Opinion Review
Copyright ©The Author(s) 2021. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Clin Cases. Sep 6, 2021; 9(25): 7306-7310
Published online Sep 6, 2021. doi: 10.12998/wjcc.v9.i25.7306
Fecal diversion in complex anal fistulas: Is there a way to avoid it?
Pankaj Garg, Vipul D Yagnik, Sushil Dawka
Pankaj Garg, Colorectal Surgery,Garg Fistula Research Institute, Panchkula 134113, Haryana, India
Pankaj Garg, Colorectal Surgery, Indus International Hospital, Mohali 140201, Punjab, India
Vipul D Yagnik, Surgical Gastroenterology, Nishtha Surgical Hospital and Research Center, Patan 384265, Gujarat, India
Sushil Dawka, Surgery, SSR Medical College, Belle Rive 744101, Mauritius
Author contributions: Garg P conceived and designed the study; Garg P and Yagnik VD collected and revised the data; Dawka S reviewed and edited the manuscript; All authors critically analyzed the data, finally approved and submitted the manuscript.
Conflict-of-interest statement: None of the authors have any conflicts of interest.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Pankaj Garg, MBBS, MS, Associate Professor, Surgeon, Colorectal Surgery, Garg Fistula Research Institute, House No. 1042, Sector-15 Near Amartex Chowk, Panchkula 134113, Haryana, India. drgargpankaj@yahoo.com
Received: May 11, 2021
Peer-review started: May 11, 2021
First decision: June 23, 2021
Revised: June 23, 2021
Accepted: July 16, 2021
Article in press: July 16, 2021
Published online: September 6, 2021
Processing time: 111 Days and 17.7 Hours
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.