Rakesh benign-anorectal-


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  • Diseases of Colon and Rectum Journal (Feb 2009) - increased risk of fistula formation with age < 40 , decreased risk in DM pts , not affected by gender, smoking history, perioperative antibiotics or HIV status
  • Perianal - most common (45%), suppuration travels inferiorly in intersphincteric space from anal gland Ischioanal - penetrate through external sphincter Horseshoe abscess - B/L extension of ischioanal abscess into deep postanal space Supralevator- MUST rule out intraabdominal pathology
  • Cryptoglandular etiology - infected anal crypt gland (obstructed by debris - feces or traumatized tissue)  stasis and overgrowth of enteric bacteria; suppurative fluid follows path of least resistance and travels to where gland terminates LGV - proctocolitis + inguinal bubos (enlarged, tender lymph nodes with hemorrhagic necrosis) Crohn’s, diverticulitis, appendicitis - more commonly cause supralevator abscesses
  • Pain worse with movement/pressure (sneezing, coughing, bearing down), better with drainage Exam - depends on LOCATION, supralevator abscesses - mass adjacent to rectal ampulla, may present with urinary retention DRE - critical with intersphincteric and supralevator (may have NO findings on external exam)
  • Pain worse with movement/pressure (sneezing, coughing, bearing down), better with drainage Exam - depends on LOCATION, supralevator abscesses - mass adjacent to rectal ampulla, may present with urinary retention DRE - critical with intersphincteric and supralevator (may have NO findings on external exam)
  • Low intersphincteric abscesses should be treated by de-roofing of the abscess and division of the internal sphincter up to a level of the dentate line. High intersphincteric abscesses are relatively frequent and mostly require staged surgery with a temporary mushroom (de Pezzer) catheter. Accurate anatomical ultrasound localization and proper drainage become important to avoid recurrences or extrasphincteric fistulas.
  • BACKGROUND: The perianal abscess is a common surgical problem. A third of perianal abscesses may manifest a fistula-in-ano which increases the risk of abscess recurrence requiring repeat surgical drainage. Treating the fistula at the same time as incision and drainage of the abscess may reduce the likelihood of recurrent abscess and the need for repeat surgery. However, this could affect sphincter function in some patients who may not have later developed a fistula-in-ano. OBJECTIVES: We aimed to review the available randomised controlled trial evidence comparing incision and drainage of perianal abscess with or without fistula treatment. SEARCH STRATEGY: Randomised trials were identified from MEDLINE, EMBASE, the Cochrane Library, and reference lists of published papers and reviews. SELECTION CRITERIA: Trials comparing outcome after fistula surgery with drainage of perianal abscess compared with drainage alone were included in the review. DATA COLLECTION AND ANALYSIS: The primary outcomes were recurrent or persistent abscess/fistula which may require repeat surgery and short-term and long-term incontinence. Secondary outcomes were duration of hospitalisation, duration of wound healing, postoperative pain, quality of life scores. For dichotomous variables, relative risks and their confidence intervals were calculated. MAIN RESULTS: We identified six trials, involving 479 subjects, comparing incision and drainage of perianal abscess alone versus incision and drainage with fistula treatment. Metaanalysis showed a significant reduction in recurrence, persistent abscess/fistula or repeat surgery in favour of fistula surgery at the time of abscess incision and drainage (RR=0.13, 95% Confidence Interval of RR = 0.07-0.24). Transient manometric reduction in anal sphincter pressures, without clinical incontinence, may occur after treatment of low fistulae with abscess drainage. Incontinence at one year following drainage with fistula surgery was not statistically significant (pooled RR 3.06, 95% Confidence Interval 0.7-13.45) with heterogeneity demonstrable between the trials (Chi(2) =5.39,df=3, p=0.14, I(2) =44.4%). AUTHORS' CONCLUSIONS: The published evidence shows fistula surgery with abscess drainage significantly reduces recurrence or persistence of abscess/fistula, or the need for repeat surgery. There was no statistically significant evidence of incontinence following fistula surgery with abscess drainage. This intervention may be recommended in carefully selected patients.
  • Recommendations of American Society of Colon and Rectal Surgeons I&D - with cruciate or elliptical incision; if cruciate excise redundant skin Abscesses requiring OR - recurrent abscesses, complex abscesses (horseshoe), supralevator and intersphincteric Antibiotics - only indicated in pts with immunosuppression (e.g. DM, leukemia/CA, HIV, malnourished), prosthetic device (valvular, intravascular, joint), valvular heart dz, ?Crohn’s dz (Cipro/Flagyl), ?history of MRSA Prophylactic fistulotomy - NOT recommended b/c high frequency of anorectal dysfxn (e.g. incontinence); only reserved for pts with horseshoe abscesses or refractory symptoms DCR study (1991) - Significantly decreased in recurrence rate and persistence rate (40% vs 3%) but more likely to have anal dysfxn (40% vs 21%) Sitz baths (or hand-held shower) - TID x15min and after BMs
  • IMPORTANT to identify anatomy and determine if there is sphincter involvement b/c increased risk of incomplete healing, fistula recurrence and sphincter injury if fistula anatomy is incorrectly delineated or an occult abscess missed EUS - sometimes methylene blue is also used Others usually only done with recurrent or complicated fistula (e.g. h/o rectal surgery, crohn’s disase) MRI - need anorectal coil TRUS pitfall - focal length of the 7-MHz U/S probe is not sufficiently deep to image beyond the external sphincter or puborectalis Fistulogram - can’t visualize sphincter muscles CT - poor resolution for fistula tracts Study - Buchanan et al, cohort of 108 patients with recurrent fistulae using digital examination, endoanal ultrasound, and MRI on each patient; Digital examination correctly identified 61% of tracks compared with 81% of tracks by endoanal ultrasound and 90% by MRI.
  • Rakesh benign-anorectal-

    1. 1. 27/06/13 Dept. of Surgery Benign Anorectal: Abscess and Fistula Rakesh Kumar Gupta, MS
    2. 2. Benign Anorectal: Abscess and Fistula Anorectal abscess and fistula-in-ano represent different stages of the same disease the abscess represents the acute inflammatory event the fistula represents the chronic process
    3. 3. Benign Anorectal: Abscess and Fistula Diagnosis and treatment requires in-depth understanding of anorectal anatomy and spaces
    4. 4. Anorectal Suppuration Epidemiology Anorectal abscesses (“Acute phase”) 100,000 cases per year Age range 20-60, 2:1 ratio M:F 30% recurrence rate* Anorectal fistula (“Chronic phase”) 25-40% of abscesses lead to fistula** 10-20% recurrence rate * Shrum RC. Dis Colon Rectum 1959; 2:469–472, **Shouler PJ et al . Int J Colorect Did 1986,1:113-5
    5. 5. 80% are submucosal, 8% extend to internal sphincter, 8% to the conjoined longitudinal muscle, 2% intersphincteric, 1% penetrate internal sphincter At the dentate line, the ducts of the anal glands empty into anal crypts 90% of anorectal abscess result fromcrytogladularinfection
    6. 6. Parks cryptoglandular theory - obstruction of anal glands leads to stasis and infection
    7. 7. Abscess Classified by location: Perianal (50%), Intersphincteric (30%), Ischioanal (15%), Supralevator (5%)
    8. 8. Classification of Anorectal Abscesses
    9. 9. Supralevator Space Intersphincteric Space Ischioanal Space HORSESHOE ABSCESS
    10. 10. Abscess - Etiology Nonspecific cryptoglandular (90%) Specific causes: Specific infection, ie TB, actinomycosis, lymphogranuloma venereum, Inflammatory bowel disease, Trauma or foreign body Surgery (episiotomy, hemorrhoidectomy, prostatectomy), Malignancy - carcinoma, lymphoma, radiation-related
    11. 11. Pain Severe, constant pain, worse with movement/pressure (sneezing, coughing, bearing down),better with drainage Swelling, Fever chills hallmark symptoms supralevator abscess may have gluteal pain rectal pain with urinary symptoms (ie. Constipation, Urinary retention) - possibly indicate intersphincteric or supralevator abscess Anorectal Abscess Clinical Presentation
    12. 12. Anorectal Abscess Clinical Presentation • Exam – Induration, fluctuance, erythema, warmth, purulent drainage – DRE
    13. 13. Abscess - Treatment Exam under anesthesia for pain out of proportion to exam Incision and drainage - trim edges to prevent coaptation I&D of supralevator abscess: depends on location - intersphincteric origin then divide internal sphincter and drain into rectum; if arises from ischianal abscess can be drained through perineal skin
    14. 14. Anorectal Abscess Treatment I&D- cruciate or elliptical incision
    15. 15. Abscess - Treatment Catheter drainage: stab incision to drain pus, mushroom catheter in cavity to drain pus make stab incision as close as possible to anus size and length of catheter should correspond to abscess cavity
    16. 16. Short distance fromanus – feel forsoft spot Place drain and trim– avoids packing Follow up in 7-10 days to remove drain
    17. 17. Catheter Types Pester catheter Solid mushroom top so stays in Less tissue ingrowth Malecot Allows tissue ingrowth More painful to remove
    18. 18. Abscess - Treatment Primary fistulotomy may be easier to identify tract eliminates source of infection decreases recurrence/need for reoperation Downsides: false passage formation with acute inflammation, 30- 50% of those with abscess likely won’t develop a fistula, need for anesthesia vs. local for I & D
    19. 19. Incision and drainage of perianal abscess with or without treatment of anal fistula. Cochrane Database Syst Rev. 2010 Jul 7; (7):CD006827. CONCLUSIONS: The published evidence shows fistula surgery with abscess drainage  Significantly reduces recurrence or persistence of abscess/fistula, or the need for repeat surgery. No statistically significant evidence of incontinence following fistula surgery with abscess drainage. Intervention may be recommended in carefully selected patients.
    20. 20. Abscess - Antibiotics Little or no role Antibiotics? Culture? Indications: Immunosuppression Valvular heart dz Prosthetic devices Sepsis or Extensive cellulitis Crohn’s dz Sitz Baths
    21. 21. Abscess - Complications Recurrence recurrence in as many as 89% of pts Extra-anal causes should be evaluated for recurrent disease (hidradenitis suppurativa, Crohn’s) Incontinence iatrogenic (superficial external sphincter), inappropriate wound care (excessive scarring from prolonged packing)
    22. 22. Abscess - Complications Can result in necrotizing anorectal infection (rare) Resuscitation, IV abx, wide debridement to healthy tissue Need for colostomy debatable - recommended if sphincter muscle is grossly infected, immunocompromised, rectal or colonic involvement/perforation Reexamination under anesthesia HBO - 100% O2 at 3atm over 2 hrs - promote leukocyte phagocytic function and fibroblast proliferation
    23. 23. Caution – Necrotizing Fasciitis
    24. 24. Anal Infection and Hematologic Diseases Anorectal suppuration with acute leukemia with mortality 45-78% Neutrophil count <500 with 11% incidence of anorectal abscess Most important prognostic factor - # days of neutropenia Presenting symptoms: fever, pain, urinary retention Antibiotics vs I & D if fluctuance, sepsis, or progression of soft tissue infection after antibiotics trial
    25. 25. Anal Infection & HIV HIV+ pts have increased risk of perianal sepsis Can be associated with in situ neoplasia Surgery + antibiotics 2/2 immunosuppression make incison site small bc pts at risk for poor wound healing
    26. 26. Fistula-in-ano Abnormal communication between any two epithelium-lined surfaces Parks classification:
    27. 27. Classification
    28. 28. Intersphincteric fistula
    29. 29. Intersphincteric Fistula-in-ano Most common type of fistula - 70% Results from perianal abscess Variations: simple low tract high tract with rectal opening or blind tract extrarectal extension pelvic disease tracking
    30. 30. Transsphincteric fistula
    31. 31. Transsphincteric Fistula Approx 23% fistulas Results from ischioanal absecesses Rectovaginal fistula is a form of transsphincteric fistula Operative mgt with setons if sphincter preservation in question
    32. 32. Suprasphincteric fistula
    33. 33. Suprasphincteric Fistula 5% of fistulas Result from supralevator abscesses Tract arises from intersphincteric abscess, travels above puborectalis, then downward lateral to external sphincters in ischioanal space
    34. 34. Extrasphincteric fistula
    35. 35. Extrasphincteric Fistula 2% of fistulas - rarest form From rectum above the levators, through them, to the perianal skin Trauma, foreign body, Crohn’s carcinoma Most common cause is iatrogenic from probing during fistulotomy surgery
    36. 36. Evaluationof AnalFistula An accurate preoperative assessment of the anatomy of an anal fistula is very important. Five essential points of a clinical examination of an anal fistula : (1) location of the internal opening. (2) location of the external opening. (3) location of the primary track . (4) location of any secondary track. (5) determination of the presence or absence of underlying disease .
    37. 37. Fistula-in-ano: Physical Examination Goodsall’s rule: transverse line across the perineum - posterior external openings have internal openings in the posterior midline anterior external openings have tract radially toward the nearest crypt greater distance from anal margin with more variability more accurate rule for posterior fistulas
    38. 38. Fistula Description Clock description Does the anus tell time? Relies on description of patient’s position: supine, lateral, prone and relative landmarks Anatomic description: more consistent Pubic bone defines anterior Coccyx define posterior Right and left *If terms be incorrect, then statements do not accord with facts; and when statements and facts do not accord, then business is not properly executed.”
    39. 39. Tailbone Right anterior Right posterior Left anterior Left posterior Right Left Pubic bone
    40. 40. High Fistulas Have High Internal Openings (opening of the duct at the crypt, is always at the level of the pectinate line) Internal Opening is Not Always Present Fistulas with Multiple Openings are Tuberculus in Origin Every Fistula Requires an MRI/Endoanal USG Which is the Best Surgery for Fistula in Ano? Controversies in Fistula in Ano
    41. 41. Mutiple external openings over the right buttock—non tuberculus
    42. 42. Investigations Additional tools available in case of difficulty. Do not replace a good clinical examination to diagnose the type & extent of fistula. Not necessary to investigate every case of fistula even the complex ones can be diagnosed fairly accurately by a good clinical examination. MRI & Endoanal ultrasound both give comparable Delineating the tracts by intra-operative dye study may be more helpful than the above investigations. Fistulograms have a very limited role in the diagnosis of fistula in ano
    43. 43. Anorectal Fistula Diagnosis
    44. 44. MRI forfistula-in-ano HALLIGAN Radiology 2006Abscesses & Extensions Contralateral disease
    45. 45. TREATMENT The objective is to cure with lowest possible recurrence rate and minimal, if any, alteration in continence, shortest period. The principles are: Control sepsis  EUA  Laying open abscesses and secondary tracts  Adequate drainage – seton insertion .
    46. 46. Define anatomy Openings and tracts Internal and External (Identification of the primary opening) Single –v- multiple Extensions / Horseshoe (Side tracts should be sought ) Relation to sphincter complex High –v- Low (Relationship to puborectalis) Exclude co-existent disease
    47. 47. Fistula-in-ano: Treatment Eliminate fistula, Prevent recurrence, Preserve sphincter function
    48. 48. Fistula-in-ano: Treatment Identification of internal opening passage of probe injection of dye, methylene blue, or hydrogen peroxide following granulation in fistula tract noting puckering of crypt with traction on fistula tract
    49. 49. Fistulotomy/fistulectomy Lay-open technique (fistulotomy) : identification of tract with unroofing tract, useful for 85-95% of primary fistulae . Appropriate for simple interspincteric and low transsphincteric Curettage is performed to remove granulation tissue. Marsupialization of the edges to improve healing times.
    50. 50. Surgical Options – Fistulotomy Fistula tract identified with probe Extent of external sphincter involvement assessed Tract and muscle divided Secondary tracts laid open +/- marsupialisation wound
    51. 51. Fistula in ano
    52. 52. Fistula in ano
    53. 53. Surgical Options – Fistulectomy • Core out tract • Direct visualisation of secondary tracts • Sphincter repair +/- advancement flap
    54. 54. Fistula-in-ano: Operative Management Seton - placement of non-absorbable suture material in fistula tract Indications for setons: Promote fibrosis around fistula tract that encircles entire sphincter mechanism Mark the site of fistula in massive anorectal sepsis Anterior high transsphincteric fistulas in women HIV pts with poor wound healing and high transsphincteric fistulas Crohn’s Any time continence is questioned
    55. 55. Surgical Options – Cutting Seton 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
    56. 56. Setons intheManagement of Difficult Fistulas
    57. 57. Fistula-in-ano: Operative Management High-transphincteric fistulas can be treated with combination lay- open technique and seton placement - division of internal sphincter to level of external opening and then seton placement Cutting setons can convert high fistulas to low fistulas Second-stage fistulotomy ~ 8 wks later
    58. 58. Fistula-in-ano: Operative Management Suprasphincteric fistula - tract involves external sphincter and puborectalis - can manage with division of internal sphincter and superficial external sphincter with seton around remaining ES or internal sphincterotomy, seton, opening of fistula tracts without division of external sphincter
    59. 59. Fistula-in-ano: Operative Management Anorectal Advancement Flap internal opening closed with absorbable suture, full-thickness flap of rectal mucosa/submucosa/IAS raised - adv 1 cm beyond internal opening base of the flap should be twice the width of the apex pros: reduction in healing time, reduced pain, little potential damage to sphincters, lack of deformity to anal canal poor outcomes in Crohn’s, pts on steroids, smokers, o/w success reported in up to 90% of pts
    60. 60. Advancement Flaps Endorectal Fistula tract probed Flap raised Mucosa + Int. Sphincter Internal opening excised/closed Flap advanced & sutured
    61. 61. Advancement Flap Anodermal Fistula tract probed Flap raised Anodermal Flap advanced & sutures External defect closed
    62. 62. Fistula-in-ano: Operative Management Fibrin Glue - used in conjuntion with AAF or alone technique: internal and external openings identified, tract curetted, fistula tract injected through connector from external opening until glue visible in internal opening, slowly withdrawn can be repeated several times without compromising continence
    63. 63. Fistula-in-ano: Operative Management Fibrin Glue - Followup: short-term follow-up with good success 70-80% longer follow-up with success falling to 60% and even 14% in pts with complex anal fistulas
    64. 64. Fistula Plug
    65. 65. Fistula Plug
    66. 66. Fistula-in-ano: Operative Management Bioprosthetic fistula plug made from surgisis Technique - identification of internal and external opening with placement of plug over probe using suture similar to seton placement Plug secured at primary opening using absorbable suture
    67. 67. Fistula-in-ano: Operative Management Technique works best with long tracts without active inflammation or sepsis Short-term follow up (3months) with higher success rate for Crohn’s fistulas when compared to fibrin glue Long-term follow up - high failure rate
    68. 68. LIFT Procedure Ligation of Intersphincteric Fistula Tract Transsphincteric fistula Draining seton – 6 weeks Tract prepared with fistula brush Debrides De-epithelializes
    69. 69. PROS CONS Cutting Seton Simple Cheap Repeat EUA Recurrence 0 – 8% Incontinence • minor 34 – 63% • major 2 – 26% Fistulotomy Simple Cheap Recurrence 2 – 9% Incontinence 50% Advancement Flap Can be difficult ?Preserves sphincter Recurrence 25 – 50% Incontinence 30 – 35% Fistula Plug Simple Preserves sphincter Plug expensive ~£400 Recurrence 20 – 85% Continence preserved LIFT Simple Preserves sphincter Recurrence 15 - 40% Continence preserved
    70. 70. Crohn’s and Anal Fistulas The most common perianal manifestation and occur in 6-34% Crohn’s pts - pts with colonic Crohn’s with higher incidence, rectal Crohn’s with 100% fistula formation Conservative approach to treatment as 38% heal without surgery
    71. 71. Crohn’s and Anal Fistulas Medications for treatment: cipro/flagyl, immunomodulators (steroids, 6MP, azathioprine, infliximab) 6-MP and azathioprine only effective in 1/3 pts with fistulizing Crohn’s Infliximab associated with 62% reduction Combination 6MP and infliximab may prolong effect of treatment Selective seton placement with infliximab + maintenance med with healing in 67%
    72. 72. Crohn’s and Anal Fistulas Operative intervention: seton placement, rectal advancement flap if rectal-sparing, poss fibrin glue/plug Avoid cutting sphincter - incontinence reported in pts with Crohn’s proctitis even without anal surgery
    73. 73. ACPGBI FIAT Trial Fistula Plug Insertion Surgeon’s Preference EUA: transsphincteric fistula ≥ 1/3 of sphincter complex Insertion of draining seton RANDOMISE MRI fistulography Advancement Flap Cutting Seton Fistulotomy LIFT
    74. 74. ACPGB&I FIAT Primary end-points Faecal incontinence QoL Generic QoL Secondary end-points Healing – 12 months Complications Faecal incontinence Re-interventions Health resource utilisation Cost effectiveness Patient identification EUA & draining seton Eligibility & Consent Randomisation 1:1 plug –v- surgeon’s preference 6-week FU 6-monthFU 12-month FU + MRI scan Surgisis® fistula plug Surgeon’s preference (fistulotomy, seton, advancement flap, LIFT) MRI scan Surgery (6-weeks post seton insertion)
    75. 75. Join the FIAT Trial!