Generally, patients present with a discharging area around the anal canal, especially after they have opened their bowels which can become infected and sometimes discharge faeces or blood. It is almost like a spot or a boil that does not heal completely. Established complex perianal fistulas are difficult to treat with surgical intervention and to control sepsis and preserve continence and there have been several treatments that have been developed over the years.

Commonly used techniques include a one step fisulotomy or fistulectomy if the sphincter is not involving any sphincters or it is a low fistula. Generally the treatment options have been conservative with fistulas involving sphincters which is the muscle that controls the continence and have been managed with a placement of a stitch which is called a Seton loosely to drain the tract so as to avoid any further infection.

1. Seton – this is a first treatment option and some patients are managed successfully over many years with a Seton. I do undertake a comfort drain which is a special Seton that does not have a knot which is much more comfortable than any of the other treatments. There are two options with the Seton. The loose Seton is where it is used for drainage and there is second option which is a cutting Seton where over time the Seton or the stitch cuts through the muscle. I avoid doing this as I want to preserve the sphincter function and therefore I do not use cutting Setons.
2. Video assisted anal fistula treatment – I have been undertaking a VAAFT video assisted anal fistula treatments for more than 5 years and have treated a lot of patients during this time. I have also spent quite a lot of time training other surgical colleagues to use this technique and I have learnt over many years of practice of optimising the treatment with the VAAFT technique itself. I feel the VAAFT technique itself could be broken into two areas – VAAFT diagnostic which is the first part where I feel it is the essential part where you are able to undertake a fistuloscopy to look into the fistula tract.
   
   Apart from the VAAFT technique there are no other treatments currently available for anal fistulas which actually help visualise the fistula tracts and also offer treatments. During this particular procedure, I am able to treat the side branches and also try and convert a complex fistula into a more simple or straight forward fistula which can be treated at a later stage. Therefore, the VAAFT diagnostic step itself can be carried out 2, 3 or more times to try and simplify the fistula itself without damaging any sphincters and also the need for other modalities of investigations including MRI scans as you are able to visualise the fistula tracts in detail. I do still rely on MRI scans as an objective marker to help me with the treatment options, but my experience has been that MRI scans tend to over predict or over call the fisula tracts.
   
   The VAAFT treatment itself includes diathermy and treating the fistula tract and also doing a mucosal advancement flap. Once the tract has been simplified, any of the treatment options that are available to us currently for sphincter preserving fistula treatment can be successfully combined with the VAAFT procedure, and I currently undertake the other procedures with the VAAFT procedure or sometimes independently, depending on the needs of the patient. I strongly feel that there is no one technique that will be successful in treating complex fistulas but a range of treatments might be needed for this group of patients. I offer most of the treatments options that are currently available.

   

3. LIFT (ligation of fistula tract) – this is where you are able identify a the fistul tract and divide it to stop the fistula from draining. This works very well in a group of patients.
   
   
4. Permacol paste – Where you are able to insert Permacol into the fistula tract itself to help with the healing of the fistula tract.
5. Advancement flap – Where you are able to do either a mucosal advancement flap or anal advancement flap, sometimes using haemorrhoidal tissue. In really complicated fistulas with deep complex fistula tracts which are discharging in multiple areas, I do have a plastic surgical colleague. We work very closely together to treat the really complex fistulas and very rarely bowel diversion might also be needed in a group of patients who have complex fistulas to treat fistulas successfully.
6. Fixcision – this is a treatment option available to excise a fistula tract completely with a form of biopsy. Sometimes the fistula tracts tend to form a hard area which can be successfully removed using this particular technique.There are other treatment options currently in the progress of being utilised including radio frequency ablation of the fistula tract and also OBSiDiAN which I am hoping to start using as well.