Definition & Overview
A fistulectomy is a surgical procedure performed for the treatment of a fistula, an abnormal connection between two hollow or tubular organs such as intestines and blood vessels. Although fistulas can develop in different parts of the body, a fistulectomy is more commonly performed on patients with an anal fistula, which forms in between the skin near the anus and the end of the bowel.
A fistulectomy is different from a fistulotomy. The latter simply involves cutting the fistulous tract open to facilitate healing while the former involves cutting it out completely. Between the two procedures, fistulectomy is deemed more effective, but fistulotomy comes with a shorter recovery period and lower risk of complications.
Who Should Undergo and Expected Results
Fistulectomy is the primary treatment recommended for patients with an anal fistula, also medically known as fistula-in-ano.
An anal fistula refers to an inflammatory tract that develops in the anal region, usually originating in the anal canal leading up to the surface of the skin and creating a visible opening. It commonly occurs when the outlet of the anal glands, which are located in between the internal and external anal sphincters, are blocked. If this happens, an abscess may develop and form an abnormal tract. Fistulas may also develop due to an existing inflammatory bowel disease or malignancy.
Anal fistulas are not generally harmful to a person’s health but can cause a lot of discomfort, itching, and irritation. They can also be very painful, cause bloody or purulent discharge, and even cause the patient’s stool to pass through the fistula, which can raise the risk of developing potentially widespread or systemic infections. This prompts most patients to seek surgical intervention.
A fistulectomy is one of several treatment methods used to resolve fistulas. Patients who undergo the procedure have a higher chance of permanently recovering from their condition, as opposed to the use of a drainage seton, fistula plug, or fistulotomy. The procedure is also expected to completely resolve associated symptoms including chronic diarrhea and incontinence.
How is the Procedure Performed?
Prior to undergoing a fistulectomy, patients complaining of a fistula are advised to first undergo a diagnostic procedure to properly identify and classify the problem. Fistulas are diagnosed through an outpatient physical examination called EUA or Examination Under Anesthesia, which usually takes the form of an anoscopy.
To diagnose the fistula, the examining physician first identifies the three key parts of the fistula, which are the external and internal openings and the tract. Common signs of a fistula include a visible opening, pain during the examination, severe reddening of the affected area, and an abnormal discharge. Upon diagnosis, the physician will classify the fistula based on its location and the degree of its effect on the sphincter muscles; the latter is identified as the Park’s classification.
If the fistula is located in the lower anal region and is subcutaneous or submucous in nature, it is classified as a low-level fistula. However, if it affects the higher anal or the pelvi-rectal region, it is considered as a high-level fistula. Depending on its effects on the sphincter muscles, a fistula is further classified as intersphincteric, transphincteric, suprasphincteric or extrasphincteric.
While low-level fistulas are commonly treated using a fistulotomy, a fistulectomy is regarded as the ideal choice for the treatment of high-level and Park’s fistulas where a considerable amount of sphincter muscle is affected.
Fistulectomy is performed in a hospital either under general or spinal anesthesia. It is an outpatient procedure, which means that unless complications occur during or after the procedure, the patient is discharged once the effects of anesthetics have worn off.
Depending on the severity of the condition, the surgeon may elect to inject a contrast dye into the fistula’s external opening and an imaging tool, such as an X-ray or MRI, to make all the parts of the fistula visible. The surgeon then proceeds to remove all three parts of the fistula while making sure that the sphincter muscle stays intact as much as possible.
The entire procedure takes only 45 minutes to an hour while patients often take 4 to 6 weeks to heal completely. However, it is possible, especially in more complicated cases, for subsequent surgeries to become necessary for the complete treatment of the fistula.
Possible Risks and Complications
A fistulectomy is an invasive procedure that involves medium to large incisions in the anal region. Thus, it comes with a number of risks and possible complications, primary of which are post-operative pain and infection.
Other potential risks include:
- Severe scarring
To help minimize or prevent risks and complications, patients are prescribed with antibiotics and given strict post-surgical care instructions following the procedure. The surgeon also schedules a number of post-operative checkups to monitor the patient’s recovery.
Chalya P., Mabula J. (2013). “Fistulectomy versus fistulotomy with marsupialization in the treatment of low fistula-in-ano: a prospective randomized controlled trial.” Tanzania Journal of Health Research volume 15, number 3. http://www.bioline.org.br/pdf?th13023
Osama Turki Abu Salem. (2012). “Fistulectomy and fistulotomy for low anal fistula.” RMJ, 37 (4), 409-411. http://www.scopemed.org/?mno=21122#references
Do Sun Kim. (2012). “Comparison of a fistulectomy and a fistulotomy with marsupialization in the management of a simple anal fistula: a randomized, controlled pilot trial.” Journal of the Korean Society of Coloproctology. Apr; 28(2): 67-68. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3349810/