Gli ascessi e le fistole anali sono espressioni diverse di una stessa malattia.
Si tratta cioè, di fasi, acute e croniche, delle suppurazioni che hanno origine dalle ghiandole del canale anale. E’ possibile affermare che l’ascesso e una fistola potenziale e la fistola e la conseguenza di un ascesso anale. La diagnosi non è difficile e la terapia è sempre chirurgica non rivestendo nessun ruolo terapeutico l’antibioticoterapia.
Il sintomo più caratteristico degli Ascessi Anali e il dolore in sede anale che è vivo, persistente e poco trattabile con i comuni antidolorifici.
Lo stato generale del paziente è sofferente e molto spesso è presente anche la febbre. L’esame clinico permette di porre facilmente la diagnosi, talvolta è possibile apprezzare la fuoriuscita spontanea del pus dalla rima anale. La palpazione, molto dolorosa, permette di apprezzare la consistenza della tumefazione nonché la tensione, l’ipertermia e talora la fluttuazione dei tessuti infiammati. L’esplorazione rettale, nel confermare la diagnosi, permette di apprezzare l’estensione intramurale dell’ascesso. Il trattamento è esclusivamente chirurgico, consiste nell’incisione e nel drenaggio della raccolta ascessuale. È opportuno, infine, essere particolarmente cauti nella ricerca del tramite fistoloso per evitare di creare tramiti iatrogeni che complicherebbero il trattamento della fistola.
La fistola anale rappresenta la fase cronica della stessa malattia e fa seguito alla fase acuta, per drenaggio spontaneo o chirurgico di un ascesso.
Nelle fistole anali è sempre possibile distinguere un orifizio interno localizzato all’interno di una cripta anale, un tramite fistoloso, che può essere semplice o complesso ed almeno un orifizio esterno, talvolta, gli orifizi esterni, possono essere multipli, che si apre nella cute perianale . Il sintomo principale è la comparsa di perdite, minime ma continue, di secreto corpuscolato, purulento o fecaloide che tengono umida la regione anale e sono causa di prurito e dermatiti. L’esame clinico ha lo scopo di identificare gli orifizi esterno ed interno, il decorso ed il rapporto tra fistola ed apparato sfinterico. La valutazione di questi elementi rappresenta il presupposto per la programmazione di un corretto piano terapeutico.
Classificazione delle fistole anali
La classificazione proposta dalla Scuola francese di Arnous è quella da noi preferita e si fonda sui rapporti fra tragitto fistoloso ed apparato sfinteriale.
Fistole anali tran sfinteriche inferiori quando il tragitto attraversa tutto il fascio sottocutaneo e la parte inferiore del fascio profondo dello sfintere esterno; sono le più frequenti (il 63% circa di tutte le fistole anali).
Fistole anali tran sfinteriche superiori quando il tragitto interessa tutto il fascio sottocutaneo e gran parte del fascio profondo dello sfintere esterno (il 27% circa di tutte le fistole anali).
Fistole anali soprasfinteriche nelle quali il tragitto attraversa tutto lo sfintere esterno e parte o tutto il muscolo puborettale (il 4% circa).
Fistole anali intersfinteriche (o intramurali) sono fistole nelle quali il tragitto è localizzato nello spazio intersfinterico di Eisenhammer, cioè tra lo sfintere interno e lo sfintere esterno (circa il 6%). Anche queste fistole hanno origine a livello della linea pettinata ma, a differenza delle altre, hanno una evoluzione in direzione ascendente. Talora possono aprirsi nel retto dando così origine alle fistole anorettali
Un ruolo diagnostico fondamentale, soprattutto nelle fistole plurirecidive, è costituito dall’ecografia transanale con sonda rotante che permette di evidenziare non solo i rapporti con l’apparato sfinterico ma anche il decorso del tramite fistoloso permettendo un approccio terapeutico più razionale.
La RMN è da riservare ai casi di fistole complesse o recidive.
Gli interventi chirurgici possibili per il trattamento delle fistole anali sono sostanzialmente tre.
La fistulotomia che consiste nella messa a piatto dell’intero tragitto fistoloso. Questa metodica è indicata nelle fistole più semplici.
La fistulectomia che consiste nella dissezione dell’intero tragitto fistoloso comprendendo alcuni millimetri di tessuto sano circostante. La ferita chirurgica viene lasciata aperta cosi che possa guarire per seconda intenzione.
La fistulectomia in due tempi necessaria nel trattamento delle fistole transfinteriche, cioè che attraversano il muscolo sfintere esterno,delle fistole soprasfinteriche e complesse. Il primo tempo comporta la dissezione retrograda della fistola dall’orifizio esterno fino al piano muscolare con abbassamento del tragitto della fistola ed il posizionamento di un filo detto propriamente setone.
Il ruolo del setone e quello di ottenere una sezione molto lenta dell’apparato sfinterico evitando cosi danni sfinteriali che possano comprometterne il corretto funzionamento. Il secondo tempo si esegue quando la sezione del piano muscolare effettuata in precedenza ha lasciato il posto ad una solida cicatrizzazione. Questo tempo può comprendere o la fistulotomia o la fistulectomia. Gli interventi di fistulotomia e di fistulectomia offrono una ottima percentuale di guarigione e se l’iter diagnostico terapeutico, ab initio, è stato corretto anche un bassissimo tasso di recidive.
Altre opzioni
Esiste anche un intervento che consiste nella esecuzione di fistulectomia (asportazione di tutto il tramite fistoloso), riparazione della breccia sfinterica e copertura (dall’interno del canale anale) della plastica muscolare mediante un “advancement flap”, cioè di un lembo di mucosa e sottomucosa del retto sovrastante che viene abbassato a coprire la sede dell’intervento e del precedente orifizio fistoloso. In questa maniera se l’intervento ha successo (percentuale intorno al 60-70%) si risparmia la muscolatura.
Si tratta del posizionamento di un “anal plug” (letteralmente “tappo anale”) a forma conica ,a coda di topo, ricavato dalla sottomucosa dell’intestino del maiale, opportunamente trattata per renderla biocompatibile. Il plug viene introdotto nel tramite fistoloso e funge da supporto per la cicatrizzazione da parte dei tessuti del paziente. Tale metodica ha una percentuale di riuscita tra il 50 e il 70% e ha anch’essa il vantaggio di rispettare le condizioni della muscolatura.
C’è il trattamento mediante iniezione di colla di fibrina (ricavata da sostanze coaugulanti presenti nel siero umano) nel tramite fistoloso. Anche qui l’integrità del tessuto muscolare non è compromessa, ma questo trattamento ha un alto tasso di recidive (oltre il 50%).
Recidive
Sono possibili e discretamente frequenti, in relazione soprattutto alla mancata individuazione dell’orifizio interno o di sue diramazioni, alla complessità della fistola e all’esperienza del chirurgo.
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