Anorectal Fistula

  • Rick Nelson


It is surprising that none of the quotes about the early use of the term fistula come from John of Arderne (1307–1392), whose classic work on the treatment of anal fistula is still in print, and who predates them all. It is possible that more has been written by surgeons about anorectal abscess and fistula than any other condition over the expanse of time and world geography [1–4]. Hippocrates (b. ∼460 BC) of course described the seton suture and Sushruta (b. ∼800 BC) described both fistulotomy and fistulectomy as well as the use of cauterizing chemicals in the fistula track. These treatments are still in common use (see below). This ongoing concern is a testament both to the prevalent nature of these disorders and the difficulty they present to the surgeon in basic decision making. The reasons for these difficult decisions are obvious. On the one hand, it is necessary to resolve sepsis and symptoms associated with it, principally pain, and yet the procedures that one employs must also preserve function in the anal canal, that is, prevent incontinence. Although surgeons have been treating anal fistulas for centuries, evidence supporting the effectiveness of these treatments is poor and scientific study scant (Box 4.1).


Anal Canal Fibrin Glue Anal Fissure Anal Fistula Internal Opening 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


  1. 1.
    Sankaran PS. Sushruta’s contribution to surgery. Varanasi: Indological Book House; 1976.Google Scholar
  2. 2.
    Ani AN. Anorectal diseases in western Nigerian adults. A field study. Dis Colon Rectum. 1983;26:381–5.PubMedCrossRefGoogle Scholar
  3. 3.
    Navruzov SN, Dul’tsev IV, Salamov KN. Causes and prevention of rectal fistula recurrences. Vestn Khir Im I I Grek. 1981;27:43–6.Google Scholar
  4. 4.
    Akinola DO, Hamed AD. Fistula in ano in Nigerians. Trop Gastroenterol. 1989;10:153–7.PubMedGoogle Scholar
  5. 5.
    Read D, Abcarian H. A prospective survey of 474 patients with anorectal abscesses. Dis Colon Rectum. 1979;22:566–8.PubMedCrossRefGoogle Scholar
  6. 6.
    Ramanujam PS, Prasad ML, Abcarian H, Tan AB. Perianal abscess and fistulas; a study of 1023 patients. Dis Colon Rectum. 1984;27:593–7.PubMedCrossRefGoogle Scholar
  7. 7.
    Sainio P. Fistula in ano in a defined population. Incidence and epidemiologic aspects. Ann Chir Gynaecol. 1984;73:219–24.PubMedGoogle Scholar
  8. 8.
  9. 9.
  10. 10.
    Vasilevsky CA, Gordon PH. The incidence of recurrent abscesses or fistula in ano following anorectal suppuration. Dis Colon Rectum. 1984;27:126–30.PubMedCrossRefGoogle Scholar
  11. 11.
    Henrichsen S, Christensen J. Incidence of fistula in ano complicating anorectal sepsis: a prospective study. Br J Surg. 1986;73:371–2.PubMedCrossRefGoogle Scholar
  12. 12.
    Goligher JC. Surgery of the anus, rectum and colon. London: Balliere Tindall; 1975.Google Scholar
  13. 13.
    Nelson RL, Prasad L, Abcarian H. Anal carcinoma presenting as a perirectal abscess or fistula. Arch Surg. 1985;120:632–5.PubMedCrossRefGoogle Scholar
  14. 14.
    Nelson RL, Abcarian H. Do hemorrhoids cause cancer? Semin Colon Rectal Surg. 1995;6:178–81.Google Scholar
  15. 15.
    Tarazi R, Nelson RL. Adenocarcinoma of the Anus. Semin Colon Rectal Surg. 1995;6:169–73.Google Scholar
  16. 16.
    Shacter E, Weitzman SA. Chronic inflammation and cancer. Oncology. 2002;16:217–36.PubMedGoogle Scholar
  17. 17.
    Kuijpers HC, Schulpen T. Fistulography for fistula-in-ano. Is it useful? Dis Colon Rectum. 1985;28(2):103–4.PubMedCrossRefGoogle Scholar
  18. 18.
    Nelson RL, Schwartz A, Pavel D. Assessment of the usefulness of a diagnostic test: patient preference in diagnostic tests of colonic inflammation. BMC Med Res Methodol. 2001;1:5.PubMedCrossRefGoogle Scholar
  19. 19.
    Chappel KS, Spencer JA, Windsor AC, Wilson D, Ward J, Ambrose NS. Prognostic value of magnetic resonance imaging in management of fistula in ano. Dis Colon Rectum. 2000;43:511–6.CrossRefGoogle Scholar
  20. 20.
    Sahni VA, Ahmad R, Buring D. Which method is best for imaging of perianal fistula? Abdom Imaging. 2008;33:26–30.PubMedCrossRefGoogle Scholar
  21. 21.
    Buchanan GN, Halligan S, Bartram CI, Williams AB, Tarroni D, Cohen CR. Clinical examination, endosonography, and MR imaging in preoperative assessment of fistula in ano: comparison with outcome based reference standard. Radiology. 2004;233:674–81.PubMedCrossRefGoogle Scholar
  22. 22.
    MacFie J, Harvey J. The treatment of acute superficial abscesses: a prospective clinical trial. Br J Surg. 1977;64:264–6.PubMedCrossRefGoogle Scholar
  23. 23.
    Murie JA. The treatment of acute superficial abscesses; a prospective clinical trial. J R Col Surg Edin. 1981;26:282–5.Google Scholar
  24. 24.
    Lundhus E, Gjoede P, Gottrup F, Holm CN, Terpling S. Bactericidal antimicrobial cover in primary suture of perianal or pilonidal abscess; a prospective, randomized, double blind clinical trial. Acta Chir Scand. 1989;155:351–4.PubMedGoogle Scholar
  25. 25.
    Lundhus E, Gottrup F. Outcome at three to five years of primary closure of perianal and pilonidal abscess; a randomised, double-blind clinical trial with a complete three-year followup of one compared with four days’ treatment with ampicillin and metronidazole. Eur J Surg. 1993;159:555–8.PubMedGoogle Scholar
  26. 26.
    Mortensen J, Kraglund K, Klaerke M, Jaeger G, Svane S, Bone J. Primary suture of anorectal abscess; a randomized study comparing treatment with Clindamycin vs. Clindamycin and Getacoll. Dis Colon Rectum. 1995;38:398–401.PubMedCrossRefGoogle Scholar
  27. 27.
    Leaper DJ, Page RE, Rosenberg IL, Wilson DH, Goligher JC. A controlled study comparing the conventional treatment of idiopathic anorectal abscess with that of incision, curettage and primary suture under systemic antibiotic cover. Dis Colon Rectum. 1976;19:46–51.PubMedCrossRefGoogle Scholar
  28. 28.
    Christensen AK, Kronborg O, Olsen H. Primaer sutur med eller uden daekke af klindamycin ved anorectal ae abscesser. Ugeskr Laeger. 1983;145:576–8.PubMedGoogle Scholar
  29. 29.
    Kronborg O, Olsen H. Incision and drainage v incision, curettage and suture under antibiotic cover in anorectal abscess; a randomized study with 3-year follow-up. Acta Chir Scand. 1984;150:689–92.PubMedGoogle Scholar
  30. 30.
    Garcia-Aguilar J, Belmonte C, Wong D, Goldberg SM, Madoff RD. Anal fistula surgery. Factors associated with recurrence and incontinence. Dis Colon Rectum. 1996;39:723–9.PubMedCrossRefGoogle Scholar
  31. 31.
    Isbister WH. Fistula in ano: a surgical audit. Int J Colorectal Dis. 1995;10:94–6.PubMedCrossRefGoogle Scholar
  32. 32.
    Multicentric randomized controlled clinical trial of Kshaarasootra (Ayurvedic medicated thread) in the management of fistula-in-ano. Indian Council of Medical Research. Indian J Med Res. 1991;94:177–85.Google Scholar
  33. 33.
    Pescatori M, Maria G, Anastasio G, Rinallo L. Anal manometry improves the outcome of surgery for fistula-in-ano. Dis Colon Rectum. 1989;32:588–92.PubMedCrossRefGoogle Scholar
  34. 34.
    Kronborg O. To lay open or excise a fistula-in-ano: a randomized trial. Br J Surg. 1985;72:970.PubMedCrossRefGoogle Scholar
  35. 35.
    Vasilevsky CA, Gordon PH. Results of treatment of fistula-in-ano. Dis Colon Rectum. 1985;28:225–31.PubMedCrossRefGoogle Scholar
  36. 36.
    Sainio P, Husa A. Fistula-in-ano. Clinical features and long term results of surgery in 199 adults. Acta Chir Scand. 1985;151:169–76.PubMedGoogle Scholar
  37. 37.
    Kuypers JH. Diagnosis and treatment of fistula-in-ano. Neth J Surg. 1982;34:147–52.PubMedGoogle Scholar
  38. 38.
    Joo JS, Weiss EG, Nogueras JJ, Wexner SD. Endorectal advancement flap in perianal Crohn’s disease. Am Surg. 1998;64:147–9.PubMedGoogle Scholar
  39. 39.
    Hesterberg R, Schmidt WU, Mueller F, Roeher HD. Treatment of anovaginal fistulas with an anocutaneous flap in patients with Crohn’s disease. Int J Colorectal Dis. 1993;8:51–4.PubMedCrossRefGoogle Scholar
  40. 40.
    Koehler A, Athanasiadis S. Die anodermale Vershiebelappenplastik als alternativee Behand­lungsmethode zu den endorectalen Verschlusstechniken bei der therapie hoher Analfisteln. Chirurg. 1996;67:1244–50.CrossRefGoogle Scholar
  41. 41.
    Malik AI, Nelson RL, Tou S. Incision and drainage of perianal abscess with or without treatment of anal fistula. Cochrane Database Syst Rev. 2010;(7):CD006827.Google Scholar
  42. 42.
    Jacob TJ, Perakath B, Keighley MR. Surgical intervention for anorectal fistula. Cochrane Database Syst Rev. 2010;(5):CD006319.Google Scholar
  43. 43.
    Shukla N. Multicentric randomized controlled clinical trial of Kshaarasootra (Ayurvedic medicated thread) in the management of fistula-in-ano. Indian Council of Medical Research. Indian J Med Res. 1991;94:177–85.Google Scholar
  44. 44.
    Belmonte Montes C, Ruiz Galindo GH, MontesVillalobos JL, Decanini Teran C. Fistulotomy vs fistulectomy. Ultrasonographic evaluation of lesion of the anal sphincter function. Rev Gastroenterol Mex. 1999;64:167–70.PubMedGoogle Scholar
  45. 45.
    Zimmerman DD, Gosselink MP, Hop WC, Darby M, Briel JW, Schouten WR. Impact of two different types of anal retractor on fecal continence after fistula repair: a prospective, randomized, clinical trial. Dis Colon Rectum. 2003;46:1674–9.PubMedCrossRefGoogle Scholar
  46. 46.
    Singer M, Cintron J, Nelson R, et al. Treatment of fistulas-in-ano with fibrin sealant in combination with intra-adhesive antibiotics and/or surgical closure of the internal fistula opening. Dis Colon Rectum. 2005;48:799–808.PubMedCrossRefGoogle Scholar
  47. 47.
    Chen XL, Huang ZH, Zhan YQ, Liu MS, et al. A minimally invasive approach in the treatment of complicated anal fistula through spatium intramuscular of anal sphincter. Zhongua Wei Chang Wai Ke Za Zhi. 2005;8:322–4.Google Scholar
  48. 48.
    Perez F, Arroyo A, Serrano P, et al. Randomized clinical and manometric study of advancement flap versus fistulotomy with sphincter reconstruction in the management of complex fistula-in-ano. Am J Surg. 2006;192:34–40.PubMedCrossRefGoogle Scholar
  49. 49.
    Gustafsson UM, Graf W. Randomized clinical trial of local gentamicin-collagen treatment in advancement flap repair for anal fistula. Br J Surg. 2006;93:1202–7.PubMedCrossRefGoogle Scholar
  50. 50.
    Garcia-Olmo D, Herreros D, Pascual I, Pascual JA, Del-Valle E, Zorrilla J, De-La-Quintana P, Garcia-Arranz M, Pascual M. Expanded adipose-derived stem cells for the treatment of complex perianal fistula: a phase II clinical trial. Dis Colon Rectum. 2009;52(1):79–86.PubMedCrossRefGoogle Scholar
  51. 51.
    Hammond TM, Porrett TR, Scott SM, Williams NS, Lunniss PJ. Management of idiopathic anal fistula using cross-linked collagen: a prospective phase 1 study. Colorectal Dis. 2010;13:94–104.CrossRefGoogle Scholar
  52. 52.
    Grimaud JC, Munoz-Bongrand N, Siproudhis L, Abramowitz L, et al. Fibrin glue is effective healing perianal fistulas in patients with Crohn’s disease. Gastroenterology. 2010;138:2275–81.PubMedCrossRefGoogle Scholar
  53. 53.
    Khafagy W, Omar W, El Nakeeb A, Fouda E, Yousef M, Farid M. Treatment of anal fistulas by partial rectal wall advancement flap or mucosal advancement flap: a prospective randomized study. Int J Surg. 2010;8:321–5.PubMedCrossRefGoogle Scholar
  54. 54.
    Rosen NG, Gibbs DL, Soffer SZ, Hong A, Sher M, Pena A. The nonoperative treatment of fistula in ano. J Pediatr Surg. 2000;35:938–9.PubMedCrossRefGoogle Scholar
  55. 55.
    Fitzgeral RJ, Harding B, Ryan W. Fistula in ano in childhood: a congenital etiology. J Pediatr Surg. 1985;20:80–1.CrossRefGoogle Scholar
  56. 56.
    Garcia-Aguilar J, Belmonte C, Wong DW, Goldberg SM, Madoff RD. Cutting seton versus two stage fistulotomy in the surgical management of high anal fistula. Br J Surg. 1998;85:243–5.PubMedCrossRefGoogle Scholar
  57. 57.
    Bennett RC. A review of the results of conventional treatment of anal fistulae. J R Soc Med. 1962;55:756–8.Google Scholar
  58. 58.
    Joy H, Williams JG. The outcome of surgery for high anal fistulas. Colorectal Dis. 2000;2:17.Google Scholar

Copyright information

© Springer-Verlag London Limited 2012

Authors and Affiliations

  1. 1.Department of SurgeryNorthern General HospitalSheffieldUK

Personalised recommendations