Recent Advances in the management of Anal Fistula

21,402 views

Published on

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.

Published in: Health & Medicine
0 Comments
10 Likes
Statistics
Notes
  • Be the first to comment

No Downloads
Views
Total views
21,402
On SlideShare
0
From Embeds
0
Number of Embeds
1,675
Actions
Shares
0
Downloads
301
Comments
0
Likes
10
Embeds 0
No embeds

No notes for slide

Recent Advances in the management of Anal Fistula

  1. 1. Recent Advance- Management of Fistula in ano Sukria Nayak Colorectal and General Surgery Christian Medical College, Vellore BHU, Varanasi 7th Sept 2012
  2. 2. Sushruta - Kshaarasootra Are we any better ?
  3. 3. 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
  4. 4. 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
  5. 5. Drainage seton Infant feeding tube Vascular sling
  6. 6. 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
  7. 7. Elastic Band Cutting Seton Hanley PH - 1978 Culp CE – 1984 Ann 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
  8. 8. Rubber band seton
  9. 9. Two stage technique
  10. 10. 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%
  11. 11. Fibrin Glue  Thrombin & Fibrinogen  2-chamber syringe  Mix at delivery  Cannula tip up to internal opening and withdrawn while injecting Early results: promising Follow up: disappointing  Against conv seton- RCT Lindsey et al:DCR2002;45:1608-15  Advocated Zmora et al:DCR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
  12. 12. 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):1817-1821 Success rate 83% at 12 months
  13. 13. Cook’s costly hardware- AFP
  14. 14. Plugging
  15. 15. Failed anal fistula plug High Cost : May not be the best
  16. 16. Lay open Vs Plug
  17. 17. 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
  18. 18. What to do ?
  19. 19. Horse shoe fistula ? best way
  20. 20. 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
  21. 21. 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
  22. 22. Steps of Procedure
  23. 23. 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
  24. 24. BioLIFT
  25. 25. 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
  26. 26. High Fistula -? Ideal operation Depends on the surgeon and the patient
  27. 27. Thank you

×