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Fistula in-ano

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Fistula in-ano

  1. 1. Fistula-in-ano: a probing of the treatment options David Jayne Professor of Surgery University of Leeds & Leeds Teaching Hospitals NHS TrustJohn GoligherColorectal Unit
  2. 2. The Problem
  3. 3. Aetiology• Cryptoglandular• Crohn’s disease• Other – Malignant – Obstetric – Radiation
  4. 4. Classification30% 45%5% 20%
  5. 5. Goodsall’s Rule
  6. 6. Treatment Aims• Eradicate disease (if possible)• Preservation of continence• Benign condition• Quality of life
  7. 7. Principles• 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
  8. 8. MRI for fistula-in-anoAbscesses & Contralateral disease Other pathology HALLIGAN Radiology 2006 Extensions
  9. 9. Surgical Options – Fistulotomy• Fistula tract identified with probe• Extent of external sphincter involvement assessed• Tract and muscle divided• Secondary tracts laid open• +/- marsupialisation wound
  10. 10. 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
  11. 11. Surgical Options – Fistulectomy• Draining seton• Core out tract• Direct visualisation of secondary tracts• Sphincter repair +/- advancement flap
  12. 12. Advancement FlapsEndorectal• Fistula tract probed• Flap raised – Mucosa + Int. Sphincter• Internal opening excised/closed• Flap advanced & sutured
  13. 13. Advancement FlapAnodermal• Fistula tract probed• Flap raised – Anodermal• Flap advanced & sutures• External defect closed
  14. 14. Fistula Plug
  15. 15. Fistula Plug
  16. 16. LIFT ProcedureLigation of IntersphinctericFistula Tract• Transsphincteric fistula• Draining seton – 6 weeks• Tract prepared with fistula brush – Debrides – De-epithelializes
  17. 17. LIFT Procedure
  18. 18. PROS CONSCutting Seton Simple Repeat EUA Cheap Recurrence 0 – 8% Incontinence • minor 34 – 63% • major 2 – 26%Fistulotomy Simple Recurrence 2 – 9% Cheap Incontinence 50%Advancement Flap Can be difficult Recurrence 25 – 50% ?Preserves sphincter Incontinence 30 – 35%Fistula Plug Simple Plug expensive ~£400 Preserves sphincter Recurrence 20 – 85% Continence preservedLIFT Simple Recurrence 15 - 40% Preserves sphincter Continence preserved
  19. 19. ACPGBI FIAT Trial EUA: transsphincteric fistula ≥ 1/3 of sphincter complex Insertion of draining seton MRI fistulography RANDOMISEFistula Plug Surgeon’s Insertion Preference Advancement Cutting Seton Fistulotomy LIFT Flap
  20. 20. ACPGB&I FIAT Patient identification EUA & draining seton Primary end-points Eligibility & Consent • Faecal incontinence QoL MRI scan • Generic QoL Randomisation 1:1 plug –v- surgeon’s preference Secondary end-points Surgery • Healing – 12 months (6-weeks post seton insertion) • Complications Surgeon’s preference • Faecal incontinenceSurgisis® fistula plug (fistulotomy, seton, advancement flap, LIFT) • Re-interventions • Health resource 6-week FU utilisation 6-monthFU • Cost effectiveness 12-month FU + MRI scan
  21. 21. FIAT FACTSRecruitment: 76Target: 500Open centres: 36Recruiting centres: 21
  22. 22. Join the FIAT Trial!
  23. 23. Fistula-in-ano: a probing of the treatment options David Jayne Professor of Surgery University of Leeds & Leeds Teaching Hospitals NHS TrustJohn GoligherColorectal Unit

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