Management of Complex Perineal Fistula Disease

Abstract

Management of complex perineal fistulas such as high perianal, rectovaginal, pouch-vaginal, rectourethral, or pouch-urethral fistulas requires a systematic approach. The first step is to control any sepsis with drainage of abscess and/or seton placement. Patients with large, recurrent, irradiated fistulas benefit from stoma diversion. In patients with Crohn's disease, it is essential to induce remission prior to any repair. There are different approaches to repair complex fistulas, from local repairs to transperineal and transabdominal approaches. Simpler fistulas are amenable to local repair. More complex fistulas, such as those secondary to irradiation, require interposition of healthy, well-vascularized tissue. The most common flap used for this treatment is the gracilis muscle with good outcomes reported. Once healing is confirmed by imaging and endoscopy, the stoma is reversed.

Clinical efficacy of anal fistula plug treatment regimens in anal fistula patients

“…However, the long-term clinical efficacy of AFP is still unknown in this study because it lacked of sufficient patients with AFP treatments and the follow-up visit only persisted 3 months. Furthermore, accumulating evidence demonstrated that the recurrence rate in complexity anal fistula patients following AFP surgery significantly elevated concomitant with the prolongation of follow-up time [11,18]. Thus, it is necessary to further confirm our results that AFP is a good choice for treating anal fistula patients by increasing the number of patient with AFP operation and prolonging the length of follow-up time.…”

“…Although anal fistula is a common disease in anorectal, the treatment methods of anal fistulas have remained a perplexing medical challenge because their lower healing rate, higher recurrence rate and serious faecal continence impairments [11]. Therefore, a large amount of anorectal surgeons constantly sought for the new technology to improve the clinical outcomes of anal fistula treatments over the past decades.…”

Complex anal fistula involving male genital tract: a new diagnostic entity

“…Local control of sepsis and abscess drainage should be done initially before any attempt for definitive treatment. Options include setons, fistulotomy or fistulectomy, endorectal advancement flap, fistula plug, fibrin glue, electrocauterisation of tract and ligation of intersphincteric fistula tract 2 5. We cannot conclude on the success of these options in the management of this particular presentation, however they can be discussed with the patient.…”

“…MRI is of the essence in managing such complex fistulas. It will help to assess the anatomy and adjacent structures, identifying branching tracts or collections and to outline the relationship of the fistula to anal sphincter 2. MRI is considered the best imaging modality for anal fistula assessment, prognosis prediction and treatment monitoring.…”

Mucocele complicating stapled hemorrhoidopexy

“…Sometimes the spontaneous partial mucus drainage inside the rectum correlates to a downsizing of the mass and a mild symptoms improvement. Bacterial colonization is a likelihood causing an abscess which may drain through the rectum or through the perineal region with a complex fistula whose healing may be challenging [5] .…”