All details of fistula and anal fissure

Dr. Julio José Del Castillo Diego has a degree and a PhD in Medicine and Surgery from the University of Cantabria and is a recognized specialist in General and Digestive System Surgery and Coloproctology. He is currently Head of Section of General and Digestive Surgery at the Marqués de Valdecilla Hospital in Santander, where he previously worked as F.E.A. of General and Digestive Surgery for two decades. In the field of teaching, he has been an honorary collaborator and is currently a teaching collaborator at the University of Cantabria.

What are the differences between fistula and anal fissure?

Actually, they are two completely different entities. An anal fissure is a wound that occurs in the anal canal and what manifests itself is a very severe pain at the moment when the patient is going to have a bowel movement. However, a fistula is the result of an infection and what it consists of is a communication between the anal canal and the skin of the perineum. The patient is consulted for an occasional spotting, it can be intermittent or for a lump that opens and closes spontaneously and in these conditions are the only conditions in which pain can appear.

What are the causes of both pathologies?

Well, they are also completely different. The cause of the fissure, the fissure is produced by an erosion in the anal canal and this can be due either to an important constipation or the opposite, to a diarrhea. In this way, the fissure is produced, which is a wound, an erosion. However, the origin of the fistula is always an infection. There are a series of glands, at the level of the anal canal, glands that, occasionally and without anything special, become infected and as a result of this infection there can be a communication, a path between that gland that communicates with the anal canal and the skin of the perineum. They are two causes, therefore, absolutely different.

Is it always necessary to operate, and if it is necessary to operate, what does the operation consist of and what is the postoperative period like?

The surgical treatment is completely different, as we have seen so far, they are two completely different entities and their treatment is completely different. If we start with the fissure, in eighty-five, ninety percent of the cases of fissure it is not necessary to operate. With a treatment with a series of dietary recommendations, with a series of topical treatments, ointments and similar creams and a series of recommendations, practically ninety percent of the fissures, even if they are chronic, can be cured. Surgical treatment does not consist in stitches, in suturing the wound, it consists in cutting, in making a small section in the internal anal sphincter. And this is a very delicate surgery because the section of the internal anal sphincter can lead the patient in the postoperative period and even more in the long run to have continence problems. He may have gas leakage or he may have leakage of liquid stool or solid stool, therefore, it is a surgery that although it is very effective, ninety-five percent of the patients improve practically immediately after the intervention, we only reserve it for patients in whom the rest of the conservative measures have failed.

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The surgery is quick, it can be done with deep sedation, it can be done with locoregional anesthesia and it can take a minute to perform. The problem is that the damage that can be done in that minute must be very carefully controlled because, as I have said, a poorly performed surgery can have irreversible effects that can lead to incontinence, even to having to wear a diaper for the rest of your life.

As far as the treatment of the fistula is concerned, the treatment of the fistula, unfortunately, is always surgical. A fistula that is established this communication that puts in contact the anal canal with the outside does not close spontaneously and therefore the treatment must always be surgical. Establishing a type of surgical treatment for fistulas is tremendously complex because there are many types of fistulas, what characterizes the fistula to all of them is its relationship with the anal sphincter. In this path of communication the two anal sphincters cross partially or totally and as we have seen before with the subject of the fissure the anal sphincters should not touch each other as far as possible. As this is a path that crosses them depending on which portion of both and which are affected the surgical treatment is variable. Therefore, there are very simple fistula surgeries in which a fistulotomy is performed, it is put in plane and the pathology is fixed, but generally the more complex fistulas can take even several surgical interventions because it is difficult to achieve a good result given that we have to solve a tunnel that crosses structures that we cannot touch.

It is also a surgery that can be done with sedation or that can be done with locoregional anesthesia, but the results have to wait in the long term for the surgery we have done to achieve the result we wanted, and as I have said, this is not always achieved. Both interventions, lateral internal sphincterotomy or fistulotomies, or the other types of techniques used for fistulas, have a postoperative period that is generally not painful. It is more painful to treat a hemorrhoidectomy, to treat a hemorrhoid patient than to treat a fissure or a fistula. The difficulty, as I say, is in both cases, by doing as little damage as possible and altering the structures of the perineum in the least possible way, to achieve a satisfactory result.