FISTULA IN - ANO

GENERAL DATA
EDG
43
MALE
MARRIED
ROMAN CATHOLIC
FILIPINO
QUEZON CITY
Fistula
Chief complaint
HISTORY OF PRESENT ILLNESS
1 year PTA:
Found to have external opening of fistula
No medications taken

Anal pain, grade 5/10
Inflamed
With episodes of pus and blood streaks
No medications taken. No consult done.
Resolution after 3 days
HISTORY OF PRESENT ILLNESS
3 weeks PTA:
External opening
No associated symptoms
Advised surgery
PAST MEDICAL HISTORY
Hypertensive
Candesartan
No previous surgeries/blood transfusion
Allergic to seafood
PERSONAL SOCIAL HISTOY
SEAMAN
Occasional smoker for 25 years
2 packs/year
Occasional alcoholic beverage
drinker
1 bottle of brandy/month
REVIEW OF SYSTEM
General survey: no weight loss, no fever
Skin: no rashes, no pruritus
Head: no headache, no dizziness
Eyes: no visual changes
Ears: no tinnitus, no hearing loss
Nose: no nose bleeding, no anosmia
Mouth and Throat: no hoarseness, no
dysphagia
REVIEW OF SYSTEM
Respiratory: no cough, no dyspnea
Cardiovascular: no chest pain, no
orthopnea
Genitourinary: no dysuria, no hematuria
Musculoskeletal: no joint pain, no arthritis
Nervous system: no seizure, no loss of
consciousness



Physical Exam
Awake, coherent, ambulatory, not in respiratory
distress
BP: 120/80 mmHg
HR: 73 bpm
RR: 19 cpm
T: 36. 2
0
C
BMI: 30.29 kg/m2



Skin: no jaundice, warm to touch, good
skin turgor

HEENT: anicteric sclerae, pink palpebral
conjunctivae, no nasoaural discharge,
moist lips, moist oral mucosa, no
tonsillopharyngeal congestion, no
cervical lymphadenopathy


Chest and Lungs: symmetrical chest
expansion, no retractions, clear breath
sounds

Heart: adynamic precordium, normal
rate, regular rhythm, no murmur





Abdomen: flabby, normoactive
bowel sounds, soft, no tenderness

Extremities: grossly normal, no
edema, full equal pulse

Digital Rectal Examination
no skin tags
no erythema in the perianal regions
(+) external opening on left anterior position
~1cm from the anal verge
good sphincter tone
no rectal masses
no rectal tenderness
no blood or fecal material on the examining
finger






Rule in Rule- out
Hidradenitis
suppurativa
Inflammation
Mucopurulent
discharge
Tenderness

Tract
External opening
Anorectal abscess Pus
Swelling
Tenderness

External opening
Tract
Fever
FISTULA IN - ANO


Internal iliac
Inferior
mesenteric artery
Internal
pudendal
artery
Via inferior mesenteric
vein
Internal iliac
Lymphatic drainage
Proximal to the dentate line
Inferior mesenteric lymph nodes and internal iliac
lymph nodes

Distal to the dentate line
Inguinal lymph node
Inferior mesenteric lymph nodes

NERVE SUPPLY
Sympathetic nerve fibers
Derived from L1-L3
Join the preaortic plexus hypogastric plexus

Parasympathetic nerve fibers
AKA nervi erigantes
From S2 S3

NERVE SUPPLY
Internal anal sphincter
Sympathetic and parasympathetic nerve fibers
Inhibit sphincter contraction

External anal sphincter and puborectalis muscles
Inferior rectal branch of the internal pudendal nerve

Levator anI muscle
Internal pudendal nerve and direct branches of S3
S5
NERVE SUPPLY



Sensory innervation
Inferior rectal branch of the pudendal nerve
FISTULA IN - ANO
Abnormal communication
between the anus and the
perianal skin

Cryptoglandular Hypothesis
Infection begins in the anal gland

Muscular wall of the anal sphincters

Anorectal abscess

Granulation tissue-lined tract
Pathophysiology
Acute
infection of
the anal
crypt
anorectal
abscess
anal
fistula
Pathophysiology
Trauma
fissures
tuberculosis
Crohn's
disease
carcinoma
radiation
Foreign body
i
n
f
e
c
t
i
o
n

F
i
s
t
u
l
a

Signs and symptoms
Perianal discharge
Perirectal abscess
Recurrent perirectal abscess

Diagnosis:
Examination , Protoscope
An indurated tract is often palpable
The internal opening is usually detectable by
anoscope examination

Parks Classification System
Fistulas are categorized based
upon their relationship to the anal
sphincter complex, and
treatment options are based
upon these classifications
1. Intersphincteric
tracks through
internal sphincter to
an external opening
near anal verge
Treatment:
Fistulotomy:
- opening the fistulous tract
- Curettage
- Healing by secondary intention


Intersphincteric
fistula with simple
low tract
tracks through
the distal internal
sphincter and
intersphincteric
space to an
external opening
near the anal
verge

2. Transsphincteric
result from an
ischiorectal abscess
extends through both
internal and external
sphincters
Treatment:
< 30% of the sphincter muscles: sphincterectomy
High transsphincteric fistula: initial placement of a
seton

Transsphincteric
fistula
an ischiorectal
abscess and
extends
through both
the internal and
external
sphincters
3. Suprasphincteric
originates in
intersphincteric plane
tracks up and around
the entire external
sphincter
Treatment:
- Seton placement


Suprasphincteric
fistula
originates in the
intersphincteric
plane and
tracks up and
around the
entire external
sphincter
Seton placement
drain placed through a fistula to maintain drainage and/or
induce fibrosis
Single-stage Cutting seton
suture or a rubber band that is placed through the fistula and
intermittently tightened
Two-stage Noncutting seton
soft plastic drain placed in the fistula to maintain drainage

(1) to drain and promote fibrosis and
(2) to cut through the fistula
4. Extrasphincteric
originates in rectal wall
tracks around both
sphincters
exit in ischiorectal fossa
Treatment:
- opened and drained


Extrasphincteric
Fistula
originates in the
rectal wall and
tracks around
both sphincters
to exit laterally,
usually in the
ischiorectal fossa
TREATMENT
GOAL: eradication of sepsis without
sacrificing continence
fistulous tracks encircle variable
amounts of the sphincter complex

FISTULOSTOMY VS FISTULECTOMY
FISTULOSTOMY
fistulas located close to the
skin.
close to the rectum and
anal tract
the preferred surgical
treatment

FISTULECTOMY
fistula is removed entirely
posterior fistulas

SETON PLACEMENT
Complex fistulas (ie, high
transsphincteric, suprasphincteric,
extrasphincteric) or multiple fistulas
Recurrent fistulas after previous
fistulotomy
Anterior fistulas in female patients
Poor preoperative sphincter
pressures
Patients with Crohn disease or
patients who are
immunosuppressed

MUCOSAL AND ADVANCEMENT FLAP
MUCOSAL AND ADVANCEMENT FLAP
Advantages include a 1-stage procedure
with no additional sphincter damage
disadvantage is poor success in patients
with Crohn disease or acute infection
total fistulectomy, with removal of the
primary and secondary tracts and
complete excision of the internal opening

PLUGS AND ADHESION
less-invasive nature
decreased postoperative morbidity and
risk of incontinence
long-term data are lacking for eradication
of disease
LIGATION OF INTERSPHINCTERIC FISTULA
TRACT
sphincter-sparing procedure for complex
transsphincteric fistulas
performed through access to the
intersphincteric plane with the goal of
performing a secure closure of the internal
opening and by removing the infected
cryptoglandular tissue
DIVERSION
creation of a diverting stoma is a rare
indication to facilitate the treatment of
complex persistent fistulas-in-ano
most common indications include but are
not limited to patients with perineal
necrotizing fasciitis, severe anorectal
Crohn disease, reoperative rectovaginal
fistulas, and radiation-induced fistulas
Thank You