Management of Complex Cryptoglandular Anal Fistula: Challenges and Solutions

Figures & data

Figure 1 A high transsphincteric fistula.

Figure 2 A high transsphincteric fistula with supralevator extension.

Figure 3 A suprasphincteric fistula.

Figure 4 An extrasphincteric fistula.

Figure 5 A 36-year-old male patient underwent surgery for a high intersphincteric fistula. Yellow arrows show the fistula tract/abscess. Left panel: preoperative MRI scans showing a high intersphincteric fistula. Middle panel: after 3 months of the first surgery, the fistula looked clinically healed with closed external opening (upper). However, the MRI scan revealed a large intersphincteric abscess (lower). The patient was operated on again. Right panel: MRI scan after 4 months of the second surgery shows complete radiological healing. The patient is doing well 18 months after the second surgery.

Table 2 Anal Fistula Classification

	Parks	St James’s University Hospital	Garg
Grade I	Intersphincteric	Intersphincteric — linear	Low — single tract (intersphincteric or transsphincteric)
Grade II	Transsphincteric	Intersphincteric — multiple tracts or associated abscess	Low — multiple tracts or associated abscess or horseshoe tract (intersphincteric or transsphincteric)
Grade III	Suprasphincteric	Transsphincteric — linear	High — single tract (intersphincteric or transsphincteric) or anterior fistula in a female or associated comorbidities^#
Grade IV	Extrasphincteric	Transsphincteric — multiple tracts or associated abscess	High — multiple tracts, associated abscess, or horseshoe tract (transsphincteric)
Grade V		Supralevator or translevator/extrasphincteric	Suprasphincteric, supralevator, or extrasphincteric

Notes: Low fistula involves less than a third 1/3 of the external sphincter; high fistula involves greater than a third of the external sphincter. ^#Comorbidities —associated Crohn’s disease, sphincter injury, or postradiation exposure.

Table 1 Overview of Challenges in Managing Complex anal Fistulae and their Solutions

	Challenges in Managing Complex Anal Fistulae	Solutions (Lettering as in Text)
1	High fistulae (including supralevator, suprasphincteric, and extrasphincteric fistulae)	A — use of appropriate imaging modalities B — using an appropriate fistula classification C — adequate management of intersphincteric tract/sepsis
2	Multiple tracts	A — use of appropriate imaging modalities B — using an appropriate fistula classification
3	Acute anorectal abscess	A — use of appropriate imaging modalities B — using an appropriate fistula classification D — managing fistulae with associated abscess
4	Internal opening not found	C — adequate management of intersphincteric tract/sepsis E — managing fistulae with “internal opening not found”
5	High recurrence rate	A — use of appropriate imaging modalities B — using an appropriate fistula classification C — adequate management of intersphincteric tract/sepsis D — managing fistulae with associated abscess E — managing fistulae with “internal opening not found” F — preventing delayed recurrence, assessing radiological healing G — proper diagnosis of associated diseases (tuberculosis)
6	Associated diseases (tuberculosis)	G — proper diagnosis of associated diseases (tuberculosis)