Recent Advance- Management of Fistula in ano

Sukria NayakColorectal and General

Surgery Christian Medical College,

VelloreBHU, Varanasi 7th Sept 2012

Sushruta - Kshaarasootra

Are we any better ?

Lay open / Fistulotomy

Oldest

Simplest

For low fistula Good healing Minimal

sphincter damage

Minimal risk of incontinence

Seton used: high fistula / > 1/3rd External sphincter involvement

Seton : Modern variation Drainage seton

Cutting seton

Two stage seton fistulotomy

Chemical seton ( Ayurvedic )

Mc Coutney JS, Finly IG - Br J Surg, 1995, 82: 448-452

MRCT: Shukla N, Indian J Med Res 1991; 94:1202-1207

Drainage seton

Infant feeding tube

Vascular sling

Cutting seton

Conventional :- Post op

adjustment / tightening required

- Painful / not tolerated well

- Break / Fall off

Elastic Band :- One time

- No post op adjustment

- Minimum risk of incontinence

A dynamic Dynamic

Elastic Band Cutting Seton

Hanley PH - 1978 Culp CE – 1984Ann Surg; 187:435- 437 Mayo Clin Proct; 59:613- 617

Ordinary glove : 2-3 mm strip, thicker sleeve, double strand fashion

Complete healing at 1 month : 45% 3 months: 100% Recurrence at 8 months: 5 %

Ankara, Turkey - Tech Coloproctology, 2004, 8:159-162

Rubber band seton

Two stage technique

Gold standard for High Fistula Transanal Rectal

Advancement Flap (AF) Pedro S et al, DCR 1985;28,7:496-498

??? Hagen SJ vander et al,Int J Colorectal Ds 2006;

21(8):784-790

Success rate : 37%

Recurrence after AF : 0-63%

Fibrin Glue Thrombin & Fibrinogen

2-chamber syringe

Mix at delivery

Cannula tip up to internal opening and withdrawn while injecting

Early results: promising

Follow up: disappointing

Against conv seton- RCT Lindsey et al:DCR2002;45:1608-15 Advocated Zmora et al:DCR 2003;46(5):584-589 With antibiotics- RCT Singer M et al: DCR 2005; 48:799-808 Advancement Flap and

Glue – RCT Paul J van et al:Int J Colorectal Ds 2008;23:697-701

Cochrane Systematic Review

Associated with worse outcome

Gone with the wind

Anal Fistula Plug ( AFP )

Johnson et al, 2006; DCR 49(3):371-376

- New biological material- Absorbable- Lyophilized porcine intestinal submucosa

Champagne BJ et al, 2006; DCR 49(12):1817-1821Success rate 83% at 12 months

Cook’s costly hardware- AFP

Plugging

Failed anal fistula plug

High Cost : May not be the best

Lay open Vs Plug

PLUG Trial - Netherlands: AFPlug Vs MAFlap : Awaited

The Anal Fistula Plug versus the mucosal advancement flap for the treatment of Anorectal Fistula (PLUG trial)

Paul J van Koperen,1 Willem A Bemelman,1 Patrick MM Bossuyt,2 Michael F Gerhards,3 Quirijn AJ Eijsbouts,4 Willem F van Tets,5 Lucas WM Janssen,6 F Robert Dijkstra,6 Annette D van Dalsen,7 and J Frederik M Slors 1

1Department of Surgery, Academic Medical Centre, Amsterdam, The Netherlands

2Department of Clinical Epidemiology and Bio-statistics, Academic Medical Centre, Amsterdam, The Netherlands

3Department of Surgery, Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands

4Department of Surgery, Spaarne Hospital, Heemstede, The Netherlands

5Department of Surgery, Sint Lucas Andreas Hospital Amsterdam, The Netherlands

6Department of Surgery, Zuwe Hofpoort Hospital, Woerden, The Netherlands

7Department of Surgery, Isala Clinics, Zwolle, The Netherlands

Will crown the winner

What to do ?

Horse shoe fistula ? best way

LIFT procedure 2007: Arun Rojanasakul, Chulalongkorn

University, Thailand: Healing – 94% 1993: Matos et al- total anal sphincter

preservation in high fistula in ano: excision of intersphincteric anal gland infection through the intersphincteric approach

Corman’s textbook : colon and rectal surgery-

mentioned

Surgical technique

• Identify internal opening• Incision at intersphincteric groove• Dissection through intersphincteric plane – find intersphincteric fistula tract• Suture ligation & excision of intersphincteric fistula tract• Curette fistula tract from external opening• Closure of external sphincter muscle defect• Closure of intersphincteric wound

Steps of Procedure

Bio LIFT Procedure C. Neal Ellis, University of South

Alabama: Study 2005-2008 /31: Published in 2010

Result: 94% Healing/No complications

Most recent sphincter saving technique for complex anal fistulas

RCT required to confirm Dis Colon Rectum 2010; 53: 1361–1364

BioLIFT

New Paths

Video Assisted Anal Fistula Treatment (VAAFT)

Radiofrequency fistulotomy: less pain ( 4MHz ) fast healing tried for low fistula only

Gupta PJ, Curr Surg 2003; 60(5): 524-528

? Laser ? Synthetic material ? Chemical

Systematic Review AI Malik, RLNelson, Colorectal Ds 2008; 10:420-430

Major gaps remain in our understanding of Anal Fistula Surgery

High Fistula -? Ideal operation

Depends on the surgeon and the patient

Thank you