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Tube loop (seton) drainage treatment of recurrent extrasphincteric perianal fistulae
Tube Loop (Seton) Drainage Treatment of Recurrent Extrasphincteric Perianal Fistulae Ga´bor Balogh, MD, PhD, Kaposvar, Hungary
Tube loop seton drainage treatment of multiply recurring high-spreading extrasphincteric perianal fistulae in 19 patients is reported in this study. The drainage loop setons make possible the rinsing of the wound following fistulectomy and also the bidirectional drainage of the wound discharge. Strangulation of the wound and an early closure of the fistula and hence the development of recurrence is prevented by means of controlled formation of scarred tissue. The sphincteral musculature of the anus is also protected from damage. Thirty-five recurring fistulae of 19 patients included in the present study were treated successfully by this method. Two fistula recurred. None of these patients developed incontinence. The use of tube loop setons was found to have advantages over the pull-out method in cases of high-spreading multiply recurring extrasphincteric or suprasphincteric perianal fistulae. Am J Surg. 1999;177:147–149. © 1999 by Excerpta Medica, Inc.
P
erianal fistulae were first classified and the main principles of their surgical treatment described by Sir Alan Parks.23 An essential and still influential contribution to the subject was made by Girona et al8 and Athanasiadis et al.2,3 Ritter26 has also given a valuable description of the phenomenon. Perianal fistulae are frequently difficult to treat and eliminate. In Crohn’s disease2,15 and also in special cases the rate of recurrence is higher; in diabetes and conditions involving immunodeficiency the fistula often persists. In the majority of cases various surgical methods can be effective if they are selected according to the types of the fistulae. However, in 2% to 9% of the cases,3,5,10,18,19,29 recurrence occurred. These data apply to all types of fistulae classified by Parks. The prevalence of extrasphincteric or suprasphincteric perianal fistulae has been reported to range between 1.3% and 17.0%.3,5,12,16,19,26,28 In cases of multiply recurring high-spreading extrasphincteric fistulae, the elimination of pus formation is a most difficult task for the surgeon, since healing has to be achieved in a site deformed by scars due to several previous surgical interventions.
From the Second Department of Surgery and Thoracic Surgery, Kaposi Mor County Hospital, Kaposvar, Hungary. Requests for reprints should be addressed to Ga´bor Balogh, MD, PhD, Kaposi Mo´r County Hospital, Second Department of Surgery and Thoracic Surgery, Kaposva´r, Tallia´n Gy. Street 20 – 34, 7400 Hungary. Manuscript submitted April 8, 1998, and accepted in revised form November 18, 1998.
© 1999 by Excerpta Medica, Inc. All rights reserved.
PATIENTS Nineteen patients with recurring high-spreading extrasphincteric perianal fistulae were treated at our department between January 1, 1988 and December 31, 1997. Loop (seton) drainage was applied in 16 males and 3 females, the youngest patient being 26 and the oldest 67, their average age being 50.9 years. The patients’ history dated back to 5 years as an average (1 to 12 years). The average number of previously performed operations was 4 (2 to 9), the number of fistulae in the 19 patients amounted to 35, and the number of drainage loop setons used was 35. Six of the patients had three fistulae each. In these patients, surgery was performed in two stages. In 6 cases in addition to the existing recurrent fistulae, abscess formation was also observed, however, not in another site but as an acute complication of the existing fistulae. The underlying disease was nonspecific perianal infection in 14 cases, Crohn’s disease in 3 cases, and tuberculosis in 2 cases. In none of the patients were used more than two drainage loop setons at the same time. The average duration of hospital treatment amounted to 7.2 days, whereas in the case of the patients treated in two stages this period was roughly twice as long. Two of the recurrences occurred in the 19 patients with 35 fistulae treated with drainage loop setons. The last patient having received drainage loop setons has been free of complaints for 1.5 years. No incontinence, temporary or permanent, occurred. These patients had been treated in other institutions, the majority having been admitted to different departments. The surgery was also carried out by different surgeons. Oncotomy, tamponade, and Pennington surgery had been carried out in each patient in the course of previous surgical interventions.24
METHOD The patient is placed on the operating table in the lithotomy position. Following Recamier dilatation, an anoscope is inserted into the anus. Through the perianal orifice of the fistula a bulbous probe is inserted, whose appearence in the lumen is monitored through the anascope. Next, a fistulectomy is carried out proceeding from the wide exposure, from the direction of the perianal skin toward the inner opening of the fistula. After rinsing the passage and the wound, a drain is inserted. A loop made of Nelaton catheter of 16-18Ch was found to be the most appropriate, causing the least discomfort to the patients (Figure). One of the branches of the rubber tube is brought out through the anal canal while the other one is led out through the passage formed after the removal of the fistula. The two branches of the drain are stitched together and tightly knotted so that each lumen is closed. Thus, a tube loop drainage is formed on which one or two side openings are made. The operation is finished after bleeding has been controlled and tamponade placed. 0002-9610/99/$–see front matter PII S0002-9610(98)00322-5
147
TUBE LOOP DRAINAGE OF RECURRENT PERIANAL FISTULAE/BALOGH
several times a day; as the first few treatments are painful, intolerant patients may require epidural anesthesia; and wearing the tube loop drainage in uncomfortable.
COMMENTS
Figure 1. Tube loop drainage treatment.
After defecation and also on one or two further occasions, the wound is rinsed through the branches of the tube loop drainage inserted. The rinsing solution is injected into the drain by pricking its branches (Figure). While the rinsing solution is being injected, both the anal canal and the scar from fistulectomy are rinsed by way of changing the position of the side opening of the loop. Depending on the character of the wound discharge, physiological saline or 3% hydroperoxide are used and occasionally, in cases of thick fibropurulent pus, an antiseptic solution of antibiotics is applied. The primary aim of the rinsing treatment is the mechanical cleansing of the wound, wound toilet after passing motions, and also the removal of the rejected tissue fragments as well as the reduction of the number of pathogens. After 7 to 10 days the drains are removed provided there are no signs of tissue inflammation, the amount of the discharge has decreased, and on the surface in contact with the tube loop drainage granulation has started. Daily antiseptic baths and sterile dressing are applied to the perineal wound until it heals. Advantages of the method are as follows: There is a minimal need for instruments; it can be carried out quickly, posing minimal operational burden on the patient; the sphincter musculature of the anus is not damaged, so no incontinence is caused; it prevents the strangulation of the passage of the fistula; a two-way drainage is created for the wound discharge; rinsing of the wound is rendered possible, thus promoting both mechanical and chemical rinsing; and tamponade is necessary only for a few days. Disadvantages of the method are that the patient needs to be treated 148
The history of perianal fistulae dates back to the times of Hippocrates. It is known from the history of medicine by Garrison7 that this topic was touched upon by John of Ardennes as early as 1376. Louis the XIV was successfully treated for this condition by Royal Surgeon Felix in the middle of the 18th century. The anatomy of musculature in the pelvic region was first described by German and French anatomists in the middle of the 19th century. The surgical anatomy of perianal fistulae was founded in terms of internal and external sphincters as well as the puborectal musculature by Milligan and Morgan20 in 1934. The anatomy of the ducts of the anal glands playing a key role in the formation and pathomechanism of fistulae was first decribed by Chiary in 1878.23 Further progress in the subject was made by Eisenhammer,6 Goliger,9 Lilius,13 and Stelzner.27 The modern surgical principles were established by Parks.22 The surgical management of high-spreading extrasphincteric fistulae has been of two types: closing or leaving open the internal opening of the fistula. Lange (cit3) in 1886 closed the internal opening following fistulectomy. In spite of its unquestionable advantage, the method had not spread widely. The “T” method was first suggested by Salamon in 1896 (cit1). This procedure involves the excision and treatment of the fistula open. This method has had several followers.13,14,18,20,28 Besides the various pullout methods (thread, metallic wire, rubber band, and so forth)10,12,14,25,27 various other surgical methods of one or two stages are also described.2,16,17,28,30 The guiding principle of the surgical elimination of perianal fistulae is complete removal of the fistular passage on the one hand, and the sparing of the sphincteric musculature of the anus, ie, the avoidance of incontinence, on the other. Furthermore, that operation technique should be applied that helps avoid recurrences. In the present paper, data on patients having had several recurrences of their fistulae classified as type III in the Parks’ classification23 are presented. Following multiple fistulectomy, the perianal tissues underwent deformation due to scarring. The majority of patients developed two or more fistulae. With use of the various pull-out methods, the foreign material pulled out induces scarring while it also contributes to the healing of the site of the excised fistula. The thread knotted every 4 to 5 days cuts through the muscular fibers of the sphincters, causing scarring, which can lead to malfunctions, ie, incontinence. Consequently, a solution that causes appropriate scarring without damaging the fibers of the sphincters, gives better functional results, and also eliminates causes leading to recurrences should be applied. In our experience, the recurrences of perianal fistulae could be avoided bearing the following principles in mind: (1) nearly total excision of the fistular passage; (2) creating a two-way tube loop drainage, so that the perianal wound can be cleaned continuously; (3) preventing reinfection associated with defecation by means of lavage; and (4) eliminating early closure of the fistula or strangulation caused by scarring due to the insertion of the tube loop drainage—“controlled” formation of scar tissue. These treatment objectives can be achieved by means of a
THE AMERICAN JOURNAL OF SURGERY® VOLUME 177 FEBRUARY 1999
TUBE LOOP DRAINAGE OF RECURRENT PERIANAL FISTULAE/BALOGH
thorough fistulectomy and tube loop drainage. The basic idea of its application comes from the fact that in all areas of surgery various drains are used in the aspiration and drainage of cavities. For the elimination of suppuration in the thorax and abdomen, various drain tubes are used for several weeks in many cases. After the removal of these drain tubes, the thoracic or abdominal wall closes spontaneously. It is rare for the scarred passage forming around the drain tube to remain open for a long time. Around the tube left in the wound for 8 to 10 days, scar tissue forms. Thus, it is not the wall of a zigzagged wound that gets scarred but that of a regular cylindrical arching cavity of the same diameter everywhere. In our experience, after the removal of the loop drain the lumen of the passage created by the tube closes and heals. In no cases have we found feculent discharge for more than 3 days. Ritter26 claims that the postoperative treatment of the wound cavity is a disputable area of fistula surgery, as tamponade is considered to be necessary while a continuous strip drain may disturb continence. When loop drainage is applied, no tamponade is necessary or it is necessary only for a few days. In the case of marsupialization loop drainage tamponade is unnecessary, as early closure or strangulation is prevented by the rubber tube inserted. The excision of perianal skin and subcutaneous fat need not be performed on such a big area as in the case of marsupialization. This also reduces the degree of postoperative scarring. As a result of this, the perisphincteric region heals with a lesser degree of deformation. Following the surgical treatment of perianal fistulae, the development of recurrences are inevitable. In cases of multiple recurrences, procedures and methods applied so far have not been successful. The appropriateness of operations performed previously is not evaluated here. For some patients, previously performed fistulectomy, tamponade, or one of the various pull-out methods had not been successful. Therefore, to eliminate their conditions necessitated solutions other than the ones mentioned previously. With the technique of pulling out rubber bands propagated by Hungarian authors,12,24 the muscle fibers of the sphincters are affected to the same extent as with the use of “seton” techniques. Loop drainage spares the anal sphincters. This is most important, as the techniques applied previously have not been successful in any of the patients included in the present study. The lavage pumped into the fistula through the openings on the side of the drain-loop makes permanent cleaning and disinfection possible. Moreover, lavage prevents reinfection resulting from defecation, which is one of the most frequent causes of the recurrence of the fistula. The data presented in the present paper allow for the conclusion that in the elimination of high-spreading multiply-recurring extrasphincteric or suprasphincteric perianal fistulae, the application of tube loop drainage technique proved to be more effective than the various pull-out methods. The guided scarring and the permanent clearing can explain the success of the present method. The application of this procedure seems to offer a new alternative in the successful surgical treatment of perianal fistulae.
REFERENCES 1. Allingham W. The diagnosis and treatment of diseases of the rectum. London: Baille´re; 1896. 2. Athanasiadis S, Girona J. Neue behandlungsmethod der perianalen fisteln bei Morbus Crohn. Langenvecks Arch Chir. 1983;360: 119 –132.
3. Athanasiadis S, Lux N, Fischbach N, et al. Die einzeitige operation hoher trans- und suprasphincterer analfisteln mittels primaer fistulectomie und verschluss des inneren fistelostiums. Chirurg. 1991;62:608 – 613. 4. Benyo´ I, Hetesi L. Primer fistulotomia´val szerzett tapasztalataink. Magy Seb. 1991;44:202–204. 5. Buchan R, Grace RH. Anorectal suppuratives. Br J Surg. 1973; 60:537–540. 6. Eisenhammer S. The anorectal fistulous abscess and fistula. Dis Colon Rectum. 1966;9:91–106. 7. Garrison FH. An Introduction to the History of Medicine. Philadelphia: WB Saunders; 1921. 8. Girona J. Neue Erkenntmisse in der Genese der analfistels und Neue Wege der Operativen Behandlung. Habilitationsschrift. Ruhr: Universitat Bochum; 1985. 9. Goligher JC. Surgery of the anus. In: Goligher JC, ed. Rectum and Colon. London: Cassel; 1961:180. 10. Hanley P. Rubber band seton in the management of abscess and anal fistula. Ann Surg. 1978;60:435– 437. 11. Karlinger T. Extrasphinctericus ve´gbe´lsipolyok muˆte´te. Magy Seb. 1952;3:166 –171. 12. Krasznai P, Somorjai B, Erde´yli B. Perianalis ta´lyogsipolyok fistuloto´mia´ja gumibehu´za´ssal. Orv Hetil. 1993;46:167–170. 13. Lilius HG. Investigation of human foetal anal ducts and intramuscular glands and clinical study of 150 patients. Acta Chir Scand 1968;(suppl):383–384. 14. Litmann I, Berentei G. Sebe´szeti muˆte´ttan. Medicina Bp. 1988; 460 – 461. 15. Lockhart-Mummery HE. Crohn disease: anal lesions. Dis Colon Rectum. 1975;18:200 –205. 16. Lux N, Athanasiadis S. Functionelle ergeblisse nach fistulectomie mit primarer muskelnacht bei de hohen analfisteln. Eine porspektive klinische in analmanometrische studie. Chirurg. 1991;62:36–41. 17. Mann CV, Clifton MA. Re-routing of the track for treatment of high anal and anorectal fistulae. Br J Surg. 1985;72:134 –137. 18. Marks CG, Ritchie JK. Anal fistulas at St Mark’s Hospital. Br J Surg. 1977;63:84 –91. 19. McElvain M, Maclean M. Surgery of perianal fistulae symposium. Dis Colon Rectum. 1975;18:646 – 649. 20. Milligan FTC, Morgan CN. Surgical anatomy of the anal canal with special reference to ano-rectal fistulae. Lancet. 1934;2:1150 – 1213. 21. Parkash S, Lakshmiratan W, Gajendran V. Fistula in ano: treatment by fistulectomy, primary closure, and reconstruction. Aust NZJ Surg. 1985;55:23–26. 22. Parks AG. The pathogenesis and treatment of fistula-in-ano. BMJ. 1961;1:463– 469. 23. Parks A, Gordon P, Handcasstle H. A classification of fistula in ano. Br J Surg. 1976;63:1–12. 24. Pennington JR. Anal and rectal fistula. JAMA. 1917;69:1501– 1509. 25. Ramanujam PS, Prasad ML, Abcariar H. The role of seton in fistulotomy of the anus. Surg Gynecol Obstet. 1983;157:419 – 422. 26. Ritter L. Analis, perianalis ta´lyog sipoly. Kandida´tusi e´rtekeze´s. MTA. 1979;82– 83. 27. Stelzner F. Die Anorektalen Fisteln. Berlin-GottingenHeidelberg: Springer; 1959. 28. Thompson JPS, Ross AHMcL. Can the external anal sphincter be preserved in the treatment of transsphincteric fistula in ano? Int J Colorect Dis. 1989;4:247–251. 29. Vasilevsky C, Gordon TH. Results of treatment of fistula-inano. Dis Colon Rectum. 1984;28:225–231. 30. Wedell J, Meier zu Essel P, Banzhaf G, Kleine L. Sliding flap advancement for the treatment of high level fistulae. Br J Surg. 1987;74:74 –79. 31. Wedell J. Chirurgische therapie hoher analfisteln. Brife an die herausgeber. Chirurg. 1992;63:1055–1056.
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Tube loop seton drainage treatment of multiply recurring high-spreading extrasphincteric perianal fistulae in 19 patients is reported in this study. The drainage loop setons make possible the rinsing of the wound following fistulectomy and also the bidirectional drainage of the wound discharge. Strangulation of the wound and an early closure of the fistula and hence the development of recurrence is prevented by means of controlled formation of scarred tissue. The sphincteral musculature of the anus is also protected from damage. Thirty-five recurring fistulae of 19 patients included in the present study were treated successfully by this method. Two fistula recurred. None of these patients developed incontinence. The use of tube loop setons was found to have advantages over the pull-out method in cases of high-spreading multiply recurring extrasphincteric or suprasphincteric perianal fistulae. Am J Surg. 1999;177:147–149. © 1999 by Excerpta Medica, Inc.
P
erianal fistulae were first classified and the main principles of their surgical treatment described by Sir Alan Parks.23 An essential and still influential contribution to the subject was made by Girona et al8 and Athanasiadis et al.2,3 Ritter26 has also given a valuable description of the phenomenon. Perianal fistulae are frequently difficult to treat and eliminate. In Crohn’s disease2,15 and also in special cases the rate of recurrence is higher; in diabetes and conditions involving immunodeficiency the fistula often persists. In the majority of cases various surgical methods can be effective if they are selected according to the types of the fistulae. However, in 2% to 9% of the cases,3,5,10,18,19,29 recurrence occurred. These data apply to all types of fistulae classified by Parks. The prevalence of extrasphincteric or suprasphincteric perianal fistulae has been reported to range between 1.3% and 17.0%.3,5,12,16,19,26,28 In cases of multiply recurring high-spreading extrasphincteric fistulae, the elimination of pus formation is a most difficult task for the surgeon, since healing has to be achieved in a site deformed by scars due to several previous surgical interventions.
From the Second Department of Surgery and Thoracic Surgery, Kaposi Mor County Hospital, Kaposvar, Hungary. Requests for reprints should be addressed to Ga´bor Balogh, MD, PhD, Kaposi Mo´r County Hospital, Second Department of Surgery and Thoracic Surgery, Kaposva´r, Tallia´n Gy. Street 20 – 34, 7400 Hungary. Manuscript submitted April 8, 1998, and accepted in revised form November 18, 1998.
© 1999 by Excerpta Medica, Inc. All rights reserved.
PATIENTS Nineteen patients with recurring high-spreading extrasphincteric perianal fistulae were treated at our department between January 1, 1988 and December 31, 1997. Loop (seton) drainage was applied in 16 males and 3 females, the youngest patient being 26 and the oldest 67, their average age being 50.9 years. The patients’ history dated back to 5 years as an average (1 to 12 years). The average number of previously performed operations was 4 (2 to 9), the number of fistulae in the 19 patients amounted to 35, and the number of drainage loop setons used was 35. Six of the patients had three fistulae each. In these patients, surgery was performed in two stages. In 6 cases in addition to the existing recurrent fistulae, abscess formation was also observed, however, not in another site but as an acute complication of the existing fistulae. The underlying disease was nonspecific perianal infection in 14 cases, Crohn’s disease in 3 cases, and tuberculosis in 2 cases. In none of the patients were used more than two drainage loop setons at the same time. The average duration of hospital treatment amounted to 7.2 days, whereas in the case of the patients treated in two stages this period was roughly twice as long. Two of the recurrences occurred in the 19 patients with 35 fistulae treated with drainage loop setons. The last patient having received drainage loop setons has been free of complaints for 1.5 years. No incontinence, temporary or permanent, occurred. These patients had been treated in other institutions, the majority having been admitted to different departments. The surgery was also carried out by different surgeons. Oncotomy, tamponade, and Pennington surgery had been carried out in each patient in the course of previous surgical interventions.24
METHOD The patient is placed on the operating table in the lithotomy position. Following Recamier dilatation, an anoscope is inserted into the anus. Through the perianal orifice of the fistula a bulbous probe is inserted, whose appearence in the lumen is monitored through the anascope. Next, a fistulectomy is carried out proceeding from the wide exposure, from the direction of the perianal skin toward the inner opening of the fistula. After rinsing the passage and the wound, a drain is inserted. A loop made of Nelaton catheter of 16-18Ch was found to be the most appropriate, causing the least discomfort to the patients (Figure). One of the branches of the rubber tube is brought out through the anal canal while the other one is led out through the passage formed after the removal of the fistula. The two branches of the drain are stitched together and tightly knotted so that each lumen is closed. Thus, a tube loop drainage is formed on which one or two side openings are made. The operation is finished after bleeding has been controlled and tamponade placed. 0002-9610/99/$–see front matter PII S0002-9610(98)00322-5
147
TUBE LOOP DRAINAGE OF RECURRENT PERIANAL FISTULAE/BALOGH
several times a day; as the first few treatments are painful, intolerant patients may require epidural anesthesia; and wearing the tube loop drainage in uncomfortable.
COMMENTS
Figure 1. Tube loop drainage treatment.
After defecation and also on one or two further occasions, the wound is rinsed through the branches of the tube loop drainage inserted. The rinsing solution is injected into the drain by pricking its branches (Figure). While the rinsing solution is being injected, both the anal canal and the scar from fistulectomy are rinsed by way of changing the position of the side opening of the loop. Depending on the character of the wound discharge, physiological saline or 3% hydroperoxide are used and occasionally, in cases of thick fibropurulent pus, an antiseptic solution of antibiotics is applied. The primary aim of the rinsing treatment is the mechanical cleansing of the wound, wound toilet after passing motions, and also the removal of the rejected tissue fragments as well as the reduction of the number of pathogens. After 7 to 10 days the drains are removed provided there are no signs of tissue inflammation, the amount of the discharge has decreased, and on the surface in contact with the tube loop drainage granulation has started. Daily antiseptic baths and sterile dressing are applied to the perineal wound until it heals. Advantages of the method are as follows: There is a minimal need for instruments; it can be carried out quickly, posing minimal operational burden on the patient; the sphincter musculature of the anus is not damaged, so no incontinence is caused; it prevents the strangulation of the passage of the fistula; a two-way drainage is created for the wound discharge; rinsing of the wound is rendered possible, thus promoting both mechanical and chemical rinsing; and tamponade is necessary only for a few days. Disadvantages of the method are that the patient needs to be treated 148
The history of perianal fistulae dates back to the times of Hippocrates. It is known from the history of medicine by Garrison7 that this topic was touched upon by John of Ardennes as early as 1376. Louis the XIV was successfully treated for this condition by Royal Surgeon Felix in the middle of the 18th century. The anatomy of musculature in the pelvic region was first described by German and French anatomists in the middle of the 19th century. The surgical anatomy of perianal fistulae was founded in terms of internal and external sphincters as well as the puborectal musculature by Milligan and Morgan20 in 1934. The anatomy of the ducts of the anal glands playing a key role in the formation and pathomechanism of fistulae was first decribed by Chiary in 1878.23 Further progress in the subject was made by Eisenhammer,6 Goliger,9 Lilius,13 and Stelzner.27 The modern surgical principles were established by Parks.22 The surgical management of high-spreading extrasphincteric fistulae has been of two types: closing or leaving open the internal opening of the fistula. Lange (cit3) in 1886 closed the internal opening following fistulectomy. In spite of its unquestionable advantage, the method had not spread widely. The “T” method was first suggested by Salamon in 1896 (cit1). This procedure involves the excision and treatment of the fistula open. This method has had several followers.13,14,18,20,28 Besides the various pullout methods (thread, metallic wire, rubber band, and so forth)10,12,14,25,27 various other surgical methods of one or two stages are also described.2,16,17,28,30 The guiding principle of the surgical elimination of perianal fistulae is complete removal of the fistular passage on the one hand, and the sparing of the sphincteric musculature of the anus, ie, the avoidance of incontinence, on the other. Furthermore, that operation technique should be applied that helps avoid recurrences. In the present paper, data on patients having had several recurrences of their fistulae classified as type III in the Parks’ classification23 are presented. Following multiple fistulectomy, the perianal tissues underwent deformation due to scarring. The majority of patients developed two or more fistulae. With use of the various pull-out methods, the foreign material pulled out induces scarring while it also contributes to the healing of the site of the excised fistula. The thread knotted every 4 to 5 days cuts through the muscular fibers of the sphincters, causing scarring, which can lead to malfunctions, ie, incontinence. Consequently, a solution that causes appropriate scarring without damaging the fibers of the sphincters, gives better functional results, and also eliminates causes leading to recurrences should be applied. In our experience, the recurrences of perianal fistulae could be avoided bearing the following principles in mind: (1) nearly total excision of the fistular passage; (2) creating a two-way tube loop drainage, so that the perianal wound can be cleaned continuously; (3) preventing reinfection associated with defecation by means of lavage; and (4) eliminating early closure of the fistula or strangulation caused by scarring due to the insertion of the tube loop drainage—“controlled” formation of scar tissue. These treatment objectives can be achieved by means of a
THE AMERICAN JOURNAL OF SURGERY® VOLUME 177 FEBRUARY 1999
TUBE LOOP DRAINAGE OF RECURRENT PERIANAL FISTULAE/BALOGH
thorough fistulectomy and tube loop drainage. The basic idea of its application comes from the fact that in all areas of surgery various drains are used in the aspiration and drainage of cavities. For the elimination of suppuration in the thorax and abdomen, various drain tubes are used for several weeks in many cases. After the removal of these drain tubes, the thoracic or abdominal wall closes spontaneously. It is rare for the scarred passage forming around the drain tube to remain open for a long time. Around the tube left in the wound for 8 to 10 days, scar tissue forms. Thus, it is not the wall of a zigzagged wound that gets scarred but that of a regular cylindrical arching cavity of the same diameter everywhere. In our experience, after the removal of the loop drain the lumen of the passage created by the tube closes and heals. In no cases have we found feculent discharge for more than 3 days. Ritter26 claims that the postoperative treatment of the wound cavity is a disputable area of fistula surgery, as tamponade is considered to be necessary while a continuous strip drain may disturb continence. When loop drainage is applied, no tamponade is necessary or it is necessary only for a few days. In the case of marsupialization loop drainage tamponade is unnecessary, as early closure or strangulation is prevented by the rubber tube inserted. The excision of perianal skin and subcutaneous fat need not be performed on such a big area as in the case of marsupialization. This also reduces the degree of postoperative scarring. As a result of this, the perisphincteric region heals with a lesser degree of deformation. Following the surgical treatment of perianal fistulae, the development of recurrences are inevitable. In cases of multiple recurrences, procedures and methods applied so far have not been successful. The appropriateness of operations performed previously is not evaluated here. For some patients, previously performed fistulectomy, tamponade, or one of the various pull-out methods had not been successful. Therefore, to eliminate their conditions necessitated solutions other than the ones mentioned previously. With the technique of pulling out rubber bands propagated by Hungarian authors,12,24 the muscle fibers of the sphincters are affected to the same extent as with the use of “seton” techniques. Loop drainage spares the anal sphincters. This is most important, as the techniques applied previously have not been successful in any of the patients included in the present study. The lavage pumped into the fistula through the openings on the side of the drain-loop makes permanent cleaning and disinfection possible. Moreover, lavage prevents reinfection resulting from defecation, which is one of the most frequent causes of the recurrence of the fistula. The data presented in the present paper allow for the conclusion that in the elimination of high-spreading multiply-recurring extrasphincteric or suprasphincteric perianal fistulae, the application of tube loop drainage technique proved to be more effective than the various pull-out methods. The guided scarring and the permanent clearing can explain the success of the present method. The application of this procedure seems to offer a new alternative in the successful surgical treatment of perianal fistulae.
REFERENCES 1. Allingham W. The diagnosis and treatment of diseases of the rectum. London: Baille´re; 1896. 2. Athanasiadis S, Girona J. Neue behandlungsmethod der perianalen fisteln bei Morbus Crohn. Langenvecks Arch Chir. 1983;360: 119 –132.
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