how do we know when it’s safe to lay open? robin phillips ... · st mark’s hospital &...

How do we know when it’s safe to lay open?

Robin PhillipsSt Mark’s Hospital, London

ACPGBIEdinburgh

July 5th 2015

• bodily redundancy• ‘incontinence’• the bully boy• ‘it does not matter how much liver you

resect, it is how much you leave behind’• ‘it does not matter how much sphincter you

cut, it is how much you leave behind’

assessment

• bowel habit, anal digitation, IBS• distance from internal opening to top of

sphincter/anorectal junction• what does the individual want

technique

• if a fistula can be cut and laid open it can be done then and there

• the ‘tight seton’ theory of more optimal sphincter preservation is a myth

João Miguel MartinsSt. Mark’s Hospital

April 2005

THE LORD OF THE

RING

review of anal fistula results from one surgeon

later published by Atkin et al. Tech Coloproctol 2011; 15: 143-150

Final assessment (n=150)

75%

14%

8% 3%Fistula fully healed, noSetonFistula controled byseton without problemsFistula controled byseton with problemsRecurrence of fistula

seton problems: 11 patients with significant mucous leakage and 1 patient with feacal leakage through the track

Atkin et al. Tech Coloproctol 2011; 15: 143-150

Final Assessment Tertiary (another colorectal consultant surgeon) referrals (n= 105)

71%

16%

10% 3% Fistula fully healed, noSetonFistula controled byseton without problemsFistula controled byseton with problemsRecurrence of fistula

Atkin et al. Tech Coloproctol 2011; 15: 143-150

First assessment of continence (n1= 43 and n2 = 111)

0%

20%

40%

60%

80%

100%

120%

Primary referrals Tertiary referrals

Fully continentIncontinent to flatus Incontinence to soft stoolIncontinence to hard stoolUrgencyIs there a colostomy

Atkin et al. Tech Coloproctol 2011; 15: 143-150

Assessment of continence in tertiary referrals (n=102)

25.6%

0102030405060708090

Fully c

ontin

ent

Inconti

nent to

flatus

Inconti

nence

to so

ft stoo

l

Inconti

nence

to ha

rd stool

Urgenc

y

Is there

a co

lostom

y

at 1st assessmentat last assessment

Atkin et al. Tech Coloproctol 2011; 15: 143-150

Assessment of continence when an intersphincteric fistula is layed open at 1st operation (n=41)

34.3%

05

10152025303540

Fully

cont

inen

t

Inco

ntin

ent

to fl

atus

Muc

ous

leak

age

Inco

ntin

ence

to s

oft s

tool

Inco

ntin

ence

to h

ard

stoo

l

Urge

ncy

Is th

ere

aco

lost

omy

at 1st assessment

at last assessment

Atkin et al. Tech Coloproctol 2011; 15: 143-150

Assessment of continence when a high anal fistula is layed open at 1st operation (n=27)

32%

05

1015202530

Fully continent

Incontinent to flatus

Incontinence to soft stool

Incontinence to hard stool

Urgency

Is there a colostomy

at 1stassessment

at lastassessment

Atkin et al. Tech Coloproctol 2011; 15: 143-150

• incontinence seems most related to internal sphincter division

• Luniss PJ, Kamm MA, Phillips RKS (1994). Factors affecting continence in fistula surgery, Br. J. Sur, 81, 1382-1385

conclusions

• excepting the most trivial, all fistula surgery has a one in three chance of flatus incontinence and mild passive soiling

• this applies equally to intersphincteric fistulas, which most people are happy to lay open, as it does to much higher transsphincteric fistulas and consent should be obtained

• people’s perspectives change with fistula persistence/recurrence; initial fear of ‘incontinence’ reverts to them being thoroughly fed up with the fistula persistence, smell and discharge

conservative surgery

● appealing, but only 50% effective● in some (usually) women with anterior fistulas

• if perineal descent/ intussusceptionà advancement flap• no perineal descent/ intussusception and ‘clean’ i.s space à

LIFT● a comfortable loose seton preserves sphincter function but at the cost

of continuing discharge● plugs and glues have future potential but are disappointing as they

are● VAAFT, fistula clip and FILAC too new to know

my fistula strategy

● lay open, lay open, lay open● if can’t (or scared) permanent (comfortable) loose

seton ● in some (usually) women with anterior fistulas

• if perineal descent/ intussusception àadvancement flap

• no perineal descent/ intussusception and ‘clean’ i.s space à LIFT

● glues and plug need development/independent evaluation

loose seton threaded through eye of probe

seton must not be bulky – just three knots

seton is number 1 Ethibond, soft and comfortable and does not dig into the flesh

‘whiskers’ on the knots tied back on themselves with 2/0 silk

resulting low profile, secure knot

24but common practice

my fistula strategy

● lay open, lay open, lay open● if can’t (or scared) permanent (comfortable) loose

seton ● in some (usually) women with anterior fistulas

• if perineal descent/ intussusception àadvancement flap

• no perineal descent/ intussusception and ‘clean’ i.s space à LIFT

● glues and plug need development/independent evaluation

St Mark’s Hospital & Academic Institute Lecture Course

Frontiers in Intestinal and Colorectal Disease

22nd–25th November 2016www.stmarksacademicinstitute.org.uk

Email: info@stmarksacademicinstitute.org.uk St Mark’s Academic Institute, St Mark’s Hospital, Northwick ParkHarrow, MiddlesexHA1 3UJ

Sir Alan Parks Visiting ProfessorProfessor Michael Solomon, Sydney, Australia

Sir Francis Avery Jones Visiting ProfessorProfessor Evelien Dekker, Amderstam, Netherlands