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Anorectal fistula
Anorectal fistula
Anorectal fistula
Anorectal fistula
Anorectal fistula
Anorectal fistula
Anorectal fistula
Anorectal fistula
Anorectal fistula
Anorectal fistula
Anorectal fistula
Anorectal fistula
Anorectal fistula
Anorectal fistula
Anorectal fistula
Anorectal fistula
Anorectal fistula
Anorectal fistula
Anorectal fistula
Anorectal fistula
Anorectal fistula
Anorectal fistula
Anorectal fistula
Anorectal fistula
Anorectal fistula
Anorectal fistula
Anorectal fistula
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Anorectal fistula

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  • 1. Dr.Vidya
  • 2.  FISTULA - Abnormal connection b/w two epithelium lined organs or vessels. It is generally a disease condition. It may be surgically created for therapeutic reasons.  ANORECTAL FISTULA - Abnormal connection b/w epithelialised surface of anal canal & the Perianal skin.  Internal opening- Anorectal lumen  External opening- Perianal skin  Pre-existing anorectal abscess burst spontaneously .  Other: rectovesicular, rectovaginal, rectourethral fistula.
  • 3. Etiology  Non specific - cryptoglandular in origin  Specific : - Crohn’s disease - tuberculosis - lymphogranuloma venereum - actinomycosis - rectal duplication - foreign body - malignancy
  • 4. Anatomy – Muscles  Internal sphincter  External sphincter  Intersphincteric groove  Puborectalis (Levator ani)
  • 5. Park’s Classification of Anorectal Fistulas  Type 1 - Intersphincteric (45%)  Type 2 -Transphincteric  Type 3 – Suprasphincteric  Type 4 - Extrasphincteric
  • 6.  Intersphincteric – through the dentate line to anal verge, tracking along the intersphincteric plane, ending in the perianal skin.  Transsphinteric – through the external sphincter into the ischiorectal fossa, encompassing a portion of internal & external sphincter ending in the skin.  Suprasphinteric – through the anal crypt & encircling the entire sphincter ending in ischiorectal fossa.  Extrasphinteric – starting high in the anal canal, enclosing the entire anal sphincter & ending in the skin.
  • 7. Park’s Classification of Anorectal Fistulas
  • 8. Clinical Presentation  H/o  Chronic drainage from “nonhealing abscess”  Pain with defecation  Pruritus ani  Systemic symptoms if abscess gets infected.  Physical exam  Draining pustule  Erythema, induration, excoriated skin
  • 9. Goodsall’s Rule  Goodsall’s rule is a guideline for internal opening & path of fistula track & aids in Rx.  Fistula can be described as anterior or posterior relating to a line drawn in the coronal plane through ischial spines across the anus - called transverse anal line.  Anterior fistulas - have a direct track into the anal canal.  Posterior fistulas - have a curved track with their internal opening lying in the posterior midline of the anal canal.  An exception to the rule - anterior fistulas lying more than 3 cm. from the anus, which may have a curved track (similar to posterior fistulas) that opens into the posterior midline of the anal canal.
  • 10.  Goodsall's rule may not be applicable when the fistula is more than 3 cm from the anal verge, as mostly these fistula are indirect.  If there are multiple anal fistulae, the course would be similar to that of posterior-opening fistulae because of branching and communication between these openings
  • 11. Diagnosis • Exam under anesthesia (EUA)- anoscopy, proctoscopy; assess for internal opening and occult abscess – Injection of Hydrogen peroxide or povidone iodine allows to visualize bubbles at internal opening(s) • Endo anal ultrasound • MRI – gold std • Fistulography • CT
  • 12. Management  Goals of Therapy  Drain local infection  Eradicate fistulous tract  Avoid recurrence while preserving native sphincter function  Surgical management  Fistulotomy  Fistulectomy  Seton technique  Advancement flaps & glues  LIFT procedure
  • 13. Fistulotomy  lay open fistula tract, make incision over entire length of fistula using probe as guide  intersphincteric fistula & trans-sphincteric fistulae involving less than 30% of the voluntary musculature .  Avoided for anteriorly placed fistulae in women  Staged Fistulotomy – seton passed across the fistula & left in place with tie  Fistula granulates & heals from above to close completely.
  • 14. Fistulotomy
  • 15. Cutting Seton (Staged Fistulotomy)
  • 16. Fistulectomy  involves coring out of the fistula by diathermy cautery  Better for fistula that cross level of sphincters and the presence of secondary extensions.  Post-op: sitz bath, antibiotics, analgesics, laxatives
  • 17. Setons  non-absorbable, nondegenerative, comfortable.  Silk or linen ligature  m/c intersphincteric fistula.  Kept for 3 months replaced by rail road tecq.  loose setons: no tension, no intent to cut the tissue. - for recurrent, post operative fistulas.  Uses of loose setons. - For long-term palliation to avoid septic and painful exacerbations by effective drainage - before ‘advanced’ techniques (fistulectomy, advancement flap, cutting seton) - staged fistulotomy - preserve the external sphincter in trans-sphincteric fistulae.
  • 18. Tight or cutting setons :  placed with the intention of cutting through the enclosed muscle.  Used if the fistula is in a high position and it passes through a significant portion of the sphincter muscle  high fistula eradication rates a/w fistulotomy.  Minimising sphincter dysfunction due to least scar formation.  cheese wiring through ice -such that the divided muscles do not spring apart.  site of the fistula track is replaced by a thin line of fibrosis as it is brought down.
  • 19. Advancement flaps  Endorectal advancement flaps:-coring out of the entire track; and closure of the communication with the anal lumen with an adequately vascularised flap consisting of mucosa and internal sphincter, sutured without tension to the anoderm.  Success rate is variable.  high recurrence rates are directly related to previous attempts to correct the fistula.
  • 20. Mucosal advancement flap
  • 21. Fibrin plugs & Glues : Fibrin plug-  Plugging the fistula with a device made from small intestinal submucosa.  The fistula plug is positioned from the inside of the anus with suture.  Success rate with this method is as high as 80%.  Fistula plug procedure requires hospitalization for only about 24 hours.
  • 22. Fibrin plugs
  • 23. •Fibrin glue: - Fibrin glue is currently the only non-surgical option for treating fistulae. - The fibrin glue is injected into the fistula to seal the tract. The glue is injected through the opening of the fistula, and the opening is then stitched closed. -long-term results for this treatment method are poor.
  • 24. LIFT Procedure  Ligation of intersphinteric fistula tract procedure.  Based on secure closure of the internal opening and removal of infected cryptoglandular tissue through the intersphincteric approach.  Essential steps -  incision at the intersphincteric groove  identification of the intersphincteric tract ligation of intersphincteric tract close to the internal opening and removal of intersphincteric tract  scraping out all granulation tissue in the rest of the fistulous tract suturing of the defect at the external sphincter muscle
  • 25. Differential diagnosis  Anal carcinoma  Anorectal abscess  Constipation  Diverticular Disease  Foreign Bodies, Rectum  Herpes Simplex  Inflammatory Bowel Disease  Pilonidal Cyst and Sinus  Proctitis
  • 26. Thank you

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