by dr: alaa a. redwan m.d., ph.d. · by dr: alaa a. redwan m.d., ph.d. prof. of g.i.t. surgery and...

ByDr: Alaa A. Redwan M.D., Ph.D.

Prof. Of G.I.T. Surgery and Laparo-EndoscopySohag University Hospital

Sohag University, Sohag, Egypt

EtiologyCryptoglandular theoryTrauma

Foreign body

Iatrogenic

Malignancy

Crohn’s disease

Tuberculosis

HIV

J.G.Williams et al. Colorectal Disease 2007

Classification Park’s classification (1976)


Goodsall’s rule

49%

90%


A range of treatment options are available, butnone is universally successful or without risk. Thekey principles for the management are described

by the acronym SNAP, which stands for Sepsis,

Nutrition, Anatomy, and Procedure. Eradication

of sepsis is the first step. A fistula will not healwhile infection is present. As with wound healing,anal fistulas heal poorly in malnourished patients.Fistula openings and the underlying trackanatomy must be always clearly identified, asfailure to recognize secondary tracks may lead totreatment failure.

Simpson et al; Management of anal fistula. BMJ 2012

Selection of the appropriate procedure is the keyof successful management. Anal fistulas will notheal without intervention, and failure to treat maylead to progression of the disease process. If leftuntreated, anal fistulas are at risk of recurrentformation of a perianal abscess interspersed withpartial healing of the fistula track. This canbecome a chronic septic focus with theestablishment of a complex fistula network. Theconsequences for the patient may include pain,bleeding, incontinence, cellulitis, and systemicsepsis.

Simpson et al; Management of anal fistula. BMJ 2012

the overall complication rate was 2.5%, whichincluded bleeding, urinary retention, infection,continence problems and recurrence.

(Hazim et al; Coloproctology J. 2015)

The more you do to avoid recurrence, the more you get incontinenceThe more you do to avoid incontinence, the more you get recurrence

Prof. Ahmad Abdelaziz (Ain Shams University)

The ttt remains a challenge as it is essential toachieve a cure while minimizing postop.complications. The most important factors determineoutcome are recurrence and anal incontinence.Incontinence can significantly affect the quality of life

of the patients with overall rates vary up to 40%depending on the type of fistula and the operativetreatment used, moreover, majority of patients hadminor incontinence. Studies have shown that simplefistulae also carry a risk of incontinence though notas high as following surgery for complex fistulae.Furthermore, studies have also shown that quality oflife and patient satisfaction may be low because ofanal incontinence despite a complete cure.

Jayarajah et al. BMC Res Notes (2017)

van Koperen, Surgical treatment of perianal fistula. 2010

The recurrence rate reported in the literatureranged from 0-30%. This wide range is a resultof the heterogeneous population selected forfistulotomy in the different studies, which makes itdifficult to compare the different outcomes. Thequestion arises as to what extent the relativelyyoung population will develop continenceproblems in the future. In the literature, manydifferent criteria are used to report incontinenceand predict its risk, and as a consequence thecontinence outcome varies a lot between differentpublications

the risk include the fistula type, the underlyingdisease state, and the operation utilized. The typeof fistula refers to the extent of muscle involvementby the tract as it extends from the internal to theexternal opening. Parks’ classification is the mostcommonly used includes submucosal fistulas (nomuscle involvement), intersphincteric fistulas(between the internal and external sphincters), aswell as transsphincteric, extrasphincteric andsuprasphincteric fistulas (indicating a variableextent of involvement of the external sphincter).Continence risk increases with increasinginvolvement of the external sphincter in theprocess

Thorson; Fecal Incontinence After Perianal Surgery, 2005

The underlying disease state can markedly affectthe success or failure of fistula surgery. Variablesinclude Crohn’s and other granulomatous diseases,immune suppression, radiation history and fistulasof anal gland origin. Most anal fistulas ariseaccording to the theory of cryptoglandular origin. Inits simplest form, this states that infectionoriginates in one of the anal glands withsubsequent extension to any one of the variousanorectal spaces as an abscess in the acute statewith subsequent evolution to a fistula in the chronicstate of anal suppurative disease.


The basic premise of fistula treatment involvestwo steps. First the inciting gland must bedestroyed and secondly, the tract must beeliminated through unroofing (with woundhealing by secondary intention), excision orfilling. Protection of the external sphincter can beenhanced by maneuvers meant to avoid divisionaltogether (fibrin glue and advancement flaps) orby the use of setons in an attempt to minimizelong-term sequelae of muscle division


Thus it would appear that the overall risk tocontinence is between 10% and 20%, with mostissues being of minor degree, in respect to thetype of fistula and operative technique. Themore significant risks lie in fistulas that are highand complex. These risks are probably related tothe amount of muscle that is divided at the timeof operation. There are alternatives thatdecrease the amount of muscle that needs to bedivided. These appear to lower the risk ofincontinence in these procedures.


Certain groups of patients can be identified as athigh risk for incontinence, as females haveshorter anal canals than males. So, a givenlength of sphincter division tends to represent agreater proportion of the sphincter and thusincreased risk, care should be taken to keep thelength of the sphincterotomy shorter. Femalesalso are at risk for incontinence related toanterior fistulas due to the relative decreasedsphincter in the rectovaginal septum.



Patients with a history of pelvic radiationpresent with increased risks of incontinence,also a history of previous anorectal surgeryfrequently harbor occult sphincter injuries thatmay impact continence following additionalanorectal surgery. Thus represent a high-riskgroup. High trans-sphincteric and supra-sphincteric fistulas increase risk of incontinencefollowing operation, as do posterior fistulas andthose with extensions. Several reports suggestthat advancing age has a negative impact oncontinence following fistula surgery.

Smoking is well known to influence wound healing invarious patient groups. It was assessed as a possiblerisk factor and discrepancies exist as to whethersmoking has an effect on the outcome of surgicaltreatment for anorectal fistula. A reduced blood flowwas noted as a possible contributing factor. However,the later study, no significant relation could be foundbetween smoking and fistula recurrence as well. Noclear risk factors for the development of a recurrentperianal fistula were found in the fistulotomy nor in therectal advancement group. Overall, continencedisturbances were infrequent and similar in bothgroups. However, a reasonable amount of patients inboth groups reported soiling

Van Koperen, Surgical treatment of perianal fistula. 2010

There are techniques in surgery that raisespossibility for complications after anal fistulasurgery; those are an advancement flap procedure(6-8%) and seton techniques (17%).Reappearance of anal fistula after fistulotomy isabout 21% and 36% after advancement flapprocedure. The overall recurrence rate isacceptable, but high fistulae continue to be difficultto treat. Identification is also essential for obtaininggood results. It is important to identify the patientswith preoperative incontinence as they are at agreater risk of deterioration after surgery.

(Jordán et al; Colorectal Dis. 2010)

Fistulotomy produces a satisfactory outcome interms of eradicating sepsis and preservingfunction in the vast majority of patients withintersphincteric fistula with intact sphincters.However, sphincter-preserving treatment maybe advocated for patients with low preoperativevoluntary contraction pressure or those whohave undergone multiple drainage surgeries.Preoperative anal manometry is useful indetermining the proper surgical procedure.

(Toyonaga et al; Int J. Colorectal Dis. 2007)

Maher A. Abbas et al; Arch. Surg. 2011

Visscher et al; Dis Colon Rectum 2015

Median follow-up was 7.8 years (range, 2.1–18.1 years). 34%of patients complained of FI. Fistula characteristics, the numberof abscesses incised, the number of FTs received and thenumber of sphincter-sparing procedures were associated withthe presence of FI during follow-up. Patients with asubcutaneous fistula tract had a lower risk of FI than those witha supra-sphincteric fistula. When >1 sphincter-sparingprocedure had been performed, the risk for FI was greater thanif no sphincter-sparing procedures were performed. Howeverafter adjusting for the other variables in the multivariateanalysis, sphincter-sparing procedures were no longerassociated with FI. Patients who underwent >1 FT were atgreater risk for FI than those who did not undergo FT. Inaddition, having a single FT in which >1 abscess was incisedand drained or having a high trans-sphincteric orsuprasphincteric fistula tract was also associated with FI.


Quality of life: All patients with FI (fecalincontinence) stated that it negatively affected theirQOL in some degree. Patients with both FI and fistula-related perianal complaints all stated that FI impairedtheir QOL. Lifestyle and everyday behavior werenegatively affected in 18% and 22% respectively.Feelings of depression were reported by 23% ofpatients, and embarrassment by 25%. Allsubcategories of the FIQL were scored lower bypatients with FI (p < 0.001). Mean FIQL subscales forlifestyle (p = 0.030), depression (p = 0.077) andembarrassment (p < 0.001) were all scored lower bypatients operated on for complex fistula than by thosetreated for simple fistula.


Jayarajah et al. BMC Res Notes (2017)

Although the primary objective of operativeintervention is to heal the fistula, equally importantis the morbidity of the procedure. Fistulotomyremains one of the most commonly performedoperations for anal fistula with a reported successrate ranging from 87% to 94%. Fistulotomy entailsthe division of a various degree of anal sphinctermuscle, putting the patient at risk for postoperativeincontinence, adversely affecting the patient’squality of life. Post-operative incontinence has beennoted in 6% to 40% of patients who undergofistulotomy.


This finding has prompted surgeons to identifythe subgroups of patients who are at anincreased risk of developing post fistulotomyincontinence and to offer such patientssphincter-preserving operations. Patients whoare predisposed to incontinence include patientswith baseline incontinence, those with a historyof anal operations, women with anterior-basedfistulas, and patients with horseshoe fistulas orhigh tracts involving a significant amount ofsphincter muscle


Postoperative fecal incontinence developed in 15.6%of patients who did not have prior baselineincontinence. Being older than 45 years and havinghigh transsphincteric and suprasphincteric fistulaswere independent predictors of postoperative fecalincontinence. These findings can be explainedphysiologically as loss of muscle tone due to aging orloss of muscle mass due to surgical intervention,both which would affect continence level. Horseshoefistula was associated with a higher risk ofpostoperative incontinence in univariate analysis.Two studies on horseshoe anal fistula reportedpostoperative incontinence rates of 21% to 29%.


Bubbers, and Cologne; Management of Complex Anal Fistulas.Clin Colon Rectal Surg 2016

There are multiple techniques available for therepair of complex anal fistulas. The besttechnique is not known, and the availableevidence suffers from a lack of high-quality data,with very few large randomized studies. Thetechnique of choice will depend on appropriatedelineation of the anatomy, surgeon preference,and familiarity with the different techniques. Ingeneral, failure is common, and one should beprepared to perform multiple procedures ifrequired.

The more you do to avoid recurrence, the more you get incontinenceThe more you do to avoid incontinence, the more you get recurrence

Prof. Ahmad Abdelaziz (Ain Shams University)

[email protected]

by dr: alaa a. redwan m.d., ph.d. · by dr: alaa a. redwan m.d., ph.d. prof. of g.i.t. surgery and...

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