Diagnosis and treatment of incomplete internal rectal fistulas

Aim of review. To present literature data on diagnosis and treatment of incomplete internal rectal fistulas. Summary. Incomplete internal rectal fistulas is an insufficiently studied «niche» in proctology. First of all, the definition itself is a terminological void which does not permit definition of these fistulas as a separate nosological entity. Second, as difficult diagnostic procedures are required (due to the absence of external orifice) preoperative assessment of the structure of fistulous tract is complicated. In regards to this the standard treatment of these fistulous does not exist. According to literature data, the frequency of recurrence of incomplete internal fistulous ranges from 8 to 22%. Conclusion. The literature analysis demonstrated that there is a small number of publications in which this problem is considered. Because of lack of classification of this pathology there is no uniform treatment approach which would allow to decrease the risk of relapses, and maintain retention function as well.

неполный внутренний свищ пря-мой кишки, иссечение свища, ликвидация свища, сегментарная проктопластика, LIFT, межсфинктер-ный абсцесс, супрасфинктерный абсцесс, магнит-но-резонансная томография, ультразвуковое иссле-дование, аноректальная манометрия

1. Аминев А.М. Руководство по проктологии. М., 1973; 3:163-345

2. Блинничев Н.М. Острый и хронический парапроктит (этиология, патогенез, клиника, диагностика, новое в оперативном лечении): Дис. … д-ра мед. наук. - 1972.

3. Дульцев Ю.В., Саламов К.Н. Парапроктит. М.; 1981

4. Eisenhammer S. The final evaluation and classification of the surgical treatment of the primary anorectal cryptoglandular intermuscular (intersphincteric) fistulous abscess and fistula. Dis Colon Rectum 1978; 21(4):237-54.

5. Marks C. G., Ritchie J.K. Anal fistulas at St Mark’s Hospital. Br J Surg 1977; 64(2):84-91.

6. Sainio P. Fistula-in-ano in a defined population. Incidence and epidemiological aspects. Ann Chir Gynaec 1984; 73(4):219-24.

7. Zanotti C. et al. An assessment of the incidence of fistulain-ano in four countries of the European Union. Int J Colorectal Dis 2007; 22(12):1459-62.

8. Предыбайло С.М. Хирургическое лечение неполных внутренних свищей прямой кишки: Дис. … канд. мед. наук. 1990

9. Иброхимов Ю.Х. Диагностика и лечение неполных внутренних свищей прямой кишки: Дис. канд. мед. наук, 2015.

10. Barwood N. et al. Fistula-in-ano: a prospective study of 107 patients. Austral and New Zealand J Surg 1997;67(23):98-102.

11. Kim J.W. et al. Comparative review of perianal sinus & fistula in ano. J Korean Soc Coloproctol 2000; 16(1):7-11.

12. Gupta P.J. A study of suppurative pathologies associated with chronic anal fissures. Tech Coloproctol 2005; 9(2):104-7.

13. Ommer A. et al. Cryptoglandular anal fistulas. Dtsch Ärzteblatt Int 2011; 108(42): 707-13.

14. Bock J.U., Jongen J. The anal fissure-conventional therapy. FALK SYMPOSIUM. Dordrecht; London: Kluwer Academic; 1999, 2001.

15. Naldini G. et al. Hiding intersphincteric and transphincteric sepsis in a novel pathological approach to chronic anal fissure. Surg Innovation 2012; 19(1): 33-6.

16. Wang D. et al. Risk factors for anal fistula: a case-control study. Tech Coloproctol 2014; 18(7):635-9.

17. Jackman R.J. Operation for anal fistulas: Some reasons for failures. Am J Surg 1945; 68(3):323-5.

18. Parks A.G., Gordon P.H. A classification of fistula-inano. Br J Surg 1976; 63: 1-12.

19. Abou-Zeid A.A. Anal fistula: Intraoperative difficulties and unexpected findings. World J Gastroenterol 2011; 17(28): 3272-6.

20. Орлова Л.П., Тихонов А.А., Титов А.Ю., Чубаров Ю.Ю., Полякова Н.А. Ультразвуковой и рентгенологический методы исследования в диагностике экстрасфинктерных свищей прямой кишки. Ультразвуковая и функциональная диагностика 2012; 1:24-31.

21. Pinsk I., Seppala R., Friedlich M.S. Anography: a technique for determining the location of the internal opening in perianal fistula. Colorectal Dis 2010; 12(9):896-900.

22. Brillantino A. et al. Role of tridimensional endoanal ultrasound (3D-EAUS) in the preoperative assessment of perianal sepsis. Int J Colorectal Dis 2015; 30(4): 535-42.

23. Toyonaga T. 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(3):217-23.

24. Wedemeyer J. et al. Transcutaneous perianal sonography: a sensitive method for the detection of perianal inflammatory lesions in Crohn’s disease. World J Gastroenterol 2004; 10(19):2859-63.

25. Youssef A.T. Imaging Classification of Perianal Fistula Using the Ultrasound. J Gastroenterol Hepatol Res 2015; 4(6):1653-9.

26. Garcia-Granero A. et al. Management of cryptoglandular supralevator abscesses in the magnetic resonance imaging era: a case series. Int J Colorectal Dis 2014;29(12):155764.

27. Siddiqui M.R.S. et al. A diagnostic accuracy meta-analysis of endoanal ultrasound and MRI for perianal fistula assessment. Dis Colon Rectum 2012; 55(5):576-85.

28. Arroyo A. et al. Fistulotomy and sphincter reconstruction in the treatment of complex fistula-in-ano: long-term clinical and manometric results. Ann Surg 2012; 255(5):935-9.

29. Jordán J. et al. Risk factors for recurrence and incontinence after anal fistula surgery. Colorectal Dis 2010;12(3): 254-60.

30. Toyonaga T. et al. Factors affecting continence after fistulotomy for intersphincteric fistula-in-ano. Int J Colorectal Dis 2007; 22(9):1071-5.

31. Visscher A.P. et al. Long-term Follow-up After Surgery for Simple and Complex Cryptoglandular Fistulas: Fecal Incontinence and Impact on Quality of Life. Dis Colon Rectum 2015; 58(5):533-9.

32. Roig J.V. et al. Changes in anorectal morphologic and functional parameters after fistula-in-ano surgery. Dis Colon Rectum 2009; 52(8):1462-9.

33. Vial M. et al. Faecal incontinence after seton treatment for anal fistulae with and without surgical division of internal anal sphincter: a systematic review. Colorectal Dis 2010; 12(3):172-8.

34. Chang S.C., Lin J.K. Change in anal continence after surgery for intersphincteral anal fistula: a functional and manometric study. Int J Colorectal Dis 2003; 18(2):111-5.

35. Gabriel W.B. The treatment of pruritus ani and anal fissure. Br Med J 1930; 2(3634):311.

36. Bernard D., Tasse D., Morgan S. High intermuscular anal abscess and fistula: analysis of 25 cases. Can J Surg 1983 Mar.; 26(2):136-9.

37. GÖttgens K.W.A. et al. Long-term outcome of low perianal fistulas treated by fistulotomy: a multicenter study. Int J Colorectal Dis 2015; 30(2):213-9.

38. Hirschburger M. et al. Fistulectomy with primary sphincter reconstruction in the treatment of high transsphincteric anal fistulas. Int J Colorectal Dis 2014; 29(2):247-52.

39. Elting A.W.X. The treatment of fistula in ano: with especial reference to the whitehead operation. Ann Surg 1912; 56(5):744-52.

40. Ramirez A., Virgilio A. Fistulas anorrectales: tratamiento quirurgico con el metodo de Robles y Picot: experiencia personal. Prensa Med Argent 1985; 72(15):511-4.

41. Kirschner M. Die Eingriffe am Mastdarm. Die Eingriffe in der Bauchhohle. Berlin-Heidelberg: Springer-Verlag 1951. 551 p.

42. Rojanasakul A. LIFT procedure: a simplified technique for fistula-in-ano. Tech Coloproctol 2009; 13(3):237-40.

43. Van Onkelen R.S., Gosselink M.P., Schouten W.R. Treatment of anal fistulas with high intersphincteric extension. Dis Colon Rectum 2013; 56(8):987-91.

44. Tan K.K., Koh D.C., Tsang C.B. Managing deep postanal space sepsis via an intersphincteric approach: our early experience. Ann Coloproctol 2013; 29(2):55-9.

45. Garcia-Granero A. et al. The use of an endostapler in the treatment of supralevator abscess of intersphincteric origin. Colorectal Dis 2014; 16(9):O335-O338.

46. Millan M., Garcia-Granero E., Esclápez P. et al.

47. Management of intersphincteric abscesses. Colorectal Dis 2006; 8(9):777-80.

48. GÖttgens K.W.A. et al. Systematic review and metaanalysis of surgical interventions for high cryptoglandular perianal fistula. Int J Colorectal Dis 2015; 30(5):583-93.

49. Kelly M.E. et al. The role of loose seton in the management of anal fistula: a multicenter study of 200 patients. Tech Coloproctol 2014; 18(10):915-9.

50. Singh M.P. et al. New approach to anorectal sinus disease.

51. Lentner A., Volker W. Long-term, indwelling setons for low transsphincteric and intersphincteric anal fistulas. Dis Colon Rectum 1996; 39(10):1097-101.

52. Garg P., Garg M. PERFACT procedure: A new concept to treat highly complex anal fistula. World J Gastroenterol 2015; 21(13):4020-9.

53. de Parades V. et al. Horseshoe tract of anal fistula: bad luck or an avoidable extension? Lessons from 82 cases. Colorectal Dis 2012; 14(12):1512-5. Koehler A., Risse-Schaaf A., Athanasiadis S. Treatment for horseshoe fistulas-in-ano with primary closure of the internal fistula opening: a clinical and manometric study. Dis Colon Rectum 2004; 47(11):18

54. Аминев А.М. Руководство по проктологии. М., 1973; 3:163-345

55. Блинничев Н.М. Острый и хронический парапроктит (этиология, патогенез, клиника, диагностика, новое в оперативном лечении): Дис. … д-ра мед. наук. - 1972.

56. Дульцев Ю.В., Саламов К.Н. Парапроктит. М.; 1981

57. Eisenhammer S. The final evaluation and classification of the surgical treatment of the primary anorectal cryptoglandular intermuscular (intersphincteric) fistulous abscess and fistula. Dis Colon Rectum 1978; 21(4):237-54.

58. Marks C. G., Ritchie J.K. Anal fistulas at St Mark’s Hospital. Br J Surg 1977; 64(2):84-91.

59. Sainio P. Fistula-in-ano in a defined population. Incidence and epidemiological aspects. Ann Chir Gynaec 1984; 73(4):219-24.

60. Zanotti C. et al. An assessment of the incidence of fistulain-ano in four countries of the European Union. Int J Colorectal Dis 2007; 22(12):1459-62.

61. Предыбайло С.М. Хирургическое лечение неполных внутренних свищей прямой кишки: Дис. … канд. мед. наук. 1990

62. Иброхимов Ю.Х. Диагностика и лечение неполных внутренних свищей прямой кишки: Дис. канд. мед. наук, 2015.

63. Barwood N. et al. Fistula-in-ano: a prospective study of 107 patients. Austral and New Zealand J Surg 1997;67(23):98-102.

64. Kim J.W. et al. Comparative review of perianal sinus & fistula in ano. J Korean Soc Coloproctol 2000; 16(1):7-11.

65. Gupta P.J. A study of suppurative pathologies associated with chronic anal fissures. Tech Coloproctol 2005; 9(2):104-7.

66. Ommer A. et al. Cryptoglandular anal fistulas. Dtsch Ärzteblatt Int 2011; 108(42): 707-13.

67. Bock J.U., Jongen J. The anal fissure-conventional therapy. FALK SYMPOSIUM. Dordrecht; London: Kluwer Academic; 1999, 2001.

68. Naldini G. et al. Hiding intersphincteric and transphincteric sepsis in a novel pathological approach to chronic anal fissure. Surg Innovation 2012; 19(1): 33-6.

69. Wang D. et al. Risk factors for anal fistula: a case-control study. Tech Coloproctol 2014; 18(7):635-9.

70. Jackman R.J. Operation for anal fistulas: Some reasons for failures. Am J Surg 1945; 68(3):323-5.

71. Parks A.G., Gordon P.H. A classification of fistula-inano. Br J Surg 1976; 63: 1-12.

72. Abou-Zeid A.A. Anal fistula: Intraoperative difficulties and unexpected findings. World J Gastroenterol 2011; 17(28): 3272-6.

73. Орлова Л.П., Тихонов А.А., Титов А.Ю., Чубаров Ю.Ю., Полякова Н.А. Ультразвуковой и рентгенологический методы исследования в диагностике экстрасфинктерных свищей прямой кишки. Ультразвуковая и функциональная диагностика 2012; 1:24-31.

74. Pinsk I., Seppala R., Friedlich M.S. Anography: a technique for determining the location of the internal opening in perianal fistula. Colorectal Dis 2010; 12(9):896-900.

75. Brillantino A. et al. Role of tridimensional endoanal ultrasound (3D-EAUS) in the preoperative assessment of perianal sepsis. Int J Colorectal Dis 2015; 30(4): 535-42.

76. Toyonaga T. 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(3):217-23.

77. Wedemeyer J. et al. Transcutaneous perianal sonography: a sensitive method for the detection of perianal inflammatory lesions in Crohn’s disease. World J Gastroenterol 2004; 10(19):2859-63.

78. Youssef A.T. Imaging Classification of Perianal Fistula Using the Ultrasound. J Gastroenterol Hepatol Res 2015; 4(6):1653-9.

79. Garcia-Granero A. et al. Management of cryptoglandular supralevator abscesses in the magnetic resonance imaging era: a case series. Int J Colorectal Dis 2014;29(12):155764.

80. Siddiqui M.R.S. et al. A diagnostic accuracy meta-analysis of endoanal ultrasound and MRI for perianal fistula assessment. Dis Colon Rectum 2012; 55(5):576-85.

81. Arroyo A. et al. Fistulotomy and sphincter reconstruction in the treatment of complex fistula-in-ano: long-term clinical and manometric results. Ann Surg 2012; 255(5):935-9.

82. Jordán J. et al. Risk factors for recurrence and incontinence after anal fistula surgery. Colorectal Dis 2010;12(3): 254-60.

83. Toyonaga T. et al. Factors affecting continence after fistulotomy for intersphincteric fistula-in-ano. Int J Colorectal Dis 2007; 22(9):1071-5.

84. Visscher A.P. et al. Long-term Follow-up After Surgery for Simple and Complex Cryptoglandular Fistulas: Fecal Incontinence and Impact on Quality of Life. Dis Colon Rectum 2015; 58(5):533-9.

85. Roig J.V. et al. Changes in anorectal morphologic and functional parameters after fistula-in-ano surgery. Dis Colon Rectum 2009; 52(8):1462-9.

86. Vial M. et al. Faecal incontinence after seton treatment for anal fistulae with and without surgical division of internal anal sphincter: a systematic review. Colorectal Dis 2010; 12(3):172-8.

87. Chang S.C., Lin J.K. Change in anal continence after surgery for intersphincteral anal fistula: a functional and manometric study. Int J Colorectal Dis 2003; 18(2):111-5.

88. Gabriel W.B. The treatment of pruritus ani and anal fissure. Br Med J 1930; 2(3634):311.

89. Bernard D., Tasse D., Morgan S. High intermuscular anal abscess and fistula: analysis of 25 cases. Can J Surg 1983 Mar.; 26(2):136-9.

90. GÖttgens K.W.A. et al. Long-term outcome of low perianal fistulas treated by fistulotomy: a multicenter study. Int J Colorectal Dis 2015; 30(2):213-9.

91. Hirschburger M. et al. Fistulectomy with primary sphincter reconstruction in the treatment of high transsphincteric anal fistulas. Int J Colorectal Dis 2014; 29(2):247-52.

92. Elting A.W.X. The treatment of fistula in ano: with especial reference to the whitehead operation. Ann Surg 1912; 56(5):744-52.

93. Ramirez A., Virgilio A. Fistulas anorrectales: tratamiento quirurgico con el metodo de Robles y Picot: experiencia personal. Prensa Med Argent 1985; 72(15):511-4.

94. Kirschner M. Die Eingriffe am Mastdarm. Die Eingriffe in der Bauchhohle. Berlin-Heidelberg: Springer-Verlag 1951. 551 p.

95. Rojanasakul A. LIFT procedure: a simplified technique for fistula-in-ano. Tech Coloproctol 2009; 13(3):237-40.

96. Van Onkelen R.S., Gosselink M.P., Schouten W.R. Treatment of anal fistulas with high intersphincteric extension. Dis Colon Rectum 2013; 56(8):987-91.

97. Tan K.K., Koh D.C., Tsang C.B. Managing deep postanal space sepsis via an intersphincteric approach: our early experience. Ann Coloproctol 2013; 29(2):55-9.

98. Garcia-Granero A. et al. The use of an endostapler in the treatment of supralevator abscess of intersphincteric origin. Colorectal Dis 2014; 16(9):O335-O338.

99. Millan M., Garcia-Granero E., Esclápez P. et al.

100. Management of intersphincteric abscesses. Colorectal Dis 2006; 8(9):777-80.

101. GÖttgens K.W.A. et al. Systematic review and metaanalysis of surgical interventions for high cryptoglandular perianal fistula. Int J Colorectal Dis 2015; 30(5):583-93.

102. Kelly M.E. et al. The role of loose seton in the management of anal fistula: a multicenter study of 200 patients. Tech Coloproctol 2014; 18(10):915-9.

103. Singh M.P. et al. New approach to anorectal sinus disease.

104. Lentner A., Volker W. Long-term, indwelling setons for low transsphincteric and intersphincteric anal fistulas. Dis Colon Rectum 1996; 39(10):1097-101.

105. Garg P., Garg M. PERFACT procedure: A new concept to treat highly complex anal fistula. World J Gastroenterol 2015; 21(13):4020-9.

106. de Parades V. et al. Horseshoe tract of anal fistula: bad luck or an avoidable extension? Lessons from 82 cases. Colorectal Dis 2012; 14(12):1512-5. Koehler A., Risse-Schaaf A., Athanasiadis S. Treatment for horseshoe fistulas-in-ano with primary closure of the internal fistula opening: a clinical and manometric study. Dis Colon Rectum 2004; 47(11):18

107. Koehler A., Risse-Schaaf A., Athanasiadis S. Treatment for horseshoe fistulas-in-ano with primary closure of the internal fistula opening: a clinical and manometric study. Dis Colon Rectum 2004; 47(11):1874-82.