Prinanal fistula disease

1. Perianal fistula disease
Overview of current treatment strategies
Mr.Mekki Hassan
Post CCT colorectal fellow
Bradford teaching hospitals foundation trust

2. Definition
 Abnormal communication between communication the anal canal mucosa and
perianal skin ( commonly site of Previous Perianal abscess drainage site)

3. Classification
 Simple Vs complex:
- simple : low ,involve <30 % of
sphinecter muscle
- complex: High, involve >30% of
sphincter muscle ,and or multiple
tracts
Parks classification
-intersphecteric (70%)
– transsphecteric (25%)
-suprasphecteric (4%)
-extrasphecteric (1%)

4. Clinical findings
 intermittent or persistent purulent or serosanguineous Perianal discharge
 Previous history of Perianal abscess drainage or perianal fistula disease
 DRE/bedside proctoscopy : external opening, discharge , scarring ,internal
opening, assess sphincter

5. assessment
 Examination under anaesthesia
(EUA): diagnostic and
therapeutic(goodsalls rule)
 Imaging : unclear fistula
anatomy /recurrent fistula/IBD
-MRI : more sensitive
-endoanal US +/- Hydrogen
peroxide(prospective study 2004).
Anal manometry: pt with previous
anorectal surgery and complex
obstetrical hx to assess sphincter
prior to surgery(fistulotomy)

6. Treatment options
 simple:
 Fistulotomy : best option for simple fistula ,if used for complex (incontinence
rate 12.5 % and 90 % recurrence rate according to RCT 2006)
 Complex :
 Seton:
-draining /simple : drain sepsis /induce fibrosis
-Cutting :change high to low fistula (staged fistulotomy)/induce fibrosis.(incon
rate 12 %-retrospective review 2009)

7.  Ligation of inter sphincteric tract(LIFT)
:90 % 4/52 success rate
 Advancement flaps: incon rate 10%, 80 %
6/12 success rate
 Fistula plugs : high sepsis ,failure rate
,cost (FIAT trial 2009 ,Retrospective
review 2010)
 Fibrin glues :50% 6/12 success rate (multi
center study 2011)
 New advances :
 Video assisted anal fistula
treatment(VAAFT)
 Lazer fistula treatment (Filac)

8. Fistula in Crohn's disease
 Drain perianal sepsis – insert seton if easily probable(ACGBPI 2019)
 Biological treatment (50-60 % healing rate)

9. Faecal Diversion(colostomy /ileostomy)
 It considered as a last resort in the following situations:
 1- uncontrolled sepsis : severe anorectal Crohn's , large pelvi rectal abscess,
necrotising fasciitis.
 2- Highly refractory fistula: multiple recurrencies , usually complex fistulas

10. summary
EUA/MRI/endoanal US
Complex
Simple seton
Consider options (keep
seton /plugs.glue/LIFT)
recurrence
Flap
simple
fistulotomy Cutting seton

11. Questions

Thank you