Recent Advances in Surgical Management of Complex Cryptoglandular Anal Fistula

1. Recent Advances in Surgical Management of Complex Cryptoglandular Anal Fistula YK Fong, Queen Mary Hospital

2. Agenda • Introduction • Etiology and pathogenesis • Classification • Management approach of anal fistula • Assessment • Surgical options • Recent advances in surgical treatment

3. Etiology and Pathogenesis • Cryptoglandular (90%) • Extension of sepsis from infected anal glands in the intersphincter space • Non-cryptoglandular • Crohn’s disease • Tuberculosis, actinomycosis • Malignancy • Hidradenitissuppurativa • Radiation • HIV infection • Immunocompromised (chemotherapy/ diabetes)

4. Classification 1) Intersphincteric 2) Transphincteric 3) Suprasphincteric 4) Extrasphincteric

5. Anal Fistula Classification • Complex: Treatment poses a high risk of incontinence • Postoperative recurrence • Multiple tracts • Tract crosses >30-50% of external sphincter muscle • Anterior in females • Pre-existing incontinence American Gastroenterological Association

6. Complex Anal Fistula -Management Approach • Assessment • To rule out ongoing anorectal sepsis • To delineate the anatomy of fistula tracts • To look for non-cryptoglandular causes • To look for any causes of poor wound healing • Immunocompromised • steroid application  • Definitive treatment

7. Principles of Treatment Control of sepsis Maintenance of continence Closure of fistula

8. Surgical Treatment Options • Conventional approaches • Cutting Seton placement • Staged fistulotomy • Anorectal advancement flap • Continence preserving approaches • Fibrin glue • Anal fistula plug • Ligation of Intersphincteric Fistula Tract (LIFT) • Video-Assisted Anal Fistula Treatment (VAAFT)

9. LIFT Procedure(Ligation of Intersphincteric Fistula Tract ) • Rojanasakul et al. from Bangkok in 2007 • Success rate: 17/18 (94.4%) Rojanasakul, Tech Coloproctol 2009

10. LIFT Procedure: A Simplified Technique for Anal Fistula

11. Rationale of LIFT Procedure • Prevention of recurrent sepsis • Avoid entrance of fecal particles via internal opening • Remove intersphincteric fistula tract • Intermittent closed septic foci and persistent sepsis due to compression between sphincter muscles

12. LIFT Procedure • Less injury to anal sphincter • Short hospital stay • Short healing time • Primary healing rate 82.2% (37/45) Shanwani et al DCR 2010

13. BioLIFT Procedure • A modification of LIFT Procedure • Placement of biologic mesh in the intersphincteric space • Barrier to re-fistulization C. Neal Ellis et al. Meeting of The American Society of Colon and Rectal Surgeons 2012

14. BioLIFT Procedure • Bioprosthetic grafts • Tolerate contamination • Remodeling without a foreign body reaction • Healing rate: 94% (29/31) C. Neal Ellis et al. Meeting of The American Society of Colon and Rectal Surgeons 2012

15. BioLIFT Procedure • Potential drawbacks of the BioLIFT technique • Requires extensive dissection in the intersphincteric space • High cost of the bioprosthetic materials

16. Unsuitable Cases for LIFT Procedure • External opening at intersphincteric groove • Abscess cavity in intersphincteric space (friable tract) • Large internal opening • Specific causes: TB, Crohn’s

17. VAAFT (Video-Assisted Anal Fistula Treatment) • Karl Storz endoscope • A small-calibered rigidscope equipped with an optical channel, a working channel and an irrigation channel

18. VAAFT

19. VAAFT: Meinero technique • Ablation of the fistula tract with unipolar electrode • Closure of the internal opening with stapler • Injection of cyanoacrylate into the fistula tract Meniero P. Tech Coloproctol 2011

20. VAAFT: Meinero technique • 98 patients with complex fistula • Performed under spinal anesthesia • Operation time: 30 to 120 minutes • Primary healing: 72 patients (73.5%) • Healing time: 2-3 months • No major complication or fecal incontinence Meniero P. Tech Coloproctol 2011

21. Conclusion • Management principles of complex anal fistula • Detailed assessment to exclude underlying disease • Anatomical +/- functional assessment • Tailored treatment • To control and eradicate sepsis (stages) • To remove tract and close internal opening • To preserve continence

22. Thank you

23. Assessment • Clinical • Digital examination • Examination under anesthesia (EUA) • Anal manometry • Radiological • Endoanal ultrasound • Magnetic resonance imaging

24. LIFT Procedure • Prospective observational study • All cryptoglandular infections • May 2007 to September 2008 • 45 patients • 33 transsphincteric • 12 complex • Median follow-up: 9 (range, 2-16) months • Primary healing: 37/45(82.2%) • Median healing time : 7 (range, 4-10) weeks Shanwani et al DCR 2010

25. QMH Experience • Since January 2009 • 25 patients • 24 transphincteric fistula • 1 suprasphincteric fistula • 15 recurrenct • Median operating time: 39 minutes (range 15-73) • Median hospital stay: 1 day • Perianal incision healing time: 14 days • Closure of external opening: 31 days • Median follow-up 9.8 months (range 1-21.5) • 2/25 (11%) recurrent rate

26. VAAFT • To identify the internal opening under direct endoscopic view and then close it with suturing or stapler • To ablate or remove the granulation tissue along the fistula tract • To fill the fistula tract with bio-prosthetic material