Fi t s l es é p r é i ana es, t ra t emen l e l us ffi cace 2012

Transcription

1 Fistules périanales, éi traitement t le plus efficace en 2012? F. Ris, B. Roche Interdisziplinäre Viszerale und Medizin am Inselspital 2012, UPDATE Proktologie Inselspital Bern 18 th October 2012

2 1686 Incision of louis XIV Félix & Bessières

3 ETIOLOGY 9 90% primary crypto g glandular Inselspital 18th October 2012

4 10% secondary Hydroadenitis, cebaceus adenitis Fissure Pilonidal Cyst Infectious disease: tbc, STD Carcinoma: anal, rectum, leukemia Post radiotherapy Debilitating illnesses (leukemia, diabetes, AIDS) Crohn s disease, HRC Iatrogenic: injections, hemorroidectomy, sclerotherapy, prostatectomy Trauma: foreign body, penetrating wounds, obstetrical tears

5 Perianal abscess Pi Primum movens of the fistula?

6 Different Abcess localisation

7 Therapeutic options Simple drainage Local anaesthesia Drainage curettage and seton General anaesthesia Drainage + fistula track treatment

8 Initial managment Litterature: t Randomised trial incision (I) versus fistulotomy (F) Y Patients Recurrence% Incontinence% I F Hebjorn et al I = F I < F Oliver et al I (29) > F (5) I (2.8) < F (36.7) Schouten et al I (40.6) > F (2.9) I (21.4) < F (39.4) Seow-Choen I (12 ) > F (0) I = Incision F= Fistulectomy

9 Simple drainage or drainage & fistula track treatment in anorectal oec abscess?

10 Simple drainage or drainage & fistula track treatment in anorectal oec abscess?

11 Natural history of the fistula 20% will close the fistula tract Putting a Seton initialy will prevent this natural healing process

12 Initial Surgical managment Seton drainage, for up to 3-6 months After healing of the abcess cavity, in case of residual fistula Prevent reccurence of the abcess

13 Initial Surgical managment Prolène 4-0 is good, 2 stiches

14 Initial Surgical managment

15 Fistula : Goals for the surgeon Define the exact anatomy of the fistulous tract Drain any associated sepsis Eradicate all the fistulous tractt Prevent recurrence Maintain sphincter function and continence Minimize healing time

16 Fistula : Goals for the surgeon surgeon Inselspital 18th October 2012

17 Current surgical managment Fistulectomy (low, distal fistula) Fistulectomy and mucosal flap Occlusion technique Plug (porcine collagen) Glue

18 Alternative surgical managment Cutting setton (40-60% risk of incontinence) Van Tests. BLS 1995;82:895-7 Hämäläinen KP. Dis Col Rect 1997;40: Garcia-Aguilar J. BJS 1998;85:243-5 Transsphincteric fistulectomy and sphincter reconstruction (>30% incontinence) Both avoided because of fecal incontinence

19 Fistulectomy: Fistulectomy

20 Fistulectomy Anodermic reconstruction Complete excision of primary orifice

21 Fistulectomy: results 464 fistulectomies 24 recurrences e ces (5.2%) No incontinence

22 Sphincter preserving complex fistula treatment

23 Sphincter preserving fistula treatment Difficult and high rate of complications such as anal incontinence treatment options: Mucosal flap New sphincter preserving treatments : Plugs, LIFT, VAAFT OVESCO, etc

24 Fistulectomy Mucosal flap

25 Preoperative care Mucosal flap technique: Antibiotic prophylaxis No Enema No Epilation No Stoma

26 Contraindications ti to flaps: Acute inflammation Extensive suture line tension Anastomosis in diseased tissue radiation fistula neoplastic fistula active Crohn s disease

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28 Postoperative care: Shower 3-6 times daily NSAID drugs Cream in the external wound Bulk forming agent or oil 1 x daily Close FU (Weekly inspection)

29 Advantages of the flap procedure: No sphincter division No keyhole deformity Less pain and rapid healing May repeat in case of recurrences

30 Geneva Results: 136 consecutive cases 82 men 54 women Age y M = 44.6 y

31 Inpatient /outpatient ratio Inpatient 97 (71.3%) Outpatient ti t 39 (28.7%)

32 Success rate Primary success (1 month) 97 (71.3%) Secondary success (delayed or minor op) 17 (12.5%) Recurrences at 1 year follow up 22 (16.2%) out of 136 flaps 83.8% 8% of success

33 Hospital stay Postoperative stay 4.1 d Wound healing delay 32.8 d (12-63) 1 suture leak No septic complications

34 continence No liquid nor solid stool incontinence 1 faecal soiling 3 gas incontinence 1 sphincter rigidity (11 operations)

35 The mucosal flap in the treatment of complex anal fistulae allows: Elimination of inflammatory tissue Sphincter preservation Locoregional anesthesia Outpatients

36 Plugs? New Surgical managment Lift procedure? VAAFT? OVESCO clip Stem cells

37 Plug technique: Identification of the fistula tract with seton Tract is washed and brushed Plug is pulled out from the primary orifice

38 Plug technique: t h i Endo anal fixation

39 From April 2007 to February patients: 12 male 4 female Complex crypto glandular fistula Seton drainage 3 months before the operation Results!!!!

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41 Results 15 recurrences (93.7%) Three month success rate 6.3% No incontinence

42 Author Date Journal Success Rate Number patients Follow-up time Champagne, BJ, 2006, Dec. Dis. Colon 83% n=46 et al Rectum F/U = 6 24 mo med = 12 mo Van Koperen, PJ, et al Scwandner, O, et al 2007, Dec. Dis. Colon Rectum 2008, Mar. Int. J Colorectal Dis. 41% n = 17 F/U = 3 9 mo med = 7mo 45.5% n = 19 F/U = 9 mo Ky, AJ, et al 2008, Mar. 11 Dis Colon 54.6% n = 45 Rectum F/U = 3 13 mo med = 6.5 mo 24% Lawes, DA et al 2008, Mar. 29 World J Surg 24% n = 17 F/U = 7.4 mo

43 Cryptoglandular, single tract, high TS 32 patients received the treatment Success rate: Plug 3/15 Flap 14/16 Early closure of the study

44 medium and high TS Cryptoglandular tract, 60 patients received the treatment Success rate: Plug 29% Flap 48% Van koperen BJS 2011

45 Variables predicting failures Smocking Diabetes Short fistula tract <4 cm High transphincteric Posterior fistula Previous plug failure

46 New plugs

47 New Gore plugs Author journal N Success rate Ratto Favreau Weltzer Colorectal disease 2012 Colorectal disease /11 9 1/9 De la Portilla DCR /19 Buchberg Am Surg /10 total 49 18/49 (37%)

48 The chinese plug 100% success rate Sang WL et al, W J Gastroenterology 2008

49 Conclusion PLUG: Easy to perform but: Plug price 800 CHF High recurrences rate 3 rd operation, most of the time more difficult.

50 LIFT procedure LIFT Ligation of Inter sphincteric Fistula Tract Described by Rojanasankul in 2007 Success rates of > 94% No deterioration in continence

51 LIFT procedure Tract probed and circumanal incision

52 LIFT procedure Complete dissection of tract

53 LIFT procedure Tract suture ligated and divided

54 LIFT procedure LIFT wound closed

55 LIFT procedure Authors Year Country N Success Rate (%) Continence Follow Up (weeks) Rojanasakul et al 2007 Thailand (94) normal not formally assessed Shanwani et al 2010 Malaysia (82) Not formally assessed Bleier et al 2010 USA (57) No FI Not formally assessed Max (90% F/U) Aboulian et al 2011 USA (68) Not assessed 27 Ellis (BioLIFT) 2010 USA (94) Not formally assessed 29 patients for 12 months Abcarian Am 2012 USA 40 29(74) Not formally assessed 12

56 LIFT is it a new technique? Goligher (Leeds 1967) 97) Excision of internal sphincter at fistula site for drainage and access to fistulotomy Healing 25/25 Incontinence: flatus 8, liquid 4,solids 7 Matos (ST Mark s, 1993) Intersphincteric approach for fistulectomy and closure of the internal sphincter from within Healing 7/13 Incontinence :flatus 3, liquid 1,solids 0

57 LIFT procedure The LIFT procedure is simple, safe and effective The LIFT procedure has no reported adverse effects on continence Failures at LIFT can be transformed to secondary closures (transphincteric fistula into low inter sphincteric fistulae amendable to fistulotomy)

58 Video assisted anal fistula treatment (VAAFT) a novel sphincter saving procedure to repair complex anal fistulas, rigid fistuloscopy

59 Video assisted anal fistula treatment (VAAFT) Identification and lifting of the internal opening

60 Video assisted anal fistula treatment (VAAFT) Cleaning of the tract by fulguration, brushing and washing

61 Video assisted anal fistula treatment (VAAFT) Closure of the internal opening with a stapler or a flap + injection of cyanoacrylate glue below the stapple line!

62 Video assisted anal fistula treatment (VAAFT) From May 2006 to May patients using VAAFT. 98 patients were followed up for a minimum of 6 months. No major complications Pi Primary healing in 72 patients t (73.5%) at 2 3 months. followed up >1 year for 62 patients, among them 87.1% healed

63 Video assisted anal fistula Sound principle p treatment (VAAFT) Cost? (equipment and staplers) Lack of evidence (one man show)

64 Stem cells Injection of stem cells in the fistula tract after closure of the internal opening Healing at 8 weeks Healing at one year Healing at end of FU 38 months Fibrin glue 3/25(12%) 3/25(12%) 2/25(8%) Fibrin glue + ASCs 17/24(71%) 15/24(63%) 7/21(33%) Garcia-Olmo et al, Exp Op. Biol Ther, 2008 Guadelajara et al, Int J Colorectal disease 2012

65 Mesenchymal Stem cells Intraveinous injection of mesenchymal stem cells 2x 1 week apart, Crohn s, clinical response at 6 weeks Response in 3 patients /9 Duijvestein M et al, GUT crohn s patients intra and perifistular injection of MSCs median 4x1x/4 weeks FU 1 year Response in 7/10, partial 3/10 role of Treg? Ciccocioppo et al, GUT 2011

66 Mesenchymal Stem cells Conclusion: Poor results so far, MSCs in Crohn could be interesting but very preliminary i

67 Ovesco clip Prosst et al, Minimally Invasive Therapy. 2012;21:

68 Ovesco clip

69 Ovesco clip

70 Conclusions Simple drainage of abscess Simple treatment t t for distal fistulas (fistulectomy)

71 Conclusions Mucosal flap remains the gold standard in 2012 Plugs fails in > 50%, 93% in our hands

72 Conclusions LIFT maybe useful Stem cells very ypreliminary OVESCO?

73 Geneva University it Hospital Geneva Course in Proctology 4-7 February 2013 Post Graduate Training day Constipation February 8 th 2013 Inscription : Tél.: Fax: martine.martelletta@hcuge.ch