ANO RECTAL DISEASES- MANAGEMENT OPTIONS
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This document discusses common diseases of the anal region, including haemorrhoids, fissures, perianal abscesses, and fistulas. It describes the symptoms, causes, diagnosis, and various surgical treatment options for each condition. For fistulas, it covers physical examination techniques, imaging modalities like MRI and endoanal ultrasound, and different procedures like seton placement, fistulotomy, fibrin glue, the LIFT procedure, VAAFT, and fistula laser closure. The goals of fistula surgery are to eradicate the disease while preserving continence and preventing recurrence.
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ANO RECTAL DISEASES- MANAGEMENT OPTIONS
- 1. DISEASES OF THE ANAL REGION Dr VIPIN V NAIR ASSO PROF SURGERY AND PLASTIC SURGEON AFMC PUNE
- 2. LEARNING OBJECTIVES HAEMORRHOIDS FISSURE IN ANO PERIANAL ABSCESS FISTULA IN ANO
- 3. HAEMORRHOIDS BLOOD FILLED VENOUS DILATATIONS IN THE ANAL CANAL
- 4. Constipation and prolonged straining when using the toilet are thought to contribute to the formation of haemorrhoids by increasing the pressure in the veins
- 5. ASYMPTOMATIC
- 7. Itching and also Pain and Discomfort
- 11. • COMMON POSITONS OF HAEMORRHOIDS
- 12. MANAGEMENT
- 17. MIPH
- 18. •FISSURE IN ANO
- 28. Anorectal suppurative disease Incidence 12.3 per 100000 in men 5.6 per 100000 in women 3rd, 4th and 5th decade of life.
- 29. PERIANAL FISTULA Chronic abnormal communication, lined by granulation tissue, with internal opening in the anal canal and external opening on the skin of the perineum or buttock 29
- 32. Etiology • Tuberculosis • IBD • Malignancy • Post op infections • Superficial skin infections 32
- 35. Simple and Complex Fistula 35 Simple Fistula Complex fistula Submucosal Fistula with multiple external openings Intersphincteric High transsphincteric, suprasphincteric, extrasphincteric Low transsphincteric Horseshoe fistula Anterior fistula in women Crohn fistula Radiation induced fistula
- 36. Low fistula • Involve only distal third part of anal sphincter High fistula • Involve the middle and/or upper third part of sphincter complex
- 37. Diagnosis •History •Perianal discharge •Swelling •Pain •Bleeding •Skin excoriation •External opening •Previous history of anorectal suppuration (40%) 37
- 38. Examination • Digital rectal examination • Proctoscopy • Examination under anesthesia • Examine in awake state • Majority – single primary fistula tract 38
- 39. Five essential points of a clinical examination of an anal fistula (1) Internal opening (2) External opening (3) Primary track (4) Secondary track (5) Underlying disease
- 41. Investigations Imaging •Identify complex fistula •Define relationship of tract to anal sphincter muscles •Plan surgical drainage and assess risk of sphincter injury Meta analysis – EUA always better
- 42. MRI • 96% sensitivity and 90% specificity – internal opening • Inv of choice for • complex fistula • Recurrent fistula 42
- 43. Endoanal Ultrasonography • 360 degree rotating probe • 7- or 10-MHz transducer with a hard plastic water-filled sonolucent cone over the transducer • Fistula tracts and abscesses - hypoechoic defects • Muscular anatomy in relation to abscess and fistula • Hydrogen peroxide acts as contrast • Limitation – cost, availability, expertise 43
- 44. 3 D endoanal USG
- 45. Sigmoidoscopy and Colonoscopy Sigmoidoscopy - In all patients with anorectal fistula
- 46. Anorectal Manometry Help identify patient at risk of post op incontinence Indications • Suspected sphincter impairment • H/O difficult labor • H/O previous fistulotomy • High fistulas • Elderly
- 47. Treatment Modalities-Aims 47 Eradicate disease 1 Preserve continence 2 Prevent recurrence 3
- 48. Surgical Options 1. Seton 2. Fistulotomy 3. Advancement flaps 4. Fibrin glue - 1990 5. Anal Fistula plug – 2006 6. LIFT (ligation of intersphincteric fistula tract)- 2007 7. Autologous Adipose derived stem cells -2009 8. Fistula Laser Closure - 2011 9. VAAFT – 2011 10. Fistula clip closure 11. Hybrid techniques 48
- 49. Seton Materials • Silk , Nylon, Prolene, Vessel loops, Rubber bands Draining seton Cutting seton 50 Success rate – 80%, one third – disturbance of incontinence
- 50. Fistulotomy • Identify the tract • Assess extent of sphincter involvement • Division of all structures lying between external and internal opening • Tract laid open and the tract curettage done • Surest way of getting rid of fistula • Success rate – 93 to 100% , Incontinence – 11.5 to 20% 51
- 51. Fistulectomy • Generally not recommended • Larger wound and sphincter damage 52
- 52. Fibrin Glue • For complex anal fistula • Thrombin and fibrinogen • Stimulate growth of fibroblasts and endothelial cells 53
- 53. Fibrin Glue Antibiotic impregnated – no difference Advantage • Safety • Ease of application • Inexpensive • Low risk of sphincter injury Meta-analysis (success rate 50 to 60%)
- 54. Anal Fistula Plug • Lyophilised porcine derived small intestinal submucosa (Surgisis®) • GORE BioA fistula plug (polyglycolic acid/ trimethylene carbonate) • Success rate 55%
- 56. Anal Fistula Plug Complications •Plug dislodgement •Infection •Failure rate – high
- 57. Advancement Flaps Endorectal advancement flaps • Flap raised • Mucosa+ submucosa + Int. Sphincter • Internal opening excised/closed • Flap advanced & sutured • External component treated by curettage or fistulotomy 58
- 59. Advancement Flaps- Advantage One stage Quick healing Limited sphincter damage Minimal anal canal deformity
- 60. Advancement Flaps Success – 59 to 72% Multiple session - 90% Incontinence – 9 to 14% Efficacy similar with fistula plug
- 61. LIFT 62 Ligation of intersphincteric fistula tract (LIFT) 2007 – Rojanasakul et al Based on closure of internal opening, removal of infected tissue Disconnection of internal opening from fistula tract at level of intersphincteric plane Injection of hydrogen peroxide – help confirm completeness of procedure
- 63. LIFT • Anal sphincter preservation • Minimal tissue injury • Shorter healing time Advantage • Healing rate – 40 to 95% • For recurrent fistula – success rate 47% Success rate
- 64. VAAFT 65 Video- Assisted Anal Fistula Treatment Dr P Meinero in 2006 5 mm fistuloscope, irrigation, diathermy Diagnostic phase – tract and opening evaluated with fistuloscope Operative phase - cauterize
- 65. VAAFT Steps • Identify tract under vision • Cauterise & debride fistula wall with bipolar energy • Endobrush to extract necrotic material • Internal opening sutured by semicircular/linear stapler or mucosal flap • 0.5 ml cyanoacrylate glue to reinforce suture line Healing rate – 73.5% at 3 months and 87.1% at 12 months
- 67. VAAFT Advantage No sphinter injury Post op pain less
- 68. Fistula Laser Closure 69 FiLaC Radial emitting laser probe Destroys the fistula epithelium and obliterates the tract by shrinkage effect Includes closure of internal opening with anorectal flap Steps – identify – debride – 14 fr catheter-400 micron laser fibre with tip at internal orifice
- 70. THANK YOU 81
Editor's Notes
- Recent evidence – paucity of bacteria… chronic infection may not be pathological process
- Flap – 5-10mm below internal opening and 10-15mm on either side Infiltrate with lignocaine or saline with adrenaline Dissection of primary tract from external opening to external sphinter not necessary but should be drained
- Porcine-derived isocyanate crosslinked acellular dermal sheet Predominantly composed of type I collagen (93–95 %) with additional type III collagen and a small amount of elastin
- Fecal incontinence increases with complexity of fistula More sphincter muscle included in fistulotomy Females – more prone Low when external anal sphinter not divided One study – fistulotomy for intersphinteric fistula (37%) and transsphinteric fistula (54%) Cutting seton doesn’t eliminate risk of incontinence 2/3rd – incontinence to flatus or liquid stool, 1/3rd to solid stool after use of cutting seton Loose seton preferred when risk of incontinence is high