Recent Advances in Surgical Management of Complex
Cryptoglandular Anal FistulaYK Fong, Queen Mary Hospital
Agenda• Introduction
– Etiology and pathogenesis– Classification
• Management approach of anal fistula– Assessment – Surgical options
• Recent advances in surgical treatment
Etiology and Pathogenesis• Cryptoglandular (90%)
– Extension of sepsis from infected anal glands in the intersphincter space
• Non-cryptoglandular– Crohn’s disease– Tuberculosis, actinomycosis– Malignancy– Hidradenitis suppurativa– Radiation– HIV infection– Immunocompromised (chemotherapy/ diabetes)
Classification 1) Intersphincteric 2) Transphincteric 3) Suprasphincteric 4) Extrasphincteric
Anal Fistula Classification• Complex: Treatment poses a high risk of
incontinence– Postoperative recurrence– Multiple tracts
– Tract crosses >30-50% ofexternal sphincter muscle
– Anterior in females– Pre-existing incontinence
American Gastroenterological Association
Complex Anal Fistula -Management Approach
• Assessment– To rule out ongoing anorectal sepsis– To delineate the anatomy of fistula tracts
• To look for non-cryptoglandular causes• To look for any causes of poor wound healing
– Immunocompromised– steroid application
• Definitive treatment
Principles of TreatmentControl of sepsis
Closure of fistula Maintenance of continence
Surgical Treatment Options• Conventional approaches
– Cutting Seton placement– Staged fistulotomy– Anorectal advancement flap
• Continence preserving approaches– Fibrin glue– Anal fistula plug– Ligation of Intersphincteric Fistula Tract (LIFT)– Video-Assisted Anal Fistula Treatment (VAAFT)
LIFT Procedure(Ligation of Intersphincteric Fistula Tract
)– Rojanasakul et al. from Bangkok in 2007– Success rate: 17/18 (94.4%)
Rojanasakul, Tech Coloproctol 2009
LIFT Procedure: A Simplified Technique for Anal Fistula
Rationale of LIFT Procedure
• Prevention of recurrent sepsis – Avoid entrance of fecal particles via internal
opening– Remove intersphincteric fistula tract
• Intermittent closed septic foci and persistent sepsis due to compression between sphincter muscles
LIFT Procedure• Less injury to anal sphincter • Short hospital stay • Short healing time • Primary healing rate 82.2% (37/45)
Shanwani et al DCR 2010
BioLIFT Procedure• A modification of LIFT Procedure• Placement of biologic mesh in the
intersphincteric space– Barrier to re-fistulization
C. Neal Ellis et al. Meeting of The American Society of Colon and Rectal Surgeons 2012
BioLIFT Procedure• Bioprosthetic grafts
– Tolerate contamination– Remodeling without a foreign body reaction
• Healing rate: 94% (29/31)
C. Neal Ellis et al. Meeting of The American Society of Colon and Rectal Surgeons 2012
BioLIFT Procedure• Potential drawbacks of the BioLIFT technique
– Requires extensive dissection in the intersphincteric space
– High cost of the bioprosthetic materials
Unsuitable Cases for LIFT Procedure
• External opening at intersphincteric groove • Abscess cavity in intersphincteric space
(friable tract) • Large internal opening • Specific causes: TB, Crohn’s
VAAFT (Video-Assisted Anal Fistula Treatment)
• Karl Storz endoscope • A small-calibered rigidscope equipped with an
optical channel, a working channel and an irrigation channel
VAAFT
VAAFT: Meinero technique• Ablation of the fistula tract with unipolar
electrode • Closure of the internal opening with stapler • Injection of cyanoacrylate into the fistula tract
Meniero P. Tech Coloproctol 2011
VAAFT: Meinero technique• 98 patients with complex fistula • Performed under spinal anesthesia • Operation time: 30 to 120 minutes• Primary healing: 72 patients (73.5%) • Healing time: 2-3 months • No major complication or fecal incontinence
Meniero P. Tech Coloproctol 2011
Conclusion• Management principles of complex anal
fistula– Detailed assessment to exclude underlying
disease– Anatomical +/- functional assessment– Tailored treatment
• To control and eradicate sepsis (stages) • To remove tract and close internal opening • To preserve continence
Thank you
Assessment
• Clinical– Digital examination– Examination under
anesthesia (EUA)– Anal manometry
• Radiological– Endoanal ultrasound– Magnetic resonance
imaging
LIFT Procedure• Prospective
observational study • All cryptoglandular
infections • May 2007 to
September 2008 • 45 patients
– 33 transsphincteric – 12 complex
• Median follow-up: 9 (range, 2-16) months
• Primary healing: 37/45(82.2%)
• Median healing time : 7 (range, 4-10) weeks
Shanwani et al DCR 2010
QMH Experience• Since January 2009
– 25 patients• 24 transphincteric fistula• 1 suprasphincteric fistula
– 15 recurrenct• Median operating time: 39 minutes (range 15-73)• Median hospital stay: 1 day• Perianal incision healing time: 14 days• Closure of external opening: 31 days• Median follow-up 9.8 months (range 1-21.5)• 2/25 (11%) recurrent rate
VAAFT• To identify the internal opening under direct
endoscopic view and then close it with suturing or stapler
• To ablate or remove the granulation tissue along the fistula tract
• To fill the fistula tract with bio-prosthetic material
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