ANORECTAL FISTULA Treatment Dr. Ayed Haddad Consultant Colorectal & General Surgeon
TREATMENT Principles Preoperative preparation: A disposable enema in the morning of operation Anesthesia: GA without muscle relaxant Spinal & epidural are CI – render pelvic floor & sphincters flaccid Position: Lithotomy Prone Lithotomy for posterior F; Prone for anterior F
Identifying the fistula tract Identifying the fistula tract - induration around the fistula is almost always identified by a careful palpation - internal opening is often felt - pressure over indurated area may be associated with the discharge of pus through the internal and external openings - traction of the external orifice will often define the internal opening and the course of the tract Saline or hydrogen peroxide irrigation Methylene blue Probing the tract Following the granulation tissue present in the fistula tract Surgical exploration of the intersphincteric plane
Probing the track A different & adequate choice of probes should be available. A soft, blunt-ended copper or silver probe with an eye (to insert a seton) is preferable. The probe should not be advanced progradely unless the probe lies almost parallel to the skin. Alternatively a probe may be advanced with a finger in the rectum, but do not push. If the probe in prograde insertion follows a course greater than 20 degree from the perianal skin should be deferred for fear of creating a false passage.
Any probe passed progradely that follows a course parallel to the anal canal is either in a secondary tract from a trans-sphincteric fistula, in which case "pushing" will create an extrasphincteric fistula, or a long intersphincteric fistula. It is much safer to pass a probe retrogradely & to mark the fistula with a nylon thread or a silicone rubber seton if there is any doubt whatsoever about the course of the fistula track.
Treatment of the intersphincteric fistulas Simple low ISF treated by lay open or excision of the tract i.e. the lower fibers of the internal sphincter and the anal mucosa.
Treatment of the intersphincteric fistulas ISF with a high blind tract - treated by extended internal sphicterotomy and excision of the anal mucosa.
Treatment of the intersphincteric fistulas ISF with a high tract opening into the rectum. The entire fistula tract is laid open, dividing the internal anal sphincter.
Treatment of the intersphincteric fistulas ISF with a high tract without a perineal opening - excision of the whole of the internal anal sphincter, and laying open the entire intersphincteric space.
Treatment of the intersphincteric fistulas ISF with a high tract and a supralevator abscess - extended sphincterotomy with excision of the anorectal mucosa. Drainage of the abscess through the perineum suprasphincteric fistula
Treatment of the intersphincteric fistulas ISF secondary to pelvic disease - The lower component of the fistula tract is laid open and the pelvic sepsis is drained while the pelvic disease is dealt with.
Treatment of the trans-sphincteric fistulas 4 options for the management of mid or high TSF: 1- fistulotomy 2- seton fistulotomy 3- excision of the fistula track only + closure of the defects by suture or mucosal advancement flap (labial fat pad advancement = Martius technique) 4- laying open the track & total sphincter reconstruction, usually with a covering stoma (exclusively for high fistulas)
Treatment of the trans-sphincteric fistulas Simple TSF - low – fistulotomy (only the lower fibers of the external sphincter are divided) / fistulectomy - mid / high – fistulotomy ; fistulectomy + closure of the defect ; seton
Treatment of the trans-sphincteric fistulas TSF with a high blind track - coring out the fistula, excision of the internal anal sphincter & drainage of the ischiorectal fossa. Drainage of the abscess through the rectum / overenthusiastic probing or curettage of the abscess (rectal perforation) extrasphincteric fistula
Treatment of the suprasphincteric fistulas Simple SSF – resection of the track lying lateral to the external sphincter & closure of the defect in levator ani + excision of the IS component (sphincterotomy). OR resection of the whole track + closure of the defect in levator ani + closure of the internal opening by mucosal advancement flap
Drainage of the abscess through the rectum ESF Treatment of the suprasphincteric fistulas With supralevator extension and abscess – as for simple SSF + wide drainage of the abscess through the perineum. Drainage of the abscess through the rectum ESF
Treatment of the extrasphincteric fistulas ESF secondary to anorectal sepsis : - TSF – excision; fistulotomy (if low) or seton for the TSF + excision of ES track + closure of the rectal defect by direct suture or preferably by anorectal advancement flap ± colostomy
Treatment of the extrasphincteric fistulas ESF secondary to trauma - removal of any foreign body, debridement of any devitalized tissue, & construction of a proximal stoma healing. If not - close the defect with an advancement flap if the sphincters are intact or by complete sphincter repair if there is a substantial defect.
Treatment of the extrasphincteric fistulas ESF secondary to pelvic sepsis – treatment of the causative disease + drainage of the pelvic abscess + drainage through ischiorectal fossa
Treatment of horseshoe fistula Intersphincteric fistulas – excision rather than division of the internal sphincter Suprasphincteric fistulas – long internal sphincterotomy Extrasphincteric fistulas - loose setons or mushroom catheters in the supra-sphincteric space or, in the case of collections in the deep postanal space dislocating the levator ani from the coccyx.
Transphincteric fistulas: Treatment of horseshoe fistula Transphincteric fistulas: 1- laying open all the tracks, identifying the trans-sphincteric midline entry site and laying it open (if there is an anterior track – ay open)
Treatment of horseshoe fistula 2- Partial fistulectomy confined to the internal opening or T-shaped portion of the fistula track so that the intersphincteric and trans-sphincteric components only are laid open and the side tracks merely curetted 3-Fistulectomy of the primary TSF & excision of all the secondary extensions. Any defect in the muscle is closed by direct suture, or the internal defect by an advancement flap 4- Seton for the posterior trans-sphincteric opening & laying open or excision of the lateral horseshoe side tracks
Special considerations in patients with Crohn's disease drainage alone – healing in 2/3 with rectal involvement any fistula surgery is CI high proctectomy rate especially with anorectal involvement anorectal advancement flap is not always possible & has bad results loose seton for drainage of sepsis is a good alternative fistulotomy or seton may be indicated with low anal fistula & normal anorectum
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