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Current Management of Fistula-in-ano Dr. Leung Tak Lun Canice Department of Surgery North District Hospital.

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Presentation on theme: "Current Management of Fistula-in-ano Dr. Leung Tak Lun Canice Department of Surgery North District Hospital."— Presentation transcript:

1 Current Management of Fistula-in-ano Dr. Leung Tak Lun Canice Department of Surgery North District Hospital

2 Case Presentation M/47 M/47 Hx of perianal abscess Hx of perianal abscess On and off perianal discharge On and off perianal discharge P/E P/E FIA with external opening at 4 oc position, 3cm from anal verge FIA with external opening at 4 oc position, 3cm from anal verge Internal opening at 4 oc, above dentate line Internal opening at 4 oc, above dentate line

3 EUA and Rigid sigmoidoscopy EUA and Rigid sigmoidoscopy Transpincteric FIA with ext. opening at 4 oc Transpincteric FIA with ext. opening at 4 oc Internal opening at 4 oc, above dentate line Internal opening at 4 oc, above dentate line External tract at left ischorectal fossa excised External tract at left ischorectal fossa excised Seton inserted Seton inserted Plan for tightening of seton in 4/52 Plan for tightening of seton in 4/52

4 At 2 nd operation At 2 nd operation Seton already broken and lost Seton already broken and lost Basically healed fistula Basically healed fistula Curettage of granulation tissue done Curettage of granulation tissue done

5 Recurrence!! 4 months later 4 months later c/o persistent discharge c/o persistent discharge MRI offered MRI offered

6 MRI finding -> transphincteric type of FIA with bifurcation tract near the anus and ending at 5 and 7 o’clock position MRI finding -> transphincteric type of FIA with bifurcation tract near the anus and ending at 5 and 7 o’clock position

7 Reoperation Intra-op finding Intra-op finding Transphincteric FIA with external opening at 4 oc Transphincteric FIA with external opening at 4 oc Internal opening at 4cm from anal verge just below level of levator ani but at the top of internal sphinter Internal opening at 4cm from anal verge just below level of levator ani but at the top of internal sphinter Curettage of the track done and seton inserted again Curettage of the track done and seton inserted again

8 Follow up Well and no discharge Well and no discharge

9 Etiology Pre-existing abscess Pre-existing abscess Anal gland theory Anal gland theory Anal glands 8 or more in number Anal glands 8 or more in number Form small abscess at interspincteric plane when infected Form small abscess at interspincteric plane when infected Other causes include congenital, pelvic sepsis, trauma, hidradenitis suppurativa, haemorrhoid, iatrogenic, inflammatory bowel disease, TB, maligancy Other causes include congenital, pelvic sepsis, trauma, hidradenitis suppurativa, haemorrhoid, iatrogenic, inflammatory bowel disease, TB, maligancy

10 Parks Classification

11 Clinical presentation Anal discharge preceded by episode of pain and perianal swelling Anal discharge preceded by episode of pain and perianal swelling Repeated episode of perianal sepsis Repeated episode of perianal sepsis

12 Clinical assessment History History Physical examination Physical examination Palpation of the perineum Palpation of the perineum Digital examination Digital examination

13 Clinical assessment EUA EUA Light GA Light GA Palpation Palpation Methylene blue, hydrogen peroxide injection Methylene blue, hydrogen peroxide injection probing probing

14 Imaging modality Fistulogram Fistulogram Endoanal ultrasound Endoanal ultrasound MRI MRI

15 Fistulography Disappointing Disappointing Accuracy 16% only Accuracy 16% only Difficult to relate the track to the sphincter and levator ani Difficult to relate the track to the sphincter and levator ani The acute track are just column of inflamed granulation tissue without a lumen The acute track are just column of inflamed granulation tissue without a lumen

16 Endoanal ultrasound High accuracy (93%) of predicting the site of internal opening of an anal fistula High accuracy (93%) of predicting the site of internal opening of an anal fistula Overall concordance for type of fistula is 82% Overall concordance for type of fistula is 82% Colorectal Disease, 4,

17 Hydrogen peroxide improve the concordance with type of fistula from 80% to 89% Hydrogen peroxide improve the concordance with type of fistula from 80% to 89% Colorectal Disease, 4,

18 Endoanal ultrasound

19 MRI Advantage of MRI Advantage of MRI Multiplanar imaging Multiplanar imaging High soft tissue differentiation to show the track system in relation to the underlying anatomy in a projection relevant to surgical exploration High soft tissue differentiation to show the track system in relation to the underlying anatomy in a projection relevant to surgical exploration

20 MRI Concordance rate with surgical exploration of 86% to 88% in initial reports Concordance rate with surgical exploration of 86% to 88% in initial reports Currently Currently Up to 100% sensitivity for primary tract Up to 100% sensitivity for primary tract 96% for abscess 96% for abscess 100% for horse extension 100% for horse extension 96% for internal opening 96% for internal opening

21 Axial / Coronal view

22 T1 axial T2 axial

23 T1 coronal T2 coronal

24 Gadolinium enhancement with fat suppression – axial view

25 Gadolinium enhancement with fat suppression – coronal view

26 Role of Imaging FIA has significant recurrence rate up to 25% FIA has significant recurrence rate up to 25% Due to part of the track system not being recognised at surgery Due to part of the track system not being recognised at surgery Inadequate drainage of sepsis Inadequate drainage of sepsis False communication found by injudicious probing False communication found by injudicious probing

27 Radiology can demonstrate clinically undetected sepsis, can guide initial surgery and reveal the site of residual sepsis Radiology can demonstrate clinically undetected sepsis, can guide initial surgery and reveal the site of residual sepsis

28 In one prospective study of MRI in primary fistula (BJS 2002) In one prospective study of MRI in primary fistula (BJS 2002) 30 patients 30 patients MRI led to further exploration in 2 cases MRI led to further exploration in 2 cases 1 patient require further surgery at a median FU of 12 months 1 patient require further surgery at a median FU of 12 months

29 Other prospective study (Lancet 2002; 360: ) Other prospective study (Lancet 2002; 360: ) 71 patients 71 patients Agreement between MRI and surgery in 25 cases -> 12% recurrence Agreement between MRI and surgery in 25 cases -> 12% recurrence MRI led to further surgery in 15 cases -> 13.3% recurrence MRI led to further surgery in 15 cases -> 13.3% recurrence Disagreement in 31 cases but no further surgery undertaken -> 51.6% recurrence Disagreement in 31 cases but no further surgery undertaken -> 51.6% recurrence

30 Recurrence rate for individual surgeons who always, sometimes or never acted on the discrepant MRI finding were 16%, 30%, 57% respectively Recurrence rate for individual surgeons who always, sometimes or never acted on the discrepant MRI finding were 16%, 30%, 57% respectively

31 Treatment outcome Low FIA Low FIA

32

33

34 Fibrin glue injection Fibrin glue injection

35 The End


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