Laser treatment for anal fistulas: what are the pitfalls?

The risk factors for failure and recurrence of LIFT procedure for fistula in ano

Objectives

Fistula in ano (FIA) is a common anorectal problem. There are several techniques that have been used for treatment; however, all of them carry risks of recurrence and incontinence. Ligation intersphincteric fistula tract (LIFT) is a type of treatment with a promising result of preserving the anal sphincter function. This study aimed to evaluate the outcome and risk factor of LIFT failure and to demonstrate the pattern of recurrence. The research funding was supported by Rajavithi Hospital.

Material and Methods

From January 2015 to January 2020, there were 250 cases of fistula in ano operations. A total of 148 patients underwent LIFT operation. The patients' average age was 39.72 ± 10.55 years and the average follow-up period was 111.86 ± 79.73 days. The average time to diagnose the recurrence was 99.12 ± 30.08 days. In addition, average time to perform a surgery after the diganosis was 64.67 ± 25.76 days. The study's analyses used data on age, sex, type of fistula, operative intervention, healing time, reinterventions, and recurrence.

Results

There were 22.97% of recurrence among 148 LIFT patients. Half of the patients who underwent the operation had a preoperative imaging study with MRI or endoanal ultrasonography in the first time due to the complexity of the disease. Factors associated with operation failure were collection, fistula tract size more than 5 millimeters, and the failure of ligating the tract in one attempt.

Conclusion

LIFT procedure is one of the several sphincter saving procedures to treat FIA. Recurrence is related with the complexity of the disease. Most of the recurrence is diseases that are easier to treat, such as performing a re-operation or fistulotomy.

Laser ablation of anal fistulae: a 6-year experience in a tertiary teaching hospital in Malaysia

BACKGROUND

Several studies have investigated the role of laser ablation of anal fistulae in the European setting. However, long-term follow-up results following laser fistula ablations are not widely investigated and no study was performed in the Asia-Pacific, a region with a distinctive prevalence of tuberculosis. The primary objective of this study is to report a single-centre experience with laser ablation of anal fistulae in Malaysia over a period of 6 years.

METHOD

This was a retrospective observational study assessing the outcomes following 70 laser ablations of anal fistulae from February 2014 till December 2019. All cases were assessed using endoanal ultrasound. The laser ablation procedures were performed using laser systems and fibres from Endoteq Medizinische Laser GmBH, Germany, and Biolitec AG, Jena, Germany. Laser fibres were introduced into the fistula tract and laser energy was emitted radially in continuous mode when activated during the procedure. Pre-defined post-procedural outcomes (primary healing, healing failure or recurrence) were recorded as either present or absent during subsequent follow-up appointments and the data was analysed.

RESULTS

Over a median follow-up period of 10 months, primary healing was reported following 42 procedures (60.0%). Healing failure was reported following 28 procedures (40.0%) whilst recurrence was seen after 16 procedures (22.86%). No new cases of incontinence were reported following the procedure.

CONCLUSION

The reported primary healing rate following laser ablation of anal fistulae in this study appears consistent with existing literature published by other international centres. The most apparent clinical advantage of this procedure is sphincter-function preservation. However, the primary healing rate after isolated laser fistula ablation is still suboptimal. Judicious patient selection and application in anal fistulae with suitable characteristics could potentially improve the post-procedural outcomes.

Comprehensive literature review of the applications of surgical laser in benign anal conditions

Surgery for benign anal conditions is a common practice and is usually followed by a good outcome. The present review aimed to summarize the emergence and evolution of different laser techniques used for the treatment of benign anal conditions and report their current outcome. PubMed and Scopus were searched for studies that assessed the use of laser in benign anal conditions. Anal conditions reviewed were hemorrhoids, anal fistula, anal warts, anal stenosis, and anal fissure. The full text of the studies retrieved was summarized in a narrative and tabular form. Laser techniques used for the treatment of hemorrhoidal disease were laser open hemorrhoidectomy, laser hemorrhoidoplasty, and Doppler-guided hemorrhoidal laser dearterialization. Resolution of hemorrhoidal symptoms was reported in 72-100% of patients after laser treatment. YAG laser, fistula laser closure, and photodynamic therapy have been used for the treatment of anal fistula with success rates ranging from 20 to 92.6%. Anal warts can be treated with photodynamic therapy with or without YAG or CO² laser with a success rate up to 88%. A few studies reported the use of laser in the treatment of chronic anal fissure and anal stenosis. The use of laser in the treatment of benign anal conditions is associated with promising outcomes. Laser was most assessed in hemorrhoidal disease and anal fistula and showed more consistent success rates with hemorrhoidal disease than with anal fistula. Preliminary reports assessed the outcome of laser treatment in other conditions as anal fissure and warts with acceptable outcomes.

Emerging Data on Fistula Laser Closure (FiLaC) for the Treatment of Perianal Fistulas; Patient Selection and Outcomes

Fistula laser closure (FiLaC) is a relatively new sphincter-sparing technique in fistula surgery that was initially reported in 2011. It involves the radial dissipation of laser energy in the fistula tract and, through a combination of coagulation and shrinkage of the tract, is proposed to result in progressive sealing of fistulas. Early studies have suggested minimal impact on continence and touted the advantage of minimal morbidity with potential of repeat procedures if the technique fails initially. Despite early promising results, ten years on, questions remain on the technique, patient selection and long-term outcomes. This narrative review assesses the evidence reported to-date of radially emitting laser fistula surgery in the treatment of perianal fistulas.