Fistula-in-ano: a probing of the treatment options

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Fistula-in-ano a probing of the treatment
options

• David Jayne
• Professor of Surgery
• University of Leeds Leeds Teaching Hospitals
  NHS Trust

John Goligher Colorectal Unit
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The Problem
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Aetiology

• Cryptoglandular
• Crohns disease
• Other
• Malignant
• Obstetric
• Radiation

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Classification
45
30
20
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(No Transcript)
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Goodsalls Rule
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Treatment Aims

• Eradicate disease (if possible)
• Preservation of continence
• Benign condition
• Quality of life

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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

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MRI for fistula-in-ano
Abscesses Extensions
Contralateral disease
Other pathology
HALLIGAN Radiology 2006
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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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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

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Surgical Options Fistulectomy

• Draining seton
• Core out tract
• Direct visualisation of secondary tracts
• Sphincter repair /- advancement flap

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Advancement Flaps

• Endorectal
• Fistula tract probed
• Flap raised
• Mucosa Int. Sphincter
• Internal opening excised/closed
• Flap advanced sutured

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Advancement Flap

• Anodermal
• Fistula tract probed
• Flap raised
• Anodermal
• Flap advanced sutures
• External defect closed

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Fistula Plug
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Fistula Plug
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LIFT Procedure

• Ligation of Intersphincteric
• Fistula Tract
• Transsphincteric fistula
• Draining seton 6 weeks
• Tract prepared with fistula brush
• Debrides
• De-epithelializes

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LIFT Procedure
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PROS CONS
Cutting Seton Simple 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
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ACPGBI FIAT Trial
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ACPGBI FIAT

• Primary end-points
• Faecal incontinence QoL
• Generic QoL
• Secondary end-points
• Healing 12 months
• Complications
• Faecal incontinence
• Re-interventions
• Health resource utilisation
• Cost effectiveness

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FIAT FACTS Recruitment 76 Target 500 Open
centres 36 Recruiting centres 21
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Join the FIAT Trial!
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Fistula-in-ano a probing of the treatment
options

• David Jayne
• Professor of Surgery
• University of Leeds Leeds Teaching Hospitals
  NHS Trust

John Goligher Colorectal Unit