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P.O.Box 2345, Beijing 100023,China World J Gastroenterol 2003;9(5):1082-1085Fax: +86-10-85381893 World Journal of Gastroenterology E-mail: [email protected] www.wjgnet.com Copyright 2003 by The WJG Press ISSN 1007-9327 Radio frequency “sutureless” fistulotomy- a new way of treating
fistula in anus
Pravin J.Gupta, Gupta Nursing Home, D/9, Laxminagar, NAGPUR-
proctocolitis; (b) Secondary to introduction of a foreign body e.g. probing of an abscess or a low fistula; (c) Associated with Correspondence to: Dr Pravin J.Gupta, Gupta Nursing Home, D/9,
anal fissure, i.e. post fissure fistula; (d) Rectum cancer Laxminagar, NAGPUR- 440022, India. [email protected] Received: 2002-08-06 Accepted: 2002-11-04
Causes of multiple fistulae include T.B, Crohn’s disease,ulcerative proctocolitis, lymphogranuloma inguinale,bilharziasis, hidradenitis suppurutiva, etc.
Abstract
Clinical features
AIM: To explore the effect of the classical lay open technique
or fistulotomy with the radio frequency surgical device in History Patients had the history of seropurulent discharge,
persistent pruritus and discomfort in the surrounding skin[2].
Patients feel pain if the fistula tract is blocked for accumulation METHODS: In our study, the conventional ‘lay open’
technique, or ‘fistulotomy’ was performed by employing the Inspection The external opening can usually be seen as an
radio frequency surgical device as an alternative to the elevation of granulation tissue often active with purulent traditional knife and scissors. In a span of 18 months starting discharge. The number and location of external openings and from July 1999 to December 2000, 210 cases with fistula in the relationships to the anal canal provide a clue as to the anus of varied types were operated in our nursing home internal origin. According to Goodsall’s rule, if the opening is exclusively applying the radio frequency device.
anterior to a transverse anal line (coronal plane), the internalopening will be in a direct radial line to the nearest crypt. If RESULTS: The results of the study were not only
the opening is posterior to the coronal line, the internal opening encouraging but also were satisfactory. A follow up of the will usually be in a posterior midline crypt, and the tract will operated patients with radio frequency surgery over a period be curved[3]. Exceptions to Goodsall’s rule include anterior of 15 months, i.e. from December 2000 to March 2002 was openings that are more than 3 cm far from the anal margin and summarized as below: (a) average time taken by the patient multiple openings. In these situations, the internal opening is to resume routine - 7 days; (b) none of the patient had any more likely to be located in one of the posterior crypts. Other interference with the continence; (c) the wounds were found clinical conditions can simulate the appearance of a fistula, healed within an average time of 47 days; (d) delayed wound including hidradenitis suppurativa, pilonidal sinus, and healing was noticed only in 7 patients; (e) recurrence/ failure Bartholin’s gland abscess or sinus[4].
rate was reduced to as low as 1.5 percent.
Palpation Palpation may reveal an indurated cord beneath
the skin in the direction of the internal opening[5]. Digital anal
CONCLUSION: This technique has been found superior to
palpation may reveal a suspicious scarred or retracted crypt.
the conventional fistulotomy in the sense that the time taken Further internal palpation may reveal posterior or lateral for the whole procedure is reduced to almost half, chances induration, indicating fistulas deep in the postanal space or of bleeding are reduced to a minimum and the use of suture horseshoe fistulas. Digital rectal examination also provides material is dispensed with. The procedure can safely be assessment of sphincter tone and voluntary squeeze pressure, called a “Sutureless fistulotomy”.
which may indicate the need for preoperative manometry.
Anoscopy It may aid in identifying the internal opening in
Gupta PG. Radio frequency “sutureless” fistulotomy- a new way the anal canal. Massaging the tract may produce a bead of pus of treating fistula in anus. World J Gastroenterol 2003; 9(5): at the dentate line. Proctosigmoidoscopy may exclude a proximal internal opening, inflammatory bowel disease, or http://www.wjgnet.com/1007-9327/9/1082.htm neoplasia. Colonoscopy is appropriate if the diagnosis ofCrohn’s disease is suspected based on a history of recurrent ormultiple fistulas or if examination is suggestive of INTRODUCTION
inflammatory bowel disease. A small-bowel series also maybe appropriate for patients with recurrent or multiple fistulas.
Fistula in anus is defined as an abnormal communication lined Fistulography This may have a role in evaluation of recurrent
by granulation tissue between the anal canal and the exterior i.
fistula, particularly when the prior surgical procedure has failed e. the skin, which causes a chronic inflammatory response.
to identify the internal opening. The external opening iscannulated with a small caliber feeding tube, and contrast Etiology
material is gently injected into the tract. X-ray images are then The most common cause is secondary to an anorectal abscess.
taken in the anteroposterior, oblique, and lateral positions.
These abscesses either have been treated inadequately, or have Complications are rare, and limiting the volume and pressure bursts spontaneously. Abscess is commonly formed secondary of contrast injection can minimize patient discomfort. Accuracy to infection of an anal gland (cryptoglandular hypothesis of rates have been reported to range from 16 to 48 percent, with Eisenhammer)[1]. Other causes are as follows: (a) Secondary to inflammatory bowel disease- Crohn’s or Ulcerative Classification There are four main types described: (1)
Transphincteric low; (2) Transphincteric high; (3) Supra- electrodes can be attached as per the requirement of the levator; and (4) Intersphincteric. However, numerous variations procedure. A ball electrode meant for coagulation, a needle electrode to incise the fistula tract and round loop electrode to Treatment The classical lay open technique is still the most
shave the surrounding infected tissue has been used in our favoured procedure[8]. Slitting the complete tract from the external to internal opening is the basis of the traditional All the patients under study were given to understand the fistulotomy. Tissues around the external openings and internal use of the new technique to be employed in the procedure and opening are excised along with a small margin of tissue lining were clearly explained the potential drawbacks like relapses the tract and the wound is kept open for healing by secondary and need for repetition that may follow. The patients were allowed an option to choose between the conventional method The traditional approach is as follows[9]. Preoperative and the radio frequency technique. An informed consent was cleansing enema is given. The patient is kept in lithotomic obtained from them before subjecting them to this new position. Anesthesia: general or regional block is OK. The procedures were as follows: Digital palpation- the tract is feltas nodule or cord. Proctoscopy- a hypertrophied anal papilla Exclusion criteria of the study
may be the point of internal opening. Probing- It is done with Only low fistulas having opening below the anus rectal ring delicate hand either retrograde (preferred) or anterograde.
were included for study. High trans sphincteric fistulas with Methylene blue dye or milk with hydrogen peroxide is injected or without high blind tract, suprasphincteric, extrasphincteric, from the external opening to locate the direction and path of and horseshoe fistulas as well as fistulas associated with inflammatory bowel disease were excluded from the study.
A director probe is inserted inside the fistula. Track is cutalong probe. Edges of wounds were trimmed and 1-3 mm of Radio frequency surgical fistulotomy procedures
tissue margins was removed. The excised tract is sent for The steps in the fistulotomy[13] were the same as described above with the following modifications. (1) Injection of This conventional procedure encounters a lot of bleeding methylene blue dye with hydrogen peroxide. (2) Director probe from the cut surfaces needing multiple ligatures to tie the inserted in the fistula. (3) To begin with, the skin overlying bleeding vessels. At times, certain raw areas, which cannot be the probe, which is in the fistula tract, was coagulated by tied individually, may need under-running also. Due to all these moving the ball electrode over its complete length. This hindrances, the whole procedure becomes somewhat messy reduced the amount of bleeding when the tract is slit opened.
(4) The track was cut open along the probe with the help of theneedle electrode that was kept in cutting and coagulation mode.
MATERIALS AND METHODS
This reduced the bleeding while cutting and the dissection In our study, the radio frequency surgical device was used became smooth without a drag on the tissues. (5) The bleeding instead of the surgical knife and scissors. The device is called edges were caught in the hemostat and were coagulated with as the Ellman Dual Frequency 4MHz unit from Ellman the ball electrode kept in coagulation mode. This avoided need of suturing or under running of the bleeding points and raw In a span of 18 months starting from July 1999 to December areas. (6) The edges along with the surrounding infected, 2000, 210 cases with fistula in anus of varied types have been fibrotic tissues were shaved with the loop electrode on cut and operated in our nursing home exclusively employing the coagulation mode. As cutting and coagulation worked aforesaid radio frequency surgery device. There were 187 simultaneously, the brisk bleeding often encountered in the males and 23 females. The mean age was 37 years old (age conventional knife and scissor dissection was avoided. (7) At range: from 22 to 63 years old). The mean duration of the this stage, we used an accessory called the suction coagulator.
disease was 19 months (ranging from 4months to 11years).
This was an accessory supplied with the radio frequency Seventeen patients had an operation for fistula once before surgical device. This helped in removing the ooze of blood from the raw area while the bleeding points are being Radio frequency surgery is a technique for cutting and coagulated. The use of this additional tool eliminated frequent coagulating the tissues using a high frequency alternate current.
mopping of the operative field while coagulating the bleeding It is a method of coagulating the tissues, which occurs because point, as both could be done simultaneously.
of heat produced by the tissue resistance to the passage of high Apart from the main procedure of fistulotomy, this radio frequency wave. The heat makes the intracellular water boil, frequency surgical device could also be used in coagulating increasing the cell inner pressure to the point of breaking it associated skin tags, and internal pile masses if present.
from inside to outside explosion[11]. This phenomenon is calledas cellular volatilization. The principle of radio frequency wave Postoperative care
surgery is using high frequency radio waves at 4.0 MHz, which This consisted of dressing the wound twice a day after warm delivers low temperature through RF micro-fiber electrodes sitz bath. The wound could be covered with sanitary napkin, and is similar to the frequency of marine band radio which helped in mopping up the discharge and kept the wound frequencies. The tissue serves as the resistance instead of the dry. The patient was required to stay in the hospital for a day electrode; hence, there is no heating of the RF micro-fiber or two. Time off work was between 5-7 days after which patient electrode. Instead, the intracellular tissue water provides the resistance and vaporizes without causing the heat and damageseen in electro surgery. This tissue vaporization also results in Comparative study
significant hemostasis without actually burning the tissue. In Encouraged by the outcome of the radio frequency fistulotomy, addition, there is no danger of shocking or burning the patient.
we carried out a separate study. This study was to compare the Most important is the fact that there is controlled and minimal efficacy of radio frequency surgical fistulotomy over the lateral tissue damage with the 4.0 MHz high frequency, low conventional one. One hundred patients of low anal fistula temperature radio frequency wave surgery[12].
treated by the classical ‘lay open’ technique were examined.
The unit is provided with a handle to which different Fifty patients were operated by conventional method, while 1084 ISSN 1007-9327 CN 14-1219/ R World J Gastroenterol May 15, 2003 Volume 9 Number 5 fifty were operated by radio frequency fistulotomy.
Results of Comparative study
The comparative data of events obsevered after conventional
and radio frequency surgical fistulotomy were shown in Table1 and Figure 2.
Failure occur mainly due to premature union of the skin edges,failure to excise the internal opening, failure to locate an extra Table 1 Comparative data of events after conventional and
tract, failure to detect a cavity leading upwards from the main tract, presence of foreign bodies and poor post fistulotomywound care[14]. In our study, the failure rate was as low as 1.5 %.
Follow up findings
A follow up of the operated patients of fistulotomy with radio
frequency surgery over a period of 15 months, i.e. from December 2000 to March 2002 was as follows. None of patients lost during the follow up of 9 days. Average time taken for complete wound healing was 47 days. Average time taken by the patient to resume routine was 7 days. Delayed wound healing happened in 7 patients (took about 80-90 days forcomplete healing). It was observed that the fistula wounds which were close to the midline, i.e., near 12 or 6’O clock positions when the patient was in lithotomic position took longer time to heal than wounds at other places. The reasonpossibly could be an excess of stress on the wounds in thatsituation due to proximity with joints.
Comparison of conventional and rf fistulotomy Four patients had a premature closure of the proximalwound while the distal remained unhealed. In case of these patients, the healed edges of the proximal wound were slit opened with needle electrode under local anaesthesia. One of them thereafter had an uneventful healing, while the wound remained unhealed in the remaining three.
Impairment Impairment Time Average Recurrence The remaining three patients continued to have discharge from a small wound left behind, which despite repeated attempts of refreshing the edges remained unresolved. So, they were labeled as cases of ‘failure of wound healing’, rather thanof recurrence. Out of these three patients, one patient was from Figure 2 Comparative findings of the results of radio frequency
the series of those seventeen patients who came with a recurrence after conventional procedure in the past.
None of these patients had any interference with the DISCUSSION
continence, anal stenosis, or mucosal prolapse[15].
The data of follow up findings was shown in Figure 1.
Radio frequency surgery, not to be confused with electrosurgery, diathermy, spark-gap circuitry, or electrocautry, uses Follow up findings after radio surgical fistulotomy a very high frequency radio frequency wave. Unlike electrocautry or diathermy, the electrode remains cold[16]. This is possible because of use of very high frequency current of 4MHz, as compared to 0.5 to 1.5 MHz used in the electrocautry.
As contrast to true cautery, which causes damage similar to 3rddegree burns, the tissue damage that does occur is verysuperficial and is comparable to that which occurs with Lasers.
Histologically, it has been shown that tissue damage with radio frequency surgery is actually less than with a conventional scalpel and equals cold scalpel[17]. Radio frequency surgery creates minimal collateral heat damage in the tissue resulting Time off work in daysDelayed wound healing in No. of patiments in rapid healing and leaves no ugly scar. Biopsies performed of the skin tissue indicate a maximum thickness of heat-denatured collagen to be 75 micrometer. This is equal to or Figure 1 Follow up findings after radio frequency fistulotomy.
even better than carbon dioxide laser used for cutting[18].
Rapidity of treatment, a nearly bloodless field, minimal Complications
postoperative pain, and rapid healing are but few advantages No major complications were encountered. Few minor ones of radio frequency surgery. Once proper technique is were discussed as follows. Deep dissection may cause more established, a scar by this method of treatment is often less scarring and longer time for healing. Excessive power of the pronounced than those produced by other surgical techniques.
unit can cause more smoke and charring. Either accidental Excising too deeply increases the likelihood of scars[19].
burns on the part of the patient or operator due to unintendedactivation of hand piece has been noted. Development of edema Precautions to be taken
in the surrounding tissue would occur, if power was too high.
Removing a lesion on someone who is on aspirin or anticoagulant Excessive discharge from the open wound was found in few therapy may be accompanied by increased bleeding.
patients. This usually happened when the tissues at the base The unit should not be used in presence of flammable or explosive liquids or gases. The surgeon must also remember to deactivate the hand piece whenever the electrodes are Parks AG, Gordon PH, Hardcastle JD. A classification of fistula-
in-ano. Br J Surg 1976; 63: 1-12
As with all radio frequency surgery machines, smoke is Kronborg O. To lay open or excise a fistula-in-ano: a random-
produced, this needs to be attended to avoid the unpleasant ized trial. Br J Surg 1985; 72: 970
McLeod RS. Management of fistula-in-ano.Roussel Lecture. Can
smell of burning. This could be achieved by employing a J Surg 1991; 34: 581-585
vacuum extractor with the help of the assistant[21].
Gingold BS. Reducing the recurrence risk of fistula in ano. Surg
The various techniques used for treating fistula[22] are Gynecol Obstet 1983; 156: 661-662
fistulectomy, fistulotomy, fistulotomy with marsupialisation[23] Pfenninger JL, Zainea GG. Common anorectal conditions: Part
of fistula, curettage of fistula and placement of flaps of II. Am Fam Physician 2001; 64: 77-88
mucosa or skin, placement of medicated Setons, insertion of Plant RL. Radiofrequency treatment of tonsillar hypertrophy.
antibiotic beads, and injection of commercial or autologous Laryngoscope 2002; 112: 20-22
fibrin glue[24]. Out of these options available to the surgeon, Golighar J, Duthie H, Nixon H. Surgery of the anus rectum and
majorities of them still rely on the classical lay open technique colon. 5thed. London: Bailliere Tindal 1992: 196-197 (fistulotomy) as the gold standard of treatment in over 90 % of Vasilevsky CA, Gordon PH. Results of treatment of fistula-in-
ano. Dis Colon Rectum 1985; 28: 225-231
Gustafsson UM, Graf W. Excision of anal fistula with closure of
Patients’ satisfaction after the surgical treatment for fistula- the internal opening: functional and manometric results. Dis Co- in-anus is associated with recurrence of the fistula, the lon Rectum 2002; 45: 1672-1678
development of anal incontinence, and the effects of anal Olivar AC, Rorouhar FA, Gillies CG, Servanski DR. Transmis-
incontinence on patient lifestyle[26]. The radio frequency sion of Electron Microscopy: Evaluation of Damage in human surgical technique of fistulotomy has been found more oviducts caused by different surgical instruments. Ann Clin Labo- acceptable than the conventional fistulotomy in the sense that ratory Sci 1999; 29: 135-139
the time taken for the whole procedure is reduced to half, Saidi MH, Setzler FD Jr, Sadler RK, FArhart SA, Akright BD.
bleeding is reduced to a minimum and the use of suture material Comparison of office loop electrosurgical conization and cold is dispensed with. None of the patients in our study had any knife conization. J Am Assoc Gynecol Laparosc 1994; 1: 135-139
Bridenstine JB. Use of ultra-high frequency electrosurgery [Radio
interference with the continence and the recurrence rate was surgery] for cosmetic surgical procedures. Dermatol Surg 1998; 24: 397-400
If compared to electrocautery or laser, the active electrode Pfenninger JL, DeWitt DE. Radio frequency frequency surgery.
does not heat up, so there is minimal or no heat generated to the Procedures for primary care physicians. St Louis: Mosby 1994: 91- surgical site. This allows the surgeon to work in direct proximity of the functional tissues that needs to be preserved[27].
Valinsky MS, Hettinger DF, Gennett PM. Treatment of Verru-
cae via Radio frequency wave Surgery. J Am Podiatr Med Assoc
CONCLUSION
1990; 80: 482-488
Inoue Y, Yozu R, Cho Y, Kawada S. Video-Assisted thoracos-
This technique has been found superior to the conventional copy system guidance in linear radiofrequency ablation. Surgery and can safely be called a “sutureless fistulotomy”.
Toady 2000; 30: 811-815
Belliveau P. Anal fistula. In: Fazio VW, eds. Current therapy in
colon and rectal surgery. Toronto: BC Decker 1990: 22-27
REFERENCES
Eu KW. Fistulotomy and marsupialisation for simple fistula-in-
Adams D, Kovalcik PJ. Fistula in ano. Surg Gynecol Obstet 1981;
ano. Singapore Med J 1992; 33: 532
153: 731-732
Abel ME, Chiu YS, Russell TR, Volpe PA. Autologous fibrin glue
Vasilevsky CA. Fistula-in-ano and abscess. In: Beck DE, Wexner
in the treatment of rectovaginal and complex fistulas. Dis Colon SD, eds. Fundamentals of anorectal surgery. New York: McGraw- Rectum 1993; 36: 136-138
Ewerth S, Ahlberg J, Collste G, Holmstrom B. Fistula-in-ano. A
Seow-Choen F, Nicholls RJ. Anal fistula. Br J Surg 1992; 79: 197-205
six-year follow up study of 143 operated patients. Acta Chir Scand Isbister WH. Fistula in ano: a surgical audit. Int J Colorectal Dis
Suppl 1978; 482: 53-55
1995; 10: 94-96
Garcia-Aguilar J, Davey CS, Le CT, Lowry AC, Rothenberger
Kuypers JH. Diagnosis and treatment of fistula-in-ano. Neth J
DA. Patient satisfaction after surgical treatment for fistula-in-ano.
Surg 1982; 34: 147-152
Dis Colon Rectum 2000; 43: 1206-1212
Kuijpers HC, Schulpen T. Fistulography for fistula in ano: is it
Pfenninger JL. Modern treatments for internal hemorrhoids. BMJ
useful? Dis Colon Rectum 1985; 28: 103-104
1997; 314: 1211-1212
Edited by Xu XQ

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