Fecal diversion in complex anal fistulas: Is there a way to avoid it?

Abstract

Temporary fecal diversion by a diverting colostomy or ileostomy is occasionally performed for serious complex fistulas. The main indications are highly complex and extensive cryptoglandular anal fistula, anal fistula associated with severe anorectal Crohn’s disease, recurrent rectovaginal fistula, radiation-induced fistula and anal fistula with associated necrotizing fasciitis. The purpose of stoma formation is to divert the fecal stream away from the anorectum and the perianal region so as to control the infective process and prevent trauma to the operated repaired tissues. Once the fistula has healed, the diverting stoma is closed. However, two questions are relevant. First, is it certain that the same disease would not relapse (or the fistula would not recur) once the colostomy is closed? Second, is there a non-surgical method which can obviate the need for a diverting colostomy? An attempt is made to answer both these questions in this review.

Keywords: Anal fistula; Fecal diversion; Diverting stoma; Colostomy; Crohn’s disease; Rectovaginal fistula

Core Tip: Fecal diversion is performed for severe and uncontrolled anal fistula disease. Though usually done as a last resort, it significantly increases morbidity and cost. We speculated on whether fecal diversion is actually the last resort, is it effective and can it be avoided? A novel non-surgical protocol [LOOP: L: Liquid diet with no fiber; O: Oral rehydration salt; O: Oral vitamins and protein powder/supplements; P: Phosphate (sodium phosphate) enema] prevents contact of fecal matter with the anorectum and has been successfully utilized to treat several acute anorectal conditions. LOOP can potentially avoid the need to divert the fecal stream in many fistula cases where it would be deemed necessary. This would markedly decrease the morbidity and cost incurred due to fecal diversion.