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