple weekly sessions of treatment needed. So it’s a long treatment that is completed over a few months.
  • The thread is a source of irritation. So there may be persistent local burning and pain.
  • It is comparatively less effective in recurrent and complex fistulas.
VAAFT

III. VAAFT ( Video Assisted Anal Fistula Treatment )

The VAAFT technique is used for the surgical treatment of Complex fistulas. It is performed with the use of a fistuloscope. The procedure consists of 2 phases

  1. Diagnostic stage: In this phase your surgeon will identify the external opening of the tract through which the scope is introduced. Once this is done, the entire tract and any accessory tracts are delineated.
  2. Treatment stage: During this phase the inner side of the tract is fulgurated from the internal opening towards the external opening. This is followed by cleaning of the tract and closing the external opening.

Advantages of VAAFT

  • No surgical wounds on the buttocks or perianal region.
  • The internal opening is precisely located which is important in the treatment of any fistula.
  • No damage to the sphincter muscle

Potential drawbacks

  • The biggest argument against VAAFT is its high rate of recurrence (~30%)

IV. LIFT ( Ligation of Interspincteric Fistula Tract )

This procedure is usually performed for Complex or Deep fistulas. A seton is first placed in the fistula tract, forcing it to widen over time. A few weeks later, the surgeon removes the infected tissue and closes the internal fistula opening. The advantage of this procedure is that the fistula is accessed between the sphincter muscles thus avoiding cutting them. However, the success rate of LIFT is ~70% with an impaired healing in 20-30% cases.

V. FISTULA PLUG

The fistula plug is a 100% synthetic bio-absorbable scaffold. This plug is placed in the fistula tract. Over time cells from the body migrate into the scaffold and new tissue is generated as the body gradually absorbs the plug material, leaving no permanent material in the body.

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Advantages of FISTULA PLUG​

  • No cutting involved and no operation wound. Therefore it is associated with less pain and faster recovery.
  • No damage to the sphincter muscle.

Potential drawbacks

  • Failures can occur due to dislodgement of plug from the fistula tract.
  • The plug can get infected
  • Failure of treatment can occur in 25-30% cases
Medstar-HealthCare-Leonardo laser

VI. FiLaC ( Fistula-tract Laser Closure )

This procedure, done using the Leonardo Laser, was first introduced in India at Healing Hands Clinic. The aim of the procedure is to gently remove the fistula tract without damaging the sphincter muscle.

The procedure is done under short General Anaesthesia and requires about 30-40 minutes. A radially emitting Laser Fibre is inserted from the outside. A defined amount of laser energy is then emitted circumferentially into the fistula tract. The laser energy causes controlled photothermal destruction of the fistula tract causing it to collapse to a high degree. This also helps supports and accelerates the healing process.

Advantages of FiLaC

  • It has an excellent healing rate as compared to all other techniques.
  • The anal sphincter is preserved so there is no risk of post-operative incontinence.
  • It can be done in complicated fistulas like recto-inguinal, recto-gluteal fistulas.
  • It is safe in high risk patients like those with hypertension, cardiac ( heart ) problems and in senior citizens.

Potential drawbacks of FiLaC

  • There may be local burning for some time
  • Post-operative subcutaneous abcess : It is usually managed with medications and dressing.
  • In rare cases it may need incision and drainage under local anaesthesia.

VII. Distal Laser Proximal Ligation ( DLPL )

Fistula is a complex disease. Ultimately the aim of any fistula treatment is not just to get rid of the existing fistula but:

  1. To save the sphincter muscle and thus prevent incontinence.
  2. To prevent recurrence, considering the nature of the disease

Most of the techniques like VAAFT, LIFT, FiLaC achieve the primary purpose of closing the fistula and saving the sphincter. However, they all have their own rates of recurrence. Considering how bothersome a fistula is, even a small chance of recurrence can be a concern for the patient.

Types of Fistula

An anal fistula ( Bhagandar / Fistula in ano ) is a small channel that develops between the end of the bowel and the skin around the anus. It frequently is the result of a previous or current anal abscess. Fistula has a tract with two openings – Internal opening into the rectum or anal canal and External opening through the skin of the buttocks.

  • Anorectal abcess – Almost all anal fistulas are a result of a preceding anorectal abcess. An anorectal abcess begins as an infection of one of the anal glands. The infection soon forms a pool of pus – abcess. An anal fistula results when the abcess fails to heal completely with/without treatment.
  • Conditions that cause inflammation of the intestines like Crohn’s disease, Diverticulitis.
  • Malignancy in the anorectal region.
  • Infections – Tuberculosis, HIV, sexually transmitted diseases
  • Iatrogenic – As a complication of a previous surgery in the region.
  • Throbbing pain that worsens on sitting
  • Swelling, tenderness, itching or redness around the anus
  • Discharge of pus, blood and debris which is usually foul smelling
  • Pain associated with bowel movements
  • Fever

Usually a brief history followed by clinical evaluation – including a digital rectal examination is enough to diagnose an anal fistula. At the same time Proctoscopy ( a minor inspection of the rectum using a small tube like scope ) is also done to check for any concomitant condition in the rectum.

An MRI Fistulogram may be needed for complicated fistulas in which the tract is difficult to delineate. Fistulography, an X-Ray of the fistula after injecting a contrast solution is not done any longer as it may lead to the formation of a false tract due to forceful injection of the dye.

I. FISTULECTOMY

This is a surgical procedure in which the fistula tract is completely excised. Done under General anaesthesia, the fistula tract is removed and the groove that is formed is left behind to heal. This procedure carries with it the risk of damage to the sphincter muscle resulting in fecal incontinence and is usually reserved as a treatment option for Complex fistula.

At Healing Hands Clinic, Laser is used as an adjunct to Fistulectomy to minimize the risk of damage to the sphincter muscle. Thus, with the added advantage of Laser the chances of post-operative incontinence are negligible.

II. KSHARSUTRA

This is an ancient Ayurvedic technique in which a special thread is used to treat the fistula. This thread is coated with Ayurvedic preparations and is inserted into the fistula tract.

The local irritation caused by the alkaline thread causes chemical cauterisation leading to inflammation within the tract. As a result the tract begins to debride. An important action of the Ksharsutra is that it allows continuous drainage of pus and debris from the tract. As all the infected material is drained, healing begins in a clean environment.

III. VAAFT ( Video Assisted Anal Fistula Treatment )

The VAAFT technique is used for the surgical treatment of Complex fistulas. It is performed with the use of a fistuloscope. The procedure consists of 2 phases

Diagnostic stage: In this phase your surgeon will identify the external opening of the tract through which the scope is introduced. Once this is done, the entire tract and any accessory tracts are delineated.
Treatment stage: During this phase the inner side of the tract is fulgurated from the internal opening towards the external opening. This is followed by cleaning of the tract and closing the external opening.

IV. LIFT ( Ligation of Interspincteric Fistula Tract )

This procedure is usually performed for Complex or Deep fistulas. A seton is first placed in the fistula tract, forcing it to widen over time. A few weeks later, the surgeon removes the infected tissue and closes the internal fistula opening. The advantage of this procedure is that the fistula is accessed between the sphincter muscles thus avoiding cutting them. However, the success rate of LIFT is ~70% with an impaired healing in 20-30% cases.

V. FISTULA PLUG

The fistula plug is a 100% synthetic bio-absorbable scaffold. This plug is placed in the fistula tract. Over time cells from the body migrate into the scaffold and new tissue is generated as the body gradually absorbs the plug material, leaving no permanent material in the body.

VI. FiLaC ( Fistula-tract Laser Closure )

This procedure, done using the Leonardo Laser, was first introduced in India at Healing Hands Clinic. The aim of the procedure is to gently remove the fistula tract without damaging the sphincter muscle.

The procedure is done under short General Anaesthesia and requires about 30-40 minutes. A radially emitting Laser Fibre is inserted from the outside. A defined amount of laser energy is then emitted circumferentially into the fistula tract. The laser energy causes controlled photothermal destruction of the fistula tract causing it to collapse to a high degree. This also helps supports and accelerates the healing process.

VII. Distal Laser Proximal Ligation ( DLPL )

Fistula is a complex disease. Ultimately the aim of any fistula treatment is not just to get rid of the existing fistula but:

  1. To save the sphincter muscle and thus prevent incontinence.
  2. To prevent recurrence, considering the nature of the disease

Most of the techniques like VAAFT, LIFT, FiLaC achieve the primary purpose of closing the fistula and saving the sphincter. However, they all have their own rates of recurrence. Considering how bothersome a fistula is, even a small chance of recurrence can be a concern for the patient.

dr.-Vincenzo-D

DR VINCENZO DI DONNA

SPECIALIST VASCULAR SURGEON

Frequently Asked Questions

It’s like taking a small nap! All you will feel is a small needle prick during your preparation for the procedure. The entire surgery takes about 30 minutes. Occasionally, only the lower half of your body is anaesthetised and you will be alert and probably having a chat with your doctor!

Yes, the laser probe is inserted within the fistula tract and the laser energy is applied circumferentially to coagulate ( burn ) it. The tract heals by a process called ‘secondary intention’.

You will normally be able to start drinking water shortly after the procedure and can start eating as soon as you are hungry. You will be able to get out of bed a few hours after surgery.
You are likely to have some pain after the procedure that is easily controlled with painkillers.

If your operation is planned as a day care procedure you can go home as soon as the effect of the anaesthetic has worn off, you have passed urine and you are comfortable, eating and drinking. Since a general anaesthetic is used, it is advisable that a responsible adult take you home and stay with you for 24 hours.
At times you may be given a discharge after 24 hours in which case you may need to stay in the hospital for a night.
Before you are discharged you will be advised about post-operative care, painkillers and laxatives.

You do not need a specific diet. Just make sure you eat a healthy, fiber-rich diet before and after surgery.

Get plenty of rest, take a Sitz bath about 3 times a day ( especially after a bowel movement ), maintain self-hygiene and consume a fibre rich diet.

You may start travelling after a week.

You do not need any special pillow after surgery.

It may take 6-8 weeks for anal fistula to completely heal. Take complete rest for the first 24 hours after surgery. You can gradually resume your daily chores and most people are back to their normal activities in 5-7 days.

  • Fever > 101 degree F
  • Pain not relieved by prescribed medicines
  • Unusual bleeding with bowel movement
  • Persistent nausea or vomiting
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