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Anorectal fistula

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Updated 2023 ESCP guidelines for the diagnosis and management of anorectal fistula.

Background

Overview

Definition
Anorectal fistula is defined as an abnormal, often infected, connection between the anal canal or rectum and the skin around the anus.
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Pathophysiology
The pathophysiology of anorectal fistula typically involves an initial infection of the anal glands, which can lead to the formation of an abscess. If the abscess ruptures, it can create a pathway or fistula between the inside of the anus or rectum and the skin surface.
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Epidemiology
The prevalence of anorectal fistula in Europe is estimated at 10-20 per 100,000 person-years.
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Risk factors
Risk factors for anorectal fistulas include IBD, specifically Crohn's disease, and a history of anorectal abscesses. Certain infections, such as tuberculosis, Actinomyces species infection, and Chlamydia species infection, are also associated with the development of anorectal fistulas.
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Disease course
Clinically, patients with anorectal fistula often present with persistent perianal discharge, pain, and recurrent abscesses.
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Prognosis and risk of recurrence
The prognosis of anorectal fistula is variable. While treatment can lead to symptom relief, the condition may recur.
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Guidelines

Key sources

The following summarized guidelines for the evaluation and management of anorectal fistula are prepared by our editorial team based on guidelines from the European Society of Coloproctology (ESCP 2023), the American Society of Colon and Rectal Surgeons (ASCRS 2022), the American College of Radiology (ACR 2021), the World Society of Emergency Surgery (WSES/AAST 2021), the American College of Gastroenterology (ACG ...
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Diagnostic investigations

History and physical examination: as per ESCP 2023 guidelines, elicit history and perform a clinical examination in patients with anal fistula to assess for other causes of fistula formation.
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  • Diagnostic imaging

  • Anal manometry

  • Evaluation for Crohn's disease

Diagnostic procedures

Examination under anesthesia: as per ESCP 2023 guidelines, do not perform examination under anesthesia alone as a diagnostic tool in patients with complex fistula, as MRI and endoanal ultrasound are superior to this approach.
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Therapeutic procedures

Seton placement, cutting: as per ESCP 2023 guidelines, do not use cutting setons for the management of patients with simple
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or high anal fistulas.
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  • Seton placement (loose)

  • Seton placement (bridging)

  • Seton placement (palliative)

  • Rerouting

  • Fistula plugging

  • Fibrin glue injection

  • Collagen injection

  • Platelet-rich plasma injection

  • Autologous stem cell injection

  • Video-assisted anal fistula treatment

  • Laser ablation of fistula tract

  • Over-the-scope clips

Perioperative care

Preoperative care: as per ESCP 2023 guidelines, assess and discuss modifiable risk factors for poor wound healing, such as smoking, diabetes, and obesity, with patients before attempting reparative surgery.
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  • Postoperative care

Surgical interventions

Fistulotomy: as per ESCP 2023 guidelines, perform fistulotomy in patients with intersphincteric or low transsphincteric anal fistula and normal preoperative continence, following a thorough assessment of fistula anatomy, symptomatology, involvement of sphincters, risk of incontinence, and exploration of patient expectations.
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  • Endoanal advancement flap repair

  • Anocutaneous advancement flap repair

  • Ligation of intersphincteric fistula tract

  • Fistulectomy with primary reconstruction

  • Suture repair of internal opening

  • Defunctioning stoma

Specific circumstances

Patients with concomitant anorectal abscess: as per ASCRS 2022 guidelines, consider performing concomitant fistulotomy along with abscess drainage in selected patients with anorectal abscess and simple anal fistula.
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  • Patients with Crohn's disease

Preventative measures

Primary prevention: as per ESCP 2023 guidelines, do not perform immediate fistulotomy at incision and drainage of an acute perianal abscess.
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