Fistula-in-Ano free pdf ebook was written by on April 22, 2004 consist of 3 page(s). The pdf file is provided by www.mssurg.net and available on pdfpedia since September 10, 2011.
fistula-in-ano: advancement flap repair
anal fistula: open tract between anorectum and..with history of anorectal abscess
other causes:
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congenital fistulas (spina bifida,sacrococcygeal teratoma,..supralevator abscess à high intersphincteric fistula
perineal trauma
ibd
tb
stds
malignancy
presentation: anal discharge preceded...
FISTULA-IN-ANO: ADVANCEMENT FLAP REPAIR
Anal fistula:
open tract between anorectum and perineum (vs. sinus)
Etiology: cryptoglandular
(uncomplicated fistula)
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(infected anal gland
à
intersphincteric abscess
à
rupture into anal canal
à
tract
left)
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50-70% with history of anorectal abscess
Other causes:
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congenital fistulas (spina bifida,sacrococcygeal teratoma, dermoid cyst)
pelvic sepsis (e.g. appendicitis, salpingitis, diverticulitis, IBD, pelvic neoplasm)
à
supralevator abscess
à
high intersphincteric fistula
perineal trauma
IBD
TB
STDs
malignancy
Presentation:
anal discharge preceded by pain, swelling, bleeding
Treatment
Simple, superficial fistula
à
fistulotomy
High fistula
à
Seton vs. advancement flap
Rectal advancement flap:
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Advantages
Low incidence of incontinence
Low recurrence rate
Less pain (no/small perineal wound)
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Technique:
-identify/cannulate fistula
-raise U-shaped mucosal flap
+/- fistulectomy, fibrin glue
-primary closure of internal os
-suture flap
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Historical Perspective:
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1902: Flap repair of traumatic rectovaginal fistula (Noble, Trans Am Gynecol soc
1902; 27: 363)
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1912: First advancement flap for fistula-in-ano (Elting AW, Ann Surg 1912; 56: 774-
52)
Current Experience:
Author
Aquilar et al (1985)
Wedell et al (1987)
Shemesh et al (1988)
Ozuner et al (1996)
Vs. Seton:
Author
Parks and Stitz (1976)
Ramanujam et al (1983)
Christensen et al (1984)
Pearl et al (1993)
n
68
45
21
116
Incontinence
17-39%
2%
62%
5%
Recurrence
NS
2%
0
3%
n
189
27
8
19
Recurrence
3
0
1
6
Flatus
Fecal
Incontinence Incontinence Soiling
13
0
0
3
0
NS
0
0
NS
NS
NS
NS
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Complications:
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Incontinence:
secondary to sphincter division: *consider patient age, baseline tone
inferior rectal nerve injury
Recurrence:
failure to identify internal os
failure to identify lateral &upward extensions
Bleeding, cellulitis, constipation/impaction, persistent sinus
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Anal Fistula and Crohn’s Disease
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10-56% incidence
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Dictum: surgery contraindicated in presence of active rectal disease
High incidence of incontinence (50%)
Poor/delayed healing
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Simple fistulas: good/acceptable results
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Complex/high fistulas: less optimistic
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(Makowiec et al;
Br J Surg
1995; 82: 602-606)
32 patients with Crohn’s, anal fistulas
à
36 advancement flap repairs
Primary failure = 4/36
Recurrence = 11/36
New fistula = 4/36
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