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Rakesh benign-anorectal-
Anorectal abscesses and fistulas represent different stages of the same disease. An abscess is the acute inflammatory event while a fistula is the chronic process. Diagnosis and treatment requires understanding of anorectal anatomy and spaces. Anorectal abscesses are usually cryptoglandular in origin and are classified by location. Treatment involves incision and drainage with or without seton placement or fistulotomy. Fistulas are classified using the Parks system. Evaluation involves physical exam, MRI, or endoanal ultrasound. Treatment goals are to eliminate the fistula while preserving sphincter function. Options include fistulotomy, seton placement, advancement flaps, fibrin glue, fistula plugs, or the LI
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Rakesh benign-anorectal-
- 1. 27/06/13 Dept. ofSurgery Benign Anorectal: Abscess and Fistula Rakesh Kumar Gupta, MS
- 2. Benign Anorectal: Abscessand Fistula Anorectal abscess and fistula-in-ano represent different stages of the same disease the abscess represents the acute inflammatory event the fistula represents the chronic process
- 3. Benign Anorectal: Abscessand Fistula Diagnosis and treatment requires in-depth understanding of anorectal anatomy and spaces
- 4. Anorectal Suppuration Epidemiology Anorectal abscesses(“Acute phase”) 100,000 cases per year Age range 20-60, 2:1 ratio M:F 30% recurrence rate* Anorectal fistula (“Chronic phase”) 25-40% of abscesses lead to fistula** 10-20% recurrence rate * Shrum RC. Dis Colon Rectum 1959; 2:469–472, **Shouler PJ et al . Int J Colorect Did 1986,1:113-5
- 5. 80% are submucosal,8% extend to internal sphincter, 8% to the conjoined longitudinal muscle, 2% intersphincteric, 1% penetrate internal sphincter At the dentate line, the ducts of the anal glands empty into anal crypts 90% of anorectal abscess result fromcrytogladularinfection
- 6. Parks cryptoglandular theory- obstruction of anal glands leads to stasis and infection
- 7. Abscess Classified by location: Perianal(50%), Intersphincteric (30%), Ischioanal (15%), Supralevator (5%)
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- 10. Abscess - Etiology Nonspecificcryptoglandular (90%) Specific causes: Specific infection, ie TB, actinomycosis, lymphogranuloma venereum, Inflammatory bowel disease, Trauma or foreign body Surgery (episiotomy, hemorrhoidectomy, prostatectomy), Malignancy - carcinoma, lymphoma, radiation-related
- 11. Pain Severe, constantpain, worse with movement/pressure (sneezing, coughing, bearing down),better with drainage Swelling, Fever chills hallmark symptoms supralevator abscess may have gluteal pain rectal pain with urinary symptoms (ie. Constipation, Urinary retention) - possibly indicate intersphincteric or supralevator abscess Anorectal Abscess Clinical Presentation
- 12. Anorectal Abscess Clinical Presentation •Exam – Induration, fluctuance, erythema, warmth, purulent drainage – DRE
- 13. Abscess - Treatment Examunder anesthesia for pain out of proportion to exam Incision and drainage - trim edges to prevent coaptation I&D of supralevator abscess: depends on location - intersphincteric origin then divide internal sphincter and drain into rectum; if arises from ischianal abscess can be drained through perineal skin
- 14. Anorectal Abscess Treatment I&D- cruciateor elliptical incision
- 15. Abscess - Treatment Catheterdrainage: stab incision to drain pus, mushroom catheter in cavity to drain pus make stab incision as close as possible to anus size and length of catheter should correspond to abscess cavity
- 16. Short distance fromanus– feel forsoft spot Place drain and trim– avoids packing Follow up in 7-10 days to remove drain
- 17. Catheter Types Pester catheter Solidmushroom top so stays in Less tissue ingrowth Malecot Allows tissue ingrowth More painful to remove
- 18. Abscess - Treatment Primaryfistulotomy may be easier to identify tract eliminates source of infection decreases recurrence/need for reoperation Downsides: false passage formation with acute inflammation, 30- 50% of those with abscess likely won’t develop a fistula, need for anesthesia vs. local for I & D
- 19. Incision and drainageof perianal abscess with or without treatment of anal fistula. Cochrane Database Syst Rev. 2010 Jul 7; (7):CD006827. CONCLUSIONS: The published evidence shows fistula surgery with abscess drainage Significantly reduces recurrence or persistence of abscess/fistula, or the need for repeat surgery. No statistically significant evidence of incontinence following fistula surgery with abscess drainage. Intervention may be recommended in carefully selected patients.
- 20. Abscess - Antibiotics Littleor no role Antibiotics? Culture? Indications: Immunosuppression Valvular heart dz Prosthetic devices Sepsis or Extensive cellulitis Crohn’s dz Sitz Baths
- 21. Abscess - Complications Recurrence recurrencein as many as 89% of pts Extra-anal causes should be evaluated for recurrent disease (hidradenitis suppurativa, Crohn’s) Incontinence iatrogenic (superficial external sphincter), inappropriate wound care (excessive scarring from prolonged packing)
- 22. Abscess - Complications Canresult in necrotizing anorectal infection (rare) Resuscitation, IV abx, wide debridement to healthy tissue Need for colostomy debatable - recommended if sphincter muscle is grossly infected, immunocompromised, rectal or colonic involvement/perforation Reexamination under anesthesia HBO - 100% O2 at 3atm over 2 hrs - promote leukocyte phagocytic function and fibroblast proliferation
- 23. Caution – NecrotizingFasciitis
- 24. Anal Infection andHematologic Diseases Anorectal suppuration with acute leukemia with mortality 45-78% Neutrophil count <500 with 11% incidence of anorectal abscess Most important prognostic factor - # days of neutropenia Presenting symptoms: fever, pain, urinary retention Antibiotics vs I & D if fluctuance, sepsis, or progression of soft tissue infection after antibiotics trial
- 25. Anal Infection &HIV HIV+ pts have increased risk of perianal sepsis Can be associated with in situ neoplasia Surgery + antibiotics 2/2 immunosuppression make incison site small bc pts at risk for poor wound healing
- 26. Fistula-in-ano Abnormal communication betweenany two epithelium-lined surfaces Parks classification:
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- 30. Intersphincteric Fistula-in-ano Most commontype of fistula - 70% Results from perianal abscess Variations: simple low tract high tract with rectal opening or blind tract extrarectal extension pelvic disease tracking
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- 32. Transsphincteric Fistula Approx 23%fistulas Results from ischioanal absecesses Rectovaginal fistula is a form of transsphincteric fistula Operative mgt with setons if sphincter preservation in question
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- 34. Suprasphincteric Fistula 5% offistulas Result from supralevator abscesses Tract arises from intersphincteric abscess, travels above puborectalis, then downward lateral to external sphincters in ischioanal space
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- 36. Extrasphincteric Fistula 2% offistulas - rarest form From rectum above the levators, through them, to the perianal skin Trauma, foreign body, Crohn’s carcinoma Most common cause is iatrogenic from probing during fistulotomy surgery
- 37. Evaluationof AnalFistula An accuratepreoperative assessment of the anatomy of an anal fistula is very important. Five essential points of a clinical examination of an anal fistula : (1) location of the internal opening. (2) location of the external opening. (3) location of the primary track . (4) location of any secondary track. (5) determination of the presence or absence of underlying disease .
- 38. Fistula-in-ano: Physical Examination Goodsall’s rule: transverseline across the perineum - posterior external openings have internal openings in the posterior midline anterior external openings have tract radially toward the nearest crypt greater distance from anal margin with more variability more accurate rule for posterior fistulas
- 40. Fistula Description Clock description Doesthe anus tell time? Relies on description of patient’s position: supine, lateral, prone and relative landmarks Anatomic description: more consistent Pubic bone defines anterior Coccyx define posterior Right and left *If terms be incorrect, then statements do not accord with facts; and when statements and facts do not accord, then business is not properly executed.”
- 41. Tailbone Right anterior Right posterior Leftanterior Left posterior Right Left Pubic bone
- 43. High Fistulas HaveHigh Internal Openings (opening of the duct at the crypt, is always at the level of the pectinate line) Internal Opening is Not Always Present Fistulas with Multiple Openings are Tuberculus in Origin Every Fistula Requires an MRI/Endoanal USG Which is the Best Surgery for Fistula in Ano? Controversies in Fistula in Ano
- 44. Mutiple external openingsover the right buttock—non tuberculus
- 45. Investigations Additional tools availablein case of difficulty. Do not replace a good clinical examination to diagnose the type & extent of fistula. Not necessary to investigate every case of fistula even the complex ones can be diagnosed fairly accurately by a good clinical examination. MRI & Endoanal ultrasound both give comparable Delineating the tracts by intra-operative dye study may be more helpful than the above investigations. Fistulograms have a very limited role in the diagnosis of fistula in ano
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- 47. MRI forfistula-in-ano HALLIGAN Radiology2006Abscesses & Extensions Contralateral disease
- 48. TREATMENT The objective isto cure with lowest possible recurrence rate and minimal, if any, alteration in continence, shortest period. The principles are: Control sepsis EUA Laying open abscesses and secondary tracts Adequate drainage – seton insertion .
- 49. Define anatomy Openings andtracts Internal and External (Identification of the primary opening) Single –v- multiple Extensions / Horseshoe (Side tracts should be sought ) Relation to sphincter complex High –v- Low (Relationship to puborectalis) Exclude co-existent disease
- 50. Fistula-in-ano: Treatment Eliminate fistula, Preventrecurrence, Preserve sphincter function
- 51. Fistula-in-ano: Treatment Identification ofinternal opening passage of probe injection of dye, methylene blue, or hydrogen peroxide following granulation in fistula tract noting puckering of crypt with traction on fistula tract
- 52. Fistulotomy/fistulectomy Lay-open technique (fistulotomy): identification of tract with unroofing tract, useful for 85-95% of primary fistulae . Appropriate for simple interspincteric and low transsphincteric Curettage is performed to remove granulation tissue. Marsupialization of the edges to improve healing times.
- 53. Surgical Options –Fistulotomy Fistula tract identified with probe Extent of external sphincter involvement assessed Tract and muscle divided Secondary tracts laid open +/- marsupialisation wound
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- 56. Surgical Options –Fistulectomy • Core out tract • Direct visualisation of secondary tracts • Sphincter repair +/- advancement flap
- 57. Fistula-in-ano: Operative Management Seton -placement of non-absorbable suture material in fistula tract Indications for setons: Promote fibrosis around fistula tract that encircles entire sphincter mechanism Mark the site of fistula in massive anorectal sepsis Anterior high transsphincteric fistulas in women HIV pts with poor wound healing and high transsphincteric fistulas Crohn’s Any time continence is questioned
- 58. Surgical Options –Cutting Seton 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
- 59. Setons intheManagement ofDifficult Fistulas
- 60. Fistula-in-ano: Operative Management High-transphincteric fistulascan be treated with combination lay- open technique and seton placement - division of internal sphincter to level of external opening and then seton placement Cutting setons can convert high fistulas to low fistulas Second-stage fistulotomy ~ 8 wks later
- 61. Fistula-in-ano: Operative Management Suprasphincteric fistula- tract involves external sphincter and puborectalis - can manage with division of internal sphincter and superficial external sphincter with seton around remaining ES or internal sphincterotomy, seton, opening of fistula tracts without division of external sphincter
- 62. Fistula-in-ano: Operative Management Anorectal AdvancementFlap internal opening closed with absorbable suture, full-thickness flap of rectal mucosa/submucosa/IAS raised - adv 1 cm beyond internal opening base of the flap should be twice the width of the apex pros: reduction in healing time, reduced pain, little potential damage to sphincters, lack of deformity to anal canal poor outcomes in Crohn’s, pts on steroids, smokers, o/w success reported in up to 90% of pts
- 63. Advancement Flaps Endorectal Fistula tractprobed Flap raised Mucosa + Int. Sphincter Internal opening excised/closed Flap advanced & sutured
- 64. Advancement Flap Anodermal Fistula tractprobed Flap raised Anodermal Flap advanced & sutures External defect closed
- 65. Fistula-in-ano: Operative Management Fibrin Glue- used in conjuntion with AAF or alone technique: internal and external openings identified, tract curetted, fistula tract injected through connector from external opening until glue visible in internal opening, slowly withdrawn can be repeated several times without compromising continence
- 66. Fistula-in-ano: Operative Management Fibrin Glue- Followup: short-term follow-up with good success 70-80% longer follow-up with success falling to 60% and even 14% in pts with complex anal fistulas
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- 69. Fistula-in-ano: Operative Management Bioprosthetic fistulaplug made from surgisis Technique - identification of internal and external opening with placement of plug over probe using suture similar to seton placement Plug secured at primary opening using absorbable suture
- 70. Fistula-in-ano: Operative Management Technique worksbest with long tracts without active inflammation or sepsis Short-term follow up (3months) with higher success rate for Crohn’s fistulas when compared to fibrin glue Long-term follow up - high failure rate
- 71. LIFT Procedure Ligation of Intersphincteric FistulaTract Transsphincteric fistula Draining seton – 6 weeks Tract prepared with fistula brush Debrides De-epithelializes
- 74. PROS CONS Cutting SetonSimple 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
- 75. Crohn’s and AnalFistulas The most common perianal manifestation and occur in 6-34% Crohn’s pts - pts with colonic Crohn’s with higher incidence, rectal Crohn’s with 100% fistula formation Conservative approach to treatment as 38% heal without surgery
- 76. Crohn’s and AnalFistulas Medications for treatment: cipro/flagyl, immunomodulators (steroids, 6MP, azathioprine, infliximab) 6-MP and azathioprine only effective in 1/3 pts with fistulizing Crohn’s Infliximab associated with 62% reduction Combination 6MP and infliximab may prolong effect of treatment Selective seton placement with infliximab + maintenance med with healing in 67%
- 77. Crohn’s and AnalFistulas Operative intervention: seton placement, rectal advancement flap if rectal-sparing, poss fibrin glue/plug Avoid cutting sphincter - incontinence reported in pts with Crohn’s proctitis even without anal surgery
- 78. ACPGBI FIAT Trial FistulaPlug Insertion Surgeon’s Preference EUA: transsphincteric fistula ≥ 1/3 of sphincter complex Insertion of draining seton RANDOMISE MRI fistulography Advancement Flap Cutting Seton Fistulotomy LIFT
- 79. ACPGB&I FIAT Primary end-points Faecalincontinence QoL Generic QoL Secondary end-points Healing – 12 months Complications Faecal incontinence Re-interventions Health resource utilisation Cost effectiveness Patient identification EUA & draining seton Eligibility & Consent Randomisation 1:1 plug –v- surgeon’s preference 6-week FU 6-monthFU 12-month FU + MRI scan Surgisis® fistula plug Surgeon’s preference (fistulotomy, seton, advancement flap, LIFT) MRI scan Surgery (6-weeks post seton insertion)
- 80. Join the FIATTrial!
Editor's Notes
- #5 Diseases of Colon and Rectum Journal (Feb 2009) - increased risk of fistula formation with age < 40 , decreased risk in DM pts , not affected by gender, smoking history, perioperative antibiotics or HIV status
- #9 Perianal - most common (45%), suppuration travels inferiorly in intersphincteric space from anal gland Ischioanal - penetrate through external sphincter Horseshoe abscess - B/L extension of ischioanal abscess into deep postanal space Supralevator- MUST rule out intraabdominal pathology
- #11 Cryptoglandular etiology - infected anal crypt gland (obstructed by debris - feces or traumatized tissue) stasis and overgrowth of enteric bacteria; suppurative fluid follows path of least resistance and travels to where gland terminates LGV - proctocolitis + inguinal bubos (enlarged, tender lymph nodes with hemorrhagic necrosis) Crohn’s, diverticulitis, appendicitis - more commonly cause supralevator abscesses
- #12 Pain worse with movement/pressure (sneezing, coughing, bearing down), better with drainage Exam - depends on LOCATION, supralevator abscesses - mass adjacent to rectal ampulla, may present with urinary retention DRE - critical with intersphincteric and supralevator (may have NO findings on external exam)
- #13 Pain worse with movement/pressure (sneezing, coughing, bearing down), better with drainage Exam - depends on LOCATION, supralevator abscesses - mass adjacent to rectal ampulla, may present with urinary retention DRE - critical with intersphincteric and supralevator (may have NO findings on external exam)
- #14 Low intersphincteric abscesses should be treated by de-roofing of the abscess and division of the internal sphincter up to a level of the dentate line. High intersphincteric abscesses are relatively frequent and mostly require staged surgery with a temporary mushroom (de Pezzer) catheter. Accurate anatomical ultrasound localization and proper drainage become important to avoid recurrences or extrasphincteric fistulas.
- #20 BACKGROUND: The perianal abscess is a common surgical problem. A third of perianal abscesses may manifest a fistula-in-ano which increases the risk of abscess recurrence requiring repeat surgical drainage. Treating the fistula at the same time as incision and drainage of the abscess may reduce the likelihood of recurrent abscess and the need for repeat surgery. However, this could affect sphincter function in some patients who may not have later developed a fistula-in-ano. OBJECTIVES: We aimed to review the available randomised controlled trial evidence comparing incision and drainage of perianal abscess with or without fistula treatment. SEARCH STRATEGY: Randomised trials were identified from MEDLINE, EMBASE, the Cochrane Library, and reference lists of published papers and reviews. SELECTION CRITERIA: Trials comparing outcome after fistula surgery with drainage of perianal abscess compared with drainage alone were included in the review. DATA COLLECTION AND ANALYSIS: The primary outcomes were recurrent or persistent abscess/fistula which may require repeat surgery and short-term and long-term incontinence. Secondary outcomes were duration of hospitalisation, duration of wound healing, postoperative pain, quality of life scores. For dichotomous variables, relative risks and their confidence intervals were calculated. MAIN RESULTS: We identified six trials, involving 479 subjects, comparing incision and drainage of perianal abscess alone versus incision and drainage with fistula treatment. Metaanalysis showed a significant reduction in recurrence, persistent abscess/fistula or repeat surgery in favour of fistula surgery at the time of abscess incision and drainage (RR=0.13, 95% Confidence Interval of RR = 0.07-0.24). Transient manometric reduction in anal sphincter pressures, without clinical incontinence, may occur after treatment of low fistulae with abscess drainage. Incontinence at one year following drainage with fistula surgery was not statistically significant (pooled RR 3.06, 95% Confidence Interval 0.7-13.45) with heterogeneity demonstrable between the trials (Chi(2) =5.39,df=3, p=0.14, I(2) =44.4%). AUTHORS' CONCLUSIONS: The published evidence shows fistula surgery with abscess drainage significantly reduces recurrence or persistence of abscess/fistula, or the need for repeat surgery. There was no statistically significant evidence of incontinence following fistula surgery with abscess drainage. This intervention may be recommended in carefully selected patients.
- #21 Recommendations of American Society of Colon and Rectal Surgeons I&D - with cruciate or elliptical incision; if cruciate excise redundant skin Abscesses requiring OR - recurrent abscesses, complex abscesses (horseshoe), supralevator and intersphincteric Antibiotics - only indicated in pts with immunosuppression (e.g. DM, leukemia/CA, HIV, malnourished), prosthetic device (valvular, intravascular, joint), valvular heart dz, ?Crohn’s dz (Cipro/Flagyl), ?history of MRSA Prophylactic fistulotomy - NOT recommended b/c high frequency of anorectal dysfxn (e.g. incontinence); only reserved for pts with horseshoe abscesses or refractory symptoms DCR study (1991) - Significantly decreased in recurrence rate and persistence rate (40% vs 3%) but more likely to have anal dysfxn (40% vs 21%) Sitz baths (or hand-held shower) - TID x15min and after BMs
- #47 IMPORTANT to identify anatomy and determine if there is sphincter involvement b/c increased risk of incomplete healing, fistula recurrence and sphincter injury if fistula anatomy is incorrectly delineated or an occult abscess missed EUS - sometimes methylene blue is also used Others usually only done with recurrent or complicated fistula (e.g. h/o rectal surgery, crohn’s disase) MRI - need anorectal coil TRUS pitfall - focal length of the 7-MHz U/S probe is not sufficiently deep to image beyond the external sphincter or puborectalis Fistulogram - can’t visualize sphincter muscles CT - poor resolution for fistula tracts Study - Buchanan et al, cohort of 108 patients with recurrent fistulae using digital examination, endoanal ultrasound, and MRI on each patient; Digital examination correctly identified 61% of tracks compared with 81% of tracks by endoanal ultrasound and 90% by MRI.