Anal fistula surgery: Difference between revisions
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__NOTOC__ | __NOTOC__ | ||
{{Anal fistula}} | {{Anal fistula}} | ||
{{CMG}} {{AE}} {{MKK}} | {{CMG}}, {{AE}}{{MKK}} | ||
==Overview== | ==Overview== | ||
The mainstay of treatment of [[anal fistula]] is surgical treatment.The principles for the management of [[anal fistula]] are described by the acronym '''SNAP''', which stands for [[sepsis]], [[nutrition]], [[anatomy]], and [[procedure]] according to British Medical Journal. Various methods of surgery are [[fistulotomy]] and [[Seton stitch|Seton]]. Sphincter-saving methods are [[fibrin]] glue, endorectal advancement flap, LIFT procedure, BioLIFT, [[stem Cells|stem cells]] and defunctioning. | |||
==Surgery== | ==Surgery== | ||
*Mainstay of treatment of anal fistula is surgical treatment. | *Mainstay of treatment of anal fistula is surgical treatment. | ||
*According to '''British Medical Journal''', the principles for the management of anal fistula are described by the acronym SNAP, which stands for sepsis, nutrition, anatomy, and procedure. | *According to '''British Medical Journal''', the principles for the management of [[anal fistula]] are described by the acronym '''SNAP''', which stands for [[sepsis]], [[nutrition]], [[anatomy]], and [[procedure]].<ref name="urlManagement of anal fistula | The BMJ">{{cite web |url=http://www.bmj.com/content/345/bmj.e6705 |title=Management of anal fistula | The BMJ |format= |work= |accessdate=}}</ref> | ||
**Treatment of sepsis is the first step. | **Treatment of [[sepsis]] is the first step. | ||
**Nutrition is very important for the healing of fistula. | **[[Nutrition]] is very important for the healing of fistula. | ||
*** | ***Patient should be healthy during the treatment of anal fistula. | ||
***In malnourished patients and patients with comorbidities, fistula heals slowly. | ***In [[malnourished]] patients and patients with [[comorbidities]], [[fistula]] heals slowly. | ||
**Anatomy of fistula should be tracked before starting the treatment. Failure to track the secondary fistula leads to failure of treatment. | **[[Anatomy]] of fistula should be tracked before starting the treatment. | ||
**Selection of the appropriate procedure is key to successful management. | ***Failure to track the secondary [[fistula]] leads to failure of treatment. | ||
**Selection of the appropriate [[procedure]] is key to successful management. | |||
*According to the '''American Society of Colon and Rectal Surgeons''', the goal of treatment of | *According to the '''American Society of Colon and Rectal Surgeons''', the goal of treatment to identify the internal opening and the course of all tracks relative to the [[sphincter]] muscles and then f obliterate the [[internal]] fistulous opening and any associated epithelialized tracks with minimal [[sphincter]] division.<ref name="urlwww.fascrs.org">{{cite web |url=https://www.fascrs.org/sites/default/files/downloads/publication/clinical_practice_guideline_for_the_management_of_anorectal_abscess_fistula-in-ano_and_rectovaginal_fistula.pdf |title=www.fascrs.org |format= |work= |accessdate=}}</ref> | ||
'''Various methods of surgery are''':<ref name="pmid17880382">{{cite journal |vauthors=Williams JG, Farrands PA, Williams AB, Taylor BA, Lunniss PJ, Sagar PM, Varma JS, George BD |title=The treatment of anal fistula: ACPGBI position statement |journal=Colorectal Dis |volume=9 Suppl 4 |issue= |pages=18–50 |year=2007 |pmid=17880382 |doi=10.1111/j.1463-1318.2007.01372.x |url=}}</ref> | '''Various methods of surgery are''':<ref name="pmid17880382">{{cite journal |vauthors=Williams JG, Farrands PA, Williams AB, Taylor BA, Lunniss PJ, Sagar PM, Varma JS, George BD |title=The treatment of anal fistula: ACPGBI position statement |journal=Colorectal Dis |volume=9 Suppl 4 |issue= |pages=18–50 |year=2007 |pmid=17880382 |doi=10.1111/j.1463-1318.2007.01372.x |url=}}</ref> | ||
*'''Fistulotomy''': It is used to treat simple anal fistula with normal anatomy and with no other complication. | *'''Fistulotomy''': It is used to treat simple anal fistula with normal [[anatomy]] and with no other complication. | ||
*'''Seton''': Used to treat complex fistula. | *'''Seton''': Used to treat complex [[fistula]]. | ||
'''Sphincter-saving methods are''': | '''Sphincter-saving methods are''': | ||
* '''Fibrin glue''': Fibrin glue is a combination of fibrinogen, thrombin, and calcium in a matrix. | * '''Fibrin glue''': [[Fibrin]] glue is a combination of [[fibrinogen]], [[thrombin]], and [[calcium]] in a matrix. | ||
**Fibrin glue heals the fistula by first forming the clot within the track and then helping in the growth of collagen fibers and healthy tissue.<ref name="pmid11331478">{{cite journal |vauthors=Sentovich SM |title=Fibrin glue for all anal fistulas |journal=J. Gastrointest. Surg. |volume=5 |issue=2 |pages=158–61 |year=2001 |pmid=11331478 |doi= |url=}}</ref><ref name="pmid21876614">{{cite journal |vauthors=Shawki S, Wexner SD |title=Idiopathic fistula-in-ano |journal=World J. Gastroenterol. |volume=17 |issue=28 |pages=3277–85 |year=2011 |pmid=21876614 |pmc=3160530 |doi=10.3748/wjg.v17.i28.3277 |url=}}</ref> | **[[Fibrin]] glue heals the [[fistula]] by first forming the [[clot]] within the track and then helping in the growth of [[collagen]] fibers and healthy tissue.<ref name="pmid11331478">{{cite journal |vauthors=Sentovich SM |title=Fibrin glue for all anal fistulas |journal=J. Gastrointest. Surg. |volume=5 |issue=2 |pages=158–61 |year=2001 |pmid=11331478 |doi= |url=}}</ref><ref name="pmid21876614">{{cite journal |vauthors=Shawki S, Wexner SD |title=Idiopathic fistula-in-ano |journal=World J. Gastroenterol. |volume=17 |issue=28 |pages=3277–85 |year=2011 |pmid=21876614 |pmc=3160530 |doi=10.3748/wjg.v17.i28.3277 |url=}}</ref> | ||
*'''Fistula plug:''' Fistula plug is made from porcine small | *'''Fistula plug:''' [[Fistula]] plug is made from [[porcine]] and [[small intestine]] mucosa. | ||
**It encourages host cells to grow and ultimately fill the fistula track. | **It encourages host cells to grow and ultimately fill the [[fistula]] track. | ||
**It is resistant to infection.<ref name="pmid22469804">{{cite journal |vauthors=O'Riordan JM, Datta I, Johnston C, Baxter NN |title=A systematic review of the anal fistula plug for patients with Crohn's and non-Crohn's related fistula-in-ano |journal=Dis. Colon Rectum |volume=55 |issue=3 |pages=351–8 |year=2012 |pmid=22469804 |doi=10.1097/DCR.0b013e318239d1e4 |url=}}</ref> | **It is resistant to [[infection]].<ref name="pmid22469804">{{cite journal |vauthors=O'Riordan JM, Datta I, Johnston C, Baxter NN |title=A systematic review of the anal fistula plug for patients with Crohn's and non-Crohn's related fistula-in-ano |journal=Dis. Colon Rectum |volume=55 |issue=3 |pages=351–8 |year=2012 |pmid=22469804 |doi=10.1097/DCR.0b013e318239d1e4 |url=}}</ref> | ||
* '''Endorectal advancement flap:'''<ref name="pmid11122184">{{cite journal |vauthors=Ortíz H, Marzo J |title=Endorectal flap advancement repair and fistulectomy for high trans-sphincteric and suprasphincteric fistulas |journal=Br J Surg |volume=87 |issue=12 |pages=1680–3 |year=2000 |pmid=11122184 |doi=10.1046/j.1365-2168.2000.01582.x |url=}}</ref><ref name="pmid16538494">{{cite journal |vauthors=van der Hagen SJ, Baeten CG, Soeters PB, van Gemert WG |title=Long-term outcome following mucosal advancement flap for high perianal fistulas and fistulotomy for low perianal fistulas: recurrent perianal fistulas: failure of treatment or recurrent patient disease? |journal=Int J Colorectal Dis |volume=21 |issue=8 |pages=784–90 |year=2006 |pmid=16538494 |doi=10.1007/s00384-005-0072-7 |url=}}</ref> | * '''Endorectal advancement flap:'''<ref name="pmid11122184">{{cite journal |vauthors=Ortíz H, Marzo J |title=Endorectal flap advancement repair and fistulectomy for high trans-sphincteric and suprasphincteric fistulas |journal=Br J Surg |volume=87 |issue=12 |pages=1680–3 |year=2000 |pmid=11122184 |doi=10.1046/j.1365-2168.2000.01582.x |url=}}</ref><ref name="pmid16538494">{{cite journal |vauthors=van der Hagen SJ, Baeten CG, Soeters PB, van Gemert WG |title=Long-term outcome following mucosal advancement flap for high perianal fistulas and fistulotomy for low perianal fistulas: recurrent perianal fistulas: failure of treatment or recurrent patient disease? |journal=Int J Colorectal Dis |volume=21 |issue=8 |pages=784–90 |year=2006 |pmid=16538494 |doi=10.1007/s00384-005-0072-7 |url=}}</ref> | ||
**Used to stop the fistula track communicating with the bowel and cover the internal opening with the disease-free anorectal wall. | **Used to stop the [[fistula]] track communicating with the [[bowel]] and cover the internal opening with the disease-free [[anorectal]] wall. | ||
**There are various types of endorectal advancement flap: | **There are various types of endorectal advancement flap: | ||
***Rhomboid flaps, anorectal flaps with proximal advancement. | ***Rhomboid flaps, [[anorectal]] flaps with proximal advancement. | ||
***Full or partial thickness flap of the proximal rectal wall. | ***Full or partial thickness flap of the proximal [[rectal]] wall. | ||
*'''LIFT procedure:''' | *'''LIFT procedure:''' | ||
**Ligation of the intersphincteric fistula track (LIFT): Between the internal and external anal sphincters, a skin incision is made, the fistula track is exposed within the intersphincteric space and subsequently ligated and divided.<ref name="pmid17427539">{{cite journal |vauthors=Rojanasakul A, Pattanaarun J, Sahakitrungruang C, Tantiphlachiva K |title=Total anal sphincter saving technique for fistula-in-ano; the ligation of intersphincteric fistula tract |journal=J Med Assoc Thai |volume=90 |issue=3 |pages=581–6 |year=2007 |pmid=17427539 |doi= |url=}}</ref> | **Ligation of the intersphincteric fistula track (LIFT): Between the internal and external anal [[sphincters]], a skin incision is made, the [[fistula]] track is exposed within the intersphincteric space and subsequently ligated and divided.<ref name="pmid17427539">{{cite journal |vauthors=Rojanasakul A, Pattanaarun J, Sahakitrungruang C, Tantiphlachiva K |title=Total anal sphincter saving technique for fistula-in-ano; the ligation of intersphincteric fistula tract |journal=J Med Assoc Thai |volume=90 |issue=3 |pages=581–6 |year=2007 |pmid=17427539 |doi= |url=}}</ref> | ||
**'''BioLIFT''' - It is modified LIFT | **'''BioLIFT''' - It is modified LIFT , a [[biological]] mesh is placed in the intersphincteric space which serves as a barrier to refistulisation. | ||
*'''Stem cells:''' | *'''Stem cells:''' | ||
**[[Stem cells]] are derived from [[adipose]] cells. | |||
**[[Stem cells]] are infused into [[fistula]] track and helps in healing of [[fistula]].<ref name="pmid19273960">{{cite journal |vauthors=Garcia-Olmo D, Herreros D, Pascual I, Pascual JA, Del-Valle E, Zorrilla J, De-La-Quintana P, Garcia-Arranz M, Pascual M |title=Expanded adipose-derived stem cells for the treatment of complex perianal fistula: a phase II clinical trial |journal=Dis. Colon Rectum |volume=52 |issue=1 |pages=79–86 |year=2009 |pmid=19273960 |doi=10.1007/DCR.0b013e3181973487 |url=}}</ref> | |||
*'''Defunctioning:''' | |||
**It is done in rare cases, when there is perianal sepsis and mutiple tracts formation. | |||
**The bowel is defunctioned by taking out the proximal [[colon]] and [[colostomy]] is done. | |||
**This helps in improvement of symptoms of perianal leakage. | |||
**It helps in diverting the [[bowel]] contents away from the anorectum, thus, defunctioning helps in resolution of [[sepsis]]. | |||
==References== | ==References== | ||
Latest revision as of 20:48, 13 February 2018
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Anal fistula Microchapters |
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Diagnosis |
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Treatment |
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Anal fistula surgery On the Web |
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American Roentgen Ray Society Images of Anal fistula surgery |
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1], Associate Editor(s)-in-Chief: Manpreet Kaur, MD [2]
Overview
The mainstay of treatment of anal fistula is surgical treatment.The principles for the management of anal fistula are described by the acronym SNAP, which stands for sepsis, nutrition, anatomy, and procedure according to British Medical Journal. Various methods of surgery are fistulotomy and Seton. Sphincter-saving methods are fibrin glue, endorectal advancement flap, LIFT procedure, BioLIFT, stem cells and defunctioning.
Surgery
- Mainstay of treatment of anal fistula is surgical treatment.
- According to British Medical Journal, the principles for the management of anal fistula are described by the acronym SNAP, which stands for sepsis, nutrition, anatomy, and procedure.[1]
- Treatment of sepsis is the first step.
- Nutrition is very important for the healing of fistula.
- Patient should be healthy during the treatment of anal fistula.
- In malnourished patients and patients with comorbidities, fistula heals slowly.
- Anatomy of fistula should be tracked before starting the treatment.
- Failure to track the secondary fistula leads to failure of treatment.
- Selection of the appropriate procedure is key to successful management.
- According to the American Society of Colon and Rectal Surgeons, the goal of treatment to identify the internal opening and the course of all tracks relative to the sphincter muscles and then f obliterate the internal fistulous opening and any associated epithelialized tracks with minimal sphincter division.[2]
Various methods of surgery are:[3]
- Fistulotomy: It is used to treat simple anal fistula with normal anatomy and with no other complication.
- Seton: Used to treat complex fistula.
Sphincter-saving methods are:
- Fibrin glue: Fibrin glue is a combination of fibrinogen, thrombin, and calcium in a matrix.
- Fistula plug: Fistula plug is made from porcine and small intestine mucosa.
- Endorectal advancement flap:[7][8]
- LIFT procedure:
- Ligation of the intersphincteric fistula track (LIFT): Between the internal and external anal sphincters, a skin incision is made, the fistula track is exposed within the intersphincteric space and subsequently ligated and divided.[9]
- BioLIFT - It is modified LIFT , a biological mesh is placed in the intersphincteric space which serves as a barrier to refistulisation.
- Stem cells:
- Stem cells are derived from adipose cells.
- Stem cells are infused into fistula track and helps in healing of fistula.[10]
- Defunctioning:
- It is done in rare cases, when there is perianal sepsis and mutiple tracts formation.
- The bowel is defunctioned by taking out the proximal colon and colostomy is done.
- This helps in improvement of symptoms of perianal leakage.
- It helps in diverting the bowel contents away from the anorectum, thus, defunctioning helps in resolution of sepsis.
References
- ↑ "Management of anal fistula | The BMJ".
- ↑ "www.fascrs.org" (PDF).
- ↑ Williams JG, Farrands PA, Williams AB, Taylor BA, Lunniss PJ, Sagar PM, Varma JS, George BD (2007). "The treatment of anal fistula: ACPGBI position statement". Colorectal Dis. 9 Suppl 4: 18–50. doi:10.1111/j.1463-1318.2007.01372.x. PMID 17880382.
- ↑ Sentovich SM (2001). "Fibrin glue for all anal fistulas". J. Gastrointest. Surg. 5 (2): 158–61. PMID 11331478.
- ↑ Shawki S, Wexner SD (2011). "Idiopathic fistula-in-ano". World J. Gastroenterol. 17 (28): 3277–85. doi:10.3748/wjg.v17.i28.3277. PMC 3160530. PMID 21876614.
- ↑ O'Riordan JM, Datta I, Johnston C, Baxter NN (2012). "A systematic review of the anal fistula plug for patients with Crohn's and non-Crohn's related fistula-in-ano". Dis. Colon Rectum. 55 (3): 351–8. doi:10.1097/DCR.0b013e318239d1e4. PMID 22469804.
- ↑ Ortíz H, Marzo J (2000). "Endorectal flap advancement repair and fistulectomy for high trans-sphincteric and suprasphincteric fistulas". Br J Surg. 87 (12): 1680–3. doi:10.1046/j.1365-2168.2000.01582.x. PMID 11122184.
- ↑ van der Hagen SJ, Baeten CG, Soeters PB, van Gemert WG (2006). "Long-term outcome following mucosal advancement flap for high perianal fistulas and fistulotomy for low perianal fistulas: recurrent perianal fistulas: failure of treatment or recurrent patient disease?". Int J Colorectal Dis. 21 (8): 784–90. doi:10.1007/s00384-005-0072-7. PMID 16538494.
- ↑ Rojanasakul A, Pattanaarun J, Sahakitrungruang C, Tantiphlachiva K (2007). "Total anal sphincter saving technique for fistula-in-ano; the ligation of intersphincteric fistula tract". J Med Assoc Thai. 90 (3): 581–6. PMID 17427539.
- ↑ Garcia-Olmo D, Herreros D, Pascual I, Pascual JA, Del-Valle E, Zorrilla J, De-La-Quintana P, Garcia-Arranz M, Pascual M (2009). "Expanded adipose-derived stem cells for the treatment of complex perianal fistula: a phase II clinical trial". Dis. Colon Rectum. 52 (1): 79–86. doi:10.1007/DCR.0b013e3181973487. PMID 19273960.