Fistula-in-ano: a probing of the treatment options

John Goligher Colorectal Unit

David JayneProfessor of Surgery

University of Leeds & Leeds Teaching Hospitals NHS Trust

The Problem

Aetiology

• Cryptoglandular

• Crohn’s disease

• Other– Malignant– Obstetric– Radiation

Classification

45%30%

20%5%

Goodsall’s Rule

Treatment Aims

• Eradicate disease (if possible)

• Preservation of continence

• Benign condition• Quality of life

Principles• Control sepsis– EUA– Laying open abscesses and secondary tracts– Adequate drainage – seton insertion

• Define anatomy– Openings and tracts

• Internal and External• Single –v- multiple• Extensions / Horseshoe

– Relation to sphincter complex• High –v- Low

• Exclude co-existent disease

MRI for fistula-in-ano

HALLIGAN Radiology 2006Abscesses &Extensions

Contralateral disease Other pathology

Surgical Options – Fistulotomy

• Fistula tract identified with probe

• Extent of external sphincter involvement assessed

• Tract and muscle divided• Secondary tracts laid open• +/- marsupialisation

wound

Surgical Options – Cutting Seton

• Lay open external tract• Draining seton replaced with

cutting seton• 1/0 Prolene suture• Tied tight around sphincter

complex• Simultaneous slow cutting

and repair of sphincter• May require re-tightening

Surgical Options – Fistulectomy

• Draining seton

• Core out tract

• Direct visualisation of secondary tracts

• Sphincter repair +/- advancement flap

Advancement Flaps

Endorectal• Fistula tract probed• Flap raised– Mucosa + Int. Sphincter

• Internal opening excised/closed

• Flap advanced & sutured

Advancement Flap

Anodermal• Fistula tract probed• Flap raised– Anodermal

• Flap advanced & sutures• External defect closed

Fistula Plug

Fistula Plug

LIFT Procedure

Ligation of IntersphinctericFistula Tract• Transsphincteric fistula• Draining seton – 6 weeks

• Tract prepared with fistula brush– Debrides– De-epithelializes

LIFT Procedure

PROS CONSCutting Seton Simple

CheapRepeat EUARecurrence 0 – 8%Incontinence• minor 34 – 63%• major 2 – 26%

Fistulotomy SimpleCheap

Recurrence 2 – 9%Incontinence 50%

Advancement Flap Can be difficult?Preserves sphincter

Recurrence 25 – 50%Incontinence 30 – 35%

Fistula Plug SimplePreserves sphincter

Plug expensive ~£400Recurrence 20 – 85%Continence preserved

LIFT SimplePreserves sphincter

Recurrence 15 - 40%Continence preserved

ACPGBI FIAT Trial

Fistula Plug Insertion

Surgeon’s Preference

EUA: transsphincteric fistula ≥ 1/3 of sphincter

complex Insertion of draining

seton

RANDOMISE

MRI fistulography

Advancement Flap

Cutting Seton Fistulotomy LIFT

ACPGB&I FIATPrimary end-points• Faecal incontinence QoL• Generic QoL

Secondary end-points• Healing – 12 months• Complications• Faecal incontinence• Re-interventions• Health resource

utilisation• Cost effectiveness

Patient identificationEUA & draining seton

Eligibility & Consent

Randomisation1:1 plug –v- surgeon’s preference

6-week FU

6-monthFU

12-month FU+ MRI scan

Surgisis® fistula plugSurgeon’s preference

(fistulotomy, seton, advancement flap, LIFT)

MRI scan

Surgery(6-weeks post seton insertion)

FIAT FACTSRecruitment: 76Target: 500Open centres: 36Recruiting centres: 21

Join the FIAT Trial!

Fistula-in-ano: a probing of the treatment options

John Goligher Colorectal Unit

David JayneProfessor of Surgery

University of Leeds & Leeds Teaching Hospitals NHS Trust