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

27