What Is a Fistulotomy?

A Surgical Treatment for a Fistula

A fistulotomy is a procedure that is done to treat a condition called a fistula. A fistula is a connection that forms between two parts of the body (such as the bowel and the vagina or the bowel and the skin) that do not normally have a connection. One form of treatment is a fistulotomy, which is a type of surgery that opens up the fistula site and helps it heal. A fistulotomy is often an outpatient procedure and may be done under general or local anesthesia in either a doctor’s office or in a hospital. 

Having a fistula can cause a significant amount of anxiety and stress. The symptoms of a fistula can interfere with having a good quality of life. Anyone who has a fistula will naturally want to get it resolved in order to go back to regular activities without discomfort or other symptoms. There are treatment methods available for fistulas, so working with a team of experienced physicians that may include a gastroenterologist and a colon and rectal surgeon is important.

Discussions about fistulas can be difficult because they impact parts of the body that are not often talked about, so it may help to remember that physicians are accustomed to helping patients deal with these issues. Asking questions is an important and valuable part of the process.

Aftercare instructions
Verywell / Brianna Gilmartin  

How Fistulas Form

Fistulas can form in many different parts of the body and the risk factors for each type will be unique. However, some common risk factors include having inflammatory bowel disease (Crohn’s disease more often than ulcerative colitis), having diverticulitis, and experiencing long or obstructed labor in childbirth. A fistula may also form as a surgical complication and in some cases, the fistula is called "spontaneous" because no underlying cause is identified. 

In many cases, the beginning of a fistula is at the site where an abscess has formed. An abscess is a pocket of pus that forms in the body which may fill with body fluids (such as urine or stool) and therefore never heals. When it becomes large enough, the abscess may break through between two organs, creating a tract that is called a fistula.

Symptoms of a fistula will depend on the location, but can include recurrent vaginal or urinary infections, vaginal or anal skin irritations, a painful lump under the skin (which could be an abscess), fluids or stool leaking from the anus or the vagina, or pain and swelling in the rectum or anal area. In some cases, if the fistula is internal, and there may not be any symptoms. 

Types of fistulas and where they are located include:

  • Anorectal: between the anus and the skin
  • Colovaginal: between the colon and the vagina
  • Enterocutaneous: between the bowel and the skin
  • Anterolateral: between two sections of the bowel
  • Rectovaginal: between the anus or rectum and the vagina
  • Urethrovaginal: between the urethra and the vagina
  • Vesicouterine: between the bladder and the uterus
  • Vesicovaginal: between the bladder and the vagina

Diagnosis and Evaluation

A fistula may be diagnosed in a number of different ways, which will depend on the suspected location. Even when signs and symptoms make it clear that a fistula is likely the cause, it’s important to know the location of the fistula, as well as its size and its path.

There are several tests that might be used to diagnose and evaluate a fistula.

Barium enema or barium swallow. During this test, a barium solution is either drunk or given as an enema and a series of X-rays are taken in the area of the suspected fistula.

Endoscopic ultrasound. This type of endoscopy procedure uses sound waves and is done by passing a tube with a camera and an ultrasound probe on it into the anus to view the organs in the digestive system.

Endoscopy procedures. Upper or lower endoscopy, which is done by passing a thin tube with a camera on the end into the throat or the anus, may be used to locate a fistula.

Fistulography. In this test, a contrast medium is introduced through the external opening of a fistula. X-rays are then taken to see the location and tract of the fistula.

Magnetic resonance imaging (MRI). This test can help provide detailed images of the organs and structures in the abdomen in order to see a fistula.

Rectal exam. A physician will insert a lubricated, gloved finger into the anus to feel for any abnormalities. This procedure is slightly uncomfortable but is over quick, and may be done initially in order to determine if further testing to look for a fistula is needed.

The Procedure

A fistulotomy is a surgical procedure that opens up the fistula so that the area can heal and close the tract. It is usually done as an outpatient procedure, so an overnight stay in the hospital usually isn’t needed. 

In some cases where a fistula is not deep or large, a fistulotomy may be done in the doctor’s office under local anesthesia. In this situation, the procedure may take about an hour. For larger or deeper fistulas, it may be done in the hospital under general anesthesia. With general anesthetic, patients feel groggy after the procedure and will not be able to drive, so it will be necessary to have a friend or family member drive to and from the hospital.

Activities for the rest of the day of the procedure might also need to be limited until the effects of the anesthetic wear off.

During the fistulotomy, an incision will be made at the site of the fistula. The fistula is opened surgically. The shape is changed from something resembling a tunnel into something more like a groove. Some of the tissue in the fistula may need to be removed and it also may be drained of any pus or other fluids.

In many cases, stitches won’t be used during a fistulotomy. Instead, the wound will be left open and either packed with gauze or covered with gauze. 

Aftercare

The surgeon will provide aftercare instructions, which will vary based on the location and size of the fistula. It will be important to keep the area clean. In some cases, there may be a dressing that needs changing at regular intervals. Some fistulas that are left open may need to be packed with gauze and this gauze will need to be changed every so often to keep the area clean.

In the case of anal fistulas, sitz baths (in which a person sits hip-deep in water to bathe) might also be suggested for use during the healing process.

There may be medications prescribed, such as pain medications or, if the fistula involves the anus, stool softeners or fiber supplements. Antibiotics may also be given. It’s important to tell the surgeon about all medications to ensure that any of these new prescriptions do not interact.

If there is a fever, significant pain, or excessive drainage from the surgery area, call the doctor for further instructions. There may be a few follow-up appointments with the doctor to check the area of the fistula and see how it is healing. 

Potential Complications 

While most fistulotomy procedures are uneventful, as with any surgery, there is the potential for complications. For procedures that involve the anal sphincter, there’s the potential for loss of bowel control (incontinence). Bleeding is another concern, as is the recurrence of the fistula or an abscess. 

Endoscopic Fistulotomy

In certain specialty centers, a fistulotomy might be done endoscopically. This means that a tool called an endoscope is used to treat the fistula. This technique is still considered experimental and it’s not yet known for which types of patients or which types of fistulas that it might be the best option. 

However, the author of one study from the Cleveland Clinic has the opinion that in Crohn’s disease, the endoscopic technique could be used for cases of perianal fistula and for bowel fistula that occurred after surgery. In the case of a perianal fistula, an endoscope might be used to make an incision, drain the area, and place a seton. Success rates are not yet known for fistulas repaired through endoscopic treatment because it has not been done yet in many patients.

A Word From Verywell

If left untreated, a fistula can become serious and can even lead to long-term complications. The success rate of fistulotomy is variable, based on a number of factors. However, according to the American Society of Colorectal Surgeons, it can be as high as 92 to 97 percent for anal fistulas. One study that took results from several different treatment centers on 240 surgeries using different methods to treat fistulas showed the healing rate for fistulotomy at three months to be 94 percent.

Treating a fistula with surgery can be effective, but it’s important to follow aftercare instructions carefully and to see the doctor right away if any complications arise. Any questions about diet, activity level, and medications during healing should be answered by the surgeon’s office.  

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Article Sources

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  1. National Institute of Diabetes and Digestive and Kidney Diseases. Colonic & Anorectal Fistulas. Published August 2019.

  2. American Society of Colon and Rectal Surgeons. Abscess and Fistula Expanded Information.

  3. Knuttinen MG, Yi J, Magtibay P, et al. Colorectal-Vaginal Fistulas: Imaging and Novel Interventional Treatment Modalities. J Clin Med. 2018;7(4). doi:10.3390/jcm7040087

  4. Shen B. Exploring endoscopic therapy for the treatment of Crohn's disease-related fistula and abscessGastrointest Endosc. 2017;85:1133-1143. doi:10.1016/j.gie.2017.01.025

  5. Hall JF, Bordeianou L, Hyman N, et al. Outcomes after operations for anal fistula: results of a prospective, multicenter, regional study. Dis Colon Rectum. 2014;57:1304-1308. doi:10.1097/DCR.0000000000000216

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