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Recent Advances in Surgical Management of Complex Cryptoglandular Anal Fistula

Recent Advances in Surgical Management of Complex Cryptoglandular Anal Fistula. YK Fong, Queen Mary Hospital. Agenda. Introduction Etiology and pathogenesis Classification Management approach of anal fistula Assessment Surgical options Recent advances in surgical treatment.

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Recent Advances in Surgical Management of Complex Cryptoglandular Anal Fistula

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  1. Recent Advances in Surgical Management of Complex Cryptoglandular Anal Fistula YK Fong, Queen Mary Hospital

  2. Agenda • Introduction • Etiology and pathogenesis • Classification • Management approach of anal fistula • Assessment • Surgical options • Recent advances in surgical treatment

  3. Etiology and Pathogenesis • Cryptoglandular (90%) • Extension of sepsis from infected anal glands in the intersphincter space • Non-cryptoglandular • Crohn’s disease • Tuberculosis, actinomycosis • Malignancy • Hidradenitissuppurativa • Radiation • HIV infection • Immunocompromised (chemotherapy/ diabetes)

  4. Classification 1) Intersphincteric 2) Transphincteric 3) Suprasphincteric 4) Extrasphincteric

  5. Anal Fistula Classification • Complex: Treatment poses a high risk of incontinence • Postoperative recurrence • Multiple tracts • Tract crosses >30-50% of external sphincter muscle • Anterior in females • Pre-existing incontinence American Gastroenterological Association

  6. 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

  7. Principles of Treatment Control of sepsis Maintenance of continence Closure of fistula

  8. 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)

  9. LIFT Procedure(Ligation of Intersphincteric Fistula Tract ) • Rojanasakul et al. from Bangkok in 2007 • Success rate: 17/18 (94.4%) Rojanasakul, Tech Coloproctol 2009

  10. LIFT Procedure: A Simplified Technique for Anal Fistula

  11. 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

  12. 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

  13. 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

  14. 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

  15. BioLIFT Procedure • Potential drawbacks of the BioLIFT technique • Requires extensive dissection in the intersphincteric space • High cost of the bioprosthetic materials

  16. 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

  17. 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

  18. VAAFT

  19. 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

  20. 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

  21. 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

  22. Thank you

  23. Assessment • Clinical • Digital examination • Examination under anesthesia (EUA) • Anal manometry • Radiological • Endoanal ultrasound • Magnetic resonance imaging

  24. 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

  25. 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

  26. 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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