What is Perianal Fistula? What are the types? How to treat it?

The success of treatment in perianal fistula disease is low compared to other rectal diseases, but the risk of recurrence is high. Therefore, it is one of the most difficult breech diseases. In this article, what is the cause of perianal fistula disease, causes, types and how to treat will be discussed in detail.

What is Perianal Fistula?

The disease can be described in the simplest and most straightforward manner as an open-ended tubular tube. One end of the tube is close to the rectum and the other end is close to the rectum. The end close to the breech can be observed by the patient. However, it cannot be seen because it will remain in the inner part close to the rectum.
The one near the rectum is called the inner mouth and the near to the rectum is called the outer mouth. The problem can be understood more clearly if the following image is examined.

What are the types?

Fistulas are divided into two groups as simple and complex depending on their relationship with breech muscles.

Simple Fistulas:

It is a type of fistula that is not associated with breech muscles. The canal is just below the skin. In this way, there is no relationship with the muscles. Since it does not pass through the muscles, it is easy to treat and the success rate is higher than the complex fistula.
It can be treated with both fistulectomy and fistulotomy techniques. Success rates are around 98-99%.
In a study, it was found that the relapse rate for the treatment of simple anal fistulas with fistulotomy ranged from 0% to 17%. (1)

(1) Whiteford, M. H. (2007). Perianal abscess/fistula disease. Clinics in colon and rectal surgery, 20(02), 102-109. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2780182/

Complex Fistulas:

Complex fistulas are divided into 4 different groups according to their relationship with breech muscles. The complex fistula is the common name for fistulas associated with breech muscles.

Treatment of breech-related fistulas is risky. The reason for this is the risk of permanent gas and fecal incontinence in patients with any damage to the muscles.

The success rate in the treatment of complex fistulas varies according to the experience of the physician and the treatment technique used. Different techniques such as seton, laser, flap shifting, gluing and chemical burning are used in the treatment.

Fistula surgery is performed by general surgeons. The branch of general surgery related to breech diseases is called proctology. The fact that the physician to be preferred is a proctologist, increases his experience by having encountered many cases. Therefore, a proctologist should be preferred when choosing a doctor. In this way, the highest success rate can be achieved.

The Reasons of Anal Fistula?

The main reason of breech fistula formation is anal abscess. The self-explosion of abscesses in the anal region causes fistula formation to a great extent. Therefore, the abscess must be vacated by the doctor.

The reason for the formation of abscess is the clogging or inflammation of the secretory glands in the anal area that provide the skin’s moistness. Inflammation accumulates under the skin and forms an abscess. If the abscess is not emptied by surgical intervention, it explodes on its own. And inflammation itself creates a way out fistula channel.

Apart from abscess, chronic diarrhea and breech trauma may cause fistula formation.

What are the symptoms?

It will not be wrong to say anal abscess which is the precursor of fistula disease. With the explosion of abscess, discharge and bad smell are noticed. And fistula occurs. Fistula symptoms can be listed as follows;

• Discharge and bad smell
• Feeling wetness
• The hole around the breech (outlet hole of the fistula tube)
• Erythema
• Itching
• Swelling around the breech
• Rope-shaped hardness (fistula duct)
• Pain (Uncommon, not severe pain)
• Mild bleeding (as a result of the disintegration of the tissue in the outer mouth of the fistula)

How to Get Treated?

If the patient presents with abscess before the fistula occurs, the treatment is very simple. The abscess is discharged by opening a small surgical incision. Drainage is installed to prevent it from recurring. This prevents fistula formation.

However, if the abscess is not evacuated by the doctor, the problem becomes a fistula at a rate of 40%. Recurrence of the abscess increases the risk of fistula.

Fistulotomy, fistulectomy, flap, seton and laser are used in the treatment of fistula.

Treatment of Simple Fistulas:

Fistulotomy

The pipe formed in this treatment is cut from the upper part and formed into a channel shape. Then the inside of the channel is cleaned by some tools. It can be applied with local anesthesia. Fistulotomy is used in the treatment of simple fistulas. It is not a suitable technique for complex fistulas. It is a successful treatment option.

Fistulectomy

It is a larger operation than fistulotomy. In this operation, the fistula tube is completely removed. As in fistulotomy, the tube is not channeled. It is cut out into a tube. Clinical conditions can be done with regional numbing. Mostly no need for hospitalization -Treatment of Complex Fistulas: Complex fistulas pass through the breech muscles. Incision in this document is risky. Damage to the muscles while making the incision can cause gas and fecal leakage. Therefore, protective measures must be taken if incision is made. Otherwise the problem of gas and fecal incontinence may be unavoidable.

Flap Surgery

The continuous discharge occurs in the formed channel. The aim of flap surgery is to prevent this discharge. For this purpose, the inner mouth of the canal is closed with a solid tissue taken from the intestine. It is easy to apply but it has a low success rate. Therefore it is not recommended.

Seton Surgery

In Seton surgery, some kinds of rope is passed through the fistula tube. The rope, which is passed through the inner and outer jaws, is suitably tied. The rope tied at sufficient tension cuts slowly so that it cannot be felt. This may take months. Thanks to the slow cutting process, the tissue has the opportunity to repair itself. In addition, damage to the muscles is prevented.

It is a form of treatment that requires troubles and patience. The success rate varies between 60 – 90% depending on the experience of the surgeon. Above is a visual illustration of how the rope slowly cuts the desired area.

Laser Fistula Treatment

Laser treatment is a preferred treatment technique for protecting muscles in the treatment of complex fistulas. In this technique, the risk of muscle damage is negligible. In laser treatment, the inner entrance hole of the fistula is closed first. Then the fistula tube is burned with laser. It is a treatment technique with high chance of success.

It does not require months of care like Seton and doesn’t need to a doctor visit. One session is enough for laser application. In addition, there is no risk of gas and fecal incontinence due to incision. The patient can return to life in the next day after the treatment.

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Reproduction or republication strictly prohibited without prior written permission. Translated by (Nasab Almlhem)