Diagnosis and surgical treatment of complex anorectal fistulas

*Anna Wiączek¹, Małgorzata Kołodziejczak¹, Iwona Sudoł-Szopińska^{1, 2, 3}

Summary
Branching fistulas belong to the category of so-called complex fistulas since they contain secondary tracts with varying number and location. The most common causes of branching fistulas include: abscesses that have been incised too late or insufficiently drained, inflammatory bowel diseases and conditions with immunodeficiency. In rare cases, secondary tracts can develop in the course of tuberculosis, actinomycosis or as a complication after radiotherapy or anal wall erosion due to cancer or anorectal trauma. Surgery for this type of fistulas is difficult, frequently involving several stages and carrying a high risk of recurrence. In order to minimise the risk of complications, complex fistulas should be treated by surgeons specialising in proctology with adequate knowledge regarding contemporary surgical techniques. A significant factor that decides about treatment success is preoperative determination of the anatomical course of fistulas and their secondary tracts. This is possible with imaging: endosonography and magnetic resonance imaging. It is also necessary to conduct functional tests and colonoscopy in order to assess the bowel in terms of inflammatory diseases and other pathologies. Moreover, a bacteriological examination should be conducted in patients carrying a high risk of complications.
These patients include individuals with Crohn’s disease, diabetes, immune deficiency, cancer or considerable inflammation of anal soft tissues. The article presents surgical techniques for branching fistulas, such as two-stage seton fistulotomy (modified Hippocrates’ technique) and different one-stage sphincter-sparing procedures.

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