Minimally Invasive Anal Fistula Treatment (MAFT)-An Appraisal of Early Results in 416 Patients

VAAFT PROCEDURE (Video-assisted Anal Fistula Treatment) versus Open Method in the Treatment of High Fistula in Ano

Background A common acquired anorectal condition is anal fistula. The treatment approaches that have been employed have been linked to erratic outcomes and sometimes life-threatening consequences. Video-assisted anal fistula treatment (VAAFT), a minimally invasive method, was introduced for adult patients in 2011.

Objective To know the efficacy of the VAAFT procedure in treating high anal fistulas and to compare it to open methods in the Basrah province.

Methods The present study was performed on 200 patients with high fistulas in ano in Basrah province. We divided the patients into 2 groups: Group A: treated by the VAAFT technique and Group B: treated by open fistulotomy

Results The patients treated with VAFFT revealed no occurrence of the following postoperative complication: Infection, incontinence, recurrence, anal stenosis, and bleeding. There was lower incidence of pain, short time for wound healing, rapid return to work, and more patient satisfaction compared with open fistulotomy

Conclusion An innovative method for managing ano fistula is VAAFT. Compared with traditional methods, it has a lot of benefits. It is day case surgeryno open wound.no damage to anal sphincter and no risk of incontinence, it is more affordable.it allow for clear identification of internal office, whole tract and its associated branches and cavity. The instrument can be used for multiple patients after good sterilization and disinfection.

Video-assisted anal fistula treatment for complex anorectal fistulas in adults: a systematic review and meta-analysis

BACKGROUND

Video-assisted anal fistula treatment (VAAFT) has gained increasing acceptance as a sphincter-sparing procedure for treating complex anorectal fistulas (CAF), but no unequivocal conclusions can yet be drawn regarding its ultimate effectiveness. We reviewed the literature and performed a meta-analysis to evaluate the efficacy and safety of VAAFT in CAF patients.

METHODS

The study protocol was registered with the PROSPERO database (CRD42021279085). A systematic literature search was performed in the PubMed, Embase, and Cochrane Library databases up to June 2021 with no restriction on language based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We used the keywords video-assisted surgery, video-assisted anal fistula treatment, and complex anorectal fistula to identify relevant studies.

RESULTS

Fourteen trials (7 prospective and 7 retrospective) with a total of 1201 patients (mean age 43.5 years) were included. The median follow-up duration was 16.5(8-48) months. Pooled analysis showed that the rates of success, recurrence and postoperative complication across the studies were 83% (95% CI 81-85%, I² = 37.9%), 16% (95% CI 14-18%, I² = 4.8%), 11% (95% CI 7-15%, I² = 72.1%), respectively. The postoperative Jorge-Wexner score used to assess the level of anal incontinence was 1.09 (95% CI, 0.9-1.27, I² = 74.6%). The internal opening detection rate was 97.6% (95% CI 96.1-99.6%, I² = 48.2%). Recurrence rates varied according to the closure method of internal opening from 21.4% after using staplers, 18.7% after suturing, to 23.5% after advancement flap. The hospital stay was 3.15 days (95% CI 2.96-3.35, I² = 49.7%). Subgroup analysis indicated that the risk of heterogeneity in the urine retention group was higher  compared with that of the overall group and that retrospective studies may be the source of heterogeneity for postoperative anal incontinence. r . Sensitivity analysis confirmed the stability of the pooled results. Begg's and Egger's tests showed no evidence of publication bias.

CONCLUSIONS

According to the available evidence, VAAFT may be a valuable alternative to fistulotomy or seton in treating CAF and has the additional long-term benefits of reducing anal incontinence and surgical morbidity, permitting earlier healing and accelerated rehabilitation.

VAAFT for complex anal fistula: a useful tool, however, cure is unlikely

BACKGROUND

Therapeutic options for complex anal fistula (CAF) are limited. Video-assisted anal fistula treatment (VAAFT) allows examination of these anatomically complex fistulae from within. The aim of the present study was to evaluate outcomes of VAAFT for a series of CAF.

METHODS

A retrospective study was conducted on consecutive patients at a single centre with complex anal cryptoglandular and Crohn's fistulae managed with VAAFT from June 2016 to June 2019. CAF was diagnosed as high intersphincteric/transsphincteric tract, multiple/secondary tracts, horseshoe or anovaginal fistulae. Patients were treated with 'therapeutic intent' if the internal opening was closed at the time of ablation and 'diagnostic/staged/palliative' VAAFT if there was no ablation/partial treatment/ablation-only, respectively. Symptom improvement was a reduction in reported pain, discharge, or pad use.

RESULTS

Eighty-four patients (73 cryptoglandular, 11 Crohn's, M:F 2.5:1, median age 43 [22-77] years), underwent 105 VAAFT procedures. Twenty patients had > 1 VAAFT. Median follow-up was 8 (1-46) months. 40 (48%) had multiple or secondary tracts; an additional 16 (19%) had horseshoe and 3 (4%) anovaginal fistulae. Of the 84 patients, 19 [16/73 (22%) cryptoglandular and 3/11 (27%) Crohn's fistulae] healed. 34 (40%) unhealed reported improved symptoms; 23 (27%) no improvement; and 6 (7%) were worse. Sixteen (19%) had CAF > 5 years of whom none healed, albeit 50% reported symptom improvement. Five patients (6%) developed faecal incontinence: 2 temporary, 1 to flatus only and 1 to liquid and 1 to solid, all managed conservatively.

CONCLUSIONS

VAAFT is a useful minimally invasive procedure for complex fistula with no other minimally invasive options. Complete healing is rare, and, although symptoms can be improved in a number of cases, there is a small risk of incontinence.

Video-assisted anal fistula treatment combined with anal fistula plug for treatment of horseshoe anal fistula

Objective

Horseshoe anal fistula is a common anorectal disease, and there is no standard procedure for its treatment. In this study, we performed a modified surgical procedure for the treatment of horseshoe anal fistula and investigated its efficacy and adverse effects.

Methods

We retrospectively analyzed the outcomes of video-assisted anal fistula treatment combined with an anal fistula plug (VAAFT-Plug) in 26 patients with a horseshoe anal fistula. The follow-up period ranged from 6 to 18 months. Preoperative and postoperative data were collected to analyze the cure rate, anal sphincter function, and incidence of complications.

Results

The surgeries were successfully performed in all patients, 23 of whom were cured (effective cure rate of 88.46%). Three patients developed recurrence and were cured after traditional surgery. No patients developed severe complications or postoperative anal incontinence. The VAAFT-Plug protocol was performed with a small incision in the fistula that subsequently promoted fistula healing and preserved sphincter function.

Conclusion

Although randomized controlled trials will be needed to fully validate these findings, our results suggest that VAAFT-Plug represents a promising treatment strategy for horseshoe anal fistulas. This technique preserves normal anal function and achieves satisfactory outcomes in most patients.

Perianal fistula mapping at 3 T: volumetric versus conventional MRI sequences

AIM

To evaluate volumetric contrast-enhanced three-dimensional T1-weighted (CE 3D T1) turbo spin-echo (TSE) with variable flip angle (SPACE), CE 3D T1 volumetric interpolated breath-hold examination (VIBE) sequences with conventional CE-two-dimensional (2D)-T1 and 2D-T2-weighted imaging (WI) sequences in assessing perianal fistulas.

METHODS AND MATERIALS

Twenty-three patients with perianal fistula were included in this prospective study and underwent pelvic magnetic resonance imaging (MRI) at 3 T including fat-supressed CE 3D T1 SPACE, CE 3D T1 VIBE, axial and coronal 2D-T1WI together with 2D-T2WI sequences in the axial and coronal planes. Acquisition times were recorded. Performance of each sequence was evaluated in terms of image quality, presence of artefacts, lesion conspicuity, fistula type, presence of abscess, visibility of internal orifice, and number of internal orifices. Results were compared with post-surgical findings defined as the reference standard.

RESULTS

Both CE 3D T1 VIBE and CE 3D T1 SPACE were the best sequences to determine fistula type and in terms of image quality, artefacts, and determining locations of internal orifices. The number of internal orifices was detected correctly in 23 (100%) patients for CE 3D T1 SPACE and CE 3D T1 VIBE sequences, in 17 (73.9%) patients on CE-T1WI, and in seven (30.4%) patients on 2D-T2WI. Lesion conspicuity was higher for CE 3D T1 SPACE and CE 3D T1 VIBE sequences compared to the 2D sequences (p<0.05). The overall acquisition time for each 3D sequence was shorter compared to the 2D sequences combined.

CONCLUSION

CE 3D T1 SPACE and CE 3D T1 VIBE sequences may outperform conventional 2D sequences in the evaluation of perianal fistulas in terms of visibility and number of internal orifices with a shorter scanning time.

Comparison of surgical outcomes between video-assisted anal fistula treatment and fistulotomy plus seton for complex anal fistula: A propensity score matching analysis - Retrospective cohort study

BACKGROUND

Video-assisted anal fistula treatment (VAAFT) is a new minimally invasive technique for treating complex anal fistula (CAF). This study aimed to compare the efficacy and safety of VAAFT with fistulotomy plus seton (FPS) for treatment of CAF.

MATERIALS AND METHODS

We included 148 patients with CAF receiving surgical treatment at our hospital between January 2017 and December 2018. Propensity score matching (PSM) analysis was conducted with patients' baseline characteristics, and surgical outcomes were compared between the matched groups. Logistic analysis was performed to identify the risk factors for fistula recurrence after VAAFT.

RESULTS

Among the study population, 68 and 80 patients underwent VAAFT and FPS, respectively. After PSM, 64 matched pairs of patients were created with no significant differences in baseline characteristics. Compared with FPS, VAAFT had greater efficiency of locating internal openings (90.6% vs. 100%), less intraoperative blood loss (26 ± 15 vs. 12 ± 5 mL), lower incidence of postoperative bleeding (10.9% vs. 1.5%), shorter postoperative hospital stay (6.8 ± 5.1 vs. 5.0 ± 3.3 days), reduced postoperative pain, and decreased wound secretion (all P < 0.05). VAAFT showed a significantly lower Wexner incontinence score than FPS (0.9 ± 1.7 vs. 1.9 ± 2.6, P = 0.003) at 3 months postoperatively, but no significant difference in the healing rate was observed either at 3-month or 1-year (P = 1.000) follow-up. A total of 12 patients (17.6%) developed fistula recurrence after VAAFT, and logistic analysis revealed that multiple fistula tracts, prolonged operating time and severe postoperative wound secretion were independent risk factors (odds risk = 2.18, 3.25 and 3.04, respectively, all adjusted P < 0.05).

CONCLUSION

Compared with FPS, VAAFT offers some advantages for treatment of CAF, including minimal damage, less pain, rapid recovery, fewer complications and better sphincter preservation.

Evaluation and management of perianal abscess and anal fistula: SICCR position statement

Perianal sepsis is a common condition ranging from acute abscess to chronic anal fistula. In most cases, the source is considered to be a non-specific cryptoglandular infection starting from the intersphincteric space. Surgery is the main treatment and several procedures have been developed, but the risks of recurrence and of impairment of continence still seem to be an unresolved issue. This statement reviews the pertinent literature and provides evidence-based recommendations to improve individualized management of patients.

Anal Fistula Laser Closure: the length of fistula is the Achilles' heel

BACKGROUND

Laser closure is a novel sphincter-saving technique for the treatment of anal fistula. The aim of this study was to report middle term results of laser treatment without closure of the internal orifice and to identify prognostic factors to improve selection criteria and maximize healing.

METHODS

A retrospective observational study was conducted on patients treated with laser for transphinteric anal fistula. A diode laser emitting laser energy of 12W at a wavelength of 1470 nm was used. The relationship between fistula healing and age, sex, previous fistula surgery, location of fistula, and length of fistula tract was investigated. A successful outcome was defined by the complete healing of the surgical wound and external opening for at least 6 months.

RESULTS

Thirty patients (16 males, median age 52 years, range 26-72 years) underwent laser fistula closure between January 2015 and December 2016. Cure was achieved in 10 patients (33.3%). The mean follow-up was 11.30 months (range 6-24 months). Patients with persistent or recurrent fistula were offered repeat surgery. Eventually 4 underwent laser treatment once more. Two patients were cured leading to an overall healing rate of 40% (12 out of 30). Only 4 minor complications occurred (13.3%). No worsening of anal continence was registered. Only fistula length had a statistically significant correlation with successful treatment. Fistula tracts shorter than 30 mm were associated with a primary healing rate of 58.3% while tracts longer than 30 mm were cured in only 16.6% of cases (p < 0.02).

CONCLUSIONS

Laser closure is a safe and effective treatment for transphinteric anal fistula. The fistula length is the only significant prognostic factor when closing anal fistulas exclusively with laser: shorter fistulas have a better outcome.

Short-term efficacy and safety of three novel sphincter-sparing techniques for anal fistulae: a systematic review

BACKGROUND

The surgical treatment of complex anal fistulae, particularly those involving a significant portion of the anal sphincter in which fistulotomy would compromise continence, is challenging. Video-assisted anal fistula treatment (VAAFT), fistula tract laser closure (FiLaC™) and over-the-scope clip (OTSC^®) proctology system are all novel sphincter-sparing techniques targeted at healing anal fistulae. In this study, all published articles on these techniques were reviewed to determine efficacy, feasibility and safety.

METHODS

A systematic search of major databases was performed using defined terms. All studies reporting on experience of these techniques were included and outcomes (fistula healing and safety) evaluated.

RESULTS

Eighteen studies (VAAFT-12, FiLaC™-3, OTSC^®-3) including 1245 patients were analysed. All were case series, and outcomes were heterogeneous with follow-up ranging from 6 to 69 months and short-term (< 1 year) healing rates of 64-100%. Morbidity was low with only minor complications reported. There was one report of minor incontinence following the first reported study of FiLaC™, and this was treated successfully at 6 months with rubber band ligation of hypertrophied prolapsed mucosa. There are inconsistencies in the technique in studies of VAAFT and FiLaC™.

CONCLUSIONS

All three techniques appear to be safe and feasible options in the management of anal fistulae, and short-term healing rates are acceptable with no sustained effect on continence. There is, however, a paucity of robust data with long-term outcomes. These techniques are thus welcome additions; however, their long-term place in the colorectal surgeon's armamentarium, whether diagnostic or therapeutic, remains uncertain.

A Systematic review and meta-analysis of the efficacy and safety of video-assisted anal fistula treatment (VAAFT)

BACKGROUND

Video-assisted anal fistula treatment (VAAFT) is a novel, minimally invasive technique for the treatment of fistula-in-ano (FIA). This review aimed to search the literature for the outcome of VAAFT regarding the recurrence and complication rates of the technique.

METHODS

A systematic literature search was conducted in compliance with the PRISMA screening guidelines. PubMed/MEDLINE and Scopus were searched for articles reporting the outcomes of VAAFT procedure from inception through April 2017. The main outcomes were patients' characteristics, technical aspects, operation time, recurrence, and complication rates.

RESULTS

Eleven studies (n = 788 patients) were included. The mean age of the patients was 39.5 years. 66.5% of patients had high or complex FIA and 18.4% underwent previous fistula surgery. The internal opening of the fistula was detected in 85.7% of patients. The mean operation time was 42 ± 14.2 min. The weighed mean rate of detection of internal opening was 93.3%. Recurrence occurred in 112 (14.2%) patients after a median follow-up of 9 months. Recurrence rates varied according to method of closure of internal opening from 15.3% after using staplers, 17.7% after suturing, to 25% after advancement flap. The weighted mean recurrence rate across the studies was 17.7%. The weighted mean complication rate was 4.8%.

CONCLUSION

VAAFT may be considered an effective diagnostic tool and a safe method for the treatment of complex and high FIA attaining satisfactory outcome and acceptably low complications. Recurrence after VAAFT may be related to previous fistula surgery and the method of closure of the internal opening.

Video-Assisted Anal Fistula Treatment (VAAFT) in Cryptoglandular fistula-in-ano: A systematic review and proportional meta-analysis

BACKGROUND

Video-Assisted Anal Fistula Treatment (VAAFT) is a relatively new minimally invasive videoendoscopic procedure for treating fistula-in-ano. We reviewed and performed metaanalysis to evaluate the efficacy of this procedure.

METHODS

Studies from the period 2010 to 2016 were searched in PubMed, Medline, Scopus, Embase, Ovid, SCI database, Cochrane Central Register of Controlled Trials (CENTRAL) & Google Scholar database. All studies which utilized VAAFT to treat fistula-in-ano were extracted. The studies in which the Cryptoglandular fistula were treated were included. Procedure's done in patients with Crohn's disease, pediatric patients and associated malignancy were excluded from the study. The primary outcome parameter was success rate in fistula healing and the secondary outcome parameters were operating time, hospital stay, return to work, incontinence rate and complication rate.

RESULTS

A total of 1378 studies were screened. Out of these, eight studies were finally included for meta-analysis. The analysis (n = 786) demonstrated a net Proportion Meta-analysis pooled rate of 76.01% (95% CI = 68.1 to 83.9) for success rate, 16.2% (95% CI = 12.1 to 20.2) for complications, 44.7 min (95% CI = 38.3 to 51.2) for operating time, 1-4.1 days for mean hospital stay and 1-11 days for return to work. None of the studies reported worsening of continence levels.

CONCLUSIONS

VAAFT is a safe videoendoscopic method to treat fistula-in-ano with an overall success rate of 76% (net Proportion Meta-analysis pooled rate). The main benefit of the procedure is minimal risk to incontinence, minimal hospital stay and early return to work.

Video-Assisted Anal Fistula Treatment: Pros and Cons of This Minimally Invasive Method for Treatment of Perianal Fistulas

Purpose

The purpose of this paper is to present results of a single-center, nonrandomized, prospective study of the video-assisted anal fistula treatment (VAAFT).

Methods

68 consecutive patients with perianal fistulas were operated on using the VAAFT technique. 30 of the patients had simple fistulas, and 38 had complex fistulas. The mean follow-up time was 31 months.

Results

The overall healing rate was 54.41% (37 of the 68 patients healed with no recurrence during the follow-up period). The results varied depending on the type of fistula. The success rate for the group with simple fistulas was 73.3%, whereas it was only 39.47% for the group with complex fistulas. Female patients achieved higher healing rates for both simple (81.82% versus 68.42%) and complex fistulas (77.78% versus 27.59%). There were no major complications.

Conclusions

The results of VAAFT vary greatly depending on the type of fistula. The procedure has some drawbacks due to the rigid construction of the fistuloscope and the diameter of the shaft. The electrocautery of the fistula tract from the inside can be insufficient to close wide tracts. However, low risk of complications permits repetition of the treatment until success is achieved. Careful selection of patients is advised.

Video-Assisted Anal Fistula Treatment (VAAFT) for Complex Anal Fistula: A Preliminary Evaluation in China

BACKGROUND Although many attempts have been made to advance the treatment of complex anal fistula, it continues to be a difficult surgical problem. This study aimed to describe the novel technique of video-assisted anal fistula treatment (VAAFT) and our preliminary experiences using VAAFT with patients with complex anal fistula. MATERIAL AND METHODS From May 2015 to May 2016, 52 patients with complex anal fistula were treated with VAAFT at Yangpu Hospital of Tongji University School of Medicine, and the clinical data of these patients were reviewed. RESULTS VAAFT was performed successfully in all 52 patients. The median operation time was 55 minutes. Internal openings were identified in all cases. 50 cases were closed with sutures, and 2 were closed with staplers. Complications included perianal sepsis in 3 cases and bleeding in another 3 cases. Complete healing without recurrence was achieved in 44 patients (84.6%) after 9 months of follow-up. No fecal incontinence was observed. Furthermore, a significant improvement in Gastrointestinal Quality of Life Index (GIQLI) score was observed from preoperative baseline (mean, 85.5) to 3-month follow-up (mean, 105.4; p<0.001), and this increase was maintained at 9-months follow-up (mean, 109.6; p<0.001). CONCLUSIONS VAAFT is a safe and minimally invasive technique for treating complex anal fistula with preservation of anal sphincter function.

The comparison of CT fistulography and MR imaging of perianal fistulae with surgical findings: a case-control study

PURPOSE

The purpose of this study was to evaluate the diagnostic efficacies of CT fistulography and MRI, in the diagnostic work-up of perianal fistula patients.

MATERIALS AND METHODS

All 41 patients who were included in the study (36 males and 5 females, with an average age of 41 years) underwent CT fistulography and MRI examinations prior to surgery. The fistula characteristics obtained from these examinations were compared with the surgical findings. The comparative results were evaluated by means of the Kappa analysis method.

RESULTS

CT fistulography predicted the correct perianal fistula classification in 30 (73.1%) of the 41 patients, whereas MRI correctly defined fistula classification in 38 (92.7%) of these patients (the K values were 0.621 and 0.896, respectively; with p < 0.001). CT fistulography depicted 29 secondary extensions in 16 patients, whereas MR imaging revealed 28 secondary extensions in 15 patients. A substantial agreement was found between surgical findings and two modalities (K value was 0.789 and 0.793 for CT fistulography and MRI, respectively, with a p value < 0.001). In terms of locations of internal openings, CT fistulography was able to detect the locations in 28 patients (68.2%), whereas MRI was more successful in this aspect, with a number of 35 patients (85.3%). Granulation tissues, inflammation and edema around the fistula, abscesses, and fistular wall fibrosis were also evaluated.

CONCLUSION

CT fistulography and MRI have different advantages in the diagnosis of perianal fistulas. A good command of knowledge concerning the issue may be a key factor in modality decision.