Case Study: Minimally Invasive Treatment for Complex Fistula in Ano

By: Dr. J. Gnanaraj and J. Regina Jeyaseeli, Bsc Nursing

INTRODUCTION

A Fistula in Ano is a connection between peri–anal skin and anal canal through a tortuous tract lined by granulation tissue and epithelial cells. It starts with an abscess having an inner and outer opening. Without adequate treatment the epithelial cells grow from either end and it does not heal. With formation of an abscess it can have multiple branches and complex tract. We describe the minimally invasive treatment for a complex fistula.

BACKGROUND

Mr. P aged 28 was diagnosed to have Fistula in ano since September 2013. He underwent a fistulotomy but had recurrence of the fistula as the healing took place from the skin side instead of healing from the bottom of the wound. He underwent several surgeries to drain the abscess with some of them after MRI diagnosis and guidance and had a seton in place. He developed abscess that was drained under MRI or CT guidance in Canada 9 times. He was evaluated extensively for tuberculosis and since it was negative started empirical treatment for Crohn’s disease.

He had two external openings one on either side with corrugated rubber setons. The one on the left side had a straight tract to the internal opening. The one on the right side initially went into a large cavity at the posterior side. The tract was visualized with an Ureterorenoscope. It had several extensions [about 5] along the side of the anal canal and the internal opening was on the left side. The entire tract was lined with epithelial cells.

The irrigating fluid was changed to Glycine and the Bugbee electrode was used to burn the epithelial lining under vision using the Ureterorenoscope. Since it was a large cavity it was packed using Povidone iodine soaked gauze with some sugar and honey inside. He was also given some deep laser heat therapy to hasten the healing process.

DISCUSSION

Fistula in ano is a common condition with a prevalence of about 7 to 12 per 100,000 populations. The availability of over ten treatment options [1] suggests that these are not very successful in treating them. The more recent modalities are the following [2]:

1. Anal fistula plug produced from sub mucosa of small intestine, a highly sophisticated absorbable material which obviously would be expensive. However, it has the advantages of being less morbid, little pain, short hospital stay, no risk of incontinence, minimal foreign body reaction, etc.
2. LIFT procedure or inter-sphincteric ligation of the fistula tract
3. VAAFT or Video Assisted Anal Fistula Treatment the classical description involves use of special scopes and linear cutting stapler.

However, the Ureterorenoscope and the bugbee electrode could be used to burn or eliminate the epithelial lining under vision and packing daily from the external opening helps with closure of the fistula from the internal opening. It is a minimally invasive procedure that has very good results even in complex fistulae and the only drawback is the need for long term dressings and Sitz bath.

Dr. J. Gnanaraj MS, MCh [Urology], FICS, FARSI, FIAGES is a urologist and laparoscopic surgeon trained at CMC Vellore. He has been appointed as a Professor in the Electronics and Instrumentation Engineering Department of Karunya University and is the Director of Medical Services of the charitable organization SEESHA. He has a special interest in rural surgery and has trained many surgeons in remote rural areas while working in the mission hospitals in rural India. He has helped 21 rural hospitals start minimally invasive surgeries. He has more than 150 publications in national and international journals, most of which are related to modifications necessary for rural surgical practice. He received the Barker Memorial award from the Tropical Doctor for the work regarding surgical camps in rural areas. He is also the recipient of the Innovations award of Emmanuel Hospital Association for health insurance programs in remote areas and the Antia Finseth innovation award for Single incision Gas less laparoscopic surgeries. During the past year, he has been training surgeons in innovative gas less single incision laparoscopic surgeries.

J. Regina Jeyaseeli, Bsc Nursing. She has 15 years experience in teaching and clinical field work. At present she is working as a Nurse-In-Charge at Seesha Community Hospital in Coimbatore.