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Fistula

ANAL  FISTULA

Scalpel surgery is now rarely needed

Dr Arun Prasad, MS, FRCS, FRCSEd

Senior Consultant Surgeon Minimal Access Surgery

Apollo Hospital, New Delhi, India

Email: surgerytimes@gmail.com

Tel: ++91-11-29871202

 

Contents ( Please click )

               

 

WHICH DISEASE ??

  BLEEDING PAIN DISCHARGE CLICK BELOW
PILES / HEMORRHOIDS ++++ + + piles
ANAL FISSURE ++ ++++ + fissure
ANAL FISTULA + ++ ++++ fistula

Please select from the above table, the most appropriate disease you may be looking for. The above is a rough guideline and needs to be confirmed with local examination by a specialist doctor.

DEFINITION

Piles in India is generally used as a loose common term to include piles, hemorrhoids, fistulas and fissures with skin tags.

True piles are those that present with PAINLESS BLEEDING due to swelling up of blood vessels in the anal canal.

Fissure with skin tags lead to painful bleeding due to a small cut at the anal margin. It is usually associated with skin tags that are mistakenly called piles. This condition resolves in majority of the patients by use of creams and medicines to treat constipation. Skin tags can sometimes be a source of great irritation due to micro-incontinence. Rarely the patient needs surgery.

Fistulas are an abnormal small opening next to the anus from where discharge keeps occurring. This is due to a tunnel like tract between the anal canal and the skin. This condition always requires surgery for cure.

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CAUSES AND TYPES

Fistula-in-ano is nearly always caused by a previous anorectal abscess. Main cause of this is an injury at external anal area due to scratching, shaving and infected hair roots etc. After injury, infection occurs and an abscess is formed. Usually that abscess drains spontaneously making an opening which may be a Fistula in ano. After spontaneous drainage or surgical occasionally a tract is left behind, causing recurrent symptoms.

Occassionally they develop secondary to trauma, Crohn disease, fissures, cancer, radiotherapy, tuberculosis, and other infections.

 

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      FEATURES

    COMMON COMPLAINTS

    Fistula in ano generally presents as a small boil - like opening around the anus at a distance of few mm. to couple of inches, in any direction. Pus or blood keeps on oozing out of this opening, continuously.

    Patients often give a history of previous pain, swelling, and spontaneous or planned surgical drainage of an anorectal abscess.  

    EXAMINATION FINDINGS

    Perianal discharge

    Painfull swelling

    Bleeding

    Skin excoriation

    External opening

    Physical examination findings remain the mainstay of diagnosis.

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        DIAGNOSIS AND INVESTIGATIONS

    The diagnosis can be made by inspection, palpation, and/or Proctoscopic examination by a Specialist Doctor.

    RADIOLOGICAL INVESTIGATIONS

    These are not performed for routine fistula evaluation. They can be helpful when the primary opening is difficult to identify or in the case of recurrent or multiple fistulae to identify secondary tracts or missed primary openings.

    Fistulography

    This involves injection of contrast via the external opening, which is followed by x-ray images to outline the course of the fistula tract.

    MRI ( Most reliable investigation )

    Findings show 80-90% concordance with operative findings when observing a primary tract course and secondary extensions.

    It is the most reliable investigation to show if the fistula is HIGH ( i.e. extending above the sphincter muscles that control the continence/ holding control of feces ) or LOW ( i.e. not involving the muscles.

    This above finding is crucial as it decides if the surgery would be in 1 or multiple stages.

    CT scan

    A CT scan is more helpful in the setting of perirectal inflammatory disease than in the setting of small fistulae because it is better for delineating fluid pockets that require drainage than for small fistulae.

    Barium series

    This is useful for patients with multiple fistulae or recurrent disease to help rule out inflammatory bowel disease.

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           TREATMENT OPTIONS

  • MEDICAL TREATMENT  

  • No definitive medical therapy is available; long-term antibiotic prophylaxis may have a role in recurrent.

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    SURGERY

    Fistulotomy/fistulectomy

    The laying-open technique (fistulotomy) is useful for 85-95% of primary fistulae.

    Complete fistulectomy creates larger wounds that take longer to heal and offers no recurrence advantage over fistulotomy.

    Seton placement

    A seton ( thread tie ) can be placed alone, combined with fistulotomy, or in a staged fashion. This technique is useful in patients with the following conditions:

    Complex fistulae (ie, high transsphincteric, suprasphincteric, extrasphincteric) or multiple fistulae

    Recurrent fistulae after previous fistulotomy

    With time, healing occurs above the seton as it gradually cuts through the muscles. The seton is tightened on subsequent weekly visits until it falls out. This could take 2-5 visits to cure.

    KSHARASUTRA ( Indian traditional seton )

    A cutting seton can also be used without associated fistulotomy.

    The 'KsharaSutra' therapy has its origin in the age old Ayurveda. The earliest references available are in 'Sushruta Samhita' - in the treatise relating to the treatment of 'Nari Vrana' (sinus), Although it has gained more popularity in relation to 'Bhagandra' (Anal Fistulas). In the chapter on 'Bhagandra' (Anal Fistulas) the author advises the reader thus - "The wise physician should use the 'KsharaSutra' to cut through the 'Bhagandra' (Anal Fistulas). The two loose ends of the thread - ( a ) coming out of the external opening, and (b) coming out of the anal canal, are gently approximated at the external opening and three knots tied. The 'KsharaSutra' ( seton ) is thus changed every week, till it cuts through the fistulous tract. The average cutting speed is about 0.5 cm/week. The cutting speed, however, may vary from patient to patient. This simultaneous process of cutting through the tract towards periphery, and healing in the opposite direction, eventually leaves the complete tract healed, when 'KsharaSutra' ( seton ) cuts through the tract.

    A lot has been talked about Laser Surgery. This as opposed to conventional scalpel and electrocautery techniques, is associated with many myths. Many doctors and quacks have touted painless or decreased pain and shortened healing times as advantages to performing surgery in this area by laser. No documented studies support these claims. In fact, most studies across the world have shown that Laser piles surgery has no advantages over standard techniques; it is also quite expensive and no less painful.

    FUTURE 

    Recent advances in biotechnology have led to the development of many new tissue-adhesive materials. Reported series exist of fibrin glue treatment of fistula-in-ano, with 1-year follow-up success rates approaching 60%. By its less invasive nature, this therapy leads to decreased postoperative morbidity. However, information on long-term success rates and modification of techniques will have to await further studies.

     

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    COST OF TREATMENT

     

    A consultation with a specialist doctor including a proctoscopic examination would cost between Rs 900 to Rs 1500. Medical treatment for 2 weeks would cost around Rs 500. Surgery if needed could cost between Rs 20,000 to 40,000 depending on the hospital / clinic.

     

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    The author Dr Arun Prasad MS, FRCS is a senior Gastro-Intestinal and laparoscopic surgeon at Apollo Hospital, New Delhi. He has been trained in Proctology Surgery at the prestigious Charing Cross Hospital in London after qualifying for the FRCS. He is one of the first surgeons in India to have started the Stapled Hemorrhoidectomy procedure and is a trainer in India for same.

     

    CONTACT INFORMATION

    WEBSITE ( HOMEPAGE)

    FREE EMAIL ADVICE

    ABOUT DR ARUN PRASAD

    PHONE

    91-11-26925801 EXT 1280

     

     

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