Surgery for Fistulas

Crohn’s disease (CD) and ulcerative colitis (UC) are the two major forms of inflammatory bowel disease (IBD). Both cause chronic inflammation in the digestive tract. While the inflammation in UC is confined to the colon and rectum, inflammation in CD can occur anywhere along the digestive tract, from the mouth to the anus.¹

One of the common complications that can occur with CD is a fistula: up to half of people with CD will eventually develop at least one fistula. A fistula is a tunnel that forms between an organ and another part of the body due to inflammation or injury.^2,3 In most cases, fistulas require surgery to treat them.

The chronic inflammation of CD can cause sores (ulcers) to form inside the walls of the intestines or other organs. The ulcers can become infected and begin to collect pus, bacteria, and other fluids. As it grows larger, it can form a tunnel to another part of the body. The most common place where fistulas form is around the anus (called “perianal” fistulas). Fistulas can also develop in other places, such as:

• Between two sections of the intestine
• Between the intestine and skin
• Between the intestine and bladder
• Between the rectum and vagina

What kinds of surgery can be used to treat fistulas?

The first step in surgical treatment of fistulas is for the surgeon to figure out the exact position of the fistula and the openings at each end of its “tunnel.”^4,5 The location and type of the fistula determines what kind of surgery needs to be performed to treat it.

For fistulas that begin in the large intestine, or other internal fistulas, a surgeon can remove the damaged section and sew the end of the fistula tunnel closed. This type of procedure is usually done laparoscopically and is minimally invasive.

For perianal fistulas, a procedure called a “fistulotomy” is the most common surgical treatment. Other types of surgeries for perianal fistulas are:

• Fistulectomy
• Seton placement
• Advancement flap
• Newer sphincter-preserving procedures

What is a fistulotomy?

During a fistulotomy, the surgeon operates to create an opening in the fistula tunnel so that it can heal on its own.⁴ This operation can be very successful for certain types of fistulas, especially those that are near the surface of the skin.

What is a fistulectomy?

A fistulectomy is a different type of procedure.⁵ The surgeon operates to remove the entire fistula tunnel, rather than letting it heal on its own.

What is a seton placement?

For people who have fistulas that cross the anal sphincter (the muscles in the anus that control bowel movements), a procedure called a seton placement may be recommended.⁴ This involves inserting a thin rubber thread (the seton) completely through the fistula tunnel. This keeps the fistula tunnel open wide enough that the fistula can drain and the infection can be treated with antibiotics. After the infection is gone, the seton is removed.

What is an advancement flap?

During an advancement flap procedure, a small flap is made from the lining of the patient’s rectum.⁴ This is used to cover the inside opening of the fistula tunnel.

What are newer sphincter-preserving procedures?

During any surgery for perianal fistula, the surgeon will try to prevent any damage to the sphincter muscles, which can affect the patient’s continence after the surgery.⁴ There are some newer procedures that have been developed to help preserve as much of the sphincter function as possible. For example, a special kind of glue called “fibrin glue” can be used to fill the fistula tunnel. In another type of procedure, the fistula can have a “plug” inserted into it that acts like a scaffold that fills up naturally with the patient’s own cells. People with fistulas that have formed between the internal and external sphincter muscles, the LIFT procedure (ligation of the intersphincteric fistula tract) can be used to close the internal opening of the tunnel and remove the infected areas from inside of the tunnel.

What are the possible side effects?

Depending on how complex the fistula is and the type of procedure performed, the surgery can be quite successful in treating the fistula.⁶ However, as with any type of surgery, there is the possibility of complications for some people. These may include:

• Losing the ability to control bowel movements (incontinence)
• Narrowing of the anus (anal stenosis)
• Sepsis, which is a severe type of infection