Ch.15 - Complex Fistulas

Question 1

What defines a complex fistula?

Answer 1

• the tract crosses more than 30 % of the external anal sphincter (high transsphincteric with or without a high blind tract, suprasphincteric, and extrasphincteric)
• horseshoe confi guration
• anterior location in a female
• multiple tracts
• recurrent fistulas
• Crohn’s disease
• prior radiotherapy
• baseline incontinence

Question 2

When you’re doing an endorectal advancement flap, what happens if your flap only consists of mucosa?

Answer 2

tend to get ischemic and fail

Question 3

• In what situations are endorectal advancement flap contraindicated?
• what’s your operation of choice in this situation?

Answer 3

• anal stricture
• incontinent patient
• prior failed flap

do a LIFT

Question 4

What are the 3 novel techniques for treatment of anal fistulas?

Answer 4

1. VAAFT: Video Assisted Anal Fistula Treatment
2. FiLaC: Fistula Laser Closure
3. Stem Cell

Question 5

• What was the initial success rate of the LIFT procedure?
• what about when Wallin repeated it with 93 pts?
• what about the most recent systematic review?

Answer 5

• initially 94%
• 40%
• about 75%

Question 6

for fibrin glue, which has a higher success rate? shorter fistula tract or longer?

Answer 6

longer fistulas have a higher success rate. (>4cm) because it holds the glue better probably (46% short vs. 89% long)

Question 7

what is the recurrence rate like when adding fibrin glue + endorectal flap?

Answer 7

actually higher recurrence when both used. just flap alone has lowest recurrence rate

Question 8

what is the reported success rate vs. recurrence rate for VAAFT?

Answer 8

70-80% with recurrence rate 15-25%

Question 9

success rate of FiLaC?

Answer 9

70-80%