Recent Advances in Surgical Management of Complex Cryptoglandular Anal Fistula YK Fong, Queen Mary Hospital

Agenda Introduction Management approach of anal fistula Etiology and pathogenesis Classification Management approach of anal fistula Assessment Surgical options Recent advances in surgical treatment

Etiology and Pathogenesis Cryptoglandular (90%) Extension of sepsis from infected anal glands in the intersphincter space Non-cryptoglandular Crohn’s disease Tuberculosis, actinomycosis Malignancy Hidradenitis suppurativa Radiation HIV infection Immunocompromised (chemotherapy/ diabetes)

Classification 1) Intersphincteric 2) Transphincteric 3) Suprasphincteric 4) Extrasphincteric

Anal Fistula Classification Complex: Treatment poses a high risk of incontinence Postoperative recurrence Multiple tracts Tract crosses >30-50% of external sphincter muscle Anterior in females Pre-existing incontinence American Gastroenterological Association American Gastroenterological Association

Complex Anal Fistula -Management Approach Assessment To rule out ongoing anorectal sepsis To delineate the anatomy of fistula tracts To look for non-cryptoglandular causes To look for any causes of poor wound healing Immunocompromised steroid application  Definitive treatment Two syringes fibrinogen, factor XIII, aprotinin, fibronectin thrombin and calcium solution A simple and repeatable technique Success rate improved by repeated injections Not interfere or compromise subsequent surgical options Avoid prolonged discomfort from wound dressing Better in more complex and longer fistula tracts Success rate: 14 to 85%

Principles of Treatment Control of sepsis Initial seton placement 6-12 weeks Allow adequate time for assessment Definite individualized surgery Closure of fistula Maintenance of continence

Surgical Treatment Options Conventional approaches Cutting Seton placement Staged fistulotomy Anorectal advancement flap Continence preserving approaches Fibrin glue Anal fistula plug Ligation of Intersphincteric Fistula Tract (LIFT) Video-Assisted Anal Fistula Treatment (VAAFT) Although complex fistulas are rare, various treatmentoptions are available, such as debridement and fibringlue injection, endorectal advancement flap closure, andthe use of seton and/or staged fistulotomy.1,4–8 Thesemethods have some elements of morbidity, particularly regardingrecurrence rates and incidence of fecal incontinence.

LIFT Procedure (Ligation of Intersphincteric Fistula Tract ) Rojanasakul et al. from Bangkok in 2007 Success rate: 17/18 (94.4%) Rojanasakul, Tech Coloproctol 2009

LIFT Procedure: A Simplified Technique for Anal Fistula Incision at the intersphincteric groove Identification of the intersphincteric tract Ligation of intersphincteric tract close to the internal opening Removal of intersphincteric tract Scraping out all granulation tissue Suturing the defect at external sphincter complex

Rationale of LIFT Procedure Prevention of recurrent sepsis Avoid entrance of fecal particles via internal opening Remove intersphincteric fistula tract Intermittent closed septic foci and persistent sepsis due to compression between sphincter muscles

LIFT Procedure Less injury to anal sphincter Short hospital stay Short healing time Primary healing rate 82.2% (37/45) Shanwani et al DCR 2010

BioLIFT Procedure A modification of LIFT Procedure Placement of biologic mesh in the intersphincteric space Barrier to re-fistulization BioLIFT Recently, a modification of the LIFT procedure has been described. After the fistula tract is identified and divided, a biologic mesh is placed in the intersphincteric space to act as a barrier to re-fistulization. A video presented at the 2010 American Society of Colon and Rectal Surgeons meeting demonstrated this technique with promising results in a single surgeon series. This procedure entails It is postulated that the benefit seen in this series derives from the bioprosthetic graft acting as a physical barrier to separate the transected ends of the fistula tract. The ability of the bioprosthetic grafts to tolerate contamination and be remodeled without a foreign body reaction makes them the most appropriate material to us in this application. Given our experience with the use of the small intestinal submucosal graft (Biodesign, Cook Surgical, Bloomington, IN) for rectovaginal fistulas, it was the only bioprosthetic used in this series. There are 2 potential drawbacks of the BioLIFT technique when compared with the LIFT procedure. To obtain the desired barrier effect, the bioprosthetic must overlap the closure of the fistula tract by at least 1 to 2 cm in all directions. This requires amore extensive dissection in the intersphincteric space than is usual for the LIFT procedure. The physiologic consequences of this dissection have not been studied. The other issue is the relatively high cost of the bioprosthetic materials. This series does not conclusively demonstrate a benefit that would justify the increased cost of the use of a bioprosthetic. C. Neal Ellis et al. Meeting of The American Society of Colon and Rectal Surgeons 2012

BioLIFT Procedure Bioprosthetic grafts Healing rate: 94% (29/31) Tolerate contamination Remodeling without a foreign body reaction Healing rate: 94% (29/31) BioLIFT Recently, a modification of the LIFT procedure has been described. After the fistula tract is identified and divided, a biologic mesh is placed in the intersphincteric space to act as a barrier to re-fistulization. A video presented at the 2010 American Society of Colon and Rectal Surgeons meeting demonstrated this technique with promising results in a single surgeon series. This procedure entails It is postulated that the benefit seen in this series derives from the bioprosthetic graft acting as a physical barrier to separate the transected ends of the fistula tract. The ability of the bioprosthetic grafts to tolerate contamination and be remodeled without a foreign body reaction makes them the most appropriate material to us in this application. Given our experience with the use of the small intestinal submucosal graft (Biodesign, Cook Surgical, Bloomington, IN) for rectovaginal fistulas, it was the only bioprosthetic used in this series. There are 2 potential drawbacks of the BioLIFT technique when compared with the LIFT procedure. To obtain the desired barrier effect, the bioprosthetic must overlap the closure of the fistula tract by at least 1 to 2 cm in all directions. This requires amore extensive dissection in the intersphincteric space than is usual for the LIFT procedure. The physiologic consequences of this dissection have not been studied. The other issue is the relatively high cost of the bioprosthetic materials. This series does not conclusively demonstrate a benefit that would justify the increased cost of the use of a bioprosthetic. C. Neal Ellis et al. Meeting of The American Society of Colon and Rectal Surgeons 2012

BioLIFT Procedure Potential drawbacks of the BioLIFT technique Requires extensive dissection in the intersphincteric space High cost of the bioprosthetic materials

Unsuitable Cases for LIFT Procedure External opening at intersphincteric groove Abscess cavity in intersphincteric space (friable tract) Large internal opening Specific causes: TB, Crohn’s

VAAFT (Video-Assisted Anal Fistula Treatment) Karl Storz endoscope A small-calibered rigidscope equipped with an optical channel, a working channel and an irrigation channel

VAAFT

VAAFT: Meinero technique Ablation of the fistula tract with unipolar electrode Closure of the internal opening with stapler Injection of cyanoacrylate into the fistula tract Meniero P. Tech Coloproctol 2011

VAAFT: Meinero technique 98 patients with complex fistula Performed under spinal anesthesia Operation time: 30 to 120 minutes Primary healing: 72 patients (73.5%) Healing time: 2-3 months No major complication or fecal incontinence Meniero P. Tech Coloproctol 2011

Conclusion Management principles of complex anal fistula Detailed assessment to exclude underlying disease Anatomical +/- functional assessment Tailored treatment To control and eradicate sepsis (stages) To remove tract and close internal opening To preserve continence

Thank you

Assessment Clinical Radiological Endoanal ultrasound Digital examination Examination under anesthesia (EUA) Anal manometry Radiological Endoanal ultrasound Magnetic resonance imaging Is it a simple or complex fistula

LIFT Procedure Prospective observational study All cryptoglandular infections May 2007 to September 2008 45 patients 33 transsphincteric 12 complex Median follow-up: 9 (range, 2-16) months Primary healing: 37/45(82.2%) Median healing time : 7 (range, 4-10) weeks Total bilirubin reached peak level earlier in groups with higher remnant liver volume. It reaches peak on day 1 to 2 post-operation in groups with remnant liver volume >=35%. While in groups with remnant liver volume <35%, total serum bilirubin peaked on post-operative day 3. Shanwani et al DCR 2010

QMH Experience Since January 2009 25 patients 24 transphincteric fistula 1 suprasphincteric fistula 15 recurrenct Median operating time: 39 minutes (range 15-73) Median hospital stay: 1 day Perianal incision healing time: 14 days Closure of external opening: 31 days Median follow-up 9.8 months (range 1-21.5) 2/25 (11%) recurrent rate Since Janurary 2009, twenty-five patients were included (19 male and 6 female) with median age of 48 years (range 22 – 64). There were 24 patients with transsphincteric fistulas and one with suprasphincteric fistula. The median distance between the external opening and the anal verge was 3 cm (range 1-15). Ten patients had first presentation of anal fistulas while the others had recurrent fistulas with previous interventions, including 11 with fistulotomy, 13 with seton insertion and 2 with anal fistula plug. Four patients had more than one procedure before the LIFT procedure. The median operating time and median hospital stay were 39 minutes (range 15-73) only one day (range 0.5-4) respectively. Perianal incision wound healed completely in 22% of our patients in the first and then up to 89% in the second follow-up, at the median time of 14 days (range 7-63). Closure of external opening of anal fistulas was noted in 72% of our patients in the first and 89% in the second follow-up, at the median time of 31 days (range 7-63). There were no complications such as incontinence or bleeding. During the median follow-up of 9.8 months (range 1-21.5), two patients (11%) had persistent fistula after the LIFT procedure. One patient had suprasphincteric fistula

VAAFT To identify the internal opening under direct endoscopic view and then close it with suturing or stapler To ablate or remove the granulation tissue along the fistula tract To fill the fistula tract with bio-prosthetic material

There is great variation in both technical difficulty and efficacy among other sphincter-preserving options for complex cryptoglandular fistulas. Mucosal advancement flaps are technically challenging and are associated with recurrence rates that vary from 2 to 54% [10–14]. These failure rates may result from some mobilization of structures or a tendency for the flap to retract or dehisce. Moreover, advancement flaps are often associated with postoperative incontinence, and the incidence of this complication has been reported to approach 35% in some series [14]. Fibrin glue injection is a technically easy, low-risk technique but results have been disappointing, showing success rates as low as 16% long term [15–20]. Similarly, the use of the anal fistula plug is a simple, sphincter-sparing technique, but very expensive [21] and with reported success rates ranging between 29% and 87% [22–26]. The latest conservative technique reported in literature is the ligation of intersphincteric fistula tract (LIFT) pro- cedure. This approach consists of ligation of the tractfistula tract. In a group of 17 patients with a median follow- up of 9 months, they report an 82.3% healing rate. This approach, like VAAFT, is aimed at destroying the tract and preserving the sphincters, but it is a procedure performed blindly, without advantages in identifying the internal opening, secondary tracts and abscess cavities. The ratio- nale of the VAAFT technique is based on the same prin- ciples as other procedures for closing the internal opening and obliterating the track, where the real innovation is the precise identification of the fistula anatomy and of the internal opening by fistuloscopy and fulguration of the tract walls under direct vision. This approach allows the iden- tification and treatment of all the secondary tracts, and the abscess cavities connected to the main pathway. We believe that the adoption of fistuloscopy together with a good technique for closing the internal opening (with a stapler or manually) and reinforcing the closure of the opening from the inner side of the staple/suture line is the most effective way of achieving a high healing rate for