Top 10 treatments for Fistula-in-Ano

Fistula-in-Ano is an inflammatory tract with an external (Secondary) opening in the area around the anus and an internal (Primary) opening in the anal canal/ rectum. This tract is lined by unhealthy tissue. To date ,different treatment options have been tried to treat Fistula-in-Ano with varying success rates.

1. Seton: Seton is a non-absorbable nylon or silk suture that is placed in the fistula tract. The main purpose of seton is to keep the tract patent so that pus discharge is easy and the patient does not experience swelling and pain. Alternatively cutting seton is also used. Seton is tightened at regular intervals to cause pressure necrosis (death of tissue) in the belief that it will cut the intervening tissue and finally Fistula will be healed without surgery.
   • Pros of Seton: it provides easy passage for pus discharge by keeping the opening patent and the patient does not feel swelling and pain. In some cases, cutting seton is successful in treating Fistula-in-Ano specially
   • Cons of Seton: 100% persistence in seton treatments when it is draining seton^[1]. Necrosis of tissue is the concept behind the working of cutting seton. It does not debride the unhealthy tissue so the success rate of seton in treating Fistula is not very good (about 20% failure), and long term incontinence may exceed 30% ^[2].
2. Fistulotomy & Lay open technique: In this treatment; a probe is passed through the fistula tract and overlying tissue is divided by a knife. In this way; Fistula is laid open and it is treated as an open wound.
   • Pros of Fistulotomy & Lay open technique: it could be a good choice for simple fistulas i.e. a single no-recurrent fistula that crosses less than 30% of the external sphincter/ fistula is not anterior in women i.e. towards vagina/ there is no history of impaired continence
   • Cons of Fistulotomy & Lay open technique: incontinence (partial or complete loss of control over the passage of stool) in about 1/4 to 1/3 of patients i.e. 25-35% cases. ^[3]
3. Fistulectomy with primary sphincter reconstruction: In this treatment; an incision is given from the internal opening to the anal verge. From there the external opening is excised i.e. cut out. Then fistula tract is excised till the external sphincter muscles.
   • Pros of Fistulectomy with primary sphincter reconstruction: No special wound care is employed, the wound can be showered starting on the first day after the operation, the patient can walk, and physical exercises should be restrained for 4–6 weeks.
   • Cons of Fistulectomy with primary sphincter reconstruction: Incontinence in approx. 23% cases ^[1]
4. Fibrin Sealant: In this treatment; first of all; the tract is debrided. After debridement the tract i irrigated with saline or hydrogen peroxide to further cleanse the tract. The sealant is slowly injected at the internal opening and allowed to set. Once the clot stabilizes at the primary opening, the sealant is injected to obliterate the entire tract. The clot is allowed to solidify for 5–10 min.
   • Pros of Fibrin Sealant: Operative procedures are typically performed as an outpatient. Oral and/or intravenous antibiotics are not necessary for this procedure. Fibrin sealant injection carries essentially no risk of incontinence as there is no division of the sphincter muscle. Additionally, there is very little postoperative pain, the procedure is easily repeatable, and most importantly it does not preclude any further surgical options later in the patient’s treatment.
   • Cons of Fibrin Sealant: The total recurrence rate was 36.95% (17/46). The long-term overall success rate was 63.04% ^[4]
5. Fistula Plug: Placement involves identifying the fistula tract with a standard fistula probe followed by curettage. Once the probe has been placed through the tract, the plug can be tied to the probe and pulled through the tract. The plug is trimmed at the level of the mucosa internally and sutured in place with an absorbable suture. The external end of the plug is also trimmed at the level of skin. It is advised that some space be left at the external opening to allow for drainage of the tract, and for this reason the plug is not sewn in distally. Depending upon the material used in plug it can be Biologic Fistula Plug or Synthetic Fistula Plug.
   • Pros of Fistula Plug: Plugs seem to be better therapeutic options because they do not require ligation of the fistula or division of the sphincters, so there is decreased risk of incontinence. Plug placement is not particularly technically demanding.
   • Cons of Fistula Plug: success rates varying from 24%-88%^[5] i.e. to say Fistula plug fails in about 12-76% of cases and recurrence is reported.
6. Advancement flap: In this treatment, the internal opening is visualized and the fistula tract is probed. Careful attention should be paid to identifying any additional tracts, as undrained tracts will contribute to failure of the flap. Beginning from below to the internal opening, a partial-thickness flap is raised. As the flap is developed, the width is gradually increase so that the base is at least twice the width of the apex of the flap to ensure adequate blood supply to the flap. Dissection of the flap continues until the flap crosses the internal opening without excessive tension. The fistula tract is curetted to remove granulation tissue and debris. The internal opening is closed. The tip of the flap, containing the internal opening, is excised. The flap is then sewn into place. It is an Endorectal advancement flap. When the skin is used as the flap and extended to the internal opening; it is termed a Dermal advancement flap.
   • Pros of Advancement flap: Endorectal flap can be used in special situations such as Crohn’s disease and rectovaginal fistulas. Dermal flap is particularly useful in the presence of coexisting anal pathology such as anal stenosis or Crohn’s disease.
   • Cons of Advancement flap: the reported success rate is widely variable, ranging from 24% to 100%.^[5] The main problem with flap procedures is the high recurrence rate of 30 to 50% ^[1]
7. Ligation of Intersphincteric Fistula Tract (LIFT): In this treatment; first of all; the Fistula probe is introduced through the tract. Then comes dissection of groove between two sphincter muscles and the identification of the fistula tract. Suture ligation of fistula tract is done above and below followed by division of the fistula tract; if the tract is quite long, a segment of the tract is excised. LIFT wound is closed loosely, and external opening of the tract is enlarged to facilitate drainage.
   • Pros of Ligation of Intersphincteric Fistula Tract (LIFT): The beauty of the LIFT is not only in its initial healing rates, but that the procedure itself, even when unsuccessful, may predispose a patient to subsequent healing without risk of incontinence.
   • Cons of Ligation of Intersphincteric Fistula Tract (LIFT):76.5% mean success rate ^[5] Successful fistula closure was achieved in 57% of the patients ^[6]
8. Video Assisted Anal Fistula Treatment (VAAFT): VAAFT works on the principle of “putting an eye” on the probe and exploring the tract from the inside under direct vision. The fistula tract is cleaned/ the waste material removed and the internal opening closed.
   • Pros of Video Assisted Anal Fistula Treatment (VAAFT): VAAFT’s main innovation is the possibility to explore the fistula tract from the inside “under vision” evaluation that includes, in addition to the main tract, secondary tracts, and abscess cavities. The fistuloscopy minimizes the risk of rupture of the fistula and plays a fundamental role in understanding the course of a complex fistula.
   • Cons of Video Assisted Anal Fistula Treatment (VAAFT): Quite expensive  overall success rate of 73.5%. ^[5]
9. Fistula Laser Closure(FiLaC): The FiLaC procedure is performed using a ceramic diode laser platform. The laser fiber is introduced into the fistula tract via the external orifice until the internal orifice is found. The fiber delivers laser energy causing shrinkage of the fistula tract around the fiber.
   • Pros of Fistula Laser Closure(FiLaC): Relatively low chances of incontinence.
   • Cons of Fistula Laser Closure(FiLaC): Quite expensive overall success of 81% which further decreases to 71% when Crohn’s disease is also there ^[5]
10. Ksharsutra Treatment: First of all Fistula tract is defined by probing or MRI fistulogram. With the help of a probe with an eye; Ksharsutra is placed in the fistula tract. Medicine present in Ksharsutra debrides the fistula tract and induces healing from the inside. This medicine works for 5-7 days so the old ksharsutra is replaced by a new one at a week or 10-day time period until the fistula heals completely.
    • Pros of Ksharsutra Treatment: Complications like incontinence are not reported and the success rate of treatment is 96.77% in Ksharsutra treatment for Fistula-in-Ano. ^[7]
• Cons of Ksharsutra Treatment: This treatment takes time. Out come of treatment largely depends on surgeon’s ability to define the tract.

1. Seyfried S, Bussen D, Joos A, Galata C, Weiss C, Herold A. Fistulectomy with primary sphincter reconstruction. Int J Colorectal Dis. 2018 Jul;33(7):911-918. doi: 10.1007/s00384-018-3042-6. Epub 2018 Apr 12. PMID: 29651553.
2. https://www.medscape.com/answers/190234-82310/what-is-the-efficacy-of-seton-placement-for-the-treatment-of-fistula-in-ano-anal-fistula
3. https://link.springer.com/chapter/10.1007/978-1-4614-9014-2_9
4. Maralcan G, Başkonuş I, Gökalp A, Borazan E, Balk A. Long-term results in the treatment of fistula-in-ano with fibrin glue: a prospective study. J Korean Surg Soc. 2011;81(3):169-175. doi:10.4174/jkss.2011.81.3.169
5. Limura E, Giordano P. Modern management of anal fistula. World J Gastroenterol. 2015;21(1):12-20. doi:10.3748/wjg.v21.i1.12
6. Bleier JI, Moloo H, Goldberg SM. Ligation of the intersphincteric fistula tract: an effective new technique for complex fistulas. Dis Colon Rectum. 2010 Jan;53(1):43-6. doi: 10.1007/DCR.0b013e3181bb869f. PMID: 20010349.
7. Dr., P.S., & Prof., M.S. (2010). Efficacy of Kshar Sutra (medicated seton) therapy in the management of Fistula-in-Ano. World Journal of Colorectal surgery, 2, 6.