“A CLINICO-PATHOLOGICAL STUDY OF

FISTULA - IN – ANO”

BY
Dr. VEERENDRA KUMAR H.M.
M.B.B.S.,

Dissertation submitted to the

Rajiv Gandhi University of Health Sciences, Karnataka, Bangalore.

In Partial fulfillment
of the requirements for the degree of

MASTER OF SURGERY
IN
GENERAL SURGERY

UNDER THE GUIDANCE OF

Dr. R.L. CHANDRASHEKAR M.S.
PROFESSOR & HEAD

DEPARTMENT OF GENERAL SURGERY

J.J.M. MEDICAL COLLEGE
DAVANGERE – 577 004.

2010

i
 RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES,
KARNATAKA

DECLARATION BY THE CANDIDATE

I hereby declare that this dissertation/thesis entitled “A CLINICO-

PATHOLOGICAL STUDY OF FISTULA - IN – ANO” is a bonafide and genuine

research work carried out by me under the guidance of

Dr.R.L.CHANDRASHEKAR M.S., Professor & Head, Department of General

Surgery, J.J.M. Medical College, Davangere.

ii
 CERTIFICATE BY THE GUIDE

This is to certify that this dissertation entitled “A CLINICO-PATHOLOGICAL

STUDY OF FISTULA - IN – ANO” is a bonafide research work done by

Dr.VEERENDRA KUMAR H.M. in partial fulfillment of the requirement for the

degree of M.S. (General Surgery).

iii
 ENDORSEMENT BY THE HOD,

THE PRINCIPAL/HEAD OF THE INSTITUTION

This is to certify that this dissertation entitled “A CLINICO-

PATHOLOGICAL STUDY OF FISTULA - IN – ANO” is a bonafide research work

done by Dr. VEERENDRA KUMAR H.M. under the guidance of

Dr.R.L.CHANDRASHEKAR M.S, Professor & Head, Department of General

Surgery, J.J.M. Medical College, Davangere.

iv
 COPYRIGHT

Declaration by the Candidate

I hereby declare that the Rajiv Gandhi University of Health Scie nces, Karnataka

shall have the rights to preserve, use and disseminate this dissertation / thesis in print or

electronic format for academic / research purpose.

 Rajiv Gandhi University of Health Sciences, Karnataka.

v
 ACKNOWLEDGEMENT

It gives me immense pleasure to express my deep sense of gratitude and sincere

thanks to Dr.R.L.CHANDRASHEKAR, Professor and Head, Department of General
Surgery, J.J.M. Medical College, Davangere for his dedicated professionalism,
indefatigable efforts, cheerful guidance, and constant encouragement during the course of
my study and preparation of this dissertation.

I am highly indebted to Dr. B. PRADEEP M.S., Professor and Former Head of

the Department of Surgery who’s practical guidance during the course of my study is
without parallel.

My sincere thanks to my Professors Dr.R.M.SHEKHAR,

Dr.M.SHIVAKUMAR, Dr. G.C.RAJENDRA, Dr.SHUBHA RAO, Dr.DINESH
M.G., Dr. J.T. BASAVARAJ, Dr.S.N.SOMASEKHAR, Dr.MANJUNATH
GOWDA, Dr. U. MAHENDRANATH PATIL, Dr.RAVISHANKAR
PURANTHAR, Dr. DEEPAK G. UDAPUDI, Dr. B.V.C. JAGADEESH, Dr.
GANESH C. EDAGUNGI, Dr.M.C. ANUP KUMAR, Dr. RUDRAIAH H.G.M.,
Dr.PATIL VIRUPAKSHA GOWDA, for allowing me to collect cases from their units
and for their valuable guidance.
I would like to thank our Readers Dr. MAHESH K, DR.SUSRUTH
MARALIHALLI, Dr. NARSIMHASWAMY, Dr. RAJENDRA PRASAD,
Dr.PRAKASH M.G., and Dr. RAJESHWAR REDDY for their guidance, suggestions
and advice during the course of my study and preparation of this dissertation.
I am also thankful to Dr. K.C. SHIVAMURTHY M.Ch., Professor of Plastic
Surgery, Dr. H.B. SHIVAKUMAR, M.Ch., Professor of Genito-Urinary Surgery,
Dr.C.J.SHANTHAKUMAR, M.Ch., Professor of Neurosurgery, Dr.HARSHA B.M.
Pediatric Surgeon, for their valuable help and suggestion.
I would like to thanks our Assistant Professors Dr. B.N. BASAVARAJ,
Dr.HARSHITH HEGDE, Dr. NATARAJ K.M., Dr.SANTOSH KUMAR K.Y.,
Dr.AVINASH K.S., for their valuable help and suggestion.

vi
 I also express my sincere thanks to the Superintendents of Chigateri General
Hospital and Bapuji Hospital, Davangere, for allowing me to study the patients of their
hospital.
I also express my thanks to Dr. H.R.CHANDRASHEKAR, M.D., Principal,
J.J.M. Medical College, Davangere.
I would like to thank Mr. P.S. MAHESH, Librarian and Mr. SANGAM, Bio-
Statistician for their help during the preparation of this dissertation.
My sincere thanks to Mr. SANJEEV KUMAR G.P. of M/s. GUNDAL
Computers Center, Davangere, for his meticulous computerised laser typing and
styling of this dissertation work.
I would like to thank my PARENTS Sri. H. MARULASIDDAPPA and
Smt.SAVITHRAMMA and my SISTERS, who inculcated in me the values of life and
stood solidly behind me at all moments and my Wife Smt. SUMA G.S. and Daughter
Kum.SRUJANA V.S. who were constant source of inspiration to put in my best efforts
into all my endevours.
I am also thankful to Mr. MAHESH, Mr. ONKARAPPA, Mr.NINGESH,
Mr.LOKESH, Mr.BYRESH, office staffs, Department of General Surgery, for their
help during my study.
Lastly I thank every one concerned, including my Friends, Patients for their co-
operation, without whom this dissertation would have never materialized.

vii
 LIST OF ABBREVATIONS USED

Cm Centimeter
Eg Example
ESR Erythrocyte sedimentation rate
EUS Endoscopic ultrasound
HIV Human immunodeficiency virus
i.e. That is
LGV Lymphogranuloma venereum
O2 Oxygen

viii
 ABSTRACT

BACKGROUND AND OBJECTIVE :

Fistula-in-ano is considered one of the commonest cause for a

persistent seropurulent discharge that irritates the skin in the neighbourhood
and causes discomfort. This study deals with it’s etiology, especially in
relation to previously burst opened perianal abscess or surgical drainage.
The different modes of treatment and their efficacy will be dealt in detail.
This is necessary to know the better treatment of choice.

Method :

A 50 patients were selected who were diagnosed as fistula in ano

admitted in Chigateri General Hospital during June 2007 to May 2009.
Patient underwent definitive treatment. Data related to the objectives of the
study were collected.

Result :

Majority of patients belonged to the age group of 31 -60 years which

accounts for 31 (62%) of patients. M:F is 11.5:1. Most of the fistulas are
low anal 37 (74%) and 34 (68%) of patients developed fistula in a
previously burst opened or surgically drained perianal abscess. About 33
(66%) of external openings are posterior to the anal axis of which 26 (52%)
followed the Goods all’s rule. Fistulectomy is commonly performed i.e., in
about 34 (78%) of cases and the operated wound is healed in a range of 2
weeks to 8 weeks with a mean duration 4 weeks.

The postoperative complications were very minimal, there was

recurrence of fistula in 1 case (2%) after 30 days and it was excised again.

ix
Interpretation and Conclusion :

I conclude that the previously burst opened or surgically drained

perianal abscess is the main aetiological factor for fistula in ano. Even with
advent of newer modalities of treatment fistulectomy is the commonest
procedure undertaken probably to get rid of the infective pathology. The
postoperative complications were very less and the newer modalities of
treatment yet to be implemented.

Keyword :

Fistula-in-ano; Low anal; Perianal abscess; Discharge; Anal canal;

External opening; Fistulotomy; Fistulectomy; Seton; Postoperative wound
infection.

x
 TABLE OF CONTENTS

PAGE NO

1. INTRODUCTION 01

2. OBJECTIVES 02

3. REVIEW OF LITERATURE 03

4. METHODOLOGY 45

5. RESULTS 50

6. DISCUSSION 65

7. CONCLUSION 70

8. SUMMARY 71

9. BIBLIOGRAPHY 73

10. ANNEXURES

ANNEXURE-I : PROFORMA 79
ANNEXURE-II : CONSENT FORM 84
ANNEXURE-III : MASTER CHART 85

xi
 LIST OF TABLES

SL.NO. TABLES PAGE

1. AGE DISTRIBUTION 50

2. SEX INCIDENCE 50

3. SYMPTOMS AND SIGNS 52

4. STANDARD CLASSIFICATION 52

5. DISTRIBUTION OF ANAL FISTULAE AROUND THE 54

ANAL CIRCUMFERENCE

6. ASSOCIATED CONDITIONS 54

7. INCIDENCE OF FISTULA- IN- ANO 56

8. TREATMENT 56

9. NUMBER OF PREVIOUS ATTACKS OF PERIANAL 58

SEPSIS IN PATIENTS WITH FISTUAL- IN- ANO

10. TIME TAKEN TO HEAL 60

11. HISTOPATHOLOGICAL REPORT 62

12. COMPLICATIONS 63

xii
 LIST OF GRAPHS

GRAPH LIST OF GRAPHS PAGE NO

NO.

1. AGE DISTRIBUTION 51

2. SEX INCIDENCE 51

3. SYMPTOMS AND SIGNS 53

4. STANDARD CLASSIFICATION 53

5. DISTRIBUTION OF ANAL FISTULAE AROUND THE 55

ANAL CIRCUMFERENCE

6. ASSOCIATED CONDITIONS 55

7. INCIDENCE OF FISTULA- IN- ANO 57

8. TREATMENT 57

9. NUMBER OF PREVIOUS ATTACKS OF PERIANAL 59

SEPSIS IN PATIENTS WITH FISTUAL- IN- ANO

10. TIME TAKEN TO HEAL 61

11. HISTOPATHOLOGICAL REPORT 62

12. COMPLICATIONS 64

xiii
 LIST OF PHOTOGRAPHS

FIG. LIST OF PHOTOGRAPHS PAGE NO

NO.

1 ANATOMY OF THE ANO- RECTUM 8

2 ANORECTAL MUSCULATURE 8

3 PARK’S CLASSIFICATION 23

4 STANDARD CLASSIFICATION 23

5 CLASSIFICATION OF ANAL FISTULAS 24

6 GOODSALL’S RULE 25

7 FISTULA- IN- ANO 25

8 FISTULOGRAM 31

9 MRI SHOWS TRANSPHINCTERIC FISTULA- IN- ANO 31

10 FISTULA- IN- ANO IN THE ANTERIOR ANAL AXIS 47

11 PROBE THROUGH THE EXTERNAL OPENING 47

12 PROBE THROUGH THE EXTERNAL AND INTERNAL 48

OPENING OF THE FISTULA

13 FISTULECTOMY PROCEDURE 48

14 FISTULECTOMY WOUND 49

15 FISTULECTOMY SPECIMEN 49

16 ILLUSTRATIONS OF SURGICAL TECHNIQUE OF 49

SETON PLACEMENT

17 SETON PLACEMENT & RETIGHTENED AT WEEKLY 49

INTERVALS

xiv
Introduction
 INTRODUCTION

Fistula- in- ano is an abnormal connection between the epithelialised

surface of the anal canal or rectum and usually in continuity with one or more

external openings in the perianal skin.

Fistula- in- ano is seen quite frequently and the frequency virtually mirrors

perianal – perirectal suppuration. The chronicity of the disease associated with

its annoying symptoms. Soiling, pruritis and recurrent suppuration renders an

otherwise healthy and active person an economic burdens, retraction from social

engagements and he loose self confidence.

There has been a lot of progress in the understanding of the anatomy of

anal canal and rectum and mechanisms of continence of the rectum. This has

enabled the surgeon to deal with keeping the spastic anorectal ring intact without

interfering with the continence and eradicating the disease.

Fistula- in- ano rarely heal spontaneously and requires surgical therapy to

achieve a cure. It is therefore possible at the present time to obtain more precise

evaluation of various methods of anal fistula- treatment.

The improved surgical techniques have rendered postoperative period

uneventful and steep fall in recurrence rate. With better training in colorectal

surgery over recent decades and more experience in surger y of the anal

sphincters, surgeons now have the confidence to try new methods for the

treatment of an anal fistula to preserve the external sphincter.

1
Objectives
 OBJECTIVES

1. To study aetiopathogenesis and clinical presentation of fistula- in- ano.

2. To study the various modes of treatment and their efficacy.

2
Review of Literature
 REVIEW OF LITERATURE

HISTORICAL REVIEW

Fistula- in- ano has been a troublesome pathology to both patient and

physician throughout surgical history. The estimated prevalence of non specific

anal fistulae is 8.6 to 10/100,000 of the population per year, with a male to

female ratio of 1.8:1. 1

Anal fistula is a condition that has been described virtually from

beginning of medical history. Hippocrates in about 430 B.C., suggested that the

disease was caused by “contusions and tubercles occasioned by rowing or riding

on horse back”. He was the first person to advocate the use of a seton (from the

Latin seta, a bristle) in treatment. 2 The early drainage was advised and

fistulotomy described even before matter is fully formed. Medicated setons were

used much earlier by Sushrutha.

The English surgeon John Ardene in 1376 wrote an excellent treatise on

this subject and his principles were extremely sound. He said that treatment of

anal fistula had fallen into disrepute because it was a troublesome condition

which brought very little credit to surgeons and required long and patient

treatment. He was first to describe the current practice of probing and laying

open method of fistula operation. 3

The surgeon who has the opportunity to treat his patient initially is the

one most likely to effect a cure, limit morbidity and minimize disability.

3
 In the late 19 th and early 20 th centuries, prominent physicians and

surgeons such as Goodsall and Miles, Miligan and Morgan, Thompson, and

Lockhart- Mummery made substantial contributions to the understanding and

treatment of anal fistulae. 1

There is usually a history of recurrent abscess that ruptured

spontaneously or was surgically drained, there may be a pink or red elevation

exuding pus or it may have healed. 4

The main reason for recurrence is an undiagnosed fistula present at the

time of abscess drainage, the incidence of about 18 to 95 percent. The primary

determinant of successive treatment of fistulas involves accurate identification of

the internal opening and course of the fistulous tract. 5

The French King Louis XIV underwent a surgical procedure performed by

the famous French Surgeon George Mareschal (1658- 1736), who was ennobled

for his services. 1 After the kings operation fistula became a fashionable disease,

so that the 17 th century has become termed as the Golden Age of Rectal

Surgeons.

Salmon established a hospital in London devoted to the treatment of anal

fistula and other rectal conditions – St. Mark’s. It ha s been said that more

surgeon’s reputations have been impugned because of problems with fistula

operations than from any other operative procedure.2

4
 In 1976, Parks refined the classification system that is still in wide spread

use. Over the last 30 years, many authors have presented new techniques and

case series in an effort to minimize recurrence rates and incontinence

complications. Despite 2500 years of experience, fistula - in- ano remains a

perplexing surgical disease. 6

Man has always dreaded fistula and has feared the operation for it’s cure.

This is not without good reasons, for in some instances, not only is the patient

not cured of his disease, but a greater affliction comforts him in the form of anal

incontinence due to poor surgical management. As Lockhart Mummery has said

“a fistula operation is not a major operation, but it is far from being a minor

one”.

5
 ANATOMY OF ANO-RECTAL REGION

A detailed description of the anatomy of anorectal region is essential in

understanding the surgery of fistula- in- ano. As the knowledge of anatomy of this

region was incomplete and controversial till the last century, Milligan and

Morgan undertook the study and their work is the foundation of modern

anorectal surgery.

ANATOMY OF RECTUM :

Although the rectum is continuous with the sigmoid colon. It has several

features which distinguish it functionally from the rest of the colon. These

features suit its specialized rate in defecation and continence in combination with

the anal canal.

The rectum is continuous wit h the sigmond colon at the level of the third

sacral vertebra and terminates at the upper end of the anal canal. It descends

along the sacrococcygeal concavity as the sacral flexure of the rectum, initially

inferoposteriorly and then inferoanteriorly to jo in the anal canal by passing

through the pelvic diaphragm.

The posterior bend is termed the perineal flexure of the rectum and the

angle it forms with the upper anal canal is termed the anorectal angle. The

rectum also deviates in three lateral curves. The upper is convex to the right, the

middle (the most prominent) bulges to the left, and the lower is convex to the

right. Both ends of the rectum are in the median plane.

6
 Although variable in absolute length, a common landmark used in clinical

practice to define the rectum is a length of 15 cm above the external anal margin.

It commences with a similar diameter to the sigmoid colon, more inferiorly it is

dilated as the rectal ampulla. The rectum differs from the sigmoid colon in

having no sacculations, appendices epiploicae, or mesentery, the taeniae blend

0.5cm above the rectosigmoid junction, forming two wide muscular bands which

descend anteriorly and posteriorly in the rectal wall, these then fuse to form an

encircling layer of longitudinal muscle which invests the entire length of the

rectum.

The upper third of the rectum is covered by peritoneum on its anterior and

lateral aspects. It is related anteriorly to the sigmoid colon or loops of ileum if

these lie in the pelvis, otherwise. It is rela ted to the urinary bladder in males or

cervix and body of the uterus in females.

The middle third of his rectum is covered by peritone um only on the

anterior aspect. The peritoneum is reflected superiorly into the urinary bladder

in males, to form the rectovesical pouch, or onto the posterior vaginal wall in

females to form the recto- uterine pouch (pouch- of- douglas).

There are no haustra in the rectum, when supply the mucosa forms a

number of longitudinal folds in it’s lower part which become effaced during

distension. In addition the rectum commonly has three (although the number can

vary) permanent semilunar transverse or horizontal folds, most marked in rectal

distension.

7
Fig.1 : Anatomy of the Ano -rectum

Fig.2 : Anorectal Musculature

8
ANATOMY OF THE ANAL CANAL :

The anal canal begins at the anorectal junction and ends at the anal ver ge.

It is angulated in relation to the rectum because the pull of the sling like

puborectalis produces the anorectal angle. It lies 2- 3 cms in front of and slight ly

below the tip of coccyx.

The canal consists of inner epithelial lining, a vascular sub epithelium, the

internal and external anal sphincters and fibromuscular supporting tissue. It is

between 2.5 and 5 cm long in adults although the anterior wall is s lightly shorter

than the posterior, is usually shorter in females. At rest it forms an oval slit in

the antero- posterior plane rather than a circular canal due to the arrangement of

the external anal sphincter.

The anal canal is attached posteriorly to the coccyx by the anococcygeal

ligament, a midline fibroelastic structure which may possess some skeletal

muscle elements, and which runs between the posterior aspect of the external

sphincter and the coccyx.

The anus is surrounded laterally and posteriorly by loose adipose tissue

within the ischioanal fossae, a potential pathway for the spread of perianal sepsis

from one side to the other.

Anteriorly the perineal body separates the anal canal from the

membranous urethra and penile bulb in males or from the lower vagina in

females.

9
MUSCLES OF THE ANAL CANAL :

The anal canal is encircled by the internal and external anal sphincters,

separated by the longitudinal layer, and has connections superiorly to puboretalis

and the transverse perinei.

Internal anal sphincter :

The internal ana l sphincter is a well defined ring of obliquely oriented

smooth muscle fibers continuous with the circular muscle of the rectum

terminating at the junction of the superficial and subcutaneous components of the

external sphincter. Its thickness varies between 1.5 and 3.5m, depending upon

the height within the anal canal and whether the canal is distended. The lower

portion of the sphincter is crossed by fibers form the conjoint longitudinal coat

which pass into the sub mucosa of the lower canal.

External anal sphincter :

The external anal sphincter is an oval tube shaped complex of striated

muscle, composed mainly of type skeletal muscle fibres, which are well suited to

prolonged contraction. Although previously described as consisting of deep

superficial and subcutaneous parts, the external anal sphincter forms a single

functional and anatomical entity.

10
 Endoanal ultrasound and magnetic resonance imaging reveal that the

uppermost fibres blend with the lowest fibres of superficial transverse perineal

muscles and posteriorly some fibres are attached to the anococcygeal raphe. The

majority of the middle fibres of the external anal sphincter surround the lower

part of the internal sphincter. This portion is attached anteriorly to the perineal

body and from each side of the sphincter decussate in these areas to form a

commissure in the anterior and posterior midline. The lower fibres lie below the

level of the internal anal sphincter and are separated from the lowest anal

epithelium by sub mucosa. The length and thickness of the external anal

sphincter varies between the sexes. 7

11
 PHYSIOLOGY OF DEFECATION

The rectum is usually empty or nearly so. Although few contents are

present, contractions do occur in this region. In fact, the upper regions of the

rectum contract segmentally more frequently than does the sigmoid colon. This

activity tends to retard the flow of contents into the rectum. When the rectum

fills it does so intermittently. During a mass movement or during an aborally

directed sequence of segmental contractions of the sigmoid colon, some material

passes into the rectum.

Normally the anal canal is closed because of contraction of the internal

anal sphincter, when the rectum is distended by fecal material however, the

internal sphincter relaxes as part of the rectosphincteric reflex. Rectal distention

also elicits a sensation that signals the urge for defecation. If environmental

conditions are not conductive to defecation, voluntary contractions of the

external sphincter can overcome the reflex, relaxation of the internal sphincter is

transient because the receptors within the rectal wall accommodate the stimulus

of distention. Thus the internal anal sphincter regains its tone, and the sensation

subsides until the passage of more contents into the rectum. The rectum can

accommodate rather large quantities of material so it acts as a storage organ.

If the rectosphincteric reflex is elicited at a time when evacuation is

convenient, defecation occurs. Defecation is accomplished by a series of

voluntary and involuntary acts. When rectal distention is followed by defecation,

12
muscle of the descending colon, sigmond colon and the rectum may contract to

propel contents toward the anal canal. Then both internal and external sphincters

relax to allow passage of the bolus. Normally these events are accompanied by

voluntary acts that raise intra abdominal pressure and lower the pelvic floor.

Intra abdominal pressure is increased by contractions of the diaphragm and

musculature of the abdominal wall. Simultaneously the musculature of the

pelvic floor relaxes to allow the increased abdominal pressure to force the floor

downward. 8

13
 AETIOPATHOGENESIS OF THE DISEASE

AETIOLOGY :

Fistula is the Latin word for a reed or pipe or flute. In surgery it implies a

chronic granulating tract connecting epithelial lined surfaces. These surfaces

may be cutaneous or mucosal.

Fistula- in- ano is an abnormal communication between the anal canal or

rectum and the perianal skin, which causes a chronic inflammatory response. The

most common cause is nearly always by a previous ano - rectal abscess and it is

found in approximately 70% of patients. There is usually a history of recurrent

abscess that ruptured spontaneously or was surgically drained. 9 The occurrence

of such abscess is mostly secondary to infection of an anal gland

(Cryptoglandular hypothesis of Eisenhammer).

Tuberculosis, lymphogranuloma inguinale, inflammatory bowel disease

like Crohn’s or ulcerating proctocolitis can also lead to development of anal

fistula. Fistulae have been reported following external injury or probing an

abscess or low anal fistula. 3 A fistula may develop in chronic anal fissure. A

colloid carcinoma of the rectum can manifest itself through an anal fistula. 10

occasionally ingested foreign bodies, such as fish or chicken bones may

penetrate the rectum. Impalement injury after falling astride a sharp object or as

a result of a road traffic accident may result in a high anorectal fistula.

14
 Other clinical cond itions that can stimulate the appearance of fistula

include hidadenitis suppurative, bilharzias, actinomycosis and Bartholins gland

abscess or sinus.

PATHOLOGY OF ANAL FISTULA :

1) Previous pyogenic abscess :

Majority of anal fistulae develop as a consequence of infection in anal

glands which communicate with anal crypts (crytoglandular disease). Once an

anal gland becomes infected, a small abscess is formed in the intersphincteric

plane and either spontaneously resolves or rupture into anal canal. And also

hence anorectal abscess may spread in one or more directions in several

locations, and subsequently results anal fistulae.

Some episodes of infection are so minor that the patient is unaware of

having had any anal sepsis. In other cases there is no apparent internal opening

to the anal canal because the infective process stimulates an area of fibrosis

which occludes the duct, a situation which predisposes to a chronic abscess

cavity. Spread of sepsis is usually caudal towards the perineum along the

fibroelastic septa of the perineal region. Less commonly the infective process

spreads upwards, resulting in a high intersphincteric or supralevator abscess

(Eisen Hammer, 1951). Lateral spread may be via a long fibroelastic septum

passing directly through the external sphincter or via the venous plexus to the

ischiorectal fossa. Occasionally the lateral spread may occur over the top of the

15
puborectalis to enter the ischiorectal fossa by penetrating the levator ani.

Alternatively, the abscess may discharge medially along it’s duct to resolve

spontaneously upward spread is less common because of continued tonic activity

of puborectalis. (Hanley, 1978)11

2) Tuberculosis :

Anal fistula occur as a well recognized complication in patients with

known pulmonary Koch’s lesions whether active or healed. Gabriel reported

about 15% - 18% in apparently healthy individuals without active lesion, based

on histopathology of excised tract.

The method of infection of the anal region in there case is presumably that

tubercle bacilli are swallowed in the sputum and enter the perineal tissue through

minute abrasions of the lining of the anal canal. The alternative of a blood- borne

infection from pulmonary lesion is theoretically possible. Blood spread from

some other unspecified tuberculous focus in the cervical, mediastinal or

mesenteric lymph nodes is another possibility. The infection might occur as

direct inoculation of tubercle bacilli during anal toilets to excoriations or cracks

in the perianal skin from the patient fingers, contaminated by contact with his

own infected sputum. 1 2

The incidence of tuberculous fistulae is decreasing and in most cases it is

probably due to a foreign body reaction rather than tuberculosis or to a Crohn’s

lesion.

16
3) Ulcerative colitis :

Anorectal abscesses and fistulas are known to develop as a complication

in ulcerative colitis. The usual course of events in the development of these

fistulae seemed to be that, first of all small septic cracks of fissures appeared and

provided an avenue of infection. In a proportion of these cases an abscess then

formed and developed into a fistula. As the bowel symptoms in these patients

may be relatively slight, the underlying inflammatory condition of the rectal

mucosa may easily be over looked if a complete rectal examination with

proctoscopy and sigmoidoscopy is not performed. Anal abscess and fistula may

also be complications of segmental forms of colitis in which the rectum itself

remains normal. 1 2

4) Crohn’s disease :

Unquestionably the most important predisposing cause, at the present time

for anal abscess and fistulae is Crohn’s disease. The site of primary disease in

the intestinal tract has an important bearing on the likelihood of these

complications occurring, for when the enteritis was confined to the small

intestine the incidence was 10%, but when large bowel was involved, the

incidence increased to 25% when the rectum itself was implicated it was 35%.

In view of the absence of any direct continuity between small bowel

lesions and anal fistulae it is assumed that infection is conveyed along the lumen

of his colon and enters the tissues of the anal canal region through minute

breaches of the lining of the anal canal, or along the anal gland. 12

17
5) Carcinoma of rectum and anal canal (Colloid carcinoma)

If the growth lies in the lower rectum or in the anal canal and such an

abscess should develop. It will be situated in one of the tissue spaces around the

anal canal, and when it ruptures it will give rise to a fistula- in- ano. Some of

these colloid carcinomata of the anorectal region may arise, not in the mucosa of

rectum or anal canal, but in the epithelial lining of anal intramuscular glands,

when there may be no growth evident in the rectal or anal lumen but only in the

fistulous tract. 12

6) Lymphogranuloma venereum :

Strictures due to LGV inguinale are quite frequently accompanied by

abscesses and fistulae in the anal region. 1 2

7) Actinomycosis :

Actinomycosis of the rectum is exceedingly rare but when it occurs it is

often associated with the development of anal fistulae discharging typical

actinomycotic pus. 12

8) Previous rectal, obstetrical or gynaecological operations :

Rarely a fistula develops following an operation such as

haemorrhoidectomy or evacuation of an anal haematoma due to skin edges

falling together and uniting to form a bridge. In female patient, anterior fistulae-

in- ano quite frequently arise after complete perineal tears during parturition or

after perineorrhapy. 12

18
ABDOMINAL DISEASE LEADING TO FORMATION OF PELVIC

ABSCES SES :

Acute appendicitis, sigmoid diverticulitis, salpingo - oophioritis, presacral

dermoid cysts are a few conditions which may lead to fistulae in- ano due to the

abscesses bursting through the levator ani muscle into the ischiorectal fossa and

lead to its being drained through an incision in the perianal region and if the

abdominal disease persists will lead to a pelvirectal fistula.

PERINEAL INJURIES :

Fistulas around the anal canal may complicate penetrating perineal

injuries due to blunt trauma, stabbings, blast injuries from mines or gunshot

wounds sustained as a result of civil or military conflict. 11

19
 CLASSIFICATION

According to Park, the anal fistula can be classified into four types –

i) Intersphincteric – 70%

ii) Transphincteric - 25%

iii) Suprasphinteric - 5%

iv) Extrasphincteric - 1% 13

However further variations of each can occur

A) Intersphinteric

1. Simple low track

2. High blind track

3. High track with opening into rectum

4. High fistula without a perineal opening

5. High fistula with extra rectal or pelvic extension

6. Fistula from pelvic disease.

B) Transphincteric

1. Un complicated

2. High blind track

20
C) Suprasphincteric

1. Uncomplicated

2. High blind tract

D) Extra sphincteric

1. Secondary to transphincteric fistula

2. Secondary to trauma

3. Secondary to anorectal disease (eg. Crohn’s)

4. Secondary to pelvic inflammation

E) Combined

F) Horseshoe

1. Intersphincteric

2. Transphincteric 14

“Complex” fistula is not a term included in the above classification, but it

has been applied to a number of papers on fistula. Simply stated, comple x

fistulas are those other than intersphincteric and low extrasphincteric fistulas.

The implication is, obviously, that they are more difficult to treat than

conventional fistulas and, in addition, are associated with increased risk of

recurrence as well as a greater likelihood of impairment of control. The word

“problematical” has also been used to describe the same perception. 15

21
Five types of fistulas are generally described by most authors:

1. Submucous

2. Intersphincteric

3. Transphincteric

4. Suprasphincteric

5. extrasphincteric

Other wise According to standard classification

1. Subcutaneous

2. Submucous

3. Low anal

4. High anal

5. Pelvirectal

GOODSALL’S RULE :

In simple cases, the goodsall rule can help to anticipate the anatomy of

fistula- in- ano. The rule states that fistulae with an external opening anterior

plane passing transversely through the center of the anus will follow a straight

radial course to the dentate line. Fistulae with their openings posterior to this

line will follow a cur ved course to the posterior midline. Exceptions to this rule

are external openings more than 3 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.

22
 Fig.3 : Park’s Classification

Fig.4 : Standard Classification

23
Fig. 5: Classification of anal fistulas. A, Intersphincteric: The tract remains in the intersphincteric
plane. 1, Simple. 2, High blind tract. There is a high extension of the fistula between the internal
sphincter and the longitudinal muscle of the upper anal canal. 3, High tract with rectal opening. 4,
High intersphincteric fistula without a perineal opening. There may or may not be a rectal opening.
5, High intersphincteric fistula with a pelvic extension. The infection spreads up to reach the true
pelvic cavity lying above the levator musculature. 6, Intersphincteric fistula secondary to pelvic
disease. This fistula results from the spread of pelvic collections via the intersphincteric plane. This
does not represent a true anal fistula because its origin is outside the anal area. There is no opening
at the dentate line. B, Trans-sphincteric: The fistula tract passes from the intersphincteric plane
through the external sphincter muscle. 1, Uncomplicated. 2, High blind tract. The upper tract
extension may go to the apex of the ischiorectal fossa or extend higher through the levator
musculature into the pelvic cavity. C, Suprasphincteric: There is an upward extension of the fistula
tract in the intersphincteric plane. The tract then passes above the level of the puborectalis muscle
and continues downward through the ischiorectal fossa to the perianal area. D, Extrasphincteric:
There is a tract that passes from the skin of the perineum through the ischiorectal fossa and the
levator muscles before entering the rectal wall. This fistula may be a consequence of an extension of a
trans-sphincteric fistula or secondary to trauma, anorectal disease, or pelvic inflammation.

24
Fig. 6: Goodsall’s Rule

Fig.7 : Fistula-in-ano

25
 CLINICAL FEATURES

Fistula- in- ano is predominantly a disease of men of middle age. The

male/female ratio is roughly 5.1 and 75% of the patients in both sexes are aged

between 30 and 60 years.

The chief complaint is intermittent or constant drainage or discharge.

There is usually a history of previous pain, swelling and recurrent abscess that

ruptured spontaneously or was surgically drained. There may be a pink or red

elevation exuding pus, or it may have healed. In Crohn’s disease or tuberculosis,

the margins may be violaceous and the discharge watery. 9

Signs and symptoms (in order of prevalence)

§ Perianal discharge

§ Pain

§ Swelling

§ Bleeding

§ Diarrhoea

§ Skin excoriation

§ External opening

Past medical history :

Important points in the history that may suggest a co mplex fistula include

the following -

§ Inflammatory bowel disease

§ Diverticulitis

26
 § Previous radiation therapy for prostate or rectal ulcer

§ Tuberculosis

§ Steroid therapy

§ HIV infection

Review of symptoms :

§ Abdominal pain

§ Weight loss

§ Change in bowel habits

Physical examination :

Physical examination findings remain the main stay of diagnosis. The

examiner should observe the entire perineum, looking for an external opening

that appears as an open sinus or elevation of granulation tissue. Spontaneous

discharge via the external opening may apparent or expressible upon digital

rectal examination.

Digital rectal examination may reveal a fibrous tract or cord beneath the

skin, it also helps delineate any further acute inflammation that is not yet

drained. Lateral or posterior induration suggests deep posterior anal or

ischiorectal extraction.

The examiner should determine the relationship between the anorectal

ring and position of the tract before the patient is rela xed by anaesthesia. The

sphincter tone and voluntary squeeze pressure should be assessed before any

surgical intervention to delineate whether pre- operative manometry is indicated.

Anoscopy is usually required to identify the internal opening. 6

27
 Passing of probe can be attempted through the external opening will

usually reveal the course more readily. The probe should never be forced, merely

gently maneuvered, otherwise it causes false passages.

SPECIAL STUDIES :

Sigmoidoscopy and colonoscopy :

Sigmoidoscopy should be performed in all patients with anorectal

pathology. The presence of associated pathology such as neoplasms,

inflammatory bowel disease, or associated secondary tracts in the rectum must be

sought. Such findings may dictate the need for full colonoscopic evaluation.

Injection techniques :

Dyes like methylene blue, indigo carmine or milk injected to identify the

tract and internal opening is no where used at present. But hydrogen peroxide

injection is probably the best means for identifying the internal opening. The

liberated O2 may be seen to bubble through the internal opening. The pressure

created by the gas may be sufficient to penetrate over stenotic tract and pass into

anal canal, obviously staining of tissues does not occur. 2

SPECIAL STUDIES :

Lab studies :

§ No specific laboratory studies are required; the normal preoperative

studies are performed based on age and comorbidities.

28
Imaging studies :

§ Radiologic studies : There are not performed for routine fistula

evaluation. They can be helpful when the primary opening is difficult to

identify or in the case of recurrent or multiple fistulae to identify

secondary tracts or missed openings.

Fistulography :

Fistulography, the radiologic delineation of a fistula tract with a water

soluble contrast agent, is thought generally to be a limited value.

But Ani and Lagundoye believed that the information gained was

generally helpful. 1 6

Fistulography may be useful in identifying unsuspected pathology,

planning surgical management, and demonstrating anatomic relationships. 17,18

The technique is quite simple :

§ This involves injection of contrast is a the internal opening, which is

followed by anterior posterior, lateral and oblique x- ray images to outline

the course of the fistulous tract.

§ The accuracy rate is 16-48%.

§ The procedure is well tolerated but requires the ability to visualize the

internal opening.

29
Endo anal / endorectal ultrasound :

§ This is a new, potentially promising technique for localizing fistula tracks

and associated abscesses in the perianal region.

§ These studies involve passage of 7 or 10 MHz transducer into anal canal

to help define muscular anatomy differentiating intersphincteric from

transphincteric lesions.

§ A standard water filled balloon transducer can help evaluate the rectal

wall for any suprasphincteric extens ion.

•
These studies are reported to be 50% better than physical examination

alone to help find internal opening of fistulas can be accurately localized

and a concomittent intersphincteric abscess may be identified. 6

§ In recurrent or complex fistula - in- ano, endo anal ultrasound proved more

accurate for detecting primary tracks and internal openings than for

detecting extensions. Hydrogen peroxide improved conspicuity of some

tracks and internal openings and so may be helpful in difficult cases,

although no over all diagnostic benefit was demonstrated. 19

§ Others concur that this technique is an accurate and minimally invasive

method for delineating the relationship between fistula tracts and the anal

sphincter mechanism as well as identifying deeper areas of sepsis.20

Magnetic Resonance Imaging (MRI) :

§ Magnetic Resonance Imaging (MRI) is useful in identifying primary and

secondary tracts. High concordance rates (80- 90%) between MRI and

operative findings have been reported.21

30
 Fig. 8 : Fistulogram

Fig.9 : MRI shows Transphincteric Fistula -in-ano

31
 § MRI is becoming the study of choice when evaluating complex fistulae It

has been shown to improve recurrence rates by providing information on

otherwise unknown extensions.

§ Digital subtraction MR – fistulography is a new, promising, non invasive

imaging technique for the detection of perianal fistulas and abscesses.22

Computerized Tomography Scan (CT scan) :

The use of computed tomography in the evaluation of anal fistulas is

limited due to poor visualization of the levators and sphincter complex. The role

of CT in anal sepsis and fistula is thus limited to the assessment of associated

pelvic pathology in patients with supra levator abscesses and in patients with

some complex anal fistulas. 2 3

§ A barium enema / smal l bowel series : This is useful for patients with

multiple fistulae or recurrent disease to help rule out inflammatory bowel

disease. 6

§ Fistuloscopy : Anorectal fistuloscopy using flexible ureteroscopes has been

recently described. 24 This is a potentially useful intraoperative technique to

identify primary fistula openings, multiple or complex tracts and iatrogenic

tracts. Modified flexible ureteroscopes are in the early development stages. 23

32
OTHER TESTS :

Anal manometry :

§ Pressure evaluation of the sphincter mechanism is helpful in certain points.

o Decreased tone observed during preoperative evaluation

o History of previous fistulotomy

o History of obstetrical trauma

o High transphincteric or suprasphincteric fistula (if known)

o Very elderly patients

If decreased, surgical division of any portion of the sphincter mechanism should

be avoided.

DIFFERENTIAL DIAGNOSIS :

§ Anal fistula of cryptogenic origin : It is the most common condition

presenting as perianal fistula. It is caused by infection of the anal gland.

§ Crohn’s disease : It should be suspected if there are numerous complex

fistulous tracts associated with oedematous skin tags or if there is

inflammation of rectal mucosa. 25

§ Tuberculous anal fistula : It is diagnosed in small proportion (about 15% -

18% in India) of patients based on histopathology of the excised tract.

§ Hidradenitis suppurativa : In this condition, the disease arises from

perianal skin and not from the anal crypts.

33
§ Actinomycosis : Sulpher like granules are seen in the abscess cavity or

fistulous tract.

§ Pilonidal sinus : It may mimic posteriorly located anal fistula, however the

examination should reveal presence of hair in the tract and absence of

communication with anus.

§ Urethral fistula : It may develop following rupture of a periurethral abscess

and is situated anterior to anus.

§ Sacrococcygeal fistula : A more important is the differentiation between a

chronic abscess and a perirectal dermoid cyst or a sacrococcygeal teratoma. If

these lesions are inadvertedly opened, total excision ma y prove difficult and

sacrococcygeal fistula develop, which often defines surgical excision. 11

34
 TREATMENT

MEDICAL THERAPY :

No definite medical therapy is available; long term antibiotic prophylaxis

and infliximab may have role in recurrent fistulae in patients with Crohn disease.

In conclusion, using endoscopic ultrasound to guide therapy for crohn’s

perianal fistula with infliximab, an immunosuppressive, and an antibiotic is

associated with a high short and long- term fistula response rate. EUS may

identify a subset of patients who can discontinue infliximab without recurrence

of fistula damage. 26

The anal fistulae due to specific diseases are treated as same as that for

non- specific fistula along with curative medical management.

SURGICAL THERAPY :

Symptoms should always guide the need for the intervention a cure. 27,28

Anorectal fistula rarely heal spontaneously and requires surgical therapy to

achieve a cure. The patient is positioned in prone jackknife position with the

buttocks tapered apart. General, regional, or local anaesthesia with intravenous

sedation should be selected based on individual patient characteristics. The three

basic surgical techniques for the treatment of anorectal fistulae are fistulotomy,

use of a seton, and endorectal advancement flaps. The use of fistulectomy is not

recommended except when it is necessary to provide histologic material. 29

The main object of surgical treatment of an anal fistula is to eradicate it

without disturbing anal continence. 30

35
 The primary determinant of successive treatment of fistulae involves

accurate identification of the internal opening and course of fistulous tract. 5

FISTULOTOMY :

Fistulotomy is an adequate procedure for simple anal fistulae. Most

anorectal fistulas may be adequately treated by the classic laying open technique

or fistulotomy. Recurrence rates are low, and risks for continence disturbances

are minimal. 3 0

During fistulotomy, a probe is passed through the fistulous tract, and the

tract is laid open by dividing the tissues overlying the tract skin, subcutaneous

tissue, lower fibres of internal and external anal sphincters. A search should be

made for any secondary tract arising from the primary tract which may need

curettage. Mar- supialization with a running continuous absorbable suture is

associated with faster healing. 3 1

Traditional fistulotomy has been performed with scalpel or electrocautery

in the lay open technique. Very recently, Gupta has described a lay- open

fistulotomy technique using radio frequency. 32 Also known as radiofrequency

fistulotomy where radiofrequency device is employed to perform the functions of

conventional instruments by generating high frequency radio waves. It is a

technique of performing simultaneous cutting and coagulation of the tissues

using high frequency alternate current. This procedure results in significant

Haemostasis, without actually burning the tissues. There is no danger of

shocking or burning the patient with only controlled and minimal lateral tissue

damage.

36
FISTULECTOMY :

Fistulectomy, currently a less used procedure, involves excision of the

whole fistulous tract. It results in larger wound in comparison to fistulotomy. It

may be useful in situations where it is not possible to pass the probe due to

partial obliteration of the tract or it is necessary to provide tissue for histologic

evaluation.

This technique involves coring out of the fistula, usually by diathermy

cartery; it allows better definition of fistula anatomy than fistulotomy, especially

the level at which the track crosses sphincters and the presence of secondary

extensions. 3 3

There is no conclusive evidence if simple drainage or sphincter cutting

procedures (which includes fistulotomy and fistulectomy) is better in the

treatment of ano rectal abscess fistula. 34

SETON PLACEMENT :

Seton is a foreign material which is inserted into the fistula tract to

encircle the sphincter muscle. It may be made of silk, nylon, polypropylene,

silicone or steel. Setons are useful in the management following conditions

where there is an appreciable risk of incontinence or poor healing, can be placed

alone, combined with fistulotomy or in staged fashion.

§ Complex fistulae (i.e. high trnasphincteric, suprasphincteric,

exhasphicteric) or multiple fistulae.

§ Recurrent fistulae after previous fistulotomy.

37
 § Anterior fistulae in female patients.

§ Poor pre- operative sphincter pressures.

§ Patients with crohn’s disease or patients who are immunosuppressed.

Complete healing of selected anorectal fistulas has been reported solely

with the use of long term setons. 3 5

Setons may be used for marking, drawing, cutting or staging setons have 2

purposes beyond giving visual identificationof the amount of sphincter muscle

involved. There are –

1. To drain and promote fibrosis

2. To cut through the fistula.

As marking seton, it may help the surgeon to assess, once the patient is

awake, the amount of muscle the fistula tract crosses. If adequate muscle is

present above the seton, fistulotomy may be performed without significant risk

of incontinence.

A loosely tied seton may provide drainage for septic process. The seton

drainage converts anal gland sepsis into a foreign body reactions, which in most

of the cases (75%) will subside spontaneously once the seton is removed after a

period of 8- 12 weeks. 27 In combination with immunomodulation therapy with

infliximab, long term drainage seton appears to improve outcome while

maintaining sphincter function in crohn’s disease with complex anal fistula. 37

38
 Cutting seton is used to gradually divide the sphincter muscle. At regular

interval, the seton is tightened, dividing the muscle by a process of ischaemic

necrosis. The cut edge of the muscle does not retract because of the fibrosis

induced by the seton. Use of a looped seton for this purpose facilitates the

process.38 While using a staging seton, the superficial fistulotomy tract is

divided upto the sphincters, the seton is placed in the remaining portion of the

tract passing through the sphincter, and tied around the sphincter. The encircled

portion of the sphincter is divided as a second stage procedure once adequate

fibrosis occurs (usually 8 weeks).

A ‘high’ fistula may be converted to a ‘low’ fistula by dividing only the

proximal portion of the tract, leaving the distal tract encircled with a seton for

division at a later date.

Medicated Ayurvedic thread has been also used, as temporary draining

seton, in the treatment of anal fistula. 3 9

Garcia – Aguilar et al showed no difference in fistula eradication,

incontinence and patient satisfaction between the patie nts treated with cutting

setons and treated with two stage seton fistulotomy in case of high anal

fistulas. 40

ADVANCEMENT FLAPS :

Advancement flaps consist of mucosa, submucosa and part of the internal

sphincter. The underlying fistula tract is debrided, and the internal opening is

sutured at the level of the muscle. The edge of elevated flap containing the

39
internal opening is excised, and the flap is advanced and sutured over the

internal defect. 23 This technique should be accompanied by adequate external

drainage and wide saucerization. It obviates the need for dividing the sphincter.

Advancement flaps after the advantage of a one stage procedure, quicker

healing, limited damage to the underlying sphincter, and minimal risk of anal

canal deformity. 3 A disadvantage is poor success in patients with Crohn’s

disease or acute infection.

FIBRIN GLUE :

Fibrin glue was first described for plutting fistulae in 1982 by Hedelin et

al. It’s use was not exclusively for fistula- in- ano but all perineal fistulae

postoperatively. A prepared mixture of fibrinogen and thrombin is injected into

the fistula tract after it has been curetted. The mode of action is thought to be by

stimulating the growth of fibroblasts and pluripotent endothelial cells into the

fistula tract to seal it off i.e. These cells then lay collagen and extracellular

matrix in the next stage of wound healing. 41

El- Shobaky et al showed that patients treated with fibringlue had 0%

incontinence whereas 10% of patients treated with the conventional s urgical

techniques incurred some form of incontinence. 4 2

This techniques represents an alternative mode of treatment in complex

cases for which standard treatment has failed.

A biodegradable eradiation of all long standing granulation tissue may

ensure complete success of fibrin sealant therapy. 43

40
 Injection of fibrin glue for the treatment of perianal fistulas is safe, simple

and associated with early return to normal activity. Although moderately

successful, it may preclude extensive surgery in more than one- half of these

patients. 4 4

The complications of fibrin glue for treatment of both types of fistulae

include formation of abscesses and new fistulae tracts.

A bio- degradable collagen plug derived from porcine submucosa has been

trialed against fibrin glue in a small sample of patients with promising results. 45

Pre -operative details :

• Rectal irrigations with enemas should be performed on the morning of the

operation.

• Anaesthesia can be general, local with intravenous sedation, or a regional

block.

• Administer pre-operative antibiotics.

• Prone Jackknife position with buttocks apart is the most advantageous

position.

Intra operative details :

• Examine the patient under anaesthesia to confirm the extent of fistula.

• Identifying the internal opening to prevent recurrence is imperative.

• A local anaesthetic block at the end of the procedure provides

postoperative analgesia.

41
Postoperative details :

•
Most patients can be treated in an ambulatory setting with discharge

instructions and close follow up care. 6

Follow up :

• Sitz baths, analgesics and stool bulking agents (eg. bran, psyllium

products) are used in follow up care.

• Frequent office visits within the first few weeks help ensure proper

healing and wound care.

• Importantly, ensure that the internal wound does not close prematurely,

causing a recurrent fistula. Digital examination findings can help

distinguish early fibrosis.

• Wound healing usually occurs within 6 weeks.6

COMPLICATIONS :

§ Early postoperative :

o Urinary retention

o Bleeding

o Foecal impaction

o Thrombosed haemorrhoids

42
 § Delayed postoperative

o Recurrence

o Incontinence (stool)

o Anal stenosis : the healing process causes fibrosis of the anal canal.

Bulking agents for stool help prevent narrowing.

o Delayed wound healing : Complete healing occurs by 12 weeks

unless an underlying disease process is present (i.e., recurrence,

crohn disease). 6

The primary cases of fistula recurrence relate to unrecognized internal

openings and inadequate drainage of abscess cavities 4 6 , and also associated with

lateral location of internal openings and fistulas with horseshoe extension.

OUTCOME AND PROGNOSIS :

§ Following standard fistulotomy, the reported rate of recurrence is 0- 18% and

the rate of any stool incontinence is 3- 7%.

§ Following seton use, the reported rate of recurrence is 0- 17% and the rate of

any incontinence of stool is 0- 17%.

§ Following mucosal advancement flap, the reported rate of recurrence is 1-

10% and the rate of any incontinence of stool is 6-8%.6

43
CONCLUSION :

1. Anorectal fistula of cryptoglandua lr origin is the most common condition

presenting as perianal fistulae.

2. A good clinical examination provides all information required for the

management of ano rectal fistulae.

3. In spite of availability of many options majority of the surgeons still rely on

the classical lay open technique (fistulotomy), as the “gold standard” for

treatment of fistula- in- ano. 47

4. Fistulotomy with sphincter reconstruction seems to be an effective resource

in the management of recurrent complex fistula - in- ano. It improves both anal

continence and manometric values in incontinent patients without

compromising them in fully continent ones. 48

44
Methodology
 METHODOLOGY

SOURCE OF DATA :

Data was collected from patients who came to Chigateri General Hospital

and Bapuji Hospital, Davangere attache d to J.J.M. Medical College, Davangere

for treatment.

METHOD OF COLLECTION OF DATA :

Sampling procedure :

The diagnosis of the fistula - in- ano, mainly depends on clinical

examination. The selected patients are subjected to pathological, biochemical

and radiological investigations. Data related to age and sex, aetiological factors

was collected. Data related to preoperative and intraoperative interventions along

with postoperative outcome was also collected. In my study 50 cases has been

studied over a period of 2 years from June 2007 to May 2009. Patients had been

enrolled as and when they present with following inclusion and exclusion

criteria.

Inclusion criteria :

The patients who are clinically diagnosed as fistula - in- ano in all ages and

both sex who are subjected to relevant investigation and undergo surgery were be

included.

45
Exclusion criteria :

§ All fistulas and sinuses occurring in the midline.

§ All fistulas due to perineal injuries.

§ All congenital fistulas.

§ Cases unfit and refused for surgery.

46
Fig.10 : Fistula-in-ano in the anterior anal axis

Fig.11 : Probe through the external opening

47
Fig. 12 : Probe through the external and internal
opening of the fistula

Fig. 13 : Fistulectomy procedure

48
 Fig.14 : Fistulectomy wound

Fig.15 : Fistulectomy specimen

Fig. 16: Illustrations of surgical Fig.17: Seton Placement

technique of Seton placement & retightened at weekly
intervals

49
Results
 RESULTS

The results obtained were analysed as follows.

TABLE – 1 : AGE DISTRIBUTION

Age in years No. of Percentage

patients

≤ 10 1 2

11 – 30 16 32

31 – 60 31 62

=61 2 4

In our study of 50 patients the age of patients from 8 years to 75 years.

Maximum number of patients were in the age group 31 – 60 years i.e., 31

patients (62%). There was 1 patient (2%) in the age group of ≤ 10 years, 16

(32%) in the age between 11 – 30 years and 2 patients in the age above 60 years.

TABLE – 2 : SEX INCIDENCE

Sex No. of Percentage

patients

Male 46 92

Female 4 8

In our study of 50 patients there were 46 (92%) male patients, 4 (8%)

female patients indicating that the disease is more common in male with a ratio

of male to female is 11.5:1.

50
 GRAPH-1 : AGE DISTRIBUTION

70
62
PERCENTAGE 60

50

40
32
30

20

10
2 4
0
<10 11-30 31-60 =61
AGE IN YEARS

GRAPH- 2: SEX INCIDENCE

8%

92%

Male Female

51
OCCUPATION AND SOCAIL STATUS :

Most of the cases were from low socio economic group and manual

labours except 10 cases wherein 6 cases were businessmen and 4 were students.

TABLE – 3 : SYMPTOMS AND SIGNS

Symptoms and signs No. of Percentage

patients
Pain 26 52.0
Discharge 50 100.0
Swelling 22 44.0
Pruritis 34 68.0
External opening 50 100.0
Internal opening 42 84.0
Bleeding per rectus 4 8.0
In the present study the commonest symptoms is discharge in all patients

with pruritis in 34 (68%) patients and pain in 26 (52%) patients. The commonest

sign is presence of external opening in all cases, internal opening in 42 (84%) of

patients and swelling in 22 (44%) cases.

TABLE – 4 : STANDARD CLASSIFICATION

Type No. of Percentage

patients
Subcutaneous 6 12%
Low anal 37 74%
High anal 2 4%
Submucous 5 10%
Pelvirectal 0 0
The above figures shows the commonest type of fistula was low anal.

52
 GRAPH-3 : SYMPTOMS AND SIGNS

Bleeding per rectus

84
Internal opening

100
External opening

68
Pruritis

44
Swelling

100
Discharge

Pain 52

0 20 40 60 80 100 120
PERCENTAGE

GRAPH-4 : STANDARD CLASSIFICATION

10% 0% 12%
Subcutaneous
4%
Low anal

High anal

Sub mucous

Pelvirectal

74%

53
TABLE – 5 : DISTRIBUTION OF ANAL FISTULAE AROUND THE ANAL

CIRCUMFERENCE

Relation to anal axis No. of Percentage

patients

Anterior 12 24

Posterior 33 66

Lateral 5 10

Relation to Goods all’s rule :

Among fifty cases studied, thirty three cases having external opening in

the posterior axis. Out of thirty three twenty seven followed Goodsall’s rule.

TABLE – 6 : ASSOCIATED CONDITIONS

Type No. of Percentage

patients

Fissure 2 4

Pulmonary TB 2 4

Haemorrhoids 4 8

BPH 3 6

Anorectal abscess 22 44
(burst opened or Surgically drained)

54
 GRAPH-5 : DISTRIBUTION OF ANAL FISTULAE AROUND
THE ANAL CIRCUMFERENCE
10%

25%

Anterior
Posterior
Lateral

65%

GRAPH-6 : ASSOCIATED CONDITIONS

25
22
20
NO. OF CASES

15

10

5 4
3
2 2
0
Fissure Pulmonary TB haemorrhoids BPH Anorectal absces

55
 TABLE – 7 : INCIDENCE OF FISTULA-IN -ANO

Aetiology No. of Percentage

patients

Chronic non specific infection 48 96

Tuberculosis 2 4

Malignancy - -

TABLE – 8 : TREATMENT

Type of operation No. of Percentage

patients

Fistulectomy 34 68

Fistulotomy 14 28

Seton placement 2 4

Mucosal advanced flap - -

Fibrin glue injectio n - -

Colostomy - -

56
 GRAPH-7 : INCIDENCE OF FISTULA-IN-ANO

Malignancy 0

Tuberculosis 4

Chr. Non specific

96
infection

PERCENTAGE

GRAPH-8 : TREATMENT

80
68
70
60
PERCENTAGE

50
40
28
30
20
10 4
0
Fistulectomy Fistulotomy Seton Mucosal Fibrin glue Colostomy
placement advanced flap injection

57
TABLE – 9 : NUMBER OF PREVIOUS ATTACKS OF PERIANAL SEPSIS

IN PATIENTS WITH FISTUAL-IN -ANO

Number of patients Number of previous attacks

of perianal sepsis

8 1

5 2

3 3

1 4

3 5

2 6

Most of the patients have 1- 3 times previous attacks of perianal sepsis

which was burst opended or surgically drained.

58
 GRAPH-9 : NUMBER OF PREVIOUS ATTACKS OF
PERIANAL SEPSIS IN PATIENTS WITH FISTULA-IN-ANO

6
6

5 5
NO.OF PREVIOUS ATTACKS

4 4

3
3

2 2

1 1

0
8 5 3 1 3 2
NO.OF PATIENTS

59
 TABLE – 10 : TIME TAKEN TO HEAL

Time No. of Percentage

patients

1 week 1 2

2 week 10 20

3 week 12 24

4 week 17 34

5 week 5 10

6 week 1 2

7 week 1 2

8 week 1 2

10 week 2 4

Total 50 100

Most of the cases healed within 2 to 4 weeks with a mean time of 3 weeks.

Follow up :

Most of the patients came for follow up only once or twice vary from

three months to six months. There was recurrence in one case after 4 weeks and

it was excised.

60
 GRAPH-10 : TIME TAKEN TO HEAL

2%
2%
2% 4% 2%
20%
10%

24%
34%

1 week 2 week 3 week 4 week 5 week

6 week 7 week 8 week 10 week

61
 TABLE – 11 : HISTOPATHOLOGICAL REPORT

Histopathology report No. of patients

Non specific inflammation 32

Tuberculosis 2

Out of 50 cases, fistulectomy done in 34 cases and the operated specimen

sent for histopathological examination. 32 cases were diagnosed as due to

nonspecific inflammation and 2 cases were of tubercular aetiology.

GRAPH-11 : HISTOPATHOLOGICAL REPORT

35 32

30

25
No.of cases

20

15

10

5 2

0
Non-specific inflammation Tuberculosis

62
 TABLE – 12 : COMPLICATIONS

Complications No. of Percentage

patients

Postoperative wound infection 8 16

Retention of urine 2 4

Postoperative headache 3 6

Recurrence 1 2

Incontinence - -

Stricture - -

A few patients had transient incontinence for fluids and flatus for about 2

weeks which was probably due to operative oedema, pain and to some extent

lack of tone of sphincter musculature.

Mortality :

In the present study of 50 patients diagnosed as fistula- in- ano and those

who underwent definitive surgical treatment had no postoperative mortality.

Thus, may be the better outcome.

63
 GRAPH-12 : COMPLICATIONS

8
8

6
NO.OF CASES

4
3
3
2
2
1
1

0
Post.op Retention of Post.op Recurrence Incontinence Stricture
wound urine headahce
infection

64
Discussion
 DISCUSSION

The incidence of fistula- in- ano and aetiological factors were studied from

cases admitted to Bapuji Hospital and Chigateri General Hospital attached to

J.J.M. Medical College, Davangere, during the year 2007-2008. The data

regarding this is analysed from selected 50 cases that were admitted to the

hospital during the same period.

The aetiology of the disease under study was concluded by investigations

and clinical presentation along with associated conditions. In this series all the

cases were non- specific except two cases of tubercular aetiology.

Laboratory investigations :

Haemoglobin percentage, urine and stool examination were done

routinely. In two cases of tuberculous fistula, the ESR was high.

Radiological examination :

Screening of the chest was done routinely Two cases showed pulmonary

tuberculosis. Fistulogram was done in three cases. The two cases showed low

ischiorectal fistula. The other one showed a perianal low fistula. It was not

much informative regarding the relation to anorectal ring.

Sigmoidoscopy :

It was done in pertinent cases. No cases showed any evidence of

malignancy, Crohn’s disease etc.

65
Hiastopathology :

In most of the cases biopsy report was non- specific. Two cases were

reported as tuberculous.

Attempts were made to classify the fistulae according to the standard

classification. In some cases there was difficulty to establish the relation of

fistulous tract to various parts of the sphincter. The different parts of the

sphincters were difficult to identify at operation, when they were infiltrated by

inflammatory process. Depth of the internal opening in the ana l canal and

distance of external opening from anal verge also provided valuable indications

for classification of the fistulae. The degree or induration of the ano rectal ring

in some areas detected by digital palpation gave information of primary

importance about the type of fistulae.

There is a more dominance in almost every reported series (Adams and

Koralcik, 1981). The male : female ratio in the 5 year review of 793 patients at

St. Marks Hospital was 4.6:1 (Marks and Ritchie, 1977). In Nigeria the male

dominance is 8:1 (Ani and Solanke, 1976). Most patients with an anal fistula

present in the third or fourth decade of life and anal fistulas were uncommon

after the age of 60 years (Vasilevsky and Gordon 1984; Bruhl, 1986). 11

In our study also there is a male predominance with a ratio of 11.5:1.

Most of the patients in our study present between the 31- 60 years and only 2

were in the age group of more than 60 years shows that our study almost matches

with their study in male: female ratio and age inc idence.

66
 As per the study done by Parks et al, Marks and Ritchie, Vsilevsky

Grodon and Garcia – Aguilar et al. (1728 patients) the incidence of anal fistula is

intersphincteric in 49.5%, transphincteric in 27.7%, suprasphincteric 6.5%,

extrasphincteric in 2.9% and more classified is 13.4%.23

In our study intersphincteric in 96% and suprasphincteric is 4%.

This disparity may be explained by the fact that our study constituted a

very small study group (50 patients).

As per marks and Ritchie (1977), the site of internal opening is anterior in

22%, posterior in 66.4% and lateral in 11.6% of the patients. 1

In our study anterior in 24%, posterior in 66% and lateral in 10%, almost

matches with their study.

Anterior Posterior Lateral

Marks and Ritchie (1977) 22 66.4 11.6

Study series 24 66 10

Vasilevsky and Gordon (1984) recorded a history of discharge in 65%,

anal pain 34%, a recurrent perianal swelling in 34%, bleeding in 12% and

pruritis in 70%. Associated fissure in ano was recorded in 14% of their patients.

Many patients also have haemorrhoids. 11

67
 In our study, a history of discharge in 100%, anal pain 52%, a recurrent

perianal swelling in 44%, bleeding in 8% and pruritis in 68% of patients.

Associated fissure in ano was recorded in 4% of patients and haemorrhoids in 8%

of patients, almost nearer to their study.

Comparison of clinical presentation between the study done by Vasilevsky

and Gordon (1984)1 and our study.

Clinical presentation Their study Present study

Pain 34% 52%

Discharge 65% 100%

Swelling 34% 44%

Pruritis 70% 68%

Bleeding / Rectum 12% 8%

Associated fissure 14% 8%

Parks and Stitz (1976) demonstrated that hospital stay and healing times

was much longer in patients treated for trnasphincteric and suprasphincteric as

compared with those treated for an intersphincteric fistula. 11

In our study also the suprashincteric anal fistulas took 10 weeks and

intersphincteric fistulas 1 weeks to 5 week to heal matches with their study.

Recurrence rates for low anal fistula in most reports is less than 10%. In

our study 1 (2%) case was recurred and excised again.

68
 True foecal incontinence is variable, ranging from nil to 26%. In our study

few patients had transient incontinence for fluids and flatus for about 2 weeks

matches with the most of the case reports. The morbidity is much low and the

present record for more conservative methods for treating extrasphincteric

fistulas is more encouraging and holds real promise for a more successful

outcome for fistula surgery in the future.

69
Conclusion
 CONCLUSION

Our study included 50 patients who were diagnosed to have fistula - in- ano,

who underwent surgical intervention. I conclude that the previously burst opened

or surgically drained perianal abscess is the main aetiological factor for fistula-

in- ano. Operative morbidity is usually low. There is a male preference for the

disease and the fistulectomy remains the commonest procedure in our study

series. Even with advent of newer techniques probably to remove the diseased

part at one stage operation. The post operative complications are usually mild in

nature and are minimal.

70
Summary
 SUMMARY

This study comprises 50 patients diagnosed to have fistula - in- ano,

regarding aetiopathogenesis and various modes of treatment. Analysing them, the

following summary were drawn.

1. Majority of patients belonged to age group of 31- 60 years which accounts

for 31 (62%) patients.

2. Male : female ratio was higher i.e., 11.5 : 1

3. Among the series of cases studied, the commonest type of fistulae were

low anal posterior.

4. The commonest aetiology was inadequately treated as pyogenic abscesses

from non- specific cases. Two cases were of tubercular aetiology.

5. The most common presenting symptoms was discharge through the

external opening and the physical findings observed on examination were

tenderness, induration, swelling and internal opening.

6. Digital examination per rectally and examination with a probe were

satisfactory methods by which the varieties, relation to anorectal ring

could be assessed.

7. Conservative treatment not advised to any patient.

71
8. In majority of the cases fistulectomy was done, in fourteen cases

fistulotomy with scooping of the discharge and in two cases seton

placement operation was done. The wound was allowed to heal by

granulation tissue. Routine toilet of the wounds was done. One case had a

recurrence within 4 weeks, wherein the track was excised and wound

allowed to heal by granulation tissue.

9. The immediate postoperative complication was acute retention of urine in

2 cases for whom catheterization was done.

10. The wound healed in majority of cases within 2- 4 weeks.

11. The specimen after fistulectomy sent for histopathological examination in

34 cases, the report was non specific inflammation in 32 cases and

tubercular infection in 2 cases.

12. Many cases of fistula- in- ano could ha ve been prevented by proper and

adequate treatment of perianal and ano - rectal suppurations and by proper

instructions to the patient about the future consequences and sequelae of

suppuration.

72
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78
Annexures
 ANNEXURE – I

PROFORMA
Name : Surgical Unit :

Age : Unit chief :

Sex : D.O.A. :

Address : D.O.O. :

I.P. No. : D.O.D. :

Diagnosis : Hospital :

I) CHIEF COMPLAINTS :

Discharge : Present/Absent Duration :

Swelling : Present/Absent Number: Duration :

Pain : Present/Absent

Fever : Present/Absent

II) H/O PRESENT ILLNESS :

a) Discharge : 1) Duration :

2) Nature : Seropurulent/Purulent/Bloody

3) Periodicity: Present/Absent

b) Swelling : 1) Number :

2) Duration :

3) Associated with discharge: Present / Absent

4) Site :

c) Pain : Yes/No

d) Fever : Yes/No

e) Pruritis : Yes/No

79
 f)Bowel habits: Regular / Irregular

Painful

g) Micturition: Normal / Regular / ↑ frequency/ Burning

h) Other symptoms :

III) PAST HISTORY :

H/o swelling in anal region burst open : Surgical

Treated

H/o of TB : Present/Absent

H/o diabetes : Present/Absent

H/o exposure to V.D: Present/Absent

IV) PERSONAL AND FAMILY HISTORY :

No. of children :

Smoker / Non- smoker

Bladder function : Normal / Altered

Nature of work :

Alcoholic / Non- alcoholic

Vegetarian / Non. : Veg/ Mixed

V) GENERAL PHYSICAL EXAMINATION :

General survey :

Build Obese Moderate Poor

Nourishment Good Moderate Poor

Lymphadenopathy General Local Non- significant

Anaemic : Yes/no

Clubbing : Yes/No

80
Jaundice : Yes/No

Pedal oedema : Yes/No

Cyanosis : Yes/No

Vital signs :

Pulse :

B.P. :

R.R. :

Temp. :

VI) OTHER SYSTEMS :

Cardiovascular system

Respiratory system

Abdominal examination

VII) LOCAL EXAMINATION :

Perianal skin - any operated scar : Yes/No

Fissures : Yes/No

External opening - Number :

Position :

Any exuberant granulation tissue: Yes/No

PALPATION :

a. Tenderness : Yes/No

b. Thickening of wall of sinus : Yes/No

c. Mobility to deeper structures : Yes/No

d. Lump in neighbouring region : Yes/No

81
 e. Mouth of sinus -

Induration - Yes/No Extent Course

Relation to anorectal ring :

Relation to axis : Anterior / Posterior / Lateral

f. Examination with probe :

Direction :

Depth :

Presence of foreign body : Yes/No

Tip of the probe enters into

bony cavity /hollow viscus

Any discharge after withdrawal of probe : Yes/No

PROCTOSCOPY :

SIGMOIDOSCOPY :

INVESTIGATIONS :

Blood : Hb% Urine : Albumin

TC: DC: Sugar

ESR Micro

RBS

Blood urea

Serum creatinine

HIV I & II

HBsAg

82
 Stool : Ova

Cyst

ECG

Screening of the chest

X- ray of PF the chest

Examination of discharge - Culture and sensitivity

X- ray examination - Plain X- ray for evidence of
Sequestrum and opaque
Foreign body
Fistulogram
HPE report of operated specimen :

TREATMENT :

a. Preoperative preparation :

Condition of skin

Any associated disease

Antibiotics – Yes/No

b. Operative treatment :

Date of operation : Unit –

Anaesthesia :

c. P.O. Treatment – Antibiotics Days -

Post – Operative progress : Any complications during immediate post-

operative period.

FOLLOW-UP :

SUMMARY :

83
 ANNEXURE-II

CONSENT FORM FOR ANAESTHESIA/OPERATION

I_____ ______________ Hosp No___________ in my full senses hereby give my

complete consent for _____________________ or any other procedure deemed

fit which is a diagnostic/therapeutic/ procedure/biopsy//transfusion/operation to

be performed on me/my/son/daughter/ward_____________age_____________

under any anaesthesia deemed fit. The nature and risks involved in the

procedure have been explained to me in my own language to my satisfaction. For

academic and scientific purpose, the operation/ procedure may be television or

photographed, or used for statistical measurements.

Date :
Signature/Thumb Impression/
Of the Patient/Guardian
Name :
Designation

Guardian
Relationship
Full Address

84
 ANNEXURE – III
MASTER CHART

Symptoms Past history Inspection Palpation

Lump in neibo.
Operation scar

Exu.Gra.tissue
Swelling burst

Ind. Of mouth
Loc. Raise of
Ext. opening
Perianal skin
Surg.treated

Tenderness

Procto: int.
Re. to anal
Discharge

Probe: int.
Histopath

Swelling

Swelling

opening

opening
of sinus
Fissure
Sl. Complica Recurr-

opened
Fever

temp.
Pain

Area
Name IP No. Hospital Age Sex ological Tretment Death

STD

DM
TB
No. tions ence
exam

1 Shashirekah 52843 BH 8 F + + - - - - + - - ME - - + - - - - + A + + - Fistulotomy - - -

2 Mahesh 528592 BH 22 M + + - + - - - - - ME - - + + - - - + P + + - Fistulotomy - - -
3 Bashir Ahmed 530265 BH 25 M + + - - - - + - - ME - - + + - - - + A + + NSI Fistulectomy - - -
4 Harry 16688 CGH 38 M - + - + - - - - + ME + - + + - + + - A + + NSI Fistulectomy - - -
5 Harsha 532006 BH 21 M + + - - - - - - - N - - + + - - - + P + + NSI Fistulectomy - - -
6 Anjanappa 19580 CGH 36 M - + - + + - - - - N - - + + - - - + P + + TB Fistulectomy - - -
7 Asmabanu 20197 CGH 25 F + + + + - - - - + ME + - + + - + + - L - - NSI Fistulectomy - - -
8 Prakash 532840 BH 36 M + + - + - - - - + N + - + + - + + + P + + NSI Fistulectomy - - -
9 Siddesh 533615 BH 22 M + + - + - - + - - N - - + + - - - - P + + - Fistulotomy - - -
10 Panchappa 21673 CGH 38 M + + - + - - - - + N + - + - - - - + P + + NSI Fistulectomy - - -
11 Ashoka 22006 CGH 39 M + + - - - - + - - ME - - + + - - - - P + + - Fistulotomy - - -
12 S.S. Patil 534245 BH 27 M + + - - - - + - - ME - - + - - - - + A + + NSI Fistulectomy - - -
Fistulectomy +
13 Rajanna 22197 CGH 48 M - + - + - - + - - N - + + + - + - + L + + NSI - - -
Lat.Sphincterotomy
14 Puttappa 24974 CGH 55 M + + - - - - - - + ME + - + + - - - - P + + NSI Fistulectomy - - -
15 Prakashpurad 537921 BH 28 M + + + - - - - - - N - - + + - + - - P + + NSI Fistulectomy - - -
16 Chandrashekar 535410 BH 31 M + + + + + - - - - N - - + - - - - + A + + TB Fistulectomy - - -
17 Jaimon 538324 BH 31 M - + + + - - + - - N - - + + - - - - L + + NSI Fistulectomy - - -
18 Dayananda 538363 BH 21 M + + - + - - - - + ME + - + - - - - + L + + NSI Fistulectomy - - -
19 Jayappa 29073 CGH 19 M + + - + - - - - + N + - + + - - - - P + + NIS Fistulectomy - - -
Fistulectomy +
20 Nagaraj 541215 BH 42 M - + + + - - + - - N - + + - - - - + P - - NIS Lords Dilatation + - - -
Lat.spincterotomy
21 Gangadharappa 542748 BH 60 M + + - - - - - - + N + - + + - - - + P + + NIS Fistulectomy - - -
22 Yallappa 543387 BH 59 M - + - - - - - - - ME - - + - - - - - P + + - Fistulotomy - - -
23 Halesh 543470 BH 27 M + + + - - - + - - N - - + + - + - + A + + NIS Fistulectomy - - -
24 Venugopal 4353 CGH 37 M + + + + - - - - + ME + - + - - + - + P + + NIS Fistulectomy - - -
25 Girish 4917 CGH 32 M - + + + - - - - + N + - + + - - - - P + + NIS Fistulectomy - - -

85
 Symptoms Past history Inspection Palpation

Lump in neibo.
Exu.Gra.tissue
Operation scar
Swelling burst

Ind. Of mouth
Loc. Raise of
Perianal skin

Ext. opening

Tenderness
Surg.treated
Discharge

Procto: int.
Probe: int.
Re. to anal
Histopath

Swelling

Swelling

of sinus

opening

opening
opened

Fissure
Sl. Complica Recurr-

Fever

temp.

Area
STD
Pain
Name IP No. Hospital Age Sex ological Tretment Death

DM
TB
No. tions ence
exam

26 Nagarathna 544416 BH 39 F - + + + - - - - - N - - + + - + - + P + + NIS Fistulectomy - - -

27 Manjanaik 544894 BH 38 M - + + + - - - - - ME - - + + - - - - L - - NIS Fistulectomy - - -
Fistulectomy+Lat.
28 Ibrahim 545621 BH 26 M + + + + - - - - - N - + + + - - - - A + + N - - -
Shincterotomy
29 Anamulal 6723 CGH 41 M - + + - - - - - - N - - + - - + - + P + + - Fistulotomy - - -
Fistulectomy +
30 Paramma 7800 CGH 58 M - + - + - - + - - ME - + + - - - - - A + + NIS - - -
Haemmloidectoy
31 Shadaksharappa 7802 CGH 30 M - + - + - - - - + N + - + - - + - + P + + NIS Fistulectomy - - -
32 Murigeppa 547272 BH 36 M - + + - - - - - - N - - + + - - - - A + + - Fistulotomy - - -
33 Ibrahim 11130 CGH 12 M - + + + - - - - - N - - + - - - - - P + + - Fistulotomy - - -
34 Keshava 551683 BH 34 M - + + + - - - - - ME - - + - - + - + P + + - Fistulotomy - - -
35 Shobhapatil 52425 BH 32 F - + + + - - + - - N - - + + - - - + P - - NIS Fistulectomy Ur.retn - -
Seton placement+
36 Thippeswamy 554323 BH 36 M - + + + - - - - + ME + - + + - - - + P + + - - - -
Fistulotomy
37 Pushpa 554395 BH 35 F + + + + - - + - - ME - - + + - + - - P + + - Fistulotomy - - -
38 Malakappa 554391 BH 75 M - + + + - - + - - N - - + - - - - + A + + NIS Fistulectomy - - -
39 Prajwal 556687 BH 37 M - + + + - - - - + ME + - + + - + - - P + + - Fistulotomy - - -
Seton placement+
40 Halesh 18918 CGH 27 M + + - - - - + - - N - - + - + - - + A + + - - - -
Fistulotomy
41 Basavarajappa 568673 BH 44 M + + + + - - + - - ME - - + - - - - + P + + NIS Fistulectomy - - -
42 Madukumar 533590 BH 26 M + + + + - - - - + N + - + + - + - - P + + - Fistulotomy - - -
43 Ramappa 20522 CGH 60 M + + + + - - - - + ME + - + - - + - + P + + NIS Fistulectomy - - -
44 Kumar 21765 CGH 34 M - + + + - - + - - N - - + + - - - - L + + NIS Fistulectomy Ur.retn - -
45 Hanumanthappa 23107 CGH 40 M - + + + - - - - - ME - - + + - + - + P + + - Fistulotomy - - -
46 Boraiah 564201 BH 58 M - + - + - - + - - N - - + - - + - - A + + - Fistulotomy - - -
47 Udaykumar 539998 BH 34 M + + + - - - - - - N - - + - + - - - P - - NIS Fistulectomy - - -
48 Ramanaik 27873 CGH 43 M + + + + - - - - - N - - + - + - - + P + + NIS Fistulectomy - - -
Fistulectomy +
49 Shivakumar 24 CGH 25 M + + + + - - - - + ME + + + - + - - + P + + NIS - - -
Haemmloidectoy
50 Ramappa 138 CGH 66 M + + + + - - + - - N - - + - - + - - A + + NIS Fistulectomy - - -

86
KEY TO MASTER CHART :

A : Anterior

BH : Bapuji Hospital

CGH : Chigater i General Hospital

DM : Diabetes Mellitus

F : Female

Hosp : Hospital

L : Lateral

M : Male

ME : Moist and oedematous

N : Normal

NSI : Nonspecific inflammation

P : Posterior

STD : Sexually Transmitted Disease

TB : Tuberculosis

Ur.retn : Urinary retention

+ : Present

- : Absent

87