Surgical Options
There are many surgical options available for fistulas depending on their location and the country of the person suffering from the fistula. Some options are practiced in certain countries, but not others.
Generally speaking, if you have a low simple fistula, you will likely be able to get a fistulotomy. Fistulotomies for simple fistulas tend to have a high success rate and a low recurrence rate.
If you are unfortunate, as I am, and have a high complicated fistula, the waters get murky. Surgeons don’t usually want to (nor should they, IMO) do a fistulotomy for a fistula that passes through your sphincter muscles as this could lead to incontinence.
Fistulotomy – This is a procedure in which the fistula tract is cut and laid open. This post explains the procedure very well (with a cool diagram!).
Fistulectomy - a surgical procedure where a fistulous tract is excised (cut out) completely. This is compared with fistulotomy, where the fistulous tract is merely laid open to heal.
Advance Flap – “the surgeon will cut a piece (or flap) of tissue near the fistula hole, and stretch it over the hole like a patch. Sutures are used to keep it in place.” Aside from this great description, this blog has a great diagram.
LIFT – During this procedure, a surgeon makes sutures the fistulous tract closed close to the rectum. This closes the tract off and prevents poop from getting in it, allowing the fistula to heal.
Video Assisted Anal Fistula Treatment (VAAFT)
Wound Vac – This isn’t a stand-alone procedure, but an option some surgeons offer to patients who have had a procedure. Wound Vac would help the area to heal faster and could give a greater chance of success.
Fistula Plug – Involves plugging the fistula with a device made from small intestinal submucosa. The fistula plug is positioned from the inside of the anus with suture.
Fibron Glue - It involves injecting the fistula with a biodegradable glue which should, in theory, close the fistula from the inside out, and let it heal naturally.
Cutting/Tightening Seton – “Cutting seton — if the fistula is in a high position and it passes through a significant portion of the sphincter muscle, a cutting seton (from the Latin seta, "bristle") may be used. This involves inserting a thin tube through the fistula tract and tying the ends together outside of the body.” These are tightened by the surgeon gradually until the seton works its way through the wound.
Seton – People have the option to have a loose or draining seton placed in and left in indefinitely. Such setons would need to be replaced (how long the seton would last depends on the individual, but I’ve heard of people having theirs in for a year before it needs to be changed).
Kshar Sutra – A medicated thread is placed through the fistula. It is changed out each week by the surgeon and gradually works its way through the area between the anal opening and fistula until it works its way completely through. This video has a great explanation. To my knowledge, this procedure is only performed in India. This treatment is NOT approved in Canada or the US. People who choose to undergo Kshar Sutra do so at their own risk.
If you go for one of these traditional North American surgeries, this post has great aftercare instructions
Since my fistula is high and complicated, my surgical options in Canada were limited. My CRS told me I could have LIFT, Advance Flap or leave my seton in for the rest of my life (no thanks).
There is a lot of conflicting information regarding success and recurrence rate. My CRS didn’t seem to know what the recurrence rates of his recommended surgeries were, but the success rates were 70% for flap and 60% for LIFT. I asked him about would vac and he told me they weren’t going to bother with that because my wound was too small.
In short, I didn’t get a good vibe from my Canadian CRS. He very clearly didn’t care. There was zero empathy or compassion and he couldn’t answer a large number of questions I had. I decided to go with my gut and chose to travel to India to have Kshar Sutra.
Which procedure you choose to have is up to you and highly personal. My only strong recommendations would be to always, ALWAYS get a second opinion, and to go with your gut.
There are many surgical options available for fistulas depending on their location and the country of the person suffering from the fistula. Some options are practiced in certain countries, but not others.
Generally speaking, if you have a low simple fistula, you will likely be able to get a fistulotomy. Fistulotomies for simple fistulas tend to have a high success rate and a low recurrence rate.
If you are unfortunate, as I am, and have a high complicated fistula, the waters get murky. Surgeons don’t usually want to (nor should they, IMO) do a fistulotomy for a fistula that passes through your sphincter muscles as this could lead to incontinence.
Fistulotomy – This is a procedure in which the fistula tract is cut and laid open. This post explains the procedure very well (with a cool diagram!).
Fistulectomy - a surgical procedure where a fistulous tract is excised (cut out) completely. This is compared with fistulotomy, where the fistulous tract is merely laid open to heal.
Advance Flap – “the surgeon will cut a piece (or flap) of tissue near the fistula hole, and stretch it over the hole like a patch. Sutures are used to keep it in place.” Aside from this great description, this blog has a great diagram.
LIFT – During this procedure, a surgeon makes sutures the fistulous tract closed close to the rectum. This closes the tract off and prevents poop from getting in it, allowing the fistula to heal.
Video Assisted Anal Fistula Treatment (VAAFT)
Wound Vac – This isn’t a stand-alone procedure, but an option some surgeons offer to patients who have had a procedure. Wound Vac would help the area to heal faster and could give a greater chance of success.
Fistula Plug – Involves plugging the fistula with a device made from small intestinal submucosa. The fistula plug is positioned from the inside of the anus with suture.
Fibron Glue - It involves injecting the fistula with a biodegradable glue which should, in theory, close the fistula from the inside out, and let it heal naturally.
Cutting/Tightening Seton – “Cutting seton — if the fistula is in a high position and it passes through a significant portion of the sphincter muscle, a cutting seton (from the Latin seta, "bristle") may be used. This involves inserting a thin tube through the fistula tract and tying the ends together outside of the body.” These are tightened by the surgeon gradually until the seton works its way through the wound.
Seton – People have the option to have a loose or draining seton placed in and left in indefinitely. Such setons would need to be replaced (how long the seton would last depends on the individual, but I’ve heard of people having theirs in for a year before it needs to be changed).
Kshar Sutra – A medicated thread is placed through the fistula. It is changed out each week by the surgeon and gradually works its way through the area between the anal opening and fistula until it works its way completely through. This video has a great explanation. To my knowledge, this procedure is only performed in India. This treatment is NOT approved in Canada or the US. People who choose to undergo Kshar Sutra do so at their own risk.
If you go for one of these traditional North American surgeries, this post has great aftercare instructions
Since my fistula is high and complicated, my surgical options in Canada were limited. My CRS told me I could have LIFT, Advance Flap or leave my seton in for the rest of my life (no thanks).
There is a lot of conflicting information regarding success and recurrence rate. My CRS didn’t seem to know what the recurrence rates of his recommended surgeries were, but the success rates were 70% for flap and 60% for LIFT. I asked him about would vac and he told me they weren’t going to bother with that because my wound was too small.
In short, I didn’t get a good vibe from my Canadian CRS. He very clearly didn’t care. There was zero empathy or compassion and he couldn’t answer a large number of questions I had. I decided to go with my gut and chose to travel to India to have Kshar Sutra.
Which procedure you choose to have is up to you and highly personal. My only strong recommendations would be to always, ALWAYS get a second opinion, and to go with your gut.
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