WHAT IS ANAL FISTULA?
Located in the breech channel, feces during the toilet softening and lubricating of the gland to provide softness, due to different causes of the secretion of the secretory channels and the development of infection. Emerging infection causes the formation of this region (anal abscess) or chronic abscess of the abscess and the formation of tunnel between the breech duct and the skin (anal fistula). It is a disease that is difficult to follow and treat for both our patients and us. Because the region is dirty and open to infection.
Hormonal causes are responsible for the development of the disease especially among the men.
There are two holes of the tunnel-shaped line (fistula traction). The inner mouth is the unseen starting point located inside the breech channel and the outer mouth is the end point located on the skin in the breech entrance and easily selectable from the outside. Although the length of the tunnels can vary from 2cm to 6-7 cm, the length of the current line that affects the course of the disease is its relation with the breech muscles.
WHAT ARE THE REASON OF ANAL FISTULA ?
It is often the infection of the glands in the anal canal, we can initiate the events like these :
- Anal trauma (during accident, injury, birth trauma or enema)
- Anal surgeries performed (interventions and surgical procedures due to hemorrhoids)
- Anal canal or rectal cancers (sometimes as a fistula!)
- Non-digestible, hard ingredients in food (fishbone, eggshell)
- After the radiotherapy applied to the last part of the intestine
- With inflammatory bowel diseases (chron and ulcerative colitis)
- It can be seen in patients with diabetes, HIV, tuberculosis and immunodeficiency.
WHAT ARE THE SYMPTOMS OF ANAL FISTULA ?
Generally, the patients' complaint; foul-smelling, yellow-colored discharge from the rectum and associated itching. It can be in the form of contamination in the laundry or sometimes with bleeding. Hardening due to chronic infection around the outer mouth and color change on the skin, the feeling of fullness in the rectum after defecation can be seen.
In case of severe pain, swelling and redness around the breech it is considered to be an anal abscess. This situation is urgent and should be surgically removed.
HOW TO DIAGNOSE ANAL FISTULA ?
The patient's history (current illnesses, surgeries) is very important for us. Generally, the diagnosis can be made with anal examination. The outer mouth around the breech entrance should be investigated, and after the external mouth is seen, the rectal button (finger examination) should be felt in the breech wall of the fistula. When this line is purged, it can be seen that there is a yellow discharge from the outer mouth.
Anoscopic examination is required for the evaluation of the inner mouth, but we prefer imaging methods in order to reveal the fistula line in every aspect. In this sense, the most common method is magnetic resonance imaging (MRI). For us, it is very important in this region to show its ablity, the length of the fistula line, how many, and its course (its relation to breech muscles). Sometimes MRI can also be performed by administering an external oral drug (contrast agent) during MRI (MR fistulography).
Another method for determining the inner mouth is under anesthesia. This examination, which is performed under general anesthesia especially in patients with complicated fistula, is both for diagnosis and treatment.
WHAT ARE THE TYPES OF ANAL FISTULA?
The course and location of the line are very important in the surgical success of this disease. Because in this region we have to protect, there are muscles that provide control of feces. In short, there are two muscle (sphincter) layers on the breech channel. The muscle that provides voluntary control that is located on the outside of them is the muscle that allows to keep the stool in unsuitable conditions, and to relax in the toilet. The channel where the fistula line is associated with these muscles is the part that makes work difficult. Because the surgical form to be made must be planned in advance and specific to the patient and protecting the muscles.
According to the anatomical relationship with the muscles and the course:
- The most common interspecific
- The second most commonTranssfincteric
SURGICAL DECISION ON ANAL FISTULA
After the name of the disease, surgery should be planned as soon as possible. If the patient remains unstable or postpone surgery, it is possible to complicate the treatment process by spreading the fistula and becoming complicated. In fact, many years of serious complaints ranging from chronic irritation to anal cancers can be seen in patients with complaints and without treatment for many years.
In patients with fistula, when the discharge is very intense, it is expected that the inflammation will regress by initiation of antibiotic treatment in the first stage and in this way the patient is prepared for surgery. In the meantime, the decrease in the flow, disappearance and the decline of complaints does not mean that the disease is treated.
In patients with fistula in the form of anal abscess, the patient should be surgically drained under local anesthesia or general anesthesia. (At least two weeks)
SURGICAL OPERATION IN ANAL FISTULA
In the treatment to be done, the gold standard is the elimination of the existing line and the protection of the muscle structures and the failure of the fecal control. FİLAC (FistulaLaserClosure, laser closure) technique is the most common method. Under spinal or general anesthesia, the inner mouth is determined by entering the anal canal with a speculum.
The fiber is then laser-terminated and the fistula line is closed by providing heat and light damage.
- No incision during surgery,
- Short operation time
- No complications such as feces and gas incontinence after surgery
- The patient may be discharged on the same day
- Minimal post-operative pain
- It is a safer option than classical methods because of short postoperative recovery period.
Another surgical method is fistulotomy. It is the method of opening the fistula line and leaving the body to its own healing process after cleaning the dirty area inside the tunnel. In general, it is preferred for short lines and uncomplicated fistulas.
Seton is a method applied in fistulas containing excess muscle tissue, which is not possible to remove or cut out the fistula line.
In loose seton application, it is passed through the fistula line using a non-absorbable material and is left there. The goal is to ensure that the current discharge and infection flows through the material and that the line is closed by means of a controlled repair process called the foreign body reaction.
In the case of cutter seton application, the material used is intended to be phased out once a week to gradually cut off the existing muscle tissue. The disadvantage is that the tightening process is painful.
After both seton and fistulotomy techniques, complications such as temporary or permanent loss of fecal and gas control and recurrence of the disease can be seen.