Ponad 7000 publikacji medycznych!
Statystyki za 2021 rok:
odsłony: 8 805 378
Artykuły w Czytelni Medycznej o SARS-CoV-2/Covid-19

Poniżej zamieściliśmy fragment artykułu. Informacja nt. dostępu do pełnej treści artykułu
© Borgis - Nowa Medycyna 1/2016, s. 29-37 | DOI: 10.5604/17312485.1203779
*Anna Wiączek1, Małgorzata Kołodziejczak1, Iwona Sudoł-Szopińska1, 2, 3
Diagnosis and surgical treatment of complex anorectal fistulas
1Warsaw Proctology Centre, Saint Elizabeth’s Hospital, Mokotów Medical Centre, Warsaw
Head of Department: Małgorzata Kołodziejczak, PhD, Associate Professor
2Department of Radiology, Eleonora Reicher National Institute of Geriatrics, Rheumatology and Rehabilitation, Warsaw
Head of Department: prof. Iwona Sudoł-Szopińska, MD, PhD
3Department of Diagnostic Imaging, Second Faculty of Medicine, Medical University of Warsaw
Head of Department: prof. Wiesław Jakubowski, MD, PhD
Branching fistulas belong to the category of so-called complex fistulas since they contain secondary tracts with varying number and location. The most common causes of branching fistulas include: abscesses that have been incised too late or insufficiently drained, inflammatory bowel diseases and conditions with immunodeficiency. In rare cases, secondary tracts can develop in the course of tuberculosis, actinomycosis or as a complication after radiotherapy or anal wall erosion due to cancer or anorectal trauma. Surgery for this type of fistulas is difficult, frequently involving several stages and carrying a high risk of recurrence. In order to minimise the risk of complications, complex fistulas should be treated by surgeons specialising in proctology with adequate knowledge regarding contemporary surgical techniques. A significant factor that decides about treatment success is preoperative determination of the anatomical course of fistulas and their secondary tracts. This is possible with imaging: endosonography and magnetic resonance imaging. It is also necessary to conduct functional tests and colonoscopy in order to assess the bowel in terms of inflammatory diseases and other pathologies. Moreover, a bacteriological examination should be conducted in patients carrying a high risk of complications.
These patients include individuals with Crohn’s disease, diabetes, immune deficiency, cancer or considerable inflammation of anal soft tissues. The article presents surgical techniques for branching fistulas, such as two-stage seton fistulotomy (modified Hippocrates’ technique) and different one-stage sphincter-sparing procedures.

Anal fistula is a chronic infection of the anal canal and the perianal tissue in the form of a canal lined with inflammatory granulation tissue connecting the internal opening located in the anus with the external opening situated on the skin or anoderm. Fistula is caused by anal crypt inflammation in most cases, and is often preceded by an anal abscess. About 5% and, according to some reports, up to 30% of fistulas are branched (1). In this case, one or more tracts ending in the skin or ending blindly in the perianal tissues can branch off from the main canal at different levels. Depending on the location of these additional canals, three types of fistula tracts have been distinguished: intersphincteric, transsphincteric and suprasphincteric. Most of the tracts extend in the intersphincteric space, in the ischioanal fossa, above the pubic-rectal muscle loop, and even higher, above the level of the levator muscles, in the supralevator space and in the pelvis. A horseshoe-shaped fistula, which branches in the shape of a horseshoe and opens into the anal canal or rectum, is a special type of branching fistula. Most of horseshoe fistulas are located posteriorly and their internal opening is usually located in the posterior midline. These posterior tracts can extend in the superficial retroanal space, anteriorly to the anococcygeal ligament or deeper, in the deep retroanal space, posteriorly to this ligament. It is a recognized location of rear horseshoe fistulas which run in deep anal space and superficial anal space. Anterior horseshoe fistulas are much less common and represent a major therapeutic problem due to a significant risk of postoperative incontinence resulting from the lack of protection of the pubic-rectal muscle of the anterior circumference of the anal canal. The tracts of the anterior branching fistulas can run towards the perineal skin, approach or communicate with the vaginal lumen, or reach the scrotal skin in men. Even more extensive tracts can penetrate into the soft tissue of the buttock or groin. In very rare cases, they can even pierce the fascia, e.g. in the posterior femoral surface, and run between muscle bellies.
The presence of additional canals, particularly those occurring in high fistulas, represents a major dilemma for the operating surgeon, who decides on procedure radicality and, at the same time, aims to maintain the largest possible portion of the sphincter due to the postoperative risk of faecal and gas incontinence. High suprasphincteric fistula tracts, which, in most cases, are difficult to excise are most problematic. Due to the risk of postoperative incontinence, these tracts are frequently only opened and curetted, which increases the risk of recurrence.
Etiopathogenesis of complex fistulas
The most common causes of branching fistulas include abscesses that have been incised too late or insufficiently drained, inflammatory bowel diseases (usually Crohn’s disease and ulcerative colitis) and conditions with immunodeficiency (HIV infection, chemotherapy). Other causes of branching fistulas, such as tuberculosis, actinomycosis, anal wall erosion due to anorectal cancer or as a complication after radiotherapy as well as anorectal trauma, are casuistic.
Iatrogenic fistulas resulting from proctological, gynaecological or urological surgeries are another group of fistulas (2-4). Fistula tracts can also result from sphincter-sparing surgeries for anal fistula followed by abscess formation, which, in turn, underlies the development of new tracts (5, 6). Similarly, quick abscess diagnosis and incision is important for the prevention of branching fistulas. Otherwise, the purulent secretion penetrates the anatomical spaces adjacent to the abscess, resulting in the formation of additional tracts.
Classification of anal fistulas
Complex fistulas are generally subject to the same divisions as simple fistulas. Parks’ classification, which is based on the relationship between the fistula tract and the external anal sphincter, is the most commonly used classification (7).
Another quite common classification of fistulas, which was proposed by Goodsall and Miles, is based on the presence of the internal fistula opening (8) and divides fistulas into complete and blind, i.e.:
– complete fistula – having two openings, one external through the skin and one internal into the anal or rectal lumen,
– external blind fistula – without an external opening,
– internal blind fistula – without (a visible) internal opening.
MRI-based classification of fistulas (9) distinguishes the types described by Perks, but also points to the coexistence of abscess and fistulous tracts:
– simple intersphincteric fistula,
– intersphincteric fistula with an intersphincteric abscess or secondary fistulous tract,
– transsphincteric fistula,
– transsphincteric fistula with an abscess or secondary fistulous tract to the ischioanal fossa,
– supra- or translevator fistula.
Fistulas passing directly through the levator muscles are rarely encountered in surgical practice. Typically, fistulous canal located in this area passes above or below the levator muscle. It seems from the above classification that group V refers to suprasphincteric and extrasphincteric fistulas.
Only type 1 fistula is associated with a good prognosis. The treatment efficacy in other types of fistula is lower and depends on both, the height of fistula and the number of secondary tracts or the location of a coexistent abscess.
Similarly to simple fistulas, the diagnosis of complex fistulas is based on medical history (per rectum) physical examination as well as imaging and functional evaluation.
Medical history

Powyżej zamieściliśmy fragment artykułu, do którego możesz uzyskać pełny dostęp.
Mam kod dostępu
  • Aby uzyskać płatny dostęp do pełnej treści powyższego artykułu albo wszystkich artykułów (w zależności od wybranej opcji), należy wprowadzić kod.
  • Wprowadzając kod, akceptują Państwo treść Regulaminu oraz potwierdzają zapoznanie się z nim.
  • Aby kupić kod proszę skorzystać z jednej z poniższych opcji.

Opcja #1


  • dostęp do tego artykułu
  • dostęp na 7 dni

uzyskany kod musi być wprowadzony na stronie artykułu, do którego został wykupiony

Opcja #2


  • dostęp do tego i pozostałych ponad 7000 artykułów
  • dostęp na 30 dni
  • najpopularniejsza opcja

Opcja #3


  • dostęp do tego i pozostałych ponad 7000 artykułów
  • dostęp na 90 dni
  • oszczędzasz 28 zł
1. Agha ME, Eid M, Mansy H, Matarawy K: Preoperative MRI of perianal fistula: Is it really indispensable? Can it be deceptive? Alexandria J Med 2013 June; 49(2): 133-144. 2. Guillaumin E, Jeffrey RB, Shea WJ et al.: Perirectal inflammatory disease: CT findings. Radiology 1986; 161: 153-157. 3. Pickhardt PJ, Bhalla S, Balfe DM: Acquired gastrointestinal fistulas: Classification, etiologies and imaging evaluation. Radiology 2002; 224(1): 9-23. 4. Yousem DM, Fishman EK, Jones B: Crohn disease: perirectal and perianal findings at CT. Radiology 1988; 167: 331-334. 5. Kołodziejczak M, Kowalski B: Ropnie i przetoki odbytu – aktualne postępowanie diagnostyczne i terapeutyczne. Post Nauk Med 2006; 5: 183-187. 6. Julie A, Rizzo MD, Anna L, Naig MD: Anorectal Abscess and Fistula-in-Ano: Evidence-Based Management. Surg Clin N Am 2010; 90(1): 45-68. 7. Parks AG, Gordon PH, Hardcastle JD: A classification of fistula-in-ano. Br J Surg 1976; 63: 112. 8. Goodsall DH, Miles WE: Anorectal Fistula. Dis Colon Rectum 1982; 25: 262-278. 9. Torkzad MR, Karlbom U: MRI for assessment of anal fistula. Insights Imaging 2010; 1: 62-71. 10. Lindsey I, Humphreys MM, George BD et al.: The role of anal ultrasound in the management of anal fistulas. Colorectal Dis 2002; 4: 118-122. 11. Buchman GN, Halligan S, Bartman CL et al.: Clinical examination, endosonography, and MR imaging in preoperative assessment of fistula in ano: comparison with outcome-based reference standard. Radiology 2004; 233: 674-681. 12. Garcia-Aguilar J, Belmonte C, Wong WD et al.: Anal fistula surgery: factors associated with recurrence and incontinence. Dis Colon Rectum 1996; 39: 723-729. 13. Ratto C, Gentile E, Merico M et al.: How can the assessment of fistula-in-ano be improved? Dis Colon Rectum 2000; 43: 1375-1382. 14. Tanaka Y, Song JF, Katori R et al.: Comparison of accuracy of physical examination and endoanal ultrasonography for preoperative assessment in patients with acute and chronic anal fistula. Tech Coloproctol 2008; 12: 217-223. 15. Sygut A, Mik M, Trzcinski R, Dziki A: How the location of internal opening of anal fistulas affect the treatment results of primary transsphincteric fistulas? Langenbecks Arch Surg 2010; 395: 1055-1059. 16. Poen AC, Felt-Bersma RJF, EIjsbouts QAJ et al.: Hydrogen-peroxide-enhanced transanal ultrasound in the assessment of fistula-in-ano. Dis Colon Rectum 1998; 41: 1147-1152. 17. Sudoł-Szopińska I, Szczepkowski M, Panorska KA et al.: Comparison of contrast-enhanced with non-contrast endosonography in the diagnostics of anal fistulas. Eur Radiol 2004; 14: 2236-2241. 18. West RL, Zimmerman DDE, Dwarkasing S et al.: Prospective Comparison of Hydrogen Peroxide – Enhanced Tree-Dimensional Endoanal Ultrasonography and Endoanal Magnetic Resonance Imaging of Perianal Fistulas. Dis Colon Rectum 2003; 46: 1407-1415. 19. Siddiqui MR, Ashrafian H, Tozer P et al.: A Diagnostic Accuracy Meta-analysis of endoanal Ultrasound and MRI for Perianal Fistula Assessment. Dis Colon Rectum 2012 May; 55: 576-585. 20. Hagen SJ, Baeten CG, Soeters PB et al.: Staged mucosal advancement flap for the treatment of complex anal fistulas: pretreatment with noncutting setons and in case of recurrent multiple abscesses a diverting stoma. Colorectal Dis 2005; 7: 513-518. 21. Athanasiadis S, Helmes Ch, Yazigi R: The direct Closure of the internal fistula opening without advancement flap fo transsphinctreic fistulas-in-ano. Dis Colon Rectum 2004; 47: 1174-1180. 22. Nelson RL, Cintron J, Abcarian H: Dermal island-flap anoplasty for transsphincteric fistula-in-ano: assessment of treatment failures. Dis Colon Rectum 2000; 43: 681-684. 23. Zimmerman DD, Briel JW, Gosselink MP, Schouten WR: Anocutaneous advancement flap repair of transsphincteric fistulas. Dis Colon Rectum 2001; 44: 1474-1480. 24. Azizi R, Mohammadipour S: New Techniques in Anal Fistula Management. Annals of Colorectal Research 2014; 2(1): e17769. 25. Dietz DW: Role of fibrin glue in the management of simple and complex fistula in ano. J Gastrointest Surg 2006; 10: 631-632. 26. Cintron JR, Park JJ, Orsay CP et al.: Repair of fistulas-in-ano using fibrin adhesive: long-term follow-up. Dis Colon Rectum 2000; 43: 944-949. 27. Loungnarath R, Dietz DW, Mutch MG et al.: Fibrin glue treatment of complex anal fistulas has low success rate. Dis Colon Rectum 2004; 47: 432-436. 28. Buchanan GN, Bartram CI, Phillips RK: Efficacy of fibrin sealant in the management of complex anal fistula: a prospective trial. Dis Colon Rectum 2003; 46: 1167-1174. 29. Hanley PH: Reflections on anorectal abscess fistula: 1984. Dis Colon Rectum 1985; 28: 528-533. 30. Utynowski K, Rosen L, Stasik J et al.: Horseshoe abscess fistula: Seton treatment. Dis Colon Rectum 1990; 33: 602-605.
otrzymano: 2016-01-14
zaakceptowano do druku: 2016-02-17

Adres do korespondencji:
*Anna Wiączek
Warszawski Ośrodek Proktologii Szpital św. Elżbiety – Mokotowskie Centrum Medyczne
ul. Goszczyńskiego 1, 02-615 Warszawa
tel. +48 509-358-696
e-mail: anawia2@wp.pl

Nowa Medycyna 1/2016
Strona internetowa czasopisma Nowa Medycyna