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27/06/13 Dept. of Surgery Benign Anorectal: Abscess and Fistula Rakesh Kumar Gupta, MS

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27/06/13 Dept. of Surgery

Benign Anorectal: Abscess and FistulaRakesh Kumar Gupta, MS

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Benign Anorectal: Abscess and Fistula

Anorectal abscess and fistula-in-ano represent different stages of the same disease

the abscess represents the acute inflammatory event

the fistula represents the chronic process

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Benign Anorectal: Abscess and Fistula

Diagnosis and treatment requires in-depth understanding of anorectal anatomy and spaces

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Anorectal SuppurationEpidemiology

Anorectal abscesses (“Acute phase”)

100,000 cases per year

Age range 20-60, 2:1 ratio M:F

30% recurrence rate*

Anorectal fistula (“Chronic phase”)

25-40% of abscesses lead to fistula**

10-20% recurrence rate

* Shrum RC. Dis Colon Rectum 1959; 2:469–472, **Shouler PJ et al . Int J Colorect Did 1986,1:113-5

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80% are submucosal, 8% extend to internal sphincter, 8% to the conjoined longitudinal muscle, 2% intersphincteric, 1% penetrate internal sphincter

At the dentate line, the ducts of the anal glands empty into anal crypts

90% of anorectal abscess result from crytogladular infection

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Parks cryptoglandular theory - obstruction of anal glands leads to stasis and infection

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Abscess

Classified by location:

Perianal (50%),

Intersphincteric (30%),

Ischioanal (15%),

Supralevator (5%)

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Classification of Anorectal Abscesses

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SupralevatorSpace

IntersphinctericSpace

Ischioanal Space

HORSESHOE ABSCESS

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Abscess - Etiology

Nonspecific cryptoglandular (90%)

Specific causes:

Specific infection, ie TB, actinomycosis, lymphogranuloma venereum,

Inflammatory bowel disease,

Trauma or foreign body

Surgery (episiotomy, hemorrhoidectomy, prostatectomy),

Malignancy - carcinoma, lymphoma, radiation-related

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Pain Severe, constant pain, worse with movement/pressure (sneezing, coughing, bearing down),better with drainage

Swelling,

Fever chills hallmark symptoms

supralevator abscess may have gluteal pain

rectal pain with urinary symptoms (ie. Constipation, Urinary retention) - possibly indicate intersphincteric or supralevator abscess

Anorectal AbscessClinical Presentation

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Anorectal AbscessClinical Presentation

• Exam

– Induration, fluctuance, erythema, warmth, purulent drainage

– DRE

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Abscess - Treatment

Exam under anesthesia for pain out of proportion to exam

Incision and drainage - trim edges to prevent coaptation

I&D of supralevator abscess:

depends on location - intersphincteric origin then divide internal sphincter and drain into rectum; if arises from ischianal abscess can be drained through perineal skin

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Anorectal AbscessTreatment

I&D- cruciate or elliptical incision

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Abscess - Treatment

Catheter drainage: stab incision to drain pus, mushroom catheter in cavity to drain pus

make stab incision as close as possible to anus

size and length of catheter should correspond to abscess cavity

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Short distance from anus – feel for soft spotPlace drain and trim – avoids packingFollow up in 7-10 days to remove drain

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Catheter Types

Pester catheter

Solid mushroom top so stays in

Less tissue ingrowth

Malecot

Allows tissue ingrowth

More painful to remove

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Abscess - Treatment

Primary fistulotomy

may be easier to identify tract

eliminates source of infection

decreases recurrence/need for reoperation

Downsides: false passage formation with acute inflammation, 30-50% of those with abscess likely won’t develop a fistula, need for anesthesia vs. local for I & D

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Incision and drainage of perianal abscess with or without treatment of anal fistula. Cochrane Database Syst Rev. 2010 Jul 7;(7):CD006827.

CONCLUSIONS: The published evidence shows fistula surgery with abscess drainage

Significantly reduces recurrence or persistence of abscess/fistula, or the need for repeat surgery.

No statistically significant evidence of incontinence following fistula surgery with abscess drainage.

Intervention may be recommended in carefully selected patients.

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Abscess - Antibiotics

Little or no role

Antibiotics? Culture?

Indications:

Immunosuppression

Valvular heart dz

Prosthetic devices

Sepsis or Extensive cellulitis

Crohn’s dz

Sitz Baths

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Abscess - Complications

Recurrence

recurrence in as many as 89% of pts

Extra-anal causes

should be evaluated for recurrent disease (hidradenitis suppurativa, Crohn’s)

Incontinence

iatrogenic (superficial external sphincter), inappropriate wound care (excessive scarring from prolonged packing)

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Abscess - Complications

Can result in necrotizing anorectal infection (rare)

Resuscitation, IV abx, wide debridement to healthy tissue

Need for colostomy debatable - recommended if sphincter muscle is grossly infected, immunocompromised, rectal or colonic involvement/perforation

Reexamination under anesthesia

HBO - 100% O2 at 3atm over 2 hrs - promote leukocyte phagocytic function and fibroblast proliferation

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Caution – Necrotizing Fasciitis

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Anal Infection and Hematologic Diseases

Anorectal suppuration with acute leukemia with mortality 45-78%

Neutrophil count <500 with 11% incidence of anorectal abscess

Most important prognostic factor - # days of neutropenia

Presenting symptoms: fever, pain, urinary retention

Antibiotics vs I & D if fluctuance, sepsis, or progression of soft tissue infection after antibiotics trial

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Anal Infection & HIV

HIV+ pts have increased risk of perianal sepsis

Can be associated with in situ neoplasia

Surgery + antibiotics 2/2 immunosuppression

make incison site small bc pts at risk for poor wound healing

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Fistula-in-ano

Abnormal communication between any two epithelium-lined surfaces

Parks classification:

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Classification

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Intersphincteric fistula

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Intersphincteric Fistula-in-ano

Most common type of fistula - 70%

Results from perianal abscess

Variations:

simple low tract

high tract with rectal opening or blind tract

extrarectal extension

pelvic disease tracking

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Transsphincteric fistula

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Transsphincteric Fistula

Approx 23% fistulas

Results from ischioanal absecesses

Rectovaginal fistula is a form of transsphincteric fistula

Operative mgt with setons if sphincter preservation in question

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Suprasphincteric fistula

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Suprasphincteric Fistula

5% of fistulas

Result from supralevator abscesses

Tract arises from intersphincteric abscess, travels above puborectalis, then downward lateral to external sphincters in ischioanal space

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Extrasphincteric fistula

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Extrasphincteric Fistula

2% of fistulas - rarest form

From rectum above the levators, through them, to the perianal skin

Trauma, foreign body, Crohn’s carcinoma

Most common cause is iatrogenic from probing during fistulotomy surgery

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Evaluation of Anal Fistula

An accurate preoperative assessment of the anatomy of an anal fistula is very important.

Five essential points of a clinical examination of an anal fistula :

(1) location of the internal opening.

(2) location of the external opening.

(3) location of the primary track .

(4) location of any secondary track.

(5) determination of the presence or absence of underlying disease .

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Fistula-in-ano: Physical Examination Goodsall’s rule:

transverse line across the perineum -

posterior external openings have internal openings in the posterior midline

anterior external openings have tract radially toward the nearest crypt

greater distance from anal margin with more variability

more accurate rule for posterior fistulas

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Fistula Description Clock description

Does the anus tell time?

Relies on description of patient’s position: supine, lateral, prone and relative landmarks

Anatomic description: more consistent

Pubic bone defines anterior

Coccyx define posterior

Right and left

*If terms be incorrect, then statements do not accord with facts; and when statements and facts do not accord, then business is not properly executed.”

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Tailbone

Right anterior

Right posterior

Left anterior

Left posterior

Right Left

Pubic bone

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High Fistulas Have High Internal Openings (opening of the duct at the crypt, is always at the level of the pectinate line)

Internal Opening is Not Always Present

Fistulas with Multiple Openings are Tuberculus in Origin

Every Fistula Requires an MRI/Endoanal USG

Which is the Best Surgery for Fistula in Ano?

Controversies in Fistula in Ano

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Mutiple external openings over the right buttock—non tuberculus

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Investigations Additional tools available in case of difficulty.

Do not replace a good clinical examination to diagnose the type & extent of fistula.

Not necessary to investigate every case of fistula even the complex ones can be diagnosed fairly accurately by a good clinical examination.

MRI & Endoanal ultrasound both give comparable

Delineating the tracts by intra-operative dye study may be more helpful than the above investigations.

Fistulograms have a very limited role in the diagnosis of fistula in ano

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Anorectal FistulaDiagnosis

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MRI for fistula-in-ano

HALLIGAN Radiology 2006Abscesses &Extensions

Contralateral disease

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TREATMENT

The objective is to cure with lowest possible recurrence rate and minimal, if any, alteration in continence, shortest period.

The principles are:

Control sepsis

EUA

Laying open abscesses and secondary tracts

Adequate drainage – seton insertion

.

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Define anatomy

Openings and tracts

Internal and External (Identification of the primary opening)

Single –v- multiple

Extensions / Horseshoe (Side tracts should be sought )

Relation to sphincter complex

High –v- Low (Relationship to puborectalis)

Exclude co-existent disease

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Fistula-in-ano: Treatment

Eliminate fistula,

Prevent recurrence,

Preserve sphincter function

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Fistula-in-ano: Treatment

Identification of internal opening

passage of probe

injection of dye, methylene blue, or hydrogen peroxide

following granulation in fistula tract

noting puckering of crypt with traction on fistula tract

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Fistulotomy/fistulectomy

Lay-open technique (fistulotomy) : identification of tract with unroofing tract, useful for 85-95% of primary fistulae .

Appropriate for simple interspincteric and low transsphincteric

Curettage is performed to remove granulation tissue.

Marsupialization of the edges to improve healing times.

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Surgical Options – Fistulotomy

Fistula tract identified with probe

Extent of external sphincter involvement assessed

Tract and muscle divided

Secondary tracts laid open

+/- marsupialisation wound

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Fistula in ano

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Fistula in ano

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Surgical Options – Fistulectomy

• Core out tract

• Direct visualisation of secondary tracts

• Sphincter repair +/- advancement flap

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Fistula-in-ano: Operative Management Seton - placement of non-absorbable suture material in

fistula tract

Indications for setons:

Promote fibrosis around fistula tract that encircles entire sphincter mechanism

Mark the site of fistula in massive anorectal sepsis

Anterior high transsphincteric fistulas in women

HIV pts with poor wound healing and high transsphincteric fistulas

Crohn’s

Any time continence is questioned

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Surgical Options – Cutting Seton

Lay open external tract

Draining seton replaced with cutting seton

1/0 Prolene suture

Tied tight around sphincter complex

Simultaneous slow cutting and repair of sphincter

May require re-tightening

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Setons in the Management of Difficult Fistulas

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Fistula-in-ano: Operative Management

High-transphincteric fistulas can be treated with combination lay-open technique and seton placement - division of internal sphincter to level of external opening and then seton placement

Cutting setons can convert high fistulas to low fistulas

Second-stage fistulotomy ~ 8 wks later

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Fistula-in-ano: Operative Management

Suprasphincteric fistula - tract involves external sphincter and puborectalis -

can manage with division of internal sphincter and superficial external sphincter with seton around remaining ES

or internal sphincterotomy, seton, opening of fistula tracts without division of external sphincter

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Fistula-in-ano: Operative Management

Anorectal Advancement Flap

internal opening closed with absorbable suture, full-thickness flap of rectal mucosa/submucosa/IAS raised - adv 1 cm beyond internal opening

base of the flap should be twice the width of the apex

pros: reduction in healing time, reduced pain, little potential damage to sphincters, lack of deformity to anal canal

poor outcomes in Crohn’s, pts on steroids, smokers, o/w success reported in up to 90% of pts

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Advancement Flaps

Endorectal Fistula tract probed

Flap raised

Mucosa + Int. Sphincter

Internal opening excised/closed

Flap advanced & sutured

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Advancement Flap

Anodermal Fistula tract probed

Flap raised

Anodermal

Flap advanced & sutures

External defect closed

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Fistula-in-ano: Operative Management

Fibrin Glue - used in conjuntion with AAF or alone

technique: internal and external openings identified, tract curetted, fistula tract injected through connector from external opening until glue visible in internal opening, slowly withdrawn

can be repeated several times without compromising continence

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Fistula-in-ano: Operative Management

Fibrin Glue - Followup:

short-term follow-up with good success 70-80%

longer follow-up with success falling to 60% and even 14% in pts with complex anal fistulas

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Fistula Plug

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Fistula Plug

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Fistula-in-ano: Operative Management

Bioprosthetic fistula plug made from surgisis

Technique - identification of internal and external opening with placement of plug over probe using suture similar to seton placement

Plug secured at primary opening using absorbable suture

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Fistula-in-ano: Operative Management

Technique works best with long tracts without active inflammation or sepsis

Short-term follow up (3months) with higher success rate for Crohn’s fistulas when compared to fibrin glue

Long-term follow up - high failure rate

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LIFT Procedure

Ligation of Intersphincteric

Fistula Tract Transsphincteric fistula

Draining seton – 6 weeks

Tract prepared with fistula brush

Debrides

De-epithelializes

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PROS CONSCutting Seton Simple

CheapRepeat EUARecurrence 0 – 8%Incontinence• minor 34 – 63%• major 2 – 26%

Fistulotomy SimpleCheap

Recurrence 2 – 9%Incontinence 50%

Advancement Flap Can be difficult?Preserves sphincter

Recurrence 25 – 50%Incontinence 30 – 35%

Fistula Plug SimplePreserves sphincter

Plug expensive ~£400Recurrence 20 – 85%Continence preserved

LIFT SimplePreserves sphincter

Recurrence 15 - 40%Continence preserved

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Crohn’s and Anal Fistulas

The most common perianal manifestation and occur in 6-34% Crohn’s pts - pts with colonic Crohn’s with higher incidence, rectal Crohn’s with 100% fistula formation

Conservative approach to treatment as 38% heal without surgery

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Crohn’s and Anal Fistulas

Medications for treatment: cipro/flagyl, immunomodulators (steroids, 6MP, azathioprine, infliximab)

6-MP and azathioprine only effective in 1/3 pts with fistulizing Crohn’s

Infliximab associated with 62% reduction

Combination 6MP and infliximab may prolong effect of treatment

Selective seton placement with infliximab + maintenance med with healing in 67%

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Crohn’s and Anal Fistulas

Operative intervention: seton placement, rectal advancement flap if rectal-sparing, poss fibrin glue/plug

Avoid cutting sphincter - incontinence reported in pts with Crohn’s proctitis even without anal surgery

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ACPGBI FIAT Trial

Fistula Plug Insertion

Surgeon’s Preference

EUA: transsphincteric fistula ≥ 1/3 of

sphincter complex Insertion of draining

seton

RANDOMISE

MRI fistulography

Advancement Flap

Cutting Seton Fistulotomy LIFT

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ACPGB&I FIATPrimary end-points

Faecal incontinence QoL

Generic QoL

Secondary end-points

Healing – 12 months

Complications

Faecal incontinence

Re-interventions

Health resource utilisation

Cost effectiveness

Patient identification

EUA & draining seton

Eligibility & Consent

Randomisation1:1 plug –v- surgeon’s

preference

6-week FU

6-monthFU

12-month FU+ MRI scan

Surgisis® fistula plug

Surgeon’s preference(fistulotomy, seton,

advancement flap, LIFT)

MRI scan

Surgery(6-weeks post seton

insertion)

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Join the FIAT Trial!

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