Anal fistula.. by. dr.saleh bakar.. taishan medical university


Published on

Anal Fistula By Dr.Saleh Bakar
Taishan Medical University Taian, Shandong, China

Published in: Health & Medicine
1 Like
  • Be the first to comment

No Downloads
Total views
On SlideShare
From Embeds
Number of Embeds
Embeds 0
No embeds

No notes for slide

Anal fistula.. by. dr.saleh bakar.. taishan medical university

  1. 1. Name : Saleh Bakar Semester : 8th Subject : Surgery Teacher : Dr . Sailendra TAISHAN Medical University Taian Shandong SURGERY PRESENTATION
  3. 3. Anal fistula, or fistula-in-ano, is an abnormal connection between the epithelialised surface of the anal canal and (usually) the perianal skin. Anal fistulae originate from the anal glands, which are located between the two layers of the anal sphincters and which drain into the anal canal. If the outlet of these glands becomes blocked, an abscess can form which can eventually point to the skin surface. The tract formed by this process is the fistula. Abscesses can recur if the fistula seals over, allowing the accumulation of pus. It then points to the surface again, and the process repeats. ANAL FISTULA
  4. 4. An anal fistula can cause bleeding and discharge when passing stools - and can be painful. An anal fistula can occur after surgery to drain an anal abscess. In some cases, an anal fistula causes persistent drainage. In other cases, where the outside of the channel opening closes, the result may be recurrent anal abscesses. The only cure for an anal fistula is surgery. Symptoms of anal fistulas Possible symptoms include: Pain, which is usually constant, throbbing and worse when sitting down Skin irritation around the anus, including swelling, redness and tenderness Discharge of pus or blood Constipation or pain associated with bowel movements Fever
  5. 5. Diagnosis of anal fistulas Usually, a clinical evaluation - including a digital rectal examination - is sufficient to diagnose an anal fistula, but some patients may require additional tests to screen for: Sexually transmitted infections Inflammatory bowel disease Diverticular disease Rectal cancer In rare cases, an examination may be done under anaesthesia. The doctor may also ask for an ultrasound, a CT scan or an MRI.
  6. 6. There are several stages to treating an anal fistula: Definitive treatment of a fistula aims to stop it recurring. Treatment depends on where the fistula lies, and which parts of the anal sphincter it crosses Treatment Doing nothing — a drainage seton can be left in place long-term to prevent problems. This is the safest option although it does not definitively cure the fistula. Lay-open of fistula-in-ano — this option involves an operation to cut the fistula open. Once the fistula has been laid open it will be packed on a daily basis for a short period of time to ensure that the wound heals from the inside out. Cutting seton — if the fistula is in a high position and it passes through a significant portion of the sphincter muscle, a cutting seton (from the Latin seta, "bristle") may be used. This involves inserting a thin tube through the fistula tract and tying the ends together outside of the body.
  7. 7. Seton stitch — a length of suture material looped through the fistula which keeps it open and allows pus to drain out. In this situation, the seton is referred to as a draining seton. Fistulotomy — till anorectal ring Colostomy — to allow healing Fibrin glue injection is a method explored in recent years, with variable success. It involves injecting the fistula with a biodegradable glue which should, in theory, close the fistula from the inside out, and let it heal naturally. This method is perhaps best tried before all others since, if successful, it avoids the risk of incontinence, and creates minimal stress for the patient Endorectal advancement flap is a procedure in which the internal opening of the fistula is identified and a flap of mucosal tissue is cut around the opening. The flap is lifted to expose the fistula, which is then cleaned and the internal opening is sewn shut.
  8. 8. Control sepsis EUA Laying open abscesses and secondary tracts Adequate drainage – seton insertion Define anatomy Openings and tracts Internal and External Single –v- multiple Extensions / Horseshoe Relation to sphincter complex High –v- Low Exclude co-existent disease PRINCIPLES
  9. 9. MRI FOR FISTULA-IN-ANO HALLIGAN Radiology 2006Abscesses & Extensions Contralateral disease Other pathology
  10. 10. Fistula tract identified with probe Extent of external sphincter involvement assessed Tract and muscle divided Secondary tracts laid open +/- marsupialisation wound SURGICAL OPTIONS – FISTULOTOMY
  11. 11. 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 SURGICAL OPTIONS – CUTTING SETON
  12. 12. •Draining seton •Core out tract •Direct visualisation of secondary tracts •Sphincter repair +/- advancement flap SURGICAL OPTIONS – FISTULECTOMY
  13. 13. Endorectal Fistula tract probed Flap raised Mucosa + Int. Sphincter Internal opening excised/closed Flap advanced & sutured ADVANCEMENT FLAPS
  14. 14. Anodermal Fistula tract probed Flap raised Anodermal Flap advanced & sutures External defect closed ADVANCEMENT FLAP
  15. 15. FISTULA PLUG
  16. 16. FISTULA PLUG
  17. 17. Ligation of Intersphincteric Fistula Tract Transsphincteric fistula Draining seton – 6 weeks Tract prepared with fistula brush Debrides De-epithelializes LIFT PROCEDURE
  19. 19. 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
  20. 20. INFECTION Some patients will have active infection when they present with a fistula, and this requires clearing up before definitive treatment can be decided. Antibiotics can be used as with other infections, but the best way of healing infection is to prevent the buildup of pus in the fistula, which leads to abscess formation. This can be done with a seton..
  21. 21. HISTORY Japan: A man suffering from anal fistula. From the Yamai no Soshi, late 12th century…
  22. 22. THANK YOU FOR YOUR ATTENTION Kshara, a traditional ayurvedic medicine treatment for fistulae and piles (inflamed hemorrhoids) consisting of herbs, has been in use in India for about 5000 years. This treatment is mentioned in ancient medical texts.
  23. 23. Dr.Saleh Bakar Taishan Medical University Cell# : 008615269868530