Herand Abcarian Editor. Anal Fistula. Principles and Management

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2 Herand Abcarian Editor Anal Fistula Principles and Management 123

3 Anal Fistula

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5 Herand Abcarian Editor Anal Fistula Principles and Management

6 Editor Herand Abcarian, M.D., F.A.C.S. Professor of Surgery The University of Illinois at Chicago Chairman, Division of Colon and Rectal Surgery John Stroger Hospital of Cook Country Chicago, IL, USA ISBN ISBN (ebook) DOI / Springer New York Heidelberg Dordrecht London Library of Congress Control Number: Springer Science+Business Media New York 2014 This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. Exempted from this legal reservation are brief excerpts in connection with reviews or scholarly analysis or material supplied specifically for the purpose of being entered and executed on a computer system, for exclusive use by the purchaser of the work. Duplication of this publication or parts thereof is permitted only under the provisions of the Copyright Law of the Publisher s location, in its current version, and permission for use must always be obtained from Springer. Permissions for use may be obtained through RightsLink at the Copyright Clearance Center. Violations are liable to prosecution under the respective Copyright Law. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. While the advice and information in this book are believed to be true and accurate at the date of publication, neither the authors nor the editors nor the publisher can accept any legal responsibility for any errors or omissions that may be made. The publisher makes no warranty, express or implied, with respect to the material contained herein. Printed on acid-free paper Springer is part of Springer Science+Business Media (

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9 Foreword Anal abscess and fistula have been a scourge of civilization for centuries. Hippocrates offered a treatise on fistula in ancient Greece. In the 1300s John of Arderne, considered by many to be the father of modern British surgery, was notorious for his successful treatment of fistulas in Knights of the Round Table. King Louis XIV of France suffered from a famous chronic fistula that gave rise to the use of a cutting seton in the1600s. Frederick Salmon in 1854 opened in downtown London the St. Mark s Hospital for Fistula and other Diseases of the Rectum. This institution is considered to be the birthplace of modern colon and rectal surgery. To this institution Dr. Joseph Mathews traveled to study anal surgery and returned to Louisville, Kentucky, to establish the first Department of Proctology in the United States, applying the knowledge gained at St. Mark s. Dr. Mathews was the first American surgeon to limit his practice to anorectal surgery and went on to become a founder of the American Proctologic Association (the precursor of the American Society of Colon and Rectal Surgeons) and its first president. Consistent among these historical developments is the clinicopathologic entity of anal fistula. Despite the relatively high frequency of this disease, treatment remains controversial primarily because of the risk of incontinence after surgery. As a result, alternate operative procedures and other palliative adjuncts that control infection without sacrificing muscle continue to evolve. Increasingly sophisticated diagnostic evaluation and imaging studies have resulted in an increasing array of possible treatments, including in some instances a return to more basic fistula operations. This volume on anal fistula is, to my knowledge, the most recent and comprehensive reference for this disease, including even a discussion of the use of stem cells. The contributors are all experienced clinicians; this lends immeasurable credibility to each of their chapters. Of equal or greater importance is the experience and expertise of the editor. As a result, we are presented with an invaluable resource to assist in the diagnosis and treatment of a historically challenging problem. Boston, MA, USA David J. Schoetz Jr., M.D. vii

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11 Preface It is almost 2 decades since the publication of the last book dedicated solely to fistula in ano by Phillips and Lunniss [1]. Since then the readers interested in management of fistula in ano have had to search the textbooks of Surgery and Colon and Rectal Surgery for relevant information. The need for a more recent book dedicated to fistula in ano arises from the proliferation of sphincter sparing procedures which have dominated the colon and rectal surgery literature since the mid 1990s. This volume represents a compilation of many chapters dealing with alternatives in sphincter sparing surgery as well as traditional fistulotomy. In addition, basic topics such as applied anatomy, relationship of anorectal abscess and fistulas, clinical assessment, and current imaging modalities have been covered. The most recent developments include the use of adiposederived stem cells in the treatment of anal fistula, video-assisted anal fistula treatment (VAAFT), and ligation of intersphincteric fistula tract (LIFT). In addition to incidence and prevalence, causes of operative failures, fistula surgery in the era of evidence-based medicine, as well as alternative approaches to fistulas which recur despite all therapeutic measures are also addressed in this volume. It is impossible to have a multi-author book and not have any redundancy among chapters. However, the repetition if any, within the context of the covered topics, in my opinion, is a plus rather than a distraction. It is my hope that this volume will be a useful companion for the interested surgeon and will be a source of reference for many alternative treatments of this frustrating disease. Chicago, IL, USA Herand Abcarian, M.D., F.A.C.S. Reference Phillips RK, Lunniss PJ, editors. Anal fistula: surgical evaluation and management. London: Hodder Education; ix

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13 Contents 1 Epidemiology, Incidence and Prevalence of Fistula in Ano... 1 Richard L. Nelson and Herand Abcarian 2 Applied Anatomy... 5 Russell K. Pearl 3 Relationship of Abscess to Fistula Herand Abcarian 4 Classification and Treatment of Anorectal Infections Adrian E. Ortega and Kyle G. Cologne 5 Clinical Assessment of Anal Fistulas Herand Abcarian 6 Clinical Assessment and Imaging Modalities of Fistula in Ano Kyle G. Cologne, Juan Antonio Villanueva-Herrero, Enrique Montaño-Torres, and Adrian E. Ortega 7 Classification and Management Strategies Herand Abcarian 8 Seton (Loose, Cutting, Chemical) Vamsi R. Velchuru 9 Fistulotomy and Lay Open Technique Philip Tozer and Robin K.S. Phillips 10 Fistulectomy with Primary Sphincter Reconstruction Alexander Herold 11 Fibrin Sealant José R. Cintron 12 Biologic Fistula Plugs Samuel Eisenstein and Alex Jenny Ky 13 Synthetic Fistula Plug Alex Jenny Ky, Michael Polcino, and Alero T. Nanna 14 Endorectal Advancement Flap Christine C. Jensen 15 Dermal Advancement Flap Christine C. Jensen 16 Ligation of Intersphincteric Fistula Tract (LIFT) Ariane M. Abcarian xi

14 xii Contents 17 Video-Assisted Anal Fistula Treatment (VAAFT) Piercarlo Meinero and Lorenzo Mori 18 Stem Cell Application in Fistula Disease Damian Garcia-Olmo and Hector Guadalajara-Labajo 19 Crohn s Disease James Fleshman and Rachel Tay 20 Tuberculosis Fistulas Pravin Jaiprakash Gupta 21 Fistula Surgery in the Era of Evidence-Based Medicine Richard L. Nelson and Herand Abcarian 22 Causes of Operative Failure Mohammad Ali Abbass and Maher Aref Abbas 23 Recurrence/Persistence After Fistula Treatment: What Next? Herand Abcarian Index

15 Contributors Herand Abcarian, M.D., F.A.C.S. The University of Illinois at Chicago, Division of Colon and Rectal Surgery, John Stroger Hospital of Cook Country, IL, USA Maher Aref Abbass, M.D., F.A.C.S., F.A.S.C.R.S. Department of Surgery, Kaiser Permanente, Los Angeles, CA, USA Center for Minimally Invasive Surgery, Los Angeles Medical Center, Los Angeles, CA, USA Mohammad Ali Abbas, M.D. Department of Surgery, Kaiser Permanente, Los Angeles Medical Center, Los Angeles, CA, USA Ariane M. Abcarian, M.D. Department of Surgery, University of Minnesota, Chicago, MN, USA José R. Cintron, M.D., F.A.C.S., F.A.S.C.R.S. Division of Colon and Rectal Surgery, John H. Stroger Jr. Hospital of Cook County, Chicago, IL, USA Kyle G. Cologne, M.D. Clinic Tower, Los Angeles, CA, USA Samuel Eisenstein, M.D. Department of Surgery, Mount Sinai School of Medicine, New York, NY, USA James Fleshman, M.D., F.A.C.S., F.A.S.C.R.S. Department of Surgery, Baylor University Medical Center, Dallas, TX, USA Ross Fraser, C.I.S.S.P., I.S.S.A.P. Sextant Corporation, Toronto, ON, Canada Damian Garcia-Olmo, M.D., Ph.D. Colorectal Surgery Unit, La Paz University Hospital, Universidad Autonoma de Madrid, Madrid, Spain Hector Guadalajara-Labajo, M.D. Colorectal Surgery Unit, La Paz University Hospital, Universidad Autonoma de Madrid, Madrid, Spain Alexander Herold, M.D., Ph.D. Deutches End-und Dickdarm-Zentrum Mannheim, Mannheim, Germany Pravin Jaiprakash Gupta, MS, F.I.C.A., F.I.C.S., F.A.I.S., F.A.S.C.R.S. Fine Morning Hospital and Research Center, Nagpur, India Christine C. Jensen, M.D., M.P.H. Department of Surgery, University of Minnesota, St. Paul, MN, USA Alex Jenny Ky, B.A., M.D. Department of Surgery, Mount Sinai School of Medicine, New York, NY, USA Piercarlo Meinero, M.D. Department of General Surgery, Sestri Levante Hospital, ASL 4 Chiavarese, Sestri Levante, Genova, Italy Enrique Montaño-Torres, M.D. Clinica Especializada en Colon, Recto y Ano (CECRA) and Hospital General Regional de Iztapalapa, Mexico DF, Mexico xiii