DISTRIBUCIÓN DE AGUA (reparto y operación)

In the Indian subcontinent, there exists a non-operative ayurvedic method of treating fistulae that was first documented in 600 BC by the ancient Indian surgeon Sushruta in his famous treatise named Sushruta Samhita. The method involves the weekly insertion of a specially prepared thread, known as Kshaarasootra along the fistula track. The thread is

prepared by multiple coatings of the latex of a cactus, tumeric and the alkaline ashes derived from another plant. Although the alkalinity of the thread, about pH 9.5, renders it caustic enough to burn away the granulation tissue, it is apparently quite acceptable to the patient. It seems also to have other antibacterial and anti-inflammatory properties. In a randomized prospective study involving 502 patients (Shukla at al 1991), apart from a longer healing time (8 weeks vs. 4 weeks), the results of this out-patient treatment were comparable with standard surgery (incontinence rate 5% vs. 9%; recurrence rate 4% vs. 9%); and in a country where anal fistulae constitute 1.6% of hospital admissions this represents a significant economic advance. A zero recurrence rate has been reported in another series using a similar technique in 80 patients (Wollfers 1986).

1.9.2.2. Fistulotomy and Immediate Reconstitution

In 1985, Parkash et al reported a series of 120 patients treated by fistulotomy and immediate reconstitution of the divided musculature and primary wound closure, quoting the success of a Muscovite surgeon, Rygick, who had treated 1700 low fistulae in this manner with a 98% success rate. Again impressive results were reported with regards healing time (88% healed within 2 weeks), recurrence rate (4%) and function (all patients were satisfied and none had soiling). All bar 2 fistulae in the series were either low intersphincteric or simple trans-sphincteric in nature, and the authors admitted that they could not expect as good results if the technique were applied to more complex fistulae. Sood (1968) had earlier published similar results in a series of 136 low fistulae treated in the same way, and demonstrated equal success but shorter healing time and less post-operative pain than 100 patients treated by conventional fistulotomy.

1.9.2.3. Fistulectomy

Lewis (1986) described his method of treating fistulae which involves a careful coring out of the track from the external opening towards the sphincter complex under direct vision, securing impeccable haemostasis en route so as readily to identify any granulation tissue which would indicate either a transected primary track or the origin of a secondary extension. The precise anatomical relationships of the fistula path are clearly defined before any division of sphincter muscle. In the case of low fistulae, the tunnel left after coring out the fistula may be laid open, but in those patients in whom laying open would incur a risk of incontinence, the coring out is continued until the internal opening is reached. The mucosal defect and sphincter tunnel are then closed with absorbable suture, and the wound external to the sphincter complex is lightly packed. Lewis reported just 2 recurrences out of 100 patients with low fistulae treated by this technique, and 1 recurrence in 18 patients with either high trans-sphincteric or suprasphincteric fistulae.

1.9.2.4. Rectal Advancement Flaps

The concept of rectal advancement flaps, although currently enjoying a resurgence in popularity, is not new. The technique was first described for the management of fistula-in-ano by Elting in 1912. Elting wrote that the two principles were: separation of the track from the communication with the bowel; and adequate closure of that communication with eradication of all diseased tissue in the anorectal wall. By ensuring that these two were fulfilled he stated that it was unnecessary to perform destructive dissection of the perirectal tissues. To Elting's principles, modern users have added ensuring adequate vascularity of the flap, and anastomosing the flap to a site well distal to the previously excised site of the internal opening.

Considerable variation exists, however, in how thick the flap should be, in the management of the external component of the track, in its applicability in inflammatory bowel disease, and whether a covering stoma is of benefit. Nevertheless, the overall results in treating idiopathic fistulae are remarkable, with an overall recurrence rate of less than 4% and little in the way of functional change (Table 1.9.1). The technique has not enjoyed such success at St.Mark's.

1.9.2.5. Other Techniques

1.9.2.5.1 Total Sphincter Conservation

A technique of total sphincter conservation recently devised by Phillips and reported from St.Mark's Hospital (Matos et al

1993) has been applied to a series of patients with challenging recurrent fistulae. The essential steps of the operation are;

1. Eradication of cryptoglandular sepsis from the intersphincteric space by a direct intersphincteric approach. Diathermy dissection assists by creating a bloodless field.

2. Dissection in the intersphincteric space is continued l-2cm cephalad to the track which facilitates closure of the internal opening from within the intersphincteric space. This procedure avoids the potential complications of flaps.

3. The fistula complex is then totally excised and the resultant hole in the external sphincter or puborectalis repaired. Finally the wound is closed primarily under antibiotic cover.

This technique has been applied to 13 patients with recurrent high trans-sphincteric or suprasphincteric fistulae, 5 of whom also had inflammatory bowel disease. If absolute success is regarded as eradication of pathology with conservation of both internal and external sphincters, then this was achieved in 7 of the 13 patients. In 69% partial success was achieved with the external sphincter preserved. When the sphincters had been

thickness track recurrence function Elting

1912

96 ? full curetted pack 1 7stenoses

4incont. Oh 1983 15 recurrent high mucosal excised drain &

pack 2 satis, in all Aguilar et al 1985 189 7 partial or full excised left open 3 10 minor symptoms Wedell et al 1987 27 11 supra- 11 midtrans- 12 high trans­

partial excised pack 0 unchanged

Jones et al 1987

4 complex partial excised drain 0 ?

Shemesh et al 1988

3 anterior high

trans-

partial curetted drain ?1 7

Reznick & Baileyl988 6 trans- supra- extra- full (3) direct closure(3) curetted 7 2 unchanged Lewis & Bartolo 1990

2 high trans­ full curetted drain 1 unchanged

only 10 (3%) recurrences. Other types, such as those associated with inflammatory bowel disease have been excluded. Flaps used have included; mucosal; mucosal and partial thickness internal

sphincter; and full thickness internal sphincter.

completely preserved normal continence was maintained except in 1 patient with inflammatory bowel disease who is occasionally incontinent to flatus. Failure of the technique such that sphincter division was necessary to obtain healing was associated with a deficit in continence in 3 of the 4. The fourth patient, with ulcerative colitis, underwent fistulotomy under protection of an ileostomy.