What are the treatments for anal fistula? What are the precautions to take before treatment of anal fistula?
Prevention: establish normal dietary habits because the occurrence of anal fistula is related to damp heat, for greasy diet, can endogenous damp heat, so should not eat more. You should eat more light foods that are rich in vitamins, such as mung beans, radish, winter melon and other fresh vegetables and fruits. For long-standing anal fistulas that are mostly deficient, eat more protein-containing foods, such as lean meat, beef, mushrooms, etc.
The most important thing is to treat anal sinusitis and anal papillitis in a timely manner to avoid perianal abscess and fistula. If you have anal burning discomfort or anal drop, investigate the cause and treat it promptly. Prevention of constipation and diarrhea is important to prevent perianal rectal abscess because dry stools can easily bruise the anal sinus, plus bacterial invasion and infection. Most people with diarrhea have the presence of proctitis and anal sinusitis, which can lead to further inflammation. Actively treat systemic diseases that may cause perianal rectal abscesses, such as ulcerative colitis and Crohn’s disease.
Develop good defecation habits Daily sitz bath after defecation to keep the anus clean has a positive effect on the prevention of infection. Actively prevent and control constipation and diarrhea. When constipation accumulates in the rectum, the fecal masses tend to block the anal fossa, leading to acute anal fossa inflammation and eventually perianal abscess. In addition, dry and hard stools can easily bruise the anal fossa during defecation and cause perianal infection. Diarrhea for a long time can also stimulate the inflammation of the anal fossa, and dilute stool can easily enter the anal fossa and induce perianal infection. Therefore, prevention of constipation and diarrhea is important to prevent perianal abscess and fistula formation. If you feel any anal discomfort or burning sensation, you should immediately take an anal sitz bath and seek medical attention.
Western medical treatment for anal fistula
Surgical treatment: Anal fistula cannot heal itself and must be treated surgically. The principle of surgical treatment is to cut open the fistula and, if necessary, to remove the scar tissue around the fistula so that the wound heals gradually from the base upwards. Depending on the depth and curvature of the fistula, the fistula can be treated with a wire, a fistula incision or an excision. In a few cases, the fistula can be excised and then sutured or implanted.
(a) Threaded treatment
This is a slow incision of the fistula. The mechanical action of the rubber band or thread (the thread still has a drug corrosion effect) is used to cause blood flow disorders in the ligated tissues and gradually compress the billet. The ligated thread can be used as a fistula drainage to drain the fistula tract and prevent acute infection from occurring. In the process of cutting the surface tissue, the basal wound begins to gradually heal at the same time. The greatest advantage of this method of gradual fistula cutting is that the anal sphincter is severed, but does not change position due to excessive sphincter contraction and generally does not cause anal incontinence.
This method is suitable for simple rectal fistulas with low or high internal or external openings within 3-5 cm of the anus, or as an adjunct to incision or excision of complex anal fistulas.
1.Method
(1) In the lateral position, first tie a rubber band to the end of the probe, then gently probe the tip of the probe from the outer mouth of the fistula inward to find the inner mouth near the dentate line of the anal canal; then stick your index finger into the anal canal, feel the tip of the probe, bend the tip of the probe and pull it out from the anal opening. Note that no violence should be used when inserting the probe in order to prevent false passage.
(2) Pull the probe tip completely out of the inner opening of the fistula so that the rubber band passes through the outer opening of the fistula into the fistula.
(3) Lift the rubber band, cut the skin layer between the inner and outer mouth of the fistula, pull it tight like a skin band, and clamp it tightly against the subcutaneous tissue with a hemostat; tighten the rubber band with a thick silk thread below the hemostat and make a double ligature, then release the hemostat. The incision is dressed with petroleum jelly gauze, and the postoperative daily sitz bath with hot 1:5000 potassium permanganate solution, and change the dressing, generally in about 10 d after surgery, the anal fistula tissue is cut by the rubber band, and the wound can be healed after 2-3 weeks.
2. The advantages of this method are
(1) The operation is simple, fast and with little bleeding.
(2) When the rubber band does not fall off, the skin incision generally does not occur “bridging”.
(3) easy to change the medicine.
3. The key points to keep the threads successfully hung.
(1) to accurately find the inner mouth, generally in the probe through the inner mouth, such as no bleeding, to prove the location of the inner mouth more correct.
(2) The wound must start from the base, so that the wound in the anal canal heals first and prevent premature adhesion of the surface skin to seal. Generally the rubber band can fall off in 7-10 d. If it does not fall off after 10 d, it means that the wire of the ligature is loose and needs to be tightened again.
(b) Anal fistula incision
The principle of surgery is to cut all the fistula and to remove the scar tissue on both sides of the incision, so that the drainage is unobstructed and the incision gradually heals. This method is only applicable to low-level straight or curved anal fistula. The operation methods are as follows.
If the fistula is bent or branched, the probe cannot be inserted into the internal opening, then inject a small amount of 1% Mebrane solution into the external opening to determine the internal opening site, and then probe with a slotted probe from the external opening to gradually cut open the tube and probe until the internal opening is detected. If you can’t find the inner mouth even after careful probing, you can treat the suspected diseased anal sinus as the inner mouth.
2, cut the fistula and fully excise the marginal tissues cut all the superficial tissues of the fistula, from the external to the internal orifice and the corresponding anal sphincter fibers. The fistula should be checked for branches after incision, and if found, they should also be incised. The entire fistula is incised and scraped clean of the decaying granulation tissue; it is usually not necessary to excise the entire fistula to avoid excessive trauma. Finally, the wound edges should be trimmed so that the wound is in a “V” shape with a small bottom and a large mouth to facilitate deep wound healing first.
The first thing you need to do is to make sure that the fistula is in the right place. do a hanging wire therapy or hanging wire staged surgery. In the first stage, the fistula below the ring is incised or excised, and the fistula above the ring is hung with a thick silk shallow and tied. In the second stage, once most of the external wound has healed and the anorectal ring has been fixed with adhesions, the anorectal ring is then incised along the hanging wire. After the fistula is incised, its posterior wall granulation tissue can be scraped away with a spatula, but generally does not need to be removed to minimize bleeding and avoid damage to the posterior wall sphincter. The excised fistula tissue should be sent for pathological examination.
4, wound treatment, postoperative wound treatment is often related to the success or failure of surgery, the key is to keep the wound from the base gradually to the surface healing. Change the dressing once a day, preferably after defecation, and gradually reduce the filling dressing in the wound until the wound in the anal canal is healed. Rectal examination every few days can dilate the anal canal, moreover, it can prevent bridge-shaped adhesions and avoid pseudo-healing.
(c) Anal fistula excision, which differs from incision in that the fistula is removed completely down to healthy tissue. This method is also suitable for low-level anal fistulas with more fibrotic canals. Method: The fistula is first injected with 1% melphalan through the external opening, followed by gentle insertion of a probe through the external opening and penetration through the internal opening. The skin of the external opening is clamped with tissue forceps, the skin and subcutaneous tissue around the external opening of the fistula is cut, and then all scar tissue around the skin, subcutaneous tissue, the blue-stained canal wall, the internal opening, and the fistula is cut with an electric knife or scissors in the direction of the probe, leaving the wound completely open. After careful hemostasis, the wound is filled with iodoform gauze or petroleum jelly gauze.
(iv) One-stage suture for anal fistula excision, this method began with Tuttle (1903) but failed to spread, probably because, theoretically, it was not quite adequate; the surgical results were unsatisfactory; and many anorectal surgeons opposed it. In 1949, Starr proposed this method again, and proposed some effective measures with more satisfactory results, and only then was it promoted. This method is only applicable to simple or complex low rectal fistulas, and is more effective if the fistula is sclerotomized when palpated. Surgical points.
① The bowel should be prepared before surgery, antibiotics should be applied before and after surgery, and the stool should be controlled for 5-6 d after surgery.
②The fistula should be completely excised, leaving a fresh wound to ensure that there is no granulation tissue or scar tissue left behind.
③The skin and subcutaneous fat should not be excised too much to facilitate wound closure. Therefore, high curved fistulas should not be sutured because they are more branched and often require too much tissue to be removed in order to cut the branches.
④ All layers of the wound should be completely sutured and aligned, leaving no dead space.
⑤ Strictly aseptic operation should be performed to prevent contamination, such as cutting through the fistula. In 1064 cases of anal fistula excision and suturing reported in the comprehensive domestic literature, the one-stage healing rate was 73.4%-97.6%, and the wound healing time was 20-22 d. Most of the cases with lower one-stage healing were complicated high anal fistulas.
(e) Post-anal fistula excision implantation, if the trauma is too large and superficial without special complications, free implantation can be considered. The pre- and post-operative requirements are the same as those for one-stage suturing of fistula excision. Surgical points.
①The wound surface should be flat and hemostasis should be complete.
②The skin suture of the free implant area should be completely closed and fixed with pressure to prevent gas or blood under the wound surface, which is one of the important measures for successful surgery.
If the wound surface is bleeding more, the implantation should be delayed, i.e., Vaseline gauze should be applied to the wound surface first, and then free implantation should be done after 2-3 d. Hughes (1953) reported 40 cases, 30 cases of implantation were completely successful, and the rest were mostly viable. Goligher (1975) reported 22 cases, all of which were low anal fistulas, and the results were poor, only 13 cases were completely viable.
(F) Treatment of hoof fistula
Fistulotomy with wire therapy should be used. In the case of posterior hoof fistula, a slotted probe is inserted from both sides of the external opening and the fistula is gradually cut until the two sides of the canal meet near the posterior midline, then the internal opening is carefully probed with a slotted probe. If the fistula passes below the rectal ring, the fistula and the lower and superficial part of the external sphincter skin can be incised all at once. If the internal opening is too high and the fistula passes above the anorectal ring, wire therapy must be used. This means that the fistula is incised in the lower part of the external sphincter, the superficial part and the lower part of the fistula, and then a rubber band is inserted through the remaining orifice and led out through the internal orifice and tied to the anorectal ring. The skin and subcutaneous tissue at the edges of the incision are then cut away, leaving the wound open and the granulation tissue of the fistula wall is scraped away. The trauma is filled with iodoform or petroleum jelly gauze.
(vii) Sliding mucosal flap anterior closure of the endograft
After complete excision of the fistula and the endograft, the defect at the rectum is repaired by transposition of the mucosal flap, which actually includes part of the thickness of the rectal wall to increase its strength. Advantages of this method.
① preservation of most of the sphincter muscle, which is suitable for rectovaginal fistulas and high trans-sphincteric anal fistulas.
(ii) Less scar formation.
③Avoidance of anatomic deformities.
Aquilar et al. (1985) treated 189 cases of high trans-sphincteric fistulas with good results, with a recurrence rate of only 2%, but 8% for contaminated underwear and strictures, 7% for mild gas incontinence, and 6% for fluid incontinence. The success rate of this method in treating anal fistulas due to clonorchiasis was only 57%, while the success rate was higher in those without clonorchiasis. However, some authors have used direct suturing of the internal opening.