Perianal Fistula

Troublesome journey ?

Adianto Nugroho
adiyusuf97@gmail.com

i care wound care ii

 X

Y
PERIANAL FISTULA - abnormal connection b/w epithelialize surface or anal
canal and the perianal skin
• Internal opening : anorectal lumen (X)
• external opening : perianal skin (Y)
Goodsall’s rule
Clinical Presentation
 Examination

• Goals :
• Identification of primary and secondary openings
and the fistula tract itself

• Assessment of the complexity of fistula including

clinical classification and the thickness of sphincter
muscle involved.
 Park’s Classification
(according to the relationship of primary tract to the anal sphincters)

Intersphincteric (45%)
Simple low tract
High tract
High tract with rectal opening
Extra rectal extention
Trans-sphincteric (40%)
Uncomplicated
High tract
Suprasphincteric
Uncomplicated
High tract
Extrasphincteric
Secondary to trauma
Secondary to anorectal disease
Secondary to pelvic inflammation

Ref: The ASCRS textbook of colon and rectal surgery

By Bruce G. Wolff, James W. Fleshman, David E. Beck
 Diagnosis

• Examination under anesthesia - internal opening and abscess

• injection of H2O2 or povidone iodine or methylene blue
to visualized bubble at internal opening

• Endo-anal ultrasound
• Fistulography
• CT
• MRI - gold standard
Management
re
Fistulotomy 57
 Fistulotomy 57
9 Fistulotomy and Lay Open Technique

Early complications re
A randomised controlled
out marsupialisation from
onstrated reduced pethid
but not improved healin
obvious, that marsupia
smaller afterwards, and
They also found that ble
ference in pain or septic
faster healing with mars
compared to 10 weeks w
the Ho and Pescatori stud
benefit in terms of recurr
that incontinence was lo
The review did not consi

Recurrence and Inc

After Fistulotomy

Fig. 9.7 Marsupialisation involves suturing the skin to the edge of the Several studies have exa
fistula tract with absorbable sutures to reduce wound size case series and some as
other techniques. Linds
Fistulotomy

Fistulectomy
 Seton
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
 Advancement
Advancement Flaps Flap

Advancement Flaps
Endorectal
• Fistula tract probed
Endorectal
• Flap •raised
Fistula tract probed
• Flap raised
– Mucosa + Int. Sphincter
– Mucosa + Int. Sphincter
• Internal opening
• Internal opening
excised/closed
excised/closed
• Flap advanced & sutured
• Flap advanced & sutured
Fistula Plug
Intersphincteric
Ligation of Intersphincteric Fistula Tract
t
ncteric fistula
eton – 6 weeks

ared with fistula

elializes
 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
surgery
Underlying Disease
Table 22.1 Etiology of anal fistula
Cryptoglandular disease
Crohn’s disease
Prior anal surgery
Obstetrical injury
Atypical infections (tuberculosis, actinomycosis)
Radiation therapy
Malignancy
Trauma
#Case 1 August 2017

Fournier’s
Gangrene
#Case 1 November 2017

Recurrent Fistula

Fistulectomy
#Case 2
#Case 2
Post-operative (wound) care

• Perianal baths
• Analgesics for pain
• Stool bulking agents
• Good perianal hygiene
 Summary

Perianal Fistula

• (most of the time) easy diagnosis

• (relatively) easy surgery
But
• Wound healing takes time
• Recurrence is high