fistulae in ano

8/2/2019 Fistulae in Ano

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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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fistulae in ano

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