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ANO-RECTAL FISTULA
DR.MAHAR NAVEED SARWARRESIDENT SURGEONWARD # 26, JPMC
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ANATOMY OF ANAL CANAL & PERIANAL SPACE
ANATOMY OFANAL CANAL &PERI ANALSPACE
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FISTULA IN ANO
Abscess is the parent of the fistula
Eisenhammer, 1956
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Fistula in ano is a track lined by granulation
tissue, that connects deeply in the anal canal orrectum & superficially on the skin around anus.
An ano rectal abcess may produce a track, theorifice of which has appearance of fistula but
does not communicate with anal canal orrectum,this is called a sinus.
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TYPES OF ANAL FISTULA
These are divided into 2 typeLow level fistulaHigh level fistula
ClassificationStandard Parks
1.subcutaneous 1.Intersphincteric2.submucous 2.transphincteric3.low anal 3.supra levator
4.high anal 4.exrasphincteric
5.pelvirectal
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PARKS CLASSIFICATIONTranssphincteric fistulae
arethe result of ischiorectal
abscesses. Account for
about 25% of all fistulae.
Intersphincteric fistulae
They result from perianal
abscesses. Account for
about 70% of all fistulae.
.Suprasphinctericfistulaeare the result ofsupralevatorabscesses. Account forabout 5% of all fistulae.
Extrasphncteric
fistulae Accounts for
about only 1% of all
fistulae. Result from
trauma,diverticulitis &
crohns disease.
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DIAGNOSIS
HISTORY Clinical features Sign & Symptoms
Physical Examination INSPECTION Granulation tissue is pouting from mouth of opening
1.Perianal discharge2.Pain3.Swelling4.Bleeding5.Skin excoriation6.External opening
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GOODSALLS RULE
Fistula with an external openingin relation to ant half of anus tend
to have a direct track.
Fistula with external opening inRelation to post half of anus usually
have curving track (horseshoe
Variety).
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PALPATIONInduration of skin around fistula.
DIGITAL RECTAL EXAMINATIONInternal opening can be felt as a nodule on wall of anal canal. PROCTOSCOPY
Reveal the internal opening of fistula as a hypertrophied
papilla. PROBING
Probing should be done under general anesthesia.
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INVESTIGATIONS
FistulographyUnreliable but useful in cases of complex fistula.
Its role is controversial. EndoluminalUltrasound MRI
Chest X-RAY BARIUM ENEMAUseful in patients with multiple fistula.
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TREATMENT
The treatment is only surgical.
Preoperative DetailsRectal irrigation with enemas should be performed on the morning of the
operation.General anesthesia should be given.Administer preoperative antibiotics.Prone jackknife position or lithotomy position should be maintained.
Intraoperative DetailsExamine the patient under anesthesia by bi digital palpationto confirm the extent of the fistula.Identifying the internal opening to prevent recurrence is imperative.A local anesthetic block at the end of the procedure providespostoperative analgesia.
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PROCEDURES
Fistulotomy/FistulectomyIntersphincteric or Lowtranssphincteric
Laying open technique (fistulotomy):1.Probe is inserted in distal orifice.2.Skin & subcutaneous tissue excised.3.Granulation tissue removed by curette
4.Fistulotomy is allowed to close bysecondary intention.
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High Transsphincteric Fistulotomy
SETON PLACEMENTA seton is typically made from a largesilk suture, silastic vessel marker, orrubber band, that is threaded through the
fistula tract.Uses of seton
1.Complex or multiple fistulae2.Recurrent fistulae after previous surgery
3.Anterior fistulae in female patients4.Poor preoperative sphincter pressures
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Seton have 2 purposes beyond giving a visualidentification of the amount of sphincter muscleinvolved.
These are
(1) to drain and promote fibrosis and
(2) to cut through the fistula
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Mucosal Advancement Flap
Mucosal advancement flap is reserved foruse in patients with chronic high fistula butis indicated for the same disease processas seton use.Advantages include a 1-stage procedure
with no additional sphincter damage.A disadvantage is poor success in patientswith Crohn disease or acute infection.This procedure involves total fistulectomy,
with removal of the primary and secondarytracts and complete excision of the internalopening.
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Fibrin glue
The use of fibrin glue is recently introducedWhich improves the healing of track.
INDICATIONSComplex or simple
Specific or non-specificShort or long track.
TECHNIQUEBowel preparationAntibiotics: i.v. / oral / local / mixed with glue One stage / two stage Track: excision / curettage / hydrogen peroxide / laser
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Follow-up
Sitz baths, analgesics, and stool bulkingagents are used in follow-up care.
Frequent follow up visits within the first
few weeks help ensure proper healing andwound care.
Digital examination findings can helpdistinguish early fibrosis.
Wound healing usually occurs within 6weeks
C li ti
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Complications
Early postoperative
Urinary retention Bleeding Fecal impaction Thrombosed hemorrhoids
Delayed postoperative
Recurrence
Incontinence (stool) Anal stenosis: The healing process causes fibrosis of the
anal canal. Delayed wound healing: Complete healing occurs by 12
weeks unless an underlying disease process is present
(ie, recurrence or crohns disease)
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