Anal Fistula

Anal fistulas usually develop as a result of inflammation in the area of the so-called proctodeal glands in the rectum. These glands are located at the transition from the colon mucosa to the anal canal. While they play an important role as scent glands in mammals, they have lost their function in humans.

As the glands open into the intestine, bacteria from the intestine can enter the glands and cause inflammation. As a result of this infection, purulent secretions form, which can migrate along the sphincter muscles and lead to a chronic infection with the formation of a duct (fistula).

Contact with the subcutaneous fatty tissue can result in an abscess around the anus (perinanal abscess). More rarely, fistulas also form in the urinary bladder or vagina. In some cases, a fistula also ends blindly in the tissue as a “dead end”.

A coccyx fistula, on the other hand, is a separate clinical picture and has no connection to the anal canal. 

• Type 1 Intersphincteric fistulas: These originate from the glands at the level of the dentate line and run between the two muscles, therefore intersphincteric (between the muscles). Operation: splitting, excision, laser.

• Type 2 Transsphincteric fistulas: These fistulas pass directly through (trans) the external sphincter muscle (sphincter) and are therefore much more problematic to treat. A simple excision would lead to sphincter weakness (incontinence). If only very little muscle tissue is affected, an excision as for type 1 can be performed. Operation Closure by laser (possibly with PRP), splitting, possibly with reconstruction, flap technique, LIFT procedure.

• Type 3 Suprasphincteric fistulas: These fistulas initially also run between the two sphincter muscles (intersphincteric) and then pull the trunk slightly upwards (supra). In this case, it is not the external sphincter muscle that is pierced as in type 2, but the higher elevator ani muscle. The fistula therefore runs above the external sphincter muscle. Operation Closure by laser (possibly with PRP), splitting, possibly with reconstruction, flap technique, LIFT procedure.

• Type 4 Extrasphincteric fistulas: These fistulas are not typical anal fistulas, as they do not originate in the glands and do not start from the so-called sphincter line. They also have no anatomical connection to the sphincter muscle, hence the term extrasphincteric (outside the sphincter muscle). There is often a connection to a chronic inflammatory bowel disease (Crohn's disease, sigmoid diverticulitis). Operation: This depends entirely on the location and origin. Major bowel surgery may be necessary.

• Type 5 Subcutaneous fistulas: This type of fistula also has no direct relationship to the sphincter muscle, and lies directly under the skin. Operation: Splitting or excision (excision)

An anal fistula always requires surgery and never heals spontaneously. However, a fistula can cause no or only minor symptoms over a longer period of time, i.e. be silent. Symptoms are usually oozing around the anus, which leads to soiling of the underwear and can also smell strongly. A small, rough swelling can often be felt around the anus.

An untreated fistula can lead to damage to the sphincter muscle due to recurring inflammation with abscess formation and, in rare cases, can also lead to malignant degeneration. The type of surgery depends on the course of the fistula. The relationship to the sphincter muscle is of decisive importance for the choice of treatment.

Due to the different locations of anal fistulas in relation to the sphincter muscle, there are a wide variety of surgical procedures. Some of these are very painful and involve a long wound healing process, but the condition is less likely to recur. On the other hand, there are less painful, minimally invasive procedures that are quite unproblematic during surgery, but lead to recurrences more frequently.

It is therefore very difficult to predict the perfect procedure before a planned operation. This is the reason why patients are usually given comprehensive information about several surgical options, such as fistula splitting, flap surgery or suture drainage.

Only under anesthesia can the length and course of the fistula tract be diagnosed using probes and only then can the appropriate treatment be decided. As the patient is under anaesthesia, they cannot be asked about this, which is why the patient assures the surgeon of their freedom to decide on the surgical method before the operation during the consultation. 

It should be noted that all operations should be performed under general anesthesia to enable optimal therapy. An examination of the duct while the patient is awake is very painful and usually has to be stopped after 1 cm.

This is treatment with the FiLaC Laser©. In order to remove the fistula tract as gently as possible, a flexible, radially emitting laser probe is inserted from the outside and precisely positioned with the help of the pilot beam.

Defined energy is emitted into the fistula in a circular pattern. The tissue is thus destroyed in a controlled manner and the fistula tract shrinks to a very high degree. This also supports and accelerates the healing process. This anal fistula operation is painless and spares the sphincter muscle.

• Easy to control
• No cutting or splitting
• Flexible probe for use even in slightly tortuous passages
• Can be performed within a few minutes
• Can be combined with any other form of therapy
• Independent of the length of the fistula tract
• Minimal pain after the operation
• Short absence from work - ideal for the self-employed

Important: Despite the good tolerability of laser therapy, an increased recurrence of the fistula is to be expected. In our experience, as with most alternative minimally invasive anal fistula therapies, this recurrence rate is around 30-40%. Therefore, if possible, splitting of the fistula should always be attempted, as this procedure leads to the best long-term results.

Platelet Rich Plasma (PRP) therapy can be carried out after laser therapy to achieve secure closure. This involves injecting the patient's own growth factors, which have been taken from the patient via a blood sample, into the fistula tract.

Like all open wounds in the anal area, the small external fistula openings should be rinsed twice a day for 2 weeks and after each bowel movement for 2 minutes with clear, additive-free water. This reduces the bacterial count. Afterwards, only a compress needs to be applied, possibly with some wound ointment such as panthenol.

It is an open wound, so there is a natural secretion of wound fluid for approx. 4-6 weeks. A yellow film appears, which is fibrin, a kind of wound adhesive of the body. This is not pus! In contrast to conventional operations, the pain can be described as moderate and we recommend taking painkillers in the first 3-5 days after an operation to prevent pain. Ibuprofen, paracetamol or metamizole (novamine sulfone) can be taken as painkillers. 

A check-up usually takes place on the day after discharge or, in the case of outpatient procedures, on the first day after the operation. If the course of the operation is normal, the patient will be seen again after 6 weeks and, if necessary, after 6 months. 

• Fistulotomy: The anal fistula is exposed with a probe and opened with an electric current (tomy). An open wound remains, which heals with wound secretion. 
• Fistula excision: Removal (excision) of the fistula. Here too, an open wound with wound fluid remains. In the case of larger defects, the sphincter muscle is sutured (sphincter reconstruction).
• Mucosal flap: The anal fistula is excised on the outside up to the sphincter area (fistulectomy). An open wound remains. Inside the anal canal, the fistula opening is cut out and sutured closed if necessary. Some prepared mucosa is pulled over it and sutured (mucosa advancement flap). A variant of this is a so-called full wall flap of the rectum.
• LIFT: In this relatively new procedure, the fistula tract of intersphincteric anal fistulas is accessed and closed with a suture. The abbreviation LIFT stands for “Ligation of the Intersphincteric Fistula Tract”

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