Anal Fistül
Özet
Anal fistül, anal kanal ile cilt arasındaki anormal bağlantı olup, çoğunlukla kriptoglandüler kaynaklı apselerin drenajı sonrası gelişen kronik bir enflamasyon aşamasıdır. Tanıda fizik muayene ve Goodsall kuralı temel alınırken; kompleks vakalarda endoanal ultrasonografi (EUS) ve MR, sfinkter ilişkisini belirlemede kritik öneme sahiptir. Parks sınıflandırması, fistülleri sfinkterle ilişkisine göre intersfinkterik, transsfinkterik, suprasfinkterik ve ekstrasfinkterik olarak dört ana gruba ayırır. Tedavinin temel amacı, anal kontinansı (dışkı kontrolü) bozmadan birincil odağı ortadan kaldırmak ve nüksü önlemektir. Basit fistüllerde fistülotomi ve fistülektomi gibi "açık bırakma" teknikleri yüksek başarı sağlarken; yüksek yerleşimli ve kompleks fistüllerde sfinkter koruyucu yöntemler (seton, ilerletme flebi, LIFT, FiLaC, VAAFT) tercih edilir. Cerrahi planlama; hastanın cinsiyeti, doğum öyküsü ve önceki ameliyatlar gibi faktörlere göre kişiselleştirilmelidir. Crohn hastalığı veya tüberküloz gibi özel durumlarda yaklaşım multidisipliner olmalı ve agresif cerrahiden kaçınılmalıdır. Tedavi sonrası iyileşme süreci hastadan hastaya değişmekle birlikte, uygun teknik seçimi yaşam kalitesini korumak için esastır.
Anal fistula is an abnormal connection between the anal canal and the skin, mostly appearing as a chronic inflammatory stage of cryptoglandular abscesses following drainage. Physical examination and Goodsall's rule are fundamental for diagnosis; however, endoanal ultrasonography (EUS) and MRI are critical in complex cases to determine the relationship with the sphincter. The Parks classification categorizes fistulas into four main groups—intersphincteric, transsphincteric, suprasphincteric, and extrasphincteric—based on their anatomical relation to the sphincter muscles. The primary goal of treatment is to achieve healing and prevent recurrence while carefully preserving anal continence. While "lay-open" techniques such as fistulotomy and fistulectomy provide high success rates in simple fistulas, sphincter-saving methods (seton, advancement flap, LIFT, FiLaC, VAAFT) are preferred for high-seated and complex fistulas. Surgical planning must be individualized based on factors such as the patient's gender, obstetric history, and previous surgeries. In special conditions like Crohn's disease or tuberculosis, a multidisciplinary approach is required, and aggressive surgery should be avoided. Although the healing process varies per patient, selecting the appropriate technique is essential to maintain the quality of life.
Referanslar
Gordon P. Anorectal abscesses and fistula-in-ano. In:Gordon PH, Nivatvong S, editors. Principles and practice of surgery for the colon, rectum and anus. St.Louis: Quality Medical Publishing; 1999. p. 241–86.
Çipe G, Işık S, Güney B, et al. The Turkish Society of Colon and Rectal Surgery (TKRCD) Terminology Commission Study Report. Turk J Colorectal Dis 2021;31:281-285.
Parks A. Pathogenesis and treatment of fistula-in-ano.Br Med J. 1961;1:463–9.
Seow-Choen F, Ho JM. Histoanatomy of anal glands.Dis Colon Rectum. 1994;37:1215–8.
Parks A, Gordon P, Hardcastle J. A classification of fistula-in-ano. BJS. 1976;63:1–12.
Liang C, Jiang W, Zhao B, et al. CT imaging with fistulography for perianal fistula: does it really help the surgeon? Clin Imaging. 2013;37:1069–76.
Buchanan G, Halligan S, Williams A, et al. Effect of MRI on clinical outcome of recurrent fistula-in-ano. Lancet.2002;360(9346):1661–2
Sileri P, Cadeddu F, D'Ugo S, et al. Surgery for fistula-in-ano in a specialist colorectal unit: a critical appraisal. BMC Gastroenterol. 2011;11:120–6.
Morris J, Spencer JA, Ambrose NS. MR imaging classification of perianal fistulas and its implications for patient management. Radiographics 2000; 20:623-635.
Whiteford MH, Kilkenny J, Hyman N, et al; Standards Practice Task Force; American Society of Colon and Rectal Surgeons. Practice parameters for the treatment of perianal abscess and fistula-in-ano (revised). Dis Colon Rectum 2005;48:1337-1342.
Garg P. Comparing existing classifications of fistula-in-ano in 440 operated patients: Is it time for a new classification? A Retrospective Cohort Study. Int J Surg. 2017;42:34-40.
Herold A. Anorectal Abscess and Fistula. Herold A, Lehur PA, Matzel KE, O’Connell PR (eds.) Coloproctology içinde. Berlin: Springer; 2017. p.59-73.
Garcia-Aguilar J, Belmonte C, Wong WD, et al. Anal fistula surgery. Dis Colon Rectum. 1996;39:723–9.
Ommer A, Herold A, Berg A, et al. S3-leitlinie: Kryptoglanduläre Analfistel. Coloproctology. 2011;33:295–324
Abcarian H. The ‘lay open’technique. Anal fistula: surgical evaluation and management. London: Chapman & Hall Medical; 1996. p. 73–80.
Kim SH. Fistula-in-ano. Lee DK (ed.) Practices of Anorectal Surgery içinde. Singapur: Springer; 2019. p.71-85.
García-Granero A, Sancho-Muriel J, Sánchez-Guillén L, et al. Simulation of Supralevator Abscesses and Complex Fistulas in Cadavers: Pelvic Dissemination and Drainage Routes. Dis Colon Rectum. 2018;61(9):1102-1107.
Thomson JP, Ross AH. Can the external anal sphincter be preserved in the treatment of trans-sphincteric fistula-in-ano? Int J Color Dis. 1989;4:247–50
Akçal T, Perek A, Ertürk S, Sungurtekin U, Yüceyar S. Perianal / Anorektal Apse / Fistüller. Menteş B, Bulut MT, Alabaz Ö, Leventoğlu S. (eds.) Anorektal Bölgenin Selim Hastalıkları içinde. Ankara: TKRCD; 2011. p.71-102.
Ortega AE, Bubbers E, Liu W, et al. A novel classification, evaluation, and treatment strategy for supralevator abscesses. Dis Colon Rectum. 2015;58:1109–1110.
Ustynoski K, Rosen L, Stasik J, et al. Horseshoe abscess fistula. Dis Colon Rectum. 1990;33(7):602–5.
Buie LA. Practical Proctology. Philadelphia, PA: W.B. Saunders Company; 1938:136.
Thompson H. Wound healing and fistula-in-ano. Lond Clin Med J. 1966;7:55.
Wang C, Lu JG, Cao YQ, et al. Traditional Chinese surgical treatment for anal fistulae with secondary tracks and abscess. World J Gastroenterol. 2012;18(40):5702-5708.
Riss S, Bachleitner-Hofmann T, Stift A. The Comfort Drain: a new device for treating complex anal fistula. Tech Coloproctol. 2014;18(11):1133-1135.
Seyfried S, Bussen D, Joos A, et al. Fistulectomy with primary sphincter reconstruction. Int J Colorectal Dis. 2018;33(7):911-918.
Zimmerman DE, Stijns J, Wasowicz DK, et al. Transanal Advancement Flap Repair: The Current Gold Standard for Cryptoglandular Transsphincteric Perianal Fistulas. Turk J Colorectal Dis. 2019;29:104-110
Rojanasakul A, Pattanaarun J, Sahakitrungruang C, et al. Total anal sphincter saving technique for fistula-in-ano; the ligation of intersphincteric fistula tract. J Med Assoc Thai. 2007;90(3):581-586.
Adegbola SO, Sahnan K, Tozer P, et al. Emerging Data on Fistula Laser Closure (FiLaC) for the Treatment of Perianal Fistulas; Patient Selection and Outcomes. Clin Exp Gastroenterol. 2021;14:467-475.
Giamundo P, De Angelis M. Treatment of anal fistula with FiLaC®: results of a 10-year experience with 175 patients. Tech Coloproctol. 2021;25(8):941-948.
Meinero P, Mori L. Video-assisted anal fistula treatment (VAAFT): a novel sphincter-saving procedure for treating complex anal fistulas. Tech Coloproctol. 2011;15(4):417-422.
Prosst RL, Joos AK, Ehni W, et al. Prospective pilot study of anorectal fistula closure with the OTSC proctology. Colorectal Dis. 2014;17:81–9
Lee WY, Park KJ, Cho YB, et al. Autologous adipose tissue-derived stem cells treatment demonstrated favorable and sustainable therapeutic effect for Crohn's fistula. Stem Cells. 2013;31(11):2575-2581.
