1. Fistula-in-ano: a probing of the treatment options
David Jayne
Professor of Surgery
University of Leeds & Leeds Teaching Hospitals NHS Trust
John Goligher
Colorectal Unit

2. The Problem

3. Aetiology Cryptoglandular Crohn’s disease Other Malignant Obstetric
Radiation

4. Classification
45%
30%
20% 5%

6. Goodsall’s Rule

7. Treatment Aims Eradicate disease (if possible)
Preservation of continence
Benign condition
Quality of life

8. Principles Control sepsis Define anatomy Exclude co-existent disease
EUA
Laying open abscesses and secondary tracts
Adequate drainage – seton insertion
Define anatomy
Openings and tracts
Internal and External
Single –v- multiple
Extensions / Horseshoe
Relation to sphincter complex
High –v- Low
Exclude co-existent disease

9. MRI for fistula-in-ano
Abscesses &
Extensions
Contralateral disease
Other pathology
HALLIGAN Radiology 2006

10. Surgical Options – Fistulotomy
Fistula tract identified with probe
Extent of external sphincter involvement assessed
Tract and muscle divided
Secondary tracts laid open
+/- marsupialisation wound

11. Surgical Options – Cutting Seton
Lay open external tract
Draining seton replaced with cutting seton
1/0 Prolene suture
Tied tight around sphincter complex
Simultaneous slow cutting and repair of sphincter
May require re-tightening

12. Surgical Options – Fistulectomy
Draining seton
Core out tract
Direct visualisation of secondary tracts
Sphincter repair +/- advancement flap

13. Advancement Flaps Endorectal Fistula tract probed Flap raised
Mucosa + Int. Sphincter
Internal opening excised/closed
Flap advanced & sutured

14. Advancement Flap Anodermal Fistula tract probed Flap raised
Flap advanced & sutures
External defect closed

15. Fistula Plug

16. Fistula Plug

17. LIFT Procedure Ligation of Intersphincteric Fistula Tract
Transsphincteric fistula
Draining seton – 6 weeks
Tract prepared with fistula brush
Debrides
De-epithelializes

18. LIFT Procedure

19. PROS CONS Cutting Seton Simple Cheap Repeat EUA Recurrence 0 – 8%
Incontinence
minor 34 – 63%
major 2 – 26%
Fistulotomy
Recurrence 2 – 9%
Incontinence 50%
Advancement Flap
Can be difficult
?Preserves sphincter
Recurrence 25 – 50%
Incontinence 30 – 35%
Fistula Plug
Preserves sphincter
Plug expensive ~£400
Recurrence 20 – 85%
Continence preserved
LIFT
Recurrence %

20. ACPGBI FIAT Trial Fistula Plug Insertion Surgeon’s Preference
EUA: transsphincteric fistula ≥ 1/3 of sphincter complex
Insertion of draining seton
RANDOMISE
MRI fistulography
Advancement Flap
Cutting Seton
Fistulotomy
LIFT

21. ACPGB&I FIAT Primary end-points Faecal incontinence QoL Generic QoL
Patient identification
EUA & draining seton
Eligibility & Consent
Randomisation
1:1 plug –v- surgeon’s preference
6-week FU
6-monthFU
12-month FU
+ MRI scan
Surgisis® fistula plug
Surgeon’s preference
(fistulotomy, seton, advancement flap, LIFT)
MRI scan
Surgery
(6-weeks post seton insertion)
Primary end-points
Faecal incontinence QoL
Generic QoL
Secondary end-points
Healing – 12 months
Complications
Faecal incontinence
Re-interventions
Health resource utilisation
Cost effectiveness

22. FIAT FACTS
Recruitment: 76
Target: 500
Open centres: 36
Recruiting centres: 21

23. Join the FIAT Trial!

24. Fistula-in-ano: a probing of the treatment options
David Jayne
Professor of Surgery
University of Leeds & Leeds Teaching Hospitals NHS Trust
John Goligher
Colorectal Unit