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Anorectal Abcess

  Anal Fistula...

Q How is Anal Fistula treated?


An anal fistula usually lasts until it is surgically removed. The following methods are available to treat anal fistula:-

1. Fistulotomy/Fistulectomy

2. Endorectal/ Anal sliding flaps

3. Seton

4.     Fibrin Glue

5. AFP - Anal Fistula Plug

6. LIFT (Ligation of Inter-sphicteric Fistula Tract)

7. VAAFT ( Video- Assisted Anal Fistula Treatment)


There is a direct relationship between incontinence and the amount of sphincter muscle divided. The goal of surgical treatment is thus two fold- to eradicate the suppurative( pus forming) process permanently without compromising anal continence

Conventionally Surgery- Fistulutomy/Fistulectomy has been the mainstay of treatment. In this surgery, the fistula tract is laid open by cutting out the whole tract with knife. This leads to a large wound from the anal opening to the buttock . Understandably this leaves the patient with lot of pain in the post operative period. The patient needs hospitalization for 4-8 days and requires dressings for this wound for 4-6 weeks .The patient obviously is off the work for few weeks. In spite of all these difficulties, this surgery is associated with a high recurrence rate. Other known methods such as seton treatment and fibrin glue method have also been not widely accepted due to requirements of repeated follow-up visits and high recurrence rates.

In high fistula(the fistulae going above the Rectal sling), the treatment is even more complex. It requires 3 operations in a staged manner. In the first stage, the anal opening is made in the abdomen wall called Diverting Colostomy (The fecal matter comes through an artificial intestinal opening created on abdomen wall with a pouch fitted over it). In the second operation, the fistula is operated upon by cutting it out  in the same manner as described above. In the third operation, the Colostomy is closed. The whole procedure takes about few months time. In spite of all this, this operation had high recurrence rates and had the inherent risk of the most dreaded complication- Bowel Incontinence (Loss of control over bowel movements). So treating high fistula has been a nightmare for both surgeons and the suffering patients alike.

Now a new method, known as Anal Fistula Plug(AFP) has dramatically changed the way we can treat this complex disease. This treatment requires placement and fixing of the plug in anal fistula by a special technique. The plug is made of highly sophisticated absorbable material which provide the scaffold over which body’s collagen gets deposited and closes the fistula.

Comparative studies have shown this method to be very effective. The best aspect of this method is that it involves no cutting at all. So there is no post operative wound and any pain. Moreover the patient can go back to work the same day . In lots of patients, AFP plug can also be inserted under local anesthesia making it a wonderful Day-care procedure for treating anal fistula. Most important, this method can be used successfully to treat High Fistula. There is no need for any Colostomy. The risk of Bowel Incontinence is also not there at all.. Compared to the staged operations where patient needs multiple hospitalizations for weeks, in this method the patient hardly needs hospitalization for 24 hours and goes back to work the next day. Somebody has remarked ”For high Fistula, AFP method is a ‘boon sent directly from heaven”. Apart from all these benefits, the success rates of Anal Fistula Plug(AFP) have been higher than all other known procedures.

In LIFT procedure, the sphincter is not divided. A cut is given and a plane is developed between the two anal sphincters and the fistula tract passing between the two sphincter muscles is isolated. This portion of fistula tract between the sphincters is ligated (tied) and excised (cut out). The internal opening of the tract is cauterized and the portion of the fistula tract outside the sphincters is curretted, cleaned and left open so that it can drain freely and get healed.

In VAAFT, a fistulascope is inserted through the external opening and the whole tract is visualized on camera. The internal opening is localized through the endoscope while visualizing the ano-rectum from outside. After this, two stitches are taken through the internal opening so as to isolate the internal opening. After this, the fistula tract is cauterized with a monopolar cautery electrode so as to coagulate (burn) the fistula mucosa (lining) from internal opening to the external opening. The necrotic burnt tissue is taken out with the help of a brush and forceps. After this,  the internal opening is lifted with the help of two stitches taken earlier and closed with a linear cutting Stapler which closes the tract at the level of the internal opening. 

Q How is Fistulectomy/Fistulotomy done ? What are the advantages and disadvantages of this procedure?

Q. How is Seton[Thread] treatment done and what are disadvantages of this procedure?

Q. How is Advancement flap treatment done and what are disadvantages of this procedure?

Q. How is Fibrin glue treatment done and what are disadvantages of this procedure?

Q. What is Anal Fistula Plug &  how is this procedure done ? What are VAAFT & LIFT procedures and how are they done?




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Dr Pankaj