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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_636_Библиотеки_им_академика_М_И_Перельмана.pdf
202
G. A. Santoro and M. A. Abbas
morbidity associated with any intervention,
failure rate of various surgical options, and
long-term consequences to the patient. Simple
procedures should be attempted rst before
more complex procedures are considered. Due
to the low incidence of this condition, few
centers worldwide have accumulated enough
experience with ileal-pouch stula management. Early referral to such centers is
advisable.
Introduction
• Anal stula may be termed “complex” when
one or more of the following ndings are
present:
– The tract crosses more than 30% of the
external anal sphincter (high transsphincteric with or without a high blind tract,
suprasphincteric, and extrasphincteric).
– Horseshoe conguration.
– Anterior location in a female.
– Multiple tracts, recurrent.
– In the setting of Crohn’s disease.
– Prior radiotherapy.
– Baseline incontinence.
– Rectovaginal stula, rectourethral stula,
anastomotic stula following colorectal
surgery, post-traumatic stula, and malig-
nant stula.
• Rectovaginal stula and Crohn’s-related stula are not covered in this chapter but dealt
with in other parts of this textbook.
Complex or Recurrent Cryptoglandular Fistulas
Clinical Assessment andDiagnostic
Evaluation
• The history should include the type of prior
anal operations, obstetrical history in females,
the presence of gastrointestinal disorders such
as inammatory bowel disease, medical
comorbidities such as diabetes, prior radiation
therapy to the pelvis, current smoking status,
and inquiry about the patient’s bowel habits
using a validated score such as the Cleveland
Clinic Florida Fecal Incontinence score (CCFFIS) grading system (Fig. 15.1).
• Physical examination can be helpful in delineating the stula anatomy and reaches a very
good accuracy in identifying supercial
(100%) and transsphincteric (100%) tracts,
but it appears inadequate for supralevator
(63.6%) and intersphincteric (33.3%) tracts.
• Considering the limitation of physical examination, it may perform imaging procedures
(two- and three-dimensional endoanal ultrasound (2D and 3D EAUS), pelvic MRI, CT
scan, and stulography).
– Information on the anatomy of the stula,
including the primary tract, internal opening,
horseshoe extension, secondary cavities or
extensions, and associated sphincter lesions.
– Clear delineation of the stula anatomy to
guide operative intervention can be helpful
for surgical planning and may impact surgical outcome.
– The difculty in comparing these modali-
ties is related to the ability to dene a true
reference standard for stula-in-ano due to
the following potential sources of bias.
• In addition to imaging, baseline assessment of
sphincter function with anorectal manometry
can be helpful in select patients (Fig.15.2a, b).
Denition, Classication,
andPathophysiology
• The aim of anal stula treatment is to eradicate the stulous tract, prevent recurrence,
minimize postoperative septic complications,
and minimally impact anal continence.
Surgical Treatment
• The goal to eradicate the stula should be balanced with the aim to preserve as much of the
sphincter integrity to avoid impairment of
continence.
15 Complex Anorectal Fistulas
203
Fig. 15.1 Cleveland
Clinic Florida Fecal
Incontinence Score
(CCF-FIS). Scale:
0,complete continence;
20,complete
incontinence
Fig. 15.2 (a) Low-compliance
water perfusion anorectal
manometry system. (b) Anorectal
manometry catheter
Type of
incontinence
Solid 0
Liquid
Gas
Wears
pad
Lifestyle
alteration
Never Rarely Sometimes Usually Always
<1/mo
1
0
0
0
0
1
1
1
1
<1/week
>1/month
2
2
2
2
2
<1/day
>1/week
3
3
3
3
3
a
>1/day
4
4
4
4
4
b
204
INITIAL CLINICAL
ASSESSMENT
• History
• Physical exam
• Anoscopy
• Proctosigmoidoscopy
• Consider colonoscopy if indicated
G. A. Santoro and M. A. Abbas
SECONDARY ASSESSMENT
• Anal ultrasound (initial modality)
• Pelvic MRI
• Pelvic CT
• Fistulography
CONDITION SPECIFIC
ASSESSMENT AND
MANAGEMENT
(refer to appropriate section)
• Malignant fistula
• Crohn’s disease
• Rectovaginal fistula
• Rectourethral fistula
• Postoperative fistula
SIMPLE FISTULA
COMPLEX FISTULA
• High transsphincteric
• Suprasphincteric
• Extrasphincteric
• Secondary tracts
• Horseshoe extension
• Sphincter damage
• Fecal incontinence
• Anterior in female
• Recurrent
Non-cutting
seton
• Fistulotomy ± sphincter reconstruction
• LIFT procedure
• Advancement flap
(endorectal/anocutaneous)
• LIFT procedure
• Fistulotomy + sphincter
reconstruction
• Anal fistula plug or fibrin glue
• Cutting seton
Healed
Unhealed
Complex
Fistula
Reassess
Fig. 15.3 Carepath for evaluation and treatment of complex anal stula secondary to cryptoglandular disease
• Figure 15.3 provides a comprehensive carepath for a structured approach to guide the
care of patients with anorectal stula.
Seton
• Seton is an important treatment option that
can provide temporary control of stula symptoms or can serve as a denitive intervention
to control or eradicate a chronic stula.
– A variety of materials including suture
material (Ethibond, silk, nylon, polypropylene, suture size #2.0 to #2, depending
on the tract width), vascular vessel loop,
Penrose drain, rubber band, cable tie, and
chemically impregnated material.
– A draining seton is tied loosely around a
stulous tract to promote drainage, to minimize acute abscess formation, and to allow
for scarring of the stulous tract (Figs.15.4
and 15.5).
• Permanent solution
• Temporary measure as the patient awaits
additional denitive stula surgery (12
or more weeks)
Fig. 15.4 Draining setons in a patient with multiple complex anorectal stulas and prior radiation therapy to the
pelvis
Simple
Fistula
ab
15 Complex Anorectal Fistulas
205
– A cutting seton is the second type of seton
(Fig.15.6a).
• The patient gradually pulls the seton
through the muscular portion of the tract
(Fig.15.6b).
• Progressive cutting by the seton produces
a slow stulotomy, which allows for
scarring of the divided tract minimizing
wide separation of the divided muscle.
• An alternative variation of the cutting
seton is the multiple seton technique,
and at various time intervals, each suture
is tightened progressively after taking
out the previously tightened suture
which becomes loose.
Fig. 15.5 Draining setons in a patient with long-standing
history of multiple stulas emanating from different internal openings in all four anal quadrants
Anal Flap
• The endorectal advancement ap is our preferred method to treat most complex anal
stula secondary to cryptoglandular disease, except for posterior-based horseshoe
stula.
• There are two types of anal aps: transanal
endorectal advancement ap and anocutaneous ap.
• Usually a non-cutting draining seton is placed
for 12 or more weeks to allow for brosis of
the stulous tract.
1. The tract is irrigated with hydrogen peroxide,
and the tract is traced with a stula probe.
2. The planned ap is outlined and inltrated
with 1% lidocaine with 1:100,000 epinephrine
for hemostasis (Fig.15.7a, b).
3. The subcutaneous portion of the external
opening is excised, and the stula is debrided
with a curette (Fig.15.7c).
4. A curvilinear incision is made approximately
1cm distal to the internal opening, and a partial- or full-thickness broad-based (3–4-cmwide) endorectal ap is raised (Fig.15.7d).
5. It is important to avoid a mucosa-only based
ap as it is associated with a higher failure
rate due to ischemia.
6. Once the ap is raised, the intramuscular
portion of the internal opening is closed with
interrupted 3-0 Vicryl suture (Fig.15.7e).
Fig. 15.6 (a) Cutting seton in a patient with suprasphinc-
teric stula. The skin and subcutaneous portion of the
tract are divided before tightening the seton. (b) The
cutting seton is connected to a Penrose drain to allow the
patient to gradually pull through the stula
206
m
ab
cd
ef
Fig. 15.7 (a–f)
Technical steps of
endorectal advancement
ap
1 cm
G. A. Santoro and M. A. Abbas
Fistula
tract
15 Complex Anorectal Fistulas
207
7. The distal portion of the ap containing the
mucosal portion of the internal opening is
trimmed.
8. The ap is matured over its muscular bed
using 3-0 Vicryl single interrupted sutures
(Fig.15.7f).
9. Upon completion of the ap, an antibioticimpregnated gelfoam is placed inside the anal
canal.
Ligation oftheIntersphincteric
Fistula Tract
1. Described in 2007 by Rojanasakul and colleagues from Thailand (Videos 15.1, 15.2,
15.3, 15.4, 15.5, 15.6, 15.7, and 15.8).
2. Division and ligation of the stulous tract in
the intersphincteric plane.
3. Suprasphincteric and horseshoe stulas can
pose technical challenges and in general are
not suitable candidates for the LIFT
procedure.
4. Wet stulas with copious drainage and those
associated with a cavity can benet from a
draining seton prior to the LIFT procedure.
5. Procedure:
• A metallic probe is inserted into the exter-
nal opening and passed gently through the
tract to exit through the internal opening
(Fig.15.8a, b).
• The intersphincteric groove is identied
externally, and a small circumanal skin
incision overlying the stula is performed
to enter the intersphincteric space between
the internal and the external sphincter
muscles.
• The dissection in the intersphincteric plane
is continued until the stulous tract is
reached and encircled (Fig.15.8c).
• The stula tract is then encircled by using a
right-angle clamp, and two absorbable
sutures (2-0 Vicryl) are used to ligate the
stula tract medially and laterally leaving a
space in between to sharply divide the stula (Fig.15.8d).
• Care is taken not to dislodge the tied
sutures (Fig.15.8e).
• The intersphincteric plane is closed in two
layers (muscle approximation and the skin)
by using single interrupted 3-0 Vicryl
(Fig.15.8f).
• Both the internal and external openings are
left opened to allow drainage.
6. Variations to the conventional LIFT procedure:
• BioLIFT procedure: a bioprosthetic porcine graft interposed between the internal
and external sphincter muscles to overlap
1–2cm area of the ligated and divided stulous tract.
• LIFT-PLUS procedure which adds a partial
stulectomy of the subcutaneous portion
of the tract from the skin to the external
sphincter muscle.
• LIFT procedure combined with endorectal
advancement ap.
Fistulotomy withSphincter
Reconstruction
1. Fistulotomy with sphincter reconstruction is a
suitable technique for complex or recurrent
stulas in incontinent patients or in patients
who are at risk for incontinence.
2. Procedure:
• If a draining seton has been previously
placed, it is removed, and a stula probe is
introduced through the external opening
and guided through the tract until it
protrudes out of the internal opening
(Fig.15.9a).
• The stula tract is completely divided
using electrocautery (Fig.15.9b).
• Curettage of the tract and any associated
cavities is performed to ensure that all
granulation tissue is debrided.
• Excision of the brous tract can be per-
formed taking care not to excise any muscle, or alternatively the brous tract is left
in situ.
• An end-to-end primary sphincteroplasty is
performed using a series of horizontal mattress sutures using 2-0 Vicryl or PDS
sutures (Fig.15.9c).
208
ab
cd
ef
G. A. Santoro and M. A. Abbas
Fig. 15.8 (a–f) Intraoperative demonstration of the LIFT procedure
• The stula bed of the divided stulous tract
is incorporated in the suturing to completely
obliterate any potential space behind the
muscle reconstruction.
• The edges of the open wound are nally
marsupialized by tacking the divided
mucosal and submucosal layer to the muscle repair (Fig. 15.9d) keeping the most
supercial aspect of the wound open to
allow for drainage.
Anal Fistula Plug
1. The anal stula plug is used to close the primary internal opening and serves as a matrix
for the obliteration of the stulous tract.
2. Procedure:
• The tract is traversed with a stula probe
and then curetted.
• A 2-0 silk suture is tied to the tapered end
of the plug and then pulled through the
internal opening using the stula probe
ab
15 Complex Anorectal Fistulas
c d
209
Fig. 15.9 (a–d) Technical steps of stulotomy with sphincter reconstruction
until it is snug inside the stula tract
(Fig.15.10a, b).
• The excess end of the plug is trimmed
inside the anal canal side using scissors
(Fig.15.10c).
• The trimmed portion of the plug is xed to
the internal opening and internal anal
sphincter muscle using 3-0 Vicryl suture
(Fig.15.10d).
• The mucosal/submucosal opening at the
internal stula opening is approximated
with the same suture.
• The external opening of the stula is left
open to drain after trimming the tapered
end of the plug (Fig.15.10e).
Fibrin Glue
• Fibrin glue (Tisseel®, Baxter, Deereld,
Illinois, USA) and synthetic glue (cyanoacrylate glue, Glubran® 2, GEM SRL,
Viareggio, Italy) are injectable products that
can be used in the treatment of anorectal
stulas.
• They act as tissue sealants and are believed to
stimulate the growth of broblasts and
pluripotent endothelial cells into the stulous
tract.
• This physiologic response triggers collagen
deposition and wound healing. Fibrin glue treatment is simple and repeatable and may be a good
initial option in patients with high stulas.
210
a b
G. A. Santoro and M. A. Abbas
c
d
e
Fig. 15.10 (a–d) Intraoperative demonstration of the
anal stula plug (Surgisis
with high transsphincteric stula. (e) Anatomical view of
®
AFP) procedure in a patient
• Associated with an overall low success rate.
• The procedure starts by identifying the external stula opening, followed by the curettage
of the stula tract. Approximately 5 ml of
reconstituted brin glue is injected through
the external opening (Fig. 15.11a) until it
extrudes from the internal opening area
(Fig.15.11b). The internal opening is closed
with 3-0 Vicryl suture.
obliterated stula tract following placement of anal stula
plug (Surgisis
®
AFP)
Newer andEvolving Technologies:
VAAFT, FiLaC™, andStem Cell
1. New technologies:
• Video-assisted anal stula treatment
(VAAFT)
• Fistula laser closure (FiLaC™)
• Stem cell therapy
2. At this stage of development, it is premature
to tell what long-term roles these evolving
ab
15 Complex Anorectal Fistulas
211
technologies will play in the eld of anorectal
stula surgery.
3. The video-assisted anal stula treatment
(VAAFT):
• The kit includes a rigid stuloscope (Karl
Storz, Tuttlingen, Germany) (Fig. 15.12),
an obturator, a unipolar electrical diathermy
probe, an endobrush, an endoscopic grasper,
and a synthetic cyanoacrylate glue.
• The stuloscope video equipment is an
8-degree angled endoscope with an optical
working channel to introduce the instruments and an irrigation channel.
• In the diagnostic phase, the stuloscope is
inserted through the external opening and
advanced by the irrigation of the glycinemannitol 1% which expands the stula tract.
• Primary and secondary openings and tracts
are explored via the stuloscope.
• During the operative phase, the aim is to
destroy the stula tract from the inside by
curetting the tract, obliterating it, and closing the internal opening.
• Through the working channel of the stuloscope, the stula tract is cauterized, and
necrotic material is removed using an
endobrush and irrigation.
• Finally, the internal opening is closed by
either suturing or stapling with a linear or
semicircular stapler or alternatively by
advancing an anal ap.
• The stula laser closure is a novel sphinctersaving technique that uses a radially emitting
laser probe [FiLaC™, Biolitec, Germany] to
destroy the stula epithelium and simultaneously obliterate the remaining stula tract.
• FiLaC™ eliminates stula epithelium and
granulation tissue in a circular manner causing shrinkage and obliteration of the tract.
– The stula tract is debrided with a curette,
and a plastic hollow 14 French catheter is
inserted using a guidewire.
Fig. 15.11 (a) Fibrin glue injection of a high transsphincteric stula through the external stulous opening. (b) Fistula
tract sealed with the brin glue. Note the brin glue extruding from the internal opening inside the anal canal
Fig. 15.12 Anal
stuloscope (Karl Storz,
Tuttlingen, Germany)