Treatment. Fistula-in-ano is thought to develop from infection in abnormally deep anal crypts just inside the dentate line

Fistula-in-ano is thought to develop from infection in abnormally deep anal crypts just inside the dentate line. The goal in treatment of the fistula is to completely open the external fistula to the internal abnormal crypt, and excise or cauterize the granulation tissue between the two openings.

The traditional method has been identification of the affected anal crypt and fistulotomy by deroofing of the fistula tract. Recurrent fistulas occur in 10% to 20% of cases. Recent reports have advocated expectant treatment for asymptomatic fistula-in-ano; most fistulas heal within 12 to 24 months without further sequelae.

Antibiotics are used if there is associated cellulitis.

The fistula tract is usually identified by placing a lacrimal probe through the entire tract to identify the abnormal crypt, then completely opening the tract and using a curette and cautery to destroy granulation tissue along the tract.

The tract lining is curetted and the wound is left open (it needs to be kept open to ensure that all infection and pus from the abcesses has been drained). If the tract is well developed with granulation tissue, a fistulectomy is an appropriate alternative to fistulotomy.

Note! Fistulectomy is a surgical procedure where a fistulous tract is excised (cut out) completely. This is compared with fistulotomy, where the fistulous tract is merely laid open to heal.

The fistula tract is almost always well inside the anal sphincter complex, so performing a full fistulotomy should not affect long-term continence. It is important, however, to warn parents that the fistula will sometimes recur and that follow up is important.

Sitz baths, stool softeners and local wound care are used in the postoperative period.

Rarely, a seton is used for high, transsphincteric fistulas. An 0-silk or a rubber band is pulled through the tract with the probe. The seton is tightened or manipulated over the course of a few weeks. The muscle fibers are slowly cut, allowing the fistula to be unroofed without risking incontinence.

Note! To keep the fistula open, surgeons will insert a seton under general anesthetic. A seton is a surgical cord that

is run into the fistula opening, through the fistula track, out the anus and then tied together, so essentually it runs around in a loop. This stops the fistula opening closing up and allows the pus to drain out over time so that there is no longer any infection inside the fistula.

Some surgeons advocate non-operative management of fistula-in-ano as this appears to be a self-limited condition. A prospective observational study found that in healthy neonates, perianal abscess and fistula-in-ano can resolve spontaneously and do not routinely require antibiotics. The patients treated in this expectant manner had symptoms for an average of 6 months and were seen frequently during that period until resolution of the problem occurred. In addition, infants in the series who had significant discomfort or systemic signs of infection underwent operative treatment. Although nonoperative therapy is an option for treatment of fistula-in-ano, it should be approached cautiously, and only if familial support allows continued re-evaluation.

Fistulas in older children or adolescents are crypto-glandular or associated with inflammatory bowel disease, mainly Crohn's disease. Crohn's disease should be ruled out in all children who present outside the typical age groups. Treatment of adolescent fistula-in-ano should be the same as in adults. The fistulous tract, once identified, is either incised and left open to granulate or excised with primary closure of the defect.

Lesson 7

Дата добавления: 2014-10-15