inselspital fistula be 18th october 2012final-1...10% secondary hydroadenitis, cebaceusadenitis...

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

Inselspital 2012, UPDATE ProktologieInselspital 2012, UPDATE Proktologie

Inselspital Bern18thOctober 18 October 2012

1686 Incision of louis XIVFélix & BessièresFélix & Bessières

Inselspital 18th October 2012

Proctology Unit

ETIOLOGY

90% 9

primaryprimary

crypto‐glandularg


Proctology Unit

10% secondary

Hydroadenitis, cebaceus adenitisFiFissurePilonidal CystInfectious disease: tbc STDInfectious disease: tbc, STDCarcinoma: anal, rectum, leukemiaPost radiotherapyPost radiotherapyDebilitating illnesses (leukemia, diabetes, AIDS)

Crohn’s disease, HRCIatrogenic: injections, hemorroidectomy, sclerotherapy, prostatectomy

Trauma: foreign body, penetrating wounds, obstetrical tears


Proctology Unit

tears

Perianal abscessP i f h fi l ?Primum movens of the fistula?


Proctology Unit

Different Abcess localisationDifferent Abcess localisation


Proctology Unit

Therapeutic optionsTherapeutic options

Simple drainage Local anaesthesia

Drainage curettage and seton General anaesthesia General anaesthesiaDrainage + fistula track treatment


Proctology Unit

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


Proctology Unit

y

Simple drainage or d i & fi t ldrainage & fistulatrack treatmenttrack treatment in anorectal abscess?o ec bscess?


Proctology Unit

Simple drainage or d i & fi t ldrainage & fistulatrack treatmenttrack treatmentin anorectal abscess?o ec bscess?


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


Proctology Unit

Initial Surgical managmentInitial Surgical managment

Seton drainage, for up to 3-6 months

After healing of the abcess cavity, in case of residual fistula

Prevent reccurence of the abcess


Proctology Unit


Prolène 4-0 is good, 2 stiches


Proctology Unit



Proctology Unit

Fistula : Goals for the surgeon•Fistula : Goals for the surgeon

Define the exact anatomy of the fistulous tract

• Drain any associated sepsis

E di t ll th fi t l t t• Eradicate all the fistulous tract

• Prevent recurrence• Prevent recurrence

• Maintain sphincter function and continence Maintain sphincter function and continence

• Minimize healing time


Proctology Unit

g

Fistula : Goals for the surgeon•Fistula : Goals for the surgeon


Proctology Unit

Current surgical managmentCurrent surgical managment

Fistulectomy (low, distal fistula)

Fistulectomy and mucosal flap

Occlusion techniqueOcclusion techniquePlug (porcine collagen)GGlue


Proctology Unit

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


Proctology Unit

Fistulectomy:

Fistulectomy


Proctology Unit

y

Fistulectomy

Anodermicreconstruction

Complete excision of i ifi


Proctology Unit

primary orifice

Fistulectomy: results

464 fistulectomies464 fistulectomies24 recurrences (5.2%)ecu e ces (5 %)

No incontinence


Proctology Unit

Sphincter preservingSphincter preservingSphincter preserving Sphincter preserving complex fistula complex fistula co p e stu aco p e stu a

treatment treatment


Proctology Unit

Sphincter preserving fistula treatment Sphincter preserving fistula treatment

DifficultDifficult andand highhigh raterate ofof complicationscomplications suchsuchDifficultDifficult andand highhigh raterate ofof complicationscomplications suchsuchasas analanal incontinenceincontinence

treatment options:treatment options:

Mucosal flapMucosal flap

New sphincter preserving treatments :New sphincter preserving treatments :

Plugs, LIFT, VAAFT OVESCO, etc


Proctology Unit

Mucosal flapFistulectomyInselspital 18th October 2012

Proctology Unit

Mucosal flapFistulectomy

Preoperative carePreoperative care

M l fl t h iMucosal flap technique:

Antibiotic prophylaxis

No Enema

No Epilationp

No StomaInselspital 18th October 2012

Proctology Unit

No Stoma

C t i di ti t flC t i di ti t flContraindications to flaps:Contraindications to flaps:

Acute inflammationAcute inflammationExtensive suture line tensionAnastomosis in diseased tissue

radiation fistularadiation fistulaneoplastic fistulapactive Crohn’s disease


Proctology Unit


Proctology Unit

Postoperative care:

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)


Proctology Unit

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


Proctology Unit

Geneva Results:Geneva Results:

136 consecutive cases136 consecutive cases82 men54 women

Age 28 - 78 y M = 44.6 y


Proctology Unit

Inpatient /outpatient ratiop p

Inpatient 97 (71.3%)

O t ti t 39 (28 7%)Outpatient 39 (28.7%)


Proctology Unit

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


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)


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


Proctology Unit

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


Proctology Unit

Pl t h iPl t h iPlug techniquePlug technique::

Endo anal fixationEndo anal fixation


Proctology Unit

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!!!!


Proctology Unit


Proctology Unit

R lResults

15 recurrences (93.7%)

Three month success rate 6.3%

No incontinenceNo incontinence


Proctology Unit

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%


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


Proctology Unit

p

medium and high TS Cryptoglandular tractmedium and high TS Cryptoglandular tract,60 patients received the treatmentSuccess rate: Plug 29%Plug 29%Flap 48%


Proctology UnitVan koperen BJS 2011

Variables predicting failuresVariables predicting failures

SmockingDiabetesDiabetesShort fistula tract <4 cmHigh transphinctericPosterior fistulaPosterior fistulaPrevious plug failure


Proctology Unit

New plugsNew plugs


Proctology Unit

New Gore plugsNew Gore plugs

Author journal N Success rate

Ratto Colorectal disease2012

11 8/11

Favreau‐Weltzer Colorectal disease2012

9 1/9

De la Portilla DCR 2011 19 3/19

Buchberg Am Surg 2010 10 6/10

total 49 18/49 (37%)


Proctology Unit

The chinese plugThe chinese plug

100% success rate

Sang WL et al, W J Gastroenterology 2008


Proctology Unit

Conclusion PLUG:Conclusion PLUG:

Easy to perform but:

Plug price 800 CHF

High recurrences rateHigh recurrences rate

3rd operation, most of the time more difficult.


Proctology Unit

LIFT procedurep

LIFT

Ligation of Inter‐sphincteric Fistula Tract

Described by Rojanasankul in 2007Success rates of > 94%No deterioration in continence


Proctology Unit

LIFT procedurep


Proctology Unit

Tract probed and circumanal incision

LIFT procedurep


Proctology UnitComplete dissection of tract

LIFT procedurep


Proctology UnitTract suture ligated and divided

LIFT procedurep


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


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


Proctology UnitIncontinence :flatus 3, liquid 1,solids 0

LIFT procedurep

The LIFT procedure is simple, safe and effective

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)


Proctology Unit

fistulotomy)

Video‐assisted anal fistulaVideo assisted anal fistulatreatment (VAAFT)( )

a novel sphincter‐saving procedure to repaircomplex anal fistulas, rigid fistuloscopy


Proctology Unit


Identification and liftingIdentification and lifting of the internal opening


Proctology Unit


Cleaning of the tract byCleaning of the tract by fulguration, brushing and washingwashing


Proctology Unit


Closure of the internal opening with a stapler or a flapClosure of the internal opening with a stapler or a flap

+ injection of cyanoacrylate glue below the stapple line!


Proctology Unit

+ injection of cyanoacrylate glue below the stapple line!


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


Proctology Unit

87.1% healed


Sound principlep p

Cost? (equipment and staplers)Cost? (equipment and staplers)

L k f id ( h )Lack of evidence (one man show)


Proctology Unit

Stem cellsStem cells

f f fInjection of stem cells in the fistula tract afterclosure of the internal openingp g

Healing at 8 weeks Healing at one year Healing at end of FU 38 months38 months

Fibrin glue 3/25(12%) 3/25(12%) 2/25(8%)

Fibrin glue + ASCs 17/24(71%) 15/24(63%) 7/21(33%)

Garcia-Olmo et al, Exp Op. Biol Ther, 2008Guadelajara et al Int J Colorectal disease 2012


Proctology Unit

Guadelajara et al, Int J Colorectal disease 2012

Mesenchymal Stem cellsMesenchymal Stem cells

fIntraveinous injection of mesenchymal stem cells2x 1 week apart, Crohn’s, clinical response at 6 p , , pweeksResponse in 3 patients /9Response in 3 patients /9

Duijvestein M et al, GUT 2010

10 crohn’s patients intra and perifistular injection of MSCs median 4x1x/4 weeksof MSCs median 4x1x/4 weeksFU 1 year

/ / f ?Inselspital 18th October 2012

Proctology Unit

Response in 7/10, partial 3/10 role of Treg?Ciccocioppo et al, GUT 2011

Mesenchymal Stem cellsMesenchymal Stem cells

CConclusion:

Poor results so far,

MSCs in Crohn could be interesting but veryli ipreliminary


Proctology Unit

Ovesco clipOvesco clip


Proctology Unit

Prosst et al, Minimally Invasive Therapy. 2012;21:307–312

Ovesco clipO esco c p


Proctology Unit

ConclusionsConclusions

Simple drainage of abscessSimple drainage of abscess

Si l t t t f di t l fi t lSimple treatment for distal fistulas (fistulectomy)(fistulectomy)


Proctology Unit


Mucosal flap remains the gold standard in 2012in 2012

Plugs fails in > 50%, 93% in our hands


Proctology Unit


LIFT b f lLIFT maybe useful

Stem cells very preliminaryy p y

OVESCO?OVESCO?


Proctology Unit

G U i it H it lG U i it H it l

GG C i P t lC i P t l

Geneva University HospitalGeneva University Hospital

Geneva Geneva Course in ProctologyCourse in Proctology44 -- 7 7 February February 20132013yy

Post Post Graduate Training Graduate Training daydaygg yyConstipationConstipation

FebruaryFebruary 88thth 20132013February February 88thth 20132013Inscription :Inscription :ppTél.: + 41 22 372 79 34 Fax:+ 41 22 372 79 09 Tél.: + 41 22 372 79 34 Fax:+ 41 22 372 79 09 [email protected] [email protected] www.proctology.ch


Proctology Unit

inselspital fistula be 18th october 2012final-1...10% secondary hydroadenitis, cebaceusadenitis...

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