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Fistula -in -ano _Anal fistula_2

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					      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 .

				
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