Video-assisted Anal Fistula Treatment Versus Seton in the Management of High Peri Anal Fistula
Condition: Post Operative Pain; Recurrence
MeSH terms: Rectal Fistula; Recurrence; Fistula; Pain, Postoperative
Study type: Interventional

Summary: 
      Anal fistula is the most common Peri anal disease. It's a disease with an incidence of 9 in
      100,000. Anal fistula is classified on the basis of its location into high and low anal
      fistula, above or below dentate line respectively.

      Multiple series have shown that the formation of a fistula tract following anorectal abscess
      occurs in 7-40% of cases. There are typically 8-10 anal crypt glands at the level of the
      dentate line in the anal canal arranged circumstantially. These glands afford a path for
      infecting organisms to reach the intramuscular spaces. The cryptoglandular hypothesis states
      that an infection begins in the anal canal glands and progresses into the muscular wall of
      the anal sphincters to cause an anorectal abscess.

      According to internal opening many author proposed certain classification but the
      standardized in all of them is Park's classification, so this study categorized the patient
      through this classification. There are four types of fistula-in-ano in Park's Classification
      intersphincteric (between internal and external sphincters is 70%), transsphincteric (across
      external sphincters is 25%), suprasphincteric (over sphincters), and extrasphincteric(above
      and through levator ani).High anal fistula is considered to be difficult to treat because of
      its location.This study diagnosed the internal opening of high perianal with the help of
      endoluminal ultrasound and MRI.

      Classic method of its treatment are fistulotomy, fistulectomy and Setone placement but these
      are associated with lots of complication like fecal incontinence,recurrence,pain.Therefore
      many method have been recently devised including Ligation of intersphincteric fistula tract
      (Lift), glue repair and flap advancement.Another recently introduced method for its treatment
      is Video-assisted anal fistula treatment (VAAFT) proposed by P. Meinero which has been
      associated with less complications.
    


Intervention name(s): SETON; VAAFT
Intervention type(s): Procedure; Procedure
Intervention description(s): In seton treatment, initially Hydrogen peroxide will be applied to the external opening with a 10-cc syringe, and the internal opening will be located by direct visualization of the anal canal via proctoscope. A probe will be inserted into the external opening and carefully maneuvered through the internal opening. Silk 1/0 suture will be then tied to the tip of the probe, which will be then squeezed out of the external opening. The suture will be then tied around the sphincter and through fistula tract. Later, the seton will be tightened at four-week intervals under local anesthesia until the suture cut through the sphincter.; Patients assigned to the VAAFT group will receive the following procedure. The external opening will be widened with a probe, and a fistulascope will be inserted to delineate the primary and secondary tracts and locate the internal opening. The internal opening will be then stitched with Vicryl™ (Polyglactin 910) 2-0 suture through the anal route with the help of a proctoscope. The tract of the fistula will be washed and debrided through the scope and cauterized. Finally, the external opening will be excised and will be sent for biopsy.
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: Single (Outcomes Assessor)
Primary purpose: Treatment