Introduction

Article Outline

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Complex anorectal fistula is probably the most frustrating and challenging pathology in colorectal surgery. It has plagued mankind since the sun came up and continues to baffle and frustrate us even in the 21st century.

Locating the primary opening is the most critical and difficult part of any fistula surgery. Failure to accomplish this condemns any procedure to failure. Accurately assessing the depth of a fistula tract—even under anesthesia—is inexact. In the absence of fixed landmarks, estimating whether the tract traverses two-thirds, one-third, or any external sphincter at all is subjective at best.

In the current issue, the Saint Marks radiology group provides the state of the art of imaging fistulas, to identify the primary opening, assess the depth of the fistula, and identify side tracts. Despite sophisticated imaging, surgically locating the primary opening, the prerequisite to closing any fistula, can still be extremely difficult.

The University of California San Francisco group summarizes the role of fistulotomy, the most appropriate procedure for superficial fistulas. However, for deep, complex fistulas, fistulotomy is not an option at all. Treatment of deep, complex fistulas boils down to a risk-benefit equation of addressing symptoms vs the risk of incontinence. It is not just a patient outcome issue but also the most common complaint in medicolegal suits in colorectal surgery. Therefore, we need to be innovative and creative to preserve the sphincter mechanism and address symptoms. We must also remember that the sphincter mechanism in fistula disease is anatomically and functionally normal, so why are we so anxious to divide it? Enter the era of sphincter-preserving fistula surgery.

The Imperial College, London colorectal group relates the history of glues for fistula. A simple and sensible innovation, fibrin glue has not withstood the test of time. The role of glues and pastes remains to be seen, but when treating complex fistulas, no option should be ignored. The Cleveland Clinic summarizes the use of flaps, the best option for through-and-through rectovaginal fistulas, but for anorectal fistulas successful flaps can be technically difficult and result in a surprisingly high incidence of anorectal incontinence.

New voices have also been added to the debate. Dr Mike Hiles from the Department of Veterinary Medicine at Purdue University has added a unique and innovative article on the use of biologics in surgery, a burgeoning class of surgical materials. The role of biologics in medicine is expanding: anti-TNF for Crohn's disease; probiotics for pouchitis; and human/animal tissue grafts for contaminated wounds and fistula.

The plug is a “first-in-class” device which is conceptually simple, but like any new device, refinements in technique and patient management continue to evolve. The Case Western University colorectal group summarizes the United States experience with the plug; Drs Schwandner, Fuerst, and Herold (Germany) relate the European perspective and Dr Pankaj Garg (India) relates the view from the East. The plug is not a panacea, but an additional option, when good options are often too few and far between. No one device or surgery will “cure” all fistulas, and no option should be dismissed. Rather, we need multiple options to address what remains one of the most complex and difficult surgical challenges. Each of these authors provides safe, sensible, and logical additions to an evolving algorithm for treatment of complex fistula.

Dr Neal Ellis from the University of South Alabama pulls all the options together as it relates to rectovaginal fistula, an area where sphincter preservation is a necessity not an option.

When all else fails, we resort to the oldest of treatments for fistula … setons … a “safe harbor” from the storms of failed fistula procedure, only to find that there is sometimes no shelter from the storm. Cutting setons result in major anorectal incontinence in a large proportion of cases and draining setons frequently fail to prevent recurrent sepsis. Drs Christopher Byrne and Michael Solomon from Sydney, Australia detail the history of setons in all their forms, from ancient history to the current day.

Hopefully, the plug has stimulated new debate and sparked new interest in a field where morale was flagging. This is good. Hopefully, new and innovative techniques will continue to evolve and provide more options for all of us. This is, after all, the purpose of surgical research.