2 The condition, current treatments and procedure
2.1 An anal fistula is an abnormal tract between the anal canal and the skin around the anus. It may cause symptoms such as pain or discomfort in the anal area, and leakage of blood or pus. It usually results from previous anal abscesses (cryptoglandular), and can be associated with other conditions such as inflammatory bowel disease and cancer.
2.2 Anal fistulas can be classified according to their relationship with the external sphincter. Intersphincteric fistulas are the most common type and cross only the internal sphincter. Trans-sphincteric fistulas pass through the internal and external sphincter.
2.3 Treatment of anal fistulas commonly involves surgery. The type of surgery depends on the location and complexity of the fistula. For intersphincteric and low trans-sphincteric anal fistulas, the most common treatment is a fistulotomy or laying open of the fistula track. For deeper fistulas that involve more muscle, and for recurrent fistulas, a seton (a piece of suture material or rubber sling) may be used, either alone or with fistulotomy. Setons can be loose (designed to drain the sepsis but not for cure), or snug or tight (designed to cut through the muscles in a slow controlled fashion). Fistulas that cross the external sphincter at a high level are sometimes treated with a mucosal advancement flap or other procedures to close the internal opening. Another less commonly used option for treating anal fistulas is to fill the track with either a plug or paste; for example, 1 type of filler is fibrin glue (a solution of fibrinogen and thrombin).
2.4 Radially emitting laser fibre treatment of an anal fistula can be done with the patient under regional or general anaesthesia. With the patient in lithotomy position, the external and internal openings of the fistula tract are identified. The fistula is then catheterised using a probe and cleaned by irrigation. Under ultrasound guidance, a radially emitting laser fibre is advanced from the external to internal orifice, activated and gradually withdrawn at about 1 mm/second. The aim is to cause destruction and sealing of the fistula tract, allowing primary closure. The procedure may be used with techniques that close the internal orifice of the tract such as an advancement flap.