Digest This - Special Edition 2008 - (Page 10)

cleveland clinic treatment approaches for anal Fistula Dr. Tracy Hull In 1349, John of Arderne wrote that a fistula was “incurable” except by a full expert in the craft. This statement continues to be true today. Treatment of anal and rectovaginal fistula require a surgeon who understands the anatomy of the anal region and is trained to perform the appropriate treatment based on the clinical findings. The goal of treating anal fistula remains to obliterate the tract while maintaining the patient’s ability to control stool. For simple fistula, unroofing the tract (fistulotomy) is acceptable. However, many fistula are complex and require skilled surgical intervention. For patients with complex fistula, a dedicated center such as that available at Cleveland Clinic, is essential to fully evaluate the problem and map out the appropriate treatment strategy. The Colorectal Department has a long tradition of treating complex fistula, particularly those patients referred who have failed previous attempts. Extensive testing is done in our anal physiology laboratory that provides information crucial to treatment planning. A common surgical treatment for anal fistula is a rectal advancement flap (RAF). This involves raising a flap of rectal lining tissue and covering the anal portion of the fistula opening. This procedure has been performed and studied extensively at Cleveland Clinic. We have published many papers about this procedure. Many times RAF is the next line of treatment when fistula are deemed more complex. Mobilizing the entire rectum as a circular sleeve of tissue (termed sleeve advancement flap or SAF) and advancing this to the dentate line to cover the internal fistula opening, has been used extensively at Cleveland Clinic for complex fistula. This procedure requires both detailed knowledge and surgical expertise to dissect in the appropriate space between the anal sphincter muscle and the rectum, without injuring either. SAFs are used when there have been previous failed attempts to repair fistula, resulting in extensive scarring. one advantage, therefore, is that SAF allows the previously scarred tissue to be removed and healthy rectum to be brought down through the anus to cover the internal opening and be sutured in place without tension. Fistula that are particularly difficult to cure require a technically more complex surgical procedure for treatment. The Turnbull-Cutait may be best suited in such cases. This procedure was modified for fistula surgery from an operation developed by Rupert Turnbull, MD, founder of the Department of Colon and Rectal Surgery at Cleveland Clinic more than 50 years ago. From an abdominal and anal approach, the rectum is fully mobilized and advanced out the anus to protrude for 7 to 10 cm. This tissue is covered with gauze and left protruding from the anus for five to seven days. This allows the healthy rectal wall to adhere to the internal fistula opening and fully seal an opening that has failed previous closure attempts. Then five to seven days later, the portion that is exterior to the anus is amputated and sewn in place. This is a very intricate surgery; however, for appropriate recalcitrant fistula, it has a high degree of success. Mobilizing the muscle of the medial thigh and placing it between the two openings of the fistula as an interposition (such as the gracillis muscle) is used at Cleveland Clinic for fistula, such as rectourethral fistula. This requires a team approach, facilitated by our colorectal surgeons and urological surgeons. Anal fistula from Crohn’s disease are considered the most dreaded and complex. Historically, many surgeons would not attempt any repairs of these fistula and recommended a permanent stoma. However, in appropriate patients, we offer surgical intervention that typically consists of advanced surgical treatment such as the SAF or the Turnbull-Cutait procedure. Cleveland Clinic is a major referral center to treat patients with Crohn’s disease. This has fostered our desire to pioneer aggressive surgical treatment for certain anal fistula from Crohn’s disease in an effort to avoid permanent stomas for these fistula. Multiple papers in the literature outlining our approach and results have been published. Another complex and difficult fistula to treat is a rectovaginal fistula, whether from obstetrical injury or Crohn’s disease. The episioproctotomy is a highly technical surgical treatment pioneered and advanced at Cleveland Clinic to treat these women. It is chosen when patients are sent to us after multiple failed repairs, as it allows full rebuilding of the area between the anus and vagina. For more information, email digestthis@ccf.org {10} Digest This Special Edition | 2008

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Digest This - Special Edition 2008 Table of Contents Investigations Institute Overview Innovations Staff Research

Digest This - Special Edition 2008

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