The enigma of the transsphincteric anal fistula. Per-Olof Nyström, M.D., Ph.D. Karolinska University Hospital, Stockholm, Sweden
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1 The enigma of the transsphincteric anal fistula Per-Olof Nyström, M.D., Ph.D. Karolinska University Hospital, Stockholm, Sweden
2 Four principles of treatment for anal fistula 1. Inactivate the fistula 2. Fill and occlude the tract 3. Lay open the fistula tract 4. Close the internal opening The practical treatment options for anal fistula Seton for drainage or cutting Fibrin glue Anal fistula plug Lay open or core out Endo-rectal mucosa flap or anodermal island flap. LIFT intersphincteric severing of tract and ligation of internal opening. VAAFT video assisted fulguration of tract and closure of internal opening.
3 Dudukian & Abcarian (Chicago) WJG 2011;17:3292
4 The failure of each sphincter-preserving procedure (30%-50% recurrence) often results in multiple operations. In essence, the price of preservation of continence at all cost is multiple and often different operations, prolonged disability and disappointment for the patient and the surgeon. Herand Abcarian, Chicago
5 Wellcome Library, London
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7 Rectum Coccyx Levator ani EAS Subcutaneous muscle
8 Torkzad & Karlbom. Insights Imaging 2010
9 Armin Kübelbeck: To be able to make this picture, I've spent lots of my own money (mainly equipment) and time.
10 P Meinero: homepage of VAAFT : Video-assisted anal fistula treatment, 2013
11 Intersphincteric fistula From Belliveau P. Anal fistula. In: Fazio VM, Church JM, Delaney CP, editors. Current therapy in colon and rectal surgery. 2nd edition. Philadelphia: Elsevier Mosby; 2005.
12 Transsphincteric fistula From Belliveau P. Anal fistula. In: Fazio VM, Church JM, Delaney CP, editors. Current therapy in colon and rectal surgery. 2nd edition. Philadelphia: Elsevier Mosby; 2005.
13 Suprasphincteric fistula From Belliveau P. Anal fistula. In: Fazio VM, Church JM, Delaney CP, editors. Current therapy in colon and rectal surgery. 2nd edition. Philadelphia: Elsevier Mosby; 2005.
14 Seton applied for high anal fistula From Belliveau P. Anal fistula. In: Fazio VM, Church JM, Delaney CP, editors. Current therapy in colon and rectal surgery. 2nd edition. Philadelphia: Elsevier Mosby; 2005.
15 LIFT: Suture ligation of intersphincteric tract with loose seton of distal tract Tsunoda et al: Manometric Study on LIFT. DCR 2013; 56:
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18 Internal sphincter Subcutaneous sphincter Tract Low posterior fistula layed open December 2008
19 Low anal fistula 2 Mar 2010
20 Low anal fistula 2 Mar 2010
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22 Seton treatment of anal fistula 47 patients with anal fistula all treated with seton. 41 completed follow-up and 37 were healed = 78 % T 50 = 9 weeks (4-64) 1 recurrence No incontinence and all patients content Theerapol et al. Sing Med J 2002;43:305-7
23 Number of continent and incontinent patients after treatment with cutting seton. 33 published studies. Mean incontinence rate 12%. 25 Number of incontinent patients Number of continent patients per study After Ritchie et al. CD 2009;11:564-71
24 Number of continent and incontinent patients after treatment with cutting seton. 17 published studies with subgroup transsphincteric fistula. Mean incontinence rate 32% Number of incontinent patients per study Number of continent patients per study After Ritchie et al. CD 2009;11:564-71
25 Number of continent and incontinent patients after treatment with cutting seton. 18 published studies with subgroup transsphincteric fistula. Mean incontinence rate 32% Number of incontinent patients per study Number of continent patients per study After Ritchie et al. CD 2009;11:564-71
26 Elective change of loose seton until fistula resolution Multicentre study of draining seton for anal fistula over 3 yrs. Common protocol for elective change of seton every 3 rd month. Required number of changes median 3 (1-8) mean 2, patients; all resolved their fistula. Failure to tolerate seton 1 % Recurrence 6 % Kelly et al. (Dublin) Tech Coloproctol 2014Oct;18:915-9
27 Abscess of anal fistula plug
28 Success rate with the Surgisis Fistula Plug as a reflection of publication time, N=33 studies Success rate of fistula plug, % Year of publication Data collected by Garg 2010, O Riordan 2012, and later PubMed search.
29 Systematic analysis of the LIFT technique 19 studies comprising 561 patients, median 25/study (15-93) Transsphincteric fistula 88 % Suprasphincteric or horse-shoe 6 % Intersphincteric fistula 6 % Previously failed other surgery: median 32% (0-100%) Weighted cure rate with LIFT 71% Other systematic reviews of LIFT Cure rate Yassin et al. CD % Hong et al. Tech Coloprotol % Alasair et al. Tech Coloprotol % Zirak-Schmidt & Perdawood. Danish Med J Dec 2014.
30 The LIFT technique
31 LIFT: Suture ligation of intersphincteric tract with loose seton of distal tract Tsunoda et al: Manometric Study on LIFT. DCR 2013; 56:
32 Result of published studies with the LIFT technique for anal fistula, N= Success rate with LIFT, % Pooled success rate in four systematic reviews 71%, 71%, 76% and 81% Year of publication
33 LIFT - Mean duration of procedure in 10 published studies as a reflection of the number of procedures Duration of operation, minutes Alasair et al. Lift systematic review, Tech Coloproctol Mean op time 39 minutes Number of procedures per study
34 Long-term outcome following mucosal advancement flap for high perianal fistulas (N=41) and fistulotomy for low perianal fistulas (N=62) van der Hagen et al. IJCRD 2006; 21:
35 Success rate of LIFT Liu et al. Dis Colon Rectum 2013; 56:
36 Outcomes after operations for anal fistula Prospective register study in New England: 16 surgeons submitted 240 fistula operations with curative intent. Procedure Result (3 month healing rate) Fistulotomy 94 % LIFT 79 % Advancement flap 60 % Fistula plug 20 % Hall et al. DCR 2014 Nov;57:
37 Success with advancement flap, % Flap Year of publication Success rate with fibrin glue, % Fibrin glue Year of publication Success rate with LIFT, % LIFT Year of publication Success rate of fistula plug, % Fistula plug Year of publication
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39 Fibrin glue of anal fistula 3-year period all-comers with fistula (cryptoglandular and Crohn) = 48 patients Seton for three months, followed by suture closure of internal opening and filling of tract with fibrin glue. Follow-up 22 months. Single treatment healing 60 % Repeat treatment healing 69 % Sentovich S. DCR 2003;46:
40 Success with fibrin glue closure of anal fistula, N=14 published studies Success rate with fibrin glue Year of publication Data collected by Rizzo et al. Surg Clin N Am 2010;90:45 68, and later PubMed search
41 Success with endorectal advancement flap for anal fistula, N=34 published studies Success with advancement flap, % Year of publication Soltani A & Kaiser AM. DCR 2010;53: , van Onkelen DCR 2014
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44 Zirak-Schmidt & Perdawood DMJ 2014
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