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Abstract
Complex anal fistulas include those with previous repeated recurrences, underlying specific pathology, irregular main track with multiple suppurative spaces, branched, spiral and horse-shoe fistulae, high fistulas (supra and extra-sphincteric), and fistulas with supra-levator extension.
While the majority of fistulas are cryptoglandular in origin, trauma, Crohn’s disease, malignancy, radiation, or unusual infections (tuberculosis, Schistosomiasis, actinomycosis) may also produce fistulas. A complex, recurrent, or nonhealing fistula should raise the suspicion of one of these diagnoses.
Among the various classifications of anal fistula, the one described by Parks et al. is the one most widely used in clinical practice.
Patients present with persistent drainage from the internal and/or external openings. An indurated track is often palpable. Identification of the external and internal openings is determined by Goodsall’s law.
Examination under anesthesia, endoanal ultrasound and MRI are important modalities for diagnosis of complex fistulae. Colonoscopy may be needed for diagnosis of Crohn’s disease.
Various procedures are used for treatment of anal fistula including fistulotomy, fistulectomy, advancement flap, anal fistula plug and seton with various rates of incontinence and recurrence.
Treatment of complex anal fistulas is one of the most challenging aspects of colorectal surgery. Complex fistulas should be treated by an experienced coloproctologist particularly when they are associated with Crohn’s disease (level of evidence: level IV, grade GP).
In this thesis we studied the results of management of complex anal fistula in terms of preoperative, operative and post operative clinico-pathological variables in100 patients admitted to the Unit of Colorectal Surgery – Alexandria Main University Hospital.
The recurrence rate found in the present study was 11%. This conforms to recurrence rates reported in the literature.
On assessment of the risk factors for recurrence in our series, we found that increasing complexity of fistula (the presence of horseshoeing of tracks, multiple external openings or high blind tracks) and presence of Crohn’s disease associated with increasing risk of recurrence so successful surgical treatment of fistula-in-ano requires recognition of internal and external openings and the track or tracks connecting them.
Lack of identification of primary fistulous opening was strongly associated with recurrence.
There was no significant difference between fistulotomy and seton as regards recurrence and incontinence.
In our series complaints about disorders of continence have been reported in 15% of patients and there were no patients with major degree of postoperative incontinence. This result was within the reported ranges.
In our study we found that there