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Anal Fistula & Fissure

Anal fistulas and fissures are two common conditions that affect the anal region, leading to significant discomfort and requiring medical intervention. Anal fistulas are abnormal connections between the epithelialised surface of the anal canal and the perianal skin. Anal fissures, on the other hand, are small tears in the lining of the anus. Both conditions can cause severe pain, bleeding, and other complications if left untreated. In Australia, advanced surgical techniques are available to effectively treat these conditions, providing relief and improving the quality of life for patients.

Anal Fistul

Anal fistulas typically develop from an anal abscess, an infected cavity filled with pus near the anus. When the abscess drains or is surgically opened, it can form a fistula. Other causes include Crohn’s disease, radiation therapy, infections, trauma, and post-surgical complications.

Fistulotomy

  • Overview: Fistulotomy is the most common surgical procedure for treating anal fistulas. It involves cutting open the entire length of the fistula to allow it to heal from the inside out.
  • Procedure:
    • Anaesthesia: Performed under general or local anaesthesia.
    • Incision: The surgeon makes an incision along the fistula tract, opening it up.
    • Cleaning: Any infected tissue or abscess is cleaned out.
    • Healing: The open fistula is left to heal naturally. The wound may be packed with gauze to absorb drainage and promote healing.
    • Post-Procedure: Recovery can take several weeks, with regular follow-up visits to monitor healing.

Seton Placement

  • Overview: Seton placement involves inserting a thin piece of surgical thread (seton) through the fistula. This technique is often used for complex or high fistulas to allow drainage and reduce the risk of incontinence.
  • Procedure:
    • Anaesthesia: Performed under general or local anaesthesia.
    • Seton Insertion: The seton is placed through the fistula tract and tied in a loop.
    • Drainage: The seton helps to keep the fistula open, allowing it to drain and gradually heal.
    • Post-Procedure: The seton may be tightened periodically to encourage the fistula to close.

Advancement Flap Procedure

  • Overview: This technique involves covering the internal opening of the fistula with a flap of healthy tissue to promote healing.
  • Procedure:
    • Anaesthesia: Performed under general anaesthesia.
    • Fistula Cleaning: The fistula tract is cleaned and any infected tissue is removed.
    • Flap Creation: A flap of tissue is created from the rectal wall and advanced to cover the internal opening of the fistula.
    • Post-Procedure: Recovery involves close monitoring to ensure the flap is healing properly and the fistula does not recur.

LIFT Procedure (Ligation of Intersphincteric Fistula Tract)

  • Overview: The LIFT procedure is a sphincter-sparing technique that involves ligating the fistula tract in the intersphincteric space.
  • Procedure:
    • Anaesthesia: Performed under general or local anaesthesia.
    • Incision: A small incision is made in the intersphincteric space to access the fistula tract.
    • Ligation: The fistula tract is ligated (tied off) and divided.
    • Post-Procedure: Recovery is typically quicker, with reduced risk of incontinence compared to other techniques.

Anal Fissure

Anal fissures are usually caused by trauma to the anal canal, such as passing large or hard stools, chronic diarrhoea, childbirth, anal intercourse, and inflammatory bowel diseases like Crohn’s disease.

Lateral Internal Sphincterotomy

  • Overview: Lateral internal sphincterotomy is the most common surgical treatment for chronic anal fissures. It involves cutting a portion of the internal anal sphincter muscle to reduce spasm and promote healing.
  • Procedure:
    • Anaesthesia: Performed under local or general anaesthesia.
    • Incision: A small incision is made in the internal anal sphincter muscle.
    • Muscle Cutting: A portion of the muscle is cut to reduce tension and spasm.
    • Post-Procedure: Recovery involves pain management and wound care. Patients typically experience immediate relief from pain.

Anal Dilatation

  • Overview: Anal dilatation involves stretching the anal canal to reduce sphincter spasm and promote healing of the fissure.
  • Procedure:
    • Anaesthesia: Performed under general anaesthesia.
    • Dilatation: The anal canal is gently stretched using dilators.
    • Post-Procedure: Recovery involves pain management and avoiding constipation.

Botox Injections

  • Overview: Botox injections can be used to treat chronic anal fissures by temporarily paralysing the sphincter muscle and reducing spasm.
  • Procedure:
    • Anaesthesia: Local anaesthesia may be used.
    • Injection: Botox is injected into the internal anal sphincter muscle.
    • Post-Procedure: Effects typically last for a few months, allowing the fissure to heal. Repeat injections may be necessary.

Proper postoperative care is essential for successful recovery and optimal results. This includes:

  • Pain Management: Pain medications are prescribed to manage postoperative discomfort.
  • Wound Care: Instructions on keeping the incision sites clean and dry, and recognising signs of infection.
  • Dietary Changes: A high-fibre diet and increased fluid intake to prevent constipation and straining during bowel movements.
  • Activity Restrictions: Guidelines on limiting physical activity and avoiding heavy lifting to allow proper healing.
  • Follow-Up Appointments: Regular follow-up visits to monitor recovery, remove sutures if necessary, and address any complications.

As with any surgical procedure, anal fistula and fissure surgery carry potential risks and considerations:

  • Bleeding: Postoperative bleeding can occur, though it is usually minimal and resolves on its own.
  • Infection: Infection at the surgical site, though rare, can occur and may require antibiotics.
  • Pain: Postoperative pain is common but can be managed with medications.
  • Incontinence: Risk of incontinence, particularly with more extensive procedures involving the sphincter muscles.
  • Recurrence: While surgery is highly effective, there is a small risk of recurrence.

Conclusion

Anal fistulas and fissures are conditions that can significantly impact a patient’s quality of life, but effective surgical treatments are available. Advanced techniques in fistulotomy, seton placement, advancement flap procedure, LIFT procedure, lateral internal sphincterotomy, anal dilatation, and Botox injections offer patients tailored solutions to achieve relief and improve their quality of life.

Understanding the causes, symptoms, and risk factors of these conditions, along with the surgical options, is crucial for those considering treatment. In Australia, skilled surgeons provide comprehensive care, ensuring the best possible outcomes for patients seeking relief from anal fistulas and fissures.

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