Transcript Treatment for Anal fistula

Treatment for Anal fistula
Dr. Wong Siu Wang
North District Hospital
Joint Hospital Surgical Grand Round
Sept 2006
Classification
 Parks classification
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Intersphincteric
Trans-sphincteric
Supra-sphincteric
Extra-sphincteric
 High vs Low
 Simple vs Complex
BJS 1976;63:1-12
Etiology
 Crytogenic
 Inflammatory bowel disease
 Malignancy
 Tuberculosis
 Pelvic sepsis
Etiology
 Crytogenic
 Inflammatory bowel disease
 Malignancy
 Tuberculosis
 Pelvic sepsis
Treatment of Anal fistula
1.
2.
3.
4.
5.
6.
Fistulotomy
Fistulectomy
Advancement flaps
Seton (loose, cutting, chemical)
Fibrin glue
Radiofrequency
1. Fistulotomy
 Standard treatment for low type fistula
 Recurrence rate ~5% - 10%
 Minor incontinence rate ~6% - 26%
 Stage fistulotomy for high type fistula
 Recurrence rate ~5% – 8%
 Minor incontinence rate ~50%
BJS 1995;82:895-7
BJS 1991;78:1159-61
Fistulotomy (New Modification)
 Marsupialisation
 Suturing the divided wound edge to the edges
of the curetted fibrous track
 Results in smaller wound and faster healing
Colorectal Dis 2006;8:11-4
BJS 1998;85:105-107
2. Fistulectomy
 Argument against fistulectomy
 RCT of Fistulectomy vs Fistulotomy
 Greater tissue loss leads to delayed healing
 Similar recurrence rates
BJS 1985;55:23-7
Fistulectomy
 Argument supporting fistulectomy
 Complete specimen for histology
 Reduces risk of missing secondary tracks
 Similar incontinence rate
 Modification:
 Core out technique
 Fistulectome
Fistulectome
The fistulectome: a new device for treatment of complex anal
fistulas by “Core-Out” fistulectomy. Dis Colon Rectum
2003;46:1566-71
Fistulectome
 Device for core out
fistulectomy
 Remove 2mm
thickness of fistula
tract
 Limited experience
and results
Dis Colon Rectum 2003;46:1566-71
3. Endorectal advancement flap
 Treatment for high type fistula
 Close the internal opening with flap
 Mucosal flap for proximal fistula, anocutaneoeus
flap for distal fistula
 Contra-indication: acute sepsis, large internal
opening, heavily scarred rectum
Endorectal advancement flap
 Results in high type fistula
 Heterogenous, depend on length of FU
 Recurrence rate ~20% - 60%
 Incontinence rate ~18.7%
Int J Colorectal Dis 1994;9:153-7
Int J Colorectal Dis 2006 Mar 15
4. Seton
i. Loose Seton
ii. Cutting Seton
iii. Chemical Seton
i. Loose Seton
 Drainage of sepsis before definitive
treatment (eg. Staged fistulotomy)
 Primary treatment for complex fistula
Loose Seton
 Procedure in St Mark’s Hospital
 Tracks and extensions outside sphincter laid
open
 passage of Seton thro’ primary track across
the external sphincter and tied loosely
 Outpatient review, remove Seton at 2-3
months if wound healed
Loose Seton
 Result for treatment of complex fistula
 Success rate 44% - 78%
 Minor incontinence rate 17% - 36%
Int J Colorectal Dis 1989;4:247-50
BJS 1990;77:898-901
ii. Cutting Seton
 Analog to staged fistulotomy
 Cutting the fistula track with tightening of
Seton
 Balance between healing speed vs
continence
 Material: silk, braided polyester, rubber
band, Penrose drain
Cutting Seton
 Results are heterogenous
 Average cutting time ~14-20 wks
 Recurrence rate ~5% (0-29%)
 Minor incontinence rate ~50%
 New Modification
 Snug Seton
Snug Seton
 1mm elastic Seton
 Silicon nerve vessel
retractor
 Slow fistulotomy
 T M Hammond et al
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29 patients idiopathic fistula (~38% high type)
Median cutting time 24 wks
No recurrence
Minor incontinence rate ~25%
Colorectal Dis 2006;8:328-37
iii. Chemical Seton
 Kshara sutra, derived
from plants (Ayurveda)
 Antibacterial, antiinflammatory
properties, alkaline
 Weekly insertion
 Slowly cut though the
tissues
Chemical Seton
 RCT comparing chemical Seton with
fistulotomy in low type fistula
 More painful with chemical Seton but no
difference in healing time, complications or
functional outcome
Tech Coloproctol 2001;5:137-41
5. Fibrin glue
 Fibrinogen solution +/- antibiotics
 Promote healing thro’ fibroblast migration and
activation, formation of collagen meshwork
 Before injection
 Curettage all granulation tissue and debris
 Contraindication: acute sepsis
Fibrin glue
 Results variable
 For complex fistula
 Successful rate ~50%
 Septic complication 3%
 For simple fistula
Dis Colon Rectum 2005;48:2167-72
 RCT fibrin glue vs conventional treatment for anal
fistula
 42 patients
 No advantage for fibrin glue over fistulotomy in simple
fistula
Dis Colon Rectum 2002;45:1608-15
6. Radiofrequency
 Radiofrequency
scalpel
 Fistulotomy/
fistulectomy
 High frequency
4MHz radiowave
 Mode: cutting,
coagulation,
fulgurate, bipolar
Radiofrequency
Radiofrequency
 Principle
 Transmit radio wave to tissue
 Cause tissue damage by intracellular heating
 Low cutting temperature 60 – 900C (vs 750 –
9000C in diathermy)
 More precise cutting, less surrounding tissue
damage, less tissue edema and pain
Radiofrequency
 Two small scale randomized trial
 Diathermy fistulotomy vs Radiofrequency
fistulotomy/ fistulectomy in low type fistula
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Less post-operative pain
Earlier return to work
Shorter wound healing time
No difference in complication & recurrence
Eur Rev Med Pharmacol Sci 2004;8:111-6
Rom J Gastroenterol. 2003;12:287-91
Treatment of Anal fistula
SUMMARY
Simple fistula
 Standard treatment
 Fistulotomy +/- Marsupialisation
 Fistulectomy
 Other treatments
 Radiofrequency fistulotomy/ fistulectomy
(emerging evidence)
 Fibrin glue (lower healing rate, no advantage)
 Seton (prolong healing)
Complex fistula
 Initial treatment
 Loose Seton (low incontinence rate)
 Other treatment
 Advancement flaps (variable result)
 Fibrin glue (variable result)
 Cutting Seton (high incontinence rate)
 Snug Seton (need more evidence)
 Stage fistulotomy (high incontinence rate)
Treatment for Anal fistula
~ End of presentation ~
Treatment of anal fistula
Question and Answer
Definition (variable)
 High type
 Involving the anorectal ring
 Internal opening above dentate line
 Complex type
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High type
Multiple side branches
Chronic inflammatory disease (Chron’s)
Previous operation/ irridation
Incontinence scoring system
 Cleveland Clinic scoring system
 Wexner Continence grading scale
 Material: solid, liquid, gas
 Frequency: rare to always
Fistulotomy and immediate
reconstruction
 Reconstruct the divided musculature and
primary wound closure
 For low type fistula
 Study from Parkash et al
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120 patients
98% low type fistula
88% wound healed by 2 weeks
Recurrence rate 4%
ANZJ Surg 1985;55:23-7
Fistulotomy and immediate
reconstruction
 For complex fistula
 Prospective study by Perez F et al
 35 patients with complex anal fistula
 85.7% high trans-sphincteric, 11.4% supra-sphincteric, 2.9%
extra-sphincteric
 31.4% incontinent patients reported improvement in
continence scores
 12.5% continent patients reported minor alternations of
continence (Wexner Continence Scale <4)
 Recurrence rate 5.7%
J Am Coll Surg 2005;200:897-903