Surgical Procedures
What are the Surgical options available?
It’s important to understand the different types of anal fistulas and the treatment options available. We understand this can be confusing, or even overwhelming.
Anal fistula surgery can be simple or complex, more complex fistulas may need surgery in stages.
Treatment of an anal fistula depends on the fistula's location, complexity and its cause. The goals are to repair the anal fistula completely to prevent recurrence and to protect the sphincter muscles.
Seton Placement
If your fistula passes through a significant portion of anal sphincter muscle, the surgeon may initially recommend inserting a seton.
A seton is a piece of surgical thread that's left in the fistula for several weeks to keep it open.
This allows it to drain and helps it heal, while avoiding the need to cut the sphincter muscles.
Loose setons allow fistulas to drain, but do not cure them. To cure a fistula, tighter setons may be used to cut through the fistula slowly.
This may require several procedures that the surgeon can discuss with you.
Or they may suggest carrying out several fistulotomy procedures, carefully opening up a small section of the fistula each time, or a different treatment.
Mucosal Advancement Flap (MAF)
An advancement flap procedure may be considered if your fistula passes through the anal sphincter muscles and having a fistulotomy carries a high risk of causing incontinence.
This involves cutting or scraping out the fistula and covering the hole where it entered the bowel with a flap of tissue taken from inside the rectum, which is the final part of the bowel.
This has a lower success rate than a fistulotomy, but avoids the need to cut the anal sphincter muscles.
Fibrin Glue
Treatment with fibrin glue is currently the only non-surgical option for anal fistulas.
It involves the surgeon injecting glue into the fistula while you're under a general anaesthetic. The glue helps seal the fistula and encourages it to heal.
It's generally less effective than fistulotomy for simple fistulas and the results may not be long-lasting. But it may be a useful option for fistulas that pass through the anal sphincter muscles because they do not need to be cut.
Fistulotomy
The most common type of surgery for anal fistulas is a fistulotomy (removal of an abnormal connection between the anus and skin)
This involves cutting along the whole length of the fistula to open it up, so it heals as a flat scar. There will be an open wound where the fistula was. This will take 2-6 weeks to heal.
A fistulotomy is the most effective treatment for many anal fistulas. But it's usually only suitable for fistulas that do not pass through much of the sphincter muscles. This is because the risk of incontinence is lowest in these cases.
If the surgeon has to cut a small portion of anal sphincter muscle during the procedure, they'll make every attempt to reduce the risk of incontinence.
In cases where the risk of incontinence is considered too high, another procedure may be recommended instead.
Ligation of the Intersphincteric Fistula Tract (LIFT)
The ligation of the Intersphincteric fistula tract (LIFT) procedure is a treatment for fistulas that pass through the anal sphincter muscles, where a fistulotomy would be too risky.
During the treatment, a cut is made in the skin above the fistula and the sphincter muscles are moved apart. The fistula is then sealed at both ends and cut open so it lies flat.
This procedure has had some promising results so far, but it's only been around for a few years, so more research is needed to determine how well it works in the short and long term.
Risks of Anal Fistula Surgery
Like any type of treatment, treatment for anal fistulas carries a number of risks.
The main risks are:
infection – this may require a course of antibiotics and severe cases may need to be treated in hospital
recurrence of the fistula – the fistula can sometimes reoccur despite surgery
bowel incontinence – this is a potential risk with most types of anal fistula treatment, although severe incontinence is rare and every effort will be made to prevent it
The level of risk will depend on things like where your fistula is located and the specific procedure you have.
Speak to the surgeon about the potential risks of the procedure they recommend.