recent advances in the management of anal fistula
DESCRIPTION
Fistula in ano has been notorious on account of difficulties in its management. There are chances of recurrences even after meticulous operative procedure and post operative care.TRANSCRIPT
Recent Advance- Management of Fistula in ano
Sukria NayakColorectal and General
Surgery Christian Medical College,
VelloreBHU, Varanasi 7th Sept 2012
Sushruta - Kshaarasootra
Are we any better ?
Lay open / Fistulotomy
Oldest
Simplest
For low fistula Good healing Minimal
sphincter damage
Minimal risk of incontinence
Seton used: high fistula / > 1/3rd External sphincter involvement
Seton : Modern variation Drainage seton
Cutting seton
Two stage seton fistulotomy
Chemical seton ( Ayurvedic )
Mc Coutney JS, Finly IG - Br J Surg, 1995, 82: 448-452
MRCT: Shukla N, Indian J Med Res 1991; 94:1202-1207
Drainage seton
Infant feeding tube
Vascular sling
Cutting seton
Conventional :- Post op
adjustment / tightening required
- Painful / not tolerated well
- Break / Fall off
Elastic Band :- One time
- No post op adjustment
- Minimum risk of incontinence
A dynamic Dynamic
Elastic Band Cutting Seton
Hanley PH - 1978 Culp CE – 1984Ann Surg; 187:435- 437 Mayo Clin Proct; 59:613- 617
Ordinary glove : 2-3 mm strip, thicker sleeve, double strand fashion
Complete healing at 1 month : 45% 3 months: 100% Recurrence at 8 months: 5 %
Ankara, Turkey - Tech Coloproctology, 2004, 8:159-162
Rubber band seton
Two stage technique
Gold standard for High Fistula Transanal Rectal
Advancement Flap (AF) Pedro S et al, DCR 1985;28,7:496-498
??? Hagen SJ vander et al,Int J Colorectal Ds 2006;
21(8):784-790
Success rate : 37%
Recurrence after AF : 0-63%
Fibrin Glue Thrombin & Fibrinogen
2-chamber syringe
Mix at delivery
Cannula tip up to internal opening and withdrawn while injecting
Early results: promising
Follow up: disappointing
Against conv seton- RCT Lindsey et al:DCR2002;45:1608-15 Advocated Zmora et al:DCR 2003;46(5):584-589 With antibiotics- RCT Singer M et al: DCR 2005; 48:799-808 Advancement Flap and
Glue – RCT Paul J van et al:Int J Colorectal Ds 2008;23:697-701
Cochrane Systematic Review
Associated with worse outcome
Gone with the wind
Anal Fistula Plug ( AFP )
Johnson et al, 2006; DCR 49(3):371-376
- New biological material- Absorbable- Lyophilized porcine intestinal submucosa
Champagne BJ et al, 2006; DCR 49(12):1817-1821Success rate 83% at 12 months
Cook’s costly hardware- AFP
Plugging
Failed anal fistula plug
High Cost : May not be the best
Lay open Vs Plug
PLUG Trial - Netherlands: AFPlug Vs MAFlap : Awaited
The Anal Fistula Plug versus the mucosal advancement flap for the treatment of Anorectal Fistula (PLUG trial)
Paul J van Koperen,1 Willem A Bemelman,1 Patrick MM Bossuyt,2 Michael F Gerhards,3 Quirijn AJ Eijsbouts,4 Willem F van Tets,5 Lucas WM Janssen,6 F Robert Dijkstra,6 Annette D van Dalsen,7 and J Frederik M Slors 1
1Department of Surgery, Academic Medical Centre, Amsterdam, The Netherlands
2Department of Clinical Epidemiology and Bio-statistics, Academic Medical Centre, Amsterdam, The Netherlands
3Department of Surgery, Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands
4Department of Surgery, Spaarne Hospital, Heemstede, The Netherlands
5Department of Surgery, Sint Lucas Andreas Hospital Amsterdam, The Netherlands
6Department of Surgery, Zuwe Hofpoort Hospital, Woerden, The Netherlands
7Department of Surgery, Isala Clinics, Zwolle, The Netherlands
Will crown the winner
What to do ?
Horse shoe fistula ? best way
LIFT procedure 2007: Arun Rojanasakul, Chulalongkorn
University, Thailand: Healing – 94% 1993: Matos et al- total anal sphincter
preservation in high fistula in ano: excision of intersphincteric anal gland infection through the intersphincteric approach
Corman’s textbook : colon and rectal surgery-
mentioned
Surgical technique
• Identify internal opening• Incision at intersphincteric groove• Dissection through intersphincteric plane – find intersphincteric fistula tract• Suture ligation & excision of intersphincteric fistula tract• Curette fistula tract from external opening• Closure of external sphincter muscle defect• Closure of intersphincteric wound
Steps of Procedure
Bio LIFT Procedure C. Neal Ellis, University of South
Alabama: Study 2005-2008 /31: Published in 2010
Result: 94% Healing/No complications
Most recent sphincter saving technique for complex anal fistulas
RCT required to confirm Dis Colon Rectum 2010; 53: 1361–1364
BioLIFT
New Paths
Video Assisted Anal Fistula Treatment (VAAFT)
Radiofrequency fistulotomy: less pain ( 4MHz ) fast healing tried for low fistula only
Gupta PJ, Curr Surg 2003; 60(5): 524-528
? Laser ? Synthetic material ? Chemical
Systematic Review AI Malik, RLNelson, Colorectal Ds 2008; 10:420-430
Major gaps remain in our understanding of Anal Fistula Surgery
High Fistula -? Ideal operation
Depends on the surgeon and the patient
Thank you