A Profile of Diagnosis and Management of Ano Rectal Fistulae

Suja, S (2009) A Profile of Diagnosis and Management of Ano Rectal Fistulae. Masters thesis, Kilpauk Medical College, Chennai.


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INTRODUCTION: Anorectal fistulae are one of the most common and complex problems in anorectal surgery. The site of the disease frequently prevents the patient from seeking early and proper medical care. The chronicity of the disease associated with the nature of the symptoms, which include purulent discharge, staining of clothes, repeated abscess formation makes a healthy person to lose his confidence, and at times his ability to work. This psychosocial morbidity in a healthy person forms the other important aspect of the disease. The incomplete and inefficient treatment of this disease, frequently by non-medical people has resulted in recurrence of the disease and worse, unwanted complications. The need for per-rectal and proctoscopic examination and probing to assess the correct status of the disease so often comes in the way of proper care to the patient and acceptance of the treatment by the patient. The last few decades has seen tremendous progress in understanding the nature of the disease, which in turn has led to better management. The delineation of the anatomy of the rectum and anal canal and the proper understanding of the function of the physiology of continence has helped in management of the disease. This understanding has enabled the surgeon to sacrifice the sphincters keeping the anorectal ring intact and thus eradicating the disease. The improved techniques of surgery have contributed for the radical treatment, short convalescence and prevention of recurrence. The methods of primary closure, primary grafting and secondary grafting has revolutionized fistula-in-ano surgery have reduced the recovery time following surgery. These methods can be adopted due to the availability of antibiotics and methods of gut sterilisation. There are also newer techniques in treatment of fistula-in ano, which include injection of fibrin glue / surgisis AFP insertion into the fistulous tract. OBJECTIVES: The objectives of the study are; 1. To study the various etio-pathological factors of fistula-in-ano. 2. To study the various modalities of treatment of fistula-in-ano and the complications associated with them. MATERIALS AND METHODS: The materials for study of clinico-pathological aspect of fistula-in-ano were randomly selected from the cases admitted in Govt. Royapettah Hospital, Chennai-during the period of May 2006 Aug 2008 patients admitted were subjected to clinical examination, laboratory examination and radiological investigations. Diagnosis was confirmed and appropriate treatment was instituted. Fifty five cases selected were studied as follows: Almost all of the cases were found to be non-specific fistulae-in-ano except 2 of them who had tuberculous pathology. No cases of fistulae as a result of inflammatory bowel disease, malignancy or actinomycosis were studied as no such patients presented to the hospital during the study period. The method of study adopted was with the aim to study the etiology, clinical picture and management. Each patient immediately after admission was investigated as follows: Clinical history and physical examination, both general and systemic was recorded according to the proforma prepared. Detailed examination of the local region with regards to the external opening or openings in relation to the axis was done. The extent of induration in relation to the axis, course and its relation to the anorectum was noted. Also the behavior to the Goodsall's rule was noted. Per-rectal and proctoscopic examination was done in order to assess the track and internal opening in relation to the anorectum and to rule out pathology in the rectum, sigmoidoscopy was routinely done in order to rule out other pathology, which might have resulted in fistula-in-ano. Detailed abdominal examination was done to rule out other conditions which could have caused fistula-in-ano. Each patient was subjected to biochemical and hematological investigations. All the patients were subjected to radiological investigations. SUMMARY AND CONCLUSIONS: 1. Low anal (anterior and posterior) is the commonest type of fistulae seen in the series. 2. The commonest predisposing factor appears to be a pyogenic perianal abscess which has not been treated or not been adequately treated. 3. There is a greater incidence in males upto a ratio of 5:1 4. The commonest age group affected is between 20-50 years 5. Discharge, pruritus and pain are the most common presenting complaints. 6. Clinical digital examination and probing is of utmost importance in diagnosing the type of fistula in relation to the anal canal. 7. All the cases have been operated under spinal anaesthesia. 8. Of the patients treated by surgical means, patients whose wound was primarily closed had a shorter healing time. 9. Primary closure of wound was attempted only in patients with low fistula in ano and sort single track. 10. Regular dressings of the wound was done. The wound healed in majority of the cases between 3-4 weeks. Primary suturing of the wound significantly shortened healing time. 11. There was no incidence of recurrence of fistula in cases of fistulectomy and primary closure done in patients with low fistula and single track. 12. Transient incontinence noted in upto 10% of the patients managed surgically which could be attributed to post-operative edema and transient low tone of the sphincters. 13. Though fistula-in-ano per se does not appear to carry any mortality, the morbidity can be minimized by proper diagnosis regarding the type of fistula and by good knowledge of ano-rectal anatomy. 14. Many a case of fistula-in-ano could have been prevented by the proper treatment of perineal and para-rectal suppurative lesions. To achieve the goals of treatment, it is necessary to completely lay open the tract with minimal / preferably no loss of sphincter muscle, proper pre operative evaluation, light general / spinal anaesthesia, gentle probing, local infiltration of dilute adrenaline to achieve almost bloodless field and clearly exposing the sphincter muscle in all cases is a key to success. In high anal fistulas where we can not do fistulectomy, it is worth while to place a SETON & stage the procedure.

Item Type: Thesis (Masters)
Uncontrolled Keywords: Ano Rectal Fistulae ; Profile ; Diagnosis ; Management.
Subjects: MEDICAL > General Surgery
Depositing User: Devi S
Date Deposited: 06 Jun 2018 15:52
Last Modified: 06 Jun 2018 15:52
URI: http://repository-tnmgrmu.ac.in/id/eprint/8240

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