RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES,

KARNATAKA, BANGALORE

ANNEXURE—II

PROFORMA FOR REGISTRATION OF

SUBJECT FOR DISSERTATION

1. / Name of the Candidate / DR. VEERESH M ANNIGERI
Post Graduate Student
M.S GENERAL SURGERY.
Department of Surgery,
MMC & RI, MYSORE
2. / Name of the Institution / MYSORE MEDICAL COLLEGE &RESEARCH INSTITUTE, MYSORE
3. / Course of Study & Subject / MS in GENERAL SURGERY
4. / Date of admission / 30-05-2012
5. / Title of the Topic:
“SURGICAL TREATMENT MODALITIES IN FISTULA IN ANO”.
6. / BRIEF RESUME OF THE INTENDED WORK:
6.1 NEED FOR THE STUDY:
FISTULA IN ANO is the latin word for a reed, pipe or flute. Goligher s definition of Fistula in surgery is a ‘chronic granulating track connecting two epithelial lined surfaces1. Fistula in Ano form a good majority of treatable benign lesions of the rectum and anal canal . 90% or so of these cases are end results of crypto glandular infections. It denotes the chronic phase of anorectal sepsis and is characterised by chronic purulent drainage or cyclical pain associated with abscess reaccumulation followed by intermittent spontaneous decompression2.
The common pathogenesis however is bursting open of an acute or an inadequately treated anorectal abscess in to perianal skin. Anorectal sepsis can be complicated by a fistula in ano in about 25% of patients during the acute phase of sepsis or within 6 months thereafter. Most fistulas derive from sepsis originating in the anal canal glands at the dentate line. The path of a fistula is determined by the local anatomy; most commonly, they track in the fascial or fatty planes, especially the intersphincteric space between the internal and the external sphincter into the ischiorectal fascia3.
More important factor is significant percent of these diseases persist or recur when the right modality of surgery is not adopted or when the postoperative care is not adequate and so also many patients tend to let their ailment nag them rather than being subject to examination owing to the site of the infection. This treatment of fistula has remained a challenging job for the surgeons. The need for this study is to evaluate the various approaches in surgical techniques as directed by the nature of the fistulas. The ultimate goal of fistula surgery is to eradicate it without disturbing or minimally disturbing the anal sphincter mechanism4. Complications of fistula surgery are myriad and include faecal soilage ,mucus discharge, varying degrees of incontinence , recurrent abscesses and fistula which will be studied in detail.
6.2  REVIEW OF LITERATURE:
This disease is as old as the mankind itself. It was described by Hippocrates as early as 430 BC.He told that the disease was caused by “contusions and tubercles occasioned by rowing or riding on horseback”. He was the first person to advocate the use of Seton in the treatment by “ taking a very slender thread of raw lint , uniting it to five folds of the length of span , and wrapping them round with a horse hair”1.
Anorectal abscess may produce a tract, the orifice of which resembles that of a fistula, but in 60% does not communicate with the anal canal or the rectum.By definition, this is a sinus not a fistula. Thus all the discharging sinuses around the anal canal may be regarded as sinuses until they are proved to be fistula5.
John Aredene who was a surgeon in England in late 14th century and early 15th century who conducted surgeries for Fistula in Ano . He was the first to describe the ‘laying open, method for Anal Fistula. David henry Goodsall (1843-1906) was a surgeon in St Marks Hospital, his best remembered work was accomplished in with Ernest Miles, Diseases of Anus and Rectum. In the chapter on Anal Fistula, the rule is espopused that has eponymously associated with Goodsall.Milligan and Morgan in 1934 stressed the importance of maintaining the integrity of ano rectal ring and anal sphincters while operating a fistula to prevent rectal incontinence and rectal prolapse1.
While post operative pain, time to healing and discharge from hospital affect quality of life, recurrence and incontinence are the most important. As it turns out, there seems to be no major difference between the various techniques used as far as recurrence rates are concerned6

V-Y advancement flap for treatment of fistula-in-ano is easy to perform, healing is rapid, and it appears to be effective in curing fistula-in-ano while preserving both external and internal anal sphincters7.

Core out fistulectomy with anal sphincter reconstruction and primary closure of internal opening is an effective procedure to be considered in the treatment of trans-sphincteric fistula (high type or long tract) with a satisfactory result while preserving both internal and external sphincters.8

Total fistulectomy with simple closure of the internal opening is effective for the long-term closure of complex cryptoglandular fistulas.However, this procedure may affect continence despite its sphincter-sparing quality. Nonetheless, the high success rate in patients with posterior transsphincteric or suprasphincteric fistulas renders this procedure a reasonable option in this subgroup of patients with complex fistulas.9

6.3  OBJECTIVES OF THE STUDY:
1.  To study the efficacy of different modalities of surgical approach for Fistula in ano.
2.  To study the success rate , complications , recurrences in different procedures done for Fistula in ano
7. / MATERIALS AND METHODS
7.1 SOURCE OF DATA:
Primary source of information method will be used on the patients admitted in the Department of General surgery, KR Hospital, MMC & RI, Mysore with symptomatic Fistula in ano will be taken up for study . The study will be conducted during the period of Dec 2012 to Aug 2014.
7.2 METHOD OF COLLECTION OF DATA
All cases before starting , consent will be taken.Purposive sampling method is used to select the cases. Study design will be a comparative study. Each patient after admission will be taken with a proper history, clinical examination including proctoscopy and per rectal examination. Specific investigations like Fistulogram and MRI anorectum done in selected cases only. Each patient will be individualized and treated accordingly. The outcomes will be documented using proforma and followed up for a period of 3 months to 1 year.
SAMPLE SIZE
50 cases with clinically diagnosed symptomatic fistula in ano will be included in the study.
DESIGN OF THE STUDY
Purposive sampling technique is used. It’s a comparative study. Statistical methods used are Descriptive statistics ,Cross tabulation, one way ANOVA, Scheffe`s post hoc test .
Using SPSS for windows(version 20.0)
INCLUSION CRITERIA FOR THE STUDY
Ø  Low Anal Fistula
Ø  High Anal Fistula
EXCLUSION CRITERIA FOR THE STUDY
Ø  Fistula in ano associated with Hemorroids and or Fissure in ano.
Ø  Fistula in ano associated with uncontrolled systemic medical conditions.
Ø  Patient s not not willing for surgery.
7.3 DOES THE STUDY REQUIRE ANY INVESTIGATION OR INTERVENTIONS TO BE CONDUCTED ON PATIENTS OR OTHER HUMANS OR ANIMALS? IF SO DESCRIBE BRIEFLY.
Yes , on Humans only.
7.4 HAS ETHICAL CLEARANCE BEEN OBTAINED FROM ETHICAL COMMITTEE OF YOUR INSTITUTION IN CASE OF 7.3
Yes :. Clearance has been obtained from Ethical Clearances Committee, MMC & RI, Mysore, and Copy has been Enclosed
8. / BIBLIOGRAPHY:
1.  Goligher.J.C ,Surgery of Anus ,Rectum and Colon ,1984, p 174-178
2.  Jenifer K Lowney & James W Fleshman Jr, Beningn disorders of Anorectum, Maingot’s Abdominal Operations, 11th edition 2007, 684
3.  Heidi Nelson, Anus, Sabiston Textbook of Surgery, 19th edition, 2012,1394-1396
4.  Kelli M Bullard Dunn & david A Rothenberger, Colon rectum & Anus, Schwartz’s Principles of Surgery, 9th edition 2010, 1064-65
5.  R. N. Mangual et al, The sphincter preserving perianal fistulectomy: A better alternative, Indian Journal of Surgery, Vol. 66, No. 1, Jan-Feb, 2004, pp. 31-35
6.  Jacob TJ, Perakath B, Keighley MR.B. Surgical intervention for anorectal fistula.Cochrane Database of Systematic Reviews2010, Issue 5. Art. No.: CD006319.
7.  Amin SN,et al,V-Y advancement flap for treatment of fistula-in-ano Dis Colon Rectum. 2003 Apr;46(4):540-3.
8.  Jivapaisarnpong P. Core out fistulectomy, anal sphincter reconstruction and primary repair of internal opening in the treatment of complex anal fistula. J Med Assoc Thai. 2009 May;92(5):638-42.
9.  Tobisch A,et al.Total fistulectomy with simple closure of the internal opening in the management of complex cryptoglandular fistulas: long-term results and functional outcome Dis Colon Rectum. 2012 Jul;55(7):750-5.