Anal fistula definition

Definition

Anal fistula definition

A fistula is an abnormal communication between two bodies which normally do not communicate between them.

An anal fistula makes communicate the interior of the anal channel with the skin of the anal margin by a kind of tunnel which walks on through the muscles of

the anus (sphincters) to open with the skin by an opening called external opening (or secondary opening)

It is the infection small glands located inside the anus (loafs about of Hermann and Desfosses) at the origin of a dent.

One does not know in a precise way why these glands are infected.

It should well be understood that the starting point is in the anal channel: one speaks about internal opening or primary education opening.

The initial infection gives a small abscess located between the sphincter intern and the external sphincter.

From there, the fistula can cross the external sphincter to various heights.

• Fistula trans sphinctérienne low: if the crossing is done of the lower part of the muscle
• Fistula trans sphinctérienne high: so more half of the muscle (or even its totality) is interested
• Horseshoe dent: the way can pass on the side opposed by precise anatomical spaces

In other cases, instead of crossing the external sphincter, the dent goes up in the space located between the two muscles.

One speaks then about abscess inter-sphinctérien or intra-mural.

Clinical manifestation

The clinical shapes of anal fistula

• Acute form: abscess
• Chronic form : flow

There exist two principal aspects: an acute form which are an abscess and a chronic form which is a simple flow

Acute form: abscess

L’abcès appears by a pain located with part of the anus.

A particular form is carried out by the abscess inter sphinctérien (or intra-mural) which gives a very high pain in the rectum, without size on the level of the anal margin and with very often of the urinary disorders.

The examination, in this shape of abscess, is very painful and will seek to evaluate the importance of this abscess and if required to find the primary education opening. These abscesses, which they are incised or that they opened spontaneously, will evolve to a chronic form with a flow sometimes intersected with pushed retention realizing of new abscesses.

The chronic form: the flow

It can settle from the start or succeed an incised abscess or evacuee spontaneously.

There exists a more or less purulent flow by one or more openings located on the skin of the anus: one speaks about external opening or secondary opening.

In the typical case of the horseshoe dent, there is an opening on each side of the line of centers.

The complementary examinations are useful only in certain forms, in particular, endo-anal echography and the MRI can be required in polish-operated or complicated forms.

The surgeon makes the examination under general anaesthesia. He will try to specify the height of the way and to find the opening primary education responsible for this fistula.

Anal fistula treatment

Treatment

Anal fistula treatment

The anal dents make communicate the interior of the anus with the skin périanale. The results of the surgery are very satisfactory:  rate repeats from 1 to 2%.

• I surgical principle: to cure the dent (or less to reduce the rate of repetition)
•  II surgical principle: to avoid anal incontinence

At the stage of the abscess, most important is to relieve the pain by evacuating the pus by an incision.  But remains to treat the dent.

The treatment of the anal dent is currently surgical and obeys two requirements: to cure the dent and to preserve the anal continence since the muscles which ensure this continence are crossed by the dent.

This is why, in certain forms, one will be obliged to proceed in several operational times.

1°) low dents

It do not require qu ` only one operation.

One locates the way and the primary education opening by a dye injected by the opening interns and one removes it to the muscle which is simply divided.

The post-operative care is simple, there is not or little pain.

This intervention can be done either with 48 hours a short hospitalization, or into ambulatory.

The cicatrization can take eight weeks.

The complications are very rare (hypocontinence with gases in approximately 1% of the cases).

The repetition in the centers accustomed to this kind of surgery is approximately 1%.

2°) higher dents

It are rarer and must be operated twice after a free interval of approximately 2 months.

In the first operation, one withdraws the way to the muscle on which one places a wire without traction (the seton).

The post-operative care is twice-daily with cleaning of the wound and the average duration of hospitalization is from 2 to 3 days.

There still, one follows the patient until cicatrization supplements .et at this time there, one will be able to practise the second intervention.

It consists is in a progressive section of the muscle by the wire which is tight the every 8-10 days, that is to say by a direct section.

The complications are not very frequent: seepages in 2% of the cases, hypocontinence to gases and urgency to go to the saddle when they are liquid in 11%. These problems regress with time.

The repetition is approximately 2% in the dedicated services or having the habit of this kind of surgery.

3°) typical cases

The horseshoe dent requires sometimes three operations, the intra-mural dent is open towards the interior of the rectum.

Lastly, certain particularly complex or polyopérées dents do not have systématisable treatment.

Techniques of safeguarding sphinctérienne

It is always shocking to cut a muscle which has an important function.

This is why, of research are directed towards the conservation of the muscle in the treatment of the anal dents.

 the scrap of advance (flap):

The way is removed to the muscle and to the level of the rectum, one lowers a muco-muscular scrap to cover the primary education opening. The currently available results are unmatched and this technique still requires other studies.

The use of adhesive biological

 One injects a “adhesive” in the sinus way for the butcher.

The results are still preliminary, promising in the simple dents.