Surgery is the mainstay of treatment of anal fistulas. The surgical treatment of complex anal fistulas, particularly those involving a significant portion of the anal sphincter, or high fistulas, in which fistulotomy would compromise continence, is challenging. Patient choice focuses on a compromise between the risk of recurrence and the risk of impairment of continence.
Extrasphincteric fistulas can originate in a segment of sigmoid diverticular disease, or from terminal ileal–sigmoid Crohn’s disease, when abdominal resection of the affected part can be quite easy. However, if the fistula arises from the rectum itself, and especially when associated sepsis is marked, surgical management can be extremely challenging.
On the other hand we can also talk about rectovaginal fistula. It may arise after obstetric injury, perianal sepsis, in Crohn’s disease, and after radiation, malignancy or trauma including iatrogenic injury. A low anastomosis after an anterior resection or restorative proctocolectomy may fistulate to the vagina. Surgery for a rectovaginal fistula is difficult and success rates are modest, particularly in Crohn’s disease. Recurrence, a permanent stoma, dyspareunia, anal stenosis, and incontinence may all ensue.
In this lecture, Phil Tozer explains the different types of complex fistulas in colorectal pathology and the most appropriate treatments in each case to obtain the best results and benefits for each patient.