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Remember that time Paradise showed us that list of unusual deaths from wikipedia? Well about 10-15 up from the bottom, a man is killed by allowing a stallion to sodomize him. I became curious as to the exact medical cause of death, and found Anal Fistulae.
I imagine each of these methods were beyond capabilities of the medical treatment at hand.
Definitive treatment Definitive treatment of a fistula aims to stop it recurring. Treatment depends on where the fistula lies, and which parts of the anal sphincter it crosses.
There are several options:
I imagine each of these methods were beyond capabilities of the medical treatment at hand.
Definitive treatment Definitive treatment of a fistula aims to stop it recurring. Treatment depends on where the fistula lies, and which parts of the anal sphincter it crosses.
There are several options:
- Doing nothing - a drainage seton can be left in place long-term to prevent problems. This is the safest option although it does not definitively cure the fistula.
- Lay-open of fistula-in-ano - this option involves an operation to cut the fistula open. Once the fistula has been laid open it will be packed on a daily basis for a short period of time to ensure that the wound heals from the inside out. This option leaves behind a scar, and depending on the position of the fistula in relation to the sphincter muscle, can cause problems with incontinence. This option is not suitable for fistulas that cross the entire anal sphincter.
- Cutting seton - if the fistula is in a high position and it passes through a significant portion of the sphincter muscle, a cutting seton may be used. This involves inserting a thin tube through the fistula tract and tieing the ends together outside of the body. The seton is tightened over time, gradually cutting through the sphincter muscle and healing as it goes. This option minimizes scarring but can cause incontinence in a small number of cases, mainly of flatus (wind). Once the fistula tract is in a low enough position it may be laid open to speed up the process, or the seton can remain in place until the fistula is completely cured.
- Fibrin glue injection is a method explored in recent years, with variable success. It involves injecting the fistula with a biodegradable glue which should, in theory, close the fistula from the inside out, and let it heal naturally. This method is perhaps best tried before all others since, if successful, it avoids the risk of incontinence, and creates minimal stress for the patient.
- Fistula plug is an "advanced" version of the fibrin glue method. It involves "plugging" the fistula with a "plug" made of porcine small intestine submucosa (sterile, biodegradable), fixing the plug from the inside of the anus with suture, and, again, letting the fistula heal "naturally" from the inside out. According to some sources, the success rate with this method is as high as 80%.
- Endorectal advancement flap is a procedure in which the internal opening of the fistula is identified and a flap of mucosal tissue is cut around the opening. The flap is lifted to expose the fistula, which is then cleaned and the internal opening is sewn shut. After cutting the end of the flap on which the internal opening was, the flap is pulled down over the sewn internal opening and sutured in place. The external opening is cleaned and sutured. Success rates are variable and high recurrence rates are directly related to previous attempts to correct the fistula.
- Anal Fistula Plug is a recently developed method known as AFP. This treatment requires placement and fixing of a plug in the anal fistula by a special technique. One advantage of this method is that it involves no cutting, so there is no post operative wound and pain. AFP plugs can sometimes be inserted under local anesthesia. This method can be used successfully to treat high fistula without colostomy. It does not carry any risk of bowel incontinence. As opposed to the staged operations, which may require multiple hospitalizations, AFP requires hospitalization for only about 24 hours. Currently, there are two different anal fistula plugs cleared by the FDA for treating ano-rectal fistulas in the United States.
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