Fissure and fistula

Fissure and fistula

1. Anal Fissure, Fistula in Ano & Pilonidal sinus DR SYED UBAID

2. Anal canal Anatomy:

3. Anal Canal Length= 3.8 to 4.0 cm Zona Columnaris : Upper ½- lined by Simple columnar Zona Hemorrhagica : Upper part of lower half ( above the Hilton’s white line) – Stratified squamous non-keratinizing epithelium Zona Cutanea : Lower part of lower half( below the Hilton’s white line)- Stratified squamous keratinizing epithelium

4. Anorectal Bundle or Ring: Demarcating Line B/W the Rectum & Anal Canal. Can be felt Posteriorly- Thickened Ridge Formed by- Puborectalis, Deep Ext Sphicter,Conjoined long Muscle & Internal Sphincter

5. Puborectalis Muscle: Maintain the angle b/w rectum & anal canal Gives off fiber to the longitudinal muscle layer. Position, Length as well as angle of the anorectal Junction - integrity & strength of the Puborectalis muscle sling.

6. Image of Anal Sphincter: Deep External Sphincter. Sub cutaneous External Sphincter Superficial External Sphincter Circular muscles of Rectum Longitudinal muscle of Rectum Internal anal S Conjoined longitudinal muscle

7. External & Internal Sphincter: External Sphincter Internal Sphincter Muscle Single muscle k/as Goligher Muscle Continue of the Circular muscular coat of the rectum Color Red Pearly white Nerve Pudendal Nerve Autonomic nervous system- Intrinsic non-adrenergic & non-cholinergic fiber Types of Muscle Somatic Voluntary Muscle Non-striated Involuntary Muscle Parts/ fts Deep, Superficial and Subcutaneous portion Always lie in the tonic state of contraction

8. Anal Canal Above the dentate line Below the dentate line Development Post- allantoic gut Proctodeum Epithelium Cuboidal /Columnar Squamous without sweat & hair gland Name Surgical anal canal Anatomical anal canal Color Pink Skin Colour Nerve Parasympathetic: painless Spinal nerves: very painful Venous Drainage Portal System Systemic-Ext iliac vein Lymphatic Drainage Para-aortic Superficial & Deep inguinal LN

9. Examination of Anal Canal: Relaxed Patient Informed Consent Private environment Good Light Position – Left Lateral Position/ Sims’s Position- most commonly used.

10. Image for different position: Lithotomy Sim’s Position Sim’s position Knee elbow position

11. P/R Examination:Inspection Skin Lesion- Psoriasis -Lichen planus - Warts - Candidiasis&Herpes simplex Whether anus is closed or patulous Position of the anus/perineum Evidence of piles/ sentinel tag ( Anal fissure or SCC) Psoriasis

12. P/R:Gloves,jelly etc……… Sling of puborectalis- Posteriorly at the apex Posterior surface of the prostate gland with median sulcus( Male) & Uterine cervix( in female)- Anteriorly . Intrarectal, Intraanal or extraluminal mass. Sphincter length Resting tone Voluntary squeeze Examining finger – Mucus, Blood, Pus Stool Color.

13. Proctoscope:

14. Proctoscopy: Position: Left lateral position Inspection of the distal rectum and anal canal Injection in Hemorrhoids Banding of Piles mass Biopsy of mass

15. Sigmoidoscopy: Mainly used for Rectal examination But Also recommended in Fissure & Hemorrhoids Cos Colitis & Rectal Carcinoma is frequently A/W Fissure & Hemorrhoids.

16. Physiology Structural Integrity of the sphincter- Endoluminal USG Neuromuscular Function –(a) Assessment of conduction velocity along with the Pudendal nerve or -(b) Needle Electromyogram(EMG)-Slightly Painful. Evacuation Proctography or Dynamic Proctography: - In Rectal Sensorimotor dysfunction( Overflow of rectal content)

17. Dynamic Proctography: Radio-opaque pseudo-stool is inserted into the rectum Rest, Squeeze and than bear down to evacuate the rectal contents under real-time imaging. Can be combined with EMG & Pressure studies

18. Dynamic Magnetic Resonance Proctography:DMRP: More popular More expensive Less physiological

19. Anal Fissure: Longitudinal tear in the anal canal Site: Posterior midline (90%) and Anterior midline in 10% case especially in female.

20. Etiology & Predisposing factors of Anal Fissure: Age: Young adult & middle aged man Gender : Male > Female Posterior midline is the commonest site because- -Maximum stretching on this site - Less tissue here -Minimal tissue perfusion

21. Etiology of Anal Fissure Main cause-Trauma–Strained evacuation of Hard stool or Less commonly - Repeated passage of stool ( diarrhea) Anterior anal fissure in 10% cases – Mostly in Women that occurs following vaginal delivery

22. Predisposing Factors: FISSURE Faces – Hard Ischemia Surgical procedure- Haemorrhoidectomy Sphincter hypertonia Underlying disease – Crohn’s , TB, L.V, Syphilis etc Repeated Childbirth Enthusiastic usage of ointments and abuse of luxatives .

23. C/F of Anal Fissure: Severe anal pain during the defecation Blood streak outside the stool Bleeding P/R- Bright Mucous Discharge Constipation Itching

24. Chronic Anal Fissure: Findings: Hypertrophied Anal Papilla- Proximally Sentinel tag- Distally Thickened edge Exposed internal sphincter i.e Ulcer overlying the fibers of internal sphincter

25. D/D –Especially if ectopic site i.e other than Posterior –midline: Crohn’s Diseases Kaposi’s Sarcoma Tuberculosis B-Cell Lymphoma Lymphogranuloma Venereum CMV Syphilis Chlamydia HIV Chancroid HSV SCC

26. Confirmation of Diagnosis: Adequate clinical examination under G/A Proctoscopy Sigmoidoscopy Take Biopsy Do Culture

27. Treatment: Conservative & Surgical Conservative treatment helpful in most of cases Main objective to treat Constipation. -Add the fiber to the diet -Encourage water intake -Laxative to make the stool soft Application of local anesthetic- Lignocaine jelly Antibiotics- Ofloxacine + Orinidazole

28. Conservative :Hot Seitz Bath

29. Conservative Treatment: Drugs that release the Nitric oxide donor- Glyceryl Trinitrate( GTN) 0.2 % & Diltiazam 2%. GTN 0.2% - QID at Anal Margin - S/E- Headache and Recurrence Diltiazam 2%- BD at anal margin - M/A- Produces NO – Relaxation of the internal Sphincter- reduces the spasm, pain & Increase the vascular perfusion to promotes healing

30. Conservative Treatment Botulinum toxin injection Site of Inj- Internal Sphincter M/A- Inhibits presynaptic release of Ach from cholinergic nerve endings- Paresis of Striated muscle and release the spasm . Other use- Achalasia cardia, Sphincter of Oddi dysfunction, Frey Syndrome

31. Operative procedure for FIA. Anal Dilatation Posterior division of the exposed fibers of the internal sphincter in the base of the fissure. Lateral Anal Sphincterotomy of Notaras Anal advancement Flap

32. Anal Dilatation: Lord’s Anal Dilatation Position- Lithotomy Under G/A Manual 4 to 8 finger sphincter dilatation Useful in Young men with very high sphincter tone Risk: Incontinence.

33. Posterior division of the exposed fibers of the internal sphincter in the base of the fissure Indication – if fissure is associated with INTERSPHINCTERIC FISTULA Disadvantage- Prolonged healing - Passive anal leakage because of resulting ‘ Keyhole gutter deformity’.

34. Lateral Anal Sphincterotomy: Position- Lithotomy Anesthesia- Regional or G.A Palpate the distal internal sphincter with the help of bivalved speculum at the intersphincteric groove. Give a small longitudinal incision in right or left lateral position

35. Lateral Anal Sphincterotomy Cut the Mucosa Get the sub- mucosal & Intersphincteric planes Allow the Exposure of Internal sphincter Cut the Internal sphincter up to the apex of the fissure Closed the wound with the absorbable suture

36. Complications of LAS: Hemorrhage Hematoma Bruising Perianal Abscess Fistula Incontinence.

37. Anal Advancement Flap: Very useful in women and those with Normal or Low Resting Anal Pressures ( persistent, chronic, non healing fissure) Excised the edge as well as base of the fissure. Inverted house shaped flap of Perianal skin is mobilized to cover the fissure. Post-op instruction- Stool softeners, Bulking agent & Topical sphincter relaxants.

38. Fistula-in- ano : Chronic abnormal communication Between the Internal opening (anorectal lumen) & External opening on the skin of the perineum or buttock Lining is Granulation tissue. Commonest cause – Non-specific, Idiopathic & Crypto glandular & Inter- Sphincteric anal gland infection.

39. Fistula-in- ano:Aetiopathogenesis Persistent anal gland Infection Anorectal Abscess Rupture inside as well as outside Fistula

40. Fistula-in- ano:Underlying Condition – CISTULA+ ARF Carcinoma Ileitis-Crohn’s Schistosomiasis Tuberculosis Ulcerative colitis L. Venereum Anal Fissure Abscess xnmc Actinomycosis Rectal Duplication Foreign Body

41. Fistula-in- ano:Clinical features Intermittent purulent discharge Pain External opening as sinus or Ulcer Bleeding/PR(sometimes)

42. Types of Fistula in ano:Standard Low type- Internal opening below the anorectal ring. High Type-Internal opening above the anorectal ring. Importance – Low type fistula- fistulotomy without damage to sphincter - High type fistula – Staged operation

43. Park’s Classification: Based on relationship of fistulous tract to the anal sphincters- 4 types. Intersphincteric Fistula In vast majority of Cases. Trans sphincteric Fistula Supra Sphincteric Fistula Extra Sphincteric Fistula

44. Park’s Classification

45. Intersphincteric Fistula: Most common type Incidence= 45% Don’t cross the external sphincter

46. Trans-sphincteric Fistula: 2 nd Most common type Incidence=40% It’s track crosses both external & Internal sphincter Passes through the Ischio-rectal fossa to reach the skin of the buttock

47. Supra-sphincteric Fistula: Very Rare Cause- Iatrogenic Very similar to high level T-S Type.

48. Extra-sphincteric Fistula: Run without specific relation to the sphincter Cause- Trauma or Pelvic Disease. Originates in the rectal Wall Tracks lateral to both Sphincters

49. Clinical Assessment/Investigation: A. Complete the General advise like -Obstetric history -Gastrointestinal history -Surgical history -Continence history -Proctosigmoidoscopy examination

50. Clinical Assessment/Investigation B.Important point about fistula Site of the internal opening & External opening. Course of the primary track Presence of the secondary extension Presence of other associated condition.

51. Goodsall’s Rule:

52. Clinical Assessment/Investigation C.Hydrogen peroxide injection : -Inject through the external opening -Find out the site of internal opening

53. Clinical Assessment/Investigation D.Gentle use of Probe

54. Clinical Assessment/Investigation E. Manometry: Resting anal tone Functional anal sphincter length Voluntary squeeze

55. F: Endoluminal USG: Sphincter integrity, tract & anal canal.

56. MRI : Gold Standard Demonstrate the secondary extension

57. Fistulography :

58. Demonstration of Fistula in Ano on CT

59. Management : Fistula in Ano: Fistulotomy Fistulectomy Setons- Loose & Tight Setons Biological Agent- Fibrin Glue Advancement Flap- To preserve both anatomy & Function . VAAFT: Video Assisted Anal Fistula Treatment.

60. Fistulotomy Laid open the track( John of Arderne) Indication : Intersphincteric & Transsphincteric Fistula. Steps: - Position - Lithotomy - Anesthesia - G/A. -Identified the internal opening

61. Fistulotomy: Steps Continue 4. Pass the probe through E.O to E.O to the I.O 5. The track is laid open over the probe. 6. Curette the granulation tissue and sent for HPE. 7.Wound edges are trimmed E.O I.O Probe Laid open

62. Fistulotomy:

63. FISTULECTOMY: Excision of whole Fistulous tract: Probe

64. Setons:Bristle material Thread Wire Proline Infant feeding tube Ksharsutra: kshar- corrosive & Sutra- Thread

65. Setons: Loose : seton Non-absorbable Non-Degradable Comfortable No intent to cut Ideal seton No tension

66. Uses of Loose Setons: 1 .Crohn’s Diseases & Problematic fistulae- To prevent the incontinence. 2.Prior steps of an “Advanced technique” like Fistulectomy, Advanced flap & Cutting Seton 3. Staged fistulotomy 4. Therapeutic strategy to preserve the external sphincter in trans-sphincteric fistula

67. Purpose to use of Loose Setons: Purpose: - Eradicate the acute sepsis & Secondary extension - To simplify the fistula - Allow fibrosis

68. Tight/Cutting Seton Placed with intention to cut the enclosed muscles. Also k/as “ Cheese Wiring through the ice” Fistulous tract is replaced by a thin line of fibrosis. Types- Elastic & Self cutting - Non elastic & tightened - Ksharsutra- most commonly used.

69. Tie the kharsutra to the eye of probe E.O Ksharsutra

70. Ksharsutra coming out through I.O I.O E.O

71. Cuting & healing simultaneously.

72. Biological Agent to fill the fistula.

73. Insertion of Fibrin Glue in the fistula

74. VAAFT:Video Assisted Anal Fistula Treatment Visualization of the F.tract with the Fistuloscope Aim is to find the correct position of Internal Opening. A stapler to close the Internal opening. Fistuloscopy is done under irrigation & F.tract as well as all granulation tissues are coagulated Total closure of the Internal opening with inserting the Cyanoacrylate

75. Home message:Fissure : Post-midline is the commonest site for Fissure ( 90% ) Main cause is Constipation – hard stool i.e trauma Pain during defecation is the commonest complaint. Clinical examination is sufficient to diagnose it GTN & Diltiazam 2% local application along with diet modification have an excellent result as equivalent to LAS. FISTULA IN ANO: Persistent anal gland infection is the commonest cause of Fistula in Ano

76. Home message: Goodsall’s rule is very useful in determining the site of external & internal opening as well as about the fistulous tract. Intersphincteric type of fistula in Ano is the commonest type ( 45%) MRI is the gold standard for fistula imaging in complicated fistula Fistulotomy, Fistulectomy & Ksharsutra are common procedure to treat it. VAAFT is the recent advance in Fistula surgery

77. Pilonidal sinus

78. Definition: Infection of the skin and subcutaneous tissue at or near the upper part of the natal cleft of the buttocks. NOT a true cyst

79. History 1833- hair containing cyst located just below the coccyx Mayo 1880- Hodge coined the term “pilonidal” Nest of hair In 19 th and 20 th century – considered to be congenital

80. In WW II Patey and Scarf – hypothesised origin of pilonidal sinus acquired by penetration of hair into subcutaneous tissue.

81. What causes pilonidal sinus??? Midline holes – Hair follicles that have enlarged Pulling forces between sacrum and skin Force concentrate on 1mm2 area where the narrow gluteal crease comes in close contact with the sharp angle of sacrum

82. Weakest point of skin gives way first– Skin at the bottom of the follicle. Primary cause – “Pit” Secondary casue – “ Hair follicles”

83. Cause of pilonidal sinus (1) Invader hair (2) Force causing hair penetration (3) Vulnerability of skin

84. Anatomy Intergluteal cleft: A groove between the buttocks that extends from just below the sacrum to the perineum. Anchoring of the deep layers of skin overlying the coccyx to the anococcygeal raphe

85. Epidemiology Incidence : 26 per 100,000 Mean age: 19 years for women and 21 years for men Sex: M/F ratio – 2:1 to 4:1 Equal incidence of acute:chronic

86. Risk factors Overweight/ obesity Local trauma or irritation Sedentary lifestyle/prolonged sitting Deep natal cleft Family history

87. Theory Acquired vs Congenital Tendency to recur following complete excision. Tendency to occur in places other than natal cleft.

88. Pathogenesis Hair and inflammation – inciting factors On sitting/bending natal cleft stretches-  breakage of follicles-  opening of a pore/pit-  collection of debris - pilonidal sinus - abscess Proof?? Pilonidal tract extends cephalad. Cavity contains hair, debris or granulation tissue.

89. Clinical manifestations Patient presentation: Acute onset mild to severe pain (sitting/bending) Intermittent mucoid/purulent/bloody discharge Recurrent / persisting pain Fever / malaise

90. Physical examination One/more pits in the natal cleft +/- painless sinus opening cephalad and lateral to cleft Tender mass or sinus draining mucoid/bloody or purulent fluid

91. Diagnosis Clinical Finding a pore/sinus in the natal cleft No imaging required

92. Differential diagnosis Perianal abscess/ fistula Hidradenitis suppurativa Perianal complications of Crohn’s disease Skin abscess/ furuncle/ carbuncle Folliculitis

93. Surgical treatment Drainage with/ without excision Marsupialisation Excision with primary closure Excision with grafting Sinus extraction Sclerosing injections

94. ACUTE ABSCESS -- Incision is performed lateral to midline midline over area of maximum fluctuance - Packing of the wound - Marsupialisation

95. Problems Recurrence rates are from 20 – 55 % During a 3 year period, 73 patients treated with I & D for first episode of pilonidal abscess Healed : 42 patients (58%; 95% CI) within 10 weeks Recurrence : 9 patients (21%;95% CI) Follow up period : median of 60 months Constant cure rate : 76% (CI 95%) after 18 months Prognosis after simple incision and drainage for a first-episode acute pilonidal abscess. Jensen SL, Harling H Br J Surg. 1988;75(1):60.

96. Chronic pilonidal sinus Surgical approaches: Excision Wound closure Primary closure in midline/ off midline > Z plasty > V-Y advancement flap > Rhomboid flap ( limberg ) (2) Reconstruction using flaps

97. Karydakis surgery Karydakis believed that hair insertion is the cause for pilonidal sinus Low recurrence rates due to: Wound placed away from midline Resulting new natal cleft was shallower Problems Sutured taken over the presacral fascia causing pain Patients requiring GA Prolonged hospital stay

98. Modified Karydakis/Basscom II/Cleft lip Use of shallow cleft Under LA Causes less pain as presacral fascia not included

99. Z- plasty

100. Z-plasty for pilonidal sinus

101. V-Y Plasty

102. Limberg flap

103. Primary versus delayed closure Time to wound healing: Total of 13 trials done (n= 1421) included data for time for wound healing (not aggregrated due to high heterogeneity) 9 trials reported a faster time to wound healing following primary closure . Largest trial (n=380) found that patients undergoing primary repair had a significant faster wound healing rate compared to open wounds(14.5 versus 60 days) Excision with or without primary closure for pilonidal sinus disease . Al-Salamah SM, Hussain MI, Mirza SM; J Pak Med Assoc. 2007 Aug;57(8):388-91.

104. Time to return to work: - A total of 11 trials done (n=1729) - 9 studies reported a faster return to work following primary closure The largest study (n=144) found that patients had a faster return to work following primary repair compared to delayed closure .(11.9 versus 17.5 days) Comparison of outcomes in Z-plasty and delayed healing by secondary intention of the wound after excision of the sacral pilonidal sinus: results of a randomized, clinical trial . Fazeli MS, Adel MG, Lebaschi AH Dis Colon Rectum. 2006 Dec;49(12):1831-6.

105. Recurrence rates : - Based on 16 trials including 1666 patients , the overall recurrence rate was 6.9%. - Primary wound closure was associated with a HIGHER recurrence rate compared to delayed wound closure. (8.7 versus 5.3 percent, relative risk RR [1.5] CI1.08-2.17

106. Rate of surgical site infection: Based on 10 trials including 1231 patients NO SIGNIFICANT DIFFERENCE between primary and delayed wound closure and risk of SSI (8 versus 10% , RR 0.76, CI 0.54-1.08)

107. Off midline versus midline primary sutured closures Sutured off midline wounds – less time to heal (n=100 , mean difference 5.4 days, 95% CI 2.3-8.5) Risk of SSI was significantly lower for off midline wounds (n=541, RR 0.27, CI 0.13-0.54) Risk of recurrence LOWER for off midline wounds (n=574, RR=0.22, CI 0.11-0.43) The overall complication rate was LOWER for off midline wounds (n=461, RR=0.23, CI0.08-0.66)

108. Types of off-midline closure While an off midline approach is superior , optimal off midline approach has not been identified. Two trials were perfomed to determine recurrence and complications rates between lateral advancement flaps ( modified Karydakis) and modified Limberg’s flap

109. N = 120 Karydakis lateral advancment flap Limberg’s flap Wound disruption patients 9 patients Rate of complications 23 % 40 % Wound infection 3% 5% Subcutaneous fluid collection 5% 0% Hypoaesthesia 10% 23% Recurrence rates 3% 2% Comparison of short-term results between the modified Karydakis flap and the modified Limberg flap in the management of pilonidal sinus disease: a randomized controlled study. Bessa SS Dis Colon Rectum. 2013;56(4):491.

110. N=295 Karydakis flap Limberg Seroma formation 19.8% 7.4% Wound dehiscence 15.4% 3.7% Flap maceration 11% 3.7% Which flap method should be preferred for the treatment of pilonidal sinus? A prospective randomized study. Arslan K, Said Kokcam S, Koksal H, Turan E, Atay A, Dogru O Tech Coloproctol. 2013 Feb;

111. In summary Patients with acute pilonidal sinus – I & D For patients with chronic pilonidal sinus – An excision of the sinus and all tracts A primary closure is associated with faster wound healing – however a delayed closure is associated with less recurrence For patients undergoing primary wound closure – off midline closure recommended

112. Role of Abx Generally limited to clinical setting of cellulitis Indications: Immunosuppresion High risk for Endocarditis MRSA Concurrent systemic illness