Potential clinical implications of direction of a trans-sphincteric anal fistula track

Abstract

Fistula tracks passed cranially and laterally through the sphincter complex in half of these patients, and were most acutely angled on MRI when internal openings were situated above the dentate line. Preoperative MRI might alert surgeons to the potential hazard of fistulotomy being more extensive than anticipated from simple palpation of the level of the internal opening.

“Video-assisted anal fistula treatment (VAAFT): a novel sphincter-saving procedure to repair complex anal fistulas” by Piercarlo Meinero and Lorenzo Mori

“…Also, it may well be that some circuitous and iatrogenic fistulae are less suited to the passage of a straight videoscope, where the same criticism could be leveled at the use of alternatives such as the recently described radial emitting laser probe for fistula management [7]. The intersphincteric route of the fistula track which is somewhat poorly defined on advanced imaging still needs to be accurately delineated by the operator in the creation of the staple ''volcano'' as Meneiro has described [8].…”

A anorectal fistula treatment with acellular extracellular matrix: A new technique

“…The outcome is generally acceptable. However, fistulotomy causes various degrees of anal sphincter injury [6,[17][18][19][20][21] . The incontinence status is underestimated.…”

Complex perirectal sepsis: clinical classification and imaging

“…Similar comparisons are made for enhanced EAUS, with reported rates for definition of the primary track and fistula anatomy ranging from 60% to 95%, delineation of the internal opening in 48%-94% of cases and horseshoeing in 75%-92% of patients [6,17,39,40,[44][45][46][47][48][49][50][51][52]. Comparative studies between enhanced and unenhanced ultrasonography suggested a significant advantage for the routine use of hydrogen peroxide in all these areas of fistula assessment [39-41, 48-50, 52] as well as in the distinction between linear and curvilinear tracks, a finding which has been suggested as being of some importance in sphincter preservation for recurrent complicated fistulae [53]. There is some evidence that peroxide-enhanced endoanal sonography may be relatively inaccurate for extra-and suprasphincteric fistulae [54] but that it is par-A.P.…”

“…Recently, Buchanan and colleagues suggested that the angulation of the primary track defines the complexity of the fistula where cranial and lateral tracks entering above the dentate line tend to be more acute in their angle of entry [53]. Although this knowledge might preserve more healthy sphincter if it is relied upon as part of the surgical decision making, the assumption is that the intersphincteric and submucosal course of the fistula is direct; this assumption is less likely if there is an associated intersphincteric abscess collection or in recurrent cases where the intersphincteric anatomy is distorted.…”