Conservative surgery for Anal Fistula is appealing but only effective in 50% of cases


 Surgical Week for Colorectal Diseases at JPMC

Conservative surgery for Anal Fistula is
appealing but only effective in 50% of cases

VAAFT, Fistula Clip, FILAC are new techniques but we still
do not know much about them - Prof. Robin Phillips

In Hemorrhoids Rubber Band Ligation is easy to perform
but technique is not standardized, Complications are
rare but it can be catastrophic - Neil Mortensen

KARACHI: Fistula in Ano has a primary track and secondary extensions. It is a chronic abscess. Sometimes it was thought that there may be some infection like H. Pylori or unusual organism which is responsible behind fistula formation but no bacteria has been found. In fact it is failure of the wound to heal for some reasons. AES is the most commonly used investigation in Europe and America but it confers little benefit for the assessment of anal fistula. Ultrasound does not give a clear picture and was not so good. However, MRI scan is excellent for anal fistula which gives accurate picture. This was stated by Prof. Robin Phillips, Consultant Colorectal Surgeon from St. Mark’s Hospital, London. He was speaking at the inaugural session of the Surgical Week for Colorectal Diseases organized by Colorectal Division, Dept. of Surgery at JPMC from September 19-22nd 2016.  Apart from Prof. Robin Phillips, Prof. Neil Mortensen another distinguished colorectal surgeon from John Red Cliff Hospital, Oxford UK was the invited guest speaker on this occasion.

Prof. Robin Phillips (left) and Prof. Neil Mortensen who were the Master Trainer and Clinical
Coordinator at the just concluded Surgical Week for Colorectal Diseases held at JPMC
photographed along with Dr. Shamim Qureshi during the inaugural session.

Colorectal Diseases Surgical Week being organized at JPMC for the last many years as usual attracted a large number of surgeons interested in colorectal surgery from all over Pakistan and over the years it has become an important academic event in the country. It may be mentioned here that it was initiated by Prof. Mumtaz Maher, an eminent colorectal surgeon while he was serving at JPMC and after his retirement, Dr. Shamim Qureshi and his team has continued this academic activity providing a rare opportunity to Pakistani surgeons to witness latest surgical techniques from the world renowned colorectal surgeons who are invited as Master Trainers every year. For a public hospital to sustain and maintain this tradition is indeed commendable particularly when there is no registration fee and the organizers manage all this with the help of the pharmaceutical trade and industry.

Prof. Robin Phillips’s whose presentation was supplemented with a number of informative slides was of the view that fistula could be idiopathic or Crohn’s related. How much sphincter you leave is important while in liver surgery, it is not important how much liver you cut. If you cannot feel internal opening, you will have to examine the patient under anesthesia. Seton, he further stated, must be comfortable and not bulky. We use just three knots. Speaking about sphincter conservative surgery, Prof. Robin Phillips said that loose Seton is non-curative as it is simply to prevent new abscess formation.  However, advancement flap is curative. Concertina closes fistula. Mucosal advancement is tension free. Delorme’s advancement flap permits downward traction, facilitating advancement.

Talking about indications  for LIFT operation Prof. Robin Phillips mentioned clean  space usually MRI validated, relatively simple and it has about 50% success, lay open declined or not suitable. In women it is mostly anterior with no perineal descent/intussusceptions. However, permanent loose Seton was unacceptable. Fistula could be a drug delivery system.  Anal Fistula Plug has a success rate of between 40-80% as reported in various studies but Cleveland Clinic from United States has reported success rate of just 16%. There was a time when everybody was using the anal plug but now everybody has stopped using it. The success rate of fistula glue also varies. He then talked about new techniques like VAAFT and Filac laser surgery and fistula clip. There is very limited but poor evidence. Tail gut cysts, Prof Robin Phillips said may become chronically infected and mimic fistula hence it needs to be removed. Referring to one of the studies, he pointed out that about 75% of fistulas heal, there is 3% recurrence, about 10% are controlled by Seton and flatus incontinence was reported in one third of cases. Conservative surgery is appealing but only effective in 50% of cases. In some women with anterior fistulas if perineal descent/intussusceptions go for advancement flap but if there is no perineal descent or intussusceptions and it is clean opt for LIFT procedure. A comfortable loose Seton preserves sphincter function but there is a continuous discharge. Plugs and glues have future potential but at present they are disappointing. VAAFT, Fistula Clip and FILAC too are new techniques and we still do not know much about them. As regards pilonidal sinus, let me confess that I really do not understand this condition. Having tried various techniques and procedures I at present only use two i.e. Lay open and marsupialisation and Dufourmentel, Prof. Robin Phillips added. 

Replying to a question regarding pruritus ani Prof. Robin Phillips said that it is because of discharge or leakage. These patients should be advised to use healthy diet, vegetarian diet is very effective. However, one should try to find out the details is it leak, mark, gas or mucous. He also talked about Colostomy in complicated anal fistula and pointed out that one cannot reverse colostomy because people will get fistula.

Prof. Neil Mortensen’s presentation was on Value of EUA/Rubber Band Ligation for Hemorrhoids compared with other operative options. He was of the view that every patient with hemorrhoids does not need surgery. It is important that one should examine the patient under anesthesia which is rarely done because of increasing time and economic pressure. He then talked about the classification of hemorrhoids i.e. grade one, two and three and mentioned the efficacy of rubber band ligation. He cautioned that one must use the right size proctoscope. Rubber Band Ligation has about 14% complications, about 2.5% have major complications, 5.8% have pain, and 1.7% have haemorrhage. Infection accounts for 0.05% and fissures and fistula for 0.4%.  About 1.2 to 2.5% of patients may have to be hospitalized.

Continuing Prof. Mortensen said that be careful of infection which could be due to band ligation which could be fatal. Use of one, two and three bands does not make any difference. Usually three bands are safe and effective and 90% of patients improve with triple banding. Do not put the bands too low. Comparing the safety and efficacy of various procedures he said that Rubber Band is better than sclerotherapy and Hemorrhoidectomy is better than Rubber Band Ligation. Over all complications rate is similar for RBL and Excision Hemorrhoidectomy. The patient has more pain with PPH. We are currently comparing Rubber Band Ligation with HALLO-RAR in which twelve UK hospitals are participating. The study was done from 2012-2014 and the publication is expected soon.

Rubber Band Ligation is easy to perform but technique is not standardized. Complications are rare but it can be catastrophic. It is most useful for Grade two as patient satisfaction and success rate is high.  After Staple Hemorrhoidectomy some patients have severe pain of anus for up to six months. His emphasis was that one should try to do simple things first and do not go for major surgery for Hemorrhoidectomy. For severe anal pain we use anesthesia for examination but in clinic we always do rectal examination. One should listen to the patient and try Rubber Band Ligation first and if it does not work then do Hemorrhoidectomy. One should also remember that after these procedures patients will improve and  will not be cured, hence always try to do simple things first. For severe anal pain relief we use local application of mild steroids and mild analgesics. Advise the patient to use high fiber diet and do other conservative measures. For management of post Hemorrhoidectomy pain, we use glycerin nitrate, local topical analgesia and metronidazole. As regards use of Rubber Band Ligation patients who are on anti-coagulants like Warfarin, if they are in good control, near the hospital facility, one should do banding. However, in high risk cases one must stop anticoagulants and do not do banding.

Earlier Dr. Shamim Qureshi introduced the two guest speakers the Master Trainer Prof.  Prof. Robin Phillips and the Clinical Coordinator Prof. Neil Mortensen. He also briefly talked about the historical background of Surgical Week for Colorectal Diseases at the JPMC and thanked all those who have helped in continuation of this Continuing Medical Education programme. Prof. Neil Mortensen in his brief address said that when he was a junior surgeon, it was always inspiring to see operating, listen to senior surgeons speak honestly, how they kept themselves update and how to do it better.  Prof. Tariq Mahmood thanked Prof. Mumtaz Maher for starting this surgical course and commended Dr. Shamim Qureshi and his team for sustaining this academic activity for all these years at a public hospital.

Presentations were followed by live demonstration of various surgical techniques from the Operation Theatre and the participants in the auditorium were also provided opportunity to ask questions to the operating surgeons.  Live surgery was also shown at some other centers in the country through Video conferencing link.

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