E69 Masterclass With Marcus Burnstein On Perianal Abscess And Fistula

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Chad Ball  00:12

Welcome to the Cold Steel surgical podcast with your hosts Ameer Farooq and Chad Ball. We’ve had the absolute privilege of chatting with some amazing Canadian as well as international guests over the past year. While the topics have been broad in range, whether clinical, social or political, our aims for the podcast continue to remain the same. We hope to inspire discussion, creativity, scholarly research and career development in all Canadian surgeons. We hope you enjoy our second season as we continue to highlight some incredible guests, deliver detailed masterclass sessions on a myriad of clinical topics and introduce some fresh new features such as debate and companion formats. We hope you relish the podcast as much as we do.

Ameer Farooq  01:12

While it may not be the most glamorous subject in the world, perianal disease is something every general surgeon will deal with while on call. Dr. Marcus Burnstein is a colorectal surgeon at St. Michael’s Hospital in Toronto, Ontario. In addition to having an absolutely gorgeous radio and podcast voice, Dr. Burnstein has a rigorous organized approach to everything, and particularly, perianal disease and he gives us a masterclass on this in this episode. We’d also like to give a shout out to a great webinar being put on by the Canadian Association of General Surgeons or CAGS on this exact topic. This webinar is happening on April 1 at 7 pm eastern time, head over to the CAGS website for more details and to register. And we put all the links in the show notes as usual. And just a reminder that you can listen to any of the excellent past CAGS webinars on the website as well if you registered to be a CAGS member, and now without further ado, Dr. Burnstein’s masterclass of perianal disease.

Chad Ball  02:19

I think most of us across the country know you certainly by reputation and all the work you’ve done for so long. But for those who may not know you as well, can you tell us where you grew up and what your training pathway looked like.

Marcus Burnstein  02:32

I grew up in Halifax, Nova Scotia, the son of a family doctor, who loved his work, very proud of his role in medicine encouraged his two boys to go into medicine, which we both did. So I didn’t really make a career decision till I was well into medical school, in fact, well into my rotating internship in 1979, when I was lucky enough to have an early rotation on the general surgery service. And I think this is not that unusual also, although certainly not the the most solid reason for picking your career. I like being with the surgeons, I like their style. I like their energy. I like the way they got things done. I just like being around them. And in those days, the competitiveness was much different than it was today. My residents can never believe it when I tell them that. In my rotating internship, I applied to one residency program, General Surgery at one University, the University of Toronto. And I got in, and that’s that’s my entry.

Chad Ball  03:44

Yes, it’s true times have changed, although I’m sure you’re in in any era, wherever you want to go, to be quite honest. You know, I’m curious. You were a program director at least in one place if not to and I were curious what sort of attracted you to that that role and and how you framed it and maybe how it altered your your practice and your your view of surgery over the years? Well, you know, as you probably are becoming increasingly aware of a lot of what happens to your career, what happens to you during your life and your career is more serendipity than planning. If I’ve only become a planning fan later in life, you know, as it’s become more clear to me that failure to plan leaves you sort of at a loss you can end up anywhere but I can’t say that a career in post grad Ed was something I planned but I will give myself this much credit. My first job was at Dalhousie, and one of the Halifax was my hometown but I had trained in Toronto and I had trained at the Lahey clinic in Boston. And when I left the Lahey and returned to Dalhousie University, then then what was called the Victoria General Hospital. One of the things that attracted me to the group there, aside from the opportunity to go home, was that it really looked like a division of general surgery where I could have an important role at an early stage in my career, because it was a quite, it was quite an old division at that time. And it really needed some young surgeons. And so it looked like there would be lots of opportunity for young surgeons to get involved, which I wanted to do, I wanted to get involved in university life I, I caught that bug during my residency at the University of Toronto. And I was right about that. And within within a few years of being at Dalhousie, I had unbelievable opportunities that you wouldn’t get at a much bigger center, or a center with much more competition amongst young surgeons because there was no competition about amongst young surgeons, because there weren’t any. So I got to be a service chief and a director of an undergraduate course. I got to be the program director of general surgery in my third year of practice. I was a Royal College examiner by my fourth year of practice. And these were opportunities that came my way as a result of being one of a few young surgeons in in one of the Royal College regions. And as you may know, and I think this is still true, but certainly at that time, the Royal College wanted regional representation on its committees like examination boards, and etc. So I had opportunities at Dalhousie that I might not have had elsewhere. But I can’t say that post grad Ed was something I planned. They they needed a new younger thinking program director and I was Johnny on the spot.

Ameer Farooq  06:45

Well, certainly, I know that the the residents in Halifax and in Toronto have have loved you and all of your trainees, including myself, even though I was only there with you for a month, I have just absolutely loved being being with you. And we learn in so many different arenas with you. And in particular, one of the things that I’ll always remember from my time on your service, as an elected resident, is actually just watching you in clinic. And you know, having talked to many of your former trainees, both here in Vancouver and in Calgary, everybody remembers that. And we’ll get into this a little bit later when we dive into our clinical topic. But can you talk a bit about how you developed your approach and how you sort of see patients in clinic?

Chad Ball  07:31

Sure, well, thank you for those nice words. And I really appreciate it. I would say that my philosophy in the operating room and the clinic has an underlying theme of failure of omission, or mistakes of omission. So I try to be as regimented and algorithmic in my approach to things that do to me, you know, you’ve operated with me as well. So I think you’ll probably agree with me when I say in the operating room, I pretty much do the same thing. The same way, every time as much as the interoperative findings will allow me I mean, one thing about our business it no two cases are identical. But I try to have the same rhythm and the same step by step approach it because it soothes me, it relaxes me to have a system. And so I have I’m sort of system oriented because it it minimizes my risk of errors of omission. And on the same way in the clinic. So I remember when I was in medical school being in an ophthalmology clinic once and I don’t know if it was one of the nurses of the the ophthalmologists themselves saying every person who walks through these doors, gets a visual acuity tests, regardless of what their ocular complaint may be. I feel the same way about the colorectal clinic, everybody who comes to see me is going to get the same bowel function inquiry. regardless of what their complaint is. If it’s anal itch, if it’s blood per rectum, if it’s anal pain, if it’s change in bowel habits, whatever it is, they’re all going to get the same inquiry, which I can go through with you if you want because it’s, it’s the same thing I do every day. But as you also know, I like to start off, it breaks the ice and as a surgeon, especially a surgeon like myself, who’s lucky enough to have a high percentage of the patients, he sees needing operations. I like to get some stuff right up front. That’s going to be very relevant for me to look back at when it comes time to filling out paperwork for operations or deciding on anesthesia consultation or other pre op consultations. As you know, after introducing myself I usually start off with what are your medications? What are your allergies to medications, and what are your significant past medical problems, operations or times in hospital because it really sets the stage for the issue of if they’re going to need an operation, what other considerations are going to have to be considered. You know, a lot of patients come in, they’re on antiplatelet agents, anticoagulants, they’re on antihypertensives, they’re on a diabetic agent, etc, etc. So all these things start factoring in. And of course, in the past medical history area for colorectal surgeons, hugely important, you know what, what is their obstetrical history and what other abdominal operations they have makes a big difference. Obviously, for those of you who do a lot of MIS work, what that past surgical history is, may be very relevant to the kind of planning you do. So I always start off do you want me to take a breath and let you jump in, or just keep going.

Ameer Farooq  10:36

Well, I just wanted to make, like, comment for our listeners that that may not appreciate what you’re saying, you know, like, it’s one thing to say that you’re you have an organized approach, but you’re not just organized. You’re what’s the word like? It’s rigid? It’s, it’s, it’s like a well-oiled machine like I can, you know, how many years has it been now, since I’ve been in lectures. And I can, I can quote, exactly, you know, when you do your examinations for people in the prone jackknife, you say, may not get this perfect, but it’s pretty close. You know, you say, don’t you’re gonna feel like you’re having a bowel movement. That’s you’re not actually having a bowel movement. It’s just a feeling that the the instrument gives. No sneak attack, I’m going to tell you exactly what you’re what I’m gonna do. Am I right? I’m pretty close. That’s what you say.

Chad Ball  11:24

Yes. Yes. I’m impressed. That’s pretty good. Well, yeah. And and again, you know, I think I’m right to say that the underlying theme is, you know, don’t leave things out. You know, in our business, I mean, I think early in my career, when I first went into practice, I would sometimes leave the operating room and have a little panic attack sometime. Oh, did I do this? Did I do that? Did I remember the crotch stitch? Did I close the mesentery? Did I check for hemostasis in the left upper quadrant, little things and, and I realized I had to know, I don’t know if all surgeons lie like this. But I think this is a very common theme to have these thoughts. And in order to control those negative thoughts, I realized I had to have systems that that were secure. And that would allow me to survive as a surgeon, and not be constantly nervous about having forgotten this or forgotten that. So the more I found that for me, the more I had systems, the more relaxed I got. And the more confident I got that I hadn’t made mistakes, that I hadn’t left things out that I hadn’t forgotten anything. And I’m not saying I have achieved perfection in this regard by any means. But systems help us as we all know.

Ameer Farooq  12:40

Yeah. And I wonder, you know, you’ve been an expert witness for many years now for the college in Ontario. You know, has that impacted sort of that?

Marcus Burnstein  12:53

Yeah. I think so I one thing ab out doing medical legal cases. And by the way, not just for the college, I, most of us, who will give medical legal opinions, I think appropriately, will give them for plaintiffs as well as defend the doctor. So I mean, I will review cases and, and try to be very fair minded, of course, in the process. But I think it’s very instructive when you do these medical legal cases. And I would say they have made me I am much more conscientious documenter of the things my residents and I do. In other words, I try to make sure there is written credits for the work we’re doing. I mean, as you go see a patient, make a note that you saw the patient on what transpired. You know, if you, if you’ve discussed, if you’ve got if you’ve done, if you’ve gone through the consent process, make sure that in addition to the pillars of it was voluntary, it was worth informed the patient had capacity. And in addition to those three pillars, that you add the fourth pillar of contemporaneous documentation. And the other thing I’ve been very careful about as a result of looking at medical legal cases is making sure I always have been clear about the follow up plan, and who’s going to call who. Sometimes patients get lost in the system, the patient thought they were going to get a call, the doctor’s office thought the patient would call them for follow up and time gets, time passes, pathology progresses, and there’s an issue. So I tried to make it very clear and document us where the responsibility was, it may not be completely protected. I mean, we still have a responsibility if if a test result comes back with something relevant. You know, we it’s not good enough to say oh, well, the patient was told to call for follow up. There is some onus on you to ensure that there’s communication but I like to share the responsibility and document that I asked the patient to call me or email me or come to the clinic, etc. and make sure that that’s written down.

Ameer Farooq  15:09

You know, before we dive into our clinical topic, if it’s okay with you, I wanted to highlight something that I just absolutely loved when I was an elective resident on your service, and that is the circle of love. Can you tell us what, what is this circle of love? And, and there is actually there, I think there’s, there’s some real hidden gems in in what this circle of love is, and why you do that.

Chad Ball  15:34

Alright, so just for those of you who have no idea what we’re talking about, so at the end of not every operation by any means, but any operation where I think there was a real team effort, maybe a little bit of hard work along the way, certainly at an anastomosis or to to be blessed. The the scrub nurse, the surgeon, the assistant surgeons, cross hands hold hands, and sort of do a list of sponge count correct. hemostasis satisfactory, doughnuts intact, tested well, no tension, good blood supply, just sort of run a list, a little mini checklist. Now, I’d love to say that I was ahead of my time. And this was really the first checklist. But it all started as a sort of a team spirit, team building kind of exercise because I realized that, you know, when we do those bigger cases, it’s a real team effort. Sometimes it’s a few hours of hard work, maybe even some moments of stress and strain. And when the operation has come to an end, and you’re ready to close, and you’re satisfied that it’s safe, and you’re ready to go, it was just it just gave me a good feeling, to sort of, as a group say, good job. We’re ready to leave. We haven’t forgotten that news gets back to my earlier comments about omission. Fear, it was sort of a last chance to make sure nothing forgotten. So and then it’s sort of caught on I started doing it and residents liked it. I liked it. The nursing staff liked it. And so I do it. I try not to do it after a hemorrhoidectomy or an internal sphincterotomy. I try to do it after, you know a more substantial undertaking. I don’t want to abuse I don’t want to abuse the circle of love. But that’s what that’s all about.

Ameer Farooq  17:31

Oh, that the for all the above reasons. I love that because it was it was your way of breaking down in your mind and double checking things, like you said, running through your checklist. But it also simultaneously brought the team together and made everyone feel really appreciated. So I I don’t I don’t know that I can pull it off like you but but certainly I will always love that and think of that fondly. So.

Marcus Burnstein  17:58

Well, I don’t know, I don’t know if you remember this, but just so your audience will know just how truly nuts I am about checking things. I don’t know if you remember that when I send a resident to pass the circular stapler per anus, to the top of a rectal remnant, they know that when I say fire, they don’t fire. Do you remember that? They say are you sure? I tell every resident who’s passing the stapler for me, when I say fire, don’t. Ask me if I’m sure so I could check again.

Ameer Farooq  18:32

That’s brilliant. That’s absolutely brilliant. And, you know, I think it’s so imperative. You know, how many years have you been doing this, but you still, you still have that same sense and same fastidiousness of just double checking and triple checking. Because it is such a high risk and high full contact kind of sport that we’re, we’re involved with. So thank you again for that experience and, and providing that role modeling. I wanted to dive into this topic, and there were many, many, many topics that we could have delved into on the podcast, but I wanted to talk with you today about perianal disease, because you know, it’s one of those things that, you know, every general surgeon across the country pretty much has to see at least on call, and yet, and a lot of times we’ve kind of say, Oh, well, you know, whatever, it’s an abscess, but there’s certainly some nuance there and, and, and ways that we can improve the care of these patients. So going back to, you know, that systematic approach that you have, if you get a patient referred to clinic, with the complaint of anal pain, how do you sort of approach that patient from it from a history and physical exam perspective?

Chad Ball  19:46

Right. Well, as you know, anal pain is one of the best opening complaints that we can get in the colorectal clinic because the vast majority of patients whose dominant complaints is anal pain are going to have fissure, thrombosed external hemorrhoid or abscess, those three pathologies, which have quite distinctive histories and, of course, very distinctive physical findings. Those three entities account for the great majority of patients with anal pain. So I won’t torture your audience with with the whole history of physical but I mean, you go through the the story about the anal pain and I always try to make sure that after I get those initial bits of meds, allergies past medical history, I get the chief complaint and exactly their words exactly, when, when it started, how it started, and what it is they’ve been experiencing for how long they’ve been experiencing it. And then I go into my routine GI inquiry about bowel habits. But physical examination is for most patients with anal pain pain, the way you’re going to confirm the diagnosis that you’ve made by listening to the patient, because, as is in a lot of medicine, the patient is telling you what’s wrong with them. If you listen carefully enough, you can make the diagnosis in the majority of patients and then you examine to confirm. And with anal pain as the dominant complaint, it’s usually pretty straightforward. Having said that, in my practice, which is a very tertiary practice, I do see more than my fair share of atypical anal pains. And most of those are going to land in either the Pruritis Ani camp, or the levator syndrome camp, which are not easy areas to deal with. But I see a fair bit of those in addition to the more conventional thrombosed external fissure and abscess fistula disease.

Ameer Farooq  21:52

If can you talk a little bit about what levator syndrome is because I think that might be a term that not everyone is familiar with.

Chad Ball  21:58

So levator syndrome is an umbrella term for pelvic pain that is thought there’s no diagnostic test that proves the levator syndrome. So it’s anorectal pelvic pain that’s thought to be arising from the levator muscles probably through tightness or spasm of the levator muscles. And it’s got some variation types. One type that’s well known for example, maybe because the name is so catchy is called Proctalgia fugax which means fleeting anorectal pain, because it’s a very characteristic scenario of often men in their 40s and 50s. Being awakened from sleep with deep severe anorectal pain, lasting anywhere 30 to 30 to 60 minutes or so and spontaneously resolving. So that’s one pattern, the more typical patterns of our chronic pain. And the anorectal examination may show nothing, although in its most classic form, a digital rectal examination with pressure on the levator muscles, often one side more than the other. And for reasons no one understands often more often left side, then both sides, some pelvic floor muscular tenderness when you press on it, when you press on the muscles, and nothing else to find. So it’s it’s to some extent a diagnosis of exclusion. And in some settings, it does deserve some workup to make sure you’re not missing a pelvic lesion or vertebral spinal cord lesion. But mostly, it’s a it’s a diagnose on history and physical examination. And unfortunately, it’s therapy is very frustrating. A lot of the therapy is reassurance to the patient that they’re not nuts that this is a legitimate entity. I have a whole cupboard full of ASCRS produced pamphlets. So there’s a I forget the name of the committee of ASCRS patient communication or something like that. They produce pamphlets on everything from fissure and hemorrhoids and pruritus ani to colonoscopy, colon cancer, diverticular disease, and they have one on levator syndrome or on pelvic pain with a section on levator syndrome. And I give them that that and I’ve talked to them about the nature of the pathology, that it’s real, that they’re not nuts, reassure them that it can spontaneously disappear. And if it’s a daily pain problem, I may give them a trial of amitriptyline, which has been shown to be helpful. And I may involve pelvic floor physiotherapy, which has also been helpful and at least in Toronto, the world of pelvic floor physio has come a long way. It used to be very borderline in my opinion, but now there are physiotherapists who dedicated their work to the pelvic floor and have been very useful in urinary incontinence, fecal incontinence, evacuation disturbance and pelvic pain related to myofascial syndromes and levator syndrome and, and other difficult pelvic pain problems.

Ameer Farooq  25:18

That’s a fantastic overview of something that I think, you know, I really learned about when I came on, elective with you in Toronto. You know, for our trainees and junior residents and perhaps medical students who might be listening to this. I wanted to zero in on perianal abscesses and perianal fistulas. Can you talk a little bit about how a one might classify perianal abscesses? And I’m curious how you sort of think of it? Do you think of it in that classic kind of sort of product classification? Or or do you think of it in a different way?

Marcus Burnstein  25:54

So the abscess itself, I don’t spend a lot of time thinking about so to speak. When I see a patient with an abscess, after a history, physical examination, I make sure I explain to the patient, the nature of the pathology, and that the abscess needs to be drained, but that it’s very often, probably about half the time, only stage one of their management. And I think that’s important for us, it’s important because it’s the right thing to do for the patient, to let them know what’s going on. But it’s important for us so that the patient will understand when our drainage procedure doesn’t solve the problem, that it wasn’t our failure to drain it properly. I see lots of patients with fistulas, who are under the impression that they’ve got a fistula because the original surgeon didn’t do the job properly. And I have to do some, some makeup work on behalf of the original draining doctor that no no that this is part of the natural history of the disease you’ve got. So if you make it clear up front, hopefully, you’ll protect a little bit of that misconception on the patient’s part. So I make sure that that that conversation happens. And as for draining the abscess, I always am on the lookout for the horseshoe element. But if it’s dominantly on one side, or more often than not exclusively on one side, and you’re lucky enough to have an area of fluctuants, then that’s where I will put my local anesthetic because I in my practice, I will invariably try to do these in the clinic setting under local, but there are for patient factor for patient reasons or for disease reasons, settings in which you might want to go to the operating room, for example, bilateral, you know, bilateral involvement might warrant a trip to the operating room. Not always, but often it’s the wise thing to do, or an extremely anxious or an extremely obese patient with a very deep seated abscess. A difficult Crohn’s situation. There are reasons why under local in the clinic or under local plus minus sedation in the emergency department may not be optimal. But as much as possible, I try to stay out of the operating room. It’s just convenient for me and often very suitable for the patients to after an appropriate discussion, local anesthetic, drain the abscess, and I just drain where it’s fluctuant. You know, there’s some texts and authorities who say, make the opening as close to the anal verge as you get it. So you have a shorter fistula. But as you know about fistulas is not their length, that really matters, it’s their height that matters. In other words, its relationship, if the relationship of the tract to the sphincters that determines favourability, or unfavorability of a fistula, and not how long it is. So I don’t take any chances of missing the cavity by airing too much towards the anal verge. I make sure I stay either central over the zone of induration and tenderness or where it’s fluctuant to make sure I hit gold with my incision. And I personally prefer the ellipse technique for ensuring an adequate opening. So I excise an ellipse of skin from over the abscess, not a huge ellipse, but certainly enough to be sure that I’ve provided good drainage. If you make a cruciate, which is also fine. You have to trim away the edges of the cruciate. And I think increasingly it’s come to be recognized. I can’t say that I’m familiar with the research. But again, from attending meetings, and hearing other experts talk, the notion that there’s loculation of these things, I think has been pretty much debunked. And I don’t start mucking around within the cavity in much of a way to break down loculation. Once I’ve hit puss, I’m pretty satisfied and stop there. Yeah, so you mentioned Sir Alan Parks and Sir Alan Parks is from St. Mark’s Hospital in London, I think probably in the 60s, but maybe the 70s but not ancient history. Did a great service to us all by advancing our understanding of the cryptoglandular hypothesis of abscess fistula disease and describing fistulas by their relationship to the sphincter as intersphinteric, transphinteric, suprasphinteric and the very unusual extrasphinteric where the internal opening is not at the dentate line within the anal canal, but it is a rectal internal opening from you know if fish bone, chicken bone, anastomotic leak, diverticulitis, Crohn’s, radiation, you know, some other pathology that has led to a transmural injury above the anus with tracking owed onto the skin, usually the skin of the buttock. So, intersphinteric, transphinteric, suprasphinteric and the the unusual extrasphinteric are the classic Park’s construct and that’s very useful to have in in your, in your thinking about fistula but when it comes to managing fistula, it’s not nearly as useful as a system that says, suitable for fistulotomy not suitable for fistulotomy because as the practitioner, that’s what you really want to know about a fistula. Can I do a fistulotomy? Or or is it unsafe to do a fistulotomy and that speaks to whether the fistula is favorable or unfavorable. And what determines favourability or unfavorability about a fistula is like everything else in our business, disease factors and patient factors. So I always say to residents, there are fistulas that in one patient are a simple fistulotomy case, same fistula in another patient absolutely cannot do a fistulotomy in this setting. Why? Well, obviously if one patient has flatus incontinence, a tendency to frequent loose stools, already wears a pad because of seepage issues. I don’t care what fistula that patient has, that’s an ugly fistula that will be unsuited to fistulotomy where in another patient with a form stool every day, perfect continence, nice long anal canal, no previous anal surgery, etc, etc. simple fistulotomy case. So what we really want to know as practitioners is, can I do a fistulotomy or can I not do a fistulotomy. Of course, this speaks to the competing goals of fistula management, which are in direct competition with each other, which is cure the fistula, preserve continence, and most patients will call preserve continence number one, cure fistula number two and as a result, we we do tend to err on the side of continence preservation and fail to do fistulotomy in settings where fistula to me may actually be the right, ultimate choice to make. But But I support that in quotation marks, err err of, of not doing a fistulotomy when a fistulotomy may actually represent the best balance of risks and benefits. I support that because patients will usually rank continence preservation above curing the fistule. That was a long answer. Sorry about that.

Ameer Farooq  33:23

No, that’s brilliant. And I think one of one of the your secrets or one of the things that I think everybody enjoys hearing from you is just that this exact way of framing questions because you’re absolutely right, that is what really matters is trying to figure out, can I can I do a fistulotomy this person or not?

Chad Ball  33:44

100%. 100%. Yeah, because in fact, one could look at Park’s classification and while it’s very helpful in helping us understand what’s going on in this disease, it doesn’t really tell us what to do. I mean, there are transphincterics that are chip shots and there are transphincterics you’d be crazy to lay open and so it it isn’t it is helpful but it is not a sufficient guide to management.

Ameer Farooq  34:14

Is there anything special that you do in terms of setup, positioning, instruments, whether you’re doing this in the in the clinic, or in the operating room?

Chad Ball  34:34

So it for incision and drainage I it’s not a terribly sophisticated effort efforts, abscess fistula management in the operating room. So the so the next stage after the primary goal of draining the local infection or in controlling the infection once that goal has been achieved and you’ve moved on to fistula stage, that’s a whole different. My scrub nursing team, it will say about me, my my setup for anal fistula surgery is more sophisticated than for coronary bypass. I mean I, I have a big set with all my toys ready to deploy at any moment that I might need them. But but abscess drainage is at the other end of the spectrum, I basically have a syringe with half percent or 1% xylocaine with epinephrine with one in 100 and 200,000 epinephrine. So I like that for these procedures, not only because the tissues are very injected and the xylocaine without epi tends to diffuse quite quickly, but also to minimize a little bit of bleeding from the wound edge because these patients are going to go home right after the drainage. And I’m not a packer by the way, I should have mentioned that where we talked earlier, I don’t pack the cavity. And until recently, I didn’t routinely use antibiotics but as you may know, there’s been some increasing interest. I’m not sure I buy it completely. But the meta analysis that was done did support the notion that the use of antibiotics at the time of abscess drainage does decrease the rate of fistula formation. I say maybe it’s a that but I think it’s reasonable. Traditionally, I only added antibiotics in diabetics, and patients I thought were immunosuppressed. Or when I thought there was excessive spreading cellulitis around the abscess. Now I’m being more liberal in my use of antibiotics, but I don’t pack the cavity. And so the abscess drainage is a particularly unsophisticated effort a little prep, local anesthesia, ellipses skin from over the abscess, and addressing home on analgesia, early follow up because there is failure to drain adequately and residual abscess is not that rare. So I tried to see the patient within a week or so and make sure they have my contact information. Send them home with a little pamphlet about abscess, fistula disease. And so when I do it in the clinic, it’s a pretty unsophisticated effort. If I take the patient to the operating room, oh, and you asked me about positioning, so I had the I consider good fortune to train in the American system and the American proctologic system. And they are very much a prone jackknife world. No colorectal surgeon, with his soul south of the border doesn’t have at least one procto table, the chest position table in their practice, and I trained in that system. And now as you know, having worked with me, I see everybody on a procto table. I just find it a much better examination of the anal rectum your your hands are free, you don’t need one hand, lifting up one buttock, you’re not bending over quite the same way lighting is easier. Any drainage within the anorectum drains away from you not owed at you. And it just and patients find it tolerable I mean, there are some patients who might prefer left lateral but most studies that have looked at this, they find that patients have no objection to knee chest and I just find it much easier examination of the anorectum and therefore that’s the position in which I’m usually draining abscesses. Now in the operating room, I’m also very liberal with my prone jackknife positioning and some surgeons do even for abscess fistula disease place the patient prone jackknife, but for abscess fistula disease, I usually I’m in the operating room do these cases in lithotomy unless I am anticipating a more sophisticated approach to the fistula such as an endoanal advancement flap or a lift procedure. Those those I do prone.

Ameer Farooq  39:04

Gotcha. That makes a lot of sense. Do you ever try to look for a fistula at the time of your index drainage?

Chad Ball  39:11

Yeah, so if I take the patient, so let me back up and say that I think the most classic abscess that I would take to the operating room rather than do anything in the emerge or in my clinic is the patient in whom I think there’s an intersphinteric abscess. So once upon a time, that was the patient where the history sounded like abscess. They were too tender to fully examine. And they didn’t have the competing diagnoses of fissure or thrombosed external hemorrhoid. And so you made the diagnosis. Well, this must be either an oculta abscess in the in a big buttock, deep in the ischioanal fossa, or more likely an intersphinteric and you go to the operating room for EUA. Nowadays with more ready availability of MR and CT I think that if it was available, you could even consider imaging such a patient and get more guidance to your EUA. But traditionally that patient would go direct to EUA and I think that’s acceptable. And at EUA with digital examination you can usually feel the intersphinteric abscess. I would usually needle the suspected space through the in the intersphinteric groove. In other words on the spot through the skin into the intersphinteric space where I think the abscess is. Confirm the abscess and then divide the anoderm, add a little bit of skin over the abscess. And try to include the gland of origin. Now sometimes that’s obvious, because you can see some purulent discharge and you can put a hooked probe right into the abscess cavity, and sometimes not. And you’re hoping that you’re laying open of the overlying anoderm internal sphincter and into the abscess cavity, got the gland of origin, in other words, primary fistulotomy, but that’s really the only common primary fistulotomy that I would consider. Now, we briefly use that horrible word horseshoe earlier in our discussion and that’s another patients who I would take to the operating room. If if there’s bilateral ischioanal fossa pus, on either obvious physical examination or on imaging, then that patient almost certainly will have a posterior midline internal opening at the level of the dentate line with a tract into the deep postanal space. So above the anococcygeal ligament and under the levator muscles, and that space is bounded laterally by the ischioanal fossa. So when a posterior midline crypt gets infected, and the infection tracks under the deep postanal space, it has readily it has ready access left and right to the ischioanal spaces creating the horseshoe problem. And if you take that patient to the operating room and put in a Hill Ferguson anoscope, looking within the anal canal for an internal opening, you will often see the criminal gland at the dentate line and the posterior midline. And what I would do there is drop a hooked probe or allow her into the internal opening, which takes me right into the deep postanal space. I would open over the tip of my louer or probe in front of the coccyx and dissect through the anal coccygeal ligament into the deep postanal space, hit the cavity of the deep postanal space and put a vessel loop seton into that newly created fistula. Now in addition, I would drain through what are often called counter incisions. I don’t know why you need the word counter. I would make incisions over the bilateral abscesses on the ischioanal fossa and usually put a bigger drain maybe a quarter inch Penrose between my external opening. So one seton in the posterior midline and two drains between the posterior midline external opening and the two lateral external openings. This is obviously much better with slides but I hope you could follow what I’m saying. And then my hope for that miserable situation is to convert the horseshoe into a transsphincteric posterior midline fistula. Let the side branches dry up, get those vessel those drains a quarter inch Penrose or vessel loops off that are off to the side, get them out, leaving the seton in place. Hope that the lateral extensions will dry up leaving you with an ugly transsphincteric posterior midline fistula to deal with at a later date. Yeah, it was that is that followable?

Ameer Farooq  44:05

That totally makes sense. And in fact, that’s probably one of the clear explanations that I’ve heard because you know, not not that I would know anything about this because our oral exam got canceled this year. But But you know, it seems to be a common oral board kind of question for the Royal College exam is is how to deal with this the the horseshoe abscess and so yes, you know, I like that concept that you what you’re what you’re trying to do is convert that problem into something that you can sort of deal with a bit more easily, readily and easily at a later date.

Chad Ball  44:40

Well, I’ll tell you from my money, this question is passed at the general surgical and colorectal surgical level in the acute phase. Once you acknowledge the deep postanal space needs to be drained also. So how you do it whether you leave drains don’t leave drains, but for the for the patient who gets to the operating room, you should be anticipating that there’s a component of this infection in the deep postanal space and this space also has to be drained. To get the best results.

Ameer Farooq  45:18

I’m sure you get people that have had multiple attempts at fistulotomy or drainage procedures, when you when you get that patient that’s had multiple attempts and multiple sort of complicated, potentially fistulas. How do you sort of think about that patient? Is there anything that goes through your mind differently when you’re trying to treat that patient?

Chad Ball  45:38

Definitely. So first of all, I the first thing I say to say it to myself is I’m not as good as I think I am. Stay humble. If others have had trouble, there’s probably a very good reason they’ve had trouble and you’re going to have trouble too. So don’t just assume because you see a lot of fistulas that you got, you got the answers to everything. So I give myself a little “Get Real” talk, and make sure that I remain humble and acknowledge that I’m probably dealing with a difficult situation. So I give myself a little pep talk, then, I think, has there been adequate workup, so some patients need a Crohn’s workup. Some patients need MRI. And I start thinking, is this a scenario where more than just my history and physical and add another trip to the operating room for EUA is the way to go? Or do we need to be a little more circumspect and take a step back and look at other issues, underlying bowel disease, for example, or atypical abscess fistula that may benefit from some imaging. So I take I think of those things, but I’ll tell you, and again, not not to throw stones at my colleagues, but one of the things I think about, especially the patients had a number of surgeons in their past is the possibility of an iatrogenic component. Because when patients have had a number of operations, there is the possibility that they have their original pathology. And they have added added pathology as a result of previous operative misadventure. And one of the first things I do when I take a patient of the operating room for management of a fistula that has been previously especially previously multiply operated on is plug the internal opening that’s obvious, and reinject the external opening to look for whether or not the obvious internal opening is actually the the real or and or only internal opening. Because I over the years I’ve been sent patients with setons in place, and I do that little maneuver, I take a dental pledget, plug the the internal opening with the seton, inject the external opening with the seton and as with my favorite, as you know, was milk but you can use hydrogen peroxide, which is probably even more popula, reinject the external opening. And sure enough, when the seton is exiting in within the anal canal is not the only internal opening the patient’s got, in other words, the seton’s iatrogenic, and the original internal opening was missed. And now you’ve got a very difficult problem that you can imagine that without finding that original internal opening, no matter what you do to the seton fistula it will not solve the patient’s problem.

Ameer Farooq  48:26

Right, like, you know, you almost got this sort of why sort of looking fistula or something like that that’s been created. And if you don’t solve that original branch, then then.

Marcus Burnstein  48:35

Right, right, right.

Ameer Farooq  48:36

Okay, so, so just walk me, you know, you’ve already talked a little bit that you get them in the prone position. In terms of, you know, retractor systems, I know, you’ve got all your toys that are there, sort of some go to things that you you like to use in particular situations.

Marcus Burnstein  48:54

So so I always try to remind the residents, who are usually doing the prep for me. And of course, prep is a bit of a show when it comes to anal operations. But I do prep and drape that treat the anus, like it’s a delicate piece of crystal, because when I approach the anus, I approach very cautiously because I don’t want any cracks or tears to be the result of, I want to know what’s there in its native state, so to speak, and not produced by us. So I prep very gently, and I approach the anus very gently, I gently separate the buttocks and have a look. Because I want to know what what is there before I started stretching the skin or sticking in retractors, etc. Because sometimes you’ll put in a even a small anoscope, and you’ll see a crack and you’ll say, Oh, did I just make that with the retractor? Or is this part of the patient’s pathology? So I approach very cautiously I want to make sure I I see what is there and not caused by me. So, I wear a headlight, I have very good lighting, I have lots of assistance. And you know, we go through our checklist etc. Most of these patients for abscess fistula problems are going to be in lithotomy position. So I sneak up and I take a look around. Now if there is an obvious external opening, usually what the first thing, the first thing I’ll do is palpate around the external opening, because very often as you know, there’ll be a ropey tract from the external opening towards the anal canal anal verge. And that supports the presence of an underlying fistula. You know, if it’s a deeper fistula, you may not have that ropey tract sensation, but many fistulas will. I always like it when I feel it because it suggests to me this will be a more favorable fistula and more amenable to the possibility of fistulotomy. Patient factors, of course have to be taken into consideration but just thinking fistula factors, I feel that rope, that’s a good sign. Then I’ll gently palpate well I’ll separate the buttocks and look within the anal canal because not all as you know not all fistulas are crypto glandular, some might arise from fissures. So especially when the external opening is in the midline and close to the verge. I always wonder is this a fistula complicating fissure? And I hopefully will have thought about that in the clinic and talk to the patient about the possibility that this is just a subcutaneous fistula arising from a chronic anal fissure that we should also add a lateral internal sphincterotomy to cure your fissure. So I do have that conversation in the clinic in advance when I’ve been smart enough to think this external opening in this position with this patient who’s having some painful defecation and doesn’t allow for a very good anorectal exam may have a fistula arising from fissure and not arising from crypto glandular disease. So before I stick a finger and I will gently separate the buttocks, have a look. Then I will usually do a well lubricated digital exam very feeling very gently around and then more firmly around seeing if I can feel the internal opening which is often palpable but not always. And then I’ll usually start with the small Hill Ferguson, it’s often not big enough, especially if the patient’s got a lot of hemorrhoidal cushion in there. It often not big enough to expose well for you, but I like to look first with the instrument that doesn’t cause any stretch related injury. And that it’ll also give me a good sense when I’ve done my digital input of the small Hill Ferguson, if I can then put in the large Hill Ferguson because a truism of anal surgery is you cannot have a one size fits all attitude. And what of course I mean by that is you can’t use the same retractors and everybody. Not all anuses are created equal. And some tiny people if you just start shoving in a bigger instruments, you will get some stretch injury or potentially can get some stretch injury. So I tried to be cognizant of that one size fits all issue. But most patients can tolerate the small and the large Hill Ferguson, but sometimes some gentle effacement of the anus is a good idea before you advance the large Hill Ferguson. And as you know, I often say to junior residents, what’s the difference between effacement and dilatation? And when they look at me like they don’t know I tell them the answer is attitude. Effacement is gentle. I don’t like the word dilate the anus. Gently efface the anus is more my approach to getting the large Hill Ferguson into place. And then quadrant by quadrant inspection. Of course, good souls rule is a reasonable guide. It’s not it’s it’s a rule that is often broken. But, you know, usually thinking along good science good souls lines, you can sort of focus on where you think the opening is most likely to be. My next step is actually not to probe very aggressively at the external opening. If the probe goes in the external opening, and I use a very blunt probe, and if it just falls along the full length of the track right into the anal canal at the suspect site of internal opening, that’s great, but usually I’ll just put it in a little bit. If it starts to meet a little resistance I quit immediately and go to my injection technique and inject while while plugging over the catheter that’s in the external opening to create a little pressure. I inject a jet of milk I like milk but peroxides good while looking within the anal canal and this is the best way to make sure you get the true internal opening no risk of false passage, at least at this not by the injection at least. So inject, inject the external opening while watching at the suspect areas in the anal canal. And then having identified the internal opening with some luck, you can then do the probing. Once you’ve probed the full length of the fistula, then you can do what really counts, which is a definition of the relationship between the fistula and the sphincter, because that’s what you’re there to do is define the anatomy of the fistula, find the external opening, find the internal opening, find the full length of the tracks, and the relationship between the tract and the muscles. And then knowing the relationship between the tracts and the muscles, and knowing your patients bowel habits and continence and the discussion you had with them about risks, benefits, etc, you can then make a decision. This is a fistulotomy case, or this is not a fistulotomy case. If it’s a fistulotomy case away you go, if it’s an a fistulotomy case, you tunnel us a vessel loop seton into place and tie it loosely with the idea that you’re going to come back another day to do a sphincter sparing operation, like lift or flap. But I’m not a big fan of lift or flap. The only operation I’m a fan of is fistulotomy, it’s the only operation with in my opinion, high success rates. The other operations I think, have low success rates, but the tremendous advantage of being more sphincter friendly, so that they have a role to play. I’m not tossing the tossing the moat of my armamentarium. Just because in my hands, they have a high failure rate. But I believe there’s only one good operation for anal fistula. That’s fistulotomy. And the others are second tier that we need to pull out from time to time. And I had no success with the infill procedures like plugs and glues. And I think biologically, they make no sense. And I’m not surprised that their failure rates are pretty much prohibitive.

Ameer Farooq  56:42

You know, the perennial question is how much sphincter can you actually divide? And obviously, this is clearly an individualized decision. But how do you go about, you know, thinking about that and figuring out? Can I do a shot of me or not?

Marcus Burnstein  56:59

Right? So, you remind me of a question I used to ask junior residents, I’d say to them, how much sphincter muscle can you safely divide? And they’d hem and they’d haw and they’d, you know, 1/3, one half, 25%? And I say no, the answer is none. There is no safe amount of sphincter you can divide. Every amount of sphincter you divide is relatively unsafe. And and I, I’m sort of teasing the junior resident with that not very sophisticated question. But the points legitimate, and that is any amount of sphincter division carries some risks. So I keep that in mind. There’s no safe division of muscle, it’s a matter of relative safety, and not complete safety. Because as you know, even the little internal sphincterotomy, the seven, eight millimeter internal sphincterotomy that we do for chronic anal fissure, one of my favorite operations of all time, with a tremendous risk benefit ratio, very low risk, very successful operation, but not zero risk. Even that operation has a small risk of flatus incontinence, true incontinence i think is virtually unheard of. But But minor flatus incontinence as you know, depending on the studies you read, is not an insignificant risk with even that minimal, a division of only one of the components. So the point I’m making all division of sphincter muscle carries some risk. And so it’s a judgment and as I’ve alluded to earlier in this conversation, the the fistula is only one piece of the puzzle, the patient factor side is at least equally important. So we all know that lots of good studies on this, women who’ve had vaginal deliveries have subclinical sphincter injuries in the 20 to 30% range, as demonstrated by endosonography. So these are patients who are living much closer to the cliff, if you do a functional inquiry of those women and ask them about their bowel habits and their flatus incontinence etc, you may get nothing but reassuring answers, but a sphincterotomy but a fistulotomy in that population may tip them over the edge. So the patient factors like obstetrical history or the patient factors like a tendency to irritable bowel when when they’re irritable bowels active three or four loose stools per day. That population is a different population from the rock solid one form stool per day perfect continence. And of course, there are local anatomic variables. Men’s sphincter is much bigger than female sphincter and it’s not just about how much muscle you cut. It’s also about how much muscle you leave. So that’s why the anterior fistule in a woman is a notoriously so treacherous fistula. You look at the fistula and say, oh, I’m cutting so little muscle. This is this surely is the safest fistulotomy. But the anterior fistule in a woman, you may cut very little, but that’s very little, maybe 30 40% of the amount of sphincter at that point in the circumference of the sphincter. So so many things to think about fistula factors, patient factors, the patient factors, their past history, anal surgery and other life events, bowel habits, as well as the, the details of the fistula. So lots to think about. So I don’t have a number, like 30% 50%, etc, in terms of sector, but let’s say all other factors are favorable. And the only determinant of whether I’m going to do a fistulotomy or not, is how much muscle is above and how much muscle is below. My fistulotomies are always going to be in fistulas that are in the lower half. So many people won’t even go as high as half. But if I’m, if I’m getting into the I think I’m only leaving half the sphincter, I’m well beyond my comfort zone, lower third, I’m comfortable. So you could start to think of the sphincter the same way we think about rectal cancer, you know, a lot of people think of rectal cancer I certainly do is the good, the bad, the ugly. You can think of fistulas purely in the looking at the level of official the same way, lower third, usually good, upper third, always ugly, no way it’s gonna be a fistulotomy. And middle third, that’s the danger zone. Some you might do a fistulotomy, some you might not. Did that help?

Ameer Farooq  1:01:47

That was that was brilliant. And, you know, the dangers of having, you know, a colorectal fellow and a master colorectal surgeon is that we could go all day and ask you, but I could ask you so many different questions, but maybe sort of in closing, what I’ll ask you about is sort of a perennial topic, which is setons.

Chad Ball  1:02:06

Oh, yes.

Ameer Farooq  1:02:06

Do you? What do you use? Do you use a cutting? Do you use a draining? And then the second part is if you’re doing if you’re if you’re putting in a seton, how long do you leave it in? Yes. You ever get that as a primary treatment? You know, in Calgary, that’s certainly something that people do.

Marcus Burnstein  1:02:22

Yes. Yeah, I love the question. And, but I suspect you will be just as frustrated at the end of my rambling, as you may be now about seton, it’s, it’s a tricky business. So one of the first things I like to tell students about seton, is that there are four potential roles for the seton. There’s the role of acting as a drain, of marking the anatomy, of causing fibrosis, and of cutting through the muscle that contained tissues. So drain, mark anatomy, cause fibrosis and cuts and of those four potential roles, there’s one role that I use almost exclusively, and that’s the drain role. Mostly, I place setons to drain the, the fistula to try to move some, let me back up and say as we know, abscess fistula is a spectrum. And in terms of treating the fistula, especially with one of the more sophisticated approaches not so critical if you’re doing a fistulotomy, but if you’re gonna do a lift or a flap, you want the fistule to be as pure a fistula with as little cavitation, chain of lakes, residual abscess cavities as possible. And the best way to get the movement from the abscess phase to the pure fistula phase is to provide drainage and let a nice mature tract evolve around the drain. So the main reason I put setons in is I’ve taken the patient of the operating room for management of abscess fistule disease, probably a patient at the fistula end of the spectrum, I get there. I don’t like the fistula I found from a simple fistulotomy perspective, I’m too nervous about continence risk. Or I’m uncertain that I understand this fistula as well as I’d like there’s too much possum capitation it’s not suitable for anything at the moment. And I’ll put a vessel loop drain and so I like to use the silastic vessel loops the from the vascular surgeons world. I use the biggest one that I can get my hands on. I tunnel it in. I usually use a blood tip probe that has a little eyelid opening at the end that’s just big enough to put the tip of the seton in so then when I pull the the probe through the fistula, it drags the vessel loop into position, I overlap it so that it’s it’s loose on the skin, put a couple of silk ties over the overlap dens, trim the ends. And so it sits there as a fairly loose rubber band within the fistula. So, my main use of fistula of seton is to provide drainage. Now, having put it into provide drainage, I also get the mark the anatomy option, which is sometimes it’s an obvious call, this patient will never get a fistulotomy, this fistula is in the upper third of a sphincter, maybe even suprasphincteric no way fistulotomy is on the cards. And the mark anatomy piece isn’t really that helpful. But sometimes in the middle third, in the operating room, especially if it’s still a little pussy a little indurated a little hard to tell what’s going on. If you examine that patient in the clinic, some months, some weeks, two months later, finger in the anal canal, squeeze relax, squeeze relax while holding on to the seton, you may get a better sense of how much anorectal ring and upper sphincter lies above the internal opening, how much lies below and patient factors taken into consideration whether a fistulotomy the only operation I like might be an option for that patient. So you’ve gotten the drainage effect you’ve gotten the mark the anatomy effect. As for cutting and fibrosis, I’m not such a big fan. I used to do so called staged fistulotomy wary and I do a partial I’d put in a heavy silk type seton to create some fibrosis, cut the skin subcutaneous tissue, maybe some of the muscle at the top some of the muscle at the bottom but leave a good ring of muscle tie it tight silk, O-silk that braided suture onto the onto the muscle with a nice long tag of the suture line and multiple multiple dots big long tag that the patient can jiggly saw with and slowly so called lower the fistula or slowly cut through or take the patient back to the operating room at intervals and divide and complete the fistulotomy either in one more stage or a few more stages. The notion being that the slower division of the muscle with the buildup of scar reduces the size of the gap of the sphincter created by the fistulotomy and decreases the functional consequences of that muscle cut, namely incontinence. But I’m less convinced by the literature or by my own experience, that that quite miserable experience for the patient is actually worth it. So that staged fistulotomy approach or cutting seton approach is not something I’ve embraced. Now I’m getting near the end because there’s one other thing I will sometimes do with setons, which is just leave them. So put them in, follow up with the patient. If they’re tolerating the seton well, if the seton has achieved the goal of improved comfort, which was the main reason to place it that make them more comfortable because of less undrained infection, the amount of discharge is tolerable, sometimes long term seton, especially in the Crohn’s population is a legitimate option. And also and I would say there’s groups that have had more success with this than I have personally had but I use it occasionally which is leave the seton in for three months, let them nice mature. So, this is all hypothetically, but the idea being leave the seton in for three months let a nice mature tract form along the the edges of the seton pull the seton out and now that a nice mature tract is there, there should be minimal discomfort minimal risk of recurrent abscess, the patient still has a fistula and may still have to put up with some minor discharge, but they may find that they have a tolerable situation and from the perspective of a very complex fistula, they may say this is tolerable. So those are the main ways I have setons in my in my bag of tricks. One last little comment with respect to the Crohn’s population, although I will often use long term seton in this population nowadays with the biologic agents. If they have a gastroenterologist, who is going to give them a biologic agent once their septic phase is under control, if I put one or multiple setons and they go off to their GI guy get their HUMIRA, Remicade, etc. infusion started, and things are going well, after one and two and after one or two infusions, and the drying up of local infection, I will often remove the setons and see how they do because those patients will usually do well with that approach.

Ameer Farooq  1:10:25

You’ve been listening to Cold Steel, the official podcast of the Canadian Journal of Surgery. If you’ve liked what you’ve been listening to, please leave us a review on iTunes. We’d love to hear your comments and feedback. So feel free to email us at podcast.cjs@gmail.com or connect with us on Twitter @CanJSurg. Thanks again.