Fi t l éi l t it t Fi t l éi l t it t Fistules périanales, traitement Fistules périanales, traitement l l ffi ? l l ffi ? leplus efficace en 2012? leplus efficace en 2012? F. F. Ris Ris, B. Roche , B. Roche Interdisziplinäre Viszerale und Medizin am Interdisziplinäre Viszerale und Medizin am Inselspital 2012, UPDATE Proktologie Inselspital 2012, UPDATE Proktologie Inselspital Bern 18 th October 18 October 2012
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Inselspital fistula BE 18th October 2012final-1...10% secondary Hydroadenitis, cebaceusadenitis Fissure Pilonidal Cyst Infectious disease: tbc, STD Carcinoma: anal, rectum, leukemia
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Fi t l é i l t it t Fi t l é i l t it t Fistules périanales, traitement Fistules périanales, traitement l l ffi ?l l ffi ?le plus efficace en 2012?le plus efficace en 2012?
F. F. RisRis, B. Roche, B. RocheInterdisziplinäre Viszerale und Medizin am Interdisziplinäre Viszerale und Medizin am
Perianal abscessP i f h fi l ?Primum movens of the fistula?
Inselspital 18th October 2012
Proctology Unit
Different Abcess localisationDifferent Abcess localisation
Inselspital 18th October 2012
Proctology Unit
Therapeutic optionsTherapeutic options
Simple drainage Local anaesthesia
Drainage curettage and seton General anaesthesia General anaesthesiaDrainage + fistula track treatment
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Initial managmentLitt t
Initial managmentLitterature: Randomised trial incision (I) versus fistulotomy (F)
Y Patients Recurrence% Incontinence%I FI F
Hebjorn et al 1984 18 20 I = F I < FOliver et al 2003 100 100 I (29) > F (5) I (2.8) < F (36.7)Schouten et al 199734 36 I (40 6) > F (2 9) I (21 4) < F (39 4)Schouten et al 199734 36 I (40.6) > F (2.9) I (21.4) < F (39.4)Seow-Choen 1997 24 21 I (12 ) > F (0) --------------
I = IncisionF= Fistulectomy
Inselspital 18th October 2012
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y
Simple drainage or d i & fi t ldrainage & fistulatrack treatmenttrack treatment in anorectal abscess?o ec bscess?
Inselspital 18th October 2012
Proctology Unit
Simple drainage or d i & fi t ldrainage & fistulatrack treatmenttrack treatmentin anorectal abscess?o ec bscess?
Inselspital 18th October 2012
Proctology Unit
Natural history of the fistulaNatural history of the fistula
20% will close the fistula tract
Putting a Seton initialy will prevent this g y pnatural healing process
Alternative surgical managmentAlternative surgical managment
Cutting setton (40 60% risk of incontinence)Cutting setton (40-60% risk of incontinence)Van Tests. BLS 1995;82:895-7Hämäläinen KP. Dis Col Rect 1997;40:1443-7
Transsphincteric fistulectomy and sphincter
Garcia-Aguilar J. BJS 1998;85:243-5
Transsphincteric fistulectomy and sphincter reconstruction (>30% incontinence)( )
Both avoided because of fecal incontinence
Inselspital 18th October 2012
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Fistulectomy:
Fistulectomy
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y
Fistulectomy
Anodermicreconstruction
Complete excision of i ifi
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primary orifice
Fistulectomy: results
464 fistulectomies464 fistulectomies24 recurrences (5.2%)ecu e ces (5 %)
No incontinence
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Proctology Unit
Sphincter preservingSphincter preservingSphincter preserving Sphincter preserving complex fistula complex fistula co p e stu aco p e stu a
Shower 3-6 times dailyNSAID drugsNSAID drugsCream in the external woundBulk forming agent or oil 1 xBulk forming agent or oil 1 x dailyClose FU (Weekly inspection)
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Advantages of the flap procedure:
No sphincter divisionpNo keyhole deformityL i d id h liLess pain and rapid healingMay repeat in case of recurrencesMay repeat in case of recurrences
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Geneva Results:Geneva Results:
136 consecutive cases136 consecutive cases82 men54 women
Age 28 - 78 y M = 44.6 y
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Inpatient /outpatient ratiop p
Inpatient 97 (71.3%)
O t ti t 39 (28 7%)Outpatient 39 (28.7%)
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Success ratePrimary success (1 month)
97 (71.3%)S (Secondary success (delayed or minor op) 17 (12.5%)p) ( )
Recurrences at 1 year follow upRecurrences at 1 year follow up22 (122 (166..22%) out of 136 %) out of 136 flapsflaps
83 8% f83 8% fInselspital 18th October 2012
Proctology Unit
83.8% of success83.8% of success
Hospital stay
Postoperative stay 4.1 d
p y
Postoperative stay 4.1 dWound healing delay 32.8 d (12-g y (63)
1 suture leakNo septic complications
Inselspital 18th October 2012
Proctology Unit
continence
No liquid nor solid stool incontinenceNo liquid nor solid stool incontinence1 faecal soiling1 faecal soiling3 gas incontinence3 gas incontinence1 sphincter rigidity (11 operations)1 sphincter rigidity (11 operations)
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Proctology Unit
The mucosal flap in the treatment ofThe mucosal flap in the treatment of complex anal fistulae allows:
Elimination of inflammatory tissue Sphincter preservationLocoregional anesthesiaOutpatients
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New Surgical managmentNew Surgical managment Plugs?Plugs?
Lif d ?Lift procedure?
VAAFT?
OVESCO clipOVESCO clip
St llInselspital 18th October 2012
Proctology Unit
Stem cells
Plug technique:Plug technique:
f f f
Plug technique:Plug technique:
Identification of the fistula tract with setonTract is washed and brushedPlug is pulled out from the primary orifice
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Proctology Unit
Pl t h iPl t h iPlug techniquePlug technique::
Endo anal fixationEndo anal fixation
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From April 2007 to February 2008
16 patients: 12 male 4 femaleComplex crypto glandular fistulaSeton drainage 3 months before the operationSeton drainage 3 months before the operation
Results!!!!
Inselspital 18th October 2012
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Inselspital 18th October 2012
Proctology Unit
R lResults
15 recurrences (93.7%)
Three month success rate 6.3%
No incontinenceNo incontinence
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Author Date Journal Success Rate Number patientsAuthor Date Journal Success Rate Number patientsFollow-up time
Champagne BJ 2006 Dec Dis Colon 83% n = 46Champagne, BJ, et al
2006, Dec. Dis. Colon Rectum
83% n = 46F/U = 6 – 24 momed = 12 mo
Van Koperen, PJ, et al
2007, Dec. Dis. Colon Rectum
41% n = 17F/U = 3 – 9 momed = 7mo
Scwandner, O, et al
2008, Mar. Int. J Colorectal Dis.
45.5% n = 19F/U = 9 mo
Ky AJ et al 2008 Mar 11 Dis Colon 54 6% n = 45Ky, AJ, et al 2008, Mar. 11 Dis Colon Rectum
54.6% n = 45F/U = 3 – 13 mo med = 6.5 mo
24%Lawes, DA et al 2008, Mar. 29 World J Surg 24% n = 17F/U = 7.4 mo
24%
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Proctology Unit
Cryptoglandular single tract high TSCryptoglandular, single tract, high TS32 patients received the treatmentpSuccess rate: Plug 3/15Plug 3/15Flap 14/16
Early closure of the study
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p
medium and high TS Cryptoglandular tractmedium and high TS Cryptoglandular tract,60 patients received the treatmentSuccess rate: Plug 29%Plug 29%Flap 48%
Described by Rojanasankul in 2007Success rates of > 94%No deterioration in continence
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LIFT procedurep
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Tract probed and circumanal incision
LIFT procedurep
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Proctology UnitComplete dissection of tract
LIFT procedurep
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Proctology UnitTract suture ligated and divided
LIFT procedurep
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Proctology UnitLIFT wound closed
LIFT procedurepAuthors Year Country N Success Rate (%) Continence Follow Up
(weeks)
Rojanasakul et al 2007 Thailand 18 17 (94) “normal” not formally
d
Max 26
assessed
Shanwani et al 2010 Malaysia 45 37 (82) Not formallyassessed
36 assessed
Bleier et al 2010 USA 35 20 (57) No FINot formally
20(90% F/U)y
assessed(9 / )
Aboulian et al 2011 USA 26 17 (68) Not assessed 27 7 7
Ellis (BioLIFT)
2010 USA 31 29 (94) Not formally assessed
29 patients for 12 months
Inselspital 18th October 2012
Proctology UnitAbcarianAm 2012 USA 40 29(74) Not formally
assessed12
LIFT is it a new technique?qGoligher (Leeds 1967)g ( 9 7)Excision of internal sphincter at fistula site for drainage and access to fistulotomyand access to fistulotomyHealing 25/25Incontinence: flatus 8, liquid 4,solids 7
Matos (ST Mark’s, 1993)Matos (ST Mark s, 1993)Intersphincteric approach for fistulectomy and closure of the internal sphincter from withinof the internal sphincter from withinHealing 7/13
The LIFT procedure has no reported adverse ffeffects on continence
“Failures” at LIFT can be transformed to “secondary closures” (transphincteric fistula into secondary closures (transphincteric fistula into low inter‐sphincteric fistulae amendable to fistulotomy)
From May 2006 to May 2011y y136 patients using VAAFT. 98 patients were followed up for a minimum of 698 patients were followed up for a minimum of 6 months. No major complications P i h li i 72 ti t (73 5%) t 2 3Primary healing in 72 patients (73.5%) at 2–3 months. followed up >1 year for 62 patients, among them87 1% healed