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Fistula in-ano
- 1. Fistula-in-ano: a probing of the treatment options David Jayne Professor of Surgery University of Leeds & Leeds Teaching Hospitals NHS Trust John Goligher Colorectal Unit
- 2. The Problem
- 3. Aetiology • Cryptoglandular • Crohn’s disease • Other – Malignant – Obstetric – Radiation
- 4. Classification 30% 45% 5% 20%
- 7. Treatment Aims • Eradicate disease (if possible) • Preservation of continence • Benign condition • Quality of life
- 8. Principles • Control sepsis – EUA – Laying open abscesses and secondary tracts – Adequate drainage – seton insertion • Define anatomy – Openings and tracts • Internal and External • Single –v- multiple • Extensions / Horseshoe – Relation to sphincter complex • High –v- Low • Exclude co-existent disease
- 9. MRI for fistula-in-ano Abscesses & Contralateral disease Other pathology HALLIGAN Radiology 2006 Extensions
- 10. Surgical Options – Fistulotomy • Fistula tract identified with probe • Extent of external sphincter involvement assessed • Tract and muscle divided • Secondary tracts laid open • +/- marsupialisation wound
- 11. Surgical Options – Cutting Seton • Lay open external tract • Draining seton replaced with cutting seton • 1/0 Prolene suture • Tied tight around sphincter complex • Simultaneous slow cutting and repair of sphincter • May require re-tightening
- 12. Surgical Options – Fistulectomy • Draining seton • Core out tract • Direct visualisation of secondary tracts • Sphincter repair +/- advancement flap
- 13. Advancement Flaps Endorectal • Fistula tract probed • Flap raised – Mucosa + Int. Sphincter • Internal opening excised/closed • Flap advanced & sutured
- 14. Advancement Flap Anodermal • Fistula tract probed • Flap raised – Anodermal • Flap advanced & sutures • External defect closed
- 15. Fistula Plug
- 16. Fistula Plug
- 17. LIFT Procedure Ligation of Intersphincteric Fistula Tract • Transsphincteric fistula • Draining seton – 6 weeks • Tract prepared with fistula brush – Debrides – De-epithelializes
- 18. LIFT Procedure
- 19. PROS CONS Cutting Seton Simple Repeat EUA Cheap Recurrence 0 – 8% Incontinence • minor 34 – 63% • major 2 – 26% Fistulotomy Simple Recurrence 2 – 9% Cheap Incontinence 50% Advancement Flap Can be difficult Recurrence 25 – 50% ?Preserves sphincter Incontinence 30 – 35% Fistula Plug Simple Plug expensive ~£400 Preserves sphincter Recurrence 20 – 85% Continence preserved LIFT Simple Recurrence 15 - 40% Preserves sphincter Continence preserved
- 20. ACPGBI FIAT Trial EUA: transsphincteric fistula ≥ 1/3 of sphincter complex Insertion of draining seton MRI fistulography RANDOMISE Fistula Plug Surgeon’s Insertion Preference Advancement Cutting Seton Fistulotomy LIFT Flap
- 21. ACPGB&I FIAT Patient identification EUA & draining seton Primary end-points Eligibility & Consent • Faecal incontinence QoL MRI scan • Generic QoL Randomisation 1:1 plug –v- surgeon’s preference Secondary end-points Surgery • Healing – 12 months (6-weeks post seton insertion) • Complications Surgeon’s preference • Faecal incontinence Surgisis® fistula plug (fistulotomy, seton, advancement flap, LIFT) • Re-interventions • Health resource 6-week FU utilisation 6-monthFU • Cost effectiveness 12-month FU + MRI scan
- 22. FIAT FACTS Recruitment: 76 Target: 500 Open centres: 36 Recruiting centres: 21
- 23. Join the FIAT Trial!
- 24. Fistula-in-ano: a probing of the treatment options David Jayne Professor of Surgery University of Leeds & Leeds Teaching Hospitals NHS Trust John Goligher Colorectal Unit