Name : Saleh Bakar

Semester : 8th

Subject : Surgery

Teacher : Dr . Sailendra

TAISHAN Medical University Taian Shandong

SURGERY PRESENTATION

ANAL FISTULA

Anal fistula, or fistula-in-ano, is an abnormal connection between the epithelialised surface of the anal canal and

(usually) the perianal skin.Anal fistulae originate from the anal glands, which are located between the two layers of the anal sphincters

and which drain into the anal canal. If the outlet of these glands becomes blocked, an abscess can form which can eventually point to the skin surface. The

tract formed by this process is the fistula.Abscesses can recur if the fistula seals over, allowing the accumulation of pus. It then points to the surface

again, and the process repeats.

ANAL FISTULA

An anal fistula can cause bleeding and discharge when passing stools - and can be painful.

An anal fistula can occur after surgery to drain an anal abscess.

In some cases, an anal fistula causes persistent drainage. In other cases, where the outside of the channel opening closes, the result may be recurrent anal abscesses. The only cure for an anal fistula is surgery.

Symptoms of anal fistulas

Possible symptoms include:

Pain, which is usually constant, throbbing and worse when sitting downSkin irritation around the anus, including swelling, redness and tendernessDischarge of pus or bloodConstipation or pain associated with bowel movementsFever

Diagnosis of anal fistulas

Usually, a clinical evaluation - including a digital rectal examination - is sufficient to diagnose an anal fistula, but some patients may require additional tests to screen for:

Sexually transmitted infectionsInflammatory bowel diseaseDiverticular diseaseRectal cancerIn rare cases, an examination may be done under anaesthesia. The doctor may also ask for an ultrasound, a CT scan or an MRI.

There are several stages to treating an anal fistula:Definitive treatment of a fistula aims to stop it recurring. Treatment depends on where the fistula lies, and which parts of the anal sphincter it crosses

Treatment

Doing nothing — a drainage seton can be left in place long-term to prevent problems. This is the safest option although it does not definitively cure the fistula.Lay-open of fistula-in-ano — this option involves an operation to cut the fistula open. Once the fistula has been laid open it will be packed on a daily basis for a short period of time to ensure that the wound heals from the inside out.

Cutting seton — if the fistula is in a high position and it passes through a significant portion of the sphincter muscle, a cutting seton (from the Latin seta, "bristle") may be used. This involves inserting a thin tube through the fistula tract and tying the ends together outside of the body.

Seton stitch — a length of suture material looped through the fistula which keeps it open and allows pus to drain out. In this situation, the seton is referred to as a draining seton.

Fistulotomy — till anorectal ring

Colostomy — to allow healing

Fibrin glue injection is a method explored in recent years, with variable success. It involves injecting the fistula with a biodegradable glue which should, in theory, close the fistula from the inside out, and let it heal naturally. This method is perhaps best tried before all others since, if successful, it avoids the risk of incontinence, and creates minimal stress for the patient

Endorectal advancement flap is a procedure in which the internal opening of the fistula is identified and a flap of mucosal tissue is cut around the opening. The flap is lifted to expose the fistula, which is then cleaned and the internal opening is sewn shut.

Control sepsisEUA

Laying open abscesses and secondary tractsAdequate drainage – seton insertion

Define anatomyOpenings and tractsInternal and External

Single –v- multipleExtensions / Horseshoe

Relation to sphincter complexHigh –v- Low

Exclude co-existent disease

PRINCIPLES

MRI FOR FISTULA-IN-ANO

HALLIGAN Radiology 2006Abscesses &Extensions

Contralateral disease Other pathology

Fistula tract identified with probe

Extent of external sphincter involvement assessed

Tract and muscle divided

Secondary tracts laid open

+/- marsupialisation wound

SURGICAL OPTIONS – FISTULOTOMY

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 – CUTTING SETON

•Draining seton

•Core out tract

•Direct visualisation of secondary tracts

•Sphincter repair +/- advancement flap

SURGICAL OPTIONS – FISTULECTOMY

EndorectalFistula tract probed

Flap raised

Mucosa + Int. Sphincter

Internal opening excised/closed

Flap advanced & sutured

ADVANCEMENT FLAPS

AnodermalFistula tract probed

Flap raised

Anodermal

Flap advanced & sutures

External defect closed

ADVANCEMENT FLAP

FISTULA PLUG

FISTULA PLUG

Ligation of Intersphincteric

Fistula TractTranssphincteric fistula

Draining seton – 6 weeks

Tract prepared with fistula brush

Debrides

De-epithelializes

LIFT PROCEDURE

LIFT PROCEDURE

PROS CONSCutting Seton Simple

CheapRepeat EUARecurrence 0 – 8%Incontinence• minor 34 – 63%• major 2 – 26%

Fistulotomy SimpleCheap

Recurrence 2 – 9%Incontinence 50%

Advancement Flap Can be difficult?Preserves sphincter

Recurrence 25 – 50%Incontinence 30 – 35%

Fistula Plug SimplePreserves sphincter

Plug expensive ~£400Recurrence 20 – 85%Continence preserved

LIFT SimplePreserves sphincter

Recurrence 15 - 40%Continence preserved

INFECTION

Some patients will have active infection when they present with a fistula, and this requires clearing up before definitive treatment can be decided.Antibiotics can be used as with other infections, but the best way of healing infection is to prevent the buildup of pus in the fistula, which leads to abscess formation. This can be done with a seton..

HISTORY

Japan: A man suffering fromanal fistula. From the Yamai noSoshi, late 12th century…

THANK YOU FOR YOUR ATTENTION

Kshara, a traditional ayurvedic medicine treatment for fistulae and piles (inflamed hemorrhoids) consisting of herbs, has been in use in India for about 5000 years. This treatment is mentioned in ancient medical texts.

Dr.Saleh BakarTaishan Medical UniversityCell# : 008615269868530Saleh.malik007@Gmail.com