Fistula -in -ano (Anal fistula) Definition : • Track of granulation tissue , extending from an opening in the perianal skin or the pelvis to the cavity of the anal canal or rectum. Aetiology and pathogenesis I)Primary due to • Cryptoglandular theory Due to infected anal gland in the intersphincteric plane II) Secondary due to • Crohn's disease • TB • Ulcerative colitis • Malignancy • Trauma Pathology • Track of granulation tissue and may be epithelized. • -Had internal and external opening that may be multiple. • Sometimes , the track is branched or showing horseshoe extension. Classification 1- Standard classification (Milligan and Margan , 1934) • According to relation of the internal opening to the anorectal ring : - High anal fistula : the internal opening above the anorectal ring -Low anal fistula : below the anorectal ring 2- Goodsall's rule : Transverse line passing through the centre of the anal canal dividing the field into : • A- anterior external opening Usually the track passes directly to the anal canal • B- Posterior external opening Usually the track curved and opened posteriorly in the midline 3- Park's classification (1976): According to the relation between the track to the external anal sphincter : • Intersphincteric (70%): The track passes between the internal and external anal sphincters. • Transsphincteric (20%): Transverses the external anal sphincter. • Supra sphincteric (5%):It passes above the external anal sphincter . • Extasphincteric (5%) - Above levator ani muscle to the rectal wall - usually had communicating track at the dentate line - usually specific Note the curved nature of the posterior fistulas and the radial .(straight) orientation of the anterior fistulas Clinical picture • History : of perianal abscess Symptoms: • Discharge • Pain • Swelling • -Pruritis • Bleeding Investigations 1-Fistulography 2-Anorectal ultrasound 3-CT 4-MRI 5-3-Dimential endoanal ultrasound Patients and Methods Fistulogram revealed a high multiple branched Antero-posterior view fistulogram revealed a high fistula tract with abscess cavity. cavity multiple branched fistula tract. Patients and Methods Fistulogram showing a long fistulous tract connecting the lower rectum. Patients and Methods Axial MRI revealed abscess formation in the pre- sacral space deep to anorectal ring (straight arrow). Rectum (curved arrow). Patients and Methods Coronal MRI revealed right sided ischiorectal fistulous track crossing the right levator ani (straight arrow) at high level. Patients and Methods Axial MRI confirms the fistulous track (curved arrow) in the right ischiorectal fossa entering the puborectalis muscle (straight arrow). Treatment Aim of treatment: • To eradicate the fistula with preservation of continence and with least recurrence. I )Treatment of low anal fistula 1- Fistulotomy (laying open): • Opening of the fistulous track and curettage of the track 2-Fistulectomy • Means complete excision of the track II)Treatment of high anal fistula 1- Seton placement • Whether cutting or two stage or drainage seton 2- Core fistulotomy and advancement flap • to cover the internal opening after curetting and closure of it 3- Fibrin glue injection • Whether commercial or autogenous fibrin glue Patients and Methods Proctoscopy was done with injection of mythelene blue to visualize the internal opening. Patients and Methods Dissection of the fistulous track. Patients and Methods Dissection of the fistulous tract. The patient was in prone jack knife position Patients and Methods Passage of the fenestrated probe included with 2-silk seton from the external opening to the internal opening. Patients and Methods Passage of 2-silk suture seton within the deep part of the sphincter muscles. Patients and Methods Passage of 2-silk suture seton within the deep part of the sphincter muscles. Patients and Methods Fixation of the seton to the shaved posteromedial portion of the thigh with gradual tightening of the seton on subsequent office visits. Patients and Methods A photograph showing the site of the external opening. Patients and Methods Coring out of the fistulous track. Patients and Methods Endo-rectal mucosal flap. Patients and Methods Suturing of the mucosal flap and the muscle defect. Patients and Methods Inspection showing recurrent anal fistula. Patients and Methods Endo anal mucosal flap after coring out of the fistulous track. Patients and Methods Photograph showing external opening in a case of recurrent fistula-in-ano. Patients and Methods Curettage of the residual part of the fistulous tract with blunt curette. Patients and Methods Injection of fibrinogen concentrate and thrombin simultaneously by double way wide bore angiocatheter after suturing of the internal opening. Patients and Methods Inspection showing recurrent anal fistula with multiple bilateral external openings. Patients and Methods Injection of mythelene blue with leakage of the dye within horse shoe fistulous track. Patients and Methods Bilateral external drainage of the track after injection of fibrin glue. Patients and Methods Healing of bilateral horse shoe fistula after treatment with fibrin glue. Rectal prolapse Definition : • Protrusion of the rectum through the anus Types : a-Partial (mucosal) B-Complete(Whole thickness ) Partial Complete length <5 cm > 5cm Mucosal -ve Often present corrugations Thickness Mucosa only Whole rectal wall Aetiology I) Partial a) In children: -Congenital straight sacrum - Loss of weight - Straining b)In adult - Advnced prolapsed piles - Straining - Loss of sphincter tone Incomplete • Due to pelvic floor weakness Clinical picture • Prolapse • Bleeding • Discharge • Incontinence • Complication : infection, haemorrhageirreducibility and gangrene Treatment In children • Spontaneous resolution usually occurs. • Avoid and treat straining , constipation and chronic cough. • Manual reduction and strapping. • Injection sclerotherapy submucosal injection of 5% phenol in almond oil or ethanolamine oleateﺯ In adult • Partial : injection sclerotherapy . • Complete by 1- Abdominal approach: A)Well's operation : –The rectum is mobilized and pulled upwards –Fixation to the presacral fascia with prolene mesh B)Rectosigmoidectomy (Mikulicz's operation): –Excision of the redundant rectum and sigmoid 2- Perineal approach Delorme's operation • Excision of the redundant mucosa above the dentate line with plication of the internal anal sphincter and re-anastmosis of the mucosa above the dental line .