1. Fistula-in-ano:
a probing of the treatment options
David Jayne
Professor of Surgery
University of Leeds & Leeds Teaching Hospitals NHS Trust
John Goligher
Colorectal Unit

2. The Problem

3. Aetiology
• Cryptoglandular
• Crohn’s disease
• Other
– Malignant
– Obstetric
– Radiation

4. Classification
30% 45%
5% 20%

6. Goodsall’s Rule

7. Treatment Aims
• Eradicate disease (if possible)
• Preservation of continence
• Benign condition
• Quality of life

8. Principles
• Control sepsis
– EUA
– Laying open abscesses and secondary tracts
– Adequate drainage – seton insertion
• Define anatomy
– Openings and tracts
• Internal and External
• Single –v- multiple
• Extensions / Horseshoe
– Relation to sphincter complex
• High –v- Low
• Exclude co-existent disease

9. MRI for fistula-in-ano
Abscesses & Contralateral disease Other pathology
HALLIGAN Radiology 2006
Extensions

10. Surgical Options – Fistulotomy
• Fistula tract identified with
probe
• Extent of external
sphincter involvement
assessed
• Tract and muscle divided
• Secondary tracts laid open
• +/- marsupialisation
wound

11. Surgical Options – Cutting Seton
• Lay open external tract
• Draining seton replaced with
cutting seton
• 1/0 Prolene suture
• Tied tight around sphincter
complex
• Simultaneous slow cutting
and repair of sphincter
• May require re-tightening

12. Surgical Options – Fistulectomy
• Draining seton
• Core out tract
• Direct visualisation of
secondary tracts
• Sphincter repair +/-
advancement flap

13. Advancement Flaps
Endorectal
• Fistula tract probed
• Flap raised
– Mucosa + Int. Sphincter
• Internal opening
excised/closed
• Flap advanced & sutured

14. Advancement Flap
Anodermal
• Fistula tract probed
• Flap raised
– Anodermal
• Flap advanced & sutures
• External defect closed

15. Fistula Plug

16. Fistula Plug

17. LIFT Procedure
Ligation of Intersphincteric
Fistula Tract
• Transsphincteric fistula
• Draining seton – 6 weeks
• Tract prepared with fistula
brush
– Debrides
– De-epithelializes

18. LIFT Procedure

19. PROS CONS
Cutting Seton Simple Repeat EUA
Cheap Recurrence 0 – 8%
Incontinence
• minor 34 – 63%
• major 2 – 26%
Fistulotomy Simple Recurrence 2 – 9%
Cheap Incontinence 50%
Advancement Flap Can be difficult Recurrence 25 – 50%
?Preserves sphincter Incontinence 30 – 35%
Fistula Plug Simple Plug expensive ~£400
Preserves sphincter Recurrence 20 – 85%
Continence preserved
LIFT Simple Recurrence 15 - 40%
Preserves sphincter Continence preserved

20. ACPGBI FIAT Trial
EUA: transsphincteric
fistula ≥ 1/3 of sphincter
complex
Insertion of draining
seton
MRI fistulography
RANDOMISE
Fistula Plug Surgeon’s
Insertion Preference
Advancement Cutting Seton Fistulotomy LIFT
Flap

21. ACPGB&I FIAT
Patient identification
EUA & draining seton
Primary end-points
Eligibility & Consent • Faecal incontinence QoL
MRI scan
• Generic QoL
Randomisation
1:1 plug –v- surgeon’s preference Secondary end-points
Surgery
• Healing – 12 months
(6-weeks post seton insertion) • Complications
Surgeon’s preference • Faecal incontinence
Surgisis® fistula plug (fistulotomy, seton, advancement flap,
LIFT)
• Re-interventions
• Health resource
6-week FU utilisation
6-monthFU • Cost effectiveness
12-month FU
+ MRI scan

22. FIAT FACTS
Recruitment: 76
Target: 500
Open centres: 36
Recruiting centres: 21

23. Join the FIAT Trial!

24. Fistula-in-ano:
a probing of the treatment options
David Jayne
Professor of Surgery
University of Leeds & Leeds Teaching Hospitals NHS Trust
John Goligher
Colorectal Unit