If the fistula tract already pierces the sphincter muscle, the effects on the sphincter muscle function must be taken into consideration when deciding on therapy. The development of fecal incontinence is very unlikely, a restriction of control of air or difficulties to control diarrhea, however, are conceivable. This may initially scare some patients away from such an operation, but it should be remembered that the chronic inflammation of the anal fistula also attacks the sphincter muscle.
There are numerous strategies for eliminating anal fistula and not affecting faecal continence. New surgical techniques are constantly being developed. Currently, none of these methods is fully satisfactory in every respect, with cure rates ranging from 30 to 70 percent.
Surgical procedures of the anal fistula to protect the sphincter muscles
In the case of excision with plastic wound closure, the fistula strand bounded by solid connective tissue is removed from the subcutaneous tissue starting from the outer opening of the anal fistula. The passage of the anal fistula through the sphincter muscle is closed with sutures. The mobilization of the surrounding mucous membrane (mucosal lobe) allows the covering of this suture by a second layer.
In up to 60 percent of the cases, the anal fistula can be closed sustainably. However, the sutured area is endangered by the constant activity of the sphincter muscle and pelvic floor and the passage of the stool enriched with bacteria.
Anal fistula: laser surgery
With this technique, the gentle removal of anal fistula is achieved through the use of laser energy. The flexible, all-round radiating glass fibre probe is inserted into the fistula duct from the outside. Then the laser is slowly retracted. The inflammatory tissue is destroyed in a controlled manner and the fistula tract contracts. The anal gland that originally caused the fistula is inactivated.
This concept seemed to be very promising when it was introduced about ten years ago and was applied again and again in selected cases. Unfortunately, one had to learn that the "welding" of the inner fistula opening by laser is not possible as hoped. We therefore always use an additional seam closure, sliding flap or clip.
Implant closure of an anal fistula
The fistula tract is not cut out, but simply freed from inflammatory tissue with a special brush. A conical implant with a circular anchoring plate made of collagen or a synthetic soluble material is then pulled through from the inside to the outside. The fistula tract is now filled with the implant. The anchoring plate is fixed to the sphincter muscle with seams.
The first studies spoke of cure rates of up to 80 percent. Unfortunately, these hopes have not been confirmed either. Further studies found success rates of only 20 percent in some cases. Most proctologists no longer use this procedure. However, the biomaterials mentioned have a benefit in complicated reconstructions to strengthen the body's own tissue, for example in anal fistulas that extend from the anus to the vagina.
Anal fistula treatment: loose thread drainage
Since ancient times the technique of a thread pulled through the anal fistula has been described, which is gradually tightened more tightly. The hope of severing the sphincter muscle in small steps and allowing the tissue behind the thread to heal immediately is not fulfilled in practice. Apart from that, the "cutting thread" is a painful procedure and should no longer be used. Good experiences with a thread impregnated with plant extracts (Ayurveda thread) have been reported from India. Details of the procedure and the composition of the thread coating were not disclosed. Therefore, other doctors could not gain any experience with this technique.
The loose thread drainage, which works with a thin silicone tube, offers the possibility to heal an acute inflammation up to a definitive operation. A thread drainage can also be useful if you are not sure about the optimal treatment of the anal fistula due to massive swelling of the tissue. In difficult cases, such as chronic inflammatory bowel diseases such as Crohn's disease, thread drainage can also be a permanent solution. The fistula does not heal, but adhesion and abscess formation are avoided.
Anal fistula cleavage with primary reconstruction
The fistula is split to allow optimal access to the entire course of the fistula. The fistula tract is then completely removed and the severed sphincter muscle portion reconstructed by sutures. Experienced surgeons achieve high healing rates of up to 90 percent. However, the healing of sutures in an unfavourable area is relied upon. The healing process is often protracted and takes months. It is not uncommon for seams to come loose prematurely. The functional result is usually nevertheless good. In difficult cases in which large parts of the sphincter muscle are affected, a temporary, artificial exit is sometimes necessary to improve the chances of healing, which is then closed again after the anal fistula has healed.
In summary, it can be stated that this option represents a stressful therapy procedure due to several interventions, hospital stays and a long healing process. We'd rather see it as a last resort if other treatments failed.
Plastic surgery procedures: Rectocele Therapy
In particularly difficult cases, anal fistulas form up to the vagina (ano-vaginal or recto-vaginal fistula). The layer between the rectum and the vagina is very delicate, so there is little "material" for closing the opening. Therefore, one usually needs the use of the body's own tissue, for example muscle fat tissue from the perineum or from the leg. Biomaterials of animal origin are also used in this situation. To protect the reconstruction, it is almost always necessary to create an artificial exit so that the bowel movement does not lead to an infection of the repaired tissue.
The treatment of anal fistula depends very much on its development. It is our goal to always proceed as minimally invasive as possible and to keep the extent of the intervention as small as possible. We have years of experience in the treatment of anal fistulas and are happy to answer all your questions on this subject.
Fistula healing without surgery
The economical, but complete removal of an anal fistula with the laser enables a lasting healing and should always be carried out if the sphincter muscle is not significantly endangered.