Transcript Fistula-in-ano: a probing of the treatment options

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
The Problem
Aetiology
• Cryptoglandular
• Crohn’s disease
• Other
– Malignant
– Obstetric
– Radiation
Classification
30%
45%
5%
20%
Goodsall’s Rule
Treatment Aims
• Eradicate disease (if possible)
• Preservation of continence
• Benign condition
• Quality of life
Principles
• Control sepsis
– 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
MRI for fistula-in-ano
Abscesses &
Extensions
Contralateral diseaseHALLIGAN
OtherRadiology
pathology
2006
Surgical Options – Fistulotomy
• Fistula tract identified with
probe
• Extent of external
sphincter involvement
assessed
• Tract and muscle divided
• Secondary tracts laid open
• +/- marsupialisation
wound
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
Surgical Options – Fistulectomy
• Draining seton
• Core out tract
• Direct visualisation of
secondary tracts
• Sphincter repair +/advancement flap
Advancement Flaps
Endorectal
• Fistula tract probed
• Flap raised
– Mucosa + Int. Sphincter
• Internal opening
excised/closed
• Flap advanced & sutured
Advancement Flap
Anodermal
• Fistula tract probed
• Flap raised
– Anodermal
• Flap advanced & sutures
• External defect closed
Fistula Plug
Fistula Plug
LIFT Procedure
Ligation of Intersphincteric
Fistula Tract
• Transsphincteric fistula
• Draining seton – 6 weeks
• Tract prepared with fistula
brush
– Debrides
– De-epithelializes
LIFT Procedure
PROS
CONS
Cutting Seton
Simple
Cheap
Repeat EUA
Recurrence 0 – 8%
Incontinence
• minor 34 – 63%
• major 2 – 26%
Fistulotomy
Simple
Cheap
Recurrence 2 – 9%
Incontinence 50%
Advancement Flap
Can be difficult
?Preserves sphincter
Recurrence 25 – 50%
Incontinence 30 – 35%
Fistula Plug
Simple
Preserves sphincter
Plug expensive ~£400
Recurrence 20 – 85%
Continence preserved
LIFT
Simple
Preserves sphincter
Recurrence 15 - 40%
Continence preserved
ACPGBI FIAT Trial
EUA: transsphincteric
fistula ≥ 1/3 of sphincter
complex
Insertion of draining
seton
MRI fistulography
RANDOMISE
Surgeon’s
Preference
Fistula Plug
Insertion
Advancement
Flap
Cutting Seton
Fistulotomy
LIFT
ACPGB&I FIAT
Patient identification
EUA & draining seton
Eligibility & Consent
MRI scan
Randomisation
1:1 plug –v- surgeon’s preference
Surgery
(6-weeks post seton insertion)
Surgeon’s preference
Surgisis® fistula plug
(fistulotomy, seton, advancement flap,
LIFT)
6-week FU
6-monthFU
12-month FU
+ MRI scan
Primary end-points
• Faecal incontinence QoL
• Generic QoL
Secondary end-points
• Healing – 12 months
• Complications
• Faecal incontinence
• Re-interventions
• Health resource
utilisation
• Cost effectiveness
FIAT FACTS
Recruitment: 76
Target: 500
Open centres: 36
Recruiting centres: 21
Join the FIAT Trial!
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