Fistula-in-Ano
BY
DR.SEFEEN SAFE ATTIA
SOHAG TEACHING HOSPITAL
INTRODUCTIONINTRODUCTION
 A fistula is an abnormal connection betweenA fistula is an abnormal connection between
two epit...
ETIOLOGYETIOLOGY
 Cryptoglandular disease (anorectal abscesses )Cryptoglandular disease (anorectal abscesses )
is respons...
Differential Diagnosis of Fistula-in-ano
Nonspecific 90%
Cryptoglandular
Specific 10%
Trauma
Foreign body
Obstetric
Hemorr...
Anorectal Abscess
 Anorectal abscesses arise from obstruction of
the anal glands and ducts,
which communicate with the an...
The location and course of theThe location and course of the
fistula typically reflects the locationfistula typically refl...
CLASSIFICATIONCLASSIFICATION
fistulae are classified as either simple or
complex.
Simple fistulae are considered to be
int...
SymptomsSymptoms
 History of an abscess that was eitherHistory of an abscess that was either
drained spontaneously or sur...
Physical ExaminationPhysical Examination
InspectionInspection
The external opening can be seen as anThe external opening c...
PalpationPalpation
 Digital rectal examination may reveal anDigital rectal examination may reveal an
indurated cord-like ...
AnoscopyAnoscopy
 This examination allows visualization of theThis examination allows visualization of the
dentate line f...
Radiological EvaluationRadiological Evaluation
Radiology has a limited role in theRadiology has a limited role in the
eval...
FistulographyFistulography
 Fistulography involves cannulation of theFistulography involves cannulation of the
external o...
CT ScanCT Scan
 CT scan has a minor role in theCT scan has a minor role in the
assessment of anal fistulae.assessment of ...
Endoanal UltrasoundEndoanal Ultrasound
The role of ultrasound is toThe role of ultrasound is to::
11--Identify the fistula...
Magnetic Resonance ImageMagnetic Resonance Image
Accurate classification of fistulae with MRI isAccurate classification of...
Locating the fistulous
tract. The probe is
carefully inserted
through the
external opening,
and allowed to
follow the trac...
Fistulotomy
After gently passing a probe down the tract through the
external opening an incision may be made on the probe
...
Seton PlacementSeton Placement
Cutting setonsCutting setons
will gradually cut through the sphincter muscle via pressurewi...
Draining setonsDraining setons
will keep the fistulous tract open, allowing for abscess drainagewill keep the fistulous tr...
Draining setonDraining seton
The seton placedThe seton placed
through the externalthrough the external
and internaland int...
Fibrin GlueFibrin Glue
Fibrin glue may be used as an alternative means of occluding theFibrin glue may be used as an alter...
Anal Fistula PlugAnal Fistula Plug
This fistula plug made from lyophilizedThis fistula plug made from lyophilized
porcine ...
Endorectal Advancement FlapsEndorectal Advancement Flaps
Endorectal advancement flaps were firstEndorectal advancement fla...
Island Flap AnoplastyIsland Flap Anoplasty
Dermal island advancement flap (anocutaneousDermal island advancement flap (ano...
Post-operative Care
After Fistulectomy
wound irrigations are recommended
three to four times daily. In order to promote th...
Results and Complications
After Treatment
Satisfactory results may be achieved in the treatment of
anal fistula. Results d...
Recurrence
Recurrence of anal fistula in cases of
cryptoglandular origin is essentially due to
failure to remove the corre...
Incontinence
Partial early post-operative incontinence is frequent
after surgery of any fistulous tract and is the result ...
Fistula in-ano
Fistula in-ano
Fistula in-ano
Fistula in-ano
Fistula in-ano
Fistula in-ano
Fistula in-ano
Fistula in-ano
Fistula in-ano
Upcoming SlideShare
Loading in …5
×

Fistula in-ano

4,589 views

Published on

Published in: Health & Medicine
  • good
       Reply 
    Are you sure you want to  Yes  No
    Your message goes here

Fistula in-ano

  1. 1. Fistula-in-Ano BY DR.SEFEEN SAFE ATTIA SOHAG TEACHING HOSPITAL
  2. 2. INTRODUCTIONINTRODUCTION  A fistula is an abnormal connection betweenA fistula is an abnormal connection between two epithelial surfaces.two epithelial surfaces.  The term fistula is derived from the LatinThe term fistula is derived from the Latin meaningmeaning ““pipe, or flute.pipe, or flute.””  An anal fistula is a tract which usuallyAn anal fistula is a tract which usually communicates an infected anal gland to acommunicates an infected anal gland to a secondary opening in perianal skin, which issecondary opening in perianal skin, which is lined with granulation tissue.lined with granulation tissue.
  3. 3. ETIOLOGYETIOLOGY  Cryptoglandular disease (anorectal abscesses )Cryptoglandular disease (anorectal abscesses ) is responsible for 90% of fistula-in-ano.is responsible for 90% of fistula-in-ano. Anorectal abscesses, represent theAnorectal abscesses, represent the acute presentation of cryptoglandular disease, whileacute presentation of cryptoglandular disease, while fistulae are the chronic evolution of the samefistulae are the chronic evolution of the same process.process.  Other less common causes of fistulae areOther less common causes of fistulae are CrohnCrohn’’s disease, trauma, anal fissures,s disease, trauma, anal fissures, carcinoma, radiation therapy, tuberculosis, andcarcinoma, radiation therapy, tuberculosis, and chlamydial infections.chlamydial infections.
  4. 4. Differential Diagnosis of Fistula-in-ano Nonspecific 90% Cryptoglandular Specific 10% Trauma Foreign body Obstetric Hemorrhoidectomy Inflammatory bowel disease Cancer Adenocarcinoma of the rectum Squamous cell carcinoma of the anus Lymphoma Infectious Tuberculosis Actinomycosis Lymphgranuloma venereum Pelvic inflammatory disease Appendicitis Extra-anal sources Presacral cyst Bartholin’s cyst Pilonidal disease Hidradenitis suppurativa
  5. 5. Anorectal Abscess  Anorectal abscesses arise from obstruction of the anal glands and ducts, which communicate with the anal crypts located at the dentate line.  The resulting infection begins in the space between the internal and external sphincters and can spread through the perianal spaces, forming pockets of purulent material. Locations of anorectal abscesses include (in order of frequency) (1) perianal, (2) ischioanal, (3) intersphincteric, (4) supralevator
  6. 6. The location and course of theThe location and course of the fistula typically reflects the locationfistula typically reflects the location of the original abscess:of the original abscess: (1) intersphincteric(1) intersphincteric (2) transsphincteric(2) transsphincteric (3) suprasphincteric(3) suprasphincteric (4)extrasphincteric(4)extrasphincteric ))55((subcutaneoussubcutaneous
  7. 7. CLASSIFICATIONCLASSIFICATION fistulae are classified as either simple or complex. Simple fistulae are considered to be intersphincteric or low transsphincteric )>30%sphincter compromise). Fistulotomy is the best treatment for this kind of fistula, and is not expected to put a patient’s continence at risk. Complex fistulae involve more than 30% of the sphincter and usually are transsphincteric, suprasphincteric, or extrasphincteric.
  8. 8. SymptomsSymptoms  History of an abscess that was eitherHistory of an abscess that was either drained spontaneously or surgically.drained spontaneously or surgically. Intermittent or continuous discharge. If itIntermittent or continuous discharge. If it is intermittent, the patient may haveis intermittent, the patient may have increased pain and pressure prior toincreased pain and pressure prior to recurrent drainage, which gives relief.recurrent drainage, which gives relief.  Other symptoms include bleeding,Other symptoms include bleeding, soreness, pruritis or perianal dermatitis.soreness, pruritis or perianal dermatitis.
  9. 9. Physical ExaminationPhysical Examination InspectionInspection The external opening can be seen as anThe external opening can be seen as an elevation of granulation tissue dischargingelevation of granulation tissue discharging pus. (This may be elicited on the digitalpus. (This may be elicited on the digital rectal examination) Scar from earlierrectal examination) Scar from earlier procedures mayprocedures may be appreciated as well as chronic skinbe appreciated as well as chronic skin changes such as thickened and rednesschanges such as thickened and redness from persistentfrom persistent drainagedrainage..
  10. 10. PalpationPalpation  Digital rectal examination may reveal anDigital rectal examination may reveal an indurated cord-like structure beneath the skin inindurated cord-like structure beneath the skin in thethe direction of the internal opening.direction of the internal opening. Inability to palpate the fistula tract implies aInability to palpate the fistula tract implies a deeper coursedeeper course and therefore higher transsphincteric fistula.and therefore higher transsphincteric fistula.  Internal openings may be felt as induratedInternal openings may be felt as indurated nodulesnodules or pits that correspond to enlarged papilla, leadingor pits that correspond to enlarged papilla, leading to a thickened tract.to a thickened tract.
  11. 11. AnoscopyAnoscopy  This examination allows visualization of theThis examination allows visualization of the dentate line for possible identification of internaldentate line for possible identification of internal openings before surgery, as well as identification ofopenings before surgery, as well as identification of other pathology such as Crohnother pathology such as Crohn’’s disease ors disease or carcinoma.carcinoma.  GoodsallGoodsall’’s rule, which states that externals rule, which states that external openings located posteriorly to the coronal lineopenings located posteriorly to the coronal line are associated with tracts that curve to theare associated with tracts that curve to the posterior midline before entering the anal canal.posterior midline before entering the anal canal. external openings anterior to the coronal lineexternal openings anterior to the coronal line track straight toward the internal opening of thetrack straight toward the internal opening of the anal canal.anal canal.
  12. 12. Radiological EvaluationRadiological Evaluation Radiology has a limited role in theRadiology has a limited role in the evaluation of anal fistulaeevaluation of anal fistulae.. Most cases can be diagnosedMost cases can be diagnosed and treated based on clinicaland treated based on clinical examinationexamination.. Radiological examinations are usefulRadiological examinations are useful in atypical cases or after reccurencesin atypical cases or after reccurences
  13. 13. FistulographyFistulography  Fistulography involves cannulation of theFistulography involves cannulation of the external opening with injection of waterexternal opening with injection of water soluble contrastsoluble contrast  It may be useful for evaluation of recurrentIt may be useful for evaluation of recurrent or complex fistulae.or complex fistulae.  Its use has been generally discouragedIts use has been generally discouraged because of risk of septicemia in a smallbecause of risk of septicemia in a small amount of patients and poor visualization ofamount of patients and poor visualization of anatomic landmarks.anatomic landmarks.  This study has been substituted by otherThis study has been substituted by other diagnostic modalitiesdiagnostic modalities
  14. 14. CT ScanCT Scan  CT scan has a minor role in theCT scan has a minor role in the assessment of anal fistulae.assessment of anal fistulae.  The main use of CT scan is toThe main use of CT scan is to distinguish an abscess requiring drainagedistinguish an abscess requiring drainage from perirectal cellulites.from perirectal cellulites.  It is done with intravenous and rectalIt is done with intravenous and rectal contrast.contrast.  It may be useful if MRI is not available orIt may be useful if MRI is not available or contraindicatedcontraindicated
  15. 15. Endoanal UltrasoundEndoanal Ultrasound The role of ultrasound is toThe role of ultrasound is to:: 11--Identify the fistula tract in relation to the internalIdentify the fistula tract in relation to the internal and external sphinctersand external sphincters 22--To determine if the fistula is simple or complex 3-To determine if the fistula is simple or complex 3- Define the location of the internal openingDefine the location of the internal opening The injection of hydrogen peroxide into the fistulaThe injection of hydrogen peroxide into the fistula opening during ultrasound improvesopening during ultrasound improves identification of fistulae and their internal openingsidentification of fistulae and their internal openings by making them hyper instead of hypoechoicby making them hyper instead of hypoechoic..
  16. 16. Magnetic Resonance ImageMagnetic Resonance Image Accurate classification of fistulae with MRI isAccurate classification of fistulae with MRI is possible in 89% of patients compared to 61%possible in 89% of patients compared to 61% using 2-D anal ultrasoundusing 2-D anal ultrasound.. Although MRI seems superior to endoanalAlthough MRI seems superior to endoanal ultrasound in the assessmentultrasound in the assessment of fistula-in-ano, anal ultrasound tends to be moreof fistula-in-ano, anal ultrasound tends to be more useful than MRI because it is more widelyuseful than MRI because it is more widely available, can be performed quickly in the officeavailable, can be performed quickly in the office setting, and is less expensivesetting, and is less expensive MRI is therefore best reserved for cases whereMRI is therefore best reserved for cases where ultrasound has already failed to identify theultrasound has already failed to identify the fistula and internal openingfistula and internal opening
  17. 17. Locating the fistulous tract. The probe is carefully inserted through the external opening, and allowed to follow the tract until it exits through the internal opening. This will serve as a guide for either subsequent fistulotomy or seton placement
  18. 18. Fistulotomy After gently passing a probe down the tract through the external opening an incision may be made on the probe using a scalpel or electrocautery through the perianal skin and rectal mucosa. The edges of the tract should be excised completely, and care should be taken not to undermine the edges Once open, the fistulous tract should be cleaned with a curette to remove any granulation tissue. At the completion of the procedure, light packing tape may be placed in the fistula tract
  19. 19. Seton PlacementSeton Placement Cutting setonsCutting setons will gradually cut through the sphincter muscle via pressurewill gradually cut through the sphincter muscle via pressure necrosis, with fibrosis behind the seton, preventing sphincternecrosis, with fibrosis behind the seton, preventing sphincter retraction and incontinenceretraction and incontinence.. A large Ethibond or other braided suture is placed through theA large Ethibond or other braided suture is placed through the internal and external openings of the fistulous tract and tiedinternal and external openings of the fistulous tract and tied down onto the sphincter complexdown onto the sphincter complex.. The seton will then beThe seton will then be ““advancedadvanced”” over the course of theover the course of the next several weeks until the fistulous tract is completelynext several weeks until the fistulous tract is completely incisedincised.. care must be taken to not advance the seton too quicklycare must be taken to not advance the seton too quickly,, as the patient will experience a tremendous amount of pain asas the patient will experience a tremendous amount of pain as well as suffer a complication of sphincter divisionwell as suffer a complication of sphincter division..
  20. 20. Draining setonsDraining setons will keep the fistulous tract open, allowing for abscess drainagewill keep the fistulous tract open, allowing for abscess drainage and tract maturation, therefore facilitating a future fistulotomy or otherand tract maturation, therefore facilitating a future fistulotomy or other advancedadvanced fistula closure technique. A vessel loop or large Ethibond suture is passedfistula closure technique. A vessel loop or large Ethibond suture is passed through the internal and external openings of the fistulous tract and tiedthrough the internal and external openings of the fistulous tract and tied loosely around the sphincter complexloosely around the sphincter complex.. indications for use of a draining seton includeindications for use of a draining seton include:: ))11((complex anorectal fistula extensively involving the externalcomplex anorectal fistula extensively involving the external sphincter, with the goal of staged fistulotomy; (2) complex anorectal fistula insphincter, with the goal of staged fistulotomy; (2) complex anorectal fistula in the setting of sepsis; (3) anterior high transsphincteric fistula in a femalethe setting of sepsis; (3) anterior high transsphincteric fistula in a female patientpatient;; ))44((high transsphincteric fistula in a patient with AIDS; (5) long-term fistulahigh transsphincteric fistula in a patient with AIDS; (5) long-term fistula treatment in a patient with active IBD; and (6) concern for fistulotomy leadingtreatment in a patient with active IBD; and (6) concern for fistulotomy leading to fecal incontinenceto fecal incontinence
  21. 21. Draining setonDraining seton The seton placedThe seton placed through the externalthrough the external and internaland internal fistulafistula openings and tiedopenings and tied loosely to maintainloosely to maintain drainagedrainage..
  22. 22. Fibrin GlueFibrin Glue Fibrin glue may be used as an alternative means of occluding theFibrin glue may be used as an alternative means of occluding the fistulous tractfistulous tract.. Following digital rectal examination, the fistulous tract is identified andFollowing digital rectal examination, the fistulous tract is identified and any granulation tissue at the internal or external openings is gentlyany granulation tissue at the internal or external openings is gently debrided with a curettedebrided with a curette.. Fibrin glue is then gently injected through the external openingFibrin glue is then gently injected through the external opening until the tract is fulluntil the tract is full.. Success of this technique is variable, with long-term healing reported atSuccess of this technique is variable, with long-term healing reported at 3131––60%60% However, it can be used to avoid a large operation in risky patientsHowever, it can be used to avoid a large operation in risky patients Fibrin glue is an activated mixture of solution containing fibrinogen,Fibrin glue is an activated mixture of solution containing fibrinogen, factor XIII, fibronectin, and aprotininfactor XIII, fibronectin, and aprotinin When applied to the fistula tract, the fibrin clot seals the tract andWhen applied to the fistula tract, the fibrin clot seals the tract and stimulates migration, proliferation, and activation of fibroblastsstimulates migration, proliferation, and activation of fibroblasts..
  23. 23. Anal Fistula PlugAnal Fistula Plug This fistula plug made from lyophilizedThis fistula plug made from lyophilized porcine intestinal collagen is designed toporcine intestinal collagen is designed to occlude the fistula tract from the internalocclude the fistula tract from the internal to the external openingto the external opening.. The plug provides a scaffold for theThe plug provides a scaffold for the ingrowth of native tissueingrowth of native tissue.. Advantages of this technique are theAdvantages of this technique are the mechanical stable configurationmechanical stable configuration,,
  24. 24. Endorectal Advancement FlapsEndorectal Advancement Flaps Endorectal advancement flaps were firstEndorectal advancement flaps were first described by Noble 1902described by Noble 1902,, This treatment modality consists of removalThis treatment modality consists of removal and patching of the internal openingand patching of the internal opening with a muscularwith a muscular––mucosal flap of rectal wallmucosal flap of rectal wall..
  25. 25. Island Flap AnoplastyIsland Flap Anoplasty Dermal island advancement flap (anocutaneousDermal island advancement flap (anocutaneous advancement flap). Its use in the treatment ofadvancement flap). Its use in the treatment of fistulae started in the pastfistulae started in the past decade, basically to avoid incontinence and mucosaldecade, basically to avoid incontinence and mucosal ectropion after mucosal flap advancementectropion after mucosal flap advancement.. This procedure has been reported forThis procedure has been reported for complex or recurrent casescomplex or recurrent cases.. There are good results in terms of healing,There are good results in terms of healing, postoperative complications, pain, andpostoperative complications, pain, and incontinenceincontinence..
  26. 26. Post-operative Care After Fistulectomy wound irrigations are recommended three to four times daily. In order to promote the healing from the depth of the wound, The wound must be kept clean. A post-operative antibiotic treatment Weekly inspection should be carried out by the surgeon. Silver nitrate may be applied to prevent overgranulation. Sphincter function must be evaluated soon after surgery, Bulky laxatives must be given to allow passage of stools without straining and to reduce pain. Non-steroidal anti-inflammatory drugs are useful to reduce local pain.
  27. 27. Results and Complications After Treatment Satisfactory results may be achieved in the treatment of anal fistula. Results depend on the type of fistula. The healing time varies from 6 weeks for the low type to 16weeks or more for the complex variety. Fistula surgery should be reserved for experienced surgeons in order to reduce as much as possible the high incidence of recurrence and prevent incontinence. Two main post-operative complications may occur after treatment of an anal fistula: recurrence and incontinence
  28. 28. Recurrence Recurrence of anal fistula in cases of cryptoglandular origin is essentially due to failure to remove the correct anal gland. The internal opening may not be found and part of the tract may be buried under the granulation tissue, including the epithelial remnants A recurrence rate of up to 10% is observed If a fistula has been adequately treated and still recurs, the possibility of Crohn’s disease must be considered.
  29. 29. Incontinence Partial early post-operative incontinence is frequent after surgery of any fistulous tract and is the result of inflammation, tissue deformity and pain If the sphincter has been divided, the initial weakness regresses, and continence has proved to be adequate within 2–3 weeks. As many as one-third of the patients have some permanent disturbance in anal continence, varying from loss of flatus control to severe faecal incontinence. To prevent incontinence, there must be a sufficient time interval between the two operative sessions in a two-stage procedure. Division of the sphincter muscle must be kept to a minimum. If sphincter division results in persistent incontinence, sphincter repair must be considered

×