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Anal Fistulotomy

Marcus Lester R. Suntay, MD, FPCS, FPSPS, FPALES1; Jaymie Ang Henry, MD, MPH2

1Philippine Children's Medical Center
2Florida Atlantic University, G4 Alliance


Fistula-in-ano is a chronic abnormal communication between the anal canal and, usually, the perianal skin. It can be described as a hollow tract that is lined with granulation tissue that connects a primary opening inside the anal canal to a secondary opening in the perianal skin. It originates from the anal glands and is frequently the result of a previous anal abscess. Anal fistulas present with pain, swelling, pruritus, skin irritation, and purulent or bloody drainage. Most anal fistulas are diagnosed based on clinical findings, but complex and deep anal fistulas usually require imaging studies such as CT scan or MRI to delineate the tract. Fistulas are categorized based on their relationship to the anal sphincter complex. An intersphincteric fistula tracks through the distal internal sphincter and intersphincteric space to an external opening near the anal verge. A trans-sphincteric fistula extends through both the internal and external sphincters. A suprasphincteric fistula originates in the intersphincteric plane and tracks up and around the entire external sphincter. An extrasphincteric fistula originates in the rectal wall and tracks around both sphincters to exit laterally, usually in the ischiorectal fossa. Currently, there is no medical treatment available and surgery is almost always necessary. A simple intersphincteric fistula can often be treated with fistulotomy (opening the fistulous tract) or fistulectomy (removing the fistulous tract), while transphincteric and suprasphincteric fistulas are treated by placement of a seton to maintain drainage and induce fibrosis. Extrasphincteric fistula treatment depends on the anatomy and etiology of the fistula. Here, we present the case of a 1-year-old male with a history of recurrent peri-anal infection, which led to the development of an anal fistula. The anal fistula was noted to be superficial and a fistulotomy was performed by threading the tract and then opening it up.

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