the Management of Perianal Abscess, Fistula and Recto-Vaginal Fistula

- Recommendations

Section 1: Initial evaluation of anorectal abscess and fistula:

•  A disease-specific history and physical examination should be performed evaluating symptoms, relevant history, abscess and fistula location, and presence of secondary cellulitis, (Good practice statement).

•  We recommend against routine use of diagnostic imaging for patients with anorectal abscess or fistula. However, imaging may be considered in selected patients with an occult anorectal abscess, recurrent or complex anal fistula, immunosuppression, or anorectal Crohn’s disease, (Strong recommendation, moderate certainty evidence ^{(10, 11)}).

 Section 2: Anorectal abscess:

•  Patients with acute anorectal abscess should be treated promptly with incision and drainage, (Strong recommendation, low certainty evidence ^{(10, 11)}).

•   Abscess drainage with concomitant fistulotomy is recommended in selected patients with simple low anal fistulae. (It is not recommended in patients with complex fistulas, recurrent abscesses, IBD, preexisting incontinence, or history of anorectal surgery), (Strong recommendation, moderate certainty evidence ^{(10, 11)}).

•  After I & D, we advise antibiotics to be reserved for patients with an anorectal abscess complicated by cellulitis, systemic signs of infection, or underlying immunosuppression, (Conditional recommendation, moderate certainty evidence ^{(10, 11)}).

Section 3: Anal Fistula

•  For patients with a simple fistula-in-ano and normal anal sphincter function, we recommend treatment with lay-open fistulotomy, (Strong recommendation, moderate certainty evidence ^{(10, 11)}).

•   We recommend treatment of recurrent fistula-in-ano with endorectal advancement flap, (Strong recommendation, moderate certainty evidence ^{(10, 11)}).

•   For transsphincteric fistulae, we recommend treatment with ligation of the intersphincteric fistula tract (LIFT) procedure, (Strong recommendation, moderate certainty evidence ^{(10, 11)}).

•  A cutting Seton is advised selectively in the management of complex cryptoglandular anal fistulae, (Conditional recommendation, low certainty evidence ^{(10, 11)}).

•  We recommend against the anal fistula plug and fibrin glue as they are ineffective treatments for fistula-in-ano, (Strong recommendation, moderate certainty evidence ^{(10, 11)}).

• Minimally invasive approaches, (that use endoscopic or laser closure techniques), to treat fistula- in-ano may be used, as they have a reasonable short-term healing rates but unknown long-term fistula healing and recurrence rates, (Conditional recommendation, low certainty evidence ^{(10, 11)}).

Section 4: Rectovaginal fistula:

•   We advise performing non-operative management for the initial care of obstetrical rectovaginal fistula and may also be considered for other benign and minimally symptomatic fistulae, (Conditional recommendation, low certainty evidence ^{(10, 11)}).

•  We recommend a draining Seton because it may facilitate resolution of acute inflammation or infection associated with rectovaginal fistulae, (Strong recommendation, low certainty evidence ^{(10, 11)}).

•  Endorectal advancement flap with or without sphincteroplasty is recommended as the procedure of choice for most patients with a rectovaginal fistula, (Strong recommendation, low certainty evidence ^{(10, 11)}).

•  Episio-proctotomy is recommended to repair obstetrical or cryptoglandular rectovaginal fistulae in patients with anal sphincter defects, (Strong recommendation, low certainty evidence ^{(10, 11)}).

•  We advise performing a gracilis muscle or bulbocavernosus (Martius) flap for recurrent or complex rectovaginal fistula, (conditional recommendation, low certainty evidence ^{(10, 11)}).

•  We recommend a transabdominal approach for repair of rectovaginal fistulae that result from colorectal anastomotic complications, (Strong recommendation, low certainty evidence ^{(10, 11)}).

•    We advise performing completion proctectomy with or without colonic pull-through or coloanal anastomosis to treat radiation-related or recurrent complex rectovaginal fistula, (Conditional recommendation, low certainty evidence ^{(10, 11)}).

Section 5: Anorectal fistula associated with Crohn’s disease:

•   We recommend management of symptomatic anorectal fistula associated with Crohn’s disease,   with a combination of surgical and medical approaches, (Strong recommendation, moderate certainty evidence ^{(10, 11)}).

•  We recommend against surgical treatment of asymptomatic fistulae in patients with Crohn’s disease, (Strong recommendation, low certainty evidence ^{(10, 11)}).

•   We recommend draining Setons in the multimodality therapy of fistulizing anorectal CD and may be used for long-term disease control, (Strong recommendation, moderate certainty evidence ^{(10, 11)}).

•  Endorectal advancement flaps and the LIFT procedure are recommended to treat fistula-in-ano associated with CD, (Strong recommendation, moderate certainty evidence ^{(10, 11)}).

•   We advise to treat symptomatic, simple, single, low anal fistulae in patients with Crohn’s disease, by lay-open fistulotomy, (Conditional recommendation, low certainty evidence ^{(10, 11)}).

•   Fecal diversion or proctectomy, is recommended for patients with uncontrolled symptoms from complex anorectal fistulizing CD, (Strong recommendation, moderate certainty evidence ^{(10, 11)}).