Fistula-in-ano (perianal fistula) - Salford Royal NHS Foundation Trust

Fistula-in-ano
(perianal fistula)
Clinical Sciences Building
Colorectal Specialist Nursing
0161 206 1249
© G15031101W. Design Services, Salford Royal NHS Foundation Trust, All Rights Reserved 2015.
Document for issue as handout. Unique Identifier: SURG07(15). Review date: March 2017
What is a fistula-in-ano?
How do they occur?
How is it treated?
Fistulotomy
A fistula-in-ano (anal fistula) is
a track running from the skin
on the outside of the buttock/
anal area to the inside of your
bottom. There are different
types of fistulae from simple to
complex branching ones.
Most commonly fistulae occur
as a result of a buttock abscess
- a collection of pus under the
skin next to the back passage.
It can occur from blockage and
infection of the glands inside
your bottom.
There can be several stages
to treatment depending on
whether the muscles around
the back passage are affected.
Often an MRI scan is carried
out to assess the fistula prior to
surgery.
This is the simplest way to treat
a fistula which involves cutting
open the length of the fistula
track to ‘open it up’. This offers
the best chance of cure. This
leaves a small raw area that will
heal with time.
Some fistulae may run through
the sphincter muscles (the ring
of muscles that open and close
the anus and are responsible
for continence). Each fistula is
individual.
It presents as a painful lump
and can be associated with
a fever (high temperature
and shivering). The abscess
can either burst itself but can
become so painful that an
operation is needed to drain it.
The aim of surgery is to drain
any infection whilst at the same
time avoiding damage to the
sphincter muscles. Damaging
these muscles could lead to
bowel incontinence (loss of
control over your wind, fluid or
solid motion). Clearly these can
be difficult decisions to make
and your surgeon would always
discuss the risks and benefits
with you.
Sometimes a small dressing is
needed but often the wound
just needs to be kept clean and
a small pad used to prevent any
soiling.
Even after discussion some
treatment decisions have to
be made whilst you are asleep
during the operation.
This operation cannot be done
if more than two thirds of your
sphincter is involved because of
the risk of incontinence.
Sphincter
muscles
Anal
fistula
Anal
fistula
Perianal
abscess
Anus
Seton
1
External drainage
close to anal sphincter
Fistulae can also occur
with conditions that
affect the bowel such
as Crohn’s disease.
The fistula can lead
to discharge of pus,
blood or mucus
from an opening
in the skin. Once
established an
operation is usually
required.
It is usually safe to cut a small
amount of the anal sphincter
muscle and initially you may
notice a reduction in your
ability to control your wind, this
should resolve with time.
Unfortunately in some cases a
fistula will come back despite
surgery. This is very frustrating
for both the patient and
surgeon. It is not unusual for
some patients to have repeated
operations.
© G15031101W. Design Services, Salford Royal NHS Foundation Trust,
All Rights Reserved 2015. Document for issue as handout.
Unique Identifier: SURG07(15). Review date: March 2017
2
Seton suture
When a fistula runs deeply
it cannot always be treated
with a fistulotomy because
it would involve cutting too
much sphincter muscle and
could result in incontinence. A
seton is a simple draining stitch
or rubber sling. It is passed
through the opening in the
skin, along the fistula track,
and back out through the anus
where it is tied loosely to form
a loop.
Once a seton is in place it will
continue to prevent problems
by acting as a drain and
stopping more abscesses from
forming. You will continue to
have a slight discharge but this
should be far more manageable
than the original fistula. This
is the safest option but it does
not cure the fistula.
To remove the fistula for good
sometimes requires several
operations using setons and
gradual laying open of the
fistula tract or a different
approach as follows.
3
Other surgical treatment
options
LIFT technique
LIFT (ligation of inter sphincteric
fistula tract) is a new procedure
and is used for fistulae that
cross the sphincter muscles. The
space between the muscles is
opened up, the track divided
and the opening stitched closed.
Initial studies suggest this can
be very effective in up to 80%
of patients. It is an attractive
option as it does not involve
cutting the sphincter muscles.
Fistula plug
A specially designed cone
shaped plug made from pig
tissue. The plug is stitched into
the track in a quick operation.
The skin opening is not
completely sealed so that the
fistula can continue to drain.
The plug acts as a scaffold
for new tissue to grow in and
close the fistula. It is a less
invasive technique with no risk
to continence but like the LIFT
procedure has a variable failure
rate.
Mucosal advancement flap
This technique is for complex
fistulas involving the sphincter
muscle where cutting the track
open carries a high risk of
incontinence.
The flap is a piece of tissue
taken from inside your bottom
and used to cover the internal
opening where the fistula was.
The fistula tract is scraped out
leaving the sphincter muscles
alone.
Ongoing research
We are still unsure which of
these techniques is the best and
there is now a national trial
(FIAT Study) to help us decide
whether LIFT, mucosal flap or a
fistula plug is the best way to
treat your fistula. We are one
of the trial centres. Please feel
free to ask any of the colorectal
team about joining this study.
An overview of the study can
be viewed at the following web
address:
http://www.acpgbi.org.uk/
members/research/fiat-trial
Alternatively the colorectal
nurses can provide a paper copy.
If you require any information
or have concerns or questions
regarding your fistula please
feel free to discuss them with
the colorectal specialist nurses.
We can offer advice and
support over the telephone or
arrange to review you in clinic.
The colorectal specialist nursing
team can be contacted on:
0161 206 1249
© G15031101W. Design Services, Salford Royal NHS Foundation Trust,
All Rights Reserved 2015. Document for issue as handout.
Unique Identifier: SURG07(15). Review date: March 2017
4
© G15031101W. Design Services
Salford Royal NHS Foundation Trust
All Rights Reserved 2015
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Unique Identifier: SURG07(15)
Review Date: March 2017
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