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The Best Surgical Treatment for Fistula-in-ano Dr John Wong PYNEH.

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Presentation on theme: "The Best Surgical Treatment for Fistula-in-ano Dr John Wong PYNEH."— Presentation transcript:

1 The Best Surgical Treatment for Fistula-in-ano Dr John Wong PYNEH

2 Etiology  Cryptoglandular theory  Trauma  Foreign body  Iatrogenic  Malignancy  Crohn’s disease  Tuberculosis  HIV J.G.Williams et al. Colorectal Disease 2007

3 Classification  Park’s classification (1976) J.G.Williams et al. Colorectal Disease 2007

4 Goodsall’s rule 49% 90% J.G.Williams et al. Colorectal Disease 2007

5 Investigation

6  Indications:  Complex fistula  Impaired sphincter function  Suspicious of secondary cause

7 Investigation  Anatomy  Endoanal Ultrasound, MRI  Physiology  Anorectal manometry  Cause  Inflammatory marker, colonoscopy, rectal biopsy

8 Endoanal Ultrasound  High accuracy (93%) to identify the internal opening  Injection of hydrogen peroxide can increase the detection rate ANZ J. Surg. 2005; 75: J.G.Williams et al. Colorectal Disease 2007

9 Endoanal Ultrasound  Disadvantage:  Pain and discomfort  Operator dependent  Limit field ~2cm from probe Limited use for trans-sphincteric or more complex FIA!

10 MRI  Gold standard  Multi-planar image  Show the fistula system in relation to the underlying anatomy  High sensitivity  Primary track: 86%  Secondary track: 91%  Horseshoe extesion 97% ANZ J. Surg. 2005; 75: J.G.Williams et al. Colorectal Disease 2007

11 Treatment

12 Principles of management  To drain abscess  To deal with the secondary track if any  Definitive treatment of the primary track

13 Fistulotomy  Lay-opening of the fistula track from external opening to internal opening  Inter-sphincteric fistula  Recurrence rate 0-21%  Disturbance in continence: 0 to 82%  Extent of external sphincter division: <30% J.G.Williams et al. Colorectal Disease 2007

14 Fistulectomy  Excision of the entire fistula track  Low lying fistula  No advantage in both recurrence and incontinence rate compared with fistulotomy  High lying fistula  ‘Core out’ technique + internal sphincterotomy Surgical intervention for anorectal fistula. The Cochrane Collaboration 2010

15 Fistulectomy + Internal Sphincterotomy

16 Seton Loose seton  Achieve drainage of the fistula track  Allow any secondary track to heal  As part of staged fistulotomy J.G.Williams et al. Colorectal Disease 2007

17 Staged fistulotomy  Low recurrence rate  Significant rate in incontinence  Major incontinence rate up to 42% J.G.Williams et al. Colorectal Disease 2007

18 Seton Tight (cutting) seton  Commonly used in high transphincteric fistula  Divide the muscle slowly to produce a gradual fistulotomy J.G.Williams et al. Colorectal Disease 2007

19 Low recurrence rate Disturbance of fine control is common Major incontinence rate >10% (up to 43%) J.G.Williams et al. Colorectal Disease 2007

20 Fibrin Glue  Fibrin clot to seal the track  Stimulate the migration, proliferation and activation of the fibroblasts  Sphincter-sparing method A.I. Malik & R.L. Nelson; Colorectal Disease 2008

21 Fibrin Glue  High recurrence rate  Long term healing rate(~14% - 60%) A.I. Malik & R.L. Nelson; Colorectal Disease 2008

22 Anal Fistula Plug  Sphincter-sparing method  Bioprosthetic plug  Internal opening must be identified

23 Anal Fistula Plug  Controversial results from different centre P. Garg et al. Colorectal Disease 2010 HYS Cheung et al. Surgical Practice 2009 PYNEH %

24 Advancement Flap + core out fistulectomy  Sphincter-sparing method  Pre-op bowel prep and antibiotics cover  Internal opening must be identified

25 Advancement Flap + core out fistulectomy  Low long term success rate  High recurrence due to:  Small flap  Excessive tension J.G.Williams et al. Colorectal Disease 2007

26 LIFT  Ligation of Intersphincteric Fistula Tract  Rojanasakul in 2007

27 LIFT  Short term success rate was encouraging (~57-94%)  Long term result still unknown Arch Surg. 2011;146(9):

28 Conclusion  No single best treatment for FIA  Treatment for FIA must be individualized  Types of the fistula  Premorbid sphincter function

29 Recommendation  Inter-sphincteric fistula (High / low lying, with or without internal opening) Fistulotomy

30 Trans-sphincteric / Supra-sphincteric fistula No internal opening Fibrin Glue Core out fistulectomy + exploration of inter-sphincteric plane +/- internal sphincterotomy

31 Trans-sphincteric / Supra-sphincteric fistula With internal opening High risk of incontinence AFP Advancement Flap Core out fistulectomy + internal sphincterotomy Cutting seton / Staged Fistulotomy Low risk of incontinence Core out fistulectomy + internal sphincterotomy Cutting seton / Staged Fistulotomy

32 Recommendation  Extra-sphincteric fistula  Usually associated with an underlying cause  Treat the underlying cause  Drain any sepsis  Never disrupt or explore the sphincter

33 Thank you!

34 Exception for Goodsall’s rule - Horseshoe fistula - Long track that extend to the anterior quadrant of the anal canal - Crohn’s disease - Iatrogenic

35 Fistulogram  Accuracy ~16-50% only  Difficult to relate the track to the sphincter anatomy  The acute track are just column of granulation tissue without a lumen  Need external opening  Painful

36 Fistulotomy in acute anorectal sepsis  Pros:  decrease the rate of recurrent anorectal sepsis  Cons:  increase risk of impair continence  Some individuals would have unnecessary surgery  Fisulotomy should be performed when internal opening can be found and the fistula is submucosal or intersphincteric (low lying) J.G.Williams et al. Colorectal Disease 2007

37 Radiofrequency fistulotomy  Use of radio-wave as energy source  Less bleeding  Less pain  Quicker recovery  No difference in recurrence and incontinence rate Surgical intervention for anorectal fistula. The Cochrane Collaboration 2010

38 Fistulotomy with marsupialization  Suturing the edge of the track to its base  Less bleeding  Shorter healing time  No difference in recurrence and incontinence rate Surgical intervention for anorectal fistula. The Cochrane Collaboration 2010

39 Fistulotomy vs Fistulectomy  No difference in recurrence and incontinence rate A.I. Malik & R.L. Nelson; Colorectal Disease 2008

40 Chemical seton  Coated with layers of latex and plant extracts  Strong alkaline outer layer  Cut through tissue at a rate of 1cm every 6 days  More painful  Evidence on recurrence and healing rate remain inconclusive A.I. Malik & R.L. Nelson; Colorectal Disease 2008

41 Anal fistula plug  Better outcome in :  Deep trans-sphincteric fistula  Long track fistula  Narrow-gauge fistula

42 Advancement Flap  Contra-indications:  Presence of proctitis  Undrained sepsis  Malignant / radiation related fistula  Stricture of the anorectum  Severe sphincter defect  Severe peripheral scaring due to previous surgery J.G.Williams et al. Colorectal Disease 2007

43 FIA with Crohn’s disease  Medical treatment, eg. Anti TNF-alpha  Infliximab  Emergency treatment  Incision and drainage of the fistula  Stabilization  Insertion of seton to optimize drainage and medical therpay J.G.Williams et al. Colorectal Disease 2007

44 Incontinence scale  Flatus, mucus, liguid, solid stool  The Cleveland Clinic (Wexner) Incontinence Score  sum of 5 parameters is on a scale from 0 (=absent) to 4 (daily) frequency of incontinence to gas, liquid, solid, of need to wear pad, and of lifestyle changes.


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