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Presented and e dite by :Dr. Hashem Fakhre Yaseri 22Jul.2019

Part2. Surgical , Endoscopic, and Future Therapies. Presented and e dite by :Dr. Hashem Fakhre Yaseri 22Jul.2019.

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Presented and e dite by :Dr. Hashem Fakhre Yaseri 22Jul.2019

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  1. Part2 Surgical, Endoscopic, and Future Therapies Presented and edite by :Dr. HashemFakhreYaseri 22Jul.2019

  2. Perianal Fistulas in Patients With Crohn’s Disease, Part 2: Surgical, Endoscopic, and Future TherapiesStephanie L. Gold,Shirley Cohen-Mekelburg,Yecheskel Schneider and Adam Steinlauf Gastroenterology & Hepatology Septem.218;14(9)

  3. Perianal Fistulas in Patients With Crohn’sDisease (PFCD) • PFCDaffect an average of 5% - 40% of patients with CD • More common in patients who have a higher severity of inflammationof the colon and rectum • Treatment of PFCDremains a clinical challenge despite the significant advances that have been made in the management of luminal IBD • Goal of surgical therapy of a fistula is to : • Define the anatomy accurately • Drain associated sepsis (UndrainedAbscess) • Eradicate the fistula tract if possible • Prevent Recurrence • Preserve sphincter integrity • Preserve continence • Pain relief • Quality of life (QOL) improvement

  4. Management Perianal Fistulizing Crohn’s disease (PFCD) • 1 - Medical

  5. Management Perianal Fistulizing Crohn’s disease (PFCD) • 2 - Surgical

  6. Perianal Fistulas in Patients With Crohn’s Disease (PFCD)

  7. Classification of Perianal Fistula[Fistula-in-ano(FIA)] Bell classification[American Gastroenterological Association (AGA) Cassification ] ABC

  8. Classification of Perianal fistula[Fistula-in-ano(FIA)] Low level fistulas High level fistulas • High level fistulas or High Trans-sphincteric fistulas involving the upper two thirds(2/3) of the external sphincter • Internal opening above the Levatorani • Remain a surgical challenge becauseFecal Incontinence(FI) • Low level Fistulas or Low trans-sphincteric Fistulas involve the lower 3rd of the External anal sphincter mechanism • Tend to be either Idiopathic or associated with Anal gland infection • Generally treated by Fistulotomywith a high success rate for cure

  9. Classification of Perianal fistula[Fistula-in-ano(FIA)] • Goodsall'slaw • Fistulas with an Anterior external opening drain directly into anterior half of the anusat the dentate lineis Direct type • Fistulas with a Posterior external opening in relation to the posterior half of the anus ,has a curved track may be of Horse-shoe type, opens in the midline posteriorly and may present with multiple external opening all connected to a single internal opening.

  10. Classification of Perianal fistula[Fistula-in-ano(FIA)] • Single External opening • Multiple External opening Which are often seen in • Tuberculosis • Ulcerative colitis • Crohns disease • Hidradenitissuppurative • Actinomycosis

  11. Differential Diagnosis of Fistula-in-ano • Infection • Cryptoglandular • Tuberclusion • Actinomycosis • Lymphogranulomavenereum • Pelvic inflamatory disease • Appendicitis • Specific • Nonspecific(90%) • Trauma • Foreign body • Obstetric • Hemorrhoidectomy • IBD • Cancer • Extra-anal sources • Presacral cyst • Bartholins cyst • Pilonidal disease • Hidradenitissuppurativa • Adenocarcinoma of the rectum • Squamous cell carcinoma of the anus • Lymphoma

  12. Perianal Fistulas in Patients With Crohn’sDisease (PFCD) Part 2- Surgical techniques

  13. Simple Perianal Fistulas • Preferred surgical intervention for Simple perianal fistulas is an Open Fistulotomy, given the low risk of Fecal Incontinence(FI) and high rate of Complete Healing • Majority of studies evaluating Open Fistulotomyfor superficial fistulas, the Healing rate is roughly 80% to 100% • Fistula Recurrence rates are approximately 0% to 20% but can vary

  14. Simple Perianal Fistulas • Fecal Incontinence(FI) after an Open Fistulotomyin patients with simple perianal fistulas is rare because the sphincter is not involved. • Although in Open Fistulotomy: • Healing rates are generally very high • Both Recurrence and Incontinence rates are low • Proper patient selection is crucial • Patients with low fistulas without macroscopic evidence of inflammation often have the best results

  15. Fistulotomy (also known as the “ Lay open Fistulotomy”) Technique

  16. Fistulotomy (also known as the “ Lay open Fistulotomy”) Technique • Fistulotomy involves cutting open the whole length and diameter of the fistula in order to flush out the infected contents. • Healing process is slow and takes 1-2 months associated with antibiotics and pain killers. • Examination under anesthesia to identify the primary and secondary openings of fistula • A probe can then be gently passed through to the external opening(or injection of diluted Methylene blue , Hydrogen peroxide) to define the tract and passed to internal opening • Once the anatomy is defined as either simple or complex,the techniques Fistulotomymay be employed.

  17. Complex Perianal Fistulas • Complex fistulas, involving the Internal or External anal sphincter, require a different surgical approach to optimize healing and prevent incontinence • Current Guidelinesstate that local infection control with an Incisionand Drainageand/or Seton placement is crucial prior to any definitive Medical or Surgical management • Incision • Drainage • Seton placement • Once the Perianal infection is controlled, management of the Enterocutaneous tract can be planned utilizing techniques such as an: • Endorectal Advancement Flap • Fistula Plug • Fibrin Glue • LaserClosure

  18. Complex Perianal Fistulas • In Complex Perianal Fistulas, combined Surgical and Medicalmanagement has been shown to be more effective than either modality alone • Despite the best therapies for chronic complex perianal fistulas, diverting stomas or even proctectomymay be necessary

  19. Fistulectomy (fistula tract resection)Technique

  20. Fistulectomy(Fistula tract resection)Technique • It is based on the principle that removal of the chronic, epithelialized tract will allow healing by secondary intention of heal thier tissue • Fistulectomyis associated with: • Larger defects (Wound) • Longer healing time • Higher risk of Fecal Incontinence(FI) • Higher Recurrence rates  • Supplemental treatments with Sitz baths and Fiber therapy can improve Healing after Fistulotomy or Fistulectomy

  21. Seton drainage (Type and Technique)

  22. Seton placement • Seton can be placed alone, combined with Fistulotomy, or in a staged fashion • Setone technique indicated in:

  23. Seton placement • Placement of a Seton drain is another frequently employed technique in Anal fistula surgery. • A seton, which can be a Non- absorbable suture, a Rubber band, or a Silastic vessel loop, is passed through the fistula tract and secured to itself externally • Three different techniques are in use Seton drainage: • 1- Drainage Seton (Loose Seton) • 2- FibrosingSeton • 3-Cutting Seton

  24. Types of Seton drainage 1- Drainage seton(Loose seton) • Aim of this technique is long-term drainage of the Abscess cavity • Loose Seton helps to prevent premature closure of the External fistula opening. • Healing rates in the retrospective observational studies identified vary between 33% -100%. • Fecalincontinance(FI) is reported in 0 to 62% • Drainage setonare used in: • IBD • More than 50% of sphincter muscle involved • Patient with poor continance • When Advancement Flap is not technically feasible

  25. 2-Fibrosing seton Types of Seton drainage • Placement of a Fibrosing Seton usually occurs either primarily or secondarily in the setting of an Acute or Persistent inflammation. • Aim is to induce Fibrosethe fistula tract before further surgical interventions. • Healing rates of nearly 100% • Associated with a high rate of Fecal Incontinence(vary 0-70%) • Fibrosingseton is used mainly in High fistulas before definitive Reconstruction surgery.

  26. 3-Cutting seton Types of Seton drainage • Use of cutting setons, in which the Seton is progressively tightened in the office until it eventually cuts through the fistula tract • Treatment of complex fistulae, Setons are usually placed loosely to allow drainage and control sepsis • Then followed by a secondary procedure [eg, EndorectalAdvancement Flap(ERAF),Fibrin glue,orFistula Plug] to avoid division of the sphincter muscle. • Healing rates(HR) were reported between 80%-100% • Fecal incontinence(FI) were between 0 -92%

  27. Draining and Cutting Setons Surgical Management • Use of a Setonin a patient with a Perianalfistula was first described by Hippocrates, who inserted Horse-hairinto an anal tract and periodically tightened it • Modern Draining Setonsare commonly made of a rubber sling or heavy nylon suture and are frequently used for patients with complex perianal fistulas. • By preventing closure of the external opening and allowing the tract to mature and heal by secondary intention, a Seton can be used as a bridge to a complex, definitive surgical repair • Patients who have had failed definitive repairs or who do not wish to undergo significant surgical interventions, a Draining Setonscan be used as a long-term remedy, keeping the tract open and preventing Abscess formation.

  28. Draining and Cutting Setons Surgical Management • Removal of a Draining Setonscan result in Fistula Recurrence in approximately 20% -80% • Although the consensus is to remove the Seton once the drainage has completely stopped • Ideal duration of the Loose or draining seton remains a clinical challenge. • Premature removal of a Setonincreases the risk of recurrence and new abscess formation, and prolonged seton placement has been associated with poor healing of the fistulous tract • In one study, a minimum of 3 weeks of drainage from a Loosesetonwas associated with complex Perianal fistula Healing; however, Bouguen et al showed improved healing when Seton placement did not exceed 34 weeks

  29. Draining and Cutting Setons Surgical Management • Unlike a Draining seton, a Cutting Seton is placed into a fistula tract and serially tightened, cutting slowly through the sphincter and allowing for healing of the proximal tissue. • Cutting Seton is minimally invasive, Healing is often quite slow, taking an average of 12 -16 weeks • Fecal incontinence(FI) has been reported in 5% -10% of patients, limiting the use of a cutting seton in the treatment of complex perianal fistulas. • Draining Setonsin combination with Medical therapy, most commonly a Biologic agent such as Infliximab, has been shown to increase the rate of Fistula closure. Draining Setons + Infliximab

  30. Draining and Cutting Setons Surgical Management • In an evaluation of the efficacy of Draining setonswhen combined with Infliximab, Regueiroet al, found that patients treated with the combination therapy had significantly better healing rates than patients treated with infliximab alone (100% vs 82.9%) • Moreover, Fistula recurrence rates were reduced with combination therapy (44%) compared with infliximab therapy alone (79%; P=.001)(Regueiro 2003)

  31. Draining and Cutting Setons Surgical Management • Two additional studies documented improved Healingwith combined Infliximab infusion and Draining Seton placement when compared with Monotherapy • There are no studies to date looking at the use of Setons in combination with Novel Biologic agents such as:  • Vedolizumab (Entyvio, Takeda) • Ustekinumab (Stelara, Janssen) 

  32. Endorectal Advancement Flaps(ERAF) • Basically Advancement flap is a piece of tissue that is removed from the rectum or from the skin around the anus • During surgery, the fistula tract is removed and the Flap is reattached where the opening of the fistula was.

  33. Endorectal Advancement Flaps(ERAF) Surgical Management • ERAF are the most common surgical technique for the definitive repair of a Complex perianal fistula, with Success rates ranging from 50% -80% • This sphincter-sparing procedure involves mobilization of a U-shaped flap of rectal mucosa, submucosa, and muscle fibers to occlude the internal orifice of the fistula tract. • Majority of research on ERAFis in patients with fistulas of Cryptoglandular origin, and not in patients with perianal CD. • Jones et al,documentedFistula Closure after placement of a ERAF in 58% (11/19) of patients with underlying CD

  34. Endorectal Advancement Flaps (ERAF) Surgical Management • Patients with Active Proctitiswere excluded from the study, and 47% (9/19) of patients with CD required a temporary Diverting stoma • Most of the studies on ERAFhave demonstrated that this procedure is most effective in patients with fistulas of Cryptoglandularorigin and is less effective in patients with underlying CD • Among patients with FistulizingCD, small bowel involvement and severe Active Proctitisare associated with lower rates of Successful fistula closure after an ERAF procedure

  35. Fistula Infill Materials Fibrin glue(Fibrin Glue)

  36. Fistula Infill Materials Fibrin glue(Fibrin Glue) • Fistula In fill Materials Fibrin glue, a mixture of Fibrinogenand calcium, can be injected directly into a Perianal fistula, sealing off the tract by forming a thrombin clot. • Initially used in conjunction with other surgical procedures such as an ERAF • Fibrin glue is now being studied as a monotherapy in patients with Perianal CD. • Most of the initial studies on Fibrin glue were conducted on patients with Cryptoglandularperianalfistulas,butstudies on patients with CD have shown Healing rates in the range of 30%-80%

  37. Fistula Infill Materials Fibrin glue(Fibrin Glue) • A small study focused on the efficacy of Fibrin glue in patients with FistulizingCD, 71%of patients had Nodrainage and 7%had Reduced drainage 3 months following Fibrin glue injection • After 2 years, 57% of patients in this study had Complete fistula closure with no long-term side effects ) • In a subsequent prospective trial, Fistula remission rates were significantly higher in the group that received fibrin glue compared with the group that was only observed (38% vs 16%; P=.04)

  38. Fibrin Glue (Technique) • Internal opening was closed with a Vicryl suture (Ethicon, Inc, Cin- cinnati, OH). • Five milliliters of Fibrin Glue (Tisseal; Baxter,Inc, Mississauga, Ontario) was reconstituted according to the manufacturer’s directions. • Fibrin Glue was instilled into the fistula tract by way of the external opening. • A non-adherent dressing was placed, and the patient was instructed to avoid lifting and vigorous physical activity for the next 7 days. • Patients were also instructed not to take a Sitz bath.

  39. Fistula Plug placement

  40. Fistula plug placement • Fistula Plug placement is another sphincter-sparing technique for Perianalfistulas,andis designed to occlude the Internal orifice of the tract and to promote healing. • The 2 most common types of Fistula Plugs that are currently being used are: • Bio-absorbable Plugs made of Lyophilized PorcineIntestinalsubmucosa • Synthetic Plugs made of PolyglycolicAcid and TrimethyleneCarbonate. • Plugs uniquely elicit minimal foreign body inflammation and essentially prohibit flow through the tract and provide a scaffold for Healing. Bio-absorbable Plugs

  41. Fistula plug placement • Majority of studies evaluating Anal plugs are quite small, with variable results and with only a small number of CD patients included. • In a systematic review of 20 studies assessing the efficacy of anal fistula plugs, Fistula closure was seen in 54.8% (23/42) of patients with underlying CD. • In a more recent systematic review, Complete closure was documented in 58.3% (49/84) of patients with CD, and Recurrence Rate in 13.6% (3/22) of the cohort.

  42. Fistula plug placement • Success rates were higher in patients who received a Bio-absorbableplug compared with a Synthetic plug. • Failure of Anal plugs is often associated with plug extrusion, which occurs in approximately 8% of patients

  43. Fistula Laser Closure (FiLaC)

  44. Fistula Laser Closure(FiLaC) • Use of laser therapy to treat FistulizingCD was first described in 2006 and revisited in 2011, with a Pilot study using a Fistula Laser Closure (FiLaC)system • FiLa C, uses a radial probe to cause denaturation and scarring along the fistula, obliterating the tract. • Giamundo et al,were the first to study FiLaCin patients with CD-associated Perianal fistulas. • Researchers documented an overall Healing rate of 72% and Recurrencerate in 5.7% of patients, and concluded that the placement of a Loose draining setonprior to laser therapy was associated with better results • A follow-up study assessing long remission in patients with CD treated with FiLaC found that 69.2% (9/13) of patients maintained complete fistula closure for 5 years

  45. Ligation of Inter-sphinctericFistula Tract(LIFT) Procedure

  46. Ligation of Inter-sphinctericFistula Tract (LIFT)Procedure • Ligation of inter-sphinctericfistula tract (LIFT) procedure is a Sphincter-sparing operation for the definitive management of patients with complex Perianal fistulas. • Procedure involves opening the Inter-sphinctericgroove, dissecting down to the Fistulous tract, and ligating the tract with interrupted sutures

  47. Ligation of Intersphincteric Fistula Tract (LIFT)technique) • The LIFT procedure is a relatively new sphincter-sparing approach that involves ligation and division of the fistula tract in the intersphincteric space. • A seton is usually placed weeks before the operation to allow fibrosis of the tract. • The procedure begins with a curvilinear incision in the intersphincteric groove. • The fistula tract is identified and dissected out. • The fistula tract next to the internal opening is ligated with absorbable suture. • The lateral tract is curetted and then suture-ligated externally to the first ligation site. • The tract is divided, and the remnant of the tract or infected gland is removed.

  48. Ligation of Inter-sphinctericFistula Tract (LIFT)Procedure • A systematic review evaluating the efficacy of the LIFT procedure for any type of fistula found primary Healing rates from 47%-95% • Of the 26 studies included, 1 was focused specifically on patients with CD. • In this study, Complete healing was seen in 60% (9/15) of patients at 2 months’ follow-up and in 67% (8/12) of patients at 1 year. • Predictors of surgical failure included Midline fistulas and Shorter fistula tracts • In a follow-up study, long-term healing was seen in 48% of patients, with a median time to failure of 9 months • Recently, a meta-analysis was presented in poster form that compared ERAP with the LIFT procedure and included patients with CD-associated fistulas.

  49. Ligation of Intersphincteric Fistula Tract (LIFT)Procedure • Of the 74 patients with CD, weighted success and recurrence rates were not significantly different between the LIFT and ERAF groups (66% vs 71% and 31% vs 29%, respectively) • Postoperative incontinence rates were significantly higher in patients who underwent an ERAF (7.8%) compared with patients who underwent the LIFT procedure (1.6%).36 Prospective, comparative studies that focus on patients with Perianal CD are needed to better understand how the LIFT procedure compares to other sphincter-sparing options.

  50. Video-Assisted Anal Fistula Treatment(VAAFT)

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