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What is an anal fistula?

The anus is the external opening through which feces are expelled from the body. Just inside the anus are a number of small glands that make mucus. Occasionally, these glands get clogged and can become infected, leading to an abscess. About half of these abscesses may develop into a fistula. Anal fistula, a rare condition, is a chronically inflamed, abnormal tunnel between the anal canal and the outer skin of the anus. It often drains watery pus, which can irritate the outer tissues and cause itching and discomfort.

Causes

What causes an anal fistula?

The leading causes of an anal fistula are clogged anal glands and anal abscesses. Other, much less common, conditions that can cause an anal fistula include:

• • Crohn’s disease (an inflammatory disease of the intestine)
• • Radiation (treatment for cancer)
• • Trauma
• • Infected Anal fissure
• • Sexually transmitted diseases
• • Tuberculosis
• • Diverticulitis (a disease in which small pouches form in the large intestine and become inflamed)
• • Cancer
• • Iatrogenic – As a complication of a previous surgery in the same region

Symptoms

What are the signs and symptoms of an anal fistula?

The signs and symptoms of an anal fistula include:

• • Frequent anal abscesses
• • Burning sensation or pain and swelling in perianal region
• • Foul smelling Pus discharge/blood discharge in perianal or from the anus. The pain may decrease after the fistula drains.
• • Irritation of the skin or Itching around the anus from drainage
• • Bleeding or Pain with bowel movements
• • Fever, chills and a general feeling of fatigue

Feel free to consult Dr. Brijendra Singh at Brij Laser and Laparoscopy Centre if you notice any of these symptoms.

Diagnosis

How is an anal fistula diagnosed?

Doctor can usually diagnose an anal fistula by examining the peri-anal area. Doctor will look for an opening (the fistula tract) on the skin and then try to determine how deep the tract is, also the direction in which it is going. In many cases, there will be drainage from the external opening.Some fistulas may not be visible on the skin's surface.
Additional tests to confirm diagnosis may include:

• • Proctoscopy is a procedure in which a special instrument is used to see inside your anus and rectum.
• • Proctoscopy is a procedure in which a special instrument is used to see inside your anus and rectum.
• • An ultrasound or MRI of the anal area to get a better view of the fistula tract.
• • Sometimes the doctor may need to examine you in the operating room (called exam under light anesthesia) to diagnose the fistula.
• • A colonoscopy is a procedure in which a flexible, lighted instrument is inserted into the colon via the anus to see if the condition is related to Crohn's disease or other inflammatory disease of the intestine. It is performed under light anesthesia.

Treatments

What are the treatments for an anal fistula?

Surgery is almost always necessary to cure an anal fistula. The surgery is performed by a colon and rectal surgeon. The goal of the surgery is a balance between getting rid of the fistula while protecting the anal sphincter muscles, which could cause incontinence if damaged.

Old Classical Technology (Sphincter cutting procedures) for anal fistula treatment

• Fistulotomy: In this procedure, the skin and muscle over the tunnel are cut open to convert it from a tunnel to an open groove. This allows the fistula tract to heal from the bottom up.

• Seton placement : A seton (a thread tie ) can be placed alone, combined with fistulotomy, or in a staged fashion. This technique is useful in patients with the following conditions: Complex fistulae (ie, high transsphincteric, suprasphincteric, extrasphincteric) or multiple fistulae Recurrent fistulae after previous fistulotomy With time, healing occurs above the seton as it gradually cuts through the muscles. The seton is tightened on subsequent weekly visits until it falls out. This could take 5-7 visits to cure.

Fistulectomy means complete excision of the fistula track.

Advanced Technology (Sphincter Saving procedures) for anal fistula treatment

• Advancement flap procedure: In this procedure the fistula is covered with a flap, or piece of tissue, taken from the rectum, like a trap door over the internal opening of fistula track.

• Fibrin glue injection: Tract filled completely with glue from internal to external opening until a blob is seen outside. It is allowed to set for 30-60secs.

• Anal Fistula Plug (Surgisis-Cook):Plug is pulled in from external opening of fistula track into the internal opening and then fixed into the fistula tract with the help of a suture.

• LIFT ( Ligation of Intersphincteric Fistula Tract) procedure: In this technique the skin above the fistula is opened up in the intersphincteric plane, the sphincter muscles are spread, and the fistula tract is tied off so that there is closure of the internal opening which is supposed to be main source of infection and anal fistula formation.

• VAAFT(Video Assisted Anal Fistula Treatment):The fistuloscope is inserted from the Ext opening with continuous irrigation of the glycine- mannitol solution, which helps to open the tract and provide a clear view.A monopolar electrode is inserted into the fistuloscope to fulgurate the fistula tract walls internally under direct vision, taking care not to miss any branching tracts or abscess cavity.

• Laser treatment for Fistula Treatment: The procedure consist of delivering laser energy at 3600 with in the lumen of fistula tract by means of a radial fiber. Laser light is transformed into thermal energy which leads to Cutting, Ablation, Vaporization, hemostasis and coagulation of tissue. These properties of Laser is used to treat anal fistula.

• Adipose derived Stem Cells: Adipose tissue has proven to severe as an abundant, accessible and rich source of adult stem cells with pluripotent properties suitable for tissue engineering and regenerative medical applications.ASCs with fibrin glue therapy is under research and clamming a safe and effective for treating complex perianal fistulae.

A anal fistula surgeries are complex surgical procedures and should be performed by an experienced surgeon.DR. Brijendra Singh at Brij Laser and Laparoscopy Centre is very much expert in each and every procedures carried out all over the globe to treat anal fistula. He discusses all treatment options with his patients before the surgery and choose best suited procedure according to patient’s severity of disease.
At Brij Laser and Laparoscopy Centre, Fistula surgery is usually done on Day Care basis, which means the patient can go home the same day. Patients who have very large or deep fistula tunnels may have to stay in the hospital for a short time after the surgery. Some fistulas may require several operations to get rid of the fistula.

Why Laser treatment is most preferred way for Anal fistula treatment?

Laser ablation is limited to the lumen of fistula tract only hence proved to be one of the best way to treat the fistula without affecting the anal sphincters and continence. Other benefits of laser surgery for anal fistula over open surgery is as follows