Optimal Management of the Transsphincteric Anal Fistula

Management of transsphincteric fistulas can pose a difficult challenge for surgeons. The goal is to cure the fistula while retaining functional capacity of the sphincter complex. The Parks system is the classic classification system, which divides fistulas into four types: intersphincteric, transsphincteric (high and low), suprasphincteric, and extrasphincteric (Fig. 32.1), based on the course of the track in relation to the anal sphincter complex [2]. Goals of management include eradicating sepsis, promoting healing of the fistula tract, maintaining continence through preservation of the sphincter complex, and preventing future recurrence. Simple submucosal, intersphincteric, and low transsphincteric fistulas can be managed effectively with conventional fistulotomy and represents the gold standard comparator owing to low incontinence and recurrence rates [3]. However, transsphincteric fistulas cross through the internal and external sphincter, predisposing patients to higher rates of incontinence following fistulotomy. Therefore, a number of alternative approaches have been developed to tackle these complex fistulas although no consensus algorithm for management exists.