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Treatment for Anal fistula Dr. Wong Siu Wang North District Hospital Joint Hospital Surgical Grand Round Sept 2006.

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Presentation on theme: "Treatment for Anal fistula Dr. Wong Siu Wang North District Hospital Joint Hospital Surgical Grand Round Sept 2006."— Presentation transcript:

1 Treatment for Anal fistula Dr. Wong Siu Wang North District Hospital Joint Hospital Surgical Grand Round Sept 2006

2 Classification Parks classification Parks classification Intersphincteric Intersphincteric Trans-sphincteric Trans-sphincteric Supra-sphincteric Supra-sphincteric Extra-sphincteric Extra-sphincteric High vs Low High vs Low Simple vs Complex Simple vs Complex BJS 1976;63:1-12

3 Etiology Crytogenic Crytogenic Inflammatory bowel disease Inflammatory bowel disease Malignancy Malignancy Tuberculosis Tuberculosis Pelvic sepsis Pelvic sepsis

4 Etiology Crytogenic Crytogenic Inflammatory bowel disease Inflammatory bowel disease Malignancy Malignancy Tuberculosis Tuberculosis Pelvic sepsis Pelvic sepsis

5 Treatment of Anal fistula 1. Fistulotomy 2. Fistulectomy 3. Advancement flaps 4. Seton (loose, cutting, chemical) 5. Fibrin glue 6. Radiofrequency

6 1. Fistulotomy Standard treatment for low type fistula Standard treatment for low type fistula Recurrence rate ~5% - 10% Recurrence rate ~5% - 10% Minor incontinence rate ~6% - 26% Minor incontinence rate ~6% - 26% Stage fistulotomy for high type fistula Stage fistulotomy for high type fistula Recurrence rate ~5% – 8% Recurrence rate ~5% – 8% Minor incontinence rate ~50% Minor incontinence rate ~50% BJS 1995;82:895-7 BJS 1991;78:

7 Fistulotomy (New Modification) Marsupialisation Marsupialisation Suturing the divided wound edge to the edges of the curetted fibrous track Suturing the divided wound edge to the edges of the curetted fibrous track Results in smaller wound and faster healing Results in smaller wound and faster healing Colorectal Dis 2006;8:11-4 BJS 1998;85:

8 2. Fistulectomy Argument against fistulectomy Argument against fistulectomy RCT of Fistulectomy vs Fistulotomy RCT of Fistulectomy vs Fistulotomy Greater tissue loss leads to delayed healing Greater tissue loss leads to delayed healing Similar recurrence rates Similar recurrence rates BJS 1985;55:23-7

9 Fistulectomy Argument supporting fistulectomy Argument supporting fistulectomy Complete specimen for histology Complete specimen for histology Reduces risk of missing secondary tracks Reduces risk of missing secondary tracks Similar incontinence rate Similar incontinence rate Modification: Modification: Core out technique Core out technique Fistulectome Fistulectome

10 Fistulectome The fistulectome: a new device for treatment of complex anal fistulas by Core-Out fistulectomy. Dis Colon Rectum 2003;46: The fistulectome: a new device for treatment of complex anal fistulas by Core-Out fistulectomy. Dis Colon Rectum 2003;46:

11 Fistulectome Device for core out fistulectomy Device for core out fistulectomy Remove 2mm thickness of fistula tract Remove 2mm thickness of fistula tract Limited experience and results Limited experience and results Dis Colon Rectum 2003;46:

12 3. Endorectal advancement flap Treatment for high type fistula Treatment for high type fistula Close the internal opening with flap Close the internal opening with flap Mucosal flap for proximal fistula, anocutaneoeus flap for distal fistula Mucosal flap for proximal fistula, anocutaneoeus flap for distal fistula Contra-indication: acute sepsis, large internal opening, heavily scarred rectum Contra-indication: acute sepsis, large internal opening, heavily scarred rectum

13 Endorectal advancement flap Results in high type fistula Results in high type fistula Heterogenous, depend on length of FU Heterogenous, depend on length of FU Recurrence rate ~20% - 60% Recurrence rate ~20% - 60% Incontinence rate ~18.7% Incontinence rate ~18.7% Int J Colorectal Dis 1994;9:153-7 Int J Colorectal Dis 2006 Mar 15

14 4. Seton i. Loose Seton ii. Cutting Seton iii. Chemical Seton

15 i. Loose Seton Drainage of sepsis before definitive treatment (eg. Staged fistulotomy) Drainage of sepsis before definitive treatment (eg. Staged fistulotomy) Primary treatment for complex fistula Primary treatment for complex fistula

16 Loose Seton Procedure in St Marks Hospital Procedure in St Marks Hospital Tracks and extensions outside sphincter laid open Tracks and extensions outside sphincter laid open passage of Seton thro primary track across the external sphincter and tied loosely passage of Seton thro primary track across the external sphincter and tied loosely Outpatient review, remove Seton at 2-3 months if wound healed Outpatient review, remove Seton at 2-3 months if wound healed

17 Loose Seton Result for treatment of complex fistula Result for treatment of complex fistula Success rate 44% - 78% Success rate 44% - 78% Minor incontinence rate 17% - 36% Minor incontinence rate 17% - 36% Int J Colorectal Dis 1989;4: BJS 1990;77:

18 ii. Cutting Seton Analog to staged fistulotomy Analog to staged fistulotomy Cutting the fistula track with tightening of Seton Cutting the fistula track with tightening of Seton Balance between healing speed vs continence Balance between healing speed vs continence Material: silk, braided polyester, rubber band, Penrose drain Material: silk, braided polyester, rubber band, Penrose drain

19 Cutting Seton Results are heterogenous Results are heterogenous Average cutting time ~14-20 wks Average cutting time ~14-20 wks Recurrence rate ~5% (0-29%) Recurrence rate ~5% (0-29%) Minor incontinence rate ~50% Minor incontinence rate ~50% New Modification New Modification Snug Seton Snug Seton

20 Snug Seton 1mm elastic Seton 1mm elastic Seton Silicon nerve vessel retractor Silicon nerve vessel retractor Slow fistulotomy Slow fistulotomy T M Hammond et al T M Hammond et al 29 patients idiopathic fistula (~38% high type) Median cutting time 24 wks No recurrence Minor incontinence rate ~25% Colorectal Dis 2006;8:328-37

21 iii. Chemical Seton Kshara sutra, derived from plants (Ayurveda) Kshara sutra, derived from plants (Ayurveda) Antibacterial, anti- inflammatory properties, alkaline Antibacterial, anti- inflammatory properties, alkaline Weekly insertion Weekly insertion Slowly cut though the tissues Slowly cut though the tissues

22 Chemical Seton RCT comparing chemical Seton with fistulotomy in low type fistula RCT comparing chemical Seton with fistulotomy in low type fistula More painful with chemical Seton but no difference in healing time, complications or functional outcome More painful with chemical Seton but no difference in healing time, complications or functional outcome Tech Coloproctol 2001;5:137-41

23 5. Fibrin glue Fibrinogen solution +/- antibiotics Fibrinogen solution +/- antibiotics Promote healing thro fibroblast migration and activation, formation of collagen meshwork Promote healing thro fibroblast migration and activation, formation of collagen meshwork Before injection Before injection Curettage all granulation tissue and debris Curettage all granulation tissue and debris Contraindication: acute sepsis Contraindication: acute sepsis

24 Fibrin glue Results variable Results variable For complex fistula For complex fistula Successful rate ~50% Successful rate ~50% Septic complication 3% Septic complication 3% Dis Colon Rectum 2005;48: For simple fistula For simple fistula RCT fibrin glue vs conventional treatment for anal fistula RCT fibrin glue vs conventional treatment for anal fistula 42 patients 42 patients No advantage for fibrin glue over fistulotomy in simple fistula No advantage for fibrin glue over fistulotomy in simple fistula Dis Colon Rectum 2002;45:

25 6. Radiofrequency Radiofrequency scalpel Radiofrequency scalpel Fistulotomy/ fistulectomy Fistulotomy/ fistulectomy High frequency 4MHz radiowave High frequency 4MHz radiowave Mode: cutting, coagulation, fulgurate, bipolar Mode: cutting, coagulation, fulgurate, bipolar

26 Radiofrequency

27 Radiofrequency Principle Principle Transmit radio wave to tissue Transmit radio wave to tissue Cause tissue damage by intracellular heating Cause tissue damage by intracellular heating Low cutting temperature 60 – 90 0 C (vs 750 – C in diathermy) Low cutting temperature 60 – 90 0 C (vs 750 – C in diathermy) More precise cutting, less surrounding tissue damage, less tissue edema and pain More precise cutting, less surrounding tissue damage, less tissue edema and pain

28 Radiofrequency Two small scale randomized trial Two small scale randomized trial Diathermy fistulotomy vs Radiofrequency fistulotomy/ fistulectomy in low type fistula Diathermy fistulotomy vs Radiofrequency fistulotomy/ fistulectomy in low type fistula Less post-operative pain Less post-operative pain Earlier return to work Earlier return to work Shorter wound healing time Shorter wound healing time No difference in complication & recurrence No difference in complication & recurrence Eur Rev Med Pharmacol Sci 2004;8:111-6 Rom J Gastroenterol. 2003;12:287-91

29 Treatment of Anal fistula SUMMARY

30 Simple fistula Standard treatment Standard treatment Fistulotomy +/- Marsupialisation Fistulotomy +/- Marsupialisation Fistulectomy Fistulectomy Other treatments Other treatments Radiofrequency fistulotomy/ fistulectomy (emerging evidence) Radiofrequency fistulotomy/ fistulectomy (emerging evidence) Fibrin glue (lower healing rate, no advantage) Fibrin glue (lower healing rate, no advantage) Seton (prolong healing) Seton (prolong healing)

31 Complex fistula Initial treatment Initial treatment Loose Seton (low incontinence rate) Loose Seton (low incontinence rate) Other treatment Other treatment Advancement flaps (variable result) Advancement flaps (variable result) Fibrin glue (variable result) Fibrin glue (variable result) Cutting Seton (high incontinence rate) Cutting Seton (high incontinence rate) Snug Seton (need more evidence) Snug Seton (need more evidence) Stage fistulotomy (high incontinence rate) Stage fistulotomy (high incontinence rate)

32 Treatment for Anal fistula ~ End of presentation ~

33 Treatment of anal fistula Question and Answer

34 Definition (variable) High type High type Involving the anorectal ring Involving the anorectal ring Internal opening above dentate line Internal opening above dentate line Complex type Complex type High type High type Multiple side branches Multiple side branches Chronic inflammatory disease (Chrons) Chronic inflammatory disease (Chrons) Previous operation/ irridation Previous operation/ irridation

35 Incontinence scoring system Cleveland Clinic scoring system Cleveland Clinic scoring system Wexner Continence grading scale Wexner Continence grading scale Material: solid, liquid, gas Material: solid, liquid, gas Frequency: rare to always Frequency: rare to always

36 Fistulotomy and immediate reconstruction Reconstruct the divided musculature and primary wound closure Reconstruct the divided musculature and primary wound closure For low type fistula For low type fistula Study from Parkash et al Study from Parkash et al 120 patients 120 patients 98% low type fistula 98% low type fistula 88% wound healed by 2 weeks 88% wound healed by 2 weeks Recurrence rate 4% Recurrence rate 4% ANZJ Surg 1985;55:23-7

37 Fistulotomy and immediate reconstruction For complex fistula For complex fistula Prospective study by Perez F et al Prospective study by Perez F et al 35 patients with complex anal fistula 35 patients with complex anal fistula 85.7% high trans-sphincteric, 11.4% supra-sphincteric, 2.9% extra-sphincteric 85.7% high trans-sphincteric, 11.4% supra-sphincteric, 2.9% extra-sphincteric 31.4% incontinent patients reported improvement in continence scores 31.4% incontinent patients reported improvement in continence scores 12.5% continent patients reported minor alternations of continence (Wexner Continence Scale <4) 12.5% continent patients reported minor alternations of continence (Wexner Continence Scale <4) Recurrence rate 5.7% Recurrence rate 5.7% J Am Coll Surg 2005;200:


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