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Treatment of fistula in ano

Abhilash

Principles
• Control sepsis
– EUA
– Laying open abscesses and secondary tracts.
– Adequate drainage- seton insertion.

• Define anatomy
– Openings and tracts
• Internal and external
• Single vs. multiple
• Extensions / Horseshoe

– Relation to sphincter complex
• High vs. low

• Exclude co-existent disease.

Complex fistulas.
• Any fistula involving more than 30 percent of the external sphincter
• Suprasphincteric fistulas
• Extrasphincteric or high fistulas, proximal to the dentate or
pectinate line
• Women with anterior fistulas
• Fistulas with multiple tracts
• Recurrent fistulas
• Fistulas related to inflammatory bowel disease
• Fistulas related to infectious diseases including tuberculosis and
human immunodeficiency virus
• Fistulas secondary to local radiation treatments
• Patients with a history of anal incontinence
• Rectovaginal fistulas

• Simple fistulas
– Fibrin glue
– Fistulotomy.

• Complex fistulas
– Fistulotomy and seton.
– LIFT
– Advancement flaps.
– Fistula plug.

Fistulotomy
• Fistula tract identified
with probe
• E0xtent of external
sphincter involvement
assessed.
• laying open the fistula
tract.
• Secondary tracts laid
open
• +/- marsupialization

• Success rates range from 79-100 percent in
various studies.
• Recurrence rate in simple fistulas – 3- 7%
• Incontinence varies from 0-18%.

• No difference in results between Fistulotomy
and fistulectomy.

Fibrin sealant
• mixture of fibrinogen,
thrombin, and calcium
ions.
• Forms a fibrin clot.
• Avoids sphincter
compromise.

• Recurrence rates of 14-69%.
• Most recurrences are evident within 3
months.
• Not recommended for complex fistulas.

Seton
• Any foreign material that encircles the
sphincter complex.
• Silk, penrose drains, sialastic vessel tubes,
nylon, polypropylene, braided steel wire.,
rubber band.
• Useful in complex fistulas, crowns, anterior
fistulas and chronic diarrheal states.

• Drainage seton
– Only for drainage. Tied loosely.

• Cutting seton
– Tied tight around the sphincter complex.
– Periodic re-tightening of the seton.

• Success rates from 80-100 %.
• Long term incontinence rate – 30%
• Draining seton – poor quality of life and low
grade incontinence.

Fistula plug
• bio absorbable xenograft made of lyophilized
porcine intestinal submucosa.
• Success rate of 35% to 87%.
• Expensive

Advancement flap
• Consists of mucosa, submucosa and internal
sphincter.
• Advantages.
– One stage procedure.
– Quicker healing
– Minimal risk of anal canal deformity
– Limited damage to sphincter.




Success rate in literature 29-95%.
Cleveland clinic – 64% success rate.
Success rate drops with successive attempts.
Good functional results in most reports.

LIFT (Ligation of
intersphincteric fistula
tract)

• Sphincter sparing
procedure.
• For complex
transsphincteric
fistulas
• Primary healing rate62%
• No incontinence.

Other options
• Cutaneous flaps
– V-Y flap
– Island flap

• Chemical seton

References
• Shackelfords Surgery of the alimentary tract.
• Jacob TJ, Perakath B, Keighley MR. Surgical
intervention for anorectal fistula. Cochrane
Database of Systematic Reviews 2010, Issue 5.
• Dis Colon Rectum. 2013 Mar;56(3):343-7.
• Dis Colon Rectum. 2008;51(10):1475.