Complex Anorectal Fistulas
The optimal management of complex anorectal fistulas such as recurrent fistula-in-ano, rectourethral fistula, and ileal-pouch fistula remains the subject of ongoing scientific research and academic debate. While numerous surgical procedures are available,
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Key Concepts • The history and physical examination are the mandatory first step, providing in most cases the appropriate information to classify a fistula as “simple” or “complex.” Anal continence should be evaluated using a validated incontinence score such as the Cleveland Clinic Florida Incontinence Score (CCF-IS) grading system. • Imaging procedures include (in order of authors’ preference) two- and three-dimensional endoanal ultrasound (2D/3D EAUS), pelvic magnetic resonance imaging (MRI), computed tomography (CT), and fistulography. Imaging can provide invaluable information on the anatomy of the fistula, including the primary track, internal opening, horseshoe extension, secondary cavities or extensions, and associated sphincter lesions and is a useful guide in surgical management. • Complex anal fistula is challenging to treat due to the risk of postoperative anal incontinence and the high rate of recurrence. Three factors determine the outcome of surgical treatment: patient-related factors, fistula characteristics, and the surgeon’s choice of operation inclusive of its technical conduct. • Each surgical procedure has advantages and disadvantages, and the choice of operative intervention should be individualized based on patient-related factors and fistula characteristics taking into account success rate as well as impact on patient anal continence. • Rectourethral fistula is often the result of prostate cancer treatment whether surgical or radiotherapy based. A multidisciplinary approach involving a urologist and a colorectal surgeon is essential. Small distal fistulas and those not radiation induced can be amenable to a local anal repair such as an endorectal advancement flap. Electronic supplementary material: The online version of this chapter (doi:10.1007/978-3-319-25970-3_15) contains supplementary material, which is available to authorized users.
Large fistulas, those induced by radiation, or persistent/ recurrent fistulas are best approached by a transperineal approach with a gracilis interposition flap or in select cases by a transabdominal approach with rectal excision. Due to its rarity, rectourethral fistula is best managed in tertiary or quaternary centers with experience managing this condition. • Ileal-pouch fistula is uncommon and can be extremely challenging to manage due to the morbidity associated with any intervention, failure rate of various surgical options, and long-term consequences to the patient. Simple procedures should be attempted first before more complex procedures are considered. Due to the low incidence of this condition, few centers worldwide have accumulated enough experience with ileal-pouch fistula management. Early referral to such centers is advisable.
Introduction According to the standards practice task force of the American Society of Colon and Rectal Surgeons (ASCRS), an anal fistula may be termed “complex” when one or more of the following findings are present: the tract crosses more than 30 % of the external anal sphincter (high transsphincteric with or without a high blind trac
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