Transcript Slide 1

Recent Advances in Surgical
Management of Complex
Cryptoglandular Anal Fistula
YK Fong, Queen Mary Hospital
Agenda
• Introduction
– 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
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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
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
Principles of Treatment
Control of sepsis
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)
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
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
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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
C. Neal Ellis et al. Meeting of The American Society of Colon
and Rectal Surgeons 2012
BioLIFT Procedure
• Bioprosthetic grafts
– Tolerate contamination
– Remodeling without a foreign body reaction
• Healing rate: 94% (29/31)
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
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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
– Digital examination
– Examination under
anesthesia (EUA)
– Anal manometry
• Radiological
– Endoanal ultrasound
– Magnetic resonance
imaging
LIFT Procedure
• Prospective
observational study
• All cryptoglandular
infections
• May 2007 to
September 2008
• 45 patients
• Median follow-up: 9
(range, 2-16) months
• Primary healing:
37/45(82.2%)
• Median healing time : 7
(range, 4-10) weeks
– 33 transsphincteric
– 12 complex
Shanwani et al DCR 2010
QMH Experience
• Since January 2009
– 25 patients
• 24 transphincteric fistula
• 1 suprasphincteric fistula
– 15 recurrenct
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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
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
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