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Anal Fistulectomy

Eric de Leon, MD1; Jaymie Ang Henry, MD, MPH2

1Perpetual Help Hospital
2Florida Atlantic University, G4 Alliance

Abstract

An anal fistula, or fistula-in-ano, is an abnormal connection between the anal canal and the skin around the anus. They are often the result of a previous or current peri-anal abscess, leaving a narrow tunnel behind. The fistula usually originates from the infected anal crypts internally and tracks to the peri-anal skin externally. The majority of the fistulas are cryptoglandular in origin, but Crohn’s disease, malignancy, radiation, trauma, or unusual infections may also produce fistulas. Diagnosis is usually made by physical examination of the peri-anal region and sometimes aided by procedures such as a fistulogram, proctoscopy, or sigmoidoscopy. An opening of the fistula may be observed, and the peri-anal region may be tender and erythematous. An induration may be felt, and foul smelling discharge may be seen coming out of the fistula. Imaging studies such as a CT scan or MRI are only indicated for deep and complex anal fistulas. Fistulas are classified by their relationship to parts of the anal sphincter complex and are classified as intersphincteric, trans-sphincteric, suprasphincteric and extrasphincteric. An intersphincteric fistula begins between the internal and external sphincter muscles, passes through the internal sphincter muscle, and opens very close to the anus. A trans-sphincteric fistula begins between the internal and external sphincter muscles, crosses the external sphincter muscle, and opens an inch or more away from the anus. A suprasphincteric fistula begins between the internal and external sphincter muscles, extends above, and crosses the puborectalis muscle, proceeding downward between the puborectalis and levator ani muscles, and opening an inch or more away from the anus. An extrasphincteric fistula begins at the rectum and proceeds downward through the levator ani muscle, and opens into the skin surrounding the anus. Intersphincteric fistulas are the most common, and extrasphincteric fistulas are the least common. These classifications are important in helping the surgeon make treatment decisions. Definitive treatment aims to prevent recurrence, and surgery is almost always necessary to cure an anal fistula. An intersphincteric fistula is treated by unroofing or removing of the fistulous tract. A trans-sphincteric or suprasphincteric fistula is treated by placing a drain through the fistula. An extrasphincteric fistula is treated based on the anatomy and etiology. Here, we present a case of an 18-year-old male diagnosed with a fistula-in-ano. Fistulectomy was performed by threading the tract and excising it, thus removing the fistula and preventing recurrence.

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