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High Anal Fistulas: Treatment-Options Fistula in ano Therapeutic Options in High Anal Fistulas A. Herold End- und Dickdarmzentrum Mannheim.

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Presentation on theme: "High Anal Fistulas: Treatment-Options Fistula in ano Therapeutic Options in High Anal Fistulas A. Herold End- und Dickdarmzentrum Mannheim."— Presentation transcript:

1 High Anal Fistulas: Treatment-Options Fistula in ano Therapeutic Options in High Anal Fistulas A. Herold End- und Dickdarmzentrum Mannheim

2 High Anal Fistulas: Treatment-Options „Standard Treatment“ of high fistulas prox. transsphincteric suprasphinctericFlap procedure extrasphincteric

3 High Anal Fistulas: Treatment-Options Flap procedure

4 High Anal Fistulas: Treatment-Options Athanasiadis S (1995): Int J Colorect Dis S. 153 TypenPersistenceRecurrence Transsph.1899 %17 % Suprasph.3520 %37 % Rectovag.1033 %40 % Recurrent f.2138 %47 % Crohn`s f.2928 %48 % Mucosal - flap: Results (1)

5 High Anal Fistulas: Treatment-Options Athanasiadis S (1995): Int J Colorect Dis S. 153 TypenPersistenceRecurrence Healing Transsph.1899 %17 %74 % Suprasph.3520 %37 %43 % Rectovag.1033 %40 %37 % Recurrent f.2138 %47 %15 % Crohn`s f.2928 %48 %24 % Mucosal - flap: Results (1)

6 High Anal Fistulas: Treatment-Options AuthorYearnTypeRec„Incont“ Williams9113mixed0 %62 % Garcia-Aguilar85151mixed2 %10 % Wedell8730trans3 %0 % Girona8796trans/supra3/8 %8/19 % Oh9315mixed13 %- EDZ0341trans10 %0 % Athanasiadis94189trans20 %21 % Athanasiadis8381mixed21 %- Schouten9944trans25 %- Jones8739trans31 %- Gustafsson0242trans45 %11 % Baeten0541mixed63 % (3Ja.) 17 % Mucosal - flap: Results (2)

7 High Anal Fistulas: Treatment-Options n = 88, 04/2001 – 04/2004, Follow up: 35 mo (18 - 60 mo), 18% recurrent, 12% horse shoe, without Crohn´s, Transsphincteric: n = 41 Total Healing: n = 35 (85 %) Primary Healing:n = 27 (66 %) EDZ - Results (transsphincteric)

8 High Anal Fistulas: Treatment-Options Transsphincteric: n = 41 Total Healing: n = 35 (85 %) Primary Healing:n = 27 (66 %) Persistence: n = 10 (24 %) Recurrence:n = 4 (10 %) EDZ - Results (transsphincteric) n = 88, 04/2001 – 04/2004, Follow up: 35 mo (18 - 60 mo), 18% recurrent, 12% horse shoe, without Crohn´s, Re-Flap healed: n = 2 Fistulectomy:n = 5 Excision + Reconst:n = 1 Still persisting:n = 6 Total Healing Rate with Flap: 71 % (Incontinent: 0%)

9 High Anal Fistulas: Treatment-Options Treatment Alternatives Anal Fistula Plug Fibrine Glue Fistulectomy and secondary repair Fistulectomy and primary repair Longterm – Seton

10 High Anal Fistulas: Treatment-Options A nal - F istula - P lug (AFP) Surgisis Anal Fistula Plug

11 High Anal Fistulas: Treatment-Options AFP - Procedure

12 High Anal Fistulas: Treatment-Options n = 25 Pat. (transsphincteric Fistulas), kryptoglandular, FU: 13 wks. Johnson E, Armstrong D (USA): Dis Colon Rectum 2006 S. 371 nHealing Fibrine1040 % Plug1587 % AFP: First Prospective Trial

13 High Anal Fistulas: Treatment-Options n = 20 Pat. (36 transsphincteric Fistulae), Crohn`s Disease, FU: 10 Mo. (3 – 24) O`Connor L, Armstrong D (USA): Dis Colon Rectum 2006 S. 1569 nHealing Simple Fistula13100 % Komplex Fistula745 % Total2080 % AFP: Prospective Trial

14 High Anal Fistulas: Treatment-Options Anal Fistula Plug: Results (USA) AuthorYearnFUHealing Robb (ASCRS 2004) 041712 Mo Champagne (Armstrong) 064612 Mo Poirier (Abcarian) 06283 Mo Ky (New York) 07423 Mo Christoforidis (Mineapolis) 07573 Mo Cintron (USA) 07283 Mo Abbas (Efron LA) 07177 Mo Safar (Wexner) 07394 Mo

15 High Anal Fistulas: Treatment-Options AuthorYearnFUHealing Robb (ASCRS 2004) 041712 Mo65 % Champagne (Armstrong) 064612 Mo83 % Poirier (Abcarian) 06283 Mo54 % Ky (New York) 07423 Mo81 % Christoforidis (Mineapolis) 07573 Mo40 % Cintron (USA) 07283 Mo54 % Abbas (Efron LA) 07177 Mo24 % Safar (Wexner) 07394 Mo14 % Anal Fistula Plug: Results (USA)

16 High Anal Fistulas: Treatment-Options Anal Fistula Plug: Results (Europe) AuthorYearnFUHealing Lenisa (I) 07278 Mo85 % Van Koperen (NL) 07177 Mo41 % Garg (Ind) 07276 Mo66 % Bohe (Sw) 07326 Mo66 % Thekkinkattil (UK) 07386 Mo39 % AFP-Workshop0715-25< 6 Mo41-70 %

17 High Anal Fistulas: Treatment-Options Anal Fistula Plug: Results Germany (Follow up 6 Mo.) AuthornFUHealing Schwandner (Gießen) 60 trans. Soetje (Wiesbaden) 59 trans. Scherer (Berlin) 25Ftr/Fsu Schwandner (Regensburg) 19 trans. Herold (Mannheim) 18trans Peters (Köln) 13trans. Kolbus (Leipzig) 7trans. Pakravan (Düsseldorf) 6trans

18 High Anal Fistulas: Treatment-Options AuthornFUHealing Schwandner (Gießen) 60 trans. 63 % Soetje (Wiesbaden) 59 trans. 74 % Scherer (Berlin) 25Ftr/Fsu48 % Schwandner (Regensburg) 19 trans. 61 % Herold (Mannheim) 18trans39 % Peters (Köln) 13trans.38 % Kolbus (Leipzig) 7trans85 % Pakravan (Düsseldorf) 6trans66 % Anal Fistula Plug: Results Germany (Follow up 6 Mo.)

19 High Anal Fistulas: Treatment-Options Anal Fistula Plug Fibrine Glue Fistulectomy and secondary repair Fistulectomy and primary repair Longterm – Seton AuthorYearnFUHealing Abel (USA) 9367 Mo75 % Cintron (USA) 005312 Mo72 % Patrlj (Yug)003028 Mo70 % Lindsey (GB)021717 Mo43 % Chan (GB)02106 Mo60 % Sentovich (USA)033622 Mo69 % Zmora (USA)031012 Mo33 % Buchanan (GB)031614 Mo16 % Loungnarath (USA) 0422< 26 Mo23 % Treatment Alternatives

20 High Anal Fistulas: Treatment-Options Anal Fistula Plug Fibrine Glue Fistulectomy and secondary repair Fistulectomy and primary repair Longterm – Seton Treatment Alternatives

21 High Anal Fistulas: Treatment-Options Fistulectomy and Secondary Repair

22 High Anal Fistulas: Treatment-Options AuthorYearnSuccess Keighley (GB) 831961 % Browning (GB)849778 % Fang (USA)847989 % Christiansen (DK)872360 % Laurberg (USA) 881947 % Ctercteko (USA)885864 % Yoshioka (GB)892774 % Jacobs (NL)903783 % Fleshman (USA)915551 % Wexner (USA)911676 % Arnaud (F)914063 % Engel (NL)945576 % Oliveira (USA)965571 % Mölle (CH)973374 % Halverson (USA)014541 % EDZ (D)043287 % Total: 35 Studies:Success rate 75 % (41 – 89 %) Secondary Repair: Results

23 High Anal Fistulas: Treatment-Options Treatment Alternatives Anal Fistula Plug Fibrine Glue Fistulectomy and secondary repair Fistulectomy and primary repair Longterm – Seton

24 High Anal Fistulas: Treatment-Options Fistulectomy and Primary Repair

25 High Anal Fistulas: Treatment-Options Fistulectomy and Primary Repair (2) : Episioproctectomy

26 High Anal Fistulas: Treatment-Options AuthorYearnTypeDehiscenceRecurr.Incontinence Parakash (Ind) 85120distal-2,5 %- Lux (D) 9146mixed00%20 % (1+2°) Christiansen (DK) 9514mixed-15 %21% (1+2°) Gemsenjäger (CH) 9621mixed5 %5 %5 % Lewis (GB) 9632mixed-9,5 % Roig (E) 9931mixed4 %10 %24% (1+2°) Perez (E) 0535mixed-6 %12 % Herold (D) 0534mixed8% (14%) 6 % - Perez (E) 0616mixed06 % (improved) Herold (D) 0684mixed5% (11%) 6 %no 3° Primary Repair: Results

27 High Anal Fistulas: Treatment-Options Primary Repair: Results correlated with involved Sphincter (1) 123

28 High Anal Fistulas: Treatment-Options √ 2,5% √ 4 % Primary Repair: Results correlated with involved Sphincter (2) Dehiscence: 0% - 20% Recurrence: 20% - 50%

29 High Anal Fistulas: Treatment-Options Dehiscence: n = 6 ( 5%) Recurrence:n = 19 (16%) Total: n = 120 Total Healing: n = 114 (94%) Primary Healing:n = 95 (79%) EDZ - Results (preliminary) n = 148, 11/2004 – 10/2007, Follow up: 20 mo (12 - 48 mo) Total Healing Rate with Primary Reconstruction: 84 % Re-Rekonstruktion: n = 6  Healing (1 Stoma) :n = 4  Persisting Fistula: n = 2 Re-Do: n = 19  Fistulectomy :n = 12  Persisting Fistula: n = 4  Rekonstruktion:n = 3 (2)

30 High Anal Fistulas: Treatment-Options Treatment Alternatives Anal Fistula Plug Fibrine Glue Fistulectomy and secondary repair Fistulectomy and primary repair Longterm – Seton

31 High Anal Fistulas: Treatment-Options Healing Rate Anal Fistula Plug 40% (15 – 85%) Flap-Procedure70% (50 – 80%) Fistulectomy with secondary Sphincter Reconstruction > 95% Fistulectomy with primary Sphincter Reconstruction 90% (80 – 95%) Fibrine Glue15% (10 – 70%) Longterm – Seton0% Conclusion:

32 High Anal Fistulas: Treatment-Options Healing Rate Incontinence (2° + 3°) Anal Fistula Plug 40% (15 – 85%) 0% Flap-Procedure70% (50 – 80%) < 10% Fistulectomy with secondary Sphincter Reconstruction > 95%20 – 50% Fistulectomy with primary Sphincter Reconstruction 90% (80 – 95%) < 20% Fibrine Glue15% (10 – 70%) < 10% Longterm – Seton0%-- Conclusion:

33 High Anal Fistulas: Treatment-Options We are on the way ……. ….. but we are far from perfect ! Summary

34 High Anal Fistulas: Treatment-Options


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