Fi t l é i l t it t Fi t l é i l t it t Fistules périanales, traitement Fistules périanales, traitement l l ffi ?l l ffi ?le plus efficace en 2012?le plus efficace en 2012?
F. F. RisRis, B. Roche, B. RocheInterdisziplinäre Viszerale und Medizin am Interdisziplinäre Viszerale und Medizin am
Inselspital 2012, UPDATE ProktologieInselspital 2012, UPDATE Proktologie
Inselspital Bern18thOctober 18 October 2012
1686 Incision of louis XIVFélix & BessièresFélix & Bessières
Inselspital 18th October 2012
Proctology Unit
ETIOLOGY
90% 9
primaryprimary
crypto‐glandularg
Inselspital 18th October 2012
Proctology Unit
10% secondary
Hydroadenitis, cebaceus adenitisFiFissurePilonidal CystInfectious disease: tbc STDInfectious disease: tbc, STDCarcinoma: anal, rectum, leukemiaPost radiotherapyPost radiotherapyDebilitating illnesses (leukemia, diabetes, AIDS)
Crohn’s disease, HRCIatrogenic: injections, hemorroidectomy, sclerotherapy, prostatectomy
Trauma: foreign body, penetrating wounds, obstetrical tears
Inselspital 18th October 2012
Proctology Unit
tears
Perianal abscessP i f h fi l ?Primum movens of the fistula?
Inselspital 18th October 2012
Proctology Unit
Different Abcess localisationDifferent Abcess localisation
Inselspital 18th October 2012
Proctology Unit
Therapeutic optionsTherapeutic options
Simple drainage Local anaesthesia
Drainage curettage and seton General anaesthesia General anaesthesiaDrainage + fistula track treatment
Inselspital 18th October 2012
Proctology Unit
Initial managmentLitt t
Initial managmentLitterature: Randomised trial incision (I) versus fistulotomy (F)
Y Patients Recurrence% Incontinence%I FI F
Hebjorn et al 1984 18 20 I = F I < FOliver et al 2003 100 100 I (29) > F (5) I (2.8) < F (36.7)Schouten et al 199734 36 I (40 6) > F (2 9) I (21 4) < F (39 4)Schouten et al 199734 36 I (40.6) > F (2.9) I (21.4) < F (39.4)Seow-Choen 1997 24 21 I (12 ) > F (0) --------------
I = IncisionF= Fistulectomy
Inselspital 18th October 2012
Proctology Unit
y
Simple drainage or d i & fi t ldrainage & fistulatrack treatmenttrack treatment in anorectal abscess?o ec bscess?
Inselspital 18th October 2012
Proctology Unit
Simple drainage or d i & fi t ldrainage & fistulatrack treatmenttrack treatmentin anorectal abscess?o ec bscess?
Inselspital 18th October 2012
Proctology Unit
Natural history of the fistulaNatural history of the fistula
20% will close the fistula tract
Putting a Seton initialy will prevent this g y pnatural healing process
Inselspital 18th October 2012
Proctology Unit
Initial Surgical managmentInitial Surgical managment
Seton drainage, for up to 3-6 months
After healing of the abcess cavity, in case of residual fistula
Prevent reccurence of the abcess
Inselspital 18th October 2012
Proctology Unit
Initial Surgical managmentInitial Surgical managment
Prolène 4-0 is good, 2 stiches
Inselspital 18th October 2012
Proctology Unit
Initial Surgical managmentInitial Surgical managment
Inselspital 18th October 2012
Proctology Unit
Fistula : Goals for the surgeon•Fistula : Goals for the surgeon
Define the exact anatomy of the fistulous tract
• Drain any associated sepsis
E di t ll th fi t l t t• Eradicate all the fistulous tract
• Prevent recurrence• Prevent recurrence
• Maintain sphincter function and continence Maintain sphincter function and continence
• Minimize healing time
Inselspital 18th October 2012
Proctology Unit
g
Fistula : Goals for the surgeon•Fistula : Goals for the surgeon
Inselspital 18th October 2012
Proctology Unit
Current surgical managmentCurrent surgical managment
Fistulectomy (low, distal fistula)
Fistulectomy and mucosal flap
Occlusion techniqueOcclusion techniquePlug (porcine collagen)GGlue
Inselspital 18th October 2012
Proctology Unit
Alternative surgical managmentAlternative surgical managment
Cutting setton (40 60% risk of incontinence)Cutting setton (40-60% risk of incontinence)Van Tests. BLS 1995;82:895-7Hämäläinen KP. Dis Col Rect 1997;40:1443-7
Transsphincteric fistulectomy and sphincter
Garcia-Aguilar J. BJS 1998;85:243-5
Transsphincteric fistulectomy and sphincter reconstruction (>30% incontinence)( )
Both avoided because of fecal incontinence
Inselspital 18th October 2012
Proctology Unit
Fistulectomy:
Fistulectomy
Inselspital 18th October 2012
Proctology Unit
y
Fistulectomy
Anodermicreconstruction
Complete excision of i ifi
Inselspital 18th October 2012
Proctology Unit
primary orifice
Fistulectomy: results
464 fistulectomies464 fistulectomies24 recurrences (5.2%)ecu e ces (5 %)
No incontinence
Inselspital 18th October 2012
Proctology Unit
Sphincter preservingSphincter preservingSphincter preserving Sphincter preserving complex fistula complex fistula co p e stu aco p e stu a
treatment treatment
Inselspital 18th October 2012
Proctology Unit
Sphincter preserving fistula treatment Sphincter preserving fistula treatment
DifficultDifficult andand highhigh raterate ofof complicationscomplications suchsuchDifficultDifficult andand highhigh raterate ofof complicationscomplications suchsuchasas analanal incontinenceincontinence
treatment options:treatment options:
Mucosal flapMucosal flap
New sphincter preserving treatments :New sphincter preserving treatments :
Plugs, LIFT, VAAFT OVESCO, etc
Inselspital 18th October 2012
Proctology Unit
Mucosal flapFistulectomyInselspital 18th October 2012
Proctology Unit
Mucosal flapFistulectomy
Preoperative carePreoperative care
M l fl t h iMucosal flap technique:
Antibiotic prophylaxis
No Enema
No Epilationp
No StomaInselspital 18th October 2012
Proctology Unit
No Stoma
C t i di ti t flC t i di ti t flContraindications to flaps:Contraindications to flaps:
Acute inflammationAcute inflammationExtensive suture line tensionAnastomosis in diseased tissue
radiation fistularadiation fistulaneoplastic fistulapactive Crohn’s disease
Inselspital 18th October 2012
Proctology Unit
Inselspital 18th October 2012
Proctology Unit
Postoperative care:
Shower 3-6 times dailyNSAID drugsNSAID drugsCream in the external woundBulk forming agent or oil 1 xBulk forming agent or oil 1 x dailyClose FU (Weekly inspection)
Inselspital 18th October 2012
Proctology Unit
Advantages of the flap procedure:
No sphincter divisionpNo keyhole deformityL i d id h liLess pain and rapid healingMay repeat in case of recurrencesMay repeat in case of recurrences
Inselspital 18th October 2012
Proctology Unit
Geneva Results:Geneva Results:
136 consecutive cases136 consecutive cases82 men54 women
Age 28 - 78 y M = 44.6 y
Inselspital 18th October 2012
Proctology Unit
Inpatient /outpatient ratiop p
Inpatient 97 (71.3%)
O t ti t 39 (28 7%)Outpatient 39 (28.7%)
Inselspital 18th October 2012
Proctology Unit
Success ratePrimary success (1 month)
97 (71.3%)S (Secondary success (delayed or minor op) 17 (12.5%)p) ( )
Recurrences at 1 year follow upRecurrences at 1 year follow up22 (122 (166..22%) out of 136 %) out of 136 flapsflaps
83 8% f83 8% fInselspital 18th October 2012
Proctology Unit
83.8% of success83.8% of success
Hospital stay
Postoperative stay 4.1 d
p y
Postoperative stay 4.1 dWound healing delay 32.8 d (12-g y (63)
1 suture leakNo septic complications
Inselspital 18th October 2012
Proctology Unit
continence
No liquid nor solid stool incontinenceNo liquid nor solid stool incontinence1 faecal soiling1 faecal soiling3 gas incontinence3 gas incontinence1 sphincter rigidity (11 operations)1 sphincter rigidity (11 operations)
Inselspital 18th October 2012
Proctology Unit
The mucosal flap in the treatment ofThe mucosal flap in the treatment of complex anal fistulae allows:
Elimination of inflammatory tissue Sphincter preservationLocoregional anesthesiaOutpatients
Inselspital 18th October 2012
Proctology Unit
New Surgical managmentNew Surgical managment Plugs?Plugs?
Lif d ?Lift procedure?
VAAFT?
OVESCO clipOVESCO clip
St llInselspital 18th October 2012
Proctology Unit
Stem cells
Plug technique:Plug technique:
f f f
Plug technique:Plug technique:
Identification of the fistula tract with setonTract is washed and brushedPlug is pulled out from the primary orifice
Inselspital 18th October 2012
Proctology Unit
Pl t h iPl t h iPlug techniquePlug technique::
Endo anal fixationEndo anal fixation
Inselspital 18th October 2012
Proctology Unit
From April 2007 to February 2008
16 patients: 12 male 4 femaleComplex crypto glandular fistulaSeton drainage 3 months before the operationSeton drainage 3 months before the operation
Results!!!!
Inselspital 18th October 2012
Proctology Unit
Inselspital 18th October 2012
Proctology Unit
R lResults
15 recurrences (93.7%)
Three month success rate 6.3%
No incontinenceNo incontinence
Inselspital 18th October 2012
Proctology Unit
Author Date Journal Success Rate Number patientsAuthor Date Journal Success Rate Number patientsFollow-up time
Champagne BJ 2006 Dec Dis Colon 83% n = 46Champagne, BJ, et al
2006, Dec. Dis. Colon Rectum
83% n = 46F/U = 6 – 24 momed = 12 mo
Van Koperen, PJ, et al
2007, Dec. Dis. Colon Rectum
41% n = 17F/U = 3 – 9 momed = 7mo
Scwandner, O, et al
2008, Mar. Int. J Colorectal Dis.
45.5% n = 19F/U = 9 mo
Ky AJ et al 2008 Mar 11 Dis Colon 54 6% n = 45Ky, AJ, et al 2008, Mar. 11 Dis Colon Rectum
54.6% n = 45F/U = 3 – 13 mo med = 6.5 mo
24%Lawes, DA et al 2008, Mar. 29 World J Surg 24% n = 17F/U = 7.4 mo
24%
Inselspital 18th October 2012
Proctology Unit
Cryptoglandular single tract high TSCryptoglandular, single tract, high TS32 patients received the treatmentpSuccess rate: Plug 3/15Plug 3/15Flap 14/16
Early closure of the study
Inselspital 18th October 2012
Proctology Unit
p
medium and high TS Cryptoglandular tractmedium and high TS Cryptoglandular tract,60 patients received the treatmentSuccess rate: Plug 29%Plug 29%Flap 48%
Inselspital 18th October 2012
Proctology UnitVan koperen BJS 2011
Variables predicting failuresVariables predicting failures
SmockingDiabetesDiabetesShort fistula tract <4 cmHigh transphinctericPosterior fistulaPosterior fistulaPrevious plug failure
Inselspital 18th October 2012
Proctology Unit
New plugsNew plugs
Inselspital 18th October 2012
Proctology Unit
New Gore plugsNew Gore plugs
Author journal N Success rate
Ratto Colorectal disease2012
11 8/11
Favreau‐Weltzer Colorectal disease2012
9 1/9
De la Portilla DCR 2011 19 3/19
Buchberg Am Surg 2010 10 6/10
total 49 18/49 (37%)
Inselspital 18th October 2012
Proctology Unit
The chinese plugThe chinese plug
100% success rate
Sang WL et al, W J Gastroenterology 2008
Inselspital 18th October 2012
Proctology Unit
Conclusion PLUG:Conclusion PLUG:
Easy to perform but:
Plug price 800 CHF
High recurrences rateHigh recurrences rate
3rd operation, most of the time more difficult.
Inselspital 18th October 2012
Proctology Unit
LIFT procedurep
LIFT
Ligation of Inter‐sphincteric Fistula Tract
Described by Rojanasankul in 2007Success rates of > 94%No deterioration in continence
Inselspital 18th October 2012
Proctology Unit
LIFT procedurep
Inselspital 18th October 2012
Proctology Unit
Tract probed and circumanal incision
LIFT procedurep
Inselspital 18th October 2012
Proctology UnitComplete dissection of tract
LIFT procedurep
Inselspital 18th October 2012
Proctology UnitTract suture ligated and divided
LIFT procedurep
Inselspital 18th October 2012
Proctology UnitLIFT wound closed
LIFT procedurepAuthors Year Country N Success Rate (%) Continence Follow Up
(weeks)
Rojanasakul et al 2007 Thailand 18 17 (94) “normal” not formally
d
Max 26
assessed
Shanwani et al 2010 Malaysia 45 37 (82) Not formallyassessed
36 assessed
Bleier et al 2010 USA 35 20 (57) No FINot formally
20(90% F/U)y
assessed(9 / )
Aboulian et al 2011 USA 26 17 (68) Not assessed 27 7 7
Ellis (BioLIFT)
2010 USA 31 29 (94) Not formally assessed
29 patients for 12 months
Inselspital 18th October 2012
Proctology UnitAbcarianAm 2012 USA 40 29(74) Not formally
assessed12
LIFT is it a new technique?qGoligher (Leeds 1967)g ( 9 7)Excision of internal sphincter at fistula site for drainage and access to fistulotomyand access to fistulotomyHealing 25/25Incontinence: flatus 8, liquid 4,solids 7
Matos (ST Mark’s, 1993)Matos (ST Mark s, 1993)Intersphincteric approach for fistulectomy and closure of the internal sphincter from withinof the internal sphincter from withinHealing 7/13
Inselspital 18th October 2012
Proctology UnitIncontinence :flatus 3, liquid 1,solids 0
LIFT procedurep
The LIFT procedure is simple, safe and effective
The LIFT procedure has no reported adverse ffeffects on continence
“Failures” at LIFT can be transformed to “secondary closures” (transphincteric fistula into secondary closures (transphincteric fistula into low inter‐sphincteric fistulae amendable to fistulotomy)
Inselspital 18th October 2012
Proctology Unit
fistulotomy)
Video‐assisted anal fistulaVideo assisted anal fistulatreatment (VAAFT)( )
a novel sphincter‐saving procedure to repaircomplex anal fistulas, rigid fistuloscopy
Inselspital 18th October 2012
Proctology Unit
Video‐assisted anal fistulaVideo assisted anal fistulatreatment (VAAFT)( )
Identification and liftingIdentification and lifting of the internal opening
Inselspital 18th October 2012
Proctology Unit
Video‐assisted anal fistulaVideo assisted anal fistulatreatment (VAAFT)( )
Cleaning of the tract byCleaning of the tract by fulguration, brushing and washingwashing
Inselspital 18th October 2012
Proctology Unit
Video‐assisted anal fistulaVideo assisted anal fistulatreatment (VAAFT)( )
Closure of the internal opening with a stapler or a flapClosure of the internal opening with a stapler or a flap
+ injection of cyanoacrylate glue below the stapple line!
Inselspital 18th October 2012
Proctology Unit
+ injection of cyanoacrylate glue below the stapple line!
Video‐assisted anal fistulaVideo assisted anal fistulatreatment (VAAFT)( )
From May 2006 to May 2011y y136 patients using VAAFT. 98 patients were followed up for a minimum of 698 patients were followed up for a minimum of 6 months. No major complications P i h li i 72 ti t (73 5%) t 2 3Primary healing in 72 patients (73.5%) at 2–3 months. followed up >1 year for 62 patients, among them87 1% healed
Inselspital 18th October 2012
Proctology Unit
87.1% healed
Video‐assisted anal fistulaVideo assisted anal fistulatreatment (VAAFT)( )
Sound principlep p
Cost? (equipment and staplers)Cost? (equipment and staplers)
L k f id ( h )Lack of evidence (one man show)
Inselspital 18th October 2012
Proctology Unit
Stem cellsStem cells
f f fInjection of stem cells in the fistula tract afterclosure of the internal openingp g
Healing at 8 weeks Healing at one year Healing at end of FU 38 months38 months
Fibrin glue 3/25(12%) 3/25(12%) 2/25(8%)
Fibrin glue + ASCs 17/24(71%) 15/24(63%) 7/21(33%)
Garcia-Olmo et al, Exp Op. Biol Ther, 2008Guadelajara et al Int J Colorectal disease 2012
Inselspital 18th October 2012
Proctology Unit
Guadelajara et al, Int J Colorectal disease 2012
Mesenchymal Stem cellsMesenchymal Stem cells
fIntraveinous injection of mesenchymal stem cells2x 1 week apart, Crohn’s, clinical response at 6 p , , pweeksResponse in 3 patients /9Response in 3 patients /9
Duijvestein M et al, GUT 2010
10 crohn’s patients intra and perifistular injection of MSCs median 4x1x/4 weeksof MSCs median 4x1x/4 weeksFU 1 year
/ / f ?Inselspital 18th October 2012
Proctology Unit
Response in 7/10, partial 3/10 role of Treg?Ciccocioppo et al, GUT 2011
Mesenchymal Stem cellsMesenchymal Stem cells
CConclusion:
Poor results so far,
MSCs in Crohn could be interesting but veryli ipreliminary
Inselspital 18th October 2012
Proctology Unit
Ovesco clipOvesco clip
Inselspital 18th October 2012
Proctology Unit
Prosst et al, Minimally Invasive Therapy. 2012;21:307–312
Ovesco clipO esco c p
Inselspital 18th October 2012
Proctology Unit
Ovesco clipO esco c p
Inselspital 18th October 2012
Proctology Unit
ConclusionsConclusions
Simple drainage of abscessSimple drainage of abscess
Si l t t t f di t l fi t lSimple treatment for distal fistulas (fistulectomy)(fistulectomy)
Inselspital 18th October 2012
Proctology Unit
ConclusionsConclusions
Mucosal flap remains the gold standard in 2012in 2012
Plugs fails in > 50%, 93% in our hands
Inselspital 18th October 2012
Proctology Unit
ConclusionsConclusions
LIFT b f lLIFT maybe useful
Stem cells very preliminaryy p y
OVESCO?OVESCO?
Inselspital 18th October 2012
Proctology Unit
G U i it H it lG U i it H it l
GG C i P t lC i P t l
Geneva University HospitalGeneva University Hospital
Geneva Geneva Course in ProctologyCourse in Proctology44 -- 7 7 February February 20132013yy
Post Post Graduate Training Graduate Training daydaygg yyConstipationConstipation
FebruaryFebruary 88thth 20132013February February 88thth 20132013Inscription :Inscription :ppTél.: + 41 22 372 79 34 Fax:+ 41 22 372 79 09 Tél.: + 41 22 372 79 34 Fax:+ 41 22 372 79 09 [email protected] [email protected] www.proctology.ch
Inselspital 18th October 2012
Proctology Unit