4.Anal Fistulas and Fissures Treatment & Management Bruce M Lo; Robert E O'connor;2010

6. BRIEF RESUME OF THE INTENDED WORK: 6.1 NEED FOR THE STUDY: FISTULA IN ANO is the latin word for a reed, pipe or flute. Goligher s definition of Fistula in surgery is a ‘chronic granulating track connecting two epithelial lined surfaces1 Fistula in Ano form a good majority of treatable benign lesions of the rectum and anal canal . 90% or so of these cases are end results of crypto glandular 2 infections. It denotes the chronic phase of anorectal sepsis and is characterised by chronic purulent drainage or cyclical pain associated with abscess reaccumulation followed by intermittent spontaneous decompression.It is the most common malady and an intriguing problem of the Ano rectal region in General population. Fistula in ano is a preventable disease provided perianal and perirectal suppurations are treated timely and in a corrective manner. Majority of them develop from perianal abscesses resulting from poor personal hygiene and hot and humid climate. The common pathogenesis however is bursting open of an acute or an inadequately treated anorectal abscess in to perianal skin.More important factor is significant percent of these diseases persist or recur when the right modality of surgery is not adopted or when the postoperative care is not adequate and so also many patients tend to let their ailment nag them rather than being subject to examination owing to the site of the infection. This treatment of fistula has remained a challenging job for the surgeons3.The need for this study is to evaluate the various approaches in surgical techniques as directed by the nature of the fistulas. Recurrence and rates of incontinence were the most important factors when considering repair[4].Anorectal abscess may produce a tract, the orifice of which resembles that of a fistula, but in 60% does not communicate with the anal canal or the rectum.By definition, this is a sinus not a fistula. Thus all the discharging sinuses around the anal canal may be regarded as sinuses until they are proved to be fistula. The surgical approach is dependent on whether the fistula is simple or complex, as well as the risk of complications such as incontinence 5The ultimate goal of fistula surgery is to eradicate it without disturbing or minimally disturbing the anal sphincter mechanism.6The three basic surgical techniques for the treatment of anorectal fistulas are fistulotomy , use of a seton , and endorectal advancement flaps.Use of fistulectomy is not recommended except when it is necessary to provide histologic material.7 Complications of fistula surgery are myriad and include fecal soilage ,mucus discharge,varying degrees of incontinence , recurrent abscesses and fistula which will be studied in detail. Clearly the surgeon who is fortunate enough to have opportunity to treat the patient initially is the one most likely to effect a cure , to limit morbidity, and to minimize disability.

6.2 REVIEW OF LITERATURE:

This disease is as old as the mankind itself. It was described by Hippocrates as early as 430 BC.He told that the disease was caused by “contusions and tubercles occasioned by rowing or riding on horseback”. He was the first person to advocate the use of Seton in the treatment by “ taking a very slender thread of raw lint , uniting it to five folds of the length of span , and wrapping them round with a horse hair”. 1

In 2500 BC Sushrutha - well known ancient surgeon of India had conducted operations on Fistula in Ano. It was known as Salya Tantra. He also traced the source of origin as Murma to the abscess in the perianal region.

John Aredene who was a surgeon in England in late 14th century and early 15th century who conducted surgeries for Fistula in Ano . He was the first to describe the ‘laying open, method for Anal Fistula.3

King Louis 15 had developed an Anal fistula and was operated in around 1686 by Charles francois Felix by his own instrument called “Le Bistouri ala Royale”.

Another surgeon Fredreich Salmon developed his own technique Salmon s back cut.In fact he established a hospital in London devoted to the treatment of Anal fistula and other rectal conditions.2

Hughas emphasized on primary or delayed primary grafting and claimed 80% success.

Milligan and Morgan in 1934 stressed the importance of maintaining the integrity of ano rectal ring and anal sphincters while operating a fistula to prevent rectal incontinence and rectal prolapse.

David henry Goodsall (1843-1906) was a surgeon in st mark s hospital, his best remembered work was accomplished in with Ernest Miles, Diseases of Anus and Rectum. In the chapter on Anal Fistula, the rule is espopused that has eponymously associated with Goodsall.

Sir Percival worked in Bartholomeua `s hospital and produced a paper on Fistula in ano in 1765. In 1779 , Sir Percival Pott advocated strongly with his vast experience that simple incision on fistula in ano and careful dressing by packing the wound was better than the tight ligature.

Goodsall and Miles (1900) , Atwington (1901) , Tuffer (1903) , Mummery(1934) contributed very much to fistula in ano specifying the extent Of sphincters that may be sacrificed without causing incontinence, which is a dreaded complication.

Chassaignac in 1856 and Stephen smith in 1879 had tried for primary suturing for fistula in ano after fistulectomy.

Simple anal fistulas may be treated by fistulotomy. The addition of marsupialization may improve the rate of wound healing. Complex anal fistula may be treated by debridement and fibrin glue injection.8 6.3 OBJECTIVES OF THE STUDY:

1 . To study the efficacy of different modalities of surgical approach for Fistula in ano. 2. To study the success rate , complications , recurrences in different procedures done for Fistula in ano

MATERIALS AND METHODS 7 SOURCE OF DATA: . The subjects admitted in our hospital wards with symptomatic Fistula in ano will be taken up for study.. 7.1 METHOD OF COLLECTION OF DATA (including sampling procedure, if any): All cases before starting , consent will be taken.Purposive sampling method is used to select the cases.Study design will be a comparative study.Each patient after admission will be taken with a proper history , clinical examination including proctoscopy and per rectal examination.Specific investigations like Fistulogram and MRI anorectum done in selected cases only. Each patient will be individualized and treated accordingly. The outcomes will be documented using proforma and followed up for a period of 3 months to 1 year. SAMPLE SIZE 50 cases with clinically diagnosed symptomatic fistula in ano will be included in the study. INCLUSION CRITERIA FOR THE STUDY: 1. Low Anal Fistula 2. High Anal Fistula EXCLUSION CRITERIA :

1. Fistula in ano associated with Hemorroids and or Fissure in ano. 2. Fistula in ano associated with uncontrolled systemic medical conditions. 3. Patient s not not willing for surgery.

. 7.3 DOES THE STUDY REQUIRE ANY INVESTIGATION OR INTERVENTIONS TO BE CONDUCTED ON PATIENTS OR OTHER HUMANS OR ANIMALS? YES , on humans only. DESIGN OF THE STUDY

Purposive sampling technique is used. It’s a comparative study.Statistical methods used are Descriptive statistics ,Cross tabulation, one way ANOVA, Scheffe`s post hoc test . Using SPSS for windows(version 20.0)

7.4 HAS ETHICAL CLEARANCE BEEN OBTAINED FROM ETHICAL COMMITTEE OF YOUR INSTITUTION IN CASE OF 7.3 Yes. Clearance has been obtained from Ethical Clearance Committee , MMC&RI , MYSORE

8. BIBILIOGRAPHY 1.Goligher.J.C (1961):Surgery of Anus ,Rectum and Colon , p 174 , London : casell. 2.Maingot s abdominal operation 2007;24;684 3.Indian journal of surgery volume66 issue1 2004

1) 4.Anal Fistulas and Fissures Treatment & Management Bruce M Lo; Robert E O'Connor;2010. 5.Current management of cryptoglandular fistula-in-ano Joshua IS Bleier and Husein Moloo World J Gastroenterol. 2011 July 28; 17(28): 3286–3291. 6.Schwartz s principles of surgery 9E 673

7.Rusell R C G, Williams N S , Bailey and Love s short practice of surgery 23edn page1136 8.Scott R. Steele, M.D. • Ravin Kumar, M.D. • Daniel L. Feingold, M.D. Janice L. Rafferty, M.D. •W. Donald Buie, M.D. Practice Parameters for the Management of Perianal Abscess and Fistula-in-Ano;2011.