As written by John Goligher in his book Diseases of the Anus Rectum and Colon, it is  more difficult to treat a patient with a complex fistulae, than a patient with rectal cancer. Probably more surgical reputations have been damaged by the unsuccessful treatment of fistula than by excision of the rectum…the bad results of a laparotomy are generally buried with flowers,while the fistulae go around the world exhibiting the unsuccessful results of the treatment(1).

It is important to tailor the operation both to the individual patient and to the position of the fistula. A young male is at much less risk of postoperative incontinence than multiparous female and the lay-open of a anterior fistula is more likely to cause incontinence than a posterior fistulotomy (2).  A perianal abscess, not related to Crohn’s disease, originates in one of the anal glands, located in the subepithelial layer of the anal canal at the level of the dentate line. There are two types of anal glands, submucosal and intramuscular. According to Parks, fifty per cent of these glands penetrates the internal sphincter, the remainder are limited to the submucosa of the lower half of the anal canal (3) The ducts of the glands end in one of the anal crypts. Obstruction of a duct, caused by stool, foreign bodies or trauma, may cause stasis and infection. Fifty per cent of the glands penetrate into the intersphincteric plane, usually causing an either low or, less frequently, high intersphincteric abscess. Perianal abscesses need to be adequately drained. The sooner it is performed the better. There is little, if any, use for antibiotics, unless the patient has a valvular heart disease(4).                                                                                                      

Eighty per cent of the patients with an anal fistula, report a stressful event prior to the onset of the disease, compared with twenty per cent of patients with hemorrhoids, thus showing that stress and the consequent reduction of immune defense, play a role in the etiology of the disease. This has sto be taken in mind when planning the treatment (5) and I will come back to this point at the end.


A number of anal glands penetrate the internal sphincter to reach the intersphincteric plane . Fistula originates by the infection of these glands. Other factors are local trauma, caused by passage of hard stools, and also an epithelization of an anal fissure. That is why, when I see a patient with anal fissure, I use to suggest a prompt and adequate treatment of the fissure plus probiotics as the fissure may give origin to a fistula.                                                          

HIGH and LOW. One may term high anal fistula the fistula whose internal orifice is above the anal crypts, low fistula the one whose internal orifice is at level of anal crypts.

SIMPLE VERSUS COMPLEX.  Simple and easy to treat in 95% of the cases, Complex and difficult to treat in 5% of the cases, when the internal opening is above the anal ring and when there is a horseshoe extension, more commonly in the ischiorectal fossa.   Alternatively may be defined as complex fistulae those who are recurrent, have their track higher than the anorectal ring ,have multiple track and/or are recurrent. Most of general surgeons will hve no experience of difficult fistulae and may not recognize their true nature. According to Zimmerman, Mitala and Schouten, in the last years COMPLEX FISTULAE have emerged as a separate clinical specialist entity (6). They include high trans-sphincteric (traversing the middle and upper thirds of the external anal sphincter) and suprasphincteric  fistulae-in-ano. Most surgeons consider a fistula COMPLEX when it cannot be cured simply  with a fistulotomy without severely impairing fecal continence (6).


Parks et al (7) identified four types of anal fistulae. 

1. INTERSPHINCTERIC, which may be low or high. If high they may be associated with a pelvi-rectal or supralevator abscess, if low with a perianal abscess. External opening is close to the anal verge. 56% (according to  Marks and Ritchie, St Mark’s Hospital) (7)

2. TRANS-SPHINCTERIC, which cross the external sphincter and may be either low or high. They may be associated with an ischio-rectal abscess. External opening is not close to the anal verge. 21% (7)

3. SUPRASPHINCTERIC, which extends upwards between the two sphincters and bend around the puborectalis muscle. External openig is far from the anal verge. 3.5% (7)

4. EXTRASPHINCTERIC ,which reach the perianal skin without penetrating the anal sphincter complex.  3% (7)

Another type of fistula may occur, the so-called SUPERFICIAL or SUBMUCOSAL or SUBCUTANEOUS or INTRASPHINCTERIC fistula, all its track being within the internal sphincter. 16% (7)

Men have more anal glands than women, therefore males are five times more likely to develop an anal fistula.


I have been research fellow of the late Sir Alan Parks for a year and he used to recommend the surgeons watching him operating a anal fistula, to spend a few minutes palpating the perianal and perirectal spaces, searching for the INDURATION represented by the chronic abscess and-or the fibrotic track of the fistula itself.   A horseshoe track may be thus demonstrated. Prior to that, just the inspection of the perianal space might well help , according to the distance of the external opening of the fistula from the anus. As above mentioned, intersphincteric fistulae usually have the external orifice close to the anus whereas transphincteric fistulae have the external orifice far from the anus (8).

Then the external perianal orifice is gently probed to have an idea of the lenght of the fistula track. Attention must be paid not to force the upper end of the fistula, aimed at not creating a iatrogenic track. As far as the internal orifice,when it is detectable, it may be gently probed using a hooked probe. Often the internal orifice is in correspondence of the posterior anal crypt, in about two-thirds of the cases according to Nicholls (9),which may be deeper and more inflamed than the others. According to the Goodsall rule,  the fistulae anterior to the anus have a radial  straight direction, whereas the posterior ones have a curved direction towards the posterior crypt in the midline.   But an anterior placed external opening  may still be associated with a midline posterior internal opening where a long horseshoe extension is present. At the end of this digital evaluation, the following should be evident: the location of the primary track and its relationship to the anorectal junction, and the presence or absence of secondary track formation.It is essential for the examination to be carried out in the awake non anesthetized patient, thus allowing voluntry contractionof the sphincter muscles.


A sound knowledge of anatomy is essential for all surgery, but is particularly important for the classification of anal fistulae and their effective management. On many occasions it may be difficult to define the exact relationship of a fistula tract to the sphincter muscle, but this is mandatory to achieve an effective treatment of the disease.                                                                                                      The muscle of the pelvic floor is arranged as two concentric cylinders. The inner cylinder consists of the involuntary circular muscle, which is thickened in this area and constitutes the internal sphincter. The outer consists of the external sphincter and the puborectalis. There are three important spaces bounded by the muscles and walls of the pelvis: the intersphincteric plane, the ischiorectal fossa and the pararectal space (supralevator).  The apex of the fossa extends above the puborectalis muscle, so that induration may be felt in this position when an abscess or a fistula is confined to the ischio-rectal fossa. Above the levator ani there is the pararectal space, and the term supralevator is used to describe extensions of a fistula track in this space.

The submucous space extends upwords from the anal sinuses to the rectum. It contains the internal hemorrhoidal plexus, lymphatics andthe sympatethic plexus.

The perianal space is situated betwen the marginal space and the ischiorectal fossa and is separated from the latter by the perianal fascia derived from the fibres of the conjoined longitudinal muscle and the superficial fascia of the gluteal region.

Several diagnostic procedures have been recommended to help identify the complete fistolous complex prior to or during surgery.


Injection of dies or hydrogen peroxide through the external opening can be performed both pre and peroperatively to detect the internal opening. External probing shoud be not carried out preoperatively in the awake patient, as it causes discomfort and may create new extensions. Fistulography after intubation of the external opening with a small-caliber tube. When contrast is injected at low pressure into the fistulous complex, it runs to easily accesssibe places. Internal openings and sidetrcks that are closed off by debris, pus or scr tissue are not filled, will not be depicted and are missed. This makes fistulography unreliable. In case the patient with abscess or fistula does not have an external orifice, he, or she, my be helped by an evacuation fistulography (as reported by Piloni).                                        

Transanal ultrasound with a rotating probe. Recently, at a Congress, Robin Phillips, from St Mark’s Hospital, stated that “it help just to write scientific papers”, but it does not help in the diagnosis of an anal fistula and/or abscess.   I have operated anal fistulae and carried out preoperative transanal US for twenty yeras and i fully disagree. During transanal US it is possible to inject peroxide hidrogen into the external orifice and this helps to better define the fistulous track.Transanal US may not be of much help to differentiate an ischiorectal by a supralevator abscess. An advantage of transanal US is that it can be performed intraoperatively.  Maybe that MRI is more helpful than transanal US, expecially in complex recurrent fistulae. The value of MRI in perianal Crohn’s disease has been demonstrated prospectively : clinical examination missed nearly half of the patients noted on MRI scanning (and confirmed at surgery) to have abcesses deep in the ischiorectal fossa (10). The same happened in one of my patients, a 35 years old woman, who had three operations prior to diagnose a Crohn’s diseases. A pelvirectal abscess, missed both at transanal US and introperative palpation, had been diagnosed by MRI. Anal endosonography may be cheaper than MRI, but the information it provides appears limited to the sphincter, where it is preminent in defining sphincter integrity. Ultrasound may not be able to differenziate some inflammatory tissue from scar tissue (11).



The identification of the external orifice is easy, but finding the internal opening may be more difficult. After the introduction of an anal retractor (Eisenhammer,Parks, Fansler, Beak Sapimed) pressure over the external opening may produce a discharge of mucopus in the anal canal, thereby revealing the position of the internal opening. If it fails, the next step is to begin to dissect the track from the external opening. The dissection is continued until a cord of tissue is obtained which runs towards the external sphincter. Gentle traction may be applied to the cord, carefully looking inside the anal canal if a depression is created in correspondence of an anal crypt.

Having identified the anatomy of the tract, we need to know what proportion  of the internal and the external anal sphincter    lie above and below the fistula. Low anal fistulae are those in which internal opening is at the dentate line and approximately 30% of the sphincters below the track. In case of high anal fistulae it will be higher in the anal canal with at least 50% of the sphincter below the fistula track.


Perianal abscess usually produce an intersphincteric fistula, whereas  ischiorectal abscess  produce a low trans-sphincteric fistula. Most surgeons agree that no fistula with an ischiorectal abscess should be operated in acute phase. Horseshoe abscesses are best drained behind the anus. Sepsis in supralevator space in association with  a high extrasphincteric fistula can be treated inserting a non cutting seton.


The track of granulation tissue (= the cord of the fistula) must be either excised (fistulectomy) or lied open (fistulectomy). The entire wound is then marsupialized aimed at preventing bleeding and reduce the wound. At our Unit we use an interlocking suture, other authors (Seow-Choen) use interrupted stitches.


The prevention of recurrence of the fistula is dependent upon careful identification of the anatomy and eradication of the fistula and all tracks. Bring the patient back for further examination until a successful outcome is achieved.


The major difficulty faced by the surgeon is in the management of high anal fistula or when the patient had previous surgery. To preserve continence, the surgeon may carry out:cutting seton, fistulectomy with sphincter repair, endoanal advancement flap, LIFT or ligation of the intersphincteric track or the innovations plug, VAAFT, Permacol paste, Laser, Stem cells which preserve anal shincters but are usually followed by up to 50% of recurrence.


This technique consists of opening the fistula in its entire length,allowing it to heal by granulation and secondary intention.

INDICATIONS: Well-established fistulae, during drainage of an acute abscess, in case of low-lying trans-sphincteric and intersphincteric fistulae.

PRINCIPLES OF SURGICAL MANAGEMENT: Careful palpation, probing (straight or gently curved probes , lacrimal probe for very narrow tracks), injection of the track with milk or methilen blue. The use of large volume  of peroxide hydrogen injected into large cavities has resulted in gas embolism to the lung.

FISTULOTOMY NOT FISTULECTOMY: the fistulectomy may cause excessive and un-necessary loss of sphincter tissue, may produce gaping wounds and may result in iatrogenic fecal incontinence.

SURGICAL TECHNIQUE: If a fistulous abscess is present, pressure on the abscess may express pus from the internal primary opening. A crypt hook is then placed in this opening and the primary opening is laid open with electrocautery. The lower part of the internal sphincter and the subcutaneous part of the external sphincter may be divided with almost no negative effect on anal continence. If the fistula is thought to be high trans-sphincteric or intersphincteric, then the lower or more superficial part of the muscle may be divided and then the patient may have a second look under anestesia after a while.    Ramanujan et al reported a large series of 1023 ptients with fistulous abscess. They were easily able to identify a fistula in 355 patients, or 34.7%. Ninety per cent of these were treated with primary fistulotomy and 10% with staged fistulotomy using a cutting seton. The average follow-up period was 36 months. The recurrence rate in the 328 patients who had undergone primary fistulotomy  was 1.8% and, in the 32 patients with staged fistulotomy (seton) was 3.1% (12).  If the fistula is thought to be high intersphincteric or low transphincteric, a portion of the musce can be divided and the rest encirced losely with a marking seton. The divided sphincter is then allowed to heal for 6-8 weeks, after which a second stage fistulotomy can be attempted with good functional results.


It is a cryptoglandular infection originating  in the midline (90% posteriorly) and extending through a trans-sphincteric track into the deep postanal space. The abscess then ruptures through the external sphincter, presenting in one or both the ischiorectal fossa. The classic procedures of unroofing the entire tract causes a large T-shaped wound, which heals very slowly, leaves severe scarring and deformity and causes fecal incontinence.

In 1965 Hanley described a more conservative approach:the deep postana abscess is unroofed through a midline trns-sphincteric fitulotomy.The secondary opening on both sides are enlarged and the track is curetted and irrigated (13).


The most complex the fistula the higher the likelyhood of recurrence and incontinence. Kuijpers reported a recurrence rate of 4% and a 10% of anal incontinence (14). Mc Elwain et al reported 1000 patients with primary fistulotomy and found a recurrence rate of 3.6%. Postoperative fecal incontinence occorre in 7% of the cases (15). Interestingly, there has been a change of surgeon’s attitude when treating a patient with anal fistula. This is due to the fact that many patients apparently are more willing to avoid postoperative incontinence then to have their fistula cured in one shot. At the department of Prof Abcarian in Chicago, the most performed operation in the last century (80% of the cases) was  fistulotomy (lay-open). Instead, after 20 years, 80% of the patients underwent  anal sphincter-saving procedures, which improved their postoperative continence, but often required more than one operation (16).  The following Table explains why many surgeons changed their approach to trans-sphincteric fistulae, from simple lay-open to sphincter saving surgeries, aimed at reducing the incontinence.




Van Tets            1994      312                 12                            24 

Garcia-Aguilar  1996      375                 29                            54

Mylonakis          2001       74                   3                            21

Cavanaugh         2002      110             24 – 60                       64

Westerterp        2003        60              12 – 48                       50

Atkin                   2011      58                 > 1                          35



In case of minor incontinence, the patient may benefit from pelvic floor rehabilitation, i.e. physiokinesitherapy, biofeed-back and transanal electrostimulation. Aternativey, transcutaneous electrostimulation of the posterior tibial nerve may be effective (17). If the injury is limited to the internal sphincter, the injection of a bulking agent is indicated: the method is costly but safe. There are several different substances that may be used, e.g. PTQ implants or Silicon microspherules, Coaptite and Durasphere (18).Durasphere improves anal continence without improving quality of life. A costless method, used at our Unit, is the injection of centrifuged autologous fat, harvested from the tight (19).

  When the external sphincter has been injured during fistula surgery, sphincter reconstruction may improve anal continence. However , the association of irritable bowel syndrome and rectal hyposensation are negative predictors of outcome (20, 21). The Devesa Dacron ring may achieve satisfactory results (22).




     Suprasphincteric                               42.3

     Extrasphincteric                                40.0

     Trans-sphincteric                              17.5

     Intersphincteric                                   5.9

     Complex                                            17.6

      Simple                                                8.1

      Recurrent                                          24.6

      Primary                                               8.7



It means to eradicate the fistula track without compromizing both anatomy and function of striated sphincters. Fistulectomy is mandatory in case of middle and high trans-sphincteric fistulae, wheras, in low transphincteric fistulae, a fistulotomy may usually be performed without compromizing anal continence.

IATROGENIC FISTULA. This condition may be caused by excessive intraoperative probing. In patientes with a trans-sphincteric fistula, once the probe has been inserted through the external orifice, we should bear in mind that, after a few centimetres, the fistula track direction is likely to change. Rather than proceeding cranially, towards the anorectum, it will CROSS THE EXTERNAL SPHINCTER. By continuing to push the probe upwards, A FALSE TRACK IS CREATED  i.e. a iatrogenic extra sphincteric fistula, across the levator ani muscle to supralevator space, which thereafter will comunicate with the external orifice at the level of perianal skin.

Carrying out a FISTULECTOMY, i.e. excising the entire track, creates a large defect and more prolonged healing time. An alternative is to perform a fistulectomy for the outer component of the track until it reaches the sphincter. A fistulotomy is then performed over the trans-sphincteric course of the fistula, provided that it is low, aimed at avoiding postoperative anal incontinence. To carry out a fistulectomy, a probe has to be gently inserted through the external orifice of the fistula.

Then, the way I perform fistula excision is to circumferentially cut the skin around the external orifice for half-one centimetre and

firmly hold this piece of tissue, pulling it and continuing to excise the tissues around the extrasphincteric portion of the fistula. When a sufficient round space of three-four cm has been created around the fistula, a dentate self-retracting device is positioned to better evidentiate the ischiorectal fossa and the sphincter complex. Once reached the small area in which the trans-sphincteric fistula crosses the middle or upper part of the external sphincter (lateral view),the dissection of the fistula “cord” should be performed slowly and carefully, aimed at not damaging the muscle around the track, until, by palpating inside the anal canal with the finger at the level of the anal crypts and above, at the level of the anorectal ring. The precise anatomical relationship of the fistula track to the sphincter musculature should  be clearly defined. All the above-mentioned maneuvres are easier if the surgeon has already found the internal orifice of the fistula. In this case, the probe has crossed the whole sphincter complex, both internal and external and the division of the tissues either by scissors or by diathermocoagulation may be completed, and the specimen removed and sent to the pathologist.

At this point the surgeon has several options.

  1. One is to SUTURE THE ORIFICE created by the fistula excision at the level of the middle or upper part of the external sphincter, using a non absorbable suture. This is the technique published in Techniques in Coloproctology           by the Italian surgeon Carlo Ratto.
  2. Alternatively to DIATHERMOCOAGULATE the tissue between the extrasphincteric  segment of the fistula, i.e. very close to external sphincter’s muscle fibres , plus the corresponding segment of the intersphincteric plane plus the corresponding segment of the internal sphincter with the epithelium of the anal canal and the anal crypt at the level of the internal orifice of the fistula. This is the technique published by the Egyptian surgeon Ali Shafik in Techniques  in Coloproctology.
  3. Or to position a CUTTING SETON along the residual space after fistula dissection. I personally use silk. The seton may be also an elastic rubber thread or a so-called chemical ayurvedic seton, and should be ligated at the level of the subcutaneous part of the external sphincter. Subsequently, the function of the seton is to slowly divide the external sphincter wheras a line of fibrosis will take place. Therefore it may be also defined a very slow fistulotomy without interruption of the anal sphincter. Every two weeks the seton has to be gently tied at level of the distal end of the anal sphincters, until is eliminated by the body of the patient or,alternatively, if just a few millimeters of muscle remain below the distal end of the seton, the tissue may be cut by the surgeon in the outpatient department. Alternatively A LOOSE SETON may be positioned to prevent the risk that the seton moves downward, but leaves a space in the upper part, therefore leaving behind a communication between the anorectum and the surrounding tissues (24). A potential disadvantage of using the seton is that it may leave a small deformity at the level of the anal verge, thus causing minor fecal soiling.
  4. ANOCUTANEOUS ADVANCEMENT FLAP. The internal opening of the fistula is exposed and the crypt bearing tissue around the internal opening as well as the overlying anodermisis are excised. The skin flap is then sutured to the underlying internal sphincter in a single layer. The perianal wound is left open. It should be noted that the flap has been  advanced and sutured to the mucosa as reported by Del Pino et al (25), using an inverted U-shaped including the perianal skin and fat curved semilunar shape.

Alternatively a RECTAL MUCOSAL FLAP may be created, consisting of both rectal mucosa and muscle, well vascularized, gently pulled down and sutured, without tension and with interrupted 2/0 vicryl stitches, at the level of the subcutaneous part of the external sphincter. The aim of the advancement flap is to create a barrier between the rectal lumen and the perirectal-perianal spaces aimed at preventing the contact of the stool with the perirectal spaces. This flap advancement cannot be carried out in presence of pus or grossly inflamed rectum(26). Crohn’s disease is not a contraindication, but in these patients there is more risk of flap dehiscence. Usually the success (=no flap detachment) is around 70- 80%. An important advantage of the flap when compared with both seton and lay-open, is that, when a flap is performed, the lower anal canal and the perianal space, full of nerve endings and responsable for the sensory part of anal continence, remain intact.

All these procedure may be read in Italian on the book ASCESSI,FISTOLE ANALI E RETTO-VAGINALI, authorM.Pescatori, Springer-Italia 2011


         has been firstly reported by Phillips at St Mark’s Hospital and     

        then ameliorated and largely used by Rojanasakul, a Thai    

         colorectal surgeon. It is a sphincter-saving-technique used in               

          patients with middle or high transphinceric and        

         suprasphincteric fistulae. It consists in approaching that

          segment of the trans-sphincteric fistula wich runs between   

         the striated external and the smooth internal sphincters,

         approaching it from below with an incision at the level of th

         intersphinceric plane. The intersphincteric part of the fistula

         is localized and then divided and ligated. Both the external

         and the internal residual segment of the trans-sphincteric

         fistula are carefully curetted (27, 28). The healing rates after   

         this procedure ranged between 57 and 99%.(29-31)

AUTHOR           YEAR    NO.PTS        COMPLICATIONS             %

Rojanasakul     2007         15         delayed wound healing    6.5

                                                             anal incontinence             0

Shanvani           2010         45         delayed wound healing    17.8

                                                              anal incontinence             0

Bleier (30)         2010         39               anal fissure                      1

                                                                 persistant pain                1

                                                                anal incontinence            0

 Aboulian             2010        22             anal incontinence           23

                                                              failed wound healing        23


Several techniques and new devices have been proposed by both the industry and colorectal surgeons during the last decade, to make available SPHINCTER SAVING PROCEDURES for the treatment of trans-sphincteric anal fistulae.

AUTOLOGOUS EXPANDED ADIPOSE-DERIVED STEM CELLS plus/minus  fibrin glue or acellular dermal matrix injections.  The healing rate was significantly higher in the second group (31)  The long-term effectiveness of such procedures is currently unknown(32). Grade of recommendation of the Italian Society of ColoRectal surgery 2C.

Injection of FIBRIN GLUE has been proposed, but is now much less used as studied demonstrated that it may be not safe for the patients as followed by local sepsis, pruritus and pain by Zmora et al (33).

PLUG  consists of an extracellular matrix derived from the sub mucosa of porcine small intestine. This matrix support remodeling  of the host tissue, resulting in closure of the fistolous tract and it does not encapsulate when implanted.  Anal sphincters remain untouched, therefore the anal continence is fully preserved. The trans-sphincteric fistula track is couretted and then filled with one or more plugs. Initially the reported healing rates were high, up to 87% (34,35). More recently, however, less promising results have been reported, with healing rates dropping to 41% (36) 24% (37) and 14% (38) in most complex fistulae. Moreover the plug has a relatively high cost.   Grade of recommendation of the Guidelines of the Italian Society of Colo-Rectal Surgery: 2B.

PERMACOL is a porcine-derived isocyanate crosslinked acellular dermal  sheet.   In an observational study with Permacol paste  50% of the patients were cured at two years of follow-up (39). Permacol is injected into the fistula channel after the courettage, and both the endoanal or rectal mucosa and the skin are stitched aimed at keeping the paste in situ. Grade of recommendation  in the Guidelines of the Italian Society of Colo-Rectal Surgery:2C

VAAFT or video-assisted fistula excision is another innovation first reported by the Italian surgeon Meinero in Techniques in Coloproctology. The author uses a fistuloscope, which, introduced through the external orifice allows a better view of the main and of the secundary fistulous tracks, then eliminates the fistula debris with cianoacrylate and finally closes the internal opening of the fistula either using staples or constructing a rectal flap advancement (40, 41). The relatively high cost of the fistuloscope may represent the limit of this procedure. Grade of recommendation in the Guidelines of Italian Society of Colo-Rectal Surgery: 2C.

FiLaC means fistula tract LASER closure is a laser technique. The thiny laser probe is gently inserted into the  fistula track and then the laser energy is switched on and destroys the fibrotic tissue of the fistula. As the deepness of the laser is just 3 mm, no damage can occurr to the anal sphincters. Giamundo observed a healing rate of 71% after a median follow-up of 30 months (42)  An endorectal advancement flap may be added to close the internal opening of the fistula. Long-term results are encouraging (43). The relatively high cost of the laser probe may represent a limit of this procedure.

Grade of recommendation of the Italian Society of Colorectal Surgeons: 2C

ITALIAN GUIDELINES FOR THE MANAGEMENT OF ANAL FISTULAE (44) This consensus statement is addressed to all practitioner and healthcare workers,with the aim of providing information supporting appropriate decision-making in the management of cryptogenic anal abscess and fistula.

In the Introduction the relationship between stressful events and onset of the anal fistule has been underlined. Body and brain are strictly connected and, when dealing with the anal fistula or anal abscess patients, we have to investigate both the anorectal disease and the mental connection. Stressful events may cause the onset of the anal sepsis, for the simple reason that stress causes a defect in the immune system and, threfore, an inadeguate response to the aggression of the pathogenic bacteria to the anal glands. A weakened immune response may favour the onset of the disease. Therefore there is often a psychosomatic component in patients with anal sepsis and the surgeon has to evaluate it with the help of a psychologist. Prior to that, the surgeon may ask some questions aimed at find out if there is a psychosomatic component. Even if we perform a a perfect operation, the persistency of psychological stress and of a weaken immune response will facilitate either a fistula recurrence or the infection of another anal gland. It is strongly advised to prescribe immunostimulants to the patient, such a echinacea, Immunomix or Immunocomplex. When we see the patient in the outpatient department or in the office, we have to ask the patient if he or she had a stressful event, e.g. loss of a relative, financial loss, change of home, even an eartquake in the area were he or she lives, in the months before the onset of the anal disease. The doctor should ask the patients if he or she takes antidepressants or tranquilizers, if he or she is under psychotherapy… and, if there is the suspect of a mental distress, depression, anxiety, the doctor may perform a test which is very quick and simple. It is a graphic test called Draw-the-family-text, described in the paper by Miliacca et al, “draw-the-family-test”, Colorectal Disease 2010. This test, which is currently used in psychosomatic patients at our Unit, allowed a canadian surgeon, Ghislain Devroede, to avoid a colectomy for constipation in a sixteen yrs old girl. This surgeon wrote a chapter in the book on Constipation edited by Steven Wexner and David Bartolo.

 Considering that most abscesses and fistulae have origin in the perianal glands, which produce mucus at the level of the anal cryptae, INSIDE the anal canal, we should recommend to our fistula patients, to properly clean the anal canal INSIDE, not only the anus, after a defecation.

Considering that the onset of the sepsis is due to the pathogenic bacteria at that level, we should advice our patients to take probiotics.

Finally, it is important that the patient stops smoking, otherwise the blood flow to the rectum will be deficient and this will increase the risk of  breakdown of sutures if we perform a rectal advancement flap. Zimmerman, of the group of Schouten, Rotterdam, wrote in the Br. J. Surgery that heavy smoke increases the risk of suture dehiscence.


1. Lockhart-Mummery HJ. Discussion of fistula-in-ano. Proc R Soc Med 22, 1331-58, 1929.

2. Pescatori M. Chapter 1, page 2. The art of surgical proctology. Pertinax Publishing, 2014.

3. Parks AG. Etiology and surgical treatment of fistula-in-ano. Dis Colon Rectum 6, 17-22, 1963.

4. Schouten W R: Abscess,Fistula in Coloproctology, European Manual of Medicine, Herold A, Lehur P-A, Matzel KE, O’Connell PR. eds Springer,2008.

5. Cioli VM, Gagliardi G, Pescatori M. Psychological stress in patients with anal fistulae. Int J Colorect Dis, 30, 1123-1129,2015.

6. Zimmerman DE, Mitalas L, Schouten WR. Reoperation in recurrent complex anal fistula. In: Reconstructive Surgery of the Rectum, Anus and Perineum. AP Zbar, RD Madoff, SD Wexner eds. Springer 2013

7. Parks AG, Gordon PH, Hardcastle JD. A classification of fistula in ano. Br J Surg, 63, 1-2, 1976.

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Prof. Mario Pescatori, Clinica Parioli, Rome, Italy