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Treatment for Anal fistulaTreatment for Anal fistulaDr. Wong Siu WangDr. Wong Siu Wang
North District HospitalNorth District HospitalJoint Hospital Surgical Grand RoundJoint Hospital Surgical Grand Round
Sept 2006Sept 2006
ClassificationClassification
Parks classificationParks classification IntersphinctericIntersphincteric Trans-sphinctericTrans-sphincteric Supra-sphinctericSupra-sphincteric Extra-sphinctericExtra-sphincteric
High vs LowHigh vs Low Simple vs ComplexSimple vs Complex
BJS 1976;63:1-12
EtiologyEtiology
CrytogenicCrytogenic Inflammatory bowel diseaseInflammatory bowel disease MalignancyMalignancy TuberculosisTuberculosis Pelvic sepsisPelvic sepsis
EtiologyEtiology
CrytogenicCrytogenic Inflammatory bowel diseaseInflammatory bowel disease MalignancyMalignancy TuberculosisTuberculosis Pelvic sepsisPelvic sepsis
Treatment of Anal fistulaTreatment of Anal fistula
1.1. FistulotomyFistulotomy
2.2. FistulectomyFistulectomy
3.3. Advancement flapsAdvancement flaps
4.4. Seton (loose, cutting, chemical)Seton (loose, cutting, chemical)
5.5. Fibrin glueFibrin glue
6.6. RadiofrequencyRadiofrequency
1. Fistulotomy1. Fistulotomy
Standard treatment for low type fistulaStandard treatment for low type fistula Recurrence rate ~5% - 10%Recurrence rate ~5% - 10% Minor incontinence rate ~6% - 26%Minor incontinence rate ~6% - 26%
Stage fistulotomy for high type fistulaStage fistulotomy for high type fistula Recurrence rate ~5% – 8%Recurrence rate ~5% – 8% Minor incontinence rate ~50%Minor incontinence rate ~50%
BJS 1995;82:895-7BJS 1995;82:895-7
BJS 1991;78:1159-61BJS 1991;78:1159-61
Fistulotomy (New Modification)Fistulotomy (New Modification)
MarsupialisationMarsupialisation Suturing the divided wound edge to the edges Suturing the divided wound edge to the edges
of the curetted fibrous trackof the curetted fibrous track Results in smaller wound and faster healingResults in smaller wound and faster healing
Colorectal Dis 2006;8:11-4Colorectal Dis 2006;8:11-4
BJS 1998;85:105-107BJS 1998;85:105-107
2. Fistulectomy2. Fistulectomy
Argument against fistulectomyArgument against fistulectomy RCT of Fistulectomy vs FistulotomyRCT of Fistulectomy vs Fistulotomy Greater tissue loss leads to delayed healingGreater tissue loss leads to delayed healing Similar recurrence ratesSimilar recurrence rates
BJS 1985;55:23-7BJS 1985;55:23-7
FistulectomyFistulectomy
Argument supporting fistulectomyArgument supporting fistulectomy Complete specimen for histologyComplete specimen for histology Reduces risk of missing secondary tracksReduces risk of missing secondary tracks Similar incontinence rateSimilar incontinence rate
Modification:Modification: Core out techniqueCore out technique FistulectomeFistulectome
FistulectomeFistulectome
The fistulectome: a new device for treatment of complex anal The fistulectome: a new device for treatment of complex anal fistulas by “Core-Out” fistulectomy. fistulas by “Core-Out” fistulectomy. Dis Colon Rectum Dis Colon Rectum 2003;46:1566-712003;46:1566-71
FistulectomeFistulectome
Device for core out Device for core out fistulectomyfistulectomy
Remove 2mm Remove 2mm thickness of fistula thickness of fistula tracttract
Limited experience Limited experience and resultsand results
Dis Colon Rectum 2003;46:1566-71
3. Endorectal advancement flap3. Endorectal advancement flap
Treatment for high type fistulaTreatment for high type fistula Close the internal opening with flapClose the internal opening with flap Mucosal flap for proximal fistula, anocutaneoeus flap for Mucosal flap for proximal fistula, anocutaneoeus flap for
distal fistuladistal fistula Contra-indication: acute sepsis, large internal opening, Contra-indication: acute sepsis, large internal opening,
heavily scarred rectumheavily scarred rectum
Endorectal advancement flapEndorectal advancement flap
Results in high type fistulaResults in high type fistula Heterogenous, depend on length of FUHeterogenous, depend on length of FU Recurrence rate ~20% - 60%Recurrence rate ~20% - 60% Incontinence rate ~18.7%Incontinence rate ~18.7%
Int J Colorectal Dis 1994;9:153-7Int J Colorectal Dis 1994;9:153-7
Int J Colorectal Dis 2006 Mar 15Int J Colorectal Dis 2006 Mar 15
4. Seton4. Seton
i.i. Loose SetonLoose Seton
ii.ii. Cutting SetonCutting Seton
iii.iii. Chemical SetonChemical Seton
i. Loose Setoni. Loose Seton
Drainage of sepsis before definitive Drainage of sepsis before definitive treatment (eg. Staged fistulotomy)treatment (eg. Staged fistulotomy)
Primary treatment for complex fistulaPrimary treatment for complex fistula
Loose SetonLoose Seton
Procedure in St Mark’s HospitalProcedure in St Mark’s Hospital Tracks and extensions outside sphincter laid Tracks and extensions outside sphincter laid
openopen passage of Seton thro’ primary track across passage of Seton thro’ primary track across
the external sphincter and tied looselythe external sphincter and tied loosely Outpatient review, remove Seton at 2-3 Outpatient review, remove Seton at 2-3
months if wound healedmonths if wound healed
Loose SetonLoose Seton
Result for treatment of complex fistulaResult for treatment of complex fistula Success rate 44% - 78%Success rate 44% - 78% Minor incontinence rate 17% - 36%Minor incontinence rate 17% - 36%
Int J Colorectal Dis 1989;4:247-50Int J Colorectal Dis 1989;4:247-50
BJS 1990;77:898-901BJS 1990;77:898-901
ii. Cutting Setonii. Cutting Seton
Analog to staged fistulotomyAnalog to staged fistulotomy Cutting the fistula track with tightening of Cutting the fistula track with tightening of
SetonSeton Balance between healing speed vs Balance between healing speed vs
continencecontinence Material: silk, braided polyester, rubber Material: silk, braided polyester, rubber
band, Penrose drainband, Penrose drain
Cutting SetonCutting Seton
Results are heterogenousResults are heterogenous Average cutting time ~14-20 wksAverage cutting time ~14-20 wks Recurrence rate ~5% (0-29%)Recurrence rate ~5% (0-29%) Minor incontinence rate ~50%Minor incontinence rate ~50% New ModificationNew Modification
Snug SetonSnug Seton
Snug SetonSnug Seton
1mm elastic Seton1mm elastic Seton Silicon nerve vessel Silicon nerve vessel
retractorretractor Slow fistulotomySlow fistulotomy
T M Hammond et alT M Hammond et al 29 patients idiopathic fistula (~38% high type)29 patients idiopathic fistula (~38% high type) Median cutting time 24 wksMedian cutting time 24 wks No recurrenceNo recurrence Minor incontinence rate ~25%Minor incontinence rate ~25%
Colorectal Dis 2006;8:328-37Colorectal Dis 2006;8:328-37
iii. Chemical Setoniii. Chemical Seton
Kshara sutra, derived Kshara sutra, derived from plants from plants (Ayurveda)(Ayurveda)
Antibacterial, anti-Antibacterial, anti-inflammatory inflammatory properties, alkalineproperties, alkaline
Weekly insertionWeekly insertion Slowly cut though the Slowly cut though the
tissuestissues
Chemical SetonChemical Seton
RCT comparing chemical Seton with RCT comparing chemical Seton with fistulotomy in low type fistulafistulotomy in low type fistula More painful with chemical Seton but no More painful with chemical Seton but no
difference in healing time, complications or difference in healing time, complications or functional outcomefunctional outcome
Tech Coloproctol 2001;5:137-41Tech Coloproctol 2001;5:137-41
5. Fibrin glue5. Fibrin glue
Fibrinogen solution +/- antibioticsFibrinogen solution +/- antibiotics Promote healing thro’ fibroblast migration and Promote healing thro’ fibroblast migration and
activation, formation of collagen meshworkactivation, formation of collagen meshwork
Before injectionBefore injection Curettage all granulation tissue and debrisCurettage all granulation tissue and debris
Contraindication: acute sepsisContraindication: acute sepsis
Fibrin glueFibrin glue
Results variableResults variable For complex fistulaFor complex fistula
Successful rate ~50%Successful rate ~50% Septic complication 3%Septic complication 3%
Dis Colon Rectum 2005;48:2167-72Dis Colon Rectum 2005;48:2167-72
For simple fistulaFor simple fistula RCT fibrin glue vs conventional treatment for anal RCT fibrin glue vs conventional treatment for anal
fistulafistula 42 patients42 patients No advantage for fibrin glue over fistulotomy in simple No advantage for fibrin glue over fistulotomy in simple
fistulafistulaDis Colon Rectum 2002;45:1608-15Dis Colon Rectum 2002;45:1608-15
6. Radiofrequency6. Radiofrequency
Radiofrequency Radiofrequency scalpelscalpel
Fistulotomy/ Fistulotomy/ fistulectomyfistulectomy
High frequency High frequency 4MHz radiowave4MHz radiowave
Mode: cutting, Mode: cutting, coagulation, coagulation, fulgurate, bipolarfulgurate, bipolar
RadiofrequencyRadiofrequency
RadiofrequencyRadiofrequency
PrinciplePrinciple Transmit radio wave to tissueTransmit radio wave to tissue Cause tissue damage by intracellular heatingCause tissue damage by intracellular heating Low cutting temperature 60 – 90Low cutting temperature 60 – 9000C (vs 750 – C (vs 750 –
90090000C in diathermy)C in diathermy) More precise cutting, less surrounding tissue More precise cutting, less surrounding tissue
damage, less tissue edema and paindamage, less tissue edema and pain
RadiofrequencyRadiofrequency
Two small scale randomized trialTwo small scale randomized trial Diathermy fistulotomy vs Radiofrequency Diathermy fistulotomy vs Radiofrequency
fistulotomy/ fistulectomy in low type fistulafistulotomy/ fistulectomy in low type fistula Less post-operative painLess post-operative pain Earlier return to workEarlier return to work Shorter wound healing timeShorter wound healing time No difference in complication & recurrenceNo difference in complication & recurrence
Eur Rev Med Pharmacol Sci 2004;8:111-6Eur Rev Med Pharmacol Sci 2004;8:111-6Rom J Gastroenterol. 2003;12:287-91Rom J Gastroenterol. 2003;12:287-91
Treatment of Anal fistulaTreatment of Anal fistulaSUMMARYSUMMARY
Simple fistulaSimple fistula
Standard treatmentStandard treatment Fistulotomy +/- MarsupialisationFistulotomy +/- Marsupialisation FistulectomyFistulectomy
Other treatmentsOther treatments Radiofrequency fistulotomy/ fistulectomy Radiofrequency fistulotomy/ fistulectomy
(emerging evidence)(emerging evidence) Fibrin glue (lower healing rate, no advantage)Fibrin glue (lower healing rate, no advantage) Seton (prolong healing)Seton (prolong healing)
Complex fistulaComplex fistula
Initial treatmentInitial treatment Loose Seton (low incontinence rate)Loose Seton (low incontinence rate)
Other treatmentOther treatment Advancement flaps (variable result)Advancement flaps (variable result) Fibrin glue (variable result)Fibrin glue (variable result) Cutting Seton (high incontinence rate)Cutting Seton (high incontinence rate)
Snug Seton (need more evidence)Snug Seton (need more evidence)
Stage fistulotomy (high incontinence rate)Stage fistulotomy (high incontinence rate)
Treatment for Anal fistulaTreatment for Anal fistula~ End of presentation ~~ End of presentation ~
Treatment of anal fistulaTreatment of anal fistulaQuestion and AnswerQuestion and Answer
Definition (variable)Definition (variable)
High typeHigh type Involving the anorectal ringInvolving the anorectal ring Internal opening above dentate lineInternal opening above dentate line
Complex typeComplex type High typeHigh type Multiple side branchesMultiple side branches Chronic inflammatory disease (Chron’s)Chronic inflammatory disease (Chron’s) Previous operation/ irridationPrevious operation/ irridation
Incontinence scoring systemIncontinence scoring system
Cleveland Clinic scoring systemCleveland Clinic scoring system Wexner Continence grading scaleWexner Continence grading scale Material: solid, liquid, gasMaterial: solid, liquid, gas Frequency: rare to alwaysFrequency: rare to always
Fistulotomy and immediate Fistulotomy and immediate reconstructionreconstruction
Reconstruct the divided musculature and Reconstruct the divided musculature and primary wound closureprimary wound closure
For low type fistulaFor low type fistula Study from Parkash et alStudy from Parkash et al
120 patients120 patients 98% low type fistula98% low type fistula 88% wound healed by 2 weeks88% wound healed by 2 weeks Recurrence rate 4%Recurrence rate 4%
ANZJ Surg 1985;55:23-7ANZJ Surg 1985;55:23-7
Fistulotomy and immediate Fistulotomy and immediate reconstructionreconstruction
For complex fistulaFor complex fistula Prospective study by Perez F et alProspective study by Perez F et al
35 patients with complex anal fistula35 patients with complex anal fistula 85.7% high trans-sphincteric, 11.4% supra-sphincteric, 2.9% 85.7% high trans-sphincteric, 11.4% supra-sphincteric, 2.9%
extra-sphinctericextra-sphincteric 31.4% incontinent patients reported improvement in 31.4% incontinent patients reported improvement in
continence scorescontinence scores 12.5% continent patients reported minor alternations of 12.5% continent patients reported minor alternations of
continence (Wexner Continence Scale <4)continence (Wexner Continence Scale <4) Recurrence rate 5.7%Recurrence rate 5.7%
J Am Coll Surg 2005;200:897-903J Am Coll Surg 2005;200:897-903