Video-assisted anal fistula treatment

An anal fistula is an abnormal connection (or tunnel) between the inside of the anus and the skin. It is sometimes called a fistula in ano. An anal fistula can cause a number of problems which include: 

• Pain
• Swelling and irritation 
• Discharge and bleeding through the fistula 
• Infection 

An anal fistula does not usually go away by itself and most patients need treatment.

Video-assisted anal fistula treatment (or VAAFT for short) involves the use of a small camera which your surgeon uses to look inside the fistula. This helps your surgeon to know the extent of the problem and how best to treat it. Traditional fistula surgery involves cutting through the skin and tissues around the anus to reach the fistula from the outside. VAAFT lets the surgeon treat the problem form the inside and does not involve cuts through the skin.

VAAFT is regularly done in some NHS hospitals and is well established in some hospitals in Europe and Asia. It has been shown to have excellent outcomes, particularly for fistulas which are difficult to reach or complex. A complex fistula usually sits deeper in the body and passes through the sphincter muscles which are used to control bowel movements. A recent review of data from around the world showed that VAAFT had higher success rates and a lower chance of the fistula coming back compared to other similar procedures.

As with all anal fistula treatments, the goal of VAAFT is to reduce the symptoms from the fistula and if possible treat the problem entirely. 

VAAFT is minimally invasive so the surgery is less painful and the recovery is faster than other procedures. 

VAAFT is also ‘sphincter saving’, meaning that it does not cause significant damage to the muscles of the back passage. This means there is a lower risk of affecting your ability to have normal bowel movements. The risk of damage to the muscles in the anus is low and you are less likely to be incontinent after the procedure. 

In some cases we will do the surgery to improve your symptoms and make the fistula easier to manage rather than heal it altogether. We may also offer you repeat procedures to help your symptoms in the long-term. We will discuss the specific benefits of your surgery with you in the outpatient clinic.

All treatments and procedures have risks and we will discuss the risks of VAAFT with you during your outpatient clinic appointment. 

Problems that may happen straight away

• Discomfort or pain around the back passage. Although it is often less painful than alternative procedures, VAAFT may cause pain straight after the procedure. Whilst you are in hospital we will give you pain medication to manage this. 
• Bleeding. The chance of having some bleeding after the procedure is around one in every one hundred patients (one percent).
• Swelling around the anus. 
• Discharge from the area. This is not uncommon and will resolve with time.

Problems that may happen later

• You may need another procedure to treat the fistula.
• The anal fistula may return. This is the case in around one in every three (thirty percent) of patients who have a VAAFT procedure. 

Problems that are rare but serious

• There is a small risk that you will get a serious infection in the area of the procedure. This is very uncommon. 

There are also risks from the general anaesthetic which we will discuss with you before the surgery.

If you decide not to have VAAFT we will offer you one of the other procedures or treatments for anal fistula where appropriate. Your surgeon will be able to give you advice about what other procedure(s) may help you, depending on the location and type of fistula you have.

Most patients will need surgery to treat their anal fistula. The goal of all of the treatments is to remove the fistula tract and preserve the anal sphincter muscles. Other types of operation include: 

• Fistulotomy – where the fistula is opened up using a surgical cut and left to heal.
• Seton placement – where surgical thread is left in the fistula to keep it open and help it drain. Fistulotomy and seton placement can be used together to treat a fistula. 
• Ligation of intersphinteric tract (LIFT) procedure – this is a procedure to remove a fistula which passes through the sphincter muscle where a fistulotomy would have a high risk of damaging the sphincter muscles. 
• Muscosal advancement flap – this involves moving tissue from the bowel and using it to close the fistula.

You will be seen in the pre-assessment clinic a few weeks before your surgery. This involves some routine tests and a consultation with a nurse or an anaesthetist to make sure that you are fit for surgery.

We will also give you advice about whether you need to stop any other medications you are taking, if you need to self- isolate before the operation as a result of the COVID-19 pandemic and when you need to stop eating and drinking before the operation. 

Most VAAFT procedures are done on a day surgery basis which means you will go home the same day. It is essential that you arrange for somone to escort you home and be with you for 24 hours after the procedure. If you do not have an escort there is a risk your procedure may be cancelled.

We want to involve you in all the decisions about your care and treatment. If you decide to go ahead with treatment, by law we must ask for your consent and will ask you to sign a consent form. This confirms that you agree to have the procedure and understand what it involves. Staff will explain all the risks, benefits and alternative treatments before they ask you to sign a consent form. If you are unsure about any part of your proposed treatment, please speak with a senior member of the team.

The procedure will be done under general anaesthetic. After you have been put to sleep the operating team will position you for the procedure. 

The surgeon will insert a long, thin camera, called a fistuloscope, into the fistula. This will allow them to find the other end of the tunnel and map out the exact shape. 

The surgeon will then clean out the inside of the tunnel and apply heat energy (diathermy) to help the tissue scar. This process helps the body to heal the fistula. 

In some cases the surgeon will close one end of the fistula with a stitch. The other end of the fistula (at the skin on the buttocks) may be widened out to help the fistula to drain and heal.

After the procedure you will be given painkillers to take home with you. These are usually paracetamol and dihydrocodeine. Please have a supply of over-the-counter pain medication at home as the hospital pharmacy does not provide these. Rarely, stronger painkillers may be required. In some cases, we will give you antibiotics to treat a pre- existing infection in or around the fistula. The most commonly used antibiotics are metronidazole and ciprofloxacin for five to seven days, however others may be used depending on your specific circumstances. Most patients will not need antibiotics after a VAAFT procedure.

You can then go home with your escort. You may be able to return to work a day after the procedure. However, we will give you a fitness to work certificate for a week. It is very unlikely that you will be off work for longer than three days. We will see you again in our clinic six to eight weeks after the procedure.

You will have a dressing over the top of the fistula. This needs to be changed when it is no longer dry. We will give you spare dressings to take home. You may experience some minor bleeding and discomfort at home but this will usually settle over time. However the following symptoms may suggest a complication: 

• Worsening discharge from the area of your surgery. 
• Your pain is too much or is not settling. 
• Bleeding from the area of your surgery which does not settle. 
• Having a fever or feeling generally unwell. 

If you have one of these symptoms or you are concerned that things are not improving at home, please do one of the following: 

• Visit your GP 
• Go to the nearest Emergency Department 
• Contact us during working hours using the number in the contacts section

We will be happy to answer any questions you may have about VAAFT.

You can find more information about anal fistulas and the treatments available on the NHS website.

UCLH cannot accept responsibility for information provided by other organisations.

Pathway Co-ordinator (Monday to Friday 09:00-17:00)
Direct line: 020 3447 7059 
Switchboard: 08451 555 000 / 020 3456 7890 ext. 77059
E-mail: uclh.giadmissionsteam@nhs.net 

Address: Colorectal Surgery Department, 250 Euston Road, London, NW1 2PG 

If you have an urgent problem which cannot wait, please go to your local Emergency Department.