SINUS & FISTULA PATHOPHYSIOLOGY

CONGENITAL
Garcia, Poligrates
 Arise from remnants of embryonic ducts that
persist instead of being obliterated and
OVERVIEW disappearing completely during embryonic
development
 Examples:
o Branchial fistula
o Tracheoesophageal
o Umbilical
o Congenital AV fistula
o Thyroglossal fistula

ACQUIRED
 Usually secondary to presence of foreign body,
necrotic tissue in affected area (or) microbial
infection (or) following inadequate drainage of
abscess
 TRAUMATIC
SINUS o Following surgery
 Blind track lined by granulation tissue leading o e.g. intestinal fistulas (faecal, biliary,
from epithelial surface down into the tissues. pancreatic)
 Latin: Hollow or a bay o Following instrumental delivery (or)
 TYPES: difficult labor
o CONGENITAL o e.g. vesicovaginal, rectovaginal,
 Preauricular sinus ureterovaginal fistula
o ACQUIRED  INFLAMMATORY
 TB sinus o Intestinal actinomycosis, TB
 Actinomycosis  MALIGNANCY
 Median mental Sinus o When growth of one organ penetrates
 Pilonidal sinus into the nearby organ
 Chronic osteomyelitis o E.g. Rectovesical fistula in carcinoma of
the rectum
FISTULA
 IATROGENIC
 Latin: flute, pipe, tube
o Cimino fistula - AVF for hemodialysis
 ABNORMAL communication
o ECK fistula - to treat esophageal varices in
o between lumen of one viscus and lumen
portal HTN
of another (INTERNAL FISTULA)
o Between lumen of one hollow viscus to
FISTULA-IN-ANO
the exterior (EXTERNAL FISTULA)
 Chronic abnormal communication usually lined to
o Between any two vessels
some degree by granulation tissue, which runs
 TYPES: outwards from anorectal lumen (internal opening)
o EXTERNAL to skin of perineum or the buttocks (external
 Orocutaneous opening)
 Enterocutaneous  Complications of chronic anal fistula:
 Appendicular o Bowel incontinence
 Thyroglossal o Recurrence of fistula
 Branchial
o INTERNAL
 Tracheoesophageal
 Colovesical
 Rectovesical
 AVF
 Cholecystoduodenal
 SURGICAL MANAGEMENT
FISTULOTOMY
 In intersphincteric and low transphincteric
fistulas
 Identification of tract with probe followed by
division of all structures between external and
internal openings
 Secondary tracts laid open
 +/- marsupialization
 Advantages
o Least chance pf recurrence
o Relatively easy procedure
o Minor degree of incontinence
 Risks
o Results in large and deep wounds that
might take months to heal

FISTULECTOMY
 All chronic (low) and also for posterior horse-
show shaped fistulas
 Excision of entire fibrous tissue and tract and
wound kept open
 Sphincter repair +/- advancement flap
 High anal fistulas +/- colostomy

SETON SUTURE PLACEMENT

 Preferable surgical option for high variety
 Setons are usually made from rubber slings
 2 types of seton suture can be placed
o Draining seton
 Facilitate draining of sepsis
 Left loose and allows fistula to
heal by fibrosis
o Cutting seton
 Slowly “cheese-wire” through the
sphincter muscle
 Allows fibrosis to take place
behind as it gradually cuts
through