MANAGEMENT OF FISTULA IN ANO SURGICAL TECHNIQUES ...
MANAGEMENT OF FISTULA IN ANO SURGICAL TECHNIQUES ...
MANAGEMENT OF FISTULA IN ANO SURGICAL TECHNIQUES ...
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<strong>MANAGEMENT</strong> <strong>OF</strong><br />
<strong>FISTULA</strong> <strong>IN</strong> <strong>ANO</strong><br />
What are the surgical Alternatives<br />
1. Lay open<br />
2. Lay open +Primary sphincter repair<br />
3. Sliding flap<br />
4. Cutting seton<br />
5. Draining seton<br />
6. Park’s fistulectomy<br />
7. Fibrin Glue<br />
8. Collagen plug<br />
9. LIFT Procedure<br />
<strong>SURGICAL</strong> <strong>TECHNIQUES</strong><br />
• Endorectal Advancement Flaps<br />
• Endorectal Advancement Flaps with<br />
Core Fistulectomy<br />
• Anocutaneous Flaps<br />
Endoanal Advancement<br />
Flap<br />
ENDORECTAL FLAPS<br />
N F/U Success<br />
Aguilar 1985<br />
151<br />
8-84 mos.<br />
98%<br />
Kodner 1993<br />
31<br />
7 mos.<br />
87%<br />
Kreis 1998<br />
24<br />
43-59 mos.<br />
75%<br />
Hyman 1999<br />
5<br />
3-90 mos.<br />
80%<br />
Dixon 2004<br />
29<br />
6 mos.<br />
69%<br />
16
<strong>MANAGEMENT</strong> <strong>OF</strong><br />
<strong>FISTULA</strong> <strong>IN</strong> <strong>ANO</strong><br />
What are the surgical Alternatives<br />
1. Lay open<br />
2. Lay open +Primary sphincter repair<br />
3. Sliding flap<br />
4. Cutting seton<br />
5. Draining seton<br />
6. Park’s fistulectomy<br />
7. Fibrin Glue<br />
8. Collagen plug<br />
9. LIFT Procedure<br />
<strong>MANAGEMENT</strong> <strong>OF</strong><br />
<strong>FISTULA</strong> <strong>IN</strong> <strong>ANO</strong><br />
When will we use a draining seton<br />
1. In patients with inflammatory bowel disease<br />
2. More than 50% sphincter muscle involved<br />
3. Patient with poor continence<br />
4. When advancement flap is not technically<br />
feasible<br />
<strong>MANAGEMENT</strong> <strong>OF</strong><br />
<strong>FISTULA</strong> <strong>IN</strong> <strong>ANO</strong><br />
What are the surgical Alternatives<br />
1. Lay open<br />
2. Lay open +Primary sphincter repair<br />
3. Sliding flap<br />
4. Cutting seton<br />
5. Draining seton<br />
6. Park’s fistulectomy<br />
7. Fibrin Glue<br />
8. Collagen plug<br />
9. LIFT Procedure<br />
17
LIFT PROCEDURE<br />
L – Lateral<br />
I – Intrasphincteric<br />
F – Fistula<br />
T – Transection<br />
DATA FROM THAILAND<br />
Number<br />
PATIENTS 17<br />
SUCCESS 16<br />
PERCENTAGE 94%<br />
Rojanasakul A, J Med Assoc Thai 2007<br />
LIFT Procedure<br />
• Overall success rate 85%<br />
100 Patients<br />
• Complex fistulas (horseshoe type) 30 cases approximately<br />
90%<br />
• Unhealed fistulas after LIFT procedure 15%<br />
Personal Communication<br />
July 7, 2008<br />
Dr. Arun Rojanasakul<br />
LIFT Procedure<br />
University of Minnesota<br />
Follow up for 4.4 months<br />
Number<br />
Patients 12<br />
Success 10<br />
Percentage 88%<br />
Continence Unchanged<br />
18
LIFT Procedure<br />
University of Minnesota<br />
Number<br />
Patients 31<br />
Male 16<br />
Female 15<br />
Mean Age 46.5<br />
Median follow up<br />
8 months<br />
Failed Prior Operation 84%<br />
Follow up<br />
• 90% follow up (28/31); median 35 weeks<br />
• Success rate: 58% (18/31)<br />
– Median time to failure: 19 weeks (range<br />
4-63); 2 failures resulted in<br />
intersphincteric fistulas<br />
– Post-op complication: 1/31 (3%) -<br />
persistent pain<br />
• Incontinence: 0%<br />
Principles of Surgical Treatment<br />
• Confirmation of Anatomy of Fistula<br />
• Not every fistula needs an operation<br />
• Be conservative<br />
• Use staged procedures<br />
HOW DO I DO IT<br />
Leave Seton until all Wounds are Healed (> 6months)<br />
Remove Seton and Asses Symptoms<br />
Tolerable<br />
Non-tolerable<br />
• Reduce to a simple tract - draining seton<br />
• Use non division techniques<br />
Follow<br />
Fibrin Glue/plug<br />
• Reassess the situation after each intervention<br />
Flap or LIFT<br />
R.S.K. Phillips<br />
THANK<br />
YOU<br />
19
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