Anal Fistula Clinical Trial
Official title:
LIFT Technique Versus Seton in Management of Anal Fistula
Abscesses and anal fistulas represent about 70% of perianal suppuration, with an estimated
incidence of 1/10,000 inhabitants per year and representing 5% of queries in coloproctology.
Anal fistula is the chronic phase of anorectal infection is characterized by chronic purulent
drainage or cyclic pain associated with acute relapse of the abscess followed by intermittent
spontaneous decompression.
Perianal fistulas have a troublesome pathology. The most widely accepted theory is that anal
abscess is caused by infection of an anal crypt gland. Suppuration moves from the anal gland
to the inter-sphincteric space, forming an abscess leading to the development of a fistula.
The incidence of fistula following an abscess is nearly 33%.
A fistula can cause pain, perianal swelling, discharge, bleeding, and other nonspecific
symptoms.
The diagnosis of fistula-in-ano may include a digital rectal examination, endoanal
ultrasound, fistulography, and MRI.
The management of the disease is difficult and sometimes a challenge for the surgeon.
The ideal treatment is based on three central principles: control of sepsis, closure of the
fistula and maintenance of continence.
The management of complex fistulas needs to balance the outcomes of cure and continence.
Success is usually determined by identification of the primary opening and dividing the least
amount of muscle as possible.
There is a risk of sphincter muscle damage during fistulotomy, which can lead to an
unacceptable risk of anal incontinence of varying degrees.
The surgical techniques described for the treatment of fistula-in-ano are fistulotomy,
core-out fistulectomy, seton placement, endorectal advancement flap, injection of fibrin
glue, insertion of a fistula plug, video-assisted anal fistula treatment (VAAFT) and ligation
of the intersphincteric fistula tract (LIFT), Surgical techniques are composed of 2 broad
categories, including sphincter sacrificing procedures, such as, fistulotomy, fistulectomy
and cutting seton. and sphincter-preserving procedures, such as fibrin glue injection,
fistula plug, rectal advancement flap, VAAFT and LIFT. In general, sphincter sacrificing
procedures have high success rates but are associated with high rates of fecal incontinence.
In contrast, sphincter-preserving procedures have more modest success rates but are
associated with a relatively minimal risk of changes in continence.
While low transsphincteric fistulae are well-addressed by fistulotomy (i.e., lay-open
technique) with minimal change in long-term bowel habits, fistulae which involve more than 30
% of the internal sphincter carry a substantial risk of fecal incontinence with this
approach.
Endorectal advancement flap is technically difficult and associated with high recurrence rate
up to 50% and risk of incontinence up to 35%.
Fibrin glue and anal fistula plug have a little effect on incontinence but are associated
with high recurrence up to 60 % and are costive.
VAAFT is effective method but is highly costive.
Setons can be employed as cutting and non-cutting kinds as dividers or markers . A few types
of setons used are the Ayurveda-medicated thread , braided sutures thread, rubber band ,
Penrose drains and cable tie seton . Seton material should be non-absorbable, from
non-slippage material, comfortable and least irritant for the patient and equally ejective in
causing focal reaction in the track, leading to fibrosis .
However, setons may cause patient discomfort, both from irritation and from persistent
drainage. In addition the incontinence rate may reach 67%.
The ligation of intersphincteric fistula tract (LIFT) was first described by Rojanasakul and
colleagues in 2007. Since then, this technique has become popular among providers due to its
simple technical elements, particularly when compared to anorectal advancement flaps, and
favorable success rate. Among the many studies published in the literature, the success rate
after LIFT ranges from 40 to 95 %, with a recurrence rate of 6-28 % .3,5-28 In comparison,
success after advancement flap ranges from 60 to 94 %.
This study is a prospective study;
B) Methodology:
Patients will be classified into two groups according to the surgical procedure performed as
follows:
- Group A: Patients undergoing cutting Seton.
- Group B: Patients undergoing LIFT technique.
Aim OF THE STUDY:
To compare between Seton and LIFT technique in management of anal fistula according to ;
1-Feasibility of the technique. 3-Postoperative pain and use of analgesia. 4-Healing time.
5-Recurrence rate. 6-Occurrence of fecal incontinence.
;
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