50 year old male patient after a car accident, multiple abdominal and pelvic surgeries with a stoma presents an anal fistula 5cm higher from the anal verge in the rectum. I am most interested in experienced trauma and anal surgeons treatment options.
Scenario - traumatic anal fistula originating from the rectum with multiple prior operations
My suggestion - One can try an anal plug with closing the inner opening of the fistula; lift-procedure is an alternative.
This is a complex anal fistula. All surgical techniques may be used but the last technique will be the Sutton procedure (loose or tied).
I would like to express my gratitude to all my colleaugues and especially to Prof. Tsimoyiannis for their contributions.
What kind of fistula is it? What do you know about the topography? How is the sphinkter function? What are the symptoms? I do not think that it is possible to recommend any treatment knowing only the height of the internal opening, if I correctly understand your question...
Considering the worst case scenario, with too much compromise of the sphincteric apparatus, maybe even compromising the puborectalis sling, I would choose a mucosal advancement flap to obliterate the region of the excised internal opening. The fistula tract, after being curettage, would be left to heal secondarily.
I am not clear whether MR fisulgram was done or not ,This delineates the anatomical details.Then proceed accordingly as discussed. I would prefer a staged procedure starting with VAFT,
It is a complex high intersphincteric post traumatic fistula and MR fistulagram is not feasible in our hospital, but a simple MRI of the has revealed the anatomy adequately. The sphincteric function is not compromised, and mucus is present daily from the perineal stoma of the fistula.
In my experience this will need an abdomino-anal pull-through procedure as recently written up by Patsouras in Colorectal disease. I do not think any local approach will succeed.
Dear Sirs,
I am quite satisfied from your contributions in such a difficult topic, and I was interested in reading the latest recommendation by Prof. Phillips citing Dr. Patsouras recent publication on similar issues.
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