Restoration of Anal Canal Resting Pressure After Fistulotomy

Clinical Algorithm for Pressure Restoration

• The American Gastroenterological Association recommends performing fistulotomy with immediate primary sphincter reconstruction if there is no active proctitis or rectosigmoid inflammation (Crohn's Disease Activity Index <150) and the patient is medically optimized for wound healing 1, 2, 3
• The American Gastroenterological Association advises against fistulotomy entirely and recommends using non-cutting seton drainage if there is active proctitis or rectal inflammation present, or if there is an anterior fistula in female patients 1, 2, 4

Critical Pitfalls to Avoid

• The American Society of Colon and Rectal Surgeons warns against performing cutting setons, which result in 57% incontinence rates from progressive sphincter transection and cannot restore normal pressures 1, 5
• The American Society of Colon and Rectal Surgeons advises against performing repeat sphincterotomy in patients with prior fistulotomy, as this further compromises already damaged sphincter and makes pressure restoration impossible 5
• The American Society of Colon and Rectal Surgeons warns against performing aggressive dilation, which causes permanent sphincter injury in 10% of patients 5