Ligation of Intersphincteric Fistulous Tract vs Endorectal Advancement.pptx

Fistula

1. Ligation of Intersphincteric Fistulous Tract vs Endorectal Advancement Flap for High-Type Fistula in Ano . supervised by: Presented by : Dr:mohammad yassen alkhuja Dr.ruqaya abdul kareem © 2022 by the American College of Surgeons. Published by Wolters Kluwer Health , Inc.

2. Fistula in ano is a common illness, with a prevalence of nearly 86 cases per million population. The disease is often neglected to chronicity before patients seek medi­cal help. The risks of postoperative anal incontinence and recurrence make the surgical cure of fistula problematic. Although several treatment methods have been described, none are free of recurrences or complications, and sometimes both

3. Low fistulas typically involve less than one-third of the external sphincter and are amenable to fis­tulotomy or fistulectomy . Incontinence rates after fistulec-tomy for a low-type fistula in ano are low (2% to 12%). division or excision of the fistulous tract is not a viable option in the treatment of high fistulas (involvement of >30% of external sphincter) because of the high risk of fecal incontinence (4% to 62%). The treatment of a high fistula in ano is based on the treatment of the tract and adequate drainage.

4. Endorectal advance­ment flap (ERAF) a 2- to 3-cm broad-base rectal flap was raised proximally, including the mucosa, submucosa , and some fibers of the internal sphincter. The flap was mobilized suf­ficiently to cover the internal opening with overlap. The mucosal flaps were closed, obliterating the dead space with the sutures . The fistulous tract extend­ing from the external opening to the external sphincter was excised and closed loosely after cleaning. The remaining fistula tract was curated to remove all granulation tissues.

5. The ligation of the intersphincteric fistulous tract (LIFT) described by Rojanasakul , its a sphincter-saving technique where the fistulous tract is disconnected at the intersphincteric plane, followed by coring out the fistulous tract .

6. METHODS   A randomized control trial was conducted on patients diagnosed with high fistula in ano ,the parameters studied were pain, hospital stay in hours, con­tinence, and quality of life at 6 months.   All patients aged 18 to 75 who consented to participate were included in the trial. Anal fistula associated with tuber­culosis, diabetes mellitus, ulcerative colitis, Crohn’s disease, and carcinoma, and those on immunosuppressants were excluded. Fistulas with multiple external openings, patients already enrolled in other studies, pregnant or lactating women, and patients unable to understand the nature of the study were also excluded.

7. The study participants were first examined by either of the 2 operat­ing surgeons . All patients with clinical suspicion of high-type fistulas were evaluated with MRI. The MRIs were reviewed by both the operating sur­geons and the radiologist. Both operating surgeons scruti­nized the cases to verify that either of the procedures (LIFT or ERAF) could be undertaken. Intersphincteric fistulas and fistulas on MRI that showed <30% sphincter involve­ment (low transsphincteric fistulas) were excluded.all relevant details like the internal and external openings , secondary tracts, and sphincter involvement was recorded.

8. The same investigator reviewed the patients 1 week after surgery to assess the pain and the surgical com­plications. No attempt was made to evaluate the integ­rity of the sphincter complex and the flap at this time point. The patients were advised to report new com­plaints like bleeding, discharge, urinary retention, fever, and continence. All patients were cautioned about mild incontinence due to stool softener used in the postop­erative period. Patients were advised to continue stool softener for at least 15 days and were asked to follow up on the first week, first month, and sixth month after surgery . A thorough perianal examination, including the digital rectal examination and proctoscopy , was done at the end of 1 month. The principal investigator also noted the anal sphincter’s tone and the integrity of the flap. Wound-related complications were also evaluated in the LIFT group.

9. discussion: . this study found that LIFT takes significantly less operative duration than ERAF, We found that LIFT is a relatively straightforward procedure compared with ERAF . ERAF requires meticulous dissection in the anal canal with rel­atively poor exposure compared with LIFT. The com­plexity of the procedure also increases due to bleeding during mucosal dissection. The flap’s survival depends on its base, which should be broad with healthy margins. Careful dissection with proper hemostasis is the prereq­uisite to flap survival.

10. Pain scores were significantly better in the LIFT group than in the ERAF group at the end of the first week and 6 months. In the first week, a higher pain score in the ERAFgroup was probably due to comparatively more dissection during flap raising. This may have resulted in more inflam­mation and hence more pain. A higher pain score in the ERAF group at 6 months was probably due to a higher failure rate than LIFT . The quality of life in the LIFT group was signif­icantly better than in the ERAF group. This can be explained by the higher rate of fistula closure in the LIFT group

11. , the incontinence rate of ERAF ranges from 0% to 51% and averages approximately 13%, but for LIFT, it is 1.4 % This wide variation in ERAF is because of the different types of flap raised.

12. in ERAF they observed partial dehiscence of the flap in 13 cases (30%) at the end of 1 month. The fistulas failed to heal in approximately 70% of the patients with flap dehiscence. Although we ensured that the flaps we raised were not too narrow and contained the mucosa, submucosa , and part of the musculature of the rectal wall, we still had a few flap dehiscence. Another significant factor leading to a low success rate may be related to the use of electrocautery during flap dissection. Although we tried to minimize the use of electrocautery during flap dissection, it could not be entirely avoided. Due to the rich vascular supply of the anal canal, mucosal dissection without electrocautery exceptionaly bloody, is In addition, bleeding during dissection may cause hemat­oma and infection during the postoperative period. Both hematoma and infection can hamper the healing and lead to flap dehiscence. In contrast, the use of electrocautery can cause ischemia at the edge of the flap. So, the use of excessive electrocautery should be avoided. Ultrasonic or harmonic scisor seem better.

13. Conclusion: At a median follow-up of 2 years, this single-center ran­domized controlled trial comparing 2 methods for treat­ing high anorectal fistulas of cryptoglandular origin found that the LIFT group had a better healing rate than the ERAF group. The results also suggest shorter operative duration, less postoperative pain, and better quality of life at 6 months in the LIFT group

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