Complex Anal Fistulas: Treatment Options Beyond Surgery

Anal fistula

The situation is as follows: I previously went to a hospital to arrange for a fistula surgery, but the doctor informed me that the fistula was too deep and the internal opening could not be located, so they were unable to perform the procedure directly.
Therefore, they did not proceed with any surgical probing, but confirmed that it was indeed a fistula.
They did not perform any surgery, possibly due to concerns about damaging the sphincter muscle.
The doctor mentioned that if the fistula is too deep and complex, what other treatment options are available? The doctor said that if there is pain, they would help me with treatment upon my return, and I suspect it might involve drainage.

Asha, 30~39 year old female. Ask Date: 2019/11/06

Dr. Ke Fangxu reply Surgery

The management of complex fistulas can be quite challenging.
Performing a fistulotomy can indeed lead to sphincter damage, so the approach is somewhat different.
The traditional surgical method is the seton procedure, which involves placing a thread through the fistula.
However, this method results in larger wounds, increased pain, and a lengthy treatment duration.
In recent years, some physicians have reported that endoscopic excision can reduce wound size and treatment time, although few surgeons are performing this technique.
Another approach is core-out fistulotomy, which simply removes the fistula tract.
While this method results in smaller wounds, it has a higher recurrence rate and is generally not recommended.
For complex fistulas, smaller hospitals may have less experience, so it is advisable to consult with a physician at a larger hospital for better management options.

Reply Date: 2019/11/06

More Info

Complex anal fistulas can be quite challenging to manage, especially when they are deep and difficult to access surgically. The primary goal of treatment is to heal the fistula while preserving anal function and minimizing discomfort. Here are some treatment options beyond traditional surgery that you might consider:
1. Fistula Seton: This is a common method for managing complex anal fistulas. A seton is a piece of material (often a thin rubber band or thread) that is placed through the fistula tract. It helps to keep the fistula open, allowing for drainage of any infection and preventing abscess formation. Over time, the seton can help to promote healing by allowing the fistula to mature and potentially close on its own. This method is particularly useful for fistulas that are too deep or complex for direct surgical intervention.

2. Fibrin Glue Injection: This is a minimally invasive technique where a special glue made from fibrin (a protein involved in blood clotting) is injected into the fistula tract. The glue helps to seal the tract and promote healing. This method is generally less painful and has a shorter recovery time compared to traditional surgery, but it may not be effective for all types of fistulas, especially those that are very complex.

3. LIFT Procedure (Ligation of Intersphincteric Fistula Tract): This technique involves identifying the fistula tract and ligating it at its intersphincteric portion. This method aims to cut off the blood supply to the fistula, allowing it to heal while preserving the surrounding sphincter muscles. The LIFT procedure has shown promising results in terms of healing rates and maintaining anal function.

4. Advancement Flap Surgery: In cases where the fistula is particularly complex, an advancement flap may be used. This involves creating a flap of healthy tissue from the surrounding area and using it to cover the internal opening of the fistula. This method can be effective in closing the fistula while minimizing the risk of incontinence.

5. Bioprosthetic Plug: This is a newer technique where a bioprosthetic plug is inserted into the fistula tract. The plug is made from materials that promote tissue growth and healing. This method is still being studied, but it has shown potential in treating complex fistulas.

6. Medical Management: In some cases, managing underlying conditions such as Crohn's disease or other inflammatory bowel diseases can help reduce the incidence of fistulas. Medications like immunosuppressants or biologics may be prescribed to control inflammation and promote healing.

7. Pain Management and Supportive Care: If the pain is significant, your healthcare provider may recommend pain management strategies, including medications or topical treatments. Additionally, supportive care, such as sitz baths and dietary modifications, can help alleviate symptoms.

It's essential to have a thorough discussion with your healthcare provider about the best treatment options for your specific situation. They can help you weigh the risks and benefits of each approach, considering the complexity of your fistula and your overall health. If surgery is deemed necessary in the future, your provider will work to minimize risks to the anal sphincter and preserve function.
In summary, while surgery is a common treatment for anal fistulas, there are several non-surgical options available that may be effective, especially for complex cases. Your healthcare provider can guide you through these options and help you make an informed decision based on your individual circumstances.

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