Breast Examination Background The role of radiographic screening for breast cancer (mammography) in women younger than 50 years

is controversial. Physical examination of the breasts is both an important adjunct to mammography and a significant screening tool in its own right. arriers to accurate and thorough examination include provider or patient discomfort! fear of misinterpretation of attention to the patient"s breasts! and lac# of #nowledge about the techni$ue. Indications %lthough evidence of benefit is insufficient to recommend clinical breast examination (& ')! it is typically incorporated into annual physical examinations. The %merican &ancer (ociety recommends clinical breast examination every ) years in women aged *0+), years. The %merican &ollege of -bstetricians and .ynecologists (%&-.) recommends that women aged /0 years or older undergo annual clinical breast examination and those aged *0+), years undergo clinical breast examination every 0+) years. The 1nited (tates Preventive (ervices Tas# 2orce (1(P(T2) concluded that the current evidence is insufficient to assess the additional benefits and harms of clinical breast examination beyond screening mammography in women aged /0 years or older.304 Contraindications ecause evidence of benefit is lac#ing! if a woman is excessively anxious about the breast examination! it can be foregone. Best Practices ecause of the sensitive nature of the breast examination! many providers choose to have a chaperone present during the examination. There are pros and cons to this approach! and a generally accepted policy is to have clinical staff who can act as chaperones available! to ensure that patients are aware that they are available! and to provide patients with an opportunity for private conversation without the chaperone present. Complication Prevention The harms of undergoing clinical breast examination include the ris#s of false reassurance or referral for unnecessary procedures. 5n the &anadian 6ational reast &ancer (creening (tudy! a high percentage of women who were diagnosed with breast cancer had undergone a screening clinical breast examination with negative findings.3/ Patient Education & Consent Patient education concerning the role of different screening modalities in the diagnosis of breast cancer is important and varies by age.

%nnual mammography for women older than /0 years has been advised! although the utility in women aged /0+/, years is controversial. 785 screening is more sensitive in younger women with denser breasts and has been recommended as an adjunct to mammography in extremely high+ris# women such as those with genetic predisposition to breast cancer. Approach Considerations (everal different palpation techni$ues can be used for clinical breast examination. 9imited comparative data on the efficacy of these techni$ues are available. :ey elements of a successful examination include careful observation and systematic palpation. Observation 2irst! with the patient sitting up with arms at her sides! the clinician observes the shape! color! and s#in characteristics of the breasts. 5t is important to note s#in retraction! ulceration! erythema! or crusting of the nipples and to note and either establish or compare with the baseline whether the nipples are inverted! everted! or flat. 6ext! the patient is as#ed to raise her arms over her head. The clinician should note the movement of the breast tissue as she does this and observe for any tethering of breast tissue to the chest wall. The clinician may also as# the patient to arch her bac# with hands on her hips! again observing for the movement of the breast tissue. Palpation ;ith the patient sitting up! palpation is started. The clinician should the flats of the finger pads! not the tips! for enhanced sensitivity and should remain cogni<ant of the patient"s nipple and avoid incidental contact with his or her hand. The examiner is responsible for evaluating all tissue between the s#in and the chest wall. %lthough it is possible to repeat the palpation pattern using different degrees of pressure (and therefore depth of tissue being assessed)! a more efficient approach is to spiral in each position from superficial to deep! paying attention to the tissue at each level. Palpation is begun at the medial portion of the chest wall below the clavicle and progresses down and up in a =vertical strips> pattern. The examiner should slide from palpation position to position rather than lifting his or her hand. Palpation is repeated on the opposite breast. 5n this position! it is difficult to have confidence in the examination of the underside of the breast. 6ext! the patient is as#ed to lie flat with the arm of the breast being examined behind the patient?s head. This stretches out the breast tissue against the chest wall. The breast is palpated following a =spo#es of the wheel> pattern. The areola and subareolar breast tissue in is included in the palpation pattern.

%ttempting to =mil#> the breast is unnecessary unless the patient has described a discharge. Examination of Associated Structures ;hen performing a breast examination for the purpose of cancer screening! it is appropriate to include an evaluation of the supraclavicular and axillary nodal groups. 'xamination of the axilla is best performed with the patient sitting upright. The patient is as#ed to raise her arm. The anterior wall of the axilla is formed by the pectoralis major muscle. ;ith palm facing forward! the examiner inserts his or her hand into the axilla! just posterior to the pectoralis major and parallel to the plane of the muscle. The patient lowers her arm with the examiner"s hand in place. The examiner then rotates his or her palm perpendicular to the plane and sweeps downward. Pathologic lymph nodes may be palpated and may @pop@ during the downward sweep. 'xamination of the supraclavicular nodes is best performed with the patient sitting upright. eginning medially within the supraclavicular fossa! the examiner palpates the supraclavicular fossa thoroughly to its lateral boundaries. 6odes that are hard! fixed to the underlying structures! or greater than 0 cm may be pathologic and warrant further investigation. ocumentation 5f an abnormality is identified! it is important to record it accurately. 1sing the nipple as the center of a cloc# face! any lesion is described by its cloc# position! distance from the nipple! and relative depth from the chest wall. 5t is useful to draw a simple diagram of the abnormalities identified. %bnormalities should be described by their contour (linear! round! or lobulated)! texture (fluctuant! soft! firm! roc# hard)! mobility (eg! fixed to the underlying tissue)! and standard findings for inflammation! if present (warm! red! tender). 5t is also important to note any associated s#in changes such as peau d'orange or ulceration. Aocumentation of a normal breast examination includes a description of symmetry! contour! and the presence of any lesions. 6ormal tissue is usually soft and may be finely granular.

!istula"in"ano Overvie# % fistula+in+ano is an abnormal tract or cavity with an external opening in the perianal area that is communicating with the rectum or anal canal by an identifiable internal opening. 7ost fistulas are thought to arise as a result of cryptoglandular infection with resultant perirectal abscess. The abscess represents the acute inflammatory event! whereas the fistula is representative of the chronic process. (ymptoms generally affect $uality of life significantly! and they range from minor discomfort and drainage with resultant hygienic problems to sepsis. The treatment of fistula+in+ano remains challenging. (urgery is the treatment of option with the goals of draining infection! eradicating the fistulous tract! and avoiding persistent or recurrent disease while preserving anal sphincter function. 30! *4 % fistula+in+ano is a hollow tract lined with granulation tissue! connecting a primary opening inside the anal canal to a secondary opening in the perianal s#in. (econdary tracts may be multiple and can extend from the same primary opening. 8eferences to fistula+in+ano date to anti$uity. The fascination with fistula+in+ano for more than *000 years is manifested by the numerous papers and boo#s on the subject. Bippocrates! in about /)0 &'! made reference to surgical therapy for fistulous disease and he was the first person to advocate the use of a seton (from the 9atin seta, a bristle) . 5n 0)CD! the 'nglish surgeon Eohn %rderne (0)0C+0),0) wrote Treatises of Fistula in Ano; Haemmorhoids, and Clysters! which described fistulotomy and seton use. Bistorical references indicate that 9ouis F5G was treated for an anal fistula in the 0Hth century. (almon established a hospital in 9ondon ((t. 7ar#?s) devoted to the treatment of fistula+in+ ano and other rectal conditions.3)4 5n the late 0,th and early *0th centuries! prominent physicianIsurgeons! such as .oodsall and 7iles! 7illigan and 7organ! Thompson! and 9oc#hart+7ummery! made substantial contributions to the treatment of anal fistula. These physicians offered theories on pathogenesis and classification systems for fistula+in+ano.3/! 54 (ince this early progress! little has changed in the understanding of the disease process. 5n 0,CD! Par#s refined the classification system that is still in widespread use. -ver the last )0 years! many authors have presented new techni$ues and case series in an effort to minimi<e recurrence rates and incontinence complications! but despite *!000 years of experience! fistula+in+ano remains a perplexing surgical disease. !re$uenc% The true prevalence of fistula+in+ano is un#nown. The incidence of a fistula+in+ano developing from an anal abscess ranges from *D+)HJ.30! D4 -ne study showed that the prevalence rate of fistula+in+ano is H.D cases per 000!000 population. The prevalence in men is 0*.) cases per 000!000 population and in women is 5.D cases per 000!000 population. The male+to+female ratio is 0.HK0. The mean age of patients is )H.) years.3C4 ifferential diagnoses The following do not communicate with the anal canalK

Bidradenitis suppurativa 5nfected inclusion cysts Pilonidal disease

artholin gland abscess in females

&reatment 2istula+in+ano is treated surgically. 6o definitive medical therapy is available for this conditionL however! long+term antibiotic prophylaxis and infliximab may have a role in recurrent fistulas in patients with &rohn disease. Patient education 2or patient education information! see the Aigestive Aisorders &enter! as well as %nal %bscess! 8ectal Pain! and 8ectal leeding. Etiolog% The vast majority of fistulas+in+ano are nearly always caused by a previous anorectal abscess. There are typically H+00 anal crypt glands at the level of the dentate line in the anal canal arranged circumferentially. These glands penetrate the internal sphincter and end in the intersphincteric plane. 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. 2ollowing surgical or spontaneous drainage in the perianal s#in! occasionally a granulation tissueMlined tract is left behind! causing recurrent symptoms. 7ultiple series have shown that the formation of a fistula tract following anorectal abscess occurs in C+/0J of cases. 3H! ,4 -ther fistulas develop secondary to trauma (eg! rectal foreign bodies)! &rohn disease! anal fissures! carcinoma! radiation therapy! actinomycoses! tuberculosis! and lymphogranuloma venereum secondary to chlamydial infection. 'elevant Anatom% % thorough understanding of the pelvic floor and sphincter anatomy is a prere$uisite for clearly understanding the classification system for fistulous disease. ((ee the image below.)

%natomy of the anal canal and perianal space. The external sphincter muscle is a striated muscle under voluntary control by ) componentsK submucosal! superficial! and deep muscle. 5ts deep segment is continuous with the puborectalis muscle and forms the anorectal ring! which is palpable upon digital examination. The internal sphincter muscle is a smooth muscle under autonomic control and is an extension of the circular muscle of the rectum.

5n simple cases! the .oodsall rule can help to anticipate the anatomy of a fistula+in+ano. The rule states that fistulas with an external opening anterior to a plane passing transversely through the center of the anus will follow a straight radial course to the dentate line. 2istulas with their openings posterior to this line will follow a curved course to the posterior midline (see image below). 'xceptions to this rule are external openings more than )cm from the anal verge. These almost always originate as a primary or secondary tract from the posterior midline! consistent with a previous horseshoe abscess. 300! 004

2istula+in+ano. .oodsall rule. Parks Classification S%stem The Par#s! .ordon! and Bardcastle (#nown as the Par#s &lassification) is the most common classification used for fistulas+in+ano. This classification system! demonstrated in the image below! defines / types of fistula+in+ano that result from cryptoglandular infectionsK intersphincteric! transsphincteric! suprasphincteric! and extrasphincteric. 30*4

Par#s classification of fistula+in+ano. %n intersphincteric fistula+in+ano is characteri<ed as followsK

5t is the result of a perianal abscess &ommon course + 5t begins at the dentate line and then trac#s via the internal sphincter to the intersphincteric space between the internal and external anal sphincters and then terminates in the perianal s#in or perineum 5ncidence + C0J of all anal fistulas -ther possible tracts + 6o perineal openingL high blind tractL high tract to lower rectum or pelvis

% transsphincteric fistula+in+ano is characteri<ed as followsK

5n its usual variety! this fistula results from an ischiorectal fossa abscess

&ommon course + 5t trac#s from the internal opening at the dentate line via the internal and external anal sphincters into the ischiorectal fossa and then terminates in the perianal s#in or perineum 5ncidence + *5J of all anal fistulas -ther possible tracts + Bigh tract with perineal openingL high blind tract

% suprasphincteric fistula+in+ano is characteri<ed as followsK

5t arises from a supralevator abscess &ommon course + 5t passes from the internal opening at the dentate line to the intersphincteric space and then trac#s superiorly to above the puborectalis muscle and it then curves downward lateral to the external anal sphincter into the ischiorectal fossa and then to the perianal s#in or perineum 5ncidence + 5J percent of all anal fistulas -ther possible tracts + Bigh blind tract (ie! palpable through rectal wall above dentate line)

%n extrasphincteric fistula+in+ano is characteri<ed as followsK

5t may arise from foreign body penetration of the rectum with drainage through the levators! from penetrating injury to the perineum! from &rohn disease or carcinoma or its treatment! or pelvic inflammatory disease &ommon course + 2rom perianal s#in via ischiorectal fossa trac#ing upwards and through the levator ani muscles to the rectal wall completely outside the sphincter mechanism with or without a connection to the dentate line 5ncidence + 0J of all anal fistulas

Current procedural terminolog% codes classification This includes the followingK

(ubcutaneous (ubmuscular (intersphincteric! low transsphincteric) &omplex! recurrent (high transsphincteric! suprasphincteric and extrasphincteric! multiple tracts! recurrent) (econd stage

1nli#e the current procedural terminology coding! the Par#s and colleagues classification system does not include the subcutaneous fistula. These fistulas are not of cryptoglandular origin but are usually caused by unhealed anal fissures or anorectal procedures! such as hemorrhoidectomy or sphincterotomy. Patient (istor% Patients often provide a reliable history of previous pain! swelling! and spontaneous or planned surgical drainage of an anorectal abscess. (igns and symptoms of fistula+in+ano! in order of prevalence! include the followingK

Perianal discharge Pain (welling leeding Aiarrhea (#in excoriation 'xternal opening

5mportant points in the patient"s history that may suggest a complex fistula include the followingK

5nflammatory bowel disease Aiverticulitis Previous radiation therapy for prostate or rectal cancer Tuberculosis (teroid therapy Buman immunodeficiency virus (B5G) infection

% review of symptoms may reveal the following in patients with a fistula+in+anoK

%bdominal pain ;eight loss &hange in bowel habits

Ph%sical Examination 6o specific laboratory studies are re$uired in the diagnosis of fistula+in+ano (although the normal preoperative studies are performed! based on age and comorbidities). 5nstead! physical examination findings remain the mainstay of diagnosis. The examiner should observe the entire perineum! loo#ing for an external opening that appears as an open sinus or elevation of granulation tissue. (pontaneous discharge of pus or blood via the external opening may be apparent or expressible on digital rectal examination. Aigital rectal examination may reveal a fibrous tract or cord beneath the s#in. 5t also helps to delineate any further acute inflammation that is not yet drained. 9ateral or posterior induration suggests deep postanal or ischiorectal extension. The examiner should determine the relationship between the anorectal ring and the position of the tract before the patient is relaxed by anesthesia. The sphincter tone and voluntary s$uee<e pressures should be assessed before any surgical intervention! to delineate whether preoperative manometry is indicated. %noscopy is usually re$uired to identify the internal opening. Proctoscopy is also indicated in the presence of rectal disease! such as &rohn disease or other associated conditions. 7ost patients cannot tolerate even gentle probing of the fistula tract in the office and this should be avoided. Imaging Studies

8adiologic studies are not performed for routine fistula evaluation since the anatomy of most fistulas+ in+ano can be determined in the operating room. Bowever! they can be helpful when the primary opening is difficult to identify or for recurrent or persistent disease. 5n the case of recurrent or multiple fistulas! such studies can be used to identify secondary tracts or missed primary openings. 30)4 (everal imaging diagnostic modalities are available to evaluate fistulas+in+ano. The efficacy of each modality is reviewed. !istulograph% This techni$ue involves injection of contrast via the internal opening! which is followed by anteroposterior! lateral! and obli$ue radiographic images to outline the course of the fistula tract. 2istulography is relatively well tolerated but it can be painful when injecting the contrast material into the fistulous tract. 5t re$uires the ability to visuali<e the internal opening. 5ts accuracy rate has been $uestioned and it ranges from 0D+/HJ.30/4 . Aue to these limitations! it is generally reserved for cases in which there is a concern about a fistulous connection between the rectum and adjacent organs such as the bladder! where it may be slightly more useful than a careful examination under anesthesia. Endoanal)endorectal ultrasonograph% These studies involve passage of a C+ or 007B< transducer into the anal canal to help define muscular anatomy differentiating intersphincteric from transsphincteric lesions. % standard water+filled balloon transducer can help to evaluate the rectal wall for any suprasphincteric extension. 5nvestigations have shown that the addition of hydrogen peroxide via the external opening can help to outline the fistula tract course. This may be useful to help delineate missed internal openings. These studies are reported to be 50J better than physical examination alone to help find an internal opening that is difficult to locali<e. This modality has not been used widely for routine clinical fistula evaluation.3054 *'I 2indings on magnetic resonance imaging (785) scans show H0+,0J concordance with operative findings when a primary tract course and secondary extensions are observed. 785 is becoming the study of choice when evaluating complex fistulas and recurrent fistulas. 5t has been shown to reduce recurrence rates by providing information on otherwise un#nown extensions. 30D! 0C4 C& scan % computed tomography (&T) scan is more helpful in the setting of perirectal inflammatory disease than in the setting of small fistulas because it is better for delineating fluid poc#ets that re$uire drainage than for delineating small fistulas. &T scanning re$uires administration of oral and rectal contrast. 7uscular anatomy is not well delineated. Barium enema)small bo#el series These studies may be useful for patients with multiple fistulas or recurrent disease to help rule out inflammatory bowel disease. Anal *anometr%

This modality is rarely used in the evaluation of patients with fistula+in+ano. Bowever! pressure evaluation of the sphincter mechanism is helpful in certain patients for operative planning! including the followingK

Patients in whom decreased tone is observed during preoperative evaluation Patients with a history of previous fistulotomy Patients with a history of obstetrical trauma Patients with a high transsphincteric or suprasphincteric fistula (if #nown) Gery elderly patients

5f a decrease in pressure is found! surgical division of any portion of the sphincter mechanism should be avoided. iagnostic Procedures Examination under anesthesia %n examination of the perineum! digital rectal examination! and anoscopy are performed after the anesthesia of choice is administered. This examination is necessary before surgical intervention! especially if outpatient evaluation causes discomfort or has not helped to delineate the course of the fistulous process. (everal techni$ues have been described to help locate the course of the fistula and! more importantly! identify the internal opening. They include the followingK

5nject hydrogen peroxide! mil#! or dilute methylene blue into the external opening and watch for egress at the dentate lineL in the authors? experience! methylene blue often obscures the field more than it helps to identify the opening Traction (pulling or pushing) on the external opening may also cause a dimpling or protrusion of the involved crypt 5nsertion of a blunt+tipped crypt probe via the external opening may help to outline the direction of the tractL if it approaches the dentate line within a few millimeters! a direct extension li#ely existed (care should be ta#en to not use excessive force and create false passages)

Proctosigmoidoscop%)colonoscop% 8igid sigmoidoscopy can be performed at the initial evaluation to help rule out any associated disease process in the rectum. 2urther colonic evaluation is performed only as indicated. &reatment Indications and Contraindications Indications Therapeutic intervention is indicated for symptomatic patients. (ymptoms usually involve recurrent episodes of anorectal sepsis. %n abscess develops easily if the external opening on the perianal s#in seals itself. &rohn disease of the perineum with multiple and often complex fistulas re$uires careful surgical treatment. %cute perianal abscess re$uires incision and drainage. Aefinitive repair of fistulas in these

patients re$uires that the intra+abdominal disease be under control with medical therapy. 5f controlled! routine therapy is warranted. 8ecurrent fistulous disease to the rectum and perineum with persistent anorectal sepsis is an indication for panproctocolectomy. (tudies have identified a role in &rohn disease for fistula therapy with infliximab! the monoclonal antibody to tumor necrosis factor! with 50+ D0J response rates for perianal fistulas. 30H! 0,4 Contraindications 5f patients are without symptoms and a fistula is found during a routine examination! no therapy is re$uired. (urgery for fistula+in+ano should not be performed for definitive repair of the fistula in the setting of anorectal abscess (unless the fistula is superficial and the tract is obvious). 5n the acute phase! simple incision and drainage of the abscess are sufficient. 3*04 -nly C+/0J of patients will develop a fistula. 8ecurrent anal sepsis and fistula formation are *+fold higher after an abscess in patients younger than /0 years and are almost )+fold higher in nondiabetics. Preoperative+ Intraoperative+ and Postoperative etails Preoperative Preoperative details include the followingK

8ectal irrigation with enemas should be performed on the morning of the operation %nesthesia can be general! local with intravenous sedation! or a regional bloc# %dminister preoperative antibiotics The prone jac##nife position with buttoc#s apart is the most advantageous position

Intraoperative 5ntraoperative considerations include the followingK

'xamine the patient under anesthesia to confirm the extent of the fistula 5dentifying the internal opening to prevent recurrence is imperative % local anesthetic bloc# at the end of the procedure provides postoperative analgesia

Postoperative 7ost patients can be treated in an ambulatory setting with discharge instructions and close follow+up care. (it< baths! analgesics! and stool+bul#ing agents (eg! bran! psyllium products) are used in follow+ up care. 2re$uent office visits within the first few wee#s help to ensure proper healing and wound care. 5mportantly! ensure that the internal wound does not close prematurely! causing a recurrent fistula. Aigital examination findings can help to distinguish early fibrosis. ;ound healing usually occurs within D wee#s. !istulotom%

The laying+open techni$ue (fistulotomy) is useful for H5+,5J of primary fistulas (ie! submucosal! intersphincteric! low transsphincteric). ((ee the image below.) 3*0! **! *)! */4

(chematic of intersphincteric and low transsphincteric fistulotomy. % probe is passed into the tract through the external and internal openings. The overlying s#in! subcutaneous tissue! and internal sphincter muscle are divided with a #nife or electrocautery! thereby opening the entire fibrous tract. %t low levels in the anus! the internal sphincter and subcutaneous external sphincter can be divided at right angles to the underlying fibers without affecting continence. This is not the case if the fistulotomy is performed anteriorly in female patients. 5f the fistula tract courses higher into the sphincter mechanism! seton placement should be performed. &urettage is performed to remove granulation tissue in the tract base. -pening the wound out on the perianal s#in for 0+*cm adjacent to the external opening with local excision of s#in promotes internal healing before external closure. (ome advocate marsupiali<ation of the edges to improve healing times. Perform a biopsy on any firm! suggestive tissue. &omplete fistulectomy creates larger wounds that ta#e longer to heal and offers no recurrence advantage over fistulotomy. Seton Placement % seton can be placed alone! combined with fistulotomy! or in a staged fashion. This techni$ue is useful in patients with the following conditions3*5! *D! *C4 K

&omplex fistulas (ie! high transsphincteric! suprasphincteric! extrasphincteric) or multiple fistulas 8ecurrent fistulas after previous fistulotomy %nterior fistulas in female patients Poor preoperative sphincter pressures Patients with &rohn disease or patients who are immunosuppressed

eyond giving a visual identification of the amount of sphincter muscle involved! the purposes of setons are to drain! to promote fibrosis! and to cut through the fistula. (etons can be made from large sil# suture! silastic vessel mar#ers! or rubber bands that are threaded through the fistula tract. Single"stage seton ,cuttingPass the seton through the fistula tract around the deep external sphincter after opening the s#in! subcutaneous tissue! internal sphincter muscle! and subcutaneous external sphincter muscle. The seton is tightened down and secured with a separate sil# tie.

;ith time! fibrosis occurs above the seton as it gradually cuts through the sphincter muscles and essentially exteriori<es the tract. The seton is tightened on subse$uent office visits until it is pulled through over D+H wee#s. % cutting seton can also be used without associated fistulotomy. ((ee the image below).

(chematic of high transsphincteric fistulotomy with seton. 8ecurrence and incontinence are important factors to consider when using this techni$ue. The success rates for cutting setons range from H*+000JL however! long+term incontinence rates can exceed )0J.
3*H! *,! )04

&#o"stage seton ,draining)fibrosingPass the seton around the deep portion of the external sphincter after opening the s#in! subcutaneous tissue! internal sphincter muscle! and subcutaneous external sphincter muscle. 1nli#e the cutting seton! the seton is left loose to drain the intersphincteric space and to promote fibrosis in the deep sphincter muscle. -nce the superficial wound is healed completely (*+)mo later)! the seton+bound sphincter muscle is divided. Two studies (C/ patients combined) supported the *+stage approach with a 0+nylon seton. -nce wound healing is complete! the seton is removed without division of the remaining encircled deep external sphincter muscle. The researchers reported eradication of the fistula tract in D0+CHJ of cases. *ucosal Advancement !lap 7ucosal advancement flap is reserved for use in patients with chronic high fistula but is indicated for the same disease process as seton use.30H! )0! )*4 %dvantages include a 0+stage procedure with no additional sphincter damage. % disadvantage is poor success in patients with &rohn disease or acute infection. This procedure involves total fistulectomy! with removal of the primary and secondary tracts and complete excision of the internal opening. % rectal mucomuscular flap with a wide proximal base (* times the apex width) is raised. The internal muscle defect is closed with an absorbable suture! and the flap is sewn down over the internal opening so that its suture line does not overlap the muscular repair. Plugs and Adhesives %dvances in biotechnology have led to the development of many new tissue adhesives and biomaterials formed as fistula plugs. y their less+invasive nature! these therapies lead to decreased

postoperative morbidity and ris# of incontinence! but long+term data are lac#ing for eradication of disease! especially in complex fistulas! which carry high recurrence rates. 3))! )/! )*4 8eported series exist of fibrin glue treatment of fistula+in+ano! with 0+year follow+up showing recurrence rates approaching /0+H0J.3)5! )D! )C4 The (urgisis fistula plug has also had mixed long+term results in direct clinical trials.3)H! ),! /04 'arly success rates have been reported for newer materials! such as acellular dermal matrix and the bioabsorbable .ore io+% fistula plug! in low fistulas and good animal model data. 3/04 'vidence regarding long+term success with plug techni$ues for complex disease awaits randomi<ed trials. .I!& Procedure 9igation of the intersphincteric fistula tract (952T) is a sphincter+sparing procedure for complex transsphincteric fistulas first described in *00C. 5t is performed through access to the intersphincteric plane with the goal of performing a secure closure of the internal opening and by removing the infected cryptoglandular tissue.3/*4 The intersphincteric tract is identified and isolated by meticulous dissection done through the intersphincteric plane after ma#ing a small incision overlying the probe connecting the external and internal openings. -nce isolated! the intersphincteric tract is hoo#ed using a small! right+angled clamp and the tract is ligated close to the internal sphincter and then divided distal to the point of ligation. Bydrogen peroxide is injected through the external opening to confirm the division of the correct tract. The external opening and the remnant fistulous tract are curetted to the level of the proximity of the external sphincter complex. 2inally! the intersphincteric incision is loosely reapproximated with an absorbable suture. The curettaged wound is left opened for dressing. 3/*! /)! //4 8esearch studies on the techni$ue are scarce owing to the novelty of the techni$ue. 5t compares similarly with the success rate of the anorectal advancement flap techni$ue in a randomi<ed trial of ), patients with complex fistula+in+ano who had failed previous procedures and were treated by the 952T techni$ue. The probability of recurrence at 0, months was HJ versus CJ for those patients treated with anorectal advancement flap. Bowever! the first group had a shorter time to return to wor# (0 vs * w#)! but there was no difference in incontinence scores. 3/54 2urther randomi<ed surgical trials are needed to determine whether this techni$ue is a viable alternative or better alternative to the other previously mentioned procedures for the treatment of fistula+in+ano. iversion The creation of a diverting stoma is a rare indication to facilitate the treatment of complex persistent fistulas+in+ano. The most common indications include but are not limited to patients with perineal necroti<ing fasciitis! severe anorectal &rohn disease! reoperative rectovaginal fistulas! and radiation+ induced fistulas. ;hile fecal diversion alone is effective in these select patients to control sepsis and symptoms! long+term success following reanastomosis is low because of recurrence from the underlying disease and should be avoided unless the underlying fistula+in+ano disease process is repaired or has healed completely! which is unli#ely. Prognosis The postsurgical prognosis in fistula+in+ano is as followsK

(tandard fistulotomy + The reported rate of recurrence is 0+0HJ! and the rate of any stool incontinence is )+CJ. (eton use + The reported rate of recurrence is 0+0CJ! and the rate of any incontinence of stool is 0+0CJ.

7ucosal advancement flap + The reported rate of recurrence is 0+0CJ! and the rate of any incontinence of stool is D+HJ3)04

Postoperative complications 'arly postoperative complications may include the followingK

1rinary retention leeding 2ecal impaction Thrombosed hemorrhoids

Aelayed postoperative complications may include the followingK

8ecurrence 5ncontinence (stool) %nal stenosis + The healing process causes fibrosis of the anal canalL bul#ing agents for stool help to prevent narrowing Aelayed wound healing + &omplete healing occurs by 0* wee#s unless an underlying disease process is present (ie! recurrence! &rohn disease)