Anal fistula
| Classification according to ICD-10 | |
|---|---|
| K60.3 | Anal fistula |
| K60.4 | Rectal fistula |
| K60.5 | Anorectal fistula |
| ICD-10 online (WHO version 2019) | |
Anal fistulas are inflammations in the rectum area that can affect different layers of skin . An exit of the inflammatory cavity to the skin surface in the anus region does not have to be part of the clinical picture.
causes
A frequent cause is abscesses in the area of the crypts of the anus / anus within the rectum , which connect to the proctodeal glands . The glands located between the parts of the sphincter can then penetrate the sphincter with their excretory ducts in various ways.
As a result, excretory ducts can often be seen on the skin of the anus, but the excretory ducts can also only be located on the mucosal side. Typical is the secretion from the fistula.
Other possible causes, albeit less common, are inflammatory bowel diseases ( Crohn's disease , ulcerative colitis ), diverticulitis , cryptitis or cancer .
Symptoms
When abscesses form, pain and general symptoms such as fever and malaise are typical. The fistulas themselves, as a consequence of the inflammation, cause relatively few complaints and are most likely to be noticed by ongoing secretions in the anus. If the fistula starts to bleed, however, it can lead to considerable pain because the bleeding cannot be stopped so easily. Inflammation is then likely.
Diagnosis
Diagnosis is made by inspection, palpation, and rectoscopy . Fistulas can often only be found when examined under anesthesia . Complex fistula courses (e.g. in Crohn's disease ) can be visualized by an MRI of the pelvic floor.
Differentiation from: perianal thrombosis , prolapse of the hemorrhoids .
therapy
In the case of abscesses , therapy consists of a sufficiently wide surgical opening and abscess drainage .
Fistulas are usually split if they run below the sphincter. Otherwise, if possible, they will be cut out while sparing the sphincter ( fistulectomy ). Since the fistulas can also run through larger parts of the continence apparatus, radical removal is sometimes problematic.
In these cases, plastic fistula closure is necessary: Here, the fistula opening in the interior of the rectum ( inner fistula ostium ) is closed with a suture and secured with a U-shaped tissue flap ( advancement flap ). Alternatively, after the sphincter has been severed, the fistula is surgically removed and then the sphincter is reconstructed ( fistulectomy with primary sphincter suture ). Since both techniques involve a significant risk of incontinence, surgical techniques that are gentle on the sphincter have recently become available:
- Fistula plug: Here the fistula duct is occluded with an absorbable implant.
- Fistula clip (OTSC Proctology): The inner fistula ostium is closed dynamically with an elastic clip made of nitinol .
- Thermal fistula closure techniques: The fistula duct is destroyed and occluded by means of heat (laser: FiLaC technique; electrocoagulation: VAAFT technique).
A thread drainage system (ribbon) is helpful when marking and draining the pus in front of a plastic fistula closure. This method is also used if the fistula is not present or is only at great risk, e.g. B. incontinence, could be surgically removed.
literature
- Joachim Lange, Bernward Mölle, Josef Girona: Surgical proctology. Springer Verlag, Berlin 2005, ISBN 3-540-20030-4 .
- A. Ommer et al. a .: Cryptoglandular anal fistulas . In: Dtsch Arztebl Int . No. 108 (42) , 2011, pp. 707-713 ( Clinical Guideline ).
Web links
Individual evidence
- ↑ RL Prosst, W. Ehni, AK Joos: The OTSC Proctology clip system for anal fistula closure: first prospective clinical data . In: Minim Invasive Ther Allied Technol . tape 22 , no. 5 , September 2013, p. 255-259 , doi : 10.3109 / 13645706.2013.826675 , PMID 23971828 .
- ↑ RL Prosst, AK Joos, W. Ehni, D. buses, A. Herold: Prospective pilot study of anorectal fistula closure with the OTSC Proctology . In: Colorectal Disease . tape 17 , no. 1 , January 2015, p. 81-86 , doi : 10.1111 / codi.12762 , PMID 25175824 .
- ^ R. Mennigen, M. Laukötter, N. Senninger, E. Rijcken: The OTSC proctology clip system for the closure of refractory anal fistulas . In: Tech Coloproctol . tape 19 , no. 4 , April 2015, p. 241-246 , doi : 10.1007 / s10151-015-1284-7 , PMID 25715788 .
