Periproctal fistula

Etiology
There are also fistulas in the area of the rectum and perineum, which may not be related to the anus (from the female genitalia, urethra, prostate). Those that arise from the anal region and rectum can be divided into congenital and acquired. anal canal, most often it is transsphincteric. If not recognized, it often recurs.
 * transsphincteric',

Periproctal fistula (fistula) is a pathological connection between the skin of the perineum and the rectum or anal canal. It occurs 8 times more often in men than in women. The overall prevalence is about 7/100,000 people. The average age is 40 years. Rare fistulas - a horseshoe fistula (horseshoe fistula) has long secondary trunks surrounding
 * extrasphincteric.




 * intersphincteric',
 * – 10-20% have other etiology: dermoid cyst, perineal trauma, Crohn's disease, pelvic inflammatory disease, TB,

carcinomas, radiation treatment, actinomycosis, chlamydial infections, or other sexually transmitted diseases.
 * intrasphincteric' (subcutaneous, submucosal),
 * – 80-90% arises on the basis of periproctal abscesses caused by anal gland infections (the so-called

cryptoglandular theory). According to the anatomical location of the tract, fistulas are divided into: We further divide them into complete' and incomplete depending on whether they have an external and an internal mouth (complete) or only one (incomplete, more often external). A complex (complicated) fistula is one whose internal mouth extends above the puborectal muscle or its tract encircles more than 3/4 of the external sphincter. Fistulas can be divided according to their "relation to the rectum" - into "anal" and "periproctal" (perianal). Congenital fistulas' - are part of the anomalies of the development of the anus.
 * Acquired fistulas:

Division
Machine Translated by Google According to Parks (intrasphincteric, transsphincteric, suprasphincteric, extrasphincteric).
 * Palpation - by palpation you can detect a stiffer strip, induration in the surrounding area. During a examination per rectum, we can

sometimes feel the inner mouth as well. A thorough anamnesis focusing on anorectal inflammation and abscesses' in this area in the past, searching for symptoms of Crohn's disease is important.
 * US - endosonographic examination has recently been widely used and replaces CT examination, which is not very profitable for

diagnosis. US can be used for primary diagnosis as well as intraoperatively.
 * Fistulography - contrast substance is used for fistulas in Crohn's disease, recurrences or a complicated course. This will

show the branching, progress and blind trunks. However, the yield of the examination is low.
 * Goodsall's rule – if we follow a transverse line, then fistulas whose external mouth is dorsal from this line lead arcuately and

have an internal mouth at no. 6 (middle back line). Fistulas that have an external mouth ventrally lead straight and open radially at approximately the same position. However, Goodsall's rule does not apply 100%, there are more deviations in women. Fistulas are manifested by ``secretion, ``itching and ``wetting of the surroundings, ``contamination of clothes with feces or pus. Pain arises when content stagnates when drainage stops. There may also be swelling and bleeding, feelings of fullness' and 'pressure in the rectum. Subfebrile may also occur. Alternation of asymptomatic periods with symptomatic ones at intervals of varying lengths is common. Clinically, an internal fistula may not manifest itself at all.
 * Fistula probing - with a stick-shaped probe, we non-violently determine the progress of the fistula, in case of great pain, it is performed

intraoperatively under anesthesia. If the inner mouth is unclear, we can use a solution of hydrogen peroxide, betadine or methylene blue.
 * Aspect - we find the external mouth of the fistula. Fistulas can have multiple external openings, but usually have only one internal

opening. The distance from the anus can tell us what type of fistula it is. Closer to the anus - rather subcutaneous, further from the anus - more complicated fistulas.

Symptoms

 * Anoscopy, rectoscopy, colonoscopy - enables evaluation of the rectal mucosa, location of the internal oral fistula, exclusion of

tumor or non-specific intestinal inflammation. The physical examination is of greatest importance: Machine Translated by Google
 * NMR - nuclear magnetic resonance is the most accurate method for imaging complicated fistulas, especially in Crohn's

disease.
 * Seton technique - (Hippocratic elastic ligature, cutting seton) is a technique used for higher transsphincteric, extraand suprasphincteric fistulas. After identification of the external and internal mouth, a non-absorbable preferably elastic

fiber (silicone, rubber) is threaded through the fistula and knotted under a gentle pull. The thread is gradually cut through the sphincter, it must be tightened to maintain approximately the same tension. AgNO3), however, is no longer used due to poor results.
 * Fistulotomy, fistulectomy (lay open) - these similar procedures are performed for simple low fistulas without a complicated

course. After clarifying the tract and the internal mouth, a grooved probe is introduced into the fistula and the fistula is dissected, excision of the surrounding tissue and excochleation of the lining is performed, and a tissue sample can be taken for histology. The wound is allowed to secondary heal, or marsupialized is performed. In fistulectomy, excision is performed on the probe. With these techniques, however, there is a greater tissue defect and a greater percentage of postoperative incontinence. There are therefore various modifications of operations with preservation of the integrity of the external sphincter (Parks fistulectomy).
 * Previously, conservative therapy with ""application of sclerosing substances"" was widely used (e.g.

The history of fistula treatment goes back to 'ancient times. Hippocrates already used methods similar to today's, threading horse hair through fistulas (seton), weighting the line with stones (cutting seton). The first comprehensive treatise on this issue comes from the 14th century (J. Ardern) and the fistulas did not escape even the French king Louis XIV.
 * Seton drainage is used for complex, multiple fistulas and fistulas in Crohn's disease. This technique

is similar, but the fiber is introduced 'loosely without tension through the fistula. In this way, non-elastic materials can also be used. Thanks to Seton drainage, the fistula gradually matures, followed by its excision. In Crohn's disease, tracing ligatures are used for long-term (weeks to months) drainage of fistulas with abscesses. Operating techniques: Conservative techniques:

Treatment
Healing takes optimally 6-8 weeks, fibrotic tissue gradually forms behind the cut fiber. In a modification, the technique can be guided by the subcutaneous tissue. Indications must be considered, there is a greater risk of incontinence in women with ventral fistulae.
 * Various fibrin tissue glues are used today, the most successful in treatment are tissue glues with intraadhesive

ATB (other - autologous tl, tl without ATB). Machine Translated by Google
 * LIFT - Ligation of the Intersphincteric Fistula Tract - a new, relatively simpler technique of intersphincteric

ligation.
 * Anal fistula plug' - use of special biological anal plugs that allow the fistula to heal.

Resources
New operating techniques: Does not cause anal deformation. The method consists in fistulectomy from the outside of the sphincters, excision of the internal orifice, which is followed by the construction of a sliding mucosal flap, which is drawn into the defect and fixed with sutures around the perimeter. The external defect is left to secondary healing. Crohn's disease
 * title = Practical Proctology
 * issue = 1
 * 'Advancement flap - has the best results, can be used for almost all types of fistulas, is advantageous for complicated
 * 'Advancement flap - has the best results, can be used for almost all types of fistulas, is advantageous for complicated

fistulas. Healing takes place preferably per primam'.
 * collective = yes
 * place = Prague

Related Articles

 * name1 = Ladislav

Links

 * surname1 = Horák
 * Fistula coagulation using RFA or laser.


 * isbn = 978-80-247-3595-5
 * publisher = Grada
 * type = book
 * VAAFT - Video Assisted Anal Fistula Treatment - endoscopic examination of the

fistula tract (fistuloscopy) with visualization of the branching and the possibility of treatment of the internal mouth using a stapler' or  cutter.
 * publisher = HealthE15
 * article = Access to patients with fistulas of the gastrointestinal tract
 * article = Access to patients with fistulas of the gastrointestinal tract

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 * https://www.goremedical.com//www.goremedical.com/na/home-na

External Sites
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