RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES

KARNATAKA, BANGLORE

ANNEXURE-II

PROFORMA FOR REGESTRATION OF SUBJECT FOR DISSERTATION

1.  NAME OF THE CANDIDATE : Dr. M. CHINNABHOVI

AND ADDRESS #95, HIG, Group-1

KHB Coloney, Hootagalli

Mysore- 18.

2.  NAME OF THE : Mysore Medical College and Research

INSTITUTION Institute, Mysore.

3.  COURSE OF STUDY AND : M. S. General Surgery

SUBJECT

4.  DATE OF ADMISSION TO : 29.09.2011

THE COURSE

5.  TITLE OF THE TOPIC : A Clinical Study of Fistula-in-ano in

K. R. Hospital, Mysore

6.  BRIEF RESUME OF THE INTENDED STUDY

6.1 Need for the study

Fistula-in-ano constitutes a wide spectrum type, of varied etiology, which is

easily accessible for clinical examination. It is a very common surgical problem with which the

patient presents to the clinician.

Most of the fistulae-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 cryptoglandular infections.

As such, the vast majority of these infections are acute and significant majority is contributed by chronic, low-grade infections, hence pointing to varying etiologies.

Most of these fistulae-in-ano are easy to diagnose with a good source of light, a

proctoscope, and a meticulous digital rectal examination. Despite the case of diagnosis, establishing a cure is problematic on two accounts. Firstly, the site of affection of the disease. Secondly, the significant percent of these diseases persist or recur when the right modality of surgery is not adopted or when the post-operative care is inadequate.

The spectrum of the condition necessitates the importance to find out the most

common cause and therefore better understanding for a focused and specialized management of

the condition.

Management is done in various methods for each type of Fistula-in-ano hence the

necessity to study the ideal modality of management for each type of Fistula-in-ano.

6.2. REVIEW OF LITERATURES

In 1981, in a study by Adams D, kovalcik P. J, an eight year retrospective review of 133

patients with fistula-in-ano, found the majority to be of crypto glandular causation. Many

patients had symptoms for longer than one year. Operation was performed safely under spinal

anesthesia, locating the internal opening in 117 patients, performing a fistulectomy in 80

patients and a fistulotomy in remainder. Associated procedures, such as hemorrhaidectomy,

could be performed safely. Early recurrence of a fistula, spinal headache, bleeding and

temporary incontinence was the complications present in 14 patients. All patients with an early

recurrence had undergone a fistulotomy.1

In 1984, Moti Khubchandani-a comparison of results of treatment of fistula-in-ano,

treated by the author between 1976 and 1982 were reviewed. The results of treatment of 137

consecutive patients with fistula-in-ano are presented. 68 were treated by the ‘lay-open’

technique and 69 by the park’s technique. The two groups being comparable. The results

slightly favor the park’s technique.2

In 2009, a rectrospective cohort study was conducted in patients with a first time peri-

anal abscess who were treated at Kaiser Permanents Los Angeles between 1995 and 2007, 148

patients met inclusion criteria (105 men, 43 women, mean age 43.6 years), During a mean follow

up of 38 months, the cumulative incidence of chronic anal fistula or recurrent sepsis was 36.5%.

Age younger than 40 years significantly increased risk. Patient with diabetic may have

decreased risk compared with non-diabetic patients, gender, smoking history, peri-operative

antibiotic treatment and HIV Status were not risk factor for chronic anal fistula or recurrent

anal sepsis.3

The goal of treatment of fistula-in-ano is eradication of sepsis without sacrificing

continence, Because fistulas tracks encircle variable amount of the sphincter complex. Surgical

treatment is dictated by the location of the internal and external openings and the course of the

fistula. High trans-sphinteric fistulas which encircles a greater amount of muscle are more

safely treated by initial placement of seton.Schwart’s principles of surgery.4 Difficult and persistent high fistula can be treated by sliding flap advancement made up of mucosa, submucosa and circular muscle to cover the internal opening. Diagnostic tests such as pelvic MRI or Endo-rectal ultra-sound and treatment by a specialist is helpful in fistula-in-ano. Sabeston text book of surgery.5

6.3. Aims and objective of the study

1.  To study the incidence of various etiologies of fistulae occurring in the ano-rectal region.

2.  To study the different modes of clinical presentations of these fistula-in-ano.

3.  To study the efficacy of different modalities of surgical approach with reference to

persistence / recurrence of fistulae and sphincteric incontinence following surgery.

7. MATERIALS AND METHODS

7.1. Source of data

The cases who will be admitted in K. R. Hospital, Mysore, attached to Mysore Medical College and Research Institute, Mysore from December 2011 to Novrmber2013 will form the material of this study. During this period cases admitted in various surgical units, selected at random will be studied in detail. This study will be of 50 cases.

7.2. Methods of collection of data

1) Detailed history of the cases.

2) Clinical examination.

3) Routine laboratory investigations.

4) Relevant special investigations.

5) Detailed pre-operative evaluation of the patient and appropriate prepration

for surgery

6) Surgical treatment according to the merit of the case decided by the attending surgeon under suitable anesthesia.

7) Operative findings.

8) Post-operative course, complications and their management.

9) Follow up.

7.3. Inclusion criteria

Fistulae-in-ano, occurring in the ano-rectal region are included in this study.

Exclusion criteria

Fissure-in-ano, sinus and Fistulas occurring in other parts of the body are

excluded in this study

7.4. Does this study require any investigations / intervention to be conducted on patients / humans / animals? If so, please describe briefly.

Yes, on the patients.

Investigations

1)  Blood-Hb%, BT, CT, TC, DC, ESR, RBS

2)  Urine-Albumin, Sugar, Microscopy.

3)  Radiological study-chest X-ray.

4)  ECG

5)  Specific investigation : Fistulogram, Pelvic MRI or endo-rectal ultra sound in selected cases

7.5. Has ethical clearance been obtained from your institution in case of 7.4?

Yes, obtained (copy enclosed)

8.  LIST OF REFERENCES

1) Adams D and Kovaleik P. J. comparison of results of fistulae-in-ano. Surq gynecol.

Obset 1981 Nov: 153(5):731-2

2) Moti Khubchandani comparison of results of fistulae-in-ano,Jour of Royal Society of

Medicine vol: 77, May 1984.369

3) Dis, colon and Rectal Surgery, Kaiser Permanente, Los Angeles, California.2009

Feb; 52(2), 217-21.

4) Stanley M. Goldberg, Santhet Nivatvangs and David, A Rothenbergber-Shwatz

principles of surgery, Edited by Seymour1. Colon Rectum and Anus. Pg 1108.

6) James P. S. Thomson, David C. Sabeston Jr. The text book of surgery, the anus. Pg

1500-1.

7) Factors affecting continence after Fistulotomy for inter-sphincteric fistula-in-ano.

Int. jour. Colorectal Dis.2007. Sept. 22(9)1071-5

8) Bioprosthetic plugs for complex anal fistulas an early experience. Journal. Surg.

Educ: 2007 Jan, 64(1)36-40

9) Long term functional out come and risk factors for recurrence after surgical

treatment fro low and high peri-anal fistulas of crypto-glandular origin. Dis. Colon

Rectum. 2008. Oct 51(10)1475-81

10) Successful sphincter-sparing surgery for all anal fistulas. Dis. Colo-rectum. 2007

Oct. 50(10)1535-9

9. Signature of the Candidate :

10. Remarks of the Guide : Study can be undertaken

11. Name and Designation of :

11.1. Guide : Prof. Dr. B .Jagadish

M. S. (General Surgery)

Professor

Department of Surgery

Mysore Medical College and

Research Institute, Mysore

11.2. Signature of the Guide :

11.3. Head of the Department : Prof. Dr. M. A. Shariff

, Professor and HOD

Department of Surgery

Mysore Medical College and

Research Institute, Mysore

11.4. Signature of Heat of the :

Department

12. Remarks

12.1. Remarks of the Dean and :

Director

12.2. Signature of the Dean and :

Director

ETHICAL COMMITTEE CLEARANCE

1.  TITLE OF THE DISSERTATION : A CLINICAL STUDY OF FISTULA-IN- ANO

2.  NAME OF THE CANDIDATE : Dr. M. CHINNABHOVI

3.  SUBJECT : M. S. GENERAL SURGERY

4.  NAME OF THE GUIDE : PROF. DR. B. JAGADISH

M. S. (GENERAL SURGERY)

PROFESSOR

DEPARTMENT OF SURGERY

MYSORE MEDICAL COLLEGE AND

RESEARCH INSTITUTE, MYSORE

5.  APPROVED / NOT-APPROVED : APPROVED

(IF NOT APPROVED, SUGGESTION)

MEDICAL SUPERINTENDENT PROFESSOR AND HOD

K. R. Hospital, Mysore Department of Surgery

K. R. Hospital, Mysore

MEDICAL SUPREINTENDENT PROFESSOR AND HOD

Cheluvamba Hospital, Mysore Dept. of Medicine

K. R. Hospital, Mysore.

MEDICAL SUPREINTENDENT

PKTB Hospital LAW EXPERT

Mysore

THE DEAN AND DIRECTOR

Mysore Medical College and Research Institute,

Mysore.