schwierige Fälle Cas complexes de fistules péri- anales ...Van der Hagen and co-workers described...
Transcript of schwierige Fälle Cas complexes de fistules péri- anales ...Van der Hagen and co-workers described...
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14.01.18
Anale Fisteln – schwierige Fälle Cas complexes de fistules péri-anales
Dr. med. Daniel Steinemann FMH Chirurgie, EBSQ Koloproktologie Leiter Beckenbodenzentrum St. Claraspital, Basel
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Fall1-Anamnese
24.02.201753-jährigePa:en:nseitmehrerenWochenintermi?erendeVerhärtung/Schwellungperianal.StörendbeimFahrradfahrenundlangemSitzen.KeinAusfluss,keineBlutungen.- ChronischeObs:pa:on- Kolonoskopie07/2016:unauffällig
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Fall1-Untersuchung
Inspek6on:perianalhufeisenförmigeIndura:on,keineDruckdolenz,keineRötung,keineFistelöffnung.Anoskopie:reizloseSchleimhaut,keineFistelöffnungEndosonographie:Rechtsperianalhypoechogene,länglicheRaumforderung,ca.3cmlang,bis1.8mmDurchmesser.
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1. An6bio6katherapie2. Verlaufskontrollein3Monaten3. MRIBecken4. ChirurgischeExplora6on
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Fall1–MRI28.02.2017
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Goodsall’srule
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1. An6bio6katherapie2. Verlaufskontrollein3Monaten3. ChirurgischeExplora6on,Abszesseröffnung,
Seton-Einlage4. ChirurgischeExplora6on,primärer
Fistelverschluss
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Fall1–Verlauf15.03.2017CiproxinundMetronidazolfür14Tage.DarunterleichteBeschwerdebesserung.Endosonographie:PerianalrechtsFistel,keinAbszess,imVergleichzurVoruntersuchungentzündlicheInfiltra:onetwaskleiner.EndosonographischfraglichVerbindungzumAnalkanalzwischen6Uhrund7Uhr(gegenSSL).
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Fall1–Verlauf
22.03.2017ChirurgischeSprechstunde:SchmerzhageIndura:onbei10UhrSSL.DiedigitalrektaleUntersuchungistschmerzfrei,keineäussereÖffnung.Anoskopie:ResiduumeinerAnalfissurbei6UhrSSL,dortmöglicherweiseinnereFistelöffnung.
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Proktodealdrüsen
10
Mensch:RudimentäreAnlageMedian6(3-10)Drüsen80%submucös16%Internus2%intersphinctär1%ExternusMänner>FrauenPosterior>Anterior
Seow-ChoenF,DisColonRectum1994
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1. NochmalsAn6bio6ka2. ChirurgischeExplora6on,Abszesseröffnung
durchAnalkanal3. ChirurgischeExplora6on,Abszesseröffnungvon
perianal,Seton-Einlage4. ChirurgischeExplora6on,primärer
Fistelverschluss5. PrimäreFistelspaltung(layopen)
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Fall1–OP28.03.2017
Abszessabdeckelung9UhrSSLSeton-Einlage(Mersilene)beitransphinctärerFistelmitinnererÖffnungbei6UhrSSL
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Seton?
13
differ between the patients with and without preoperativeseton drainage (Table 1). No differences in healing rateswere found between the series from Leiden and Rotterdam(Table 2).
Discussion
Perianal fistulas passing through the upper or middle thirdof the external anal sphincter present a challenge to manysurgeons. Despite new treatment modalities such as closureof the fistulous tract with fibrin glue or a bioprosthetic plug,transanal advancement flap repair still provides a usefultool in the treatment of these fistulas. It enables healing ofthe fistula without damage of the external sphincter andconsequent fecal incontinence. Initially, the reported heal-ing rates varied between 84% and 100% [12–15]. However,during the last decade, it has become clear that TAFR failsin one out of three patients [1–7]. Until now, no definiterisk factor for failure has been identified. Recently, weexamined the outcome of repeat flap repair in 26 patients,who encountered a failure after the initial procedure [8]. Inall these patients, we noticed complete healing of theadvancement flap, except at the site of the original internalopening. This remarkable clinical finding and the lack ofpredictive factors for failure suggest that persistence of thefistula might be due to ongoing disease within theremaining fistulous tract. Obliteration of this tract with asurgical adhesives such as fibrin glue and Bio Glue® as anadjunct to flap repair [7, 16–18] has not only failed toimprove the healing rate, but even had a detrimental effecton the outcome. Some authors advocate preoperative setondrainage, since it allows drainage of the fistulous tract,thereby reducing the inflammatory activity within the tractand resolving secondary tracts [5, 9, 10]. In a retrospective
study, Sonoda and co-workers were the first to observe abeneficial effect [3]. In a relatively large series of 105patients, 56 patients underwent preoperative seton drainage.Comparing patients with and without preoperative setondrainage, they found a healing rate of 73.2% and 51.2%,respectively. This difference was statistically significant.However, their study included a large number of patientssuffering from a rectovaginal fistula and patients with afistula due to Crohn's disease. Only 44 patients presentedwith a fistula of cryptoglandular origin. Unfortunately, theauthors omitted to provide data regarding preoperativeseton drainage in this group of patients. Van der Hagen andco-workers described the outcome of TAFR after preoper-ative seton drainage in 23 patients with a fistula ofcryptoglandular origin [5]. Five of these patients also hada diverting stoma. Although the healing rate was quite high(78%), no comparison was made with patients undergoingTAFR alone. Two other studies, conducted by Zimmermanet al. and by Van Koperen and co-workers indicate thatpreoperative seton drainage does not affect the outcome ofTAFR [6, 11].
The present series comprised 278 patients. Sixty-eight ofour patients underwent seton drainage prior to TAFR. Sincewe were not able to show any beneficial effect ofpreoperative seton drainage in this relatively large series,it seems unlikely that this type of preoperative treatmentprovides a useful tool to enhance the outcome of TAFR.However, a drawback of the present study is its retrospec-tive design. We have considered the possibility that thecomplexity of the fistula might have been a reason to allowpreoperative seton drainage. Reviewing the clinical charts,we found no specific reasons for seton placement. Bothcenters are tertiary referral centers, and the major part of thepatients was referred from smaller hospitals. A part of thesepatients were admitted to one of both centers with a seton insitu. Many surgeons are not confident with treating hightranssphincteric fistulas, and the policy of some of thesereferring surgeons is to place a seton to bide the time untildefinite treatment. Moreover, we analyzed the fistulacharacteristics. We found no differences in the baselinefistula and patients characteristics between patients withand without preoperative seton drainage. Patients admitted,to any of the centers, with a seton did not have a morecomplex fistulae. Moreover, clinical chart review revealed
Table 1 Comparison of baseline patients and fistula characteristicsbetween patients with and without preoperative seton drainage
Seton No seton
Internal opening Posterior 63% 70%
Anterior 29% 26%
Lateral 7% 4%
Horseshoe extension Yes 50% 47%
No 50% 53%
Prior attempts at repair Yes 59% 56%
No 41% 44%
Gender Ratio (M/F) 2:1 2:1
Age (range) 43 (21–69) 46 (19–73)
Body mass index 24 25
Smoking Yes 56% 52%
No 44% 48%
Table 2 Healing rates in patients with and without preoperative setondrainage
Leiden Rotterdam Both centers
Seton drainage 64% 69% 67%
No seton drainage 68% 62% 63%
Overall 66% 63% 64%
Int J Colorectal Dis (2010) 25:1499–1502 1501
MitalasLE,IntJColorectalDis2010
TranssphinctäreFisteln,nichtrandomisiert,N=278VerschlussmioelsMucosaflap/Fistulektomie
KeineVerbesserungderHeilungsratedurchpraeopera6veSeton-Drainage
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1. SetonbeiRückgangderSekre6onenYernen,SpontanheilungderFistelabwarten
2. Setonbelassenundopera6venFistelverschlussplanen
3. Setonregelmässignachspannen(cuZngSeton)
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Cu?ngSeton
15
Omeretal.S3LeitlinienkryptoglanduläreAnalfistelnRitchieetal.2009Vialetal.2010
HoheHeilungsraten über90%Inkon6nenzraten 12-25%S3Richtlinien:inakzeptabelhoheInkon6nenzrate
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Fall1–Verlauf
11.05.2017ReizloseäussereFistelöffnungmiteinliegendemFadenseton.DRUunauffällig,ohneIndura:onen.WenigSekre:on.TranssphinktäreAnalfistelbei6UhrSSL
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1. Plas6scherVerschlussmitMucosaflapoderInternusflap
2. AnalFistulaPlug3. FistelspaltungundLayopen4. FistelspaltungundprimäreRekonstruk6on5. LigaturdesintersphinctärenFisteltraktes
(LIFT)
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Fall1–OP04.07.2017
04.07.2017FistelverschlussmieelsLigaturdesintersphinktärenFisteltraktes(LIFT)
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Fall1–Kontrolle
27.09.2017
PerianalunauffälligeNarbe.DRUunauffälligmitkrägigemSphinkertonus.Anoskopie:vernarbteinnereFistelöffnung.Endosonographie:keineHinweiseaufRestkollek:onoderpersis:erendeFistel.
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Fall1_Evidenz
S3RichtlinieKryptoglanduläreAnalfisteln,Coloproctology2017
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21
Analfistel
EAS
Distal
Fistulotomie
Proximal
Seton
Sphincter-schonendeOpera:on
Plas:scherVerschluss AFPLIFT OTSC?VAAFT
Mind.6Wochen
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Fall2–Anamnese11.11.1661-jährigerPa:entProgredienteSchmerzenamSteissbeinesseiteinemJahr.3xtäglichIrfen.KeinBlutabgangabano,keineSekre:onvonPus.PerianalsowieimBereichderRimaanieinunauffälligerBefundohneIndura:onenDRU:harteResistenzaufHöhederLineadentatabei6UhrSSL.Anoskopie:kreisförmigeNarbemiteinerÖffnungohneEntleerungvonFlüssigkeit.Leichtblutend.Kolonoskopie:unauffällig,innereFistelöffnungbei6UhrSSL
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Fall2-MRI28.10.2016
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Fall2-MRI28.10.2016
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Fall2-MRI
MRIBecken:SinustraktvomAnalkanalausgehendbiszuzurSpitzedesOscoccygeumsmitentzündlichenVeränderungenentlangdesTraktesundderSpitzedesOscoccygis.BlindendenderSinusausgehendvonLineadentatabei6UhrSSLRichtungOscoccygeum
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1. An6bio6katherapie2. Biopsieentnahme3. DrainagenachperianalundSeton-Einlage4. ErweiterungderinnerenFistelöffnungund
Drainagenachendoanal5. PrimäreFistelspaltungundRekonstruk6on
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Fall2–OP
6.12.16Rektoskopie,endoanaleSonographie,Drainagenachperianal,Seton-EinlageundFisteldébridementundDrainage(EasyFlow)
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MRI20.1.17
TranssphinktäreT-förmigeAnalfistel(Parks-RoschkeIIB)mitprae-coccygealemAbszessundV.a.Osteomyeli:s
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1. An6bio6katherapieundAbwarten2. Debridement,Knochenbiopsien3. Fistelverschluss4. Drainageverbessern
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Fall2-OP
2.2.17IntersphinktäreFistelligatur(LIFT),par6elleFistulektomieAbszessdrainageprae-coccygeal,Knochenbiopsie
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Fall2-Osteomyeli:sMikrobiologieKulturaerob:S.lugdunensis,E.colianaerob:B.fragilisHistologieHautexzisatinnereFistelöffnung:keineepitheloidzelligenundeineriesenzelligenGranulome,keinemalignenVeränderungenBiopsieOscoccygis:ZeichenderchronischenOsteomyeli:s;keineGranulome
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Fall2-Osteomyeli:s 08.02.14 14.2.17 CRP 7 5 Leukocyten 5.3 5.6
VorschlagInfek6ologieAugmen:n3x2.2giv/dweitersolangewieKnochennochfreiliegendist.SobaldKnochen
• Avalox1x400mgpo/Tag• Dalacin3x600mgpo/Tag(i.e.Dalacin300mgKps.2-2-2)
Therapiedauer3Monate
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Fall2-Verlauf
4.4.17KeineSchmerzenmehr,auchseikeineWundsekre:on.DerStuhlgangistregelmässigundunproblema:sch.DieKon:nenzistgutunderhalten.àniveaugranuliertenochkleinfingerkuppengrosseWundeimBereichdesehemaligenAbszesses.DRU:unauffälligerBefundAnoskopie:reizloseNarbe.
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Fall2-Verlauf10.05.2017NachSis:erenderAn:biosewiederdiegleichenSchmerzenimSitzenimBereichdesSteissbeines.CRPvon2mg/l,normwer:genLeukozytenPerianalunauffälligerBefundmitreizlosverheilteräussererNarbeDRU:unauffällig,Vernarbungszonebei6UhrSSLAnoskopie:Vernarbungdorsal,jedochkeinAnhaltspunktfüreineinnereFistelöffnung.Endosonographie:unauffälligeVerhältnisse,keineFlüssigkeitskollek:on,keinHinweisaufeinFistelrezidiv.
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Fall2-MRI
DeutlicheRegredienzderOsteomyeli6s,deutlicheRegredienzdesT-förmigenFistelsystems,NachkraniallässtsichjedocheinT-förmiges,schmallumigesReswistel-SystemnachweisenimSinneeinernochnichtvollständigobliteriertenFistel.
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1. NochmalsAn6bio6ka2. UntersuchunginNarkose3. NochmaligeperianaleDrainage4. Abwarten
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Fall2-OP
30.05.17FistulektomieSeton-EinlageKnochenbiopsienoscoccygeum
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September17VermehrtFlüssigkeitinnerhalbdesT-förmigenFistelsystemsmitvermehrterKontrastmioelaufnahmeimSinneeinervermehrtenentzündlichenAk:vität.DiepostentzündlichenVeränderungenanderäusserstenSpitzedesOscoccygeumsindwenigerdeutlichausgeprägt.
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Fall2-Verlauf21.09.1730.05.2017SetondrainageSchmerzenbeimSitzenimBereichderäusserenFistelöffnungmitEntleerungvonwenigleichtputriderFlüssigkeit.DerStuhlgangunddieKon:nenzbereitenkeineProbleme.DerbeNarbeumdieäussereFistelöffnungetwasdruckdolentmiteinliegendemFadenseton.KeineDruckdolenzüberdemOscoccygeum.
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1. Plas6scherFistelverschlussmieelsFlap2. LIFT3. AFP4. Setonbelassen
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Fall2-OP
18.10.17FisteldébridementundVerschlussmitAnalFistulaPlug(CookBioA)
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Fall2-Verlauf8.12.17/10.1.18ReizloseNarbenverhältnisseLeichteSchmerzenbeimSitzenpersis:erend.WeitereKontrollegeplant.
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Fall324-jährigerPa:ent1. St.n.rezidivierendenAnalabszessenseit2007
St.n.Analfistelspaltung2/2011St.n.Analabszessen2011,1/2012und6/2012St.n.Seton-EinlagebeitranssphinctärerAnalfistelam13.10.2013
2. PsoriasisinversaTherapiemitHumira
Ileokolonoskopieunauffällig.
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Fall3
24.11.142.Fistelöffnungperianalrechtswahrscheinlichblindendend.
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Fall4
29.03.2016VorstellungmiterneutemgrossemAbszessmitSchwellungbisindenOberschenkelrechts
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Fall4
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1. AbszessabdeckelungperianalundGegeninzisionamOberschenkel,Seton-EinlageundDrainage
2. Abszessabdeckelungnurperianal3. AbszessabdeckelungnuramOberschenkel4. AbszessdrainageinsRektum
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Fall3-OP
SupralevatorischeperianaleFistelbei6UhrSSL• mitpararektalemAbszessbei6-9UhrSSL• FistulierungzumOberschenkelrechtssei:gEinlageSetoninFistelbei6UhrSSL,AbdeckelungAbszesspararektalundGegeninzisionamOberschenkel,EinlageDrainageinFistelzumOberschenkel
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Fall4
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1. VerschlussderAnalfistelmieelsPlug,SpaltenderOberschenkelfistel
2. VerschlussderAnalfistelmieelsPlugundDrainagederOberschenkelfistel
3. VerschlussderAnalfistelmieelsFlapundDrainagederOberschenkelfistel
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Fall4-OP
28.06.2016DrainagederFistelamOberschenkelmitSetonundVerschlussderanalenFistelmitAnalFistulaPlug
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Fall3-OP
16.09.2016Rezidiv-FistelmitRezidivAbszessperianalundentlangderOberschenkel-FistelErneuteDrainageundSeton-EinlagePerianal,par6elleFistulotomieimOberschenkelundgetrennterSeton.
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Fall3-OP
23.11.2016SpaltungdesdistalenTeilderFistelundAnlageeinesVAC-Verbandes
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Fall3-OP23.11.2016SpaltungdesdistalenTeilderFistelundAnlageeinesVAC-Verbandes27.02.2017FistelverschlussmitVerschiebelappen03.03.2017ErneuteDrainagebeiRezidiv18.04.2017FistelverschlussmieelsdirekterNaht,DrainagemitEasy-Flow
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Fall3
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1. Nochmalsplas6scherFistelverschluss2. Humiraabsetzen?3. Fistulotomieundprimäre
Sphinkterrekonstruk6on
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Fall3-OP
18.04.2017FistelverschlussmieelsdirekterNaht,DrainagemitEasy-Flow14.11.2017ErneutesRezidiv,erneuterFistelverschlussmieelsdirekterNaht
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Fall3-Evidenz
S3RichtlinieKryptoglanduläreAnalfisteln,Coloproctology2017