Treatment for Anal fistula Dr. Wong Siu Wang North District Hospital Joint Hospital Surgical Grand Round Sept 2006.

Treatment for Anal fistulaTreatment for Anal fistulaDr. Wong Siu WangDr. Wong Siu Wang

North District HospitalNorth District HospitalJoint Hospital Surgical Grand RoundJoint Hospital Surgical Grand Round

Sept 2006Sept 2006

ClassificationClassification

Parks classificationParks classification IntersphinctericIntersphincteric Trans-sphinctericTrans-sphincteric Supra-sphinctericSupra-sphincteric Extra-sphinctericExtra-sphincteric

High vs LowHigh vs Low Simple vs ComplexSimple vs Complex

BJS 1976;63:1-12

EtiologyEtiology

CrytogenicCrytogenic Inflammatory bowel diseaseInflammatory bowel disease MalignancyMalignancy TuberculosisTuberculosis Pelvic sepsisPelvic sepsis

EtiologyEtiology

CrytogenicCrytogenic Inflammatory bowel diseaseInflammatory bowel disease MalignancyMalignancy TuberculosisTuberculosis Pelvic sepsisPelvic sepsis

Treatment of Anal fistulaTreatment of Anal fistula

1.1. FistulotomyFistulotomy

2.2. FistulectomyFistulectomy

3.3. Advancement flapsAdvancement flaps

4.4. Seton (loose, cutting, chemical)Seton (loose, cutting, chemical)

5.5. Fibrin glueFibrin glue

6.6. RadiofrequencyRadiofrequency

1. Fistulotomy1. Fistulotomy

Standard treatment for low type fistulaStandard treatment for low type fistula Recurrence rate ~5% - 10%Recurrence rate ~5% - 10% Minor incontinence rate ~6% - 26%Minor incontinence rate ~6% - 26%

Stage fistulotomy for high type fistulaStage fistulotomy for high type fistula Recurrence rate ~5% – 8%Recurrence rate ~5% – 8% Minor incontinence rate ~50%Minor incontinence rate ~50%

BJS 1995;82:895-7BJS 1995;82:895-7

BJS 1991;78:1159-61BJS 1991;78:1159-61

Fistulotomy (New Modification)Fistulotomy (New Modification)

MarsupialisationMarsupialisation Suturing the divided wound edge to the edges Suturing the divided wound edge to the edges

of the curetted fibrous trackof the curetted fibrous track Results in smaller wound and faster healingResults in smaller wound and faster healing

Colorectal Dis 2006;8:11-4Colorectal Dis 2006;8:11-4

BJS 1998;85:105-107BJS 1998;85:105-107

2. Fistulectomy2. Fistulectomy

Argument against fistulectomyArgument against fistulectomy RCT of Fistulectomy vs FistulotomyRCT of Fistulectomy vs Fistulotomy Greater tissue loss leads to delayed healingGreater tissue loss leads to delayed healing Similar recurrence ratesSimilar recurrence rates

BJS 1985;55:23-7BJS 1985;55:23-7

FistulectomyFistulectomy

Argument supporting fistulectomyArgument supporting fistulectomy Complete specimen for histologyComplete specimen for histology Reduces risk of missing secondary tracksReduces risk of missing secondary tracks Similar incontinence rateSimilar incontinence rate

Modification:Modification: Core out techniqueCore out technique FistulectomeFistulectome

FistulectomeFistulectome

The fistulectome: a new device for treatment of complex anal The fistulectome: a new device for treatment of complex anal fistulas by “Core-Out” fistulectomy. fistulas by “Core-Out” fistulectomy. Dis Colon Rectum Dis Colon Rectum 2003;46:1566-712003;46:1566-71

FistulectomeFistulectome

Device for core out Device for core out fistulectomyfistulectomy

Remove 2mm Remove 2mm thickness of fistula thickness of fistula tracttract

Limited experience Limited experience and resultsand results

Dis Colon Rectum 2003;46:1566-71

3. Endorectal advancement flap3. Endorectal advancement flap

Treatment for high type fistulaTreatment for high type fistula Close the internal opening with flapClose the internal opening with flap Mucosal flap for proximal fistula, anocutaneoeus flap for Mucosal flap for proximal fistula, anocutaneoeus flap for

distal fistuladistal fistula Contra-indication: acute sepsis, large internal opening, Contra-indication: acute sepsis, large internal opening,

heavily scarred rectumheavily scarred rectum

Endorectal advancement flapEndorectal advancement flap

Results in high type fistulaResults in high type fistula Heterogenous, depend on length of FUHeterogenous, depend on length of FU Recurrence rate ~20% - 60%Recurrence rate ~20% - 60% Incontinence rate ~18.7%Incontinence rate ~18.7%

Int J Colorectal Dis 1994;9:153-7Int J Colorectal Dis 1994;9:153-7

Int J Colorectal Dis 2006 Mar 15Int J Colorectal Dis 2006 Mar 15

4. Seton4. Seton

i.i. Loose SetonLoose Seton

ii.ii. Cutting SetonCutting Seton

iii.iii. Chemical SetonChemical Seton

i. Loose Setoni. Loose Seton

Drainage of sepsis before definitive Drainage of sepsis before definitive treatment (eg. Staged fistulotomy)treatment (eg. Staged fistulotomy)

Primary treatment for complex fistulaPrimary treatment for complex fistula

Loose SetonLoose Seton

Procedure in St Mark’s HospitalProcedure in St Mark’s Hospital Tracks and extensions outside sphincter laid Tracks and extensions outside sphincter laid

openopen passage of Seton thro’ primary track across passage of Seton thro’ primary track across

the external sphincter and tied looselythe external sphincter and tied loosely Outpatient review, remove Seton at 2-3 Outpatient review, remove Seton at 2-3

months if wound healedmonths if wound healed

Loose SetonLoose Seton

Result for treatment of complex fistulaResult for treatment of complex fistula Success rate 44% - 78%Success rate 44% - 78% Minor incontinence rate 17% - 36%Minor incontinence rate 17% - 36%

Int J Colorectal Dis 1989;4:247-50Int J Colorectal Dis 1989;4:247-50

BJS 1990;77:898-901BJS 1990;77:898-901

ii. Cutting Setonii. Cutting Seton

Analog to staged fistulotomyAnalog to staged fistulotomy Cutting the fistula track with tightening of Cutting the fistula track with tightening of

SetonSeton Balance between healing speed vs Balance between healing speed vs

continencecontinence Material: silk, braided polyester, rubber Material: silk, braided polyester, rubber

band, Penrose drainband, Penrose drain

Cutting SetonCutting Seton

Results are heterogenousResults are heterogenous Average cutting time ~14-20 wksAverage cutting time ~14-20 wks Recurrence rate ~5% (0-29%)Recurrence rate ~5% (0-29%) Minor incontinence rate ~50%Minor incontinence rate ~50% New ModificationNew Modification

Snug SetonSnug Seton

Snug SetonSnug Seton

1mm elastic Seton1mm elastic Seton Silicon nerve vessel Silicon nerve vessel

retractorretractor Slow fistulotomySlow fistulotomy

T M Hammond et alT M Hammond et al 29 patients idiopathic fistula (~38% high type)29 patients idiopathic fistula (~38% high type) Median cutting time 24 wksMedian cutting time 24 wks No recurrenceNo recurrence Minor incontinence rate ~25%Minor incontinence rate ~25%

Colorectal Dis 2006;8:328-37Colorectal Dis 2006;8:328-37

iii. Chemical Setoniii. Chemical Seton

Kshara sutra, derived Kshara sutra, derived from plants from plants (Ayurveda)(Ayurveda)

Antibacterial, anti-Antibacterial, anti-inflammatory inflammatory properties, alkalineproperties, alkaline

Weekly insertionWeekly insertion Slowly cut though the Slowly cut though the

tissuestissues

Chemical SetonChemical Seton

RCT comparing chemical Seton with RCT comparing chemical Seton with fistulotomy in low type fistulafistulotomy in low type fistula More painful with chemical Seton but no More painful with chemical Seton but no

difference in healing time, complications or difference in healing time, complications or functional outcomefunctional outcome

Tech Coloproctol 2001;5:137-41Tech Coloproctol 2001;5:137-41

5. Fibrin glue5. Fibrin glue

Fibrinogen solution +/- antibioticsFibrinogen solution +/- antibiotics Promote healing thro’ fibroblast migration and Promote healing thro’ fibroblast migration and

activation, formation of collagen meshworkactivation, formation of collagen meshwork

Before injectionBefore injection Curettage all granulation tissue and debrisCurettage all granulation tissue and debris

Contraindication: acute sepsisContraindication: acute sepsis

Fibrin glueFibrin glue

Results variableResults variable For complex fistulaFor complex fistula

Successful rate ~50%Successful rate ~50% Septic complication 3%Septic complication 3%

Dis Colon Rectum 2005;48:2167-72Dis Colon Rectum 2005;48:2167-72

For simple fistulaFor simple fistula RCT fibrin glue vs conventional treatment for anal RCT fibrin glue vs conventional treatment for anal

fistulafistula 42 patients42 patients No advantage for fibrin glue over fistulotomy in simple No advantage for fibrin glue over fistulotomy in simple

fistulafistulaDis Colon Rectum 2002;45:1608-15Dis Colon Rectum 2002;45:1608-15

6. Radiofrequency6. Radiofrequency

Radiofrequency Radiofrequency scalpelscalpel

Fistulotomy/ Fistulotomy/ fistulectomyfistulectomy

High frequency High frequency 4MHz radiowave4MHz radiowave

Mode: cutting, Mode: cutting, coagulation, coagulation, fulgurate, bipolarfulgurate, bipolar

RadiofrequencyRadiofrequency

RadiofrequencyRadiofrequency

PrinciplePrinciple Transmit radio wave to tissueTransmit radio wave to tissue Cause tissue damage by intracellular heatingCause tissue damage by intracellular heating Low cutting temperature 60 – 90Low cutting temperature 60 – 9000C (vs 750 – C (vs 750 –

90090000C in diathermy)C in diathermy) More precise cutting, less surrounding tissue More precise cutting, less surrounding tissue

damage, less tissue edema and paindamage, less tissue edema and pain

RadiofrequencyRadiofrequency

Two small scale randomized trialTwo small scale randomized trial Diathermy fistulotomy vs Radiofrequency Diathermy fistulotomy vs Radiofrequency

fistulotomy/ fistulectomy in low type fistulafistulotomy/ fistulectomy in low type fistula Less post-operative painLess post-operative pain Earlier return to workEarlier return to work Shorter wound healing timeShorter wound healing time No difference in complication & recurrenceNo difference in complication & recurrence

Eur Rev Med Pharmacol Sci 2004;8:111-6Eur Rev Med Pharmacol Sci 2004;8:111-6Rom J Gastroenterol. 2003;12:287-91Rom J Gastroenterol. 2003;12:287-91

Treatment of Anal fistulaTreatment of Anal fistulaSUMMARYSUMMARY

Simple fistulaSimple fistula

Standard treatmentStandard treatment Fistulotomy +/- MarsupialisationFistulotomy +/- Marsupialisation FistulectomyFistulectomy

Other treatmentsOther treatments Radiofrequency fistulotomy/ fistulectomy Radiofrequency fistulotomy/ fistulectomy

(emerging evidence)(emerging evidence) Fibrin glue (lower healing rate, no advantage)Fibrin glue (lower healing rate, no advantage) Seton (prolong healing)Seton (prolong healing)

Complex fistulaComplex fistula

Initial treatmentInitial treatment Loose Seton (low incontinence rate)Loose Seton (low incontinence rate)

Other treatmentOther treatment Advancement flaps (variable result)Advancement flaps (variable result) Fibrin glue (variable result)Fibrin glue (variable result) Cutting Seton (high incontinence rate)Cutting Seton (high incontinence rate)

Snug Seton (need more evidence)Snug Seton (need more evidence)

Stage fistulotomy (high incontinence rate)Stage fistulotomy (high incontinence rate)

Treatment for Anal fistulaTreatment for Anal fistula~ End of presentation ~~ End of presentation ~

Treatment of anal fistulaTreatment of anal fistulaQuestion and AnswerQuestion and Answer

Definition (variable)Definition (variable)

High typeHigh type Involving the anorectal ringInvolving the anorectal ring Internal opening above dentate lineInternal opening above dentate line

Complex typeComplex type High typeHigh type Multiple side branchesMultiple side branches Chronic inflammatory disease (Chron’s)Chronic inflammatory disease (Chron’s) Previous operation/ irridationPrevious operation/ irridation

Incontinence scoring systemIncontinence scoring system

Cleveland Clinic scoring systemCleveland Clinic scoring system Wexner Continence grading scaleWexner Continence grading scale Material: solid, liquid, gasMaterial: solid, liquid, gas Frequency: rare to alwaysFrequency: rare to always

Fistulotomy and immediate Fistulotomy and immediate reconstructionreconstruction

Reconstruct the divided musculature and Reconstruct the divided musculature and primary wound closureprimary wound closure

For low type fistulaFor low type fistula Study from Parkash et alStudy from Parkash et al

120 patients120 patients 98% low type fistula98% low type fistula 88% wound healed by 2 weeks88% wound healed by 2 weeks Recurrence rate 4%Recurrence rate 4%

ANZJ Surg 1985;55:23-7ANZJ Surg 1985;55:23-7

Fistulotomy and immediate Fistulotomy and immediate reconstructionreconstruction

For complex fistulaFor complex fistula Prospective study by Perez F et alProspective study by Perez F et al

35 patients with complex anal fistula35 patients with complex anal fistula 85.7% high trans-sphincteric, 11.4% supra-sphincteric, 2.9% 85.7% high trans-sphincteric, 11.4% supra-sphincteric, 2.9%

extra-sphinctericextra-sphincteric 31.4% incontinent patients reported improvement in 31.4% incontinent patients reported improvement in

continence scorescontinence scores 12.5% continent patients reported minor alternations of 12.5% continent patients reported minor alternations of

continence (Wexner Continence Scale <4)continence (Wexner Continence Scale <4) Recurrence rate 5.7%Recurrence rate 5.7%

J Am Coll Surg 2005;200:897-903J Am Coll Surg 2005;200:897-903