The formation of a connection (channel or tunnel) between two body parts that should not normally exist is called fistula. The formation of an abnormal connection between the intestinal section in the anus (primary mouth) and the skin (secondary mouth) is called anal fistula or, in medical terms, "perianal fistula", "anorectal fistula" or "anal fistula". An anal fistula, which occurs in almost all cases as a result of a previous abscess, is a small channel like a tunnel connecting the gland where the abscess developed and the skin from which the abscess emptied.
How common is an anal fistula?
• Anal fistula is encountered with a frequency of 8-10 per 100,000 people in society.
• Gender: Anal fistula is 2 to 7 times more common in men than in women.
• Age: Anal fistula is seen between the ages of 20-60, and the average age is around 40.
How does anal fistula occur?
There are two muscle layers around the anus area, which forms the last part of the stomach and intestinal system. gets. The outer muscular layer, or external anal sphincter, consists of striated or voluntary muscle fibers that provide the function of retaining feces. The inner muscle layer or internal anal sphincter consists of smooth or involuntary muscle fibers and the person cannot control these fibers. Both muscle fibers have serious effects on gas and fecal retention (continence). There are hair and sweat glands called anal crypt, which open where the anal canal meets the skin. The function of these glands is to provide lubrication of the anus and facilitate defecation. Inflammation of these glands is called 'anal cryptitis' and then a tunnel develops between the intestine and the skin, which is called 'anal fistula'.
Which diseases cause anal fistula?
• Anal abscess
• Anal Fissure
• Crohn's Disease
• Some infections: actinomycosis, chlamydia, HIV
• Anal Cancer
• Due to radiation therapy (radiotherapy): After treatment for anal cancer or prostate cancer
Anus What are the symptoms of fistula?
- Recurrent anal abscesses
- Swelling in the anus
- Painful bowel movements and passing gas
- Blood coming from the anus
- Yellow and foul-smelling anus discharge
- Development of diaper rash or "anal dermatitis" around the anus
- Signs of infection such as fever, chills and weakness
Diagnosis and treatment of anal fistula Why is it problematic?
As can be understood from the history mentioned above, the treatment of anal fistula disease, which has been known for 2,500 years, has a high rate of post-operative recurrence (2-10%) or recurrence and the external anal muscle (external anal muscle) during surgery. It is the possibility of injury to the fecal retention muscle (sphincter), which results in fecal incontinence (0-20%) and is a very difficult condition to correct.
Does personal hygiene have an effect on the development of anal fistula?
It has been determined that not keeping the anal area sufficiently clean (personal hygiene), defecation or cleaning of the anal area has anything to do with the development of anal fistula or anal abscess.
Do defecation habits have an effect on the development of anal fistula?
Some patients with anal fistula have constipation and some have diarrhea. Therefore, no relationship has been determined between defecation habits or bowel movements.
How are anal fistulas classified?
The classification system for anal fistulas defined by Parks in 1976 is still widely used today. There are four main types of anal fistula.
1. Inter-sphincteric fistula:
- It is the most common type of anal fistulas and constitutes 45%.
- They start from the toothed line in the anal canal and extend to the point where the anal skin begins (anal verge).
- They are located between the internal anal muscle (internal anal sphincter) and the external anal muscle (external anal sphincter).
2. Trans-sphincteric fistula:
- It constitutes 30% of anal fistulas.
- It passes through the external anal muscle (external anal sphincter) and opens into the ischio-rectal pit, and from there it extends to the anus skin (perineum).
3. Supra-sphincteric fistula:
- Anal fistula It constitutes 20% of the penis.
- It emerges from the hair and sweat glands called anal crypt, surrounds the entire anus muscles and then opens into the ischiorectal pit.
4. Extra-sphincteric fistula:
- It constitutes 5% of anal fistulas.
- They extend to the levator ani muscle (the muscle that surrounds the base of the pelvis), which has a very important place in retaining the anus muscles and stool, and from there to the intestine called the rectum. .
How is the distinction between simple and complicated anal fistulas?
- Simple anal fistula: there is a single fistula tract (tract), and 30% of the external anal muscles (external anal sphincter) are affected. It is associated with less than 50 of them.
- Complicated anal fistula: there is more than one fistula tract (tract) and it is associated with more than 30-50% of the external anal muscles (external anal sphincter).
Which diseases can anal fistula be confused with?
- Bartholin gland abscess
- Sebaceous cyst
- Sweat gland inflammation (dog udders, hydrozadenitis)
- Tuberculosis
- Actinomycosis
- Bone inflammation (osteomyelitis)
- Anal cancer
- Rectum cancer
- Ingrown hair
- Anal itching
- Crohn's disease: An inflammatory bowel disease Anal fistula develops at a rate of 15-40% in Crohn's disease.
- Proctitis is caused by gonorrhea (gonorrhea), syphilis and chlamydia microbes.
- Inflammation of the prostate (prostatitis)
How is anal fistula diagnosed?
1. Magnetic resonance imaging (MRI): with medicated (contrast) MRI performed for the anal canal (anal canal), the course of the fistula within the anal canal, its length, width, its relationship with the stool retention muscle (external anal muscle or external anal sphincter) and the floor muscles of the pelvis. It is useful to reveal.
2. ERUS: The course of the fistula tract (tractus) is investigated with endorectal ultrasound or ultrasonography that examines only the anal canal (endoanal ultrasonography - EAUS). The aim here is to understand the relationship between the fecal retention muscle (external anus muscle, external anal sphincter) or the floor muscles of the pelvis during the course of the fistula and to prepare for the surgery by making detailed pre-operative planning. Its difference from magnetic resonance imaging is that a finger-thick object called an ultrasound probe is inserted into the anus. It is carried out with esi.
3. Fistulography: X-ray is taken by administering medication through the mouth of the fistula. With fistulography; The length of the fistula, its location, its relationship with the fecal retention muscle (external anus muscle or external anal sphincter) and the base muscles of the pelvis are tried to be understood. With magnetic resonance imaging becoming more widespread, this method is rarely preferred.
4. Endoscopy: Only the anal canal can be examined with anoscopy, or more detailed examinations such as rectoscopy, sigmoidoscopy or colonoscopy can be performed to determine the underlying inflammatory bowel disease (Crohn's disease), etc., especially in recurrent anal fistulas. Its presence is investigated.
Does anal fistula cause cancer?
If anal fistula disease continues for many years (more than about 8-10 years), anal cancer rarely occurs as a result of the damage to the fistula area. (anal cancer, anus cancer) may develop. In these cases, 44% colloid cancer, 34% squamous cancer and 22% adenocarcinoma develop.
What are the main principles in the treatment of anal fistula?
The main principle in the treatment is with the intestine (primary mouth). It eliminates the tunnel (fistula) that has developed between the skin (secondary mouth). It is generally preferred to make an incision or "fistulotomy" connecting the inner and outer mouths of the fistula. During this procedure, some of the muscles that control the anal area are also cut. If it is determined that the fistula has a strong relationship with the muscle that controls the stool (external anus muscle, external anal sphincter or voluntary muscle), then staged repair can be preferred and the procedure can be reinforced with a second surgery. If there is a need to cut the external muscle fibers that help hold the stool, then the "seton procedure" is preferred. The Seton process is carried out by connecting the inner and outer mouths of the tunnel with a rope, nylon or a rubber. With this procedure, the fistula remains open and drains out continuously, thus preventing an anal abscess from developing and providing the advantage of not injuring the external muscle fibers that hold the stool. In more complicated cases, techniques such as the mucosal shift method may need to be used. In addition, regional anesthetic substances such as marcaine and bupivacaine are injected into the anal area during the surgery, thus ensuring the patient's anesthetic after the surgery. The pain is significantly reduced and thus the need for painkillers is significantly reduced.
Can anal fistula heal spontaneously?
Spontaneous closure occurs in 6-13% of anal fistula cases.
What happens if anal fistula is not treated?
1. It constantly harbors a focus of infection in the body, causing other organs to be at risk of infection. Periodic fatigue, sweating, joint pain, etc. may cause complaints.
2. When a simple anal fistula is left untreated, it affects the anus muscles and pelvic floor muscles, making the treatment much more difficult and the recurrence rate increases despite treatment.
3. If anal fistula disease continues for more than 8-10 years, anal cancer may rarely develop as a result of the damage to the fistula area.
Anal fistula surgeries
Laser technique: After cleaning the path of complicated anal fistulas with a brush, the fistula tunnel is closed in a 360o circular manner with a thin laser bar. This technique is called "Fistula laser closure" or abbreviated as "FILAC" or "Laser ablation of the fistula tract" or simply "LAFT" in English sources. The main purpose here is to close the gap by burning it with a laser, as if filling it with silicone. It is a current technique that causes very little anal pain and burning in the anus after surgery and has very good results.
LIFT technique: This technique is the abbreviation of the expression 'ligation of intersphincteric fistula tract' and is used between the stool retention muscles. It means the ligation of the fistula tract. In this technique, the internal anal muscle (internal anal sphincter) and the external anal muscle (external anal sphincter) are separated from each other, and then the inner mouth and outer mouth of the fistula are closed with absorbable stitches. While the success rates in the first publication were around 94%, the success rates in subsequent publications were between 60-95%.
Seton technique: In the presence of a fistula that is located high or involves the external anal sphincter (external anal muscle, stool retention muscle), the seton technique preferable. In this technique, the fistula opens the openings in the intestine (inner) and skin (outer).
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