SETON , SURGICAL traetement for peri anal fistula What causes an anal fistula?

1. PERI ANAL FISTULA SURGICAL TRAETEMENTالدكتور نزار أحمد الأسودDr. Nizar Al ASWADCONSULTANT GENERAL SURGEONK.F.H MOH / TaifAL THAGHER H MOH / JeddahABDALLAH SAIM AL DAHR H / JeddahAL-QASSEEM NATIONAL HOSPITAL / BurayidaAL ZAFER H / Jeddah

2. SETON , SURGICALtraetement for peri anal fistulaWhat causes an anal fistula? The anatomical anal canal extends from the perineal skin to the lineadentata .Surgically, the anal canal extends from the perineal skin to the anorectal ring, this is the circular upper border of thepubo rectal muscle . Anal sphincter anatomy The anal sphincter is comprised of three layer 1-Internal sphincter it is the continuous circular smooth muscle of the rectum . Involuntary and contracted during rest relax at defecation . 2-Intra sphincteric space 3-External sphincter voluntary , striated muscle , divided in 3 layers that function as one.

3. Fistula-In-Ano Anal fistula : Is a chronic phase of anorectal sepsis and is characterized by chronic purulent drainage or cyclical pain associated with abscess formation, followed by intermittent spontaneous decompression The anorectal fistula (Fistula-in-Ano) is an abnormal communication between the anus and the perianal skin. 

4. Anal canal glands  The anal canal glands , produce fluid that drains into the rectum to make defecation easier, they are the origin of source infection is from Hermann and Desfosses gland, starting from one crypte fossa. situated at the dentate line afford a path for infecting organisms to reach the intramuscular spaces, anal abscess occurs when the duct to an anal gland becomes blocked.

5. Normal Hermann and Desfosses Glands

6. Causes of fistula-In-Ano • Following surgical or spontaneous drainage to peri anal abscess in the peri anal skin .Occasionally a granulation tissue-lined tract is left behind, causing recur. We must inform that to the patient . • Fistulas can be caused by underlying conditions such as irritable bowel syndrome or Crohn's disease ,these conditions can cause ulcerations in the bowel tract which can eventually turn into fistulae.

7. Other causesAn anal fistula may also develop as a result of: • Acomplication of, anal surgery , heamorroidectomy , fissurectomy . • Ahealth problem you were born with • Anal fistulae are also a common complication of conditions , that cause , the intestines to become inflamed, such as: • diverticulitis – the formation of small pouches that stick out of the side of the large intestine (colon), which become infected and inflamed • ulcerative colitis – a chronic condition that causes the colon to become inflamed and can cause ulcers to form on the lining of the colon • Crohn's disease – a chronic condition that causes inflammation of the lining of the digestive system • cancer of the rectum – the rectum is an area at the end of the colon where faeces are stored • tuberculosis (TB) – a bacterial infection that mainly affects the lungs, but can also spread to many different parts of the body • HIV and AIDS – a virus that attacks the body's immune system (its defence against disease and infection) • chlamydia – a sexually transmitted infection that often causes no symptoms • syphilis – a bacterial infection that is passed on through sexual contact .

8. Diagnosis Present illness history Patient normally complaining of anal pain ( BAWASSIR ). Interrogation : Any illness : age , diabetics , chronic bowel disease , diarrhoea . Recurrent anal pain , illness duration , pus discharge or bloody pus discharge, recurrent abscess , previous operation fistulectomy or for abscess drainage ???. Clinical examination Position of patient , about the habet of the surgeon , small orifice or orifices , pus discharge . cord sign, it is FRENCH TERMINATION (we can follow subcutaneous indurations lick a cord sensation , from the external orifice up to the anal margin) .

9. Complementary examination Complementary isnotnecessary Fistulogram : It is painful , difficult , minor benefits , ? External orifice is closed in the time of exam . Rung result MRI , pelvic MRI , with intravenous contrast , necessary in a- recurrent cases , b- in case of multiple external orifices . c- in negligent Pt with old history it is better to interpret the result with the Radiologist The best for diagnosis during operation time under anesthesia . Patient position : lithotomy , coccyx out of the table ,knee to chest . Inspection to perinealarea In order to help the examiner predict the trajectory of the tract, and probable localization of the internal opening, Goodsall's Rule can be applied ,with the patient in the lithotomy position:

10. Goodsall’s Rule • If the external opening is anterior to an imaginary line drawn horizontally through the anus, the fistula usually runs directly into the anal canal. In case of anterior fistula, multi external orifices ,there is multi trajectory direct in to the anal canal . • If the external opening is posterior to this line, the fistula usually curves to the posterior midline of the anal canal. If there is in posterior fistula case , multiple external orifices , there is only one trajectory into anal canal . • It should be noted, however, that the further away , the less reliable Goodsall's Rule becomes , additionally, the trajectory of a multi operated and recurrences fistula , the trajectory of complex fistula is unpredictable. In this case MRI very essential .

11. Classifications Different types of anal fistula ; The most widely used classification is the Parks Classification which distinguishes four kinds of fistula: intersphincteric, transsphincteric, suprasphincteric and extrasphincteric. The most common fistulas are the intersphincteric and the transsphincteric.The extrasphincteric fistula is uncommon and only seen in patients who had multiple operations, in these cases the connection with the original fistula tract to the bowel is lost. A superficial fistula is a fistula that has no relation to the sphincter or the perianal glands and is not part of the Parks classification. We must note that , these all proper perianal fistulae ( Bye definition ) are related to the sphincter complex . It is very important for the choice of surgical methods .

12. Treatment Peri anal fistula recurrence is distressing to the patient and embarrassing to the surgeon. Treatment is focused on the elimination of the primary and secondary tracts, prevention of recurrence and to retain anal continence. Incontinence for both gas or stool may become an infirmity for whole of the life .

13. Procedures 1 – Fistulotomy The surgical treatment given depends on the surgical anatomy to the fistula, if it is a simple fistula with a low mucosal defect it can be probed to identify the tract and the mucosal defect at the linea dentata, then the tract can be layed opened. This is only possible if the external sphincter is not involved, or we can sacrificed small part from the external sphincter . (Simple Fistulotomy). By cauthery .

14. 2- Gradual fistulotomy Fistulotomy in one session,with sacrification of important part from the anal sphincter , in cas of trancesphicterec ,inrasphincterc or suprasphincterec . Continence is surely threatened. The new idea , to insert thin rubber as a drainage inside the fistula tract for 2 months to get fibroses and destruction to the granulation tissue , then multiple gradually cut of the sphincter after healing the previous cutting , under G/A . Sometimes several operations are necessary.

15. Drainage and multiples gradually cut

16. 3 - Seton fistulectomy technique Patient should be informed that he will feel a linear structure in anal region This is the Seton which will be inserted to treat the fistula. Seton application , is a piece of thread which is left in the fistulous tract. This may be considered if the patient is at high risk to developing incontinence when the fistula crosses the sphincter muscles. Seton It is a technique where by a rubber ligature or vessel loop is pulled through the fistulous tract, and then it is tightened every 2 weeks in order to obtain continuous pressure necrosis , so that the Seton is slowly pulled and gradually cut through the sphincteric muscle.

17. Seton Technique Advantage The advantage , is that the muscle is slowly cut and fibroses at the same time in order to cause as little damage as possible to the sphincter complex. This session s can be done in OPD under xylocain spray , Im pain killer injection . 30 minutes befor If there is an extrasphincteric fistulous tract in the perineum, far from the anal margin , this part must be opened by cauthery on the probe up to sphincter contraction. (partial fistulotomy ) .The trans sphincteric part is treated by a Seton Personally I prefer to push my indications in this way

18. INTRA OPERATIVE … Under general or spinal anesthesia , starting by examining the perineal area. Inspection : by looking to external orifice or orifices , anterior or posterior position in relation to the imaginary line passing from the both Ischial tuberosities, open or closed, presence of purulent discharge or granulation tissue overhanging it. Then to follow the cord signs. Digital Rectal Examination . and proctoscopy for diagnosis of another anal or rectal lesion . After complete examination of the perineal area, we may have different possibilities:   We can inject air or hydrogen peroxide through the external orifice , and feel the bubbles with left index.

19. 1-The external orifice is far from the anal margin and it is open, we can start by exploration through a probe, with lubricator , left index in the anal canal , the right hand gently pulls the probe through the fistula tract, vice versa position of hands for the other side fistula.   ...Two possibilities a-The probe appears directly in the anal canal . It is a simple case. b-We can feel the probe by the left index through the anal mucosa , but the internal opening is closed. We can pull gently and open this internal orifice. Partial fistulotomy by cauthary is done up to the anal sphincter contraction and seton inserted in the transsphincteric path

20. . 2-Multiple external orifices .Posteriorly. Normally, all communicated together we can pass multiple probes from one to two, from two to three. Among all the probes only one probe will directly enter into the anal canal. By cautery we can open the external tracts . DON’T CROSS THE POSTIRIOR MIDLINE BY YOUR INCISIONS. and the one who goes to the anal canal, can be opened up to the anal sphincter contraction and Seton inserted.

21. . 3-If the external orifice is closed, follow by palpation,thefistula cord, try to open gently by the probe but do not force due to risk of wrong way, hold the disclosed external opening by using Allis forceps. Elliptic incision by cautery very low degree and use the cautery as spatula decsector , coagulation in the same time , in the direct contact of the tract . Open the skin gradually by cautery .If you have one or more centimeters from the fistula tract. You can do cut-down and try to insert the probe , if easy to pass or difficult. Continue your dissection gently up to the contraction of anal sphincter. Now pull the fistula tract, you can see the depression of the internal opening. Try with your probe retrograde intubation.

22. . The probe form for easy manipulation and retrograde intubation 4-In case of multi anterior perianal fistula, or one anterior and one posterior , we can insert multi-seton (one or two) and tighten alternatively in 10 days interval

23. Elastic Rubber Seton fistulotomy technique In this technique, under the usual operative preparations for perianal fistula operation, anaesthesia and lithotomy position, after EUA ( examination under anaesthesia), the external opening of the fistula is gently probed with the help of a malleable metallic probe, and by gentle manipulation the fistulous tract, is traced till its internal opening. The probe is advanced and passed through the whole fistula once it exits from the internal opening , partial fistulotomy on the probe up to external sphincter contraction . Silk No 0 is looped on the end of the probe to make a secure hold, after that gently the probe is pulled back as it was inserted before, in this way it will bring the silk suture in its place passing through the whole fistulous tract. Now the elastic rubber piece is tied with the loop of silk suture to make a secure connection at the external end and is slide through the fistulous tract with gentle pull on the silk suture. Now the elastic rubber is inside the fistulous tract transverse from external to internal opening. The both ends of the rubber are tied together with moderate pressure by silk suture near to the skin margin. The extra length of the rubber is cut so that the patient will have less discomfort after. This elastic rubber is tightened for 10 days or 2 weeks basis in OPD clinic with another silk suture with again moderate pressure , more nearer to the skin than the old one , after spraying xylocaine spray in the area. In this way a continuous pressure necrosis is applied over the sphincter in contrast to the ordinary way of seton placement.

24. CUT IT THIN ELASTIC BAND FROM FOLLEYS CATHETER

25. Stepces Seton Methode

26. Dressing We use the sanitary napkin or sanitary pad as a dressing for male and female. Patient can change his/her dressing if needed.

27. PATIENTS OPERATED IN AL-GASSEEM NATIONAL HOSPITALBURAYDA . 2011-2012 -2013

29. MRI date : 19/09/2013 Ttas-sphintericperianal fistula in acute exacerbation, with abscess cavety at the left ischio-rectal fossa, mucosal opening at 2 to 4 o,clock, grade IV according to St. James classification .

30. 45 Days drainage ) )MRI date : 04/11/2013The descripted MRI features are those of supra-levator high perianal fistula, according to St. James classification it is grade v.

31. ( 92 Days Drainage )MRI date : 25/01/2014 Low trans-sphincteric perianal fistula with fibrosis. No abscess or sided branches. St. James typs 2.

32. MRI date : 25/01/2014 ( 92 Days Drainage )Low trans-sphinctericperianal fistula with fibrosis. No abscess or sided branches. ST. James typs 2.

33. THANK YOUالدكتور نزار أحمد الأسودDr. Nizar Al ASWADCONSULTANT GENERAL SURGEONdrnizaralaswad@yahoo.comMob: 05 03 71 98 33